Jared Powell (00:11):
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 from a qualified health professional before proceeding.
Jared Powell (00:46):
Today's guest is Franco Impellizzeri. Franco is a returning guest on the podcast, having previously been on the show, talking about the Nordic hamstring exercise with Kristian Thorborg. That was episode 17, if you keen to give it a listen. In this episode though, I'm interested in the ongoing debate about injury prevention, which Franco and his colleagues have recently published on. If, for example, we give an athlete an exercise program to prevent an injury, say an ACL injury, and that athlete subsequently tears their ACL, does this mean we should refrain from using injury prevention in our common vernacular? Or should we soften our language and use terms such as injury reduction and injury mitigation? Also, what are the ethical and legal consequences of saying prevention, but then not preventing, or again, are we just getting bogged down in linguistic games, which seems to be commonplace in contemporary health science discussions?
Jared Powell (01:49):
We'll see what Franco reckons, and then you as a critical thinking person can make your own mind up Before we start the podcast, a quick note from our sponsor, Clinico Clinico is a practice management software that's used by 65,000 practitioners worldwide. It's great for busy physios, which is why it's an endorsed partner of the Australian Physiotherapy Association and the Charted Society of Physiotherapy. In the uk, you'll find everything you need to run a successful physio practice in one place, like treatment notes, digital forms, online booking tools, customizable body charts, and much more. Clinico meets privacy legislation for Australia, the uk, the US and Canada. So wherever you base Clinico will help keep you compliant. Charitable donations in giving back are a big part of Clinico. A minimum of 2% of all CLINICO subscriptions are donated to charity each month, which means more than 1 million Australian dollars in total has been donated since Clinico was founded. Shoulder Physio Podcast listers can get 60 days for free. Signing up takes less time than this message. Visit clinico.com/shoulder hyphen physio. Without any further delay, I bring to you my conversation with Franco Impellizzeri. Franco Impellizzeri, welcome to the show.
Franco Impellizzeri (03:06):
Thank you again for the invitation. Happy to be here again. Yeah, it was a long time.
Jared Powell (03:13):
Yeah, yeah, yeah. We, we, uh, we spoke episode 17, the last time you're on the show with Kristian Thorborg talking about the Nordic hamstring exercise. So, so listeners kind of know who you are, but in light of that, because everybody knows who you are, because you're kind of famous these days, Franco, I'm not gonna ask who you are, what you do, what's a normal Monday to Friday. I wanna ask you through or four quick questions right off the bat so we get more of an idea about what makes you tick. Is that okay with you? Perfect. All right, good. So number one, what is your favorite sport or physical activity to watch, observe, or participate in?
Franco Impellizzeri (03:56):
Well, that's a tough question because I don't want to disappoint anyone, but I, uh, my sport where I grew up is combat sport. So I love combat sports. I love, uh, boxing and mma, any, any combat sport, uh, uh, when there is a, on the tv, someone fighting , which, so yeah, combat sport are my prefer. Even if I haven't, I haven't studied combat sports actually for various reasons. And also now not that much, but when I could, I also practice, uh, combat sports. Other than that, in sports in general, but now it's more complicated because in the last I say 20 years, uh, working in this area, the inter when, when I watch a game, it's, it's different. It's always trying to figure out some something. So I, I don't really enjoy while combat sport I enjoy because I don't think about any science or whatever. I just watch, enjoy.
Jared Powell (05:08):
You just get to switch off and, and enjoy it. Yeah, that's, that's, that's good. Okay. Number two. This is a bit of a personal one, Franco. So excuse me. What is your biggest failure and what did you learn from that experience?
Franco Impellizzeri (05:21):
Well, I don't know if I can identify a single big failure. I had a lot of failures and I, I, I think that what I could do is to use the failures to improve. And again, this is related to my, it is a cultural issue maybe, and it is related to my history, because when you fight, when you lose or you give up or you train harder, and I used to train harder. So this is interesting because I'm, I'm actually actually working since the lack of time on a paper in which I want to show my errors. Uh, because, you know, when you work a bit, now I'm working a bit in meta researcher, so I'm con I'm investigating the quality of research of other people, but people may complain because it seems they are punting the finger, which is not true. Actually. This is meta research and this is why use it for, but that's another maybe topic for another, for another podcast.
Franco Impellizzeri (06:24):
But I, I was thinking that I can show using my errors what other people can, can learn. So I, I will say that I, I consider the errors and the failure part of life. I think that if you are smart, you transform these as, uh, opportunities to improve and to become better. And if you just, uh, uh, uh, live these, uh, experiences in a passive way, you don't get anything from them. It's, it's just a negative experience and nothing else. So, yeah, I think I had, I had, um, well, uh, my biggest failure probably is not related to science. It's more personal. For example, the, the time I didn't dedicate to my family in the past, that's probably what they suffer more, but yeah, now they are, my son are own. They, they're , they're independent, so
Jared Powell (07:22):
Living their own lives. So it sounds, it sounds like being a good bayesian learning from your experience, right? Updating, updating your beliefs and your priors. You try something, you fail, you try again with more information.
