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[Physio Explained] Optimising Osteoarthritis rehab: hip, knee, and beyond with Dr Allison Ezzat

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In this episode with Dr Allison Ezzat we talk about the GLA:D Program (Good Life With Osteoarthritis Denmark) which is a rehabilitation program for hip and knee Osteoarthritis. We discuss: 

  • GLA:D outcomes for individuals with hip and knee osteoarthritis
  • Pros and cons of GLA:D delivered in-person vs telehealth
  • How to assist patients to self-management from the program
  • How we can market this rehabilitation program better to patients

This episode is closely tied to Allison’s Practical she did with us. With Practicals you can see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster.

👉🏻 Watch Allison’s Practical here with our 7-day free trial: https://physio.network/practicals-ezzat 

Dr. Allison Ezzat is a physiotherapist and postdoctoral research fellow at La Trobe Sport and Exercise Medicine Research Centre, as well as a Clinical Assistant Professor in the Department of Physiotherapy at the University of British Columbia (UBC). Allison has been involved in Good Life with osteoArthritis in Demark (GLA:D) in Canada since 2017 sitting on numerous national leadership committees as well as working clinically with patients who have osteoarthritis both in-person and virtually. 

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Our host is Michael Rizk from Physio Network

SPEAKER_01:

There have been numerous publications now publishing data from Denmark, from Canada and from Australia showing the benefits of the program, things such as improved quality of life, reduced pain, reduced desire for joint replacement surgery, improved functional outcomes, those ones I just mentioned as well.

UNKNOWN:

Music

SPEAKER_02:

How do we help patients with knee OA? Today we had Alison Ezzat on who is all across the studies, a Canadian physio now living in Melbourne and working with La Trobe. Alison goes through what GLAD is, the outcomes we can achieve, but also compared doing GLAD live and online and hybrid models and really showing us that there aren't too much differences between groups and also some interesting findings about how the patients perceive that and how physios perceive that. Some really insightful tips here from Alison got me thinking about how we can do GLAAD better and help people with NeoA. Please enjoy this episode. My name is Michael Risk and this is Physio Explained. Welcome Alison and thank you for joining us.

SPEAKER_01:

Great. Thanks for having me.

SPEAKER_02:

Now we're talking all things, I guess, NeoA, specifically the GLAAD program. You've been involved in a lot of research and then another branch of that, the arm of research around doing GLAAD via telehealth. Could we start with just a quick overview of what is GLAD, what's in it, how long is it, and what does it look like?

SPEAKER_01:

For sure. Yeah, so the GLAD program, GLAD stands for Good Life with Osteoarthritis in Denmark, and it was started actually 10 years ago now by two physiotherapist researchers and clinicians, Dr. Ivo Roos and Soren Sku, who were essentially frustrated that even though we had all this research supporting exercise therapy and education as first-line treatments for knee osteoarthritis. We had the research, but they weren't seeing it happening in practice. And so they came up with the GLAD program, which essentially consists of two education sessions, two one-hour education sessions and 12 one-hour group-based exercise sessions over a six-week period. So it's essentially twice a week for six weeks of a group-based exercise class that is individualized and tailored to that individual patient. And I should say it's for people with knee and with hip osteoarthritis.

SPEAKER_02:

And so that's two sessions, one hour, and then two sessions a week for six weeks. So 14 sessions total. Is that right?

SPEAKER_01:

That's correct. Yeah.

SPEAKER_02:

Awesome. And I had some thoughts off of that. What was the outcomes that that study showed or the repeated studies that led to GLAD?

SPEAKER_01:

Yeah. Well, so... What's great about GLAAD is that we also have a patient registry as part of it. And so this, again, started in Denmark, but now is also in Australia and I should also say in 10 other countries around the world. And so patients who sign up for GLAAD. They complete some baseline questions, including a 40-meter walk test and a 30-second sit-to-stand test. So we collect that at baseline. Then those same functional tests and outcome measures are repeated at three months, so after they finish the program. And then they also do some online questions again at 12 months. And so what's great is we actually have real world data on the people who've done the program. And so there have been numerous publications now publishing data from Denmark, from Canada, and from Australia showing the benefits of the program, things such as improved quality of life, reduced pain, reduced desire for joint replacement surgery, improved functional outcomes, those ones I just mentioned as well.

