Ep 213: What women want to know after knee injury, with Melissa Haberfield

[00:00:04] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today. Did you know that only about 10% of the participants in sports medicine and sports physiotherapy research are women?

[00:00:29] When people are underrepresented in research, it might mean that we as a clinical and research community don't do as good a job as we could when working with women and girls to support them to achieve best outcomes of treatment. My guest today has just finished a project where she worked with women who had experienced serious knee injury to learn from the women themselves about what they wanted to know about managing knee health. And she's here to share the results with us.

[00:00:56] Melissa Haberfield is a physiotherapist with 15 years of clinical experience, including her current work in elite women's Australian football. Mel is a PhD candidate at the La Trobe Sports and Exercise Medicine Research Centre in Melbourne, Australia, where she works with women to explore the influence of sex and gender on outcomes after knee injury. Melissa Haberfield, welcome to JOSPT Insights. Thanks for having me, Claire. I'm very excited to have a chat. I'm very much looking forward to having a chat with you, Mel.

[00:01:25] JOSPT readers and listeners know that we've got a really strong focus on engaging patients and participants as true partners when we do research. And that's not simply an academic exercise. It's how we work towards producing research that's really meaningful to our listeners' clinical practice and ultimately to the lives of the patients and the people whom our listeners are trying to help. And today we're talking about your work with women who have lived experience of knee injury.

[00:01:54] Mel, you set up a consumer advisory group for your research project. Tell us who was involved and why was it important to ask their opinions? So I was really lucky at the start of my PhD project to have the opportunity to set up a consumer advisory group to really guide the work that I was doing. Let the consumers dictate or help decide what you're going to do as part of your project. So it's kind of cool.

[00:02:22] And we have six women involved in my consumer advisory group. And five of these women have lived experience of a knee injury, a serious knee injury. So they've all had an ACL injury and or meniscal injury as well.

[00:02:38] And then I also had a physiotherapist who's very passionate about treating women with knee injury in the consumer advisory group because we thought it was important to represent not only the patients, but the people who treat the patients as well. And some of our women went through the public health system here in Australia. Here we have a private and a public system. So some of our women did their rehab and surgery through the private system.

[00:03:07] And then others went through the public system. We also have women who are living out in rural Victoria and some living in inner city Melbourne. We have women who have caring responsibilities and some that don't. And we also have women that have a higher physical function. So they're out running regularly. And others that are just doing yoga and walking. And that's what they want to be doing.

[00:03:33] So I've got a really broad spectrum of experience within the six women in my little consumer advisory group. So it's really nice. Yeah, I was going to comment on that breadth of experience, life experience, work, activity, caring, geography. And I guess that's also a really important thing to bring into research when we're trying to capture the breadth of people's experiences in the health system.

[00:03:59] So congratulations for capturing such diversity of perspectives. I guess before we keep going, let's hear a little bit about broadly your PhD work, the research program that you're working on. And that will help set us up nicely for the rest of our chat today.

[00:04:17] So my PhD broadly is looking at sex gender differences following ACL injury and also trying to see if we can create solutions to improve outcomes for women and females following ACL injury. So that broadly is what my PhD is looking at. I'm using a participatory action research approach. So that really is where, and as clinicians, this makes total sense because we put the patient at the center.

[00:04:47] So that really is what the consumer advisory group is all about. So putting the patient voice at the center and saying, what do you actually need and want? And what should we be doing in our research? Are there things we're missing? Do we have blind spots? Because sometimes, and clinicians probably can feel this a little bit, researchers can get in their little research bubble and we sort of lose touch with reality sometimes.

[00:05:15] So I think that is why it's so important to have the voice of the consumer involved in research. So it really guides where we're going and it makes the research meaningful and hopefully has a real world impact on what we actually then do in the clinic with our real patients.

[00:05:35] And I think sometimes this can take the form of almost sense checking where you as a research team go away, you do your research work, you come back to the advisory group and say, hey, here's what we think is going on. Here's what we think we're seeing. What do you reckon? I get the sense though, Mel, that you're doing more than that. You're actually creating an environment where your advisory group is really getting in on the ground floor, so to speak, and saying, no, these are the things that we think are important to study.

