Jared Powell:
Welcome to the shoulder physio podcast, a podcast dedicated to exploring meaningful topics in musculoskeletal healthcare. I'm your host Jared Powell. Before we begin, the primary purpose of this podcast is to educate and inform the views expressed in this podcast by myself and any guests are information only do not constitute professional advice and are general in nature. If you act on the basis of any podcast episode, you should obtain specific advice for am a qualified health professional before proceeding
Jared Powell:
Today's guest is Jack Hickey. Jack is a leading hamstring researcher out of Melbourne Australia. In this conversation, we discussed an interesting paper authored by Jack published in the journal of orthopedic and sports physical therapy in 2020, which investigated PainFREE versus pain threshold rehabilitation, following acute hamstring strain injury, the results of Jack's research may be different to what you might expect. Stay tuned for the big reveal. Coming up in this episode, the conversation was originally recorded in July, 2020 for my YouTube show on the shoulders of giants. Before we get into the nitty gritty of the conversation and for your information for the first time in two years, I am running my one day shoulder workshop in Sydney and Melbourne in may and June of 2022, tickets are limited to 30 participants at each workshop. The course offers a complete distillation of the evidence base for shoulder pain management, equipping you with UpToDate knowledge techniques, and clinical reasoning skills that are clinically actionable. If this is something you are interested in, check the show notes for more information without any further delay. I bring to you my conversation with Jackie here.
Jared Powell:
All right. Here we with Mr Jack Hickey. The hamstring extraordinaire from down in Victoria, Melbourne, which is going through a, the moment which we mate,
Jack Hickey:
Don't know about extraordinarie mate but I've been called worst things before. So I'll, I'll take that. Thanks mate. It's ncie to be able to have a chat and we don't have a lot else to do down here at the moment we down. So yeah, happy to jump online for a chat.
Jared Powell:
Yeah. So the, I reached out for a, is a randomized control trial, which which is really an excellent paper that you've released, I think, in the JST this year. Yep. All right. So before we get into that paper, which was concerning the hamstring, you mind just giving me and the audience, a bit of a introduction about you and what you like to do mate, outside of your academic work, as well as your academic interest as
Jack Hickey:
Well. Yeah, sure. So I suppose my kinda academic journey, I suppose at this point was I mean I finished my undergrad was pretty much 10 years ago. Now that was in what was called then called human movements probably shows you how, how long ago it was you know, commonly known as exercise science now. So that was at RM I T university down here in Melbourne. And that's where I first got exposed to a couple of people were pretty influential in the, the path that I eventually took. So Anthony shield and David were both, Tony was a, was lecture one of my first lecturers there at RMT. And Dave was a actually I think a, a final year undergrad student when I was a first year student there and basically met him while he was doing his honors under Tony and got involved in, in the, the initial sort of research the guys were doing in looking at hamstring injuries and learning some lab skills and that sort of stuff.
Jack Hickey:
And as, as most undergrad students tend to do have a bit of an interest in, in those sorts of things. So that kind of sparked an initial interest in, in research, but it wasn't sort of the pathway that I initially wanted to take. And, you know, I went as a, you know, relatively naive 20, 21 year old, finished my undergrad and really wanted to, to get out in the workforce and work. And for me that was pursuing a master's in clinical exercise physiology having a real passion for, for exercises, a motive, you know, not only rehabilitation, but also for, for treatment and you know, for chronic disease and that sort of thing. So did that at deacon university down here in Melbourne, and then went out and worked in clinical practice for, for a few years primarily in, in skeletal rehabilitation and private practice, and that combined with keeping an involvement with both Dave and Tony over that period of time, sort of then sparked a few clinical questions and some interest in hamstring injury rehab.
Jack Hickey:
You know, fortunately enough Dave, who did his PhD up in, up in Queensland, under Tony, after leaving Melbourne, he came back to Melbourne where he originally from, and he got in touch and sort of wanted see if I was still perhaps keen on, on pursuing research. And it wasn't something I, I really thought I would do, but you know, Dave created an environment that was, you know, really enjoyable to the band. And we had a building team down at ACU in Melbourne. He had Tims as his first PhD and myself and another guy in RA Manar came on sort of at the same time to start out PhDs Rav more so in environ mechanics and myself, more in the clinical sphere looking at rehab. So, yeah, that was back in 2015, started the PhD and that sort of evolved over the next few years and finished that in, in 2018.
Jack Hickey:
So, so that's sort of the journey I took to, to finish the PhD, which was in hamstring injury rehab. And then over the past couple of years I've been fortunate enough to stay on at ACU in a full-time academic role. So a combination of, of lecturing and and research and a little bit of clinical work through our internal clinic as well, but primarily teaching and research teaching our, our masters programs in clinical EP Tal and sports injury rehab. So yeah, that's, that's the boring stuff, mate, in terms of the sort of academic pathway and where we've got to. And I suppose what started all that was just the general interest in sport and exercise and, you know, keeping and healthy. And although I'm certainly not that fit and healthy at the moment, particularly with the current lockdown situation, we can't get out as much as we'd like, but yeah, that that's sort what, what my interest and that's, I enjoy work is keeping active keeping and healthy.
Jared Powell:
Are you an AFL man down there?
Jack Hickey:
Mate, it's hard not to be here in Melbourne. I'm an AFL man. I'm a somewhat long suffering supporter. I've had an interesting time over the past, particularly 10 years. So when I was a kid, it was little bit different, but yeah, no, I do do love my AFL just generally as a sport being Melbourne, but big fan of all sports. But yeah, AFL, it's hard to, hard to sort of focus on too much else down here in, in the bubble.
Jared Powell:
Yeah. I'm a bombers fan as well. So it's got finally good to commiserate together, although this year seems promising. Yeah,
Jack Hickey:
We've been, we've been there before it looks promising and doesn't go anywhere. So I'm not holding a breath.
Jared Powell:
Have you had a hamstring injury yourself, Jack?
Jack Hickey:
I haven't. Interestingly enough, it's a question that I do get asked a little bit. I probably probably the reason is I've never run fast enough to do one, so play a lot of footy growing up and into, into my early twenties, but yeah, probably never covered the ground at any great speed. And so hence my hamstrings were never in any great danger of of injury. Yeah.
Jared Powell:
So, so classic injury in AFL and any sporting or footballing code is, is a hamstring injury and it ruin careers. You know, people still is a classic example. Didn't ruin his three outta a fantastic career, but C certainly missed a chunk of games due to recurrent hamstring strains. And we could name many, many others as well. So it's, it's important that us as clinicians and health practitioners, that we know how to actually manage these conditions because they have a tremendous effect on and quality of life and all these sorts of things as well. So kinda a nice segue in, into the paper potentially that you've published. Do you mind just sort of setting the scene roughly in terms of the methodology of the paper and your aims and your hypotheses and, and then quickly some results and we'll sort of explore some interesting parts of it? Yeah,
Jack Hickey:
Sure. So I suppose where, where it all started was coming back to, to do a PhD and, and knowing that, or wanted to do, wanted to do it in hamstring injury generally, but then also with a, with a rehabilitation focus coming from a, a clinical background, I probably had some some questions on my own that I, I felt were, were relatively interesting, at least to me. They probably needed to be, be refined a little bit under guidance of, of people like Dave and and my other PhD supervisors. And through that process, we sort of looked at well, how do clinicians make decisions during rehabilitation? And one of the things that I always, I guess, struggled with to an extent when, when working in, in private practice is you'd see a patient with whatever kind of injury or condition they might have and knowing what to do that day when they walk in.
