A/Prof Kade Paterson: Bridging Research, Elite Sport and the 'Humanity' of Podiatry Practice

WEBVTT
00:00:03.319 --> 00:00:05.299
Welcome to Sole Science, the official podcast
00:00:05.299 --> 00:00:07.179
of Sports and Exercise Podiatry Australasia,
00:00:07.339 --> 00:00:09.980
where your hosts Pat and Darcy, both sports podiatrists
00:00:09.980 --> 00:00:11.279
with a passion for advancing the profession.
00:00:11.800 --> 00:00:14.019
In each episode, we dive into the latest research,
00:00:14.240 --> 00:00:16.219
share compelling stories from clinicians and
00:00:16.219 --> 00:00:18.239
feature special guests who've made significant
00:00:18.239 --> 00:00:20.280
contributions to the world of sports and exercise
00:00:20.280 --> 00:00:23.620
podiatry and low -limb sports medicine. Darcy?
00:00:24.579 --> 00:00:27.539
Patrick, how are we today? Not too bad. Let's
00:00:27.539 --> 00:00:30.399
step right into it. Today's episode is more than
00:00:30.399 --> 00:00:32.719
a professional conversation. It is a powerful
00:00:32.719 --> 00:00:35.020
insight into elite performance, leadership and
00:00:35.020 --> 00:00:37.100
human potential and a blueprint for anyone striving
00:00:37.100 --> 00:00:39.460
to lead, grow and sustain excellence over time.
00:00:39.799 --> 00:00:42.719
Our guest is Associate Professor Kade Paterson.
00:00:43.060 --> 00:00:46.159
Kade is a Dame Cate Campbell Fellow for the Centre
00:00:46.159 --> 00:00:48.399
of Health, Exercise and Sports Medicine at the
00:00:48.399 --> 00:00:50.679
University of Melbourne and a certified sports
00:00:50.679 --> 00:00:53.579
podiatrist, consulting through Lakeside Sports
00:00:53.579 --> 00:00:55.460
Medicine Centre and with the Collingwood Football
00:00:55.460 --> 00:00:58.840
Club in the AFL. His research career focused
00:00:58.840 --> 00:01:02.090
on large clinical trials and biomechanical investigations
00:01:02.090 --> 00:01:04.810
exploring non -drug, non -surgical interventions
00:01:04.810 --> 00:01:07.549
for musculoskeletal conditions with particular
00:01:07.549 --> 00:01:10.909
expertise in foot and knee pain. He's published
00:01:10.909 --> 00:01:13.569
more than 90 peer -reviewed research papers,
00:01:13.890 --> 00:01:16.930
co -authored a biomechanics textbook and presented
00:01:16.930 --> 00:01:19.189
extensively at national and international conferences.
00:01:19.489 --> 00:01:22.390
Alongside academia, Kade maintains an extensive
00:01:22.390 --> 00:01:25.129
clinical career spanning over 15 years, working
00:01:25.129 --> 00:01:27.450
with professional and recreational athletes across
00:01:27.450 --> 00:01:30.340
Australia. continuously bridging the gap between
00:01:30.340 --> 00:01:32.159
research evidence and real world performance
00:01:32.159 --> 00:01:34.840
environments. Beyond clinical and research excellence,
00:01:35.040 --> 00:01:37.480
Kade currently serves as the incumbent president
00:01:37.480 --> 00:01:39.359
of Sports and Exercise Podiatry Australasia.
00:01:39.680 --> 00:01:41.920
He contributes nationally through the Sports
00:01:41.920 --> 00:01:43.900
Medicine Australia Member Education Advisory
00:01:43.900 --> 00:01:46.640
Committee and as a fellow of the Australian Sports
00:01:46.640 --> 00:01:49.959
Medicine Federation. But this conversation moves
00:01:49.959 --> 00:01:52.000
beyond titles and achievements. This episode
00:01:52.000 --> 00:01:54.200
offers a rare look at leadership, resilience
00:01:54.200 --> 00:01:57.390
and the balance between pressure and care at
00:01:57.390 --> 00:02:00.129
the very top exploring how clinicians evolve
00:02:00.129 --> 00:02:03.310
into leaders how professions grow and how high
00:02:03.310 --> 00:02:05.549
performance maintain humanity while operating
00:02:05.549 --> 00:02:08.090
in demanding environments because at the highest
00:02:08.090 --> 00:02:11.069
level performance is never just physical or intellectual
00:02:11.069 --> 00:02:14.930
it's deeply human Associate Professor Kade Paterson
00:02:14.930 --> 00:02:17.629
welcome to Sole Science great to have you with
00:02:17.629 --> 00:02:20.669
us hi darcy um yeah thank that thanks for that
00:02:20.669 --> 00:02:23.110
introduction that was uh that was very kind very
00:02:23.110 --> 00:02:27.060
nice thank you Kade um What does sports and exercise
00:02:27.060 --> 00:02:29.580
podiatry mean to you? And how has that definition
00:02:29.580 --> 00:02:31.860
changed throughout your career? Yeah, look, I
00:02:31.860 --> 00:02:34.319
mean, it's, you know, activity, isn't it? It's
00:02:34.319 --> 00:02:37.139
sports and activity. So we focused historically
00:02:37.139 --> 00:02:40.879
on the sports and we're now recognising that,
00:02:40.919 --> 00:02:43.840
you know, the movement, the activity related
00:02:43.840 --> 00:02:46.860
things that people do are probably a greater
00:02:46.860 --> 00:02:51.259
component of our work and a more important target
00:02:51.259 --> 00:02:55.569
for our work as well. Hence, obviously, the name
00:02:55.569 --> 00:02:57.530
changed with Sports and Exercise Podiatry Australia.
00:02:58.849 --> 00:03:01.669
Yeah, just to kind of bring the exercise in.
00:03:02.389 --> 00:03:08.090
As we all know, it is a very relevant and increasing
00:03:08.090 --> 00:03:11.750
part of our assessment and our treatment. How's
00:03:11.750 --> 00:03:18.150
it changed? Yeah, I think that's reflected in...
00:03:19.849 --> 00:03:22.870
in the name as i said in the name change that
00:03:22.870 --> 00:03:26.330
we've kind of moved away a bit more from that
00:03:26.330 --> 00:03:29.909
kind of passive approach you know in our field
00:03:29.909 --> 00:03:32.689
focusing on biomechanics to to shifting a little
00:03:32.689 --> 00:03:35.530
bit more to sort of load and exercise based interventions
00:03:35.530 --> 00:03:38.189
and i've certainly seen that in my my career
00:03:38.189 --> 00:03:41.189
yeah take us back to the beginning Kade um what
00:03:41.189 --> 00:03:43.110
drew you into podiatry and how did it all begin
00:03:43.110 --> 00:03:46.330
mate yeah i can't i get asked that question all
00:03:46.330 --> 00:03:48.949
the time like why why are you into podiatry um
00:03:49.770 --> 00:03:52.610
I'm sure we all do, actually. Yeah, mine started
00:03:52.610 --> 00:03:58.110
as an interest in exercise. I was a runner and
00:03:58.110 --> 00:04:01.009
a skateboarder. That's my sort of hidden secret.
00:04:01.110 --> 00:04:04.150
And I was really into it. I wasn't so much into
00:04:04.150 --> 00:04:07.599
watching sport, but I did enjoy exercise. And
00:04:07.599 --> 00:04:10.240
so I did an exercise science degree and just
00:04:10.240 --> 00:04:12.639
fell in love with biomechanics from the very
00:04:12.639 --> 00:04:15.419
first subject. And so, yeah, sort of got to the
00:04:15.419 --> 00:04:18.240
end of the degree and was fortunate enough to
00:04:18.240 --> 00:04:20.120
get asked to do an honours year. So I did an
00:04:20.120 --> 00:04:22.000
honours year and it just so happened that my
00:04:22.000 --> 00:04:25.600
supervisor had been looking at foot biomechanics.
00:04:26.170 --> 00:04:28.389
And so he said, I think you should look at foot
00:04:28.389 --> 00:04:31.069
biomechanics. And so I was like, okay. So I did
00:04:31.069 --> 00:04:33.089
an honours year project looking at something
00:04:33.089 --> 00:04:35.470
called the foot progression angle, which I won't
00:04:35.470 --> 00:04:38.449
go into and bore anyone with. And certainly absolutely
00:04:38.449 --> 00:04:41.850
nothing has come of it. But yeah, I kind of got
00:04:41.850 --> 00:04:44.430
halfway through and just loved it and loved the
00:04:44.430 --> 00:04:48.370
complexity of foot mechanics and how little we
00:04:48.370 --> 00:04:50.069
knew, I guess. And so I went away and I looked
00:04:50.069 --> 00:04:53.430
around at what jobs could not only assess foot
00:04:53.430 --> 00:04:57.199
mechanics, but treat. book mechanics. And I knew
00:04:57.199 --> 00:04:59.759
a physio, so I enrolled and got into physio.
00:05:00.420 --> 00:05:03.319
But while I was waiting, I remember I was in
00:05:03.319 --> 00:05:06.180
a prosthetist's office and they had a brochure
00:05:06.180 --> 00:05:08.060
for podiatry at La Trobe. And I was like, oh,
00:05:08.100 --> 00:05:11.019
what's this? I hadn't really heard of it. And
00:05:11.019 --> 00:05:13.540
yeah, I looked through the brochure and thought
00:05:13.540 --> 00:05:15.339
that's exactly what I want to do. So I changed
00:05:15.339 --> 00:05:19.420
my preference and here I am, got into podiatry.
00:05:19.740 --> 00:05:23.819
Did you... Start off with a mixture of academia
00:05:23.819 --> 00:05:27.480
and clinical practice. And has that always carried
00:05:27.480 --> 00:05:29.980
across or did you ever kind of dichotomise and
00:05:29.980 --> 00:05:34.540
just specialise in one area? I started, I guess,
00:05:34.560 --> 00:05:39.139
not in research, but in academia. So I did both.
00:05:39.379 --> 00:05:42.560
So when I studied podiatry, I was actually in
00:05:42.560 --> 00:05:44.800
the unenviable position of also doing a little
00:05:44.800 --> 00:05:47.660
bit of teaching and I got a job tutoring my same
00:05:47.660 --> 00:05:50.810
year level that I was studying with. So it was
00:05:50.810 --> 00:05:53.310
like, you know, Monday, Tuesday, I was in class
00:05:53.310 --> 00:05:55.350
with them. Wednesday, I was taking tutes for
00:05:55.350 --> 00:05:57.209
them. And then Thursday, Friday, back in class
00:05:57.209 --> 00:05:59.509
with them. And yeah, that was an interesting
00:05:59.509 --> 00:06:02.189
experience. But yeah, so I sort of kept up tutoring,
00:06:02.310 --> 00:06:07.230
I guess. And then when I first graduated, I had
00:06:07.230 --> 00:06:10.430
a crack at just doing clinic on its own. And
00:06:10.430 --> 00:06:12.410
I got about nine months into just full -time
00:06:12.410 --> 00:06:15.910
clinic and realized I just, I really missed the
00:06:15.910 --> 00:06:19.819
academic environment. and the research as well.
00:06:19.899 --> 00:06:21.839
So I got a job back at my old university two
00:06:21.839 --> 00:06:25.060
days a week doing like a lab manager position.
00:06:25.839 --> 00:06:29.600
And so that was a little bit of tutoring, really
00:06:29.600 --> 00:06:34.600
small scale research projects. And yeah, I've
00:06:34.600 --> 00:06:37.360
sort of maintained it. So I guess, yeah, apart
00:06:37.360 --> 00:06:42.019
from that nine month window. of just doing clinic.
00:06:42.100 --> 00:06:44.639
I've always had a little bit of academia. And
00:06:44.639 --> 00:06:46.199
then as the years gone on, I've been sort of
00:06:46.199 --> 00:06:48.120
fortunate enough to be able to take on a research
00:06:48.120 --> 00:06:52.560
only role within my academic role. And so, yeah,
00:06:52.600 --> 00:06:55.500
I'd say for the last 10 years, what are we, 26,
00:06:55.699 --> 00:06:58.420
13 years, I've just been focused on research.