Franco Impellizzeri (07:34):
Yeah. The secret is, uh, avoid to start to be too strong priors, because, uh, yeah, because that's that, and this is actually part of my studies or my articles are pushing that direction. Because if you think that some intervention can be so effective, you start with a strong prior when you implement, or when you read literature not supporting this, uh, this idea that you, you you created, uh, in other people and in yourself, it's much more difficult that you, you change your behaviors or your practice. So having priors that are balanced and really commensurate to the evidence, for example, it's something usable, not only in science, but I think in life.
Jared Powell (08:25):
Yeah. I, I totally agree. It's something we should all strive to do, sort of however we must, we must say it, it is hard to do, isn't it? It's very uncomfortable to do. It's, it, it doesn't feel good when you, when you have a particular belief and, and something comes out that challenges that belief. And so I guess that's why you say keep your beliefs as neutral and as commensurate to what the, the literature says as much as possible, and don't get too attached to a particular belief.
Franco Impellizzeri (08:52):
Yeah, you should, uh, this is something I suggest to my friends also, when you work for a team, whatever you say, uh, don't be too prescriptive and don't be too, um, don't communicate too much certainty. Mm-hmm. Cause if you say, no, we have to do this because this works, and there's tons of stuff is a, and these kind of things, and something happened that, uh, in theory should lead you to change idea. You don't, because you, you said to something, uh, to too many people, you don't want now to change or, you know, you want to avoid to look Canadian or something like that. So the only, you have to prevent the situation that I, I know it's uncomfortable because it happened to me in the past. Mm-hmm. , uh, the difference is that when it happened to me, I also tried to to, to support my old ideas in a biased way. But I knew I was, uh, supporting something that in reality, I probably didn't believe anymore. But yeah. So it's better to prevent that, uh, than, uh, to, to, to cure, you know? So
Jared Powell (10:05):
Prevent is a, prevent is a topical word for today, Franco. We're gonna come back to that in a, in a minute. Um, okay. Number three. How on earth has Italy not qualified for back to back football World Cups? What is going on over there?
Franco Impellizzeri (10:21):
Well, uh, I have to be careful what I say, but , um, I think the problem is, this is something I experienced several times. Italy is a country where some, you don't always have, uh, the support that you would like or, or you would deserve as a support, uh, system or whatever. But, and this is the reason why Italians are quite flexible, let's say, because we survive, we have to survive in several situations. So sometimes even if we don't have the strongest team or, or the strongest support in a way or in another, we, we, we survive mm-hmm. . And surviving sometimes means also qualifying for, for, uh, for a work cup or winning the European championship. And not qualifying after for, for the work cup because, uh, uh, this happens when you don't have a system. I always say that when the success are, the successes are random is because there's no system behind.
Franco Impellizzeri (11:30):
So you cannot, uh, um, um, you cannot make systematic, the performance is, is very raonic. And this is, for example, uh, uh, something that in, in industry, in the process control, you try to, to control. If you read the literature on, on, uh, quality management, these kind of things, you, one of the first thing you learn is that variation is considered an indicator of low quality. Cause when you cannot ensure the same standards and you have very good products and very bad product, this is considered bad. And, and, and there's no system behind or there's no enough control, uh, on the system. So I think the problem is that Italy didn't qualify because we don't have a, a, a system. We just, uh, survive day by day with, uh, uh, with random initiatives from some groups. Teams. And so we can have this spike of excellence and these drop in the quality of the performance. Yeah.
Jared Powell (12:36):
Sounds like chaos. Okay. So , so I, I, I've, I've been to, I've been to Rome, I've been to Italy a few times actually. And w walking down the streets of Rome, I was so overstimulated by all of the things happening. And it, it was, it was cool. It was one of the best experiences of my life, but it was, it felt like a chaotic experience. Would you say that that's, chaos is not a negative term here. It's like a lively, everything's happening all at once. Everyone's doing their own thing. Is that like a typical kind of Italian thing without trying to stereotype?