Jack Hickey:
So how they present today is that gonna tell me whether I can do exercise a, B or C being an exercise physiologist. That's what I, I use as my intervention is, is exercise. So the way that I'm gonna determine what exercises I do might be through a clinical assessment, or it might be through an exercise based assessment seeing, you know, what they can handle at a sub max level and then progressing them on from there. And so I suppose it's that decision making process to be really interested me because when reading a lot of the literature around hamstring strain, injury rehab, we're making decisions about when should I introduce certain exercises or certain stimulus in rehab, there's sort of some arbitrary cut points and criteria that are, that are thrown out there and they give clinicians a good guide as to, to what we should do.
Jack Hickey:
So you might see things like, you know, once someone is pain free in a range of motion tests, that's when we can start doing long length exercises, like an RDL or something like that. Or maybe once they're pain free with an isometric contraction, we're gonna introduce eccentric stimulus and you they're fairly logical progression milestones. But I suppose what I saw as a bit of a disconnect is someone who's more worked in with patients. There's all sorts of conditions and prescribing exercises. What happens in a clinical assessment of range of emotional strength doesn't necessarily carry over to what happens with exercise prescription. And then when looking at specifically progressing exercises, the main thing that people do is they say, well, can you do exercise a without pain once you can do that, right? We're gonna to exercise B. And that is the, probably the easiest progression point to use is, you know, when someone can do something pain free, we're going to allow them firstly, to continue doing that and then to progress them on.
Jack Hickey:
Whereas if they have pain, we're probably gonna pull the ranges on them slightly, which, which makes, makes sense at a relatively simplistic level. But I suppose what we look looked at with that is, is the hard and fast line of complete pain avoidance necessary. And in the early stages of my PhD, we did a systematic review and we looked at criteria for progressing rehabilitation, as well as a decision making around return to play clearance. But specifically with that rehab progression and continuing with the exercise, it was primarily pain and the need to be pain free that kept coming up in the literature. And that's not to say that's what every practitioner does because we know that practitioners, you know, they improvise and they they'll do things that they find works for them. And certainly practitioners will use, or allow pain during exercise for certain conditions, but particularly with acute muscle injuries, especially in the initial week following an injury, people will tend to avoid pain, you know, while performed rehabilitation cause they're of fear of re-injury or exacerbating symptoms or anything like that.
Jack Hickey:
But we sort of thought, well, is there a certain level that we might be able to push it to, you know, do we need to be absolutely PainFREE and what is absolutely pain free? What does that actually look like? Versus if we allowed a, a low level, what would be considered a low level of pain during exercises first is that safe? And also, secondly, does it lead to any improvement in clinical outcomes, whether that be in strength or muscle structure or function, or maybe even time to return to play. So that was our, our overarching research question that we wanted to answer. And so then when we put together the, the study, we basically thought, well, what we need to do is have two groups of participants or randomized to either a or what we term to pain threshold approach. And they follow the exact same rehab program.
Jack Hickey:
They do the same exercises, the same exposure in terms of the amount of times they come in, all that sort of thing. So no differences between the groups, apart from the fact that when performing exercise those in the PainFREE would only be allowed to continue with exercise or progress exercise if they reported absolutely no pain, versus those in what we call the pain threshold group were allowed to continue or progress exercises up to a limit of four out of 10 pain. So where we got that four out of 10, it's a relatively arbitrary number and anyone who works with pain scales and, you know, knows the, the challenges and the subjectivity in them. But for me, the important thing is, is using your pain scale. And we use a zero to 10 numeric rating scale, whereby we explain that zero means absolutely no pain at the side of injury.
Jack Hickey:
And 10 is the worst pain that you can imagine at the side of injury. And so we said to them, if you're experiencing a four or below where okay to continue in the pain threshold group, whereas anything on the scale and the pain free group, we sort of pulled the reigns and, and backed them off in terms of what they were, what they were doing. So that's the crux of the research question, how we set the, the study up and then basically to, yeah. Recruit participants. We had, I just put an open invite out there to people who suspected of the hing Australia within the last seven days. And they needed to come in and have a clinical confirm presence of acute injury. And then from there, if they were interested in doing some rehab with us they were randomized to, to one of the groups.
Jared Powell:
Cool. So if I can, if I can just briefly summarize, so essentially there, you, you sort of noticed you had a look at the literature and you also had some experience yourself and there was this hierarchy arbitrary, very progression of exercise that you must in order to go to the next phase, you have to have completed the first phase without pain. And therefore that qualifies you to, to jump a level and do a little bit more movement or load, or what have you, is that, is that correct?
Jack Hickey:
Yeah. And I think that's the other part of the, I mean the main crux of the RCT is comparing PainFREE to pain threshold. What we've probably found are the more interesting findings for, from our work more so observationally throughout doing it was in the way that we put together our, our rehab protocol. We didn't wanna have a, a structure whereby you have phases of rehab whereby you've got phase one, and you've got a list of exercises that you're allowed to do. And then you have some progression criteria to then move to phase two, and then a new list of exercises that are generally progressions from the ones earlier from working in clinical practice, you know, that different people will progress with different things at different. So to say that me and you both have an exact same grade, two hamstring strain injury, and at the same time from injury and all that sort of thing, I might be able to tolerate a single leg RDL, no problems, but I might, you know, only be able to do a double leg hamstring bridge, whereas you might be able to do a single leg hamstring bridge, even with, you know, 10 kilo dumbbell across your PEL, but you might be really struggling with your hip hinge movement.
Jack Hickey:
So you're doing, you know, just a bilateral movement there. So because we're gonna move a different rates, we decided to take more of an individualized approach to how we progress each exercise that we prescribe. So every participant was exposed to the same free exercises in their first rehab session when they came in and they were relatively stubborn, more exercises, all bilateral. So they could kind of, I guess, protect their injured limb as much as they felt they needed to with their ed limb. So that was just a basic hamstring bridge a 45 degree back extension using room and chair bilateral and then a eccentric sliding leg curl, which is performed bilateral as well. So they can underload, I will unload, sorry, their injured leg as much as they liked. And then once they could perform the exercise through full range of motion for a predetermined rep range within whichever group they were allocated to which in their, in their pain limits, they were then allowed to progress to say a unilateral variation.