00:06:58.860 --> 00:07:01.079
A week for you at the moment, Kate, is primarily
00:07:01.079 --> 00:07:03.639
research, not doing too much teaching or any
00:07:03.639 --> 00:07:06.660
clinical work for now. What about with the Collingwood,
00:07:06.800 --> 00:07:09.720
the great old Collingwood? Great old Collingwood,
00:07:09.779 --> 00:07:14.860
yeah. People will tune off after this. So I'm
00:07:14.860 --> 00:07:18.800
four days as an academic, and as I said, I'm
00:07:18.800 --> 00:07:22.000
a research, they call it research -focused academic,
00:07:22.040 --> 00:07:24.439
but within that I've got sort of a little bit
00:07:24.439 --> 00:07:26.600
of a leadership role, but also I do do a bit
00:07:26.600 --> 00:07:29.680
of teaching. Not much. I'll do a couple of guest
00:07:29.680 --> 00:07:32.339
lectures, and then we've got a Masters of Sports
00:07:32.339 --> 00:07:34.959
Medicine, and I teach the biomechanics unit in
00:07:34.959 --> 00:07:38.790
that. But that's just wrapped up. I'll probably
00:07:38.790 --> 00:07:40.670
pick up a little bit more teaching next year
00:07:40.670 --> 00:07:44.250
because some of my grants are wrapping up. So,
00:07:44.290 --> 00:07:47.009
yeah, so that's Monday, Tuesday, Thursday, Friday,
00:07:47.009 --> 00:07:50.089
and pretty much, you know, whenever else it's
00:07:50.089 --> 00:07:52.170
needed. And then on Wednesdays I'm in the clinic,
00:07:52.209 --> 00:07:56.730
so I've got a practice, a sports medicine practice
00:07:56.730 --> 00:07:59.910
that I work Wednesdays and every second Saturdays.
00:08:00.189 --> 00:08:03.339
And then, yeah, with the football club. I try
00:08:03.339 --> 00:08:05.240
to squeeze it into Wednesday afternoon, but we
00:08:05.240 --> 00:08:08.800
often, the days in at the club are often backdated
00:08:08.800 --> 00:08:11.079
from game day, coming game day. So that can be
00:08:11.079 --> 00:08:13.560
a bit variable as well. I'm fortunate that the
00:08:13.560 --> 00:08:17.779
club's on my ride to uni. So I ride along the
00:08:17.779 --> 00:08:20.319
arrow, just cross the arrow, jump into the club.
00:08:20.360 --> 00:08:22.959
And so I can see them before I start at uni as
00:08:22.959 --> 00:08:27.610
well. Yeah. How did you navigate, I guess, your
00:08:27.610 --> 00:08:30.029
direction early on, Kade? Did you have a clinical
00:08:30.029 --> 00:08:34.470
mentor or an academic mentor? And how did you,
00:08:34.509 --> 00:08:41.730
I guess, find that mentor? I had a research mentor,
00:08:41.990 --> 00:08:46.490
so my honours supervisor, Noel Lithgow, who was
00:08:46.490 --> 00:08:51.820
at Melbourne Uni and is... has moved to RMIT
00:08:51.820 --> 00:08:57.340
now um so I'd say he was my research mentor uh
00:08:57.340 --> 00:09:01.200
early on I was yeah I was sort of a bit at sea
00:09:01.200 --> 00:09:03.580
to be honest like as I said I practiced initially
00:09:03.580 --> 00:09:05.759
and then and then I actually went overseas for
00:09:05.759 --> 00:09:07.899
about a year and a half and didn't work in either
00:09:07.899 --> 00:09:11.019
industry um you know I did what good Australians
00:09:11.019 --> 00:09:13.720
do overseas and I worked in a bar for a year
00:09:13.720 --> 00:09:16.360
and a half which was lots of fun um and so when
00:09:16.360 --> 00:09:20.620
I got back I had really low skills and um I got
00:09:20.620 --> 00:09:24.639
a job initially in aged care, which was a really
00:09:24.639 --> 00:09:26.720
flexible job, which suited me. And then I picked
00:09:26.720 --> 00:09:30.100
up the research, that lab stuff that I talked
00:09:30.100 --> 00:09:33.860
about before. And then from there, got a job
00:09:33.860 --> 00:09:36.080
in a general practice. And I worked with a couple
00:09:36.080 --> 00:09:40.980
of people. Actually, there was a woman I worked
00:09:40.980 --> 00:09:45.320
with, Michaela. Yeah, I just remember bouncing
00:09:45.320 --> 00:09:49.500
a lot of ideas off her and she was going through
00:09:49.500 --> 00:09:52.799
the surgical program as well. And she got about
00:09:52.799 --> 00:09:55.159
five years into it. This really stuck with me.
00:09:55.220 --> 00:09:58.399
She got about five years into it and then decided
00:09:58.399 --> 00:10:01.799
to throw it in. And I won't go into why, but
00:10:01.799 --> 00:10:04.639
certain things that were entrenched in that program,
00:10:04.799 --> 00:10:06.919
she didn't really like. And I remember thinking,
00:10:07.039 --> 00:10:11.080
God, she's just put so much into it and gone
00:10:11.080 --> 00:10:16.240
so far and is ready to sort of shift focus and
00:10:16.240 --> 00:10:19.759
move into this completely new area within podiatry,
00:10:19.820 --> 00:10:21.379
you know, give up all of that, start our own
00:10:21.379 --> 00:10:23.080
practice and do those sorts of things. And it
00:10:23.080 --> 00:10:25.580
just, I remember, yeah, being empowering, I guess.
00:10:25.620 --> 00:10:28.820
So I didn't, like I didn't have anyone at the
00:10:28.820 --> 00:10:30.980
time within sports medicine, but that kind of
00:10:30.980 --> 00:10:32.840
made me step back and think, all right, well,
00:10:32.860 --> 00:10:37.000
am I happy here? And I don't think I was. And
00:10:37.000 --> 00:10:41.039
so then I sort of started pursuing sports a little
00:10:41.039 --> 00:10:44.090
bit more. which I'm happy to go into. But then
00:10:44.090 --> 00:10:47.210
I met someone a lot of us will know in Melbourne,
00:10:47.289 --> 00:10:50.929
Jason Agosta. He was a very prominent sports
00:10:50.929 --> 00:10:54.450
podiatrist down here. And I sat in with him and,
00:10:54.570 --> 00:10:58.769
yeah, that was it for me. Got the bug for sports
00:10:58.769 --> 00:11:04.090
and went all in, or tried to. Took a while. Kate,
00:11:04.110 --> 00:11:08.850
I'm going to fast forward to 2021 where you released
00:11:08.850 --> 00:11:13.659
a randomised controlled trial. with sham orthoses
00:11:13.659 --> 00:11:18.059
and contoured orthoses in that paper. I thought
00:11:18.059 --> 00:11:21.759
it was a fantastic read. But part of, I guess,
00:11:21.779 --> 00:11:25.500
that research, like one of the questions I was
00:11:25.500 --> 00:11:28.580
reading, like stuck with me, which was, should
00:11:28.580 --> 00:11:32.559
we be separating symptom modification from disease
00:11:32.559 --> 00:11:36.080
modification in how we think about? prescribing
00:11:36.080 --> 00:11:39.620
orthoses? Well, I think the symptoms is always
00:11:39.620 --> 00:11:43.460
the reason the patient comes to see you. We are
00:11:43.460 --> 00:11:46.899
treating symptoms, not diseases. And with conditions
00:11:46.899 --> 00:11:49.600
like osteoarthritis, we are very much moving
00:11:49.600 --> 00:11:52.200
away from imaging if we're thinking of disease
00:11:52.200 --> 00:11:55.879
in that sense. And we're very much focused on
00:11:55.879 --> 00:11:59.600
symptoms. And obviously, the two are really interlinked.
00:12:00.879 --> 00:12:05.700
So I would argue, yeah, your primary focus is
00:12:05.700 --> 00:12:09.899
the symptoms. And very much so until we can come
00:12:09.899 --> 00:12:14.500
up with some disease modifying treatments. And
00:12:14.500 --> 00:12:16.820
there's been, you know, a few proposed, but nothing
00:12:16.820 --> 00:12:19.559
so far. There's no panacea that I'm aware of
00:12:19.559 --> 00:12:23.259
for a disease modifying agent. I think orthoses,
00:12:23.360 --> 00:12:28.720
well, most of our treatments really will want
00:12:28.720 --> 00:12:32.610
to improve symptoms by modifying. the disease
00:12:32.610 --> 00:12:34.870
and you know we i think podiatrists are very
00:12:34.870 --> 00:12:37.190
good at trying to understand the mechanisms of
00:12:37.190 --> 00:12:42.129
disease and target those mechanisms um with you
00:12:42.129 --> 00:12:43.970
know with the ultimate intention of improving
00:12:43.970 --> 00:12:46.230
symptoms is that sort of what you were getting
00:12:46.230 --> 00:12:54.149
at definitely yeah um i thought it was a really
00:12:54.149 --> 00:12:57.409
good read um and i was uh also reading up on
00:12:57.409 --> 00:13:00.590
your um article back in 2020 where you did the
00:13:00.590 --> 00:13:03.990
survey across the UK and Australia for clinical
00:13:03.990 --> 00:13:07.429
practice. What that paper found, I guess some
00:13:07.429 --> 00:13:09.529
of the results we were finding was there was
00:13:09.529 --> 00:13:11.990
heavily favouritism obviously with podiatrists
00:13:11.990 --> 00:13:14.370
favouring orthoses and then physios favouring
00:13:14.370 --> 00:13:19.289
exercise. Given our recent name changes over
00:13:19.289 --> 00:13:22.629
the years for SEPA, what do you think exercise
00:13:22.629 --> 00:13:25.370
is catching on a lot more in podiatry or do you
00:13:25.370 --> 00:13:28.220
still think it's still trendy? I do think it
00:13:28.220 --> 00:13:30.940
is, yeah. And sort of to quickly summarise, so
00:13:30.940 --> 00:13:33.519
we did an international survey of podiatrists
00:13:33.519 --> 00:13:37.340
and physios to see how they managed first metastasophelangeal
00:13:37.340 --> 00:13:42.659
joint osteoarthritis and looked at how they assessed
00:13:42.659 --> 00:13:45.240
and then how they managed it. And one of the
00:13:45.240 --> 00:13:48.340
main findings, as you said, Pat, was that physios
00:13:48.340 --> 00:13:52.200
overwhelmingly use exercise, much less often
00:13:52.200 --> 00:13:56.460
use foot orthoses. And then podiatrists, it was
00:13:56.460 --> 00:13:59.500
in reverse. So many, many more used orthoses,
00:13:59.620 --> 00:14:03.480
particularly custom foot orthoses. And from memory,
00:14:03.539 --> 00:14:06.580
it was something like only about 40%, somewhere
00:14:06.580 --> 00:14:10.559
around there, high 30s, used exercise. That was
00:14:10.559 --> 00:14:12.919
probably the most surprising finding, actually,
00:14:13.039 --> 00:14:16.059
of that study. But I think you're right. It does
00:14:16.059 --> 00:14:18.679
kind of reflect the state of play back then.
00:14:18.740 --> 00:14:21.299
So that was published, what did we say, 2020?
00:14:21.679 --> 00:14:25.539
I think 2020. Yeah, I think it was 2020. So,
00:14:25.639 --> 00:14:27.220
you know, the survey was probably done 2018,
00:14:27.480 --> 00:14:31.820
2019. So we're looking at eight -ish years old
00:14:31.820 --> 00:14:35.419
now. And I think in that time, particularly I
00:14:35.419 --> 00:14:39.799
would say, what, the last three or four years
00:14:39.799 --> 00:14:44.799
exercises increasingly becoming prominent within
00:14:44.799 --> 00:14:46.960
the profession, like I said, right back at the
00:14:46.960 --> 00:14:50.429
start. I don't even really remember learning
00:14:50.429 --> 00:14:54.129
about exercise when I went through, you know,
00:14:54.149 --> 00:14:57.090
general exercise, let alone sort of targeted
00:14:57.090 --> 00:15:01.070
strength exercise or something like that. And
00:15:01.070 --> 00:15:04.090
so, you know, I have never prescribed it, God.
00:15:05.070 --> 00:15:07.889
That's what exercise physiologists and physios
00:15:07.889 --> 00:15:11.830
did. And so I think over time, yeah, that's definitely
00:15:11.830 --> 00:15:14.490
changed. We're now getting a good body of research
00:15:14.490 --> 00:15:19.049
out there on foot exercises in particular. So
00:15:19.049 --> 00:15:21.710
I'd hope that if we did that survey again, that
00:15:21.710 --> 00:15:25.149
that would shift somewhat, not necessarily a
00:15:25.149 --> 00:15:27.909
reduction in the use of foot orthoses, but hopefully
00:15:27.909 --> 00:15:31.669
we would see that exercise prescription, even...