Franco Impellizzeri (13:10):
No, uh, I, I think that this is basically what I just said. Uh, we have, uh, this, um, uh, we have a system that it's, it's not under control. So, uh, this is a good or bad thing because this allow us to be very flexible because we have to adapt, uh, easily and quickly to several situations. You don't do the same thing, for example, you don't do the same document and you follow always the same procedure or the same. Uh, so sometimes you go there, you do the document, and you make the document in 10 minutes, and the other time you take three days. So it's always, uh, it's always run. Yeah. But that's absolutely, I think it's culture. I think that Latin countries and for example, commonwealth countries, they have these differences. And I, I actually suffer both. I enjoy both. Cause there are things that I like in, depends on the situation. From a a professional perspective, I, I prefer a very, uh, under controlled system. I mean, I worked for 10 years in Switzer, which, which is fantastic. Switzerland is, uh, is, is, is really, uh, is true, is is really well organized. And there are a lot of stereotypes that are wrong, actually. Like, you know, they are a bit cold. That's not true. People I know, they're very friendly and yeah. So yeah, your feeling was, was right.
Jared Powell (14:40):
. Yeah. Good. Okay. So hopefully everybody has gotten to know you a little bit better. Let's get into the, to the meat of the conversation. I'm, I'm gonna go straight, straight to the heart of the point, which we're gonna sort of anchor ourself to today. Injury prevention, reduction, or mitigation. Where has all this controversy come from, Franco?
Franco Impellizzeri (15:01):
Well, I don't know actually why in sperm medicine, at one point this topic, uh, became so popular. I remember when I came back years ago, I, I heard, I read especially on, on on social media, someone complained about this term, but honestly I didn't hear much. But over years, this topic has become more and more common. So the idea that you, you shouldn't use prevention. And, um, in recent, probably the last year, this is becoming very strong. And as we have written, it's, I don't want to say it's a nonsense because they understand some arguments, uh, um, uh, that some people, um, arise about the, the use of the term prevention. But most of the technical arguments are in our opinion and wrong. So it is not a pro, if you don't like to use prevention, you don't use it, use whatever you want. It's a matter.
Franco Impellizzeri (16:08):
The problem is when you start to say to others that they shouldn't use it, because in that situation, you should have strong arguments. And I, I don't want to say evidence because they're here, we are not talking about evidence. It's more an opinion based discussion. But the argument should be strong enough, should have a sort of a logical consistency. And you, you cannot just say something to support. Uh, because in that case, we enter more in a scientific area where the use of the terms have a specific meaning, and the problems should be context contextualized. Because now I see that the narrative is a big changing. And, uh, this is something I see often when you start to chasing a topic, people change a bit, uh, and they, they rise other arguments. There is a, there is a, a name for this that I don't say because it is very, I polite, but there is, when people jump on different topics, when you, um, maybe support, uh, with good counterarguments, the original ones. So I dunno why it started. And actually this is in indeed something that you see mainly in sperm medicine. You don't see in other areas where prevention used for any kind of disease, even severe and, and, and disease that can cause death. And they use the term prevention without problems. You can see also policies, uh, that are where the term prevention we use. So yeah, I dunno. I dunno why , honestly.
Jared Powell (17:54):
So what's the, what's the best argument that the prevention opponents, so, so the naysayers, those who are saying don't use the term prevention, what are, what are they saying as to, to explain why they're so steadfast in why we shouldn't say prevention?
Franco Impellizzeri (18:11):
Well, if you, if we start from what is, uh, what was said initially and what was written also in some papers, even as an opinion, but in some papers, uh, there were technical arguments such as, we don't prevent injuries in all individuals. So the only thing we can do is to reduce the risk, which is, uh, something that may sound, uh, right, but is technically wrong because, uh, uh, when you say that you prevent something in medical context, you are saying that you are either decreasing the risk or increasing the time to have a disease or whatever. Mm-hmm. So, uh, prevention has, uh, is a general term that include different aspects. And indeed we have a primary prevention, secondary prevention, third, third year prevention. We actually have also primary prevention or ary prevent. We have a lot of other prevention depending when the actions, uh, where the actions, uh, are, uh, uh, compared to the initiation of the disease.
Franco Impellizzeri (19:23):
So if it's before, after, during this kind of things. So the idea that, uh, you cannot use prevention because you cannot prevent an event in all individuals is, um, is technically wrong because this is, uh, not what the term prevention in medical setting, uh, means. If we go to, and we take the dictionary definitions, this may be the case, but I mean, I can't find, you know, when, when you look at the additional definition, you can find 10 D definitions. So I can pick the one that support better my, my opinion. But here we are in a, in a, in a, in a medical context. So we, we rely on, on, on the medical context, the, the, the new arguments are in instead about the communication. And in terms of communication, I think, uh, there I can see the, the, the reason why one may prefer to use the term risk, because they, they may think that saying prevention can create too much expectations, but the question is, first, if it may be a problem, but if this is a so big problem, why this is a problem only for medicine and not in other, for other diseases, for example.