Jack Hickey:
And so you might have some guys who in their first session or already up to doing a single leg roam chair extension, but they can't even do five reps of a double leg bridge. And that's fine rather than saying, you're in phase one, you, you should be doing these exercises. And then in phase two, you're gonna do all of these exercises cause people won't necessarily fit that, that, and I guess that's something that I'm reasonably big on pushing is that sort of individualized sort of exercise, specific approach to progression rather than the sort of phase based progressions that we often see recommended. And it's not to say that those approaches are bad as to, and because they're a general guideline and I think clinicians are smart enough to know that they're a general guideline and people can then adapt within those. So we know that practitioners do that, but I suppose there's never been, I guess, a clear message out there to say, well, it's actually okay to progress at different with exercises and more the point is it okay to allow pain when we, when we do acute muscle injury point of view, at least anyway.
Jared Powell:
Yeah. Great. So that, that, that paints a beautiful picture. So then, so that was the setup. And then, and then, so how many people did you get? And so then how long did they do it for, and then what, what did you follow up with and what were the results? Tell me what the,
Jack Hickey:
Yeah, sure. So it a good couple years of work. So it's quite a ago now. I mean, the study was published at least published in print earlier this year. It was accepted for publication, I think sort of, probably around this time, time, last year, but the actual study itself, it feels like a lifetime ago now to be honest, mate, it was I think it would've started, was it 2016 into 2017? I'm probably stretching my memory a bit, but I'm pretty sure we were almost I'm with data collection by the end of 2017 which would be right. Cause I finished my PhD in mid 2018. So yeah, we were wrapped up data collection for this study in, would've been the end of AFL season down here in Melbourne. So September, 2017, which is nearly three years ago now. So we had throughout sort of a, a two year period, we were able to approximately sort of 50 50 guys came in and presented at least, but then in the actual meeting inclusion criteria and enrolling in the study, we had 43.
Jack Hickey:
So we had 22 who were randomly allocated to the PainFREE and 21 who were randomly allocated to the pain threshold group. And so they came in twice a week and time they'd come in, they did a underwent a clinical assessment. So that was conducted by a, an investigator who was blinded to their group allocation. So basically one of the other guys is in the research team would assess their range of motion, their strength, pain with to sort of determine how they're progressing with their rehab from a clinical standpoint. And then I would pick up their rehab and I supervised all the rehab sessions. And so the rehab sessions weren't informed by the results of the clinical assessment. They were purely based on how they performed each exercise on an individual basis as we sort of alluded to before. And so they came in for that twice per week, the assessment and the rehab.
Jack Hickey:
So the rehab was those, those exercises that I mentioned as well as a progressive running protocol, which was a relatively basic return to running plan, which started with your, your typical walk to jog sort of shuttle progressions with like an acceleration, a hole and a deceleration phase. And then that built up to a jog jog, run jog, and then like a run sprint run by the end of rehab. So that was their exposure with, with us that we controlled. And then we basically advised them about their gradual return to generally team sport training. So most of the participants were either sub elite or semi-professional footballers being down in Melbourne. Most of them were, were Aussie rules players, but we had a, a good, good batch of soccer players was a couple of cricketers thrown into mix to keep us interested over summer as well.
Jack Hickey:
But the majority of participants were, were during the winter period playing Aussie rule footy. So yeah, that was their sort of progression through the study until they, they met predetermined return to play clearance criteria. And at that point, we then compared their outcomes on those clinical assessments, the, so to, was there a difference between the PainFREE and the pain threshold group in, you know, recovery of strength? We also measured their muscle architecture. So I mentioned Ryan Timmins to you earlier. So Ryan who did his PhD under Dave by OUS long head muscle architecture, he assessed their classical length every session when they came in. So we had that as another outcome there, but then I suppose the, the primary outcome measure, which is how long did it take them to get to that return to play clearance point. And basically there was no difference between the two groups. So they both,
Jared Powell:
Before we, before we go into that, can I ask about the, so was the hamstring strain clinically diagnosed or confirmed by imaging or how that,
Jack Hickey:
So not confirmed? Yeah, so not confirmed by imaging, just clinical assessment. And so based on, you know, evidence based sort of guidelines of having pain, or first and foremost, in my opinion, most importantly, having a, a clear mechanism of hamstring strain injury, the caused acute onset posterior eye pain that made them stop what they were doing. So we had a few guys present that, you know, might have had onset acute onset pain, but then they didn't stop. And they sort of played out the rest of the game. And then, you know, a few days later pulled up a bit sore. So they weren't included in study. They had to have acute onset pain stop, but they were doing straight away then present within seven days to us, they had to have pain with help patient at the, the side of injury. And they had to have pain with range of motion assessment and also strength assessment, basically clinical diagnosis, which is certainly a, in some respects of limitation of the study and also a strength.
Jack Hickey:
I think the limitation is obviously we don't know what the the imaging severity was. And I dare say that the severity would've been on the, the lower end of the spectrum, cause most hamstring general hamstring strain ind tend to be the typical sort of grade ones. Some of them may even have been according to imaging, potentially MRI negative. The importance for us is that they were clinically positive. And therefore that's what a practitioner is going to see is I've got someone who has clinical signs and symptoms of a hammering injury. If I have someone like that, what can I do with them? So certainly in future work, we'd like to be able to have access to MRI for, for all participants. We know that some of the guys in the study off their own back, you know, or through their sporting club did get, but they weren't part of the study.
Jack Hickey:
So we certainly know subsequently from chatting with you guys, you know, what some of the MRI results were, but that doesn't really inform our findings at all. It wasn't across the board. So cool. The main thing as well is that between the two groups, there was no difference in, in clinical severity. So in terms of strength, deficit, objectively range of amount of pain at the time of injury and on clinical assessments. So we can say that at least clinically, there's no difference between the two groups, whether they're both really severe or really mild, almost doesn't matter whether the points we've got a, an even cohort that we
Jared Powell:
Cool. So yeah, it was uniform or homogenous across both groups.
Jack Hickey:
Yeah. And, and when I say homogenous, like within groups is gonna be some more severe and less, but then when you, between the groups it averages out. Yeah.
Jared Powell:
Did you measure any sort of psychosocial factors that baseline beliefs or any of that sort stuff?
Jack Hickey:
The measure we had was apart from a general clinical sorry, general subjective interview that, that you conduct as a, as a practitioner where we picked up just some, some interesting comments and things like that, but in terms of actual outcome measures, the only one was the Tampa scale of phobia, which is certainly not a you know, muscle injury, specific questionnaire or, you know, specific injury by any means, but we used it. And it was really just to give us an, an indication of whether exposure to pain during rehab would alter someone's response on that questionnaire into whether they were fearful of movement. So we measured that at, at baseline. And then once they met all their return to play clearance criteria, we then gave them the survey game or the questionnaire to fill out. So with that, we, as you'd expect in both groups, the fear of movement was much higher at baseline than it was at, at return to play.
Jack Hickey:
There wasn't a statistically significant difference between the groups, in terms of the amount of change looking at it. I mean, it looks like the paint threshold has a slightly larger change, but it didn't make statistical significance. And I think that's more down to the fact that at the time of injury, you're gonna have more fear of movement. And then as they go through rehab, regardless of whether it's PainFREE or pain threshold, their fear of movement reduced, and probably more importantly, the pain threshold approach didn't increase fear of movement. As some people might have aver to, they might feel that if I allow pain during rehab, are they going to fearful of pain because of negative experiences or something like that, but we found the opposite. It was the same, if not a slightly better response than in the PainFREE group.