[00:06:05] Is that right? Have I got that right? And I guess, can you give us a bit of a sense of the different levels in which you might engage people or patients as participants in your research? Yeah, so I'll start with the different levels. So there's some well-acknowledged frameworks for consumer engagement or consumer involvement around the world and they're different levels. It's like a ladder.

[00:06:26] So at the bottom you have informing consumers and that's just where as researchers we're telling people with lived experience what the research is saying. So you're through infographics, podcasts and things like that. And then we go up the levels and at the peak of the ladder or the peak of the pyramid, it's consumer driven. So that's where the consumers actually become part of the research team and are driving the research.

[00:06:53] So I'm at about the mid-level where our consumers are still doing their everyday lives and their everyday jobs, but we are really involving them in some of the decision making. I then go and do some of the work and then go back to them exactly what you said, the sense checking.

[00:07:12] And at the start of my PhD program, we thought, well, we don't actually know what women with ACL injury or serious knee injury, we don't actually know what they want us to study. So we thought it would be really cool to just sit with them, do a brainstorming session, see what they had to say, and then also do a priority setting activity to see what their top priorities were.

[00:07:41] And once we actually started doing that, we realised we actually should publish this because it's really unique and important. So it was initially just going to be to set up my PhD, the direction of my PhD. But then we realised it was really important to get it out into the world because our consumer advisory group had some really great things to say. A quick note on terms before we keep going with our chat.

[00:08:09] You're using the word consumer and the term consumer advisory group where other people might use patient and public involvement or patient engagement. So to clarify that we mean the same thing, and I think as people are hearing you speak, they'll get that. I think it's helpful if we're clear that there are multiple terms that are used in research to mean the same thing.

[00:08:34] Now, Mel, you said you realised that you had no idea what women and girls wanted to know or wanted to study in ACL injury research. That's shocking to me when you think about the ACL is probably the most researched part of the body in our sports medicine musculoskeletal rehabilitation field.

[00:08:56] So it just, my mind is a bit sort of blown at the fact that we still don't really know what the people who are getting the injury are interested in and want to know. Which leads me to ask you, I guess, why should clinicians care that the perspectives of women and girls haven't really been prioritised in sports injury and musculoskeletal health research? It's a very good question.

[00:09:20] And I think this came out of other work that we had done previously over the last couple of years. So in the ACL space specifically, we know that women and females experience unacceptable rates of knee injury to start off with. So higher rates than men and males. And we also know that they have more burden following that injury. So Andrea Bruder from our research group led a really great systematic review.

[00:09:49] And I recommend everyone go and have a read of that and we can put it in the show notes. There's a link in the show notes for people. What Andrea did was look at all the outcomes following ACL injury for women, female and girls compared to males, men and boys. And what we found is, for example, women and girls have a 25% lower odds of returning to sport in the first five years following an ACL injury.

[00:10:15] They have worse self-reported outcomes such as quality of life and function. Why should clinicians care? The first reason is because women and girls have worse outcomes following ACL injury than men and boys. We also know that women are chronically underrepresented in the sports medicine research space.

[00:10:37] So this is some other work done by one of my other colleagues, Sally Cowan, where we looked at all the papers published in over a space of 10 years and looked at who were the participants, but who were the authors as well. And what we found in the sports medicine space was that women and girls made up less than 10% of study participants. So we're not including women as participants. The ones that we do include, we know that they have worse outcomes.

[00:11:06] So I think we actually need to think about this specifically. And maybe we should be doing something a little bit differently in the clinic. I don't know. We don't know the answer to that yet. But maybe that's why clinicians should care. Now, what did you find from your work with your consumer advisory group? What is it that women with these serious knee injuries want to know about their future knee health?

[00:11:31] There were three broad themes or three key themes from the work out of our study. The first theme was best practice management and support for ACL injury and rehabilitation. The second theme was social and gendered influences on joint health, which I'll speak to in a minute. And then the third theme was physical, psychological and personal influences on joint health.

[00:11:55] And if I get down into the crux of what the women wanted, our CAG really wanted for their knee injury and rehab journey to be supported by evidence-based best practice approaches. There was a need for better informed decision making throughout their knee injury journey. For example, whether they should undergo surgery or not. So they felt the decision making wasn't really supported or there.

[00:12:23] They felt uncertain about where or how to access specialised practitioners to support their rehabilitation. So people, practitioners that know how to rehabilitate ACL injury. And they also didn't know what should be included in best practice rehab. They didn't know what that was. They wanted accountability from practitioners, especially about goal setting and the frequency of sessions.