Franco Impellizzeri (20:43):
So it seems a bit logical, maybe they have the same problem, but probably they didn't see this problem as big as we, we see. And the other, the other issue is that this, uh, this doesn't apply only to the term prevention, but this probably apply to any term that you use when you communicate with the patients, and you have to adjust the way you communicate and the terminology you use based on the person you have in front of you. So I don't think that you solve the problem, eliminating the term prevention. You solve the problem eventually by saying to calibrate the terminology based on the patient and based on what they understand and what they get. Because you can use even the term risk, and they can attributal risk and meaning that is to, that is not the, the one that you, you wanted to communicate.
Franco Impellizzeri (21:40):
Also, I'll give you another example of risk mitigation. We use this term mitigation, but mitigation, for example, I know mitigation because I had, uh, for some medication and quality management. And the term mitigation in other areas is more mitigating the effect of something that already happened. So let's say you had an injury and you want to mitigate the effect of the injury. So in several areas, mitigation is used with this meaning is not as a synonym of reduction, for example, is more to say something happened. And now we, we have to, to find a way to reduce the, the consequences of what happened. So again, if I'm a manager and you talk about mitigation, uh, I can interpret it in that way. If, you know, I'm a manager and you know, this differentiation, maybe you don't use mitigation, you use another term. So at the end of the day, the, the, the problem of communication is really, is, is really an important topic, but is only marginal related to the abolition of the term prevention.
Franco Impellizzeri (22:48):
It's, it's more generic. Uh, and if you, if you think that in your, your activity, in your communication, prevention created problems, you, you don't use it, it's fine. So I don't have any, people can use whatever they want. And, um, I'm, the article we wrote is not to say that they cannot use and they have to use prevention. We just said, you can use prevention. And the the reasons why people, uh, try to convince others not to use it are most, are technically wrong. Some are partially true. So don't use it if you don't want one. But don't tell me not to use prevention, which is used everywhere and technically is right in medical context, of course,
Jared Powell (23:33):
Yeah. You, you're not a prevention profit. You're not out there trying to convert people to use the word prevention. You are just, no, you're just, you're just cha challenging this notion that we can't use the term prevention. And I think you're right in that mitigation and reduction have their issues as well. So if we're gonna be a stickler for words, then we should face that as well. And I, I do love your point. The issue is, well, not the issue, the most significant part of all of this is, is in our communication and explanation, the term is one thing, and it's a small thing, but it's our explanation to the person or the patient about what this might mean for them. And I think that's such a good point. We get stuck on, on the terms. Should we use this term, should we use that term terms probably irrelevant. It's more the explanation that matters.
Franco Impellizzeri (24:21):
Yeah. Uh, I mean, at the end, uh, if you think, uh, we, we, for example, we, we, we use, uh, often the term risk and maybe we communicate, uh, the reduction in risk based on the studies, and we say, oh, you can have 20% reduction in risk, but it is a relative risk. And, uh, the way people can interpret this 20, 30, 40, 50% is, uh, is most of the time is, is, uh, an overinterpretation because it depends on the absolute risk you have. So 20%, uh, decreasing relative risk if the, the risk or increase in the risk. If the risk is 5%, mean it means going from five to 6%, which is something that in real life probably don't. You don't, you cannot see so clearly. Mm-hmm. But if you say, oh, there is a 20% increase in the risk, people may be, you know, scared and, but if the baseline risk is a 20%, of course this is a, this means increasing an absolute risk, which is much higher.
Franco Impellizzeri (25:26):
And the can also a much higher clinical impact. So even when we discuss about risk that we think is much clearer, it's not, it's, it is not that there are a lot of, uh, situations in which, uh, um, we use the term risk, uh, for example, in a, an app in appropriate way. We most studies present odd ratios and odds, which are not risk, or rates which are not risk. Can people interpret, interpret as a, as a risk. They are not risk. A risk is a probability statement and goes from zero to one, the, the probability of having an event. So if, if we enter in this semantic, uh, fights, I think there may be stronger argument to, to question how people communicate things because it is based on, uh, uh, uh, an optimal understanding of some basic concept, for example, of epidemiology, things that I didn't know years ago. And I, I, I realized studying and I realized this is, these are the errors I made. I said, well, I wrote things that are technically wrong and I'm, I want to write this paper in which I want to explain what I did wrong so that people, other people can avoid to commit the same error.
Jared Powell (26:46):
I like that paper idea, Franco. It sounds like the, the memoirs of Franco, what I did wrong and what you can learn from my mistakes, it's, uh, I'll definitely read it should make it a book.
Franco Impellizzeri (26:56):
That's, that, that's the problem is that there are a lot of errors. So 20 years, uh, it's too long. So I have to select the, the most important or the most frequent error.