Jared Powell:
Yeah. I actually think that's one of the most important findings to be honest, where it can empower clinicians to actually have the courage to load someone or prescribe an that is to their threshold, which might be outta 10 or whatever's comfortable or tolerable to that person. And I think that's something that is actually instilled into us for me anyway, at university where I was, it had to be pain free. And that remained me for the first five years of my, my professional career, to be honest until, until I started to actually investigate it a little bit further. And, and now all the tendinopathy research good for that, you know, pain during loading is, is OK. And in fact, somewhat wanted, that was a great
Jack Hickey:
One. Yeah, absolutely. And I think it's the concept of what is paying free. It, the general understanding that like when we do exercises should be paying free, makes sense, right. We shouldn't be doing exercise and getting a really high pain response. It's probably not, not what we're after, but the thing is if we, if we're staying hard and fast, PainFREE means zero out of 10 on a numeric rating scale. And that's what we wanted to look at was if, if we actually employ that as a rule hard and fast, compared to just allowing a low level, we weren't saying you can have eight outta, we, you know, said for them, if they were above a, above a four, we were pulling thes on them. So it's not to say that we just opened the flood gates and let 'em do anything, but being a little bit more flexible and more importantly, educating patient for clients on what we mean when we ask them about pain as well.
Jack Hickey:
Because I think it's important with say a hamstring strain injury. When we talk about pain during an exercise and we ask, is it, you know, is that making your pain worse? Or do you have pain when you do that? We're talking about pain specific to the side of injury, not general muscle soreness, not sort of a stretching feeling in the muscle if it's like an eccentric contraction, but we're talking about that feeling of pain localized at that side of injury. So being really clear on that, I think helped give the, the participant's confidence in, in what we were talking about when we talked about pain and that doesn't just go for an acute muscle injury. It's for you working with shoulders. It's, you know, often pain is a lot in general and it's not as focal as it might be in a hamstring injury. It be a more diffuse region of, and so the explanation might be slightly different, but the understanding that some level of is, is it's a we've is, you know, pain threshold approach to rehabbing the literature has been around for, well over 20 years.
Jack Hickey:
I mean, stuff in Emeral, joint pain from like roll Tommy back in 1997, I think it's, that was sort of the first clear sort of study in the literature where they looked at that, and then that, you know, flown onto Achilles tendinopathy with current silver, a and two. And you mentioned Jill cook and, and Ebony Rio and their research. And ebbs was a supervisor mine throughout my, my PhD. And you know, was really influential in, you know, helping us design this study in terms of talking about what pain is and educating patients on pain. So yeah, we really just took what people have done before and of look to apply, apply it to to hamstring strain injury or acute muscle injury. Yeah.
Jared Powell:
That was, it was done. So did you, so how did you, it, in terms of education to people who, for the, who had the threshold rehab, did you have a sort of around pain and hurt equals doesn't always equal harm and all these sorts of things? Or was it individualized or how did you go around that? Yeah,
Jack Hickey:
Look, it was we wanted to be consistent cause we wanted the, the message to be consistent for, for all participants. So clearly each individual will interpret it differently as well. Totally acknowledge that, but basically what happened is after their initial confirmation of hamstring strain injury, and, you know, if they then said after they've come in for that initial assessment, they're like, yeah, look, I'd love to come in and, and do some rehab with you guys. And, you know, the benefit of it being a study was it was, you know, free of charge for them. So they were like, right, cool, come in in a couple times a week and do my rehab with you guys when they were happy to, to do so. They got randomized to one of the two groups. And so I would then sit down with them and we'd go through, they'd either be allocated to PainFREE or pain threshold, and basically they'd be shown a pain scale.
Jack Hickey:
And so if you're in the PainFREE group, you got shown that pain scale and basical said, look, explain the two anchor points. Exactly the same to both groups. That zero is absolutely no pain. Ten's the worst you can imagine. But when we are doing our rehab, what we want you to do is we only want you to continue exercise if you write down at the zero end of the scale and the PainFREE group. Cause we think that if you are somewhere on that scale, you know, the, we didn't necessarily, we didn't wanna put fear into them. We just said, look, that's that's what's recommended is that we remain PainFREE during exercise. So therefore we wanna keep you down at that level. If you report, you know, anything on that scale, we're just gonna make the exercise a bit easier or, or regress it slightly. Whereas in the pain threshold group, we show them that same scale and say, look, we're actually happy due to keep exercising up until four out of 10.
Jack Hickey:
So anywhere on a, you know, from 0 1, 2 or three, four, we're okay with that didn't mean that they have to hit for every time. It just meant that if, when I asked them when they were doing a double leg bridge, how you feeling that? Yeah, not too bad. Like a two outta 10. Yeah. That's cool. Keep, keep rolling on through. And the other important caveat was they had to also feel comfortable continuing. So if they said two outta 10, but I don't wanna keep going. Well, they can stop that's that's on them, but it was educating them that we think that's actually. Okay. And so what I found quite interesting is a clinician is working with these these guys in both the pain friend, the pain threshold group, after a certain amount of rehab sessions, they probably had a bit of a learning effect where if they were someone who wanted to push themselves and be more progressive, even if they were in the PainFREE group, they quickly learned that.
Jack Hickey:
Well, if I say zero outta 10, I'm gonna be able to keep doing this exercise or potentially progress if I do it well enough in the pain threshold group, by the same token, if someone was a bit more conservative, all of a sudden the magic number for them is five. Cause they know when they say five, I'm like, okay, we gotta pull you back a little bit. So it's a perfect system. But I think it's certainly in the pain threshold group, we didn't have many cases of that, where it appeared that guys, you know, wanted to stop. They were, they were pretty willing to push. And, you know, I found even in the PainFREE group, most guys were pretty keen to, to push through and a little bit of discomfort often wasn't they didn't see it as a barrier. So my general advice to people, particularly with hamstring strain injuries, if someone feels, if a patient feels comfortable to continue with the exercise, that's probably totally fine.
Jack Hickey:
Regardless of what number they called on a pain scale. If you say to them, do you feel comfortable continuing we're we're probably pretty good with that because especially with gym-based exercise, it's generally fairly slow in control, especially in early stages of rehab too. If something doesn't start to feel right on rep number six, we can, we can intervene maybe a little bit different. We say we might need to be slightly more conservative when we get up to like high speed running and that sort of thing where it's a little bit more of a less controlled environment and team training and that type of thing. But by that point, hopefully exercise is, is
Jared Powell:
Muscle injury versus a, a chronic or persistent, vague musculoskeletal pain where they're the ones who often report sort of potentially their report of pain is not related to the, to the peripheral tissue versus in the acute. It's more like, okay, if it hurts little bit, that's fine, but they're, they're more likely to actually speak to that accurately versus in the population that I see usually with, with typically chronic shoulder pain, it's more, any pain that has to be avoided and they hypervigilant and they're really fearful. And so we more have to go down the, the pathway. Well, it's okay to have a little bit of so on and so forth. So I think that kind of highlights the difference between sort of acute Al injury, especially in young athletic males, by the sounds of it versus a different population. So I think I should consider.