00:15:32.570 --> 00:15:35.350
load like activity modification was quite low
00:15:35.350 --> 00:15:39.049
for the podiatrists in that study as well which
00:15:39.049 --> 00:15:43.409
was really surprising um yeah so so i'd hope
00:15:43.409 --> 00:15:46.190
that we'd see that shift over time after the
00:15:46.190 --> 00:15:48.190
last eight years or so as well you'd hope that
00:15:48.190 --> 00:15:50.490
um i guess all the professions would be utilizing
00:15:50.490 --> 00:15:53.490
some shoes that have more rocker and higher longitudinal
00:15:53.490 --> 00:15:56.070
bending stiffness that'd probably be one of the
00:15:56.070 --> 00:16:01.549
other changes hopefully but um yeah i agree darcy
00:16:01.549 --> 00:16:03.350
yeah yeah i agree because then if you look at
00:16:03.350 --> 00:16:06.909
the flip like you look at the physios um and
00:16:06.909 --> 00:16:08.610
again this is this is from memory looking at
00:16:08.610 --> 00:16:12.830
the physios sort of footwear advice um was very
00:16:12.830 --> 00:16:16.669
very low um and and in fact i think like shoe
00:16:16.669 --> 00:16:18.830
stiffening inserts i don't think they recommended
00:16:18.830 --> 00:16:21.429
them at all whereas the pods did so i think that's
00:16:21.429 --> 00:16:24.960
a good comment now do you think um kade different
00:16:24.960 --> 00:16:27.759
orthoses designs or prescriptions could have
00:16:27.759 --> 00:16:30.500
led to different outcomes than what was tested
00:16:30.500 --> 00:16:35.899
in that RCT? Yeah, I do, Pat. And look, we anticipated
00:16:35.899 --> 00:16:43.519
that. You get a lot of opinions on which orthoses
00:16:43.519 --> 00:16:46.860
would have been better and that we had clearly
00:16:46.860 --> 00:16:50.080
used the wrong one, obviously. So yeah, so in
00:16:50.080 --> 00:16:52.879
that study, we based it actually a little bit
00:16:52.879 --> 00:16:55.700
on the sorry on the on the clinical trial the
00:16:55.700 --> 00:16:57.480
one that we talked about earlier where we found
00:16:57.480 --> 00:16:59.279
no difference in the contoured foot orthoses
00:16:59.279 --> 00:17:03.460
versus the the sham flat insole so we based that
00:17:03.460 --> 00:17:05.960
on the earlier survey that we're now discussing
00:17:05.960 --> 00:17:08.960
to see what pods did and we there was some background
00:17:08.960 --> 00:17:11.660
data that wasn't published in the paper that
00:17:11.660 --> 00:17:14.640
showed which devices they they use more commonly
00:17:14.640 --> 00:17:17.640
what are the most common modifications they might
00:17:17.640 --> 00:17:20.319
make to the to the orthoses under what circumstances
00:17:20.319 --> 00:17:22.859
and those sorts of things so we We then pulled
00:17:22.859 --> 00:17:26.339
that data out and we formed like a bit of an
00:17:26.339 --> 00:17:29.460
expert consensus group and we met and we went
00:17:29.460 --> 00:17:31.059
through that data and we said, all right, well,
00:17:31.099 --> 00:17:35.200
what's the best approach to use here? So we had
00:17:35.200 --> 00:17:37.700
a combination, I guess, of the clinicians. I
00:17:37.700 --> 00:17:40.660
think we had 100 and whatever podiatrists and
00:17:40.660 --> 00:17:43.900
then this small focus group of around 10 research
00:17:43.900 --> 00:17:47.900
clinician pods to finalise the orthoses that
00:17:47.900 --> 00:17:50.319
we would use in the ultimate clinical trial.
00:17:51.259 --> 00:17:54.359
What was interesting, I think, in that one is
00:17:54.359 --> 00:17:58.779
there was about a 50 -50 split in the data, the
00:17:58.779 --> 00:18:01.279
survey data, and in the expert consensus about
00:18:01.279 --> 00:18:05.380
whether to use either a first rate cutout for
00:18:05.380 --> 00:18:08.940
people with big toe OA or a Morton's extension.
00:18:09.279 --> 00:18:13.259
I think it was about a 50 -50 split for both
00:18:13.259 --> 00:18:16.799
of those. And in the end for the trial, we went
00:18:16.799 --> 00:18:20.819
with a form thotic. because prefab was the most
00:18:20.819 --> 00:18:23.539
commonly prescribed. We went with the cutout
00:18:23.539 --> 00:18:27.799
and then the consensus group said that if the
00:18:27.799 --> 00:18:30.880
person had no range of motion or very, very minimal
00:18:30.880 --> 00:18:33.619
range of motion, or if the cutout hurt, you would
00:18:33.619 --> 00:18:36.099
then use an extension instead. So we tried to
00:18:36.099 --> 00:18:38.519
get a little bit of, I guess, you know, that
00:18:38.519 --> 00:18:41.339
customization that we all do. And then there
00:18:41.339 --> 00:18:43.279
was an added provision if they had a foot posture
00:18:43.279 --> 00:18:46.640
score above, I think it was seven or eight, you'd
00:18:46.640 --> 00:18:49.480
add on a varus wedge. Would we have got a different
00:18:49.480 --> 00:18:52.779
result if we used a different orthosis? Probably.
00:18:52.839 --> 00:18:55.400
Well, actually, you know what? I'm going to say
00:18:55.400 --> 00:18:58.900
no. I don't think we would have. I apologize
00:18:58.900 --> 00:19:01.660
for the finding and I apologize for saying that.
00:19:01.720 --> 00:19:03.259
We all want to think what we do works. But I
00:19:03.259 --> 00:19:07.460
think the reason is in that word custom. And
00:19:07.460 --> 00:19:09.740
it's custom for a reason. And it's custom because
00:19:09.740 --> 00:19:15.009
our patients are all unique. And it's just so
00:19:15.009 --> 00:19:18.769
hard to capture that in a clinical trial with
00:19:18.769 --> 00:19:23.349
a mechanical intervention that's specific for
00:19:23.349 --> 00:19:26.950
that specific person in your clinic room that
00:19:26.950 --> 00:19:29.529
day with their particular features and their
00:19:29.529 --> 00:19:32.089
particular activity levels and all of those sorts
00:19:32.089 --> 00:19:35.130
of things. If we could allow in a clinical trial
00:19:35.130 --> 00:19:37.970
a full customization process, and I know Chris
00:19:37.970 --> 00:19:40.130
Bishop did that a little while ago with a plantar
00:19:40.130 --> 00:19:44.339
heel pain study. then maybe we would see a difference.
00:19:44.680 --> 00:19:46.819
The other thing that might be worth pointing
00:19:46.819 --> 00:19:50.059
out in that study, we did use a sham foot orthosis
00:19:50.059 --> 00:19:52.259
to compare the contoured foot orthosis to, and
00:19:52.259 --> 00:19:55.460
the sham was about a three mil layer of EVA,
00:19:55.500 --> 00:19:59.539
same density as the orthosis. And we actually
00:19:59.539 --> 00:20:02.079
had a letter to the editor after we published
00:20:02.079 --> 00:20:05.799
the paper by Jill. helstead which some of you
00:20:05.799 --> 00:20:08.880
may know from the uk and jill argued that perhaps
00:20:08.880 --> 00:20:13.140
the sham insole reduced forces under the joint
00:20:13.140 --> 00:20:16.400
because although it was thin and it wasn't contoured
00:20:16.400 --> 00:20:19.759
it could still help reduce forces during walking
00:20:19.759 --> 00:20:22.740
when she's she's absolutely right so we're now
00:20:22.740 --> 00:20:27.170
doing A new trial looking at cushioning insoles
00:20:27.170 --> 00:20:31.130
versus a sham insole. And before we did the study,
00:20:31.170 --> 00:20:33.509
we actually trialled a bunch of different materials,
00:20:33.809 --> 00:20:37.289
different densities, different thicknesses for
00:20:37.289 --> 00:20:42.049
both the cushioned insole and the sham, just
00:20:42.049 --> 00:20:44.269
to make sure that the cushioned insole was reducing
00:20:44.269 --> 00:20:47.549
those forces under the Hallux and First MTP and
00:20:47.549 --> 00:20:50.849
the sham wasn't reducing the forces. So stay
00:20:50.849 --> 00:20:54.160
tuned for the findings of that one. Kate, I'm
00:20:54.160 --> 00:20:55.859
interested to hear both of you guys' opinions
00:20:55.859 --> 00:21:00.200
just on the first MTPJ and orthotics. So say
00:21:00.200 --> 00:21:02.940
if we took our, you know, researcher statistical
00:21:02.940 --> 00:21:06.619
significance hats off and just talked about maybe
00:21:06.619 --> 00:21:09.859
what foot orthotics may or may not be more helpful
00:21:09.859 --> 00:21:13.200
for, we'll say, you know, a reasonably far down
00:21:13.200 --> 00:21:17.720
the road first MTPJ OA with the idea that the
00:21:17.720 --> 00:21:21.160
footwear is, you know, a Brooks ghost, something
00:21:21.160 --> 00:21:25.210
very... normal and, you know, non -offensive.
00:21:26.910 --> 00:21:28.910
My thought would be that, you know, potentially
00:21:28.910 --> 00:21:32.170
a rigid device, Morton's extension or not, even
00:21:32.170 --> 00:21:35.109
just the materials of that where you try and
00:21:35.109 --> 00:21:37.069
bend that device in the sagittal plane and it's
00:21:37.069 --> 00:21:39.210
not really possible compared to, say, a formothotic.
00:21:39.210 --> 00:21:43.210
Obviously, I'm not having a go at the methods,
00:21:43.329 --> 00:21:45.910
but what are your guys' opinions on how that
00:21:45.910 --> 00:21:49.630
works based on your clinical experience and first
00:21:49.630 --> 00:21:51.759
principles thinking? Well, I guess there's a
00:21:51.759 --> 00:21:54.079
couple of things. So as I said, we chose the
00:21:54.079 --> 00:21:58.759
formula based on what people were mostly prescribing.
00:21:59.099 --> 00:22:02.000
But remembering that included New Zealand and
00:22:02.000 --> 00:22:08.019
UK pods. And so that was diluted. I would personally
00:22:08.019 --> 00:22:12.960
mainly use like a stiffer device. If it was end
00:22:12.960 --> 00:22:15.140
stage or towards end stage, like you mentioned,
00:22:15.180 --> 00:22:18.079
Darcy, I think I'd be much more likely to use
00:22:18.079 --> 00:22:21.490
an extension. And then, of course, we've got,
00:22:21.490 --> 00:22:24.450
you know, Shannon Montanew and Hilton Men's simple
00:22:24.450 --> 00:22:27.049
trial, which looked at shoe stiffened inserts.
00:22:27.650 --> 00:22:30.730
And they did actually find an improvement, whereas
00:22:30.730 --> 00:22:37.569
we didn't. So, yes. Well, what I would do, I
00:22:37.569 --> 00:22:40.269
never prescribe anything straight away. I never,
00:22:40.369 --> 00:22:43.630
ever. Very, very rarely. So what I would probably
00:22:43.630 --> 00:22:46.849
do is try a bunch of stuff first. I'd tape them
00:22:46.849 --> 00:22:50.380
up, a pad, you know. with and without combination
00:22:50.380 --> 00:22:53.000
of their footwear. And normally I do that over
00:22:53.000 --> 00:22:55.220
a couple of weeks and we find the best combination
00:22:55.220 --> 00:22:57.900
and then I'd make something up. Yeah, sure. I
00:22:57.900 --> 00:23:00.200
think I'd do a similar approach, really lean
00:23:00.200 --> 00:23:02.339
on the shoes. And I always will try and like
00:23:02.339 --> 00:23:06.200
heavily mobilize some of those stiff first MTBJs
00:23:06.200 --> 00:23:09.519
as well. Sometimes the capsular thickening and
00:23:09.519 --> 00:23:12.140
stiffness there I've found to be a limiting factor
00:23:12.140 --> 00:23:14.339
and getting that moving actually pretty helpful.
00:23:15.190 --> 00:23:17.390
And again, an excellent point. And it's something
00:23:17.390 --> 00:23:19.390
we haven't talked about is that, you know, and
00:23:19.390 --> 00:23:21.730
I'm sure like both of you and most people listening
00:23:21.730 --> 00:23:23.990
would never just give a device either. You sort
00:23:23.990 --> 00:23:27.410
of do that as a multimodal program. And in actual
00:23:27.410 --> 00:23:32.289
fact, that survey and then the focus group, we
00:23:32.289 --> 00:23:37.029
did put together a full program. So although
00:23:37.029 --> 00:23:39.410
the LARD clinical trial just tested the footwear
00:23:39.410 --> 00:23:42.960
orthosis component. We did run a pilot study
00:23:42.960 --> 00:23:45.880
at the time as well. And the pilot study combined
00:23:45.880 --> 00:23:48.700
exercise, mobilization, like you said, which
00:23:48.700 --> 00:23:52.799
I do do, and I'll teach the patient to do it
00:23:52.799 --> 00:23:56.480
themselves. We had footwear, we had the orthoses,
00:23:56.579 --> 00:23:59.920
and then we had a bunch of education, load modification
00:23:59.920 --> 00:24:04.059
stuff. And so we ran that as a pilot versus GP.