Jared Powell (27:07):
Okay, Franco, so one of my favorite parts of your paper, and it was a really elegant description and almost analogy, I guess, um, equating disease prevention with the polio vaccine and sort of vaccines a loaded term at the moment. Do you mind just sort of summarizing to, to me in the audience this metaphor or analogy that you used about disease prevention with the polio vaccine and then perhaps relate it to injury prevention in the sporting context?
Franco Impellizzeri (27:36):
Yeah. Well, we, we tried to use this as example because we thought maybe more familiar, cause the polio vaccine is, uh, is quite popular, uh, intervention. And the idea was to explain that there may be different situations when you implement the intervention. And two of these situations are actually similar in terms of concept, even if they have different names. So when you say you cannot use prevention, we said you can, you are saying that we cannot also use causal cause the concept are similar. So basically we explain that when you, you, uh, use, uh, uh, a poly vaccine, uh, you may have four situations, one situation in which people are considered considered because these are people that, uh, um, would contract the vaccine with or without, uh, sorry, the, the poly with or without the vaccine because they don't have maybe an immune system strong enough to react and create the immune response. Yeah. So this people are doing whatever, even if you give the vaccine, they will have, um, they will have the, uh, the poly.
Jared Powell (28:50):
So with or without the vaccine, they're gonna get polio no matter what.
Franco Impellizzeri (28:53):
We have people that are immune, meaning that, uh, um, they wouldn't have the vaccine with or without, uh, the poly with or without the vaccine because they, for some reason, they have a strong immune system. So not only they, so they, they can fight the virus by their own. They don't need the, the, the vaccine. So these are immune, whatever you, you do, if you give it or you don't give it, they are immune. And after we have other two categories, which are the most relevant for this depression, in which we have people that, uh, in which, uh, the, the, the vaccine is effective because they developed this, uh, response. So these are people, they may contract the polio without the va, the vaccine, but when you give the vaccine, they will not, and these are, uh, the, the people in which this intervention was preventive.
Franco Impellizzeri (29:42):
And after you have people in which the vaccine create problems, um, in which there is a causal effect of the vaccine in terms of, um, being harmful. So because this, if you use, uh, uh, uh, um, the, the live virus, um, they can actually develop, uh, uh, they can contract the polio. So the point is that, uh, the terms prevention and causal are using these classification just to define two different outcomes. But the, their causal ef uh, the causal, um, effect is the same one cause a beneficial outcome and the other cause harm harmful outcome. When they cause a beneficial outcome, they are set to be preventive. When they cause an harmful, they, they're set to be causally or causative. But the concept are the same, is just the how you classify the outcome, the change, and you change the way you define the, but this means that if you're saying that you cannot use prevention, you cannot also say that something can cause, uh, an, uh, can be harmful food because it's exactly the same.
Franco Impellizzeri (31:02):
So are you, are, are we saying that you, we we should get rid of prevention and also of causal effects, uh, and uh, harmful effects? I don't think so. But the point was to explain people that sometimes, and that's, it's fine. Sometimes we say things, we try to support our arguments, but we don't realize the consequences that these arguments can have in general. Because the, the, what we should understand is that if we don't want to use prevention for injury, we are saying that we don't have to use prevention for a, any other kind of diseases. So we can just say as, as someone told me, no, but it's more related to in, no, it's not related to in this is this is related to everything or we use it or we don't use it. So that was a bit, uh, the example. But if you think about, for example, let's say so that I don't touch the knowledge cam sprinting, let's say that we use printing to prevent harvesting injuries, like some suggested as potentially effective, you can sprint and you can be a doom player or athlete because widow or without you have an injury, so you're doomed.
Franco Impellizzeri (32:19):
There are people that sprinting or with, with or without sprinting, they wouldn't have an injury. And these, uh, are, are the, the, the so-called immune, you can have those that with sprinting, they don't develop, uh, the the, the injury, but without, they may prevent, may develop an injury. And after you can have someone that they get an injury on the arm scene while they're sprinting for preventing. So in that, that person's this, uh, intervention create a problem, so was, uh, create an harmful effect. So again, you say that it's preventive if decrease, uh, the number of injuries in that group, if it's in study and you say that it's harmful in, in those people in which increase the injury. The concept is exactly the same again, is just that in one case, the causal process is, is the same, the causal link. So again, if you don't want to use prevention, it's fine. But you're saying that we don't have to use prevention. Yeah. We have to ban the term prevention in medicine, not in medicine.
Jared Powell (33:35):
Yeah. That's, that's awesome. So, so yeah, prevention is a causal term and it's accurate to use. If you want to, if you want to be strong in saying that you can't use the term prevention, then you probably can't use the term causation. Mm-hmm.