Jack Hickey:
Yeah, absolutely. And it's certainly, I believe there would be be some, some real differences there, but by the same token, it would be interesting to know the correlation between actual tissue damage and the amount of pain reported in, in an acute in injury cohort as well. So if we did have access to MRI, you know, is there a relationship there? The interesting thing for us is the amount of pain reported during clinical tests, certainly didn't correlate with their progression through rehab. So that was probably for me, the independent of the actual findings of the RCT. We've got some of that shows that there's a real lack of relationship between not only pain, but also deficits observe on range of motion and strength testing and someone's ability to perform gym based exercise or, you know, things like eccentric or even running progressions be that's really important.
Jack Hickey:
Cause it says that those progression criteria of being pain free or relatively symmetrical on a clinical measure before moving to the next exercise, they're really not related. And so we need that more individualized approach. So data that we're, we're working on and have been for a long time trying to, to get it published, it's hard data to get published because it's sort of it's observational data that we found throughout a randomized control trial. So sort of fitting to a typical study design approach and writing up for journalism challenge, but it's something we're working through and it's data we've presented and talked about conferences and things like that. And it's people have had interest in it. So we really trying to get it out there.
Jared Powell:
So if I clarify, so what you found observation with the, at pain and strength and function weren't correlated, meaning you could have sort of higher subjective reports of pain, but also pretty good strength and vice versa as
Jack Hickey:
Well. Yeah, so that is one thing. Certainly if we just look specifically within clinical assessments, you know, you'd have some guys reporting high levels of pain, but they're between li asymmetry and say isometric strength objectively measured you know, might have been well within 10% or they might have reported no pain, but had big deficits. But to me that's actually makes kind of sense in a way, because if, if we both again take the case that we've both gotta grade two hamstring strain and we present on day three postin injury and we do a 90, 90 knee flexer squeeze. And let's say you give it a real crack, cause you're a bit less fearful of pain. For example, when you have a real crack and you actually get the same strength score on both legs, but you report a seven outta 10 pain cause you had a real crack at it.
Jack Hickey:
So, you know, you, you gave a bit of a nudge, whereas I'm conservative. And so I hold back, therefore I've got like a 50% strength deficit, but I didn't push to the level that would elicit any pain. So there is a bit of a lack of relationship there potentially, or an inverse relationship in, in some senses. But more to the point, it was more that when we go back and look at this data, we can see guys who were able to do what it typically thought to be end stage exercises, such as single leg loaded back extensions with, you know, 10, 15 kilo plate or naughty hamstring exercises through nearly full range. Being able to do those sorts of exercises in their first couple of rehab sessions, maybe well within their first week of rehab, which in typical protocols are recommended to not be introduced either based on time, like as in, towards the second or third week of rehab, or if based on criteria, the criteria is typically being paying free and relatively symmetrical on clinical testing, like, like wrong testing.
Jack Hickey:
What we found is because we progressed each exercise individually, regardless of their clinical profile, we go back and look at their clinical profile. A lot of these guys still had big between limb deficits on strength and they were still reporting high levels of pain sometimes like six, seven outta 10 and deficits on a, an isometric squeeze test. Yet when they came into the gym, they were able to do a bilateral slider. They progressed to an Nordic and they could do, you know, six reps of an Nordic with absolutely no pain or maybe one or two outta 10 pain. But do it even with relative between lymph symmetry, when we measure them, say using an board, for example. So there's a lack of specificity with our clinical tests in terms of how much they tell us about what we can do in rehab. And for me that's the most important clinical message.
Jack Hickey:
Cause if I'm a practitioner holding someone by because they haven't achieved symmetry or they're not paying free on a clinical test and I'm not exposing them to say an eccentric stimulus cause of that, I'm potentially underloading that person. Whereas they could be doing that loading much earlier, getting the stimulus required for adaptation, which we know by introducing them earlier, we actually do get changes. So we, we saw in this cohort, regardless of group allocation, we saw increases in classical length. We saw increases in strength and we saw relative maintenance of that. Those changes couple of months after rehab as well. So we know we can actually get change if we implement this approach, not to say it's a perfect approach, but there's the potential that we might be. Underloading people, if we implement criteria that aren't related to the task that we're saying, they might, they, they might
Jared Powell:
Be doing. I gotcha. So there was there wasn't a, an IR one Toone relationship between your clinical testing versus what they could tolerate in a rehabilitation setting.
Jack Hickey:
Absolutely. So
Jared Powell:
That's so if I, if I relate that to the shoulder, which is what gonna me saying, you you've Nonsense, not yeah. Any sense when you think about
Jack Hickey:
It and when you boil it down, you go again, I don't think this is, it's not a novel approach. People are, are already doing this when they prescribe their exercises, they don't actually go and look at their clinical tests and then do it. That's not really what we're saying, but what we're saying is that if you look at particularly hamstring injury rehab protocols published in literature, that's, that is what they say. They say, don't do these exercise, you've this criteria. So that's why we're keen to get this data out there. Even though we know that practitioners are probably already doing a lot of this stuff, we need to confirm that it is actually safe. And that as you mentioned, you know, just because someone has an internal rotation deficit doesn't mean they can't jump on a bench person, punch you out a 75 kilo bench with no pain, no problems.
Jack Hickey:
They might have, you know, a lot weakness when you do a resisted external rotation, strength test doesn't mean that they can't do, you know, some sort of overhead drawing route they might be able to. So I, I like to think what we do. It's, it's not, it's not that groundbreaking. It's actually common sense. If you wanna know, if someone can do something well, firstly give them a slightly you know, less intense version of that and gradual progress them up rather than trying to come up with a kind of like a miracle test. That's gonna tell you, you know, crystal ball, all right, next session. You're going to be able to do this cause at the end of the day, well, I can save you a lot of time and not even bother doing that. Let's keep in the gym and let's see if you can do it with two legs first. Can you do that? Yep. Cool. Any pain? Yeah, little bit. Oh, well that's not too bad. Have a with one leg. Is it okay? Actually bit too much. Cool. We'll regress it quick, simple. That's that's what we wanna go with.
Jared Powell:
But then you're taking away the, the guru and know these tests and know cluster blah, if all, and to we we have drawn to that if I have three tests, which give me a sensitivity and specificity of this, then I know with certainty, which fits into my worldview and doesn't challenge me too much that this person shouldn't be doing this activity or this person has this particular Anato won't, but in the same with patients and with they want, they want it, it needs to make sense and be coherent to them as well. Right? So they're like, well, this physio did a restricted me flexer test on me and it hurt my hamstring and I'm not OK to run until that is negative. And that, that makes sense it's effect, but the pain is not causing effect.