00:24:05.640 --> 00:24:08.500
care and the gp care was based on another study
00:24:08.500 --> 00:24:11.900
that we had done which was looking at general
00:24:11.900 --> 00:24:14.740
practice consultations from 2010 to 2016 and
00:24:14.740 --> 00:24:18.079
seeing what they most commonly did and as i'm
00:24:18.079 --> 00:24:19.920
sure you can guess they most commonly prescribed
00:24:19.920 --> 00:24:24.640
medication even if the patient was new and in
00:24:24.640 --> 00:24:27.460
fact Again, from memory, I think they prescribed
00:24:27.460 --> 00:24:31.099
opioids almost as much as they referred to a
00:24:31.099 --> 00:24:34.099
podiatrist or a physiotherapist, which is just
00:24:34.099 --> 00:24:38.339
super scary. And that's changed. But point being,
00:24:38.480 --> 00:24:42.980
yeah, so we do use all of these approaches. And
00:24:42.980 --> 00:24:45.640
we did run that pilot study and we put in for
00:24:45.640 --> 00:24:48.579
a grant and we haven't been successful. I think
00:24:48.579 --> 00:24:51.700
I put that grant in about three times. Yeah,
00:24:51.720 --> 00:24:53.160
the government won't fund it, unfortunately.
00:24:53.380 --> 00:24:57.460
Or I'm writing bad grants. Both probably true.
00:24:58.019 --> 00:25:02.019
Kate, I'd like to touch on a paper that I think
00:25:02.019 --> 00:25:05.619
you were involved in, but not obviously the main
00:25:05.619 --> 00:25:09.559
contributors, the 2025 Delphi paper on the consensus
00:25:09.559 --> 00:25:11.279
-based guidelines for intervention protocols
00:25:11.279 --> 00:25:13.799
targeting the foot spring mechanism during landing.
00:25:14.900 --> 00:25:17.700
I guess... I'm a bit of a dreamer in a sense
00:25:17.700 --> 00:25:20.180
that when I see some really cool papers, I try
00:25:20.180 --> 00:25:22.700
to link it in with other research and then see
00:25:22.700 --> 00:25:25.180
if I can combine it into a super hypothesis,
00:25:25.359 --> 00:25:27.960
right? Which is probably why I've never been
00:25:27.960 --> 00:25:30.140
a researcher because I probably ask too many
00:25:30.140 --> 00:25:33.119
big questions, not enough specific ones. But
00:25:33.119 --> 00:25:37.259
basically that paper was talking about storing
00:25:37.259 --> 00:25:40.420
and releasing energy through arch deformation
00:25:40.420 --> 00:25:44.559
and recoil. How do you think that... affects
00:25:44.559 --> 00:25:47.359
the pathogenesis of first metastatic joint osteoarthritis
00:25:47.359 --> 00:25:49.740
given that prevention is probably better than
00:25:49.740 --> 00:25:53.220
reaction yeah good good question lots of good
00:25:53.220 --> 00:25:56.420
questions um yeah that that paper by i think
00:25:56.420 --> 00:26:00.299
i can't remember how to pronounce this yes yes
00:26:00.299 --> 00:26:03.759
um who just did a brilliant job on that you know
00:26:03.759 --> 00:26:06.900
that was wrangling a bunch of us sheep trying
00:26:06.900 --> 00:26:09.940
to you know get sorry i should say cats wrangling
00:26:09.940 --> 00:26:13.160
cats um these these large kind of they're called
00:26:13.160 --> 00:26:15.539
delphi studies where you try and get agreements
00:26:15.539 --> 00:26:19.299
they're very very difficult to do um and to get
00:26:19.299 --> 00:26:21.779
everybody sort of moving in the same direction
00:26:21.779 --> 00:26:25.640
um so so well done on that paper i yeah i was
00:26:25.640 --> 00:26:27.819
wasn't my paper i was involved but um yeah it
00:26:27.819 --> 00:26:30.200
was their project and they did a great job um
00:26:31.130 --> 00:26:33.309
do i think well i guess you've got two things
00:26:33.309 --> 00:26:35.349
right so with with the foot spring that we all
00:26:35.349 --> 00:26:39.750
now learn and like and um you're getting you're
00:26:39.750 --> 00:26:42.250
getting that deformation with loads it's storing
00:26:42.250 --> 00:26:44.549
storing the elastic energy which is released
00:26:44.549 --> 00:26:47.569
as we move into propulsion and it helps with
00:26:47.569 --> 00:26:51.289
propulsion right so so you improve that energy
00:26:51.289 --> 00:26:55.789
storage and release you improve hopefully propulsion
00:26:55.789 --> 00:26:59.619
it's also a two -way street So if you've got
00:26:59.619 --> 00:27:05.359
an osteoarthritic first MTP, that can really
00:27:05.359 --> 00:27:09.259
hamper, I guess, that propulsive and energy release.
00:27:10.859 --> 00:27:13.059
But I think you used the word prevention. Was
00:27:13.059 --> 00:27:15.720
that right, Pat? Yeah. Well, I guess preventing
00:27:15.720 --> 00:27:17.599
would save the health system a lot more money
00:27:17.599 --> 00:27:20.839
than treating, right? Yeah. Yeah. And I think
00:27:20.839 --> 00:27:24.140
that's a really good perspective and approach.
00:27:25.000 --> 00:27:27.099
You know, we should be trying to get these people
00:27:27.099 --> 00:27:31.160
early and using some of these exercise approaches
00:27:31.160 --> 00:27:36.680
that target these particular mechanisms. You
00:27:36.680 --> 00:27:39.619
know, essentially that whole thing is like a
00:27:39.619 --> 00:27:42.240
stretch shortening cycle, which we've all learnt,
00:27:42.440 --> 00:27:47.599
where the muscle fibres are shortening and storing
00:27:47.599 --> 00:27:49.779
that energy, which is released upon lengthening.
00:27:49.900 --> 00:27:53.380
And, you know, those approaches we can... We
00:27:53.380 --> 00:27:55.079
know how to capture them. We know how to improve
00:27:55.079 --> 00:27:57.900
them. And so early on in the disease process,
00:27:58.059 --> 00:28:02.319
if you're able to improve propulsion, you know,
00:28:02.319 --> 00:28:06.400
you keep the person moving. Hopefully it is keeping
00:28:06.400 --> 00:28:08.779
the joint healthy, which goes back to Darcy's
00:28:08.779 --> 00:28:12.079
point earlier around the joint capsule. You know,
00:28:12.099 --> 00:28:13.779
if you're keeping it moving well, you're keeping
00:28:13.779 --> 00:28:16.759
that capsule hopefully healthy, stimulating synovial
00:28:16.759 --> 00:28:20.119
fluid production. So keeping the internal environment
00:28:20.119 --> 00:28:23.849
of the joint healthy as well. I don't know if
00:28:23.849 --> 00:28:26.730
I've answered your question. I've spoken, but
00:28:26.730 --> 00:28:30.529
I don't know if I've answered it. Yeah, so I
00:28:30.529 --> 00:28:32.029
think there's potentially a role. I think we
00:28:32.029 --> 00:28:33.849
also do need to be a little bit careful, though,
00:28:33.890 --> 00:28:37.309
because, you know, if the joint is really stiffening
00:28:37.309 --> 00:28:43.150
up, we do run the potential of losing that component
00:28:43.150 --> 00:28:48.529
of the foot spring. And, you know, maybe that
00:28:48.529 --> 00:28:51.069
is where we lean a little bit more towards the
00:28:51.069 --> 00:28:53.269
rocker shoe approach or something like that.
00:28:54.109 --> 00:28:56.509
Probably another thing is that people can just
00:28:56.509 --> 00:28:58.730
be very unlucky, can't they? Just with the morphology
00:28:58.730 --> 00:29:01.069
of their forefoot, just with the relative lengths
00:29:01.069 --> 00:29:03.309
of the first and second metatarsal and toes and
00:29:03.309 --> 00:29:06.430
things. And I guess there's a spectrum of people,
00:29:06.509 --> 00:29:08.730
you know, obviously from being more. flexible
00:29:08.730 --> 00:29:11.670
they can have their own first mtpj problems bunions
00:29:11.670 --> 00:29:13.930
and things and i guess the people that are just
00:29:13.930 --> 00:29:17.190
stiff everywhere all the time and their their
00:29:17.190 --> 00:29:19.490
joints don't move much to begin with and just
00:29:19.490 --> 00:29:23.210
get uh just reduce faster and faster and we i
00:29:23.210 --> 00:29:25.390
don't know we keep those people comfortable some
00:29:25.390 --> 00:29:27.150
of them that it's sort of just going to happen
00:29:27.150 --> 00:29:29.190
anyway to a lot of those people isn't it we can
00:29:29.190 --> 00:29:32.180
try our best though Absolutely. Yeah, absolutely.
00:29:32.420 --> 00:29:34.720
And so, you know, if we're finding that the first
00:29:34.720 --> 00:29:38.500
MTP is stiff and other aspects are stiff, you
00:29:38.500 --> 00:29:41.059
know, it doesn't reduce the importance of physical
00:29:41.059 --> 00:29:43.720
activity in our role in promoting physical activity
00:29:43.720 --> 00:29:46.720
because, you know, you don't have to just strengthen
00:29:46.720 --> 00:29:50.059
the foot to get the benefits of strength exercise.
00:29:50.359 --> 00:29:53.000
You can strengthen other aspects of the body
00:29:53.000 --> 00:29:56.700
and we do have these, you know, very systemic.
00:29:57.420 --> 00:30:00.240
well -documented systemic benefits of exercise
00:30:00.240 --> 00:30:04.720
that can help the big toe as well as the rest
00:30:04.720 --> 00:30:09.559
of the body. And we know that there are, for
00:30:09.559 --> 00:30:14.000
example, remote pain -relieving effects of systemic
00:30:14.000 --> 00:30:17.579
or general exercise that can help systemically
00:30:17.579 --> 00:30:22.980
as well. So if someone's toe is super stiff and
00:30:22.980 --> 00:30:25.170
so they can't bend it and... you know, limits
00:30:25.170 --> 00:30:27.710
your ability, I don't know, to prescribe plyometrics
00:30:27.710 --> 00:30:30.069
or whatever it might be, you know, prescribe
00:30:30.069 --> 00:30:32.130
other exercise that they can do. How have you
00:30:32.130 --> 00:30:35.990
gone with the footballers and first MTBJ pain?
00:30:36.049 --> 00:30:39.089
I guess that'd be a pretty tricky one. I get
00:30:39.089 --> 00:30:43.369
stomped on and narrow boots. Oh, stomping Darcy.
00:30:43.549 --> 00:30:46.390
It's like you get someone, you try all of this
00:30:46.390 --> 00:30:50.130
stuff and, you know, I've had one recently that's
00:30:50.130 --> 00:30:52.349
been pretty creative and I'm like, yeah, I've
00:30:52.349 --> 00:30:55.079
done a really good job here. pat myself on the
00:30:55.079 --> 00:30:56.960
back i've had a couple of people help me with
00:30:56.960 --> 00:30:59.980
it tom braff and sam turner and you know look
00:30:59.980 --> 00:31:02.180
how good we are and then bang he goes and plays
00:31:02.180 --> 00:31:06.339
and someone steps on it you're right back so
00:31:06.339 --> 00:31:09.740
actually i heard em uh emma pointed in your in
00:31:09.740 --> 00:31:12.920
your last podcast talk about she'd love to do
00:31:12.920 --> 00:31:17.200
a study um on the prevalence of first mtp problems
00:31:17.200 --> 00:31:21.099
in in this population and Em, if you ever listen
00:31:21.099 --> 00:31:23.319
to this, shoot me a text. I reckon that would
00:31:23.319 --> 00:31:26.400
be a great study. You do see it quite a bit.
00:31:26.400 --> 00:31:29.200
You're right, Darcy. It does appear to be common.
00:31:30.319 --> 00:31:32.220
And I think, you know, I think we are good at
00:31:32.220 --> 00:31:37.519
managing the mechanics. You know, it hurts with
00:31:37.519 --> 00:31:40.079
propulsion. Okay. So we, you know, if we need
00:31:40.079 --> 00:31:42.420
to, we can stiffen that up. We'd rather not,
00:31:42.480 --> 00:31:45.440
but if we have to. But it also hurts with kicking.