Franco Impellizzeri (33:52):
. Yeah. Yeah. They, they, because the other argument that people use, uh, use several times and still insist on that, is that you cannot prevent, uh, the occurrence of injury in all the individuals and therefore you just decrease the risk. Mm-hmm. Again, this is, uh, something that, uh, I try to explain technically. So when you run a study, what do you do? You compare the risk of injury in one group with the risk of injury in the contra group intervention group. And the difference in risk, um, is the absolute, uh, difference or the relative d uh, difference is the effect, which means that some in, in the intervention group, some others that were supposed to have an injury, didn't have an injury because they were under the intervention. And the other, the opposite occurred in, in the other people, people that were supposed to have an injury.
Franco Impellizzeri (34:50):
They had an injury because they, they didn't have this preventive intervention, which means that some pe in some people, you prevented the injury. And this is the way that our studies are conducting any field. So it's never, uh, or, or, or nothing is just a proportion of people that were supposed to have an injury, didn't have an injury because of the intervention. And this is when you can say that something is effective. So it actually prevented the occurrence of the event in some individuals, and not in, in no individuals. But this is for any kind of, uh, intervention. And in, in unless is, uh, something, is a, the so-called sharp, uh, causal effect in which, uh, you assume that without that factor, uh, or with that factor, all the individuals would have or wouldn't have an event, which is an assumption that is made sometimes for statistical reasons, but it is not, it's not real or is very rarely real. I mean, if you drink something radioactive substance, probably 100% of people with problems. Um, but if exclude these extreme situations, normally this is happen. So again, yeah, it doesn't, we don't prevent in all, in all, uh, in all individuals, but when you say that decrease the risk, it doesn't decrease the risk in all individuals too. Someone willing, decrease the risk of some others will not. So exactly the same situation. Mm-hmm.
Jared Powell (36:39):
, an example that's coming to my mind as I'm listening to listening to talk Franco is seat belts and driving a car, you know, seat belts will prevent deaths. They're not gonna prevent everyone who has a car accident from dying. But if you are wearing a seatbelt, you will prevent some deaths. So you don't have to prevent every single injury or every single disease or every single death in order for something to have a preventive effect.
Franco Impellizzeri (37:05):
Right. In, in addition, also, the death can also cause problem rare situations, but it may happen. So again, is is as I said, if it's prevention or is harmful, just a question of outcome, the direction of the outcome. But you can say if you say it's arm can be sometimes harmful, you can say it's also preventive. Yeah. So,
Jared Powell (37:28):
So if we're gonna use this term injury prevention, Franco, should we be careful in, in guaranteeing results? So should we be a little bit careful in our language here? Should we embed some uncertainty into our prediction whether this person's going to get injured or not? Or, or should we, shouldn't we bother? For example, can we say that this program of exercises is going to prevent a shoulder injury next season? I guarantee it. I know what you're gonna say here, but I'm setting you up.
Franco Impellizzeri (37:54):
Yeah. Actually the, this is a bit, uh, busy with my message with the nor study. The, the, the point there was to say there is uncertainty around effectiveness of, of this intervention, and we need to communicate this, uh, intervention. So I was against to say decrease the risk, uh, by 50% first because it's not true, uh, uh, technically. Cause the 50% is from a random effect model. So it is not the estimation of the true effect on intervention. It is an estimation of a distribution of effects, which means some, in some groups, maybe 50, in some group, maybe lower May, maybe higher, some maybe even harmful. So the point was that we need to communicate uncertainty, but this is, is for, for any kind of, uh, not not only intervention for health, but also for training outcomes. When you train someone, and I think this is the main problem we have that we don't communicate well, uncertainty, and we don't accept the uncertainty as, uh, professionals or practitioners, we don't accept uncertainty.
Franco Impellizzeri (39:05):
We, we, we have really issues in dealing with uncertainty. Uh, it's like, uh, the difficulty say, I don't know, there are people that they cannot say I don. No. Yeah. And so, uh, yeah, that's the main point. But it's not related to the term. It's related in to communication in general because, uh, uh, I can say this intervention can decrease the risk by 50% that you're communicating a strong message anyway. If you say this can, uh, um, this, uh, uh, intervention can prevent injuries. You are communicating the same things. If you say the decreas by 50%, the the covid injury, that if you think that what you are saying can create too much expectation because you are using the term prevention, you can use, yeah. You can use also something else mm-hmm. . But sometimes when you speak with the patient, you don't even use risk where you say it decrease the chance of having something.
Franco Impellizzeri (40:07):
So you can use so many terms and it, it, it really depends. But when we, we discuss, especially to communicate with the papers or with the profe between peers and professional colleagues, we need, uh, uh, to communicate in a precise way in our opinion, saying that is, uh, is preventive, is, is, is precise enough. We, we wrote the definitions from different, uh, the, the cancer associations, the w o and because for example, if you read the definition, they say it's an action aim to, uh, eliminate something and people say, oh, you see, it's, uh, they, they, they wrote eliminate. Yeah, but it's anion aim too. So that's the intention doesn't mean that you eliminate in all individuals. Yeah. So it depends how you interpret it, because if you want to interpret in that way, okay, that's fine. But I don't know even how to argue because that's a question of opinion.