Jack Hickey:
And I think that's an important point. Cause it's not to say that we should throw the baby out with the bath water as well. I'm a big believer in doing a good thorough clinical assessment, but it's understanding why you're doing it. That's important. So the reason for me, as a, as an exercise physiologist, why I would a clinical assessment on some is to identify what are their clinical deficits in a, you know, an objective measure of strength, range of motion or function or, or otherwise what are their, you know, deficits? Because sometimes those are actually well correlated with things like the time that it's gonna take them to get back to sport, or maybe it's gonna be related to their longer term functional outcomes. If it's, we're talking about something like Neo osteoarthritis or you know, other populations. So there's still a time and a place and a purpose for doing these tests where I don't think it's very relevant is to tell you that same day, what are they going to be able to do on the gym for?
Jack Hickey:
And there might be cases where it is more related, but as a general rule, if I wanna know that I'm gonna get them on the gym floor and do something lower level and then progress them. So it's important to know that we're not trying to say you shouldn't do a clinical assessment because there's some great work out there such as rod Whiteley's work from, from Asar where, you know, he's shown some, some nice relationships between particularly deficits in out range, strength and with PELP patient and being able to give a prognosis for return to play. And we know how important that is for particularly hamstring strain injury in a, you know, which can be one to two weeks. So there can be six to eight weeks giving a relatively informed prognosis, but as rod would fairly admit, like that's also not perfect, you know, there's going to be outliers within that data as well. So it's about understanding why we're doing those tests and just clarifying that. And some of those tests that are also used as criteria to return to sport. So once someone is pain free on an asymmetric and has an equal range of motion and no pain with palpation, you know, they're often guidelines that are used to say, okay, we're ready to return to fulltime and training for example, that that's what is out there at the moment. So
Jared Powell:
Yeah, so I think use your clinical testing, you know, to be a good clinician, rule out pathology, confirm your diagnosis, et cetera, cetera. And you can get a how that tolerates load for example, but then don't have that completely inform exercise prescription, you know, use some other variables in there as well.
Jack Hickey:
Yeah. And again, it's not in absolute it's it probably informs to an extent, but the point we're trying to make is that if you are employing that as an absolute rule, you cannot do this exercise until you pass this criteria. Well, that's bit of a fallible approach, just like, you know, the exercise specific approach that we employ, just because you can do 10 reps of a double leg bridge. It doesn't mean the same session you are going to be able to do a single leg bridge just means that you can do a double leg. So we can now start progressing you towards a single leg bridge fairly safely. It's not perfect. It doesn't doesn't predict. And it doesn't tell us and this sort of obsession that's with prediction and being able to say, you did this today, she's going to do this tomorrow. Like we all just need to chill out a little bit, I think, and just realize that we don't have to have all the answers, just have the system in place that right.
Jack Hickey:
If this happens, you can try this. And if that is okay, keep it pushing up until a certain point where we want you to then bring it back and find that place. That's what we we're trying to do here. We're not trying to say that I'm gonna know in two weeks time, Jared, exactly what you are gonna be doing in your rehab sessions. Got no idea. I might have a guess at it out of experience, but you know, I'm probably gonna be wrong, you know, 50 times. So I'm just gonna give you some guidelines to say, look over the next week. Cause in private practice, especially we might see someone on a Monday morning after they pop their hand on the weekend. We might not see them again until the following Monday. So rather than just give them a set of exercises to do for that week, which doesn't allow for progression regression, what we need to be better at, in my opinion, with, as prescribing exercise is prescribing the rules for progression regression.
Jack Hickey:
So saying, all right, jar, I'm gonna give you these three exercises to start with. We'll have a crack at them here in the clinic and make sure you can do do them. Okay. And then we can maybe individualize a bit more, but then you're gonna feel different tomorrow. You're gonna feel different again on Thursday and different again next Saturday. So when you do each exercise, if you do the prescriber at range and it feels relatively easy and you've got a low level of pain or less, then I'm happy for you to progress that and start trying a single leg version, or I'm happy for you to start adding load just like you do. If you were prescribing a general program for a 16 year old and wants to put on a bit of muscle, doesn't have any injury just saying, right. You know, you gonna start with this then gradually progress. But if it starts to hurt too much or your form, you know, isn't that good, then we're gonna bring you back. So I think that's what we need to do as exercise professionals and exercise prescribing exercises, an intervention is not just prescribing intervention, but tell someone how they progress. And cause for me, that's a missing ingredient a lot of the time.
Jared Powell:
Yeah, mate. That's yeah. We, that's such a, that's such a good point to, to keep it moving along. How about, so what happened with so return to play was the same in terms of time was the same between both groups. What about re-injury right?
Jack Hickey:
Yeah. So it's important to note and as well with the return to play was time to return to play clearance that we use as our measure rather than actual return to sport. Cause we there's a lot of confounding factors there in terms of different sports and excuse me, different levels of sport been talking too much and all that sort of thing. But yeah. In terms of meeting those criteria for return to play clearance, there was no difference between the two groups which tells us that campaign threshold doesn't accelerate. That that time it does mean is that it didn't didn't things at all. It was no different. And more importantly, within the same timeframes, we saw some greater improvements in strength and also muscle classical length, which means that it didn't take longer. It just took the same amount of time, but with maybe a bit more exposure or earlier exposure, we saw some, some greater improvements in, in function or, or muscle structure is in the case as well.
Jack Hickey:
As far as reinjury goes, we need to be a little bit careful interpreting findings there because we did follow them up for, for a six month period afterwards, the difficulty with any study where you looking at re-injury particularly like hamstring injury study, you need really big numbers. And so as mentioned, we had 43 participants, which in a couple of years, as part of PhD project, I was stoked with, but in the big scheme of things, it's nowhere near enough that know anything about re-injury risk. The good thing is there was no difference between the two groups and we had a, an overall, relatively low re-injury rate. So we had two guys in the PainFREE as well as two guys in the pain threshold group that that suffered injuries. So you can't say that there's any difference. There obviously it's the same amount, but to statistically analyze it, you need much bigger, much bigger numbers to really know what was most interesting with the re-injury data.
Jack Hickey:
Was that three of the, if you just pull all the four Rangers together, three of those four Reju injuries in these cohort occurred in guys that returned to sport, oh, sorry. Occurred within two weeks of return to sport. So that relatively quick timeframe for, for return to sport you know, might enhance your, your risk of injury. So it tells us as well that our criteria for return to play clearance, certainly isn't perfect. Obviously we didn't use things like imaging. There's been some recent work getting out of Asar that shows that from a hamstring injury, you don't need to have complete resolution of signs of injury on MRI to make a full return to sport. So how do we know when you should? And when you shouldn't, it's a really challenging, probably the most challenging decision with, with having injury rehab. So yeah, for, for those major outcomes of return to re injury, no difference between the two, there was the only subtle difference that we observed was that strength that return to play clearance was greater or the improvement was greater in the pain threshold group within the same timeframe.
Jack Hickey:
And at two months follow up, when we looked Atal length, the improvements achieved throughout rehab were better maintained in the pain threshold and the PainFREE. So they're only subtle, subtle differences, and certainly PainFREE group still made significant improvements in strength and muscle architecture. So if you're a bit more conservative, you'd rather remain PainFREE, that's probably okay. But we know that it is safe to allow low levels of pain. And more importantly, that in both groups we saw improvements in those strength, architectural variables by prescribing exercise, the way we did it as a relatively individualized approach. For me, that's, what's the most important finding I think.