00:31:45.640 --> 00:31:47.559
You're like, oh, God. Okay. So then you sort
00:31:47.559 --> 00:31:51.170
of deal with that. And then, yeah, as I said,
00:31:51.190 --> 00:31:53.130
someone stomps on it and all your good work's
00:31:53.130 --> 00:31:56.670
undone. If we hop a bit more laterally to some
00:31:56.670 --> 00:31:59.549
of the other content that you've published over
00:31:59.549 --> 00:32:03.329
the years, in 2022 you had that article cutting
00:32:03.329 --> 00:32:05.170
through the hype on platelet -rich plasma. Can
00:32:05.170 --> 00:32:09.849
you tell us more about that paper? Yeah, Hype
00:32:09.849 --> 00:32:13.670
or Hope, the platelet -rich plasma study. certainly
00:32:13.670 --> 00:32:16.369
been the the biggest study i've ever been involved
00:32:16.369 --> 00:32:18.710
with and i was lucky to to run that trial it
00:32:18.710 --> 00:32:21.289
was really complex based out of melbourne and
00:32:21.289 --> 00:32:26.349
sydney um and in fact for for you know early
00:32:26.349 --> 00:32:30.549
early career practitioners um we started that
00:32:30.549 --> 00:32:33.309
study myself and the sports doc in our clinic
00:32:33.309 --> 00:32:36.289
we had no budget um he was treating people with
00:32:36.289 --> 00:32:40.230
prp and we thought um how cool to run a little
00:32:41.100 --> 00:32:43.960
small randomized controlled trial and so we sort
00:32:43.960 --> 00:32:48.180
of got some ethics and we um yeah had had a bunch
00:32:48.180 --> 00:32:50.900
of people that were happy to to receive placebo
00:32:50.900 --> 00:32:53.599
if at the end of the trial they got prp as well
00:32:53.599 --> 00:32:55.799
and so we did a little pilot study and it got
00:32:55.799 --> 00:32:58.400
published and when i moved across to university
00:32:58.400 --> 00:33:02.319
of melbourne um the director of our center professor
00:33:02.319 --> 00:33:05.880
kim thought why don't we do a big scale version
00:33:05.880 --> 00:33:08.660
of that so she put in for a large grant and got
00:33:08.660 --> 00:33:11.900
that and we did the trial and um yeah it was
00:33:11.900 --> 00:33:16.299
it was really exciting to be involved in um And
00:33:16.299 --> 00:33:19.700
we knew we'd get a lot of pushback at the end
00:33:19.700 --> 00:33:21.799
of the trial if we didn't find a difference.
00:33:21.960 --> 00:33:24.960
And spoiler alert, that's what we found. We found
00:33:24.960 --> 00:33:30.039
that the placebo group improved, but so did the
00:33:30.039 --> 00:33:33.480
PRP group. And the improvements weren't different
00:33:33.480 --> 00:33:35.599
between the two groups. So that meant. whether
00:33:35.599 --> 00:33:38.599
you got placebo or PRP, it didn't really matter.
00:33:38.940 --> 00:33:42.240
You still improved. And interestingly, you improved
00:33:42.240 --> 00:33:45.099
above what we call a minimal clinically important
00:33:45.099 --> 00:33:48.000
difference. So that's the pain improvements that's
00:33:48.000 --> 00:33:52.279
meaningful for that person. So both groups improved
00:33:52.279 --> 00:33:56.200
above that. There could be a lot of reasons for
00:33:56.200 --> 00:34:00.460
that. It could be that saline injections, which
00:34:00.460 --> 00:34:04.250
was our placebo. are a treatment and there's
00:34:04.250 --> 00:34:06.809
there's a body of research that actually supports
00:34:06.809 --> 00:34:09.710
that we're not exactly sure why and if there's
00:34:09.710 --> 00:34:12.769
independent of the you know the so -called placebo
00:34:12.769 --> 00:34:15.449
or contextual effects we're actually injecting
00:34:15.449 --> 00:34:18.909
saline into a joint um can have therapeutic benefits
00:34:18.909 --> 00:34:23.489
um so whether it's that whether it's that our
00:34:23.489 --> 00:34:28.500
particular prp preparation wasn't a good prp
00:34:28.500 --> 00:34:31.300
preparation and god knows like the orthoses we've
00:34:31.300 --> 00:34:34.599
we've received a lot of quote unquote advice
00:34:34.599 --> 00:34:37.980
on on the fact that our prp wasn't the one that
00:34:37.980 --> 00:34:41.260
they would use um so yeah it could it could be
00:34:41.260 --> 00:34:43.260
either of those things or it could just be that
00:34:43.260 --> 00:34:47.340
the prp is not effective with the with the prp
00:34:47.340 --> 00:34:49.860
and the and the dose there of the platelets so
00:34:49.860 --> 00:34:52.639
um like i think some of the more successful studies
00:34:52.639 --> 00:34:54.940
have sort of got the the total platelets you
00:34:54.940 --> 00:34:57.469
know per injection up towards like yeah eight
00:34:57.469 --> 00:35:01.030
to ten thousand correct me if i'm wrong was the
00:35:01.030 --> 00:35:04.829
regen one more like two to three thousand was
00:35:04.829 --> 00:35:08.230
that so yeah that's that absolutely correct darcy
00:35:08.230 --> 00:35:10.929
and so at the time when we were designing the
00:35:10.929 --> 00:35:15.139
study the definition of platelet rich plasma
00:35:15.139 --> 00:35:19.280
was anything above circulating volumes of platelets
00:35:19.280 --> 00:35:22.400
but it sort of got narrowed down to a minimum
00:35:22.400 --> 00:35:25.039
of two times your circulating volume at least
00:35:25.039 --> 00:35:28.679
and up so based on that we had a few different
00:35:28.679 --> 00:35:30.900
options there were a few products on the market
00:35:30.900 --> 00:35:34.840
whose published data suggested they were more
00:35:34.840 --> 00:35:37.980
than two times the volume including the one that
00:35:37.980 --> 00:35:40.780
we used from regen labs there was home cooked
00:35:40.780 --> 00:35:43.940
prp which is a pretty effective way at concentrating
00:35:45.329 --> 00:35:47.769
In the end, we went with the kit and we went
00:35:47.769 --> 00:35:50.309
with the kit for a couple of reasons. It was
00:35:50.309 --> 00:35:53.050
very commonly used in Australia at the time by
00:35:53.050 --> 00:35:58.630
sports docs and radiologists. It was standardised,
00:35:58.650 --> 00:36:01.070
whereas, you know, home cooked, it's quite difficult
00:36:01.070 --> 00:36:03.550
to standardise. So we sort of early on leaned
00:36:03.550 --> 00:36:07.250
towards doing a kit. And then we reached out
00:36:07.250 --> 00:36:10.809
to a few different companies and... Regen were
00:36:10.809 --> 00:36:13.150
the first to come back and say that they would
00:36:13.150 --> 00:36:15.650
be happy for us to use their product. And I should
00:36:15.650 --> 00:36:18.550
say they didn't give us any money at all. We
00:36:18.550 --> 00:36:23.309
just received the kits. We ran into a problem
00:36:23.309 --> 00:36:25.190
early on in that study. I don't know if this
00:36:25.190 --> 00:36:28.809
is of interest or not, but the kit somehow, when
00:36:28.809 --> 00:36:31.469
you concentrate the platelets, does something
00:36:31.469 --> 00:36:34.690
called aggregation. And that means the platelets
00:36:34.690 --> 00:36:36.849
themselves are quite sticky. And when you spin
00:36:36.849 --> 00:36:39.250
them around, they stick together and they aggregate.
00:36:39.719 --> 00:36:42.440
And we could actually see this early on when
00:36:42.440 --> 00:36:47.460
we were practising the protocol. Yeah, I sort
00:36:47.460 --> 00:36:50.679
of had probably about 10 litres of blood drained
00:36:50.679 --> 00:36:54.360
from me over the piloting of that study. But,
00:36:54.380 --> 00:36:58.610
yeah, we saw these platelet aggregates. That
00:36:58.610 --> 00:37:01.230
meant it was very, very difficult for us to count
00:37:01.230 --> 00:37:03.349
the platelet concentration. We'd put it in the
00:37:03.349 --> 00:37:05.550
platelet counter and it would just come back
00:37:05.550 --> 00:37:08.389
with ridiculously low values, like, you know,
00:37:08.389 --> 00:37:12.070
not physiological values. And we reached out
00:37:12.070 --> 00:37:15.230
to the company and they said that counting doesn't
00:37:15.230 --> 00:37:18.369
work in that manner, but the platelets disaggregate
00:37:18.369 --> 00:37:20.590
once you inject them in. And we were like, okay.
00:37:21.309 --> 00:37:24.210
So we went ahead and we used that particular
00:37:24.210 --> 00:37:29.880
product. One of the downsides of that study was
00:37:29.880 --> 00:37:31.800
that we couldn't, as I said, we couldn't actually
00:37:31.800 --> 00:37:34.400
count what we were putting into people and we
00:37:34.400 --> 00:37:37.400
had to rely on company data, which you correct
00:37:37.400 --> 00:37:41.239
us, it was two to three times concentration factor.
00:37:41.460 --> 00:37:44.480
What we did do though, and we could do, was we
00:37:44.480 --> 00:37:48.400
could measure the growth factors. And what we
00:37:48.400 --> 00:37:52.139
were able to show is what we injected was very
00:37:52.139 --> 00:37:58.280
high. in concentrations of growth factors, stem
00:37:58.280 --> 00:38:01.639
cell differentiation cells, but it was also very
00:38:01.639 --> 00:38:05.559
low in things like pro -inflammatory cytokines.
00:38:05.719 --> 00:38:08.380
So it had all of the good stuff and it was pretty
00:38:08.380 --> 00:38:12.639
low in the bad stuff, like quite marked. And
00:38:12.639 --> 00:38:15.780
certainly the growth factors, the high and low
00:38:15.780 --> 00:38:18.380
ones in the correct direction were all within
00:38:18.380 --> 00:38:23.099
the range that was recommended. We got criticised
00:38:23.099 --> 00:38:26.619
afterwards. Well, people misread the table, firstly.
00:38:27.619 --> 00:38:31.179
The platelet concentration they took was the
00:38:31.179 --> 00:38:34.039
person's platelet concentration, not the PRP's,
00:38:34.099 --> 00:38:36.579
but that's a whole other story. So we did get
00:38:36.579 --> 00:38:38.780
criticised for that and we got criticised that,
00:38:38.860 --> 00:38:41.159
you know, the platelet concentration is much
00:38:41.159 --> 00:38:46.019
higher or should have been much higher. But,
00:38:46.099 --> 00:38:48.159
you know, our argument to that was twofold. One.
00:38:48.590 --> 00:38:51.409
Well, it was certainly showing the growth factors
00:38:51.409 --> 00:38:55.289
that it should have showed for PRP. And two,
00:38:55.550 --> 00:38:58.190
in terms of higher concentrations, that wasn't
00:38:58.190 --> 00:39:00.510
really the norm when we started the trial. Things
00:39:00.510 --> 00:39:03.989
sort of moved. And now I've seen the latest systematic
00:39:03.989 --> 00:39:06.369
reviews sort of showing, yeah, like you said,
00:39:06.409 --> 00:39:09.210
very high, like six, eight times concentrations
00:39:09.210 --> 00:39:12.829
of platelets. And yeah, we called that trial,
00:39:13.030 --> 00:39:15.210
we called Restore. And I've just reached out.
00:39:15.519 --> 00:39:18.380
Said we should do a restore more, which is a
00:39:18.380 --> 00:39:23.380
higher concentration. I don't know if that'll
00:39:23.380 --> 00:39:27.159
fly though. But yeah, it was an interesting trial.
00:39:27.239 --> 00:39:29.019
I think at the end of the day, it reflected clinical
00:39:29.019 --> 00:39:33.539
practice. And so I was happy with that. No, definitely.