SPEAKER_02:

That's huge. The surgery one sticks with me that, yeah, reduced need for I guess, ongoing care. Had they compared any of the studies you've been involved with, compared that to, say, usual care? Like you get the choice to go do what you want or maybe just traditional physio?

SPEAKER_01:

Yeah, I think that's the tricky thing is because what is usual care, right? I think that's the tricky part is because actually we don't have good data on what is usual care. And there is some studies Actually happening right now, led by Christian Barton, where we're trying to look at what is actually usual care here in Melbourne and here in Australia, because, yeah, we don't know. And there's a lot of variability in that. And so I guess the short answer is we don't know right now. There hasn't been a comparison of glad to usual care, but hopefully that will be coming.

SPEAKER_02:

Yeah, I was thinking like the RESTORE trial, they kind of said, this is our program and compare it to usual care. But then when they looked at the usual care group, it was so varied. So it was hard to draw conclusions anyway, I feel. That'll be interesting. Keep an eye on the space. And you've gone specifically into some research around telehealth. And did this change anything? And do you want to kick us off with how telehealth changed outcomes or if it did at all?

SPEAKER_01:

For sure, yeah. I'm a clinician, a physiotherapist by background and never really planned on getting involved in telehealth research. Then, you know, the pandemic hit and we all, at least I was in Canada at the time and actually in Canada, physiotherapy was really mandated to be online. You weren't allowed to do in person. And so at the time I was doing a GLAD class and we just moved our class online, really just trying to see how it would work. And we had no guidance. We really had no clue what we were doing. But, you know, since then, there has been quite a lot of research on telehealth in general coming out. And I've been involved with leading some research in particular looking at the GLAAD program delivered by telehealth.

SPEAKER_02:

In that research, were there differences or things that surprised you?

SPEAKER_01:

Yeah, so I guess one study I can talk about, and the ironic part about this is that actually before the pandemic, Here in Australia, they'd started a randomized control trial, randomizing people to GLAD in person or GLAD by telehealth. And then when the pandemic started, they had to pause the trial because they weren't allowed to do the in-person GLAD anymore. Yeah. So a bit ironic that that happened, but I was involved with leading some qualitative interviews with these patients who were involved either with GLAAD by telehealth or GLAAD in person. And so what we found that was really interesting was that the patient acceptability of telehealth really varied depending on which group they were in. So remember, patients were randomized. So the people who were randomized to telehealth said that they were surprised that they actually really liked it. They found it to be convenient and flexible. And they reported the benefits that we would expect from in-person, like reduced pain, improved confidence, improved function. Whereas the people who were randomized into the in-person sort of said, oh, I'm really glad that I didn't get put into that telehealth group because I don't think it would have worked for me. And again, they also reported those same benefits from doing the GLAD program in person. I think what that really showed us is that patients Certainly are a bit skeptical about it, and they're not quite sure that they're going to get the same value as in person. But once they've tried it, the vast majority of patients do actually find it works. And it does have benefits, as I mentioned, some of the flexibility and convenience. And I've also found this clinically as well.

UNKNOWN:

Thank you.

SPEAKER_00:

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SPEAKER_02:

I wonder where that comes from, the expectation or comparison to the other group. Do you think that's just in the mind of the consumer at the moment that we would do that in person? Because when I see a physio or a massage therapist that tends to be in person, is that just an assumption made?

SPEAKER_01:

You know, it's hard because I guess as a physio as well, I do telehealth right now, but I would certainly say that it's not probably my favorite to in person either. And that certainly... I think from a physio perspective and a patient perspective, there are those benefits to telehealth, especially the flexibility and convenience. But sometimes it is really nice just to see somebody in person. So I don't necessarily think that telehealth is going to replace all in-person physio, but I think there is certainly a role for it. And there may even be opportunities for more hybrid models of care. And I certainly heard this in other research where, again, patients would talk about it'd be great to do an in-person assessment. and then do a follow-up session by telehealth or maybe do in-person once every couple of months and then in between do a telehealth session. So I think there's ways that we can be creative about it as well.

SPEAKER_02:

Yeah, a bit of a hybrid model to maybe just break down some of the barriers and expectations first where you could see them in the clinic first and then give them the choice after that. Yeah, that's super interesting. And you went further to evaluate... a bigger body of research in GLAD and telehealth. Were there any more things that came up for you that surprised you or didn't surprise you?