Jared Powell:
And it's interesting. So better strength perhaps in the pain threshold group trend towards better muscle architecture, but still same sort of injury rate as well. Even though again, with the analysis of that statistically. So, but that, that's another interesting point and something that I'm looking at a little bit in my PhD, can't, can't reveal too much about it at the moment, but looking at the relationship between strength and whether that predicts the onset of pain or injury, and it's a tenuous link if I'm want. Yeah. That's another rabbit hole we can go down, but it sort of speaks that a little bit as well, doesn't it?
Jack Hickey:
Yeah, absolutely. You know, and the someone's profile at return to play is often not very indicative of whether they'll get ranged or not. It's probably got much more to do with their exposure to high speed running, you know, even during rehab, but also afterwards their continuation with you know, preventative stimulus as well. That sort of thing. So, and I think, again, it's rod Wiley, he sort of talks about like the stronger athletes are often the ones that go on and get reinjure. So in terms of absolute strength and isn't that just because they're exposing their previously injured muscle to high levels of force, you know, I touched on earlier when we were chatting, you know, I was never quick enough to tear hammer me. I probably was never strong enough either. So I probably wasn't putting enough forces through my hamstrings to, to elicit to hamstring injury.
Jack Hickey:
So certain individuals are just more prone prone injury. So it's a real challenge. And again, it's trying to come with that magic test that tells this you will or won't get rein injuries, probably a very limited approach. And it's such a multifactorial injury that if we're only looking at strength, we're only looking at architecture, or we're only looking at high speed running where we're not considering how all those pieces of the puzzle might fit together. And a lot of the time just general, you know, would progressive overload and, you know, return to training programs. And once someone's backing the team environment, making sure their exposure to training is graduating. Things like that is probably more important than what they actually did in rehab. Anyway. So
Jared Powell:
Yeah. And just so, so injury is a Aline, right? And it's when we say injury and in this case it's probably really relevant for your paper. Cause there was no path anatomical confirmation via an MRI. So perhaps there was a perception of pain in the area without any corresponding actually tissue trauma, pain, pain is pain is not just related to tissue damage. It it's the potential of tissue damage as well. So yeah, so that's, that's another, a really fascinating point. So, so injury or pain can come on fire a number of different factors. It can be to their sleep hygiene to, are they having any psychosocial stress outside of the environment is theirs around contract or they fatigue all these sorts of things. Right? So yeah, it's the re-injury thing is really hard to, to investigate or examine too deeply because it's so multifactorial.
Jack Hickey:
Yeah. And, and at what point in time with a hamstring injury is an example is a, re-injury a recurrence of that original injury or is it a new injury and challenge with that is we know that, you know, the hamstrings take a long time to actually structurally remodel after an injury, a long time after people generally go back to sport. And we probably suspect that that's why we see those high rates of re injury within generally the first two weeks to three months following hamstring strain. And there's a good argument to say, that's we just don't, haven't allowed enough time for it to actually heal. But the problem is if we then hold everyone up for an extra two months in rehab, or what happens to all the guys who were able to successfully go back to sports. So where do you draw the line?
Jack Hickey:
It's ones like the argument with ACL rehab and saying, you know, you have to have a minimum of nine months or 12 months or whatever. You know, what, if I am the athlete who is fine at nine months or six months, you know, I'm gonna be pretty off if you told me back, but I actually could have gone to the Olympics in six months time. So it's such an individual thing. It's, it's really challenging the argument of whether it, the hamstring strain injury is in fact, an acute injury or is it a chronic accumulation of damage? Like, and it's just the straw that broke the camels back rather than one acute event. You know, there's a, an interesting discussion point there as well. So the concept of acute versus chronic sports injury or muscular skeletal injury in general is, is quite interesting, I think. And, you know, we mentioned, and you mentioned the shoulder obviously is generally speaking, being thought of as a more chronic injury, but of course you can still get an acute presentation of shoulder injury as well. And same with a hamstring injury, you can have sort of more of a chronic onset of, of pain and that sort of thing. So what do we do with those individuals? It's yeah, that's a bit of a Pandora's box once you're stuck into the, that level of think.
Jared Powell:
Yeah, because, because we're talking about pain and it's always gonna be a Pandora's box because then, then you leave it open to individual beliefs and societal beliefs and et cetera, cetera. So I think how you did it was, was, was excellent in that you kinda focused on what you could control and then had the two different groups, pain threshold, whatever that means for, cause they, I don't know how many of the words 22 or 21 in that group, but that person would've had an individual belief on what pain is and they may have felt pain differently as well, but you, you take it as a whole and you can say on average pain threshold rehabilitation in that group, certainly wasn't damaging to their recovery and perhaps was, was beneficial. And I think that's the point.
Jack Hickey:
I think one thing that I, I didn't, I should have touched on before when talking about the setup of this study as well, is the, when they were allocated to their, to their groups both groups at that time and also throughout the whole duration of this study were unaware that there was another group. So they just got told that, right. You're in, you know, you are doing pain threshold rehab, like you are, you know, now allocated to this group, they basically just got handed an envelope that they opened in that envelope contained information about rehab. And so that information was either about PainFREE or paying threshold limits. And so I think the strength there is that there was some, some blinding of the participants to an extent because they, they were blinded to the, I guess, chances of another intervention. So if you were in a pain group, but you knew that, you know, as the other guy is getting pain threshold rehab that comes in on a Wednesday, you might start to think, well, I wanna do that.
Jack Hickey:
I wanna push harder. Whereas they're thinking that they're both thinking that they're getting what is best practice effectively. So there's a buy-in and there's a belief in effectively. We didn't know what was best practice and technically speaking, we still don't really. But it's getting that buy-in from someone to say that, well, yeah, this is why I'm doing it and I'm agreeing to it. So therefore yeah, we're on the same page. And then there's, there's some gray within that. As I mentioned before, where guys might, they just change? What for them, what a one out 10 means is different to what a five outta 10 means for someone in the pain threshold group. Cause those BARR shifted.
Jared Powell:
Yeah. The, the best practice thing is funny, isn't it? Because still both groups did exactly in essence. So there's still probably no best. There's still two ways of looking at the best practice guideline. It's the same, it's the same in the shoulder, not one way of exercising or rehabbing a shoulder is not superior to another. We know that we know isometric eccentric, concentric, isotonic, open chain all has the exact same outcomes to, so perhaps it's just getting that person moving putting a little bit of load through their system as they allow. Cause even though it's four outta pain threshold, it's still tolerable. You know, it's still, that person feels comfortable. They don't feel threatened by it not overloading their system. So it's still, it's kind a variation of the, a similar, it's just irritability of the symptoms. Right? You say, don't do something you don't wanna do.