00:39:34.230 --> 00:39:36.170
because it was a very tight trial and it was
00:39:36.170 --> 00:39:38.269
using, you know, something that you could standardise
00:39:38.269 --> 00:39:41.630
in the RegenLab product. Yeah, future research,
00:39:41.690 --> 00:39:43.530
if it does, you know, turn out that a larger
00:39:43.530 --> 00:39:44.969
trial, I think a couple of them are looking,
00:39:45.010 --> 00:39:47.130
you know, somewhat promising that have compared,
00:39:47.230 --> 00:39:49.389
you know, low, medium and high doses that the,
00:39:49.389 --> 00:39:52.789
you know, effect size or scale across the platelet
00:39:52.789 --> 00:39:55.829
dose, essentially. At least then we've got a
00:39:55.829 --> 00:39:58.250
baseline for what doesn't work and if things
00:39:58.250 --> 00:40:00.920
work in the future. But I guess it'd be... Like
00:40:00.920 --> 00:40:05.199
anything else with the PRP, the exact person
00:40:05.199 --> 00:40:08.019
is going to be quite different. Like I don't
00:40:08.019 --> 00:40:10.420
really know, but I would imagine that, you know,
00:40:10.440 --> 00:40:13.659
25 -year -olds platelets and growth factors would
00:40:13.659 --> 00:40:17.280
be profoundly more helpful at healing things
00:40:17.280 --> 00:40:20.019
than, you know, a 75 -year -old person wants
00:40:20.019 --> 00:40:22.019
you to take their own blood and put it back in.
00:40:22.059 --> 00:40:23.920
It's probably going to have an impact too, right?
00:40:24.739 --> 00:40:27.820
Well, that's absolutely spot on. And, you know,
00:40:27.820 --> 00:40:31.380
they saw it with my blood versus one of our research
00:40:31.380 --> 00:40:33.559
assistants' blood who's younger and bitter and
00:40:33.559 --> 00:40:36.000
had a much higher concentration. So you're spot
00:40:36.000 --> 00:40:37.500
on. And that's, you know, that's where the stem
00:40:37.500 --> 00:40:39.880
cell world's moving to. You know, you can get
00:40:39.880 --> 00:40:42.079
autologous stem cells, but you get these expanded
00:40:42.079 --> 00:40:45.460
stem cell lines now where they get fit, young,
00:40:45.480 --> 00:40:48.699
healthy people and get their stem cells. And
00:40:48.699 --> 00:40:51.320
then they expand lines of those and get a very
00:40:51.320 --> 00:40:54.079
high. concentration and so you get injected with
00:40:54.079 --> 00:40:58.820
someone who has better cells than you um yeah
00:40:58.820 --> 00:41:01.179
so we'll see if we'll see if that works but um
00:41:01.179 --> 00:41:04.820
yeah yeah i don't know i would genuinely i mean
00:41:04.820 --> 00:41:07.119
we've we've probably got enough studies now the
00:41:07.119 --> 00:41:09.019
problem is most of the studies are really low
00:41:09.019 --> 00:41:11.619
quality um i don't know if we want to get into
00:41:11.619 --> 00:41:14.019
that or not but yeah a lot like i would say the
00:41:14.019 --> 00:41:17.639
majority by far are low quality studies um yeah
00:41:17.639 --> 00:41:19.860
when we at this stage when we look at the high
00:41:19.860 --> 00:41:23.530
quality studies um The evidence isn't great,
00:41:23.670 --> 00:41:26.050
but I don't know that we've got enough high quality
00:41:26.050 --> 00:41:29.329
studies of high concentrations. And I think that
00:41:29.329 --> 00:41:31.150
would be, yeah, that would be really interesting.
00:41:31.530 --> 00:41:33.469
Yeah, I think a lot of the studies are currently
00:41:33.469 --> 00:41:36.690
low impact factor at this point in time. Yeah,
00:41:36.750 --> 00:41:39.469
but they've got really high bias. So we were
00:41:39.469 --> 00:41:43.900
at pains to blind the. patients and the treating
00:41:43.900 --> 00:41:46.300
doctors we did a bunch of different things to
00:41:46.300 --> 00:41:49.280
try you know figure out how we were best to blind
00:41:49.280 --> 00:41:54.300
them and in the end we used tubes that had like
00:41:54.300 --> 00:41:56.760
an opaque needle base so you couldn't see the
00:41:56.760 --> 00:42:00.079
darker color the needle itself was wrapped in
00:42:00.079 --> 00:42:04.969
a generic label The blood was taken out by the
00:42:04.969 --> 00:42:07.269
radiologist. The nurse took it into another room,
00:42:07.329 --> 00:42:09.170
stayed in that room for five minutes and either
00:42:09.170 --> 00:42:12.349
centrifuged or didn't centrifuge and then brought
00:42:12.349 --> 00:42:15.369
that needle back into the doctor. We asked both.
00:42:15.570 --> 00:42:18.510
There's a special survey. I won't go into it,
00:42:18.550 --> 00:42:20.849
but it's a blinding index to see if the patients
00:42:20.849 --> 00:42:23.269
and the treating doctor was blinded and they
00:42:23.269 --> 00:42:27.150
both were blinded. And so these other studies,
00:42:27.170 --> 00:42:29.989
Pat, they... They either don't mention their
00:42:29.989 --> 00:42:32.190
blinding process, they might just say it's blinded,
00:42:32.190 --> 00:42:35.829
they don't describe it, or they don't blind either.
00:42:36.349 --> 00:42:39.190
Yeah. It was funny, though, just a super quick
00:42:39.190 --> 00:42:41.349
anecdote. When we were trying to come up with
00:42:41.349 --> 00:42:44.969
the way to blind the needle, I did all of this
00:42:44.969 --> 00:42:47.949
research and I found these black syringes. And
00:42:47.949 --> 00:42:51.110
I'm like, oh, that's cool. So I went to our doctor
00:42:51.110 --> 00:42:53.730
and he's like, no, don't use that. He said, black
00:42:53.730 --> 00:42:56.010
hurts. Whatever you do, don't give them black
00:42:56.010 --> 00:43:00.960
needles. So we didn't end up with black needles.
00:43:02.579 --> 00:43:05.480
Kate, throughout your career, you've done a lot
00:43:05.480 --> 00:43:08.119
of impact -based research and obviously quite
00:43:08.119 --> 00:43:11.119
a good clinician as well. Talk to us more about
00:43:11.119 --> 00:43:13.360
stepping into the role as the president of SEPA.
00:43:13.800 --> 00:43:17.639
Has that obviously changed how you think about
00:43:17.639 --> 00:43:19.780
the profession or has that kind of enhanced how
00:43:19.780 --> 00:43:22.500
you think about the profession? And I guess talk
00:43:22.500 --> 00:43:24.659
to us about some of the responsibilities that
00:43:24.659 --> 00:43:26.420
come with your leadership at the national level.
00:43:27.840 --> 00:43:34.079
Thanks, Pat. I've loved it. Has it changed my
00:43:34.079 --> 00:43:38.019
perception? You get a real window into what people
00:43:38.019 --> 00:43:41.360
are doing around the country and, you know, our
00:43:41.360 --> 00:43:44.440
members are just doing such wonderful work and,
00:43:44.500 --> 00:43:48.360
you know, our executive officer, Sophie, is now
00:43:48.360 --> 00:43:50.119
starting to highlight some of the stuff that
00:43:50.119 --> 00:43:52.079
people are doing and I think that's been a really
00:43:52.079 --> 00:43:55.840
good initiative to put in our e -news. I've loved
00:43:55.840 --> 00:43:57.960
that she's sort of getting that, you know, our
00:43:57.960 --> 00:44:00.000
board members will often send things in that
00:44:00.000 --> 00:44:03.059
people they know that they're doing. And it's,
00:44:03.059 --> 00:44:05.639
you know, it's been really rewarding to see that.
00:44:06.219 --> 00:44:09.179
Our group is just, it's so funny, whenever we
00:44:09.179 --> 00:44:13.179
get outsiders, normally speakers, they're just
00:44:13.179 --> 00:44:16.780
amazed at the sense of culture and community
00:44:16.780 --> 00:44:20.639
that we have. And I think we, well, not me, but
00:44:20.639 --> 00:44:23.480
I think people that don't go to a lot of conferences,
00:44:24.190 --> 00:44:27.210
um you know professional or academic don't really
00:44:27.210 --> 00:44:31.210
know how unique cpa is and and i don't want to
00:44:31.210 --> 00:44:33.389
say this as as the president i want to say this
00:44:33.389 --> 00:44:36.110
is a person that's been to all of these conferences
00:44:36.110 --> 00:44:39.530
and just it's just it's totally different it's
00:44:39.530 --> 00:44:43.190
it's just fun and it's supportive and you know
00:44:43.190 --> 00:44:46.670
yeah we all learn as well um it's it's really
00:44:46.670 --> 00:44:50.460
really interactive um You know, we're all just
00:44:50.460 --> 00:44:52.840
peers at the end of the day, learning from each
00:44:52.840 --> 00:44:56.599
other and trying to improve our practice for
00:44:56.599 --> 00:44:59.639
our patients. So I think taking on the role,
00:44:59.860 --> 00:45:04.480
seeing that has been awesome. Anyone that turns
00:45:04.480 --> 00:45:08.420
up to the AGM at the SMA conference every year
00:45:08.420 --> 00:45:12.820
will hear me say every time. that that our board
00:45:12.820 --> 00:45:15.940
is just outstanding and i can't sort of not mention
00:45:15.940 --> 00:45:18.480
it again you know we're all we're volunteers
00:45:18.480 --> 00:45:20.840
and it does it takes up a lot of time you know
00:45:20.840 --> 00:45:23.340
dan banana has organized a huge conference and
00:45:23.340 --> 00:45:26.900
he's had help um from you know from hayley and
00:45:26.900 --> 00:45:29.400
from sophie and from from carly and from you
00:45:29.400 --> 00:45:32.179
know a bunch of others um but you know that's
00:45:32.179 --> 00:45:33.920
that's difficult to do and he's not getting paid
00:45:33.920 --> 00:45:37.960
to do that So there's a lot of work behind the
00:45:37.960 --> 00:45:41.059
scenes as well from these amazing board directors.
00:45:41.440 --> 00:45:44.579
And I'm just really, really fortunate to have
00:45:44.579 --> 00:45:49.559
them all and them all contributing. So it's been,
00:45:49.639 --> 00:45:51.519
yeah, it's been a really rewarding experience
00:45:51.519 --> 00:45:54.619
and it's been really promising. Actually, just
00:45:54.619 --> 00:45:56.320
the other thing, I guess, is the trajectory,
00:45:56.480 --> 00:45:58.659
just seeing it grow, like going from being a
00:45:58.659 --> 00:46:03.500
member myself early on to then. being asked uh
00:46:03.500 --> 00:46:06.980
i started to then yeah joining the board um and
00:46:06.980 --> 00:46:09.420
then now moving into the the presidency we've
00:46:09.420 --> 00:46:11.360
had sort of two strategic reviews in that time
00:46:11.360 --> 00:46:12.840
we've just finished the second one and we'll
00:46:12.840 --> 00:46:15.219
talk about that at the conference the outcomes
00:46:15.219 --> 00:46:17.780
of that seeing the organization grow and do so
00:46:17.780 --> 00:46:21.980
much um yeah that's that's been a really pleasing
00:46:21.980 --> 00:46:27.239
side of being in this role as well where do you
00:46:27.239 --> 00:46:29.119
think the direction of um sports and exercise
00:46:29.119 --> 00:46:32.519
podiatry is moving and Where do you think we
00:46:32.519 --> 00:46:39.059
need to focus our advocacy? It's moving up, that's
00:46:39.059 --> 00:46:43.800
for sure. I think it will be more and more common
00:46:43.800 --> 00:46:49.219
to see a sports podiatrist in clubs other than
00:46:49.219 --> 00:46:53.139
elite clubs. I think at the moment, you know,
00:46:53.159 --> 00:46:56.860
often they'll... the athletes, the players, the
00:46:56.860 --> 00:46:59.039
public, whatever, they'll go and see a podiatrist.
00:46:59.079 --> 00:47:01.340
I think more and more we'll start to see, hopefully,
00:47:01.420 --> 00:47:05.000
podiatrists embedded within some of these clubs
00:47:05.000 --> 00:47:07.820
and some of these organisations. So I think that
00:47:07.820 --> 00:47:14.760
part of things will grow. And I think, yeah,
00:47:15.139 --> 00:47:23.260
I guess the interdisciplinary nature will be
00:47:23.260 --> 00:47:26.900
a really good, consequence of that as well being
00:47:26.900 --> 00:47:30.760
embedded within clubs they will learn kind of
00:47:30.760 --> 00:47:33.599
what we do and and how valuable what we do is
00:47:33.599 --> 00:47:37.380
and we can talk to the snc coaches and help inform
00:47:37.380 --> 00:47:41.760
the foot and ankle strength program we can talk
00:47:41.760 --> 00:47:47.659
to um you know the the boot makers and help modify
00:47:47.659 --> 00:47:50.139
boots or runners or buck or you know whatever
00:47:50.139 --> 00:47:53.300
it is um we've obviously got our first season
00:47:53.300 --> 00:47:56.690
and general footwear skills as well. I think
00:47:56.690 --> 00:48:01.090
them seeing that and how useful it can be, I
00:48:01.090 --> 00:48:03.829
think we'll only see our role grow going forward.