[00:12:51] What I found really interesting about what they wanted was the social gendered theme that really came out. And there was a lot of talk about being undervalued or the expectations being set really low. And they felt that was because they were women, which I find so fascinating. So, yeah, they often spoke about interactions with their practitioners as negative or limiting to their recovery journey.

[00:13:19] They wanted to know, are these interactions influenced by gender? Do we treat women and men patients differently in the clinic? And that was their lived experience. They gave lots of examples of being undervalued or the expectations being set low because they are a woman. So, for example, you don't need to return to sport because you want to have a baby.

[00:13:46] And then there was other social gendered factors that came out, including like a lack of time to allocate to rehab because of family and caring responsibilities. And then finally, more on the physical side. So, the women wanted to understand the enduring impact of knee injuries on their future knee health. So, for example, are they more likely to get other injuries or osteoarthritis?

[00:14:12] They also were really interested in the significance of loading through physical activities like running on their knee health. And they wanted to know what safe loading was after they had had a knee injury. Another really interesting factor was the influence of women's unique sex-based physical factors such as pregnancy, gynaecological and menstrual health.

[00:14:38] They often spoke about how that might influence their ability to rehab or participate in physical activity. And that they felt that that was never considered. Wow, Mel, that's really so interesting, shocking and so much to unpack in the work that you've been doing with these women advisors. I guess one thought that immediately comes to mind for all of our listeners is to think about that.

[00:15:06] How do I treat people in the clinic? Do I automatically, you know, this is our cognitive biases. Am I thinking about the goals and expectations that I'm setting with women and with men differently? So, Mel, the top priorities were for better specialist knee care and better post-injury decision-making for women. And helping women better understand how to stay active while they manage their knee load for the rest of their lives, essentially.

[00:15:36] What do you see that looking like in your practice as a physiotherapist? Should we be going out and designing different programs that are specifically for women and girls? I personally think it's worth a go. I think we should design something specifically for women and see how if we can improve any outcomes. I think it's worth a go. What have we got to lose? Having said that, obviously, there's a whole process that we need to go through.

[00:16:06] So, we need to co-design an intervention with women and with the people that treat these women. We need to test and evaluate the intervention before we know whether it's worth doing or not. But I think it's worth a go. And actually, it's really interesting because out of this work that we've done with the Consumer Advisory Group,

[00:16:27] that's actually one of the next steps I'm taking in my work is we're looking at designing an intervention specifically for women. So, that's Andrea Bruder's work as well. And my next PhD project is actually a concept mapping approach. So, it's where I've asked women who've had a recent knee injury and then the practitioners that treat these women.

[00:16:52] So, physios, strength and conditioning professionals, sports dieticians, sports physicians. We've got a whole bunch of people. And we've asked them what factors do they think are important for the ACL rehabilitation for women. And that's the first step in that co-design process of designing an intervention. So, for all the practitioners out there, watch this space. Something is coming, which is exciting.

[00:17:21] But with the caveat of, well, we don't know if it's going to work, but I think it is worth a crack. As clinicians right now, I think what we need to be aware of is what are our women patients telling us and what do they want? So, just having an awareness of how treatment is offered and received in your clinical practice.

[00:17:43] So, some clear examples are the language you use with your patient interactions, shared decision-making, expectation and goal setting. Making sure that really is shared and that you actually having a two-way conversation with the woman in front of you. And information sharing in that education piece. It's like the women really want to know the why. They want the information. So, give it to them.

[00:18:10] And then, also having a think about these other factors that we rarely ever think about with ACL rehabilitation or knee rehabilitation, such as women's health factors. So, the impact of pregnancy, gynecological and menstrual health. You might not have ever thought about that in the clinic when you're sitting there with your patient who you're planning an ACL rehab for. You might need to ask about these things and caring responsibilities.

[00:18:38] Do you need to have your appointment scheduled after hours so that you have someone to look after your child? Or do we need to design some of your programs so it's at home, can be done at home so that you don't have to access a gym? So, just little things like that, thinking about those factors I think could make a big difference. While we wait for the research to catch up, as we know, it's notoriously slow, but it's coming. It is. And as you say, it's coming.

[00:19:08] And you and particularly your colleagues at La Trobe University in