Franco Impellizzeri (41:08):
I'm not, uh, I'm, I'm not, um, my, my native language is not English. But the way I, I read and other people, uh, that around me, uh, read that is that is is is an action aim too. It doesn't mean that it has to have an effect. Mm-hmm. You want to say, I use the term injury prevention only for intervention in which I have evidence that they can really prevent or cause their injuries. This is again, another, another kind of discussion. I may, I may agree, but it depends because if I say, okay, we are doing these things, um, the, these interventions to try to prevent injuries, I'm communicating some uncertainty. I'm not telling you, I'm sure we just, we are just trying. So I'm communicating to the intention of the interventions. Mm-hmm. , but yeah,
Jared Powell (42:00):
There's a, in, in physiotherapy we have something called the Kiran O Sullivan test, and Kiran o Sullivan is a physio from from Ireland. And he said he proposed a number of years ago that after you finish perhaps explaining something to someone, say, you are gonna do this injury prevention program to prevent a c l injury. Then you ask that patient or person to explain back to you what that means to them, right? So then you can have a conversation about, well, if they say, oh, this is gonna definitely prevent my a C L injury, then you'll say, well, I can't say definitely there's some uncertainty there, blah, blah, blah, blah, blah. Yeah. So is that kind of what you're alluding to there?
Franco Impellizzeri (42:38):
Well, this strategy to ask the, the person to communicate, to tell you what they understood, I, I dunno when and how it was developed in physiotherapy, but this is written in several papers and is probably 30 years. Cause I was, was in orthopedics, it was a common, common idea. So this, but this is related to the communication issue. It's not medicine, it's in general in terms of communication. So this is something several years ago. So absolutely, I agree. If someone, uh, in physiotherapy propose to use this approach, I agree. Mm-hmm. . Yeah.
Jared Powell (43:17):
Good. Perfect. So finishing off Franco, what, what are you working on? What myths are you busting at the moment? I know you're, uh, you're sitting there in your lab like, uh, like an evil mastermind trying to bust all these myths that we desperately cling onto. So what are you doing right now?
Franco Impellizzeri (43:32):
I don't want to bust. I, I mean, I never wanted, I, I didn't wake up in the morning and said, oh, what I do, bus today just happened. And, and sometimes it happened for personal experiences, uh, for example, or maybe I, I have connections with teams and athletes and coaches and maybe they always show me some literature. Always, always, anyway say, yeah, look, this literature is a bit weak and say, yeah, but is is, is, um, published here and there, the, the consensus, this kinda things. And maybe I speak with the doctor and say, oh, but I haven't read anyone complaining about this. Say, okay, so I have to raise something so I can say, look, I'm telling you this is not actually right. And I have also written in a scientific publication, so now I can't. And that's actually one of the reason why I, I did that.
Franco Impellizzeri (44:29):
So I'm not, I, I, I'm really, really, my goal is to improve, to improve, uh, the research in our area. And I'm also in a, in a moment in my career in which I have to, to make some decisions that I don't want to, to make, whether to do research first person or to move in another area where I have to create a new, a future generation of people that can do the research. And I will probably move in that direction because alone, you cannot do anything. You need to build this, uh, this a new generation. And because I know this may sound so bad for my colleagues, but I think my generation has ruined this area. And so I think we need to fix and we, we need to fix what we, we, we have broken. And I feel being part of this generation a bit responsible.
Franco Impellizzeri (45:27):
And that's why I, I want to try to, to improve the area. What people in our area don't understand and accept is that scientific, uh, uh, the scientific process include discussion. And, and there's plenty of, of, uh, uh, situations in the past in which scientists argue with each other. So that's part of the normal process of science because since you want to defend your position, you have first developed argument that are logically sound internally consistent based on good literature and evidence, these kind of things. And maybe they can stimulate you to do better or better studies. And the other problem is that when we communicate things to practitioners, I feel uncomfortable when the information I'm providing, I know they are potentially wrong because I know the papers are weak and maybe biased. And this is something that we should avoid. Because if we want to use the evidence-based approach, we should, uh, provide reliable information.
Franco Impellizzeri (46:39):
And there's a lot of bias for various reasons. I have the advantage that I moving academia later, so I'm not really in, in this publishing parish, better people say, ah, but you have publish. Yeah, but it's, it happened. I didn't care when I was working in the first 10 years, my, my boss saw this as a waste of time just to tell you. So I had really, I really didn't, uh, uh, needed to, to, to publish. I was just curious. So the publications I have are just the consequence of my curiosity. And they can tell you that sometimes I, I give the idea to other people. I call friends and say, oh, this is something interesting to understand. I don't have time. If you do it, I would be very happy and let me know the answer. Cuz I'm curious. That's why, why I'm doing research.