00:48:05.230 --> 00:48:08.530
Fantastic. I guess that takes us to our tech
00:48:08.530 --> 00:48:11.010
and tools spotlight, gateways to innovation.
00:48:11.610 --> 00:48:17.349
Yeah. I thought you liked that one. Yeah, I liked
00:48:17.349 --> 00:48:21.469
it. What tech do you think has generally improved
00:48:21.469 --> 00:48:24.699
musculoskeletal care? in podiatry in recent years?
00:48:26.500 --> 00:48:29.659
The obvious one would be, I think Sam talked
00:48:29.659 --> 00:48:33.980
about this in his interview, is scanners. You
00:48:33.980 --> 00:48:37.099
know, scanners, when I started, it was just plaster
00:48:37.099 --> 00:48:39.840
and God knows I was messy. I'd get more plaster
00:48:39.840 --> 00:48:43.420
on myself and the patient. um their clothes than
00:48:43.420 --> 00:48:45.500
i would have their feet um so sort of moving
00:48:45.500 --> 00:48:47.840
away to that into the you know the slipper sock
00:48:47.840 --> 00:48:50.199
and now into the scanning early on those scanners
00:48:50.199 --> 00:48:51.800
were like twenty thousand dollars i remember
00:48:51.800 --> 00:48:54.000
getting a quote early on in my practice thinking
00:48:54.000 --> 00:48:56.760
like that's just prohibitive so to now be able
00:48:56.760 --> 00:48:59.380
to get these lovely scanners that attach to your
00:48:59.380 --> 00:49:02.420
to your tablet and you know you can scan and
00:49:02.420 --> 00:49:04.500
send it to the lab instantaneously that's been
00:49:04.500 --> 00:49:07.889
i think that's been really valuable um it's something
00:49:07.889 --> 00:49:10.030
that i've loved and you can talk about the pros
00:49:10.030 --> 00:49:11.769
and cons of the different scanners but i think
00:49:11.769 --> 00:49:16.769
overall it's been really valuable um the other
00:49:16.769 --> 00:49:19.789
one you know look not all of us have access to
00:49:19.789 --> 00:49:24.130
it but plant pressure uh you know it's it's so
00:49:24.130 --> 00:49:27.730
so useful like Planted pressure is the output,
00:49:27.849 --> 00:49:30.989
isn't it? And so, you know, you can sort of see
00:49:30.989 --> 00:49:33.230
exactly where forces are going. It's really useful
00:49:33.230 --> 00:49:35.750
for patients as well and athletes as well to
00:49:35.750 --> 00:49:38.809
see that. But to be able to, you know, scan someone
00:49:38.809 --> 00:49:42.369
walking, have a look at their pressure distribution,
00:49:42.730 --> 00:49:45.889
intervene right there and then have a look at
00:49:45.889 --> 00:49:48.869
it again, you know, and then potentially build
00:49:48.869 --> 00:49:51.489
that into something more permanent, like that's
00:49:51.489 --> 00:49:56.519
really powerful. They are still pretty expensive.
00:49:56.820 --> 00:50:00.619
And, you know, do you guys use them? Yeah, I
00:50:00.619 --> 00:50:03.840
am fortunate enough to have the Zebras set up
00:50:03.840 --> 00:50:08.199
in clinic. So, yeah, I use that daily. And like
00:50:08.199 --> 00:50:09.920
you said, the pre and post is super valuable.
00:50:09.960 --> 00:50:14.500
And even just being able to view a pattern, you
00:50:14.500 --> 00:50:16.960
know, just a... common pattern that you would
00:50:16.960 --> 00:50:19.460
see over and over again and then just seeing
00:50:19.460 --> 00:50:22.440
how the the archetype of that pattern changes
00:50:22.440 --> 00:50:24.099
a little bit and then what you might do differently
00:50:24.099 --> 00:50:26.900
and how the different it's just so powerful the
00:50:26.900 --> 00:50:30.860
the um pattern recognition skills over the course
00:50:30.860 --> 00:50:33.780
of using it for you know a year or longer is
00:50:33.780 --> 00:50:38.139
just so powerful yeah yeah i agree yeah i still
00:50:38.139 --> 00:50:41.760
phone box Kade um and actually Our unreleased
00:50:41.760 --> 00:50:44.920
panel special for orthoses was recorded the other
00:50:44.920 --> 00:50:48.019
week. And I did mention something along the lines
00:50:48.019 --> 00:50:50.940
of, do we really accurately capture heel expansion
00:50:50.940 --> 00:50:54.300
with a scanner versus a semi -weight -bearing
00:50:54.300 --> 00:50:57.260
phone box? But that's a hidden trade secret that
00:50:57.260 --> 00:50:59.880
we'll hopefully publish once that episode gets
00:50:59.880 --> 00:51:02.440
released. That's interesting. Yeah, I'll listen
00:51:02.440 --> 00:51:05.320
out for that. Wasn't there a study that did compare?
00:51:06.579 --> 00:51:11.429
There was. I think there was. Yeah. Yeah. And
00:51:11.429 --> 00:51:13.909
I did, yeah, that, you know, the heel expansions
00:51:13.909 --> 00:51:15.849
are really, well, foot expansion really, but
00:51:15.849 --> 00:51:17.969
yeah, heel expansions are really a really good
00:51:17.969 --> 00:51:20.670
one. And we obviously correct for that within
00:51:20.670 --> 00:51:23.150
the software, but do you really correct for it?
00:51:24.409 --> 00:51:27.050
We had this, we had this discussion to death
00:51:27.050 --> 00:51:30.309
last week and yeah, some, some good takes. All
00:51:30.309 --> 00:51:33.710
right. So stay tuned for the orthoses podcast
00:51:33.710 --> 00:51:39.170
episode. We'll be out next week. Look forward
00:51:39.170 --> 00:51:41.630
to it. Let's head into our unpopular opinion
00:51:41.630 --> 00:51:45.050
segments where we go around the country and get
00:51:45.050 --> 00:51:47.309
some unpopular opinions and then debate them
00:51:47.309 --> 00:51:50.530
graciously on our episode. I like this one. This
00:51:50.530 --> 00:51:53.809
is like for any of you that listen to ABC footy,
00:51:53.869 --> 00:51:56.969
like Corbin Middlemass has a flesh it out or
00:51:56.969 --> 00:52:00.110
throw it out. It brings up a controversial. Yeah,
00:52:00.170 --> 00:52:02.449
it's great. It's great. All right. The first
00:52:02.449 --> 00:52:05.190
one, Darcy, we'll start with you. Evidence -based
00:52:05.190 --> 00:52:07.550
practice is often misunderstood in clinical sport.
00:52:08.969 --> 00:52:12.150
Do you think evidence -based is a buzzword? Would
00:52:12.150 --> 00:52:15.610
you like to debate that? I do think it is a little
00:52:15.610 --> 00:52:18.889
bit of a buzzword, to be honest. I think that
00:52:18.889 --> 00:52:21.889
research is very valuable and we need to do more
00:52:21.889 --> 00:52:24.250
of it and we're getting better at it over time.
00:52:24.429 --> 00:52:28.989
But research is not as good at taking complex
00:52:28.989 --> 00:52:31.969
clinical pictures and telling us exactly what
00:52:31.969 --> 00:52:34.289
to do with them. And with most sports, we've
00:52:34.289 --> 00:52:38.039
got a pretty chaotic environment often. a person
00:52:38.039 --> 00:52:40.460
with their own unique challenges, problems, strengths
00:52:40.460 --> 00:52:43.599
and weaknesses. So I think we can't rely too
00:52:43.599 --> 00:52:48.780
much on the research for that. Okay. Yeah, I
00:52:48.780 --> 00:52:51.760
don't know if it's a surprise or not. I agree.
00:52:52.559 --> 00:52:57.159
I think, yeah, I think my academic qualifications
00:52:57.159 --> 00:53:00.820
in the club are almost looked at with disdain
00:53:00.820 --> 00:53:07.079
rather than favour. Yeah. It is. As Darcy said,
00:53:07.179 --> 00:53:09.199
look, it's really hard. You know, it's such a
00:53:09.199 --> 00:53:13.360
nuanced environment that research is really difficult
00:53:13.360 --> 00:53:15.940
to apply a lot of times. You're really dealing
00:53:15.940 --> 00:53:20.420
with, I hate the term, but unicorns. They're
00:53:20.420 --> 00:53:22.980
really, really unique people in a really, really
00:53:22.980 --> 00:53:26.159
unique environment. And, yeah, oftentimes we
00:53:26.159 --> 00:53:31.760
can sort of be maybe evidence informed but not
00:53:31.760 --> 00:53:37.639
evidence based. Number two, pain is an incomplete
00:53:37.639 --> 00:53:39.739
outcome measure in musculoskeletal research.
00:53:39.960 --> 00:53:44.880
So why are we focusing solely on pain when should
00:53:44.880 --> 00:53:47.559
we be measuring performance as the outcome? Darcy?
00:53:49.840 --> 00:53:52.260
I don't know about performance, maybe function.
00:53:52.920 --> 00:53:56.800
Yeah. I guess pain could be an incomplete measure.
00:53:59.059 --> 00:54:04.579
Yeah. I'm not sure how I'll stand to that. I
00:54:04.579 --> 00:54:06.599
agree. I don't know about performance either,
00:54:06.679 --> 00:54:09.840
but I agree that pain doesn't capture, you know,
00:54:09.840 --> 00:54:13.400
and when you work in sport at all levels, really,
00:54:13.480 --> 00:54:16.840
you get people that are playing in pain. And
00:54:16.840 --> 00:54:20.139
it, you know, bothers people to a greater or
00:54:20.139 --> 00:54:22.960
a lesser degree. But what matters is that they're
00:54:22.960 --> 00:54:27.400
playing for them, for a lot of them. In clinical
00:54:27.400 --> 00:54:30.519
trials, sorry to... drag you back into the research
00:54:30.519 --> 00:54:33.559
world we try to get around that we do have other
00:54:33.559 --> 00:54:35.199
you know we take a lot of different outcomes
00:54:35.199 --> 00:54:38.039
our trials are often set up and powered which
00:54:38.039 --> 00:54:40.000
means the number of people we need to find the
00:54:40.000 --> 00:54:43.119
effect we're looking for if it exists um are
00:54:43.119 --> 00:54:46.980
often based on one sometimes two outcomes and
00:54:46.980 --> 00:54:48.559
then we have a bunch of secondary outcomes and
00:54:48.559 --> 00:54:50.599
we normally include like a global improvement
00:54:50.599 --> 00:54:53.980
within that on like a seven point scale and you
00:54:53.980 --> 00:54:56.139
know you could almost argue that that's that's
00:54:56.139 --> 00:54:59.159
more important that's whether the person thinks
00:54:59.159 --> 00:55:02.360
they've improved or not um but yeah getting into
00:55:02.360 --> 00:55:06.360
sports well i guess you know as another aside
00:55:06.360 --> 00:55:09.079
we're looking at um netball and basketball boots
00:55:09.079 --> 00:55:11.199
at the moment as well and we're finding some
00:55:11.199 --> 00:55:13.880
really subtle differences in the biomechanics
00:55:13.880 --> 00:55:18.559
of how they perform but we're finding no difference
00:55:18.559 --> 00:55:22.199
in the performance outcome So do those biomechanical
00:55:22.199 --> 00:55:24.460
variables matter if they're jumping just as high
00:55:24.460 --> 00:55:29.500
and running just as fast? Yeah. The next one
00:55:29.500 --> 00:55:33.659
is actually inputted by me because I actually
00:55:33.659 --> 00:55:36.400
attended the Heidi AI conference very recently,
00:55:36.519 --> 00:55:39.440
and they were releasing a new product called
00:55:39.440 --> 00:55:43.000
AI Care Partner. So one of the unpopular opinions
00:55:43.000 --> 00:55:45.739
is research translation, not research volume,
00:55:45.980 --> 00:55:49.429
is the real problem. And this product kind of
00:55:49.429 --> 00:55:51.409
sort of answers my question where now there is
00:55:51.409 --> 00:55:54.269
an AI product that can help synthesize research.
00:55:55.010 --> 00:55:57.610
But then again, on the other side of things,
00:55:57.730 --> 00:56:00.409
it should be the responsibility of the clinician
00:56:00.409 --> 00:56:03.190
to be able to be up to date with research. But
00:56:03.190 --> 00:56:07.269
how do you feel about it, Darcy? In terms of
00:56:07.269 --> 00:56:11.050
AI? Research translation, not research volume
00:56:11.050 --> 00:56:15.829
is the problem. Yeah, I guess there's a lot of...