Jack Hickey:
Yeah. And I mean, that number is said, came out of, it was largely from the pain monitoring model. You mentioned Tommy before, like that original model is sort of zero to two being, being completely fine. And then two to five being sort of safe, but just be a bit wary. And then above that we wanna stop that we can employing that same model. And then we just thought, well, we're just gonna adapt it slightly. And to be honest, it's a very arbitrary decision. We say, well, rather than five, let's go slightly more conservative and just knock down to a four, but probably wouldn't have made any difference if we said five or four, to be honest. Technically speaking, it's actually the same rule. Cause we, when they hit four, they were still able to exercise at four really five was the limit. If you're looking at it in that respect, the problem is what if someone says 4.5, cause guys will do that.
Jack Hickey:
Or, you know, they play around within those scales too. Yeah. It's, it's, it's interesting. And I think, you know, you can worry too much about the arbitrary number aspect, I think, as you mentioned, it's they feel comfortable to continue and their description of the pain. It's like, yeah, look, it's a bit uncomfortable, but I'm, I'm happy to continue. I'm absolutely confident that that person's gonna be OK. Whereas one says, oh, it's a one outta 10, but it's quite sharp. And I'm really just doesn't feel good. I'm gonna pull that. Even though if they're one outta 10, you know, that understanding of a pain scale, but what they're describing to me doesn't sound, they don't sound confident to continue. And me pushing them is probably gonna lead to a bit of a negative response from them. So it's gotta be quite individualized, I think in terms of your approach yeah. Everyone and particularly those with the previous injury versus those are first timers potentially might respond differently as well in terms how tolerable they're or how cool they're of pain, but depending they've previously been told as well. So that's a big thing is they've they've seen someone else previously who's either really pushed them into pain or said, no, you've gotta completely avoid it. Pain is bad. It's gonna cause damage. So their own beliefs and past experiences are gonna inform what, what happens
Jared Powell:
Hundred percent. It's just hard to capture that in an average population, isn't it. But I think the key take from, for me from your, is that the absence of pain during rehabilitation is not required. So think to be honest, that's that that should inform or actually be applicable to every clinician who was watching this in their practice the next day. And I think you can extrapolate it to other musculal injuries as well. I don't think it just hamstring pain, individual irrespective of where you that.
Jack Hickey:
Yeah, absolutely. I think if you, if you had to just put one line on it and sum it up, which it's a somewhat deflating experience mate, when you, you do X amount of years of work and it comes down to one line, but effectively that's what it is. It's like what we've been able to show apart from is that it's okay to allow low levels of pain during acute muscle injury or hamstring strain, injury rehab. You, you don't have to have complete absence of pain. Yeah. That, that is what, you know, it's, it's no more complicated. It's no more exciting than that. Whether you think that's interesting or not is then up up to you. And you kinda just have to, as the person who done the studies, put your ego to the and say, yeah, hopefully that's contributed
Jared Powell:
If it hasn't. I think that, I think that's actually really good. I think it was, I dunno, it was Einstein Orman or something. You said that if you have a, if you have a formula, you should be able to write it on your shirt. So think
Jack Hickey:
We're past, if I'm being to Einstein, you're trying to over.
Jared Powell:
I, I you've, well, it was a, it was a really terrific paper. Thanks. Thanks. Very for coming on and having a
Jack Hickey:
Pleasure
Jared Powell:
Mate, I've heaps, but I'm so up publications should be.
Jack Hickey:
Yeah. I mean, like I mentioned before, there's probably at the moment due to the COVID restrictions, it's a frustrating time. Cause we can't really do a lot in the lab and we can't be recruiting participants in doing face to face stuff, which is it's frustrating. Cause it's what we love doing is, is research scientist. So it's it's yeah, it is what it is, but same time, very fortunate to still be in a job and being able to do what we do more so from a teaching perspective at the moment. So that's sort of the focus right now. But the, the other benefit is it gives us some time to work on those things I alluded to before where we've still got data that was, you know, collected quite a long time ago now that we're still trying to push out for publication. And now the R CT is out there and has some recognition.
Jack Hickey:
I think that makes it a little bit easier to hopefully publish some of that work. And a lot of people are there who, who followed our group our group's work or maybe seen as presenting conferences or probably well aware of some of the findings that, that we are trying to get published at the moment too, because we have discussed those observational findings previously, and I've discussed them here too. But to get them out in, in print in the literature is, is really what we're, we're striving for at the moment. So definitely a challenge. And I'm sure, you know, you you'll go through similar things to your PhD self, but that's all part of the process. And, you know, once we get get that and once we then hopefully start collecting data again, you know, we've, we've got ongoing projects, you know, some small lab based pieces of work, but then also for myself wanting to do some more rehab work and particularly delve a little bit more into the, the high speed running side of things and how we can maybe be best implement that in rehab.
Jack Hickey:
And yeah, sort of what's the, I guess my overarching thing with particularly any kind of rehab that Hammi rehab is, is not over complicating it and how can we simplify things as best possible to get good outcomes for, for a clinician practice and hopefully our RCTs gone some way to, to doing that, but there's certainly a lot more work that needs to be done to, to optimize for one of the better term what, what we doing rehab. So that's the, the long term AATE, but in the in the meantime, we'll just get through isolation and yeah. Try not to try insane sight.
Jared Powell:
Yeah. thought are with you guys stay of the border down in Victoria, going through a tough time. Don't, don't come to Queensland, whatever you do's police everywhere.
Jack Hickey:
I've been warned off, mate. We'll stay away at the moment. So we'll bell be lots of new hobbies and stuff that will be taken up a lot more people in worse situations than us mates. We'll be right.
Jared Powell:
Are you on social media or anything? Where can people find about you?
Jack Hickey:
I am, I'm not very active or probably more used used Twitter when we research to, to obviously just people aware of that and more than having to engage conversation with people though through social media. So I think my Twitter handle if I bring it up, I think it's just my name using the Twitter handle. Some people use I quite a lot unless you wanna see photos of me and the misses on a holiday. It's probably not that to be honest. So yeah. Look, Twitter is probably where I'd, you know, keep things a bit more academic. And it's a good place just to touch base. And if people wanna ever have a chat or have some questions related to our research, I'm always more than happy to chat. I find that it helps drive good convers. It helps us as research is even, even with the clinical background, stay in touch with what people are doing day to day, because although I still consult a little bit, it's, you know, a very limited amount of time. So you feel like you do lose touch a bit with what's happening. So I, I love having those discussions with people. So yeah, more than happy for people to reach out and have a chat.
Jared Powell:
Awesome. All right, mate. We'll we'll leave it there. Thanks very much. And stay safe down there.
Jack Hickey:
Good man. Thanks jar. Enjoy the sunshine.
Jared Powell:
Thanks Todd. See ya.
Jared Powell:
Thank you for listening to this episode of the shoulder, your podcast with Jack HKI in the time that has elapsed since July, 2020, when we recorded this conversation, the content discussed is still accurate. And up to date, if you want more information about today's episode, check out our show notes at www dot shoulder, physio.com. If you like what you heard today, don't forget to follow and subscribe on podcast, player of choice and lever rating or review. It really helps the show reach more people. Thanks for listening. I'll chat to you soon. The shoulder physio podcast would like to acknowledge that this episode was recorded from the lands of the Uganda people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning and working from every day. I pay my respects to elders past, present and emerging and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