Franco Impellizzeri (47:33):
So I, I don't, I don't know what I'm going to do in the future if I'm busting some other, there's something that I, I I, we are going to, to just a bit. Uh, but uh, it's more statist oriented by Yeah, it is, again, it is a methodological, these are methodological discussions, which are not academic stats. People say, oh, but this statistical methodological, it's all academic. That's because it's, this has a huge impact in practice because it, it is related to the information and to the reliability and political information that we give people that are potentially going to use this information every day in their practice. So there was a discussion within our group about how to implement the knowledge, and they said, well, that's the last of the problem I have personally. Now what I I want to understand is what knowledge we need to implement because we don't have to implement everything.
Franco Impellizzeri (48:39):
Because if the knowledge is not strong enough, it's also risky. So I think we need first to understand what's the, the knowledge that is strong enough to be implemented and disseminated. And after we can discuss about how to do that. Cause it's not true that information don't reach the, the field. That's not true. There are information that reached the field too quick and too soon. That's a problem that I don't want to, to give examples to because, uh, I want to be polite. But there are a lot of things that are absolutely at least questionable and they are widespread everywhere. And if you read the papers and, uh, I, I ask people from other field and they say, I cannot believe you, you're doing that. And yeah, that's, this is what I'm doing. So that's why I'm, I'm, I, I want to, to work. I'm working, uh, meta research and trying to improve the research. I want to give, uh, practitioners reliable information. I don't want to trick anyone.
Jared Powell (49:40):
Good. Well, thank you for all that you do, Franco. You're making us all better scientists, better clinicians, and hopefully, uh, by extension and improving the outcomes of our, of our patients as well. So, so keep it up. Thank you very much. Uh, before we go, Franco, are you still on social media? Where are you at these days? Where can people find you?
Franco Impellizzeri (49:59):
Yeah, I, I'm, I'm less, I'm, I'm, uh, honestly, um, less present on the media recently in the last year for two reasons. One is that I'm really, really busy. And the second is that I use the media when I need them. And, and because I know how they work, but I don't want to be a victim of, uh, of the media. So I now I have seen also friends that are becoming very argumentative because being argumentative is what create visibility. So if I say this meter can be done in a better way, no one care If I say this meter is a, old people start to comment and I know this is how it works. So I, I, I can be, I'm honest, sometimes I know, and in the past I use some posts in a more, in a stronger way because I know that in this way I could reach more people and I wanted to communicate something.
Franco Impellizzeri (50:59):
It doesn't mean that is because I'm like that, it's more because otherwise you don't have, I cannot, I cannot give visibility to some messages that I think are important. So now I'm, I'm a bit, um, I'm staying a bit, uh, far from the, from from social media. I use a lot actually. Cause I have a network where there are very good researchers. And from time to time I see the papers maybe more methodological statistic. That's why I download the paper. I can't read the paper, the paper. So yeah, but I'm still on, on, uh, on Twitter. Uh, Facebook is more for personal things. I don't use a lot of Instagram. I'm a bit, a bit of a mover actually with social media that people think I'm, I'm good, but I'm not, and I'm migrating on master, uh, which is becoming, uh, is not so widespread as I was thinking. But it's becoming, uh, a sort on which, uh, uh, there are more, uh, let's say technical information, especially regarding what I'm interested. So yeah, this is my present in the social media.
Jared Powell (52:10):
Now, could I respect your, um, not wanting to feed the outrage machine that is Twitter. And you know, it's impossible to speak in a way on Twitter that someone will not misunderstand you and yell at you. And I'm experiencing that. I'm, I'm, I'm getting a little bit bored and tired of the whole thing anyway, so I respect you from removing yourself a little bit.
Franco Impellizzeri (52:32):
And you know, I, I'm unfortunately because of my past, I'm the kind of person that, or move away or fight back mm-hmm. . And I'm too busy to fight back, so I prefer to stay away because if you slap me, it's more likely give you a punch. That's the way normally I react . So yeah, I, uh, when I, sometimes I see thing, uh, pause and say I don't answer. I don't have to answer because I know that I will, I'm going to lose one hour if I do that. So
Jared Powell (53:05):
Totally take a deep breath and move on. Move on with your life. All right, Frank Franco, thank you so much, and, uh, I'll talk to you soon. Thank you for listening to this episode of the Shoulder Physio podcast with Franco and Plaz. If you want more information about today's episode, check out our show [email protected] If you liked what you heard today, don't forget to follow and subscribe on your podcast Player of Choice and Liber 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 LAN 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.