00:56:16.079 --> 00:56:17.980
research papers that haven't been replicated
00:56:17.980 --> 00:56:23.639
um with research you know it's not like uh there
00:56:23.639 --> 00:56:25.460
is a lot of volume out there so trying to get
00:56:25.460 --> 00:56:28.440
all of the research on all of the topics and
00:56:28.440 --> 00:56:30.519
start to date on that all the time is is not
00:56:30.519 --> 00:56:35.019
easy i am a bit of an ai nerd my myself and um
00:56:35.019 --> 00:56:40.880
i even though the the reasoning capability of
00:56:40.880 --> 00:56:45.730
ai is you know improving exponentially The sycophancy
00:56:45.730 --> 00:56:47.769
levels of just telling you what you want to hear
00:56:47.769 --> 00:56:51.570
is still quite hard to filter out, even if you
00:56:51.570 --> 00:56:57.030
request it. So I'd be hesitant to take things
00:56:57.030 --> 00:57:01.489
from AI at face value and would like to look
00:57:01.489 --> 00:57:07.650
at that myself. It was me personally. Just as
00:57:07.650 --> 00:57:09.530
a quick aside, I don't know if people are in
00:57:09.530 --> 00:57:12.190
meetings very often, but for those of us that
00:57:12.190 --> 00:57:16.860
are. We often use AI to record as you were, Pat,
00:57:17.019 --> 00:57:18.860
and I noticed when you asked that question, AI
00:57:18.860 --> 00:57:22.599
just got turned off. Did you notice that? See
00:57:22.599 --> 00:57:27.800
how it's gone? There you go. There you go. Yeah,
00:57:28.099 --> 00:57:32.840
I 100 % agree. We use it quite a bit and it's
00:57:32.840 --> 00:57:35.500
quite often wrong. I mean, it's brilliant, like
00:57:35.500 --> 00:57:38.139
it is absolutely brilliant, and I think if you're
00:57:38.139 --> 00:57:41.059
busy in terms of summarising, it can be really
00:57:41.059 --> 00:57:45.320
useful. But you, you know, like anything, like
00:57:45.320 --> 00:57:48.420
social media, right, like you can't always believe
00:57:48.420 --> 00:57:52.539
what you see and you should do your due diligence.
00:57:52.800 --> 00:57:54.900
And the other thing that we touched on before
00:57:54.900 --> 00:58:00.710
was quality of research. And AI has... unless
00:58:00.710 --> 00:58:05.110
you specifically ask it, it's just going to trawl
00:58:05.110 --> 00:58:08.510
Reddit sites and trawl research papers and whatever,
00:58:08.670 --> 00:58:11.889
and they'll have equal weighting. So some comment
00:58:11.889 --> 00:58:15.130
on Reddit can have equal weighting as a paper
00:58:15.130 --> 00:58:17.849
published in the Journal of the American Medical
00:58:17.849 --> 00:58:21.130
Association. So you need to be careful. It's
00:58:21.130 --> 00:58:23.289
the phrase, garbage in, garbage out. So you need
00:58:23.289 --> 00:58:25.949
to be careful what you're prompting it to get
00:58:25.949 --> 00:58:27.789
the information you want, and you probably need
00:58:27.789 --> 00:58:30.989
to check it as well. Well, you do need to check
00:58:30.989 --> 00:58:33.809
it. And then the other part of your question,
00:58:33.869 --> 00:58:36.030
I think, Pat, was about translation. And, yeah,
00:58:36.170 --> 00:58:39.869
we're notoriously bad at translating as clinician
00:58:39.869 --> 00:58:44.809
researchers. And the government is trying to
00:58:44.809 --> 00:58:47.289
get us better at it and has schemes targeted
00:58:47.289 --> 00:58:51.469
to exactly that. That's fantastic. Last one.
00:58:52.329 --> 00:58:54.969
A lot of young clinicians feel pressure to specialise
00:58:54.969 --> 00:58:58.300
too early. Do you think niching early is the
00:58:58.300 --> 00:59:06.880
way to go, Darcy? I think generally, I could
00:59:06.880 --> 00:59:10.739
say it both ways. Pat, I think that it'd be hard
00:59:10.739 --> 00:59:12.559
for anyone to truly specialize. It's not like
00:59:12.559 --> 00:59:15.420
a podiatrist who wants to do purely pediatrics
00:59:15.420 --> 00:59:18.539
or purely sports medicine is going to get a caseload
00:59:18.539 --> 00:59:21.539
that has a majority of those things in it, you
00:59:21.539 --> 00:59:25.230
know, most of the time. But I think... it could
00:59:25.230 --> 00:59:27.150
be helpful in some ways where you would enhance
00:59:27.150 --> 00:59:28.750
the skills that you want to enhance and then
00:59:28.750 --> 00:59:30.550
you would slowly pick up other ones that you
00:59:30.550 --> 00:59:32.730
weren't focused on and i could see that the other
00:59:32.730 --> 00:59:36.250
way around as well i think people should take
00:59:36.250 --> 00:59:39.409
interest in in things and really go down rabbit
00:59:39.409 --> 00:59:41.969
holes and try things out and look to explore
00:59:41.969 --> 00:59:45.050
and expand knowledge on their interest area no
00:59:45.050 --> 00:59:51.210
matter who they are okay you waiting on me no
00:59:52.159 --> 00:59:56.659
I agree with you, Pat. I think early, I thought
00:59:56.659 --> 00:59:58.059
actually when you started this, I thought you
00:59:58.059 --> 00:59:59.860
were going to say early specialisation in sport
00:59:59.860 --> 01:00:03.099
as in like athletes, which we're getting really
01:00:03.099 --> 01:00:06.179
good evidence that that's not so good. So I think
01:00:06.179 --> 01:00:09.639
like sport generally, you should try and stay
01:00:09.639 --> 01:00:12.159
general for a little while. You know, again,
01:00:12.239 --> 01:00:14.159
sorry to keep referring back to previous podcasts,
01:00:14.440 --> 01:00:18.900
but Emma talked about, you know, her main role.
01:00:19.369 --> 01:00:22.690
which was general foot care in the sporting setting.
01:00:22.829 --> 01:00:25.130
So you've really got to make sure your general
01:00:25.130 --> 01:00:30.210
skills are really good. So, yeah, I think generalisation
01:00:30.210 --> 01:00:33.989
is really helpful. The other thing is, you know,
01:00:34.050 --> 01:00:38.489
in sport, like you'd be seeing the whole world
01:00:38.489 --> 01:00:41.389
of people in a small environment. So people will
01:00:41.389 --> 01:00:45.010
come in with lots of other conditions, you know,
01:00:45.010 --> 01:00:47.150
certainly less frequently, way less frequently,
01:00:47.269 --> 01:00:48.750
but, you know, you need to be aware of them.
01:00:49.280 --> 01:00:53.320
um so yeah generalization i think is good and
01:00:53.320 --> 01:00:55.639
then that's a that's a really solid base to to
01:00:55.639 --> 01:00:58.460
build your sports and exercise specialization
01:00:58.460 --> 01:01:02.840
in fantastic all right Kade um i guess for your
01:01:02.840 --> 01:01:07.300
future footprint um what research questions still
01:01:07.300 --> 01:01:10.559
need urgently answering and these are great puns
01:01:10.559 --> 01:01:13.400
you're getting here and you know if you were
01:01:13.400 --> 01:01:15.719
to leave a life of legacy what is the answer
01:01:15.719 --> 01:01:17.380
the question that you want to answer yourself
01:01:19.690 --> 01:01:25.289
What question do I want to answer? It's really
01:01:25.289 --> 01:01:32.269
tough. I would like, look, you know, I got into
01:01:32.269 --> 01:01:34.489
research because I like to know how things work.
01:01:34.590 --> 01:01:40.550
So I guess I would like to know how, what the,
01:01:40.570 --> 01:01:43.110
you know, pathomechanics really are because I
01:01:43.110 --> 01:01:45.730
do love biomechanics of course and as an example
01:01:45.730 --> 01:01:47.289
we're you know we're doing a lot of work at the
01:01:47.289 --> 01:01:49.090
moment in patellofemoral pain and adolescence
01:01:49.090 --> 01:01:54.070
in particular with patellofemoral pain and we're
01:01:54.070 --> 01:01:58.730
sort of finding that our measures of force aren't
01:01:59.150 --> 01:02:02.210
necessarily a big factor in the pathomechanics
01:02:02.210 --> 01:02:06.110
or the progression of patellofemoral pain, which
01:02:06.110 --> 01:02:08.730
just doesn't make sense to me because it's a
01:02:08.730 --> 01:02:11.250
loading -based condition. It hurts when you bend
01:02:11.250 --> 01:02:15.110
knees and you increase those forces. So are we
01:02:15.110 --> 01:02:20.610
looking at force wrong? I'm going to say that.
01:02:20.730 --> 01:02:23.309
Are we looking at force wrong? We've used amazing
01:02:23.309 --> 01:02:26.909
models here, EMG, neuromusculoskeletal models.
01:02:27.969 --> 01:02:31.550
But, you know, do we need sort of MRI patient
01:02:31.550 --> 01:02:34.150
-specific models to look at some of these forces?
01:02:34.329 --> 01:02:37.070
So what do you reckon? Is that an all right one?
01:02:37.369 --> 01:02:40.469
Are we looking at force wrong? I've thought of
01:02:40.469 --> 01:02:42.289
the same thing a lot, Kate. That's a really cool
01:02:42.289 --> 01:02:44.809
one. I hope you make some progress on that over
01:02:44.809 --> 01:02:46.389
time. Actually, it will be really cool to see
01:02:46.389 --> 01:02:48.969
how that plays out, you know, just broadly over
01:02:48.969 --> 01:02:51.929
the next 10 to 20 years as we're able to. You
01:02:51.929 --> 01:02:53.670
know, capture a lot more information, process
01:02:53.670 --> 01:02:56.369
a lot more information, even using AI and then
01:02:56.369 --> 01:02:57.929
getting a better understanding of what's happening
01:02:57.929 --> 01:02:59.389
there. Just because obviously the methods that
01:02:59.389 --> 01:03:01.610
we've got at the moment are pretty crude, really.
01:03:02.250 --> 01:03:03.929
But obviously they're the best that we can do.
01:03:03.989 --> 01:03:07.469
Like, it's honestly amazing that we can do what
01:03:07.469 --> 01:03:10.050
we can do. But in the scheme of, you know, where
01:03:10.050 --> 01:03:14.210
each individual, you know, newton of load goes
01:03:14.210 --> 01:03:17.769
in when the foot hits the ground to when it's
01:03:17.769 --> 01:03:20.780
dissipated by the whole body. That's a very complex
01:03:20.780 --> 01:03:22.900
thing for anyone to measure. So it'd be cool
01:03:22.900 --> 01:03:25.099
to see how we go with that over time. Well, exactly.
01:03:25.280 --> 01:03:27.960
And, you know, different tissues respond to different
01:03:27.960 --> 01:03:31.199
forces, stresses, strains. Frequencies. Yeah,
01:03:31.380 --> 01:03:34.099
exactly. So, you know, if we're just measuring
01:03:34.099 --> 01:03:36.780
one component, which typically we are, like a
01:03:36.780 --> 01:03:39.340
compressive force, then, you know, we're probably
01:03:39.340 --> 01:03:44.780
missing a lot of it. Kade, where can our listeners
01:03:44.780 --> 01:03:49.199
follow your work and upcoming projects? Oh, so
01:03:49.199 --> 01:03:56.320
my ECT is at Kade Paterson. So I'm Kade and
01:03:56.320 --> 01:04:02.900
Paterson with one T. Yeah, I'm not on Insta
01:04:02.900 --> 01:04:04.840
very much. I just sort of started that recently.
01:04:05.219 --> 01:04:09.579
Kade Paterson pod is my handle there. And then
01:04:09.579 --> 01:04:12.039
I'm at the University of Melbourne. I've got
01:04:12.039 --> 01:04:15.480
a profile here and we publish a lot of our work
01:04:15.480 --> 01:04:18.750
up on there as well. So those are probably the
01:04:18.750 --> 01:04:23.670
main areas. Fantastic. Hey, you've had an amazing
01:04:23.670 --> 01:04:26.110
career and it's still going. So hopefully we
01:04:26.110 --> 01:04:28.389
can get you back on to soil science in the future.
01:04:28.670 --> 01:04:30.550
Thanks for coming on. Thank you very much.