SPEAKER_01:

Yeah, so this was, again, as I mentioned with GLAD, because we have this big data registry here in Australia where patients, again, are providing that data baseline at three months and at 12 months. During the pandemic, we did collect data on patients who did the GLAD program by telehealth. And again, what we found was that for all the different self-reported measures, like pain levels, quality of life, and even the functional tests, like the 30-second sit-to-stand test, we found no difference between the GLAAD telehealth compared to previously published data on in-person GLAAD. So that was actually, to be honest, not unexpected from us, but maybe surprising to some. And even patient satisfaction was also very high when they're asked about how satisfied they are with the program. So we found The patients were very happy doing GLAD by telehealth. And then we also talked to the physios. So we talked to physiotherapists, doctors who were the ones who did do GLAD by telehealth. And then we also did interviews with physiotherapists, non-adopters. So the ones who chose not to do telehealth. So we kind of got into some questions with them about why did they do it and what did they like about it? And I would say the general consensus was that a lot of them did say that they felt saw patients improved, they saw the value of it. But again, most physios, if they had a choice, they didn't want to be doing only telehealth as, you know, their main way of treating patients, but they certainly saw a space for it or, you know, a space, especially in a country like Australia, where it is a large country and, you know, telehealth has potential opportunities to improve access to care for people living in rural and remote areas or people who may have carer responsibilities where it's hard to get somebody to look after your kids for an hour or it might have to be two hours by the time you drive to the appointment and park and go versus if you can just join from home. Sometimes there are those other advantages to it.

SPEAKER_02:

Where do you think we go next? Because it is interesting that physios, maybe they had a bit of resistance, but also it's probably just speaking to variability. I don't think we want to be 100% online physically. A little bit of a mix or a hybrid model sounds nice and flexible. Where do you think we go with GLAD next as far as marketing it to patients, surgeons, GPs and physios?

SPEAKER_01:

I really like trying to do a hybrid model of GLAD of starting off with doing in-person, you know, doing an in-person assessment, doing the first couple exercise sessions in person, really, you know, focusing on the technique with patients, but then gradually having them over those 12 sessions transition to a more setting it up in their own home environment, right? And getting them a little more independent because that's something that I found in my research, but also others have published as well is that telehealth can really empower patients to just to become more confident in exercising in their own space and really helping them transition to self-management at the end of a program like GLAD, which is designed to be transitioned to sort of independent exercise after that six weeks, ideally.

SPEAKER_02:

For physios who are thinking about this, you were saying that you're still doing telehealth here from Melbourne with your clients in Canada. How are they finding you? Is that generally through GP and surgical referral or are you listed on the GLAD website? How does that happen?

SPEAKER_01:

Yeah, for me right now, because I'm still affiliated with a private practice clinic back in Vancouver. So that's how I'm getting patients through my clinic sort of back in Vancouver typically. But we are still trying to really spread the word about GLAAD to other health professionals, especially GPs, especially surgeons. And some other work we're doing right now is really trying to help GPs to actually really just increase their awareness of what is the GLAD program because what we found is they have the knowledge generally. They know that patients with knee arthritis, all patients, regardless of the severity of arthritis, the first-line care should be exercise therapy, education, and weight loss if indicated. The GPs know that, but they don't necessarily know how to get them that, right? And especially if the community health centers have long wait lists and private one-on-one physiotherapy can be expensive, that introducing them to the GLAD program, a lot of them have been very positive about that as a potential option to refer them to. But even though GLAD's been in Australia since 2016, it's still trying to work to get the word out about that.

SPEAKER_02:

It sounds like a little bit more marketing so that primary, what's considered primary healthcare, like GP and surgeons, know exactly what GLAD is, know what the outcomes are, and maybe they can introduce the idea that it's hybrid or online. So that way that That would just combat, I was thinking with the randomized group to the in-person GLAAD, we're thinking that, no, if my GP and surgeon started with the message that it's hybrid or online, it might normalize it a little bit.

SPEAKER_01:

Yeah, I agree. I think it's at this point, it's just even getting the GPs to refer to in-person GLAAD. That would be great

SPEAKER_02:

too.

SPEAKER_01:

That's a first step.

SPEAKER_02:

and sharing your knowledge about GLAAD and telehealth with us.

SPEAKER_01:

No worries. Thanks for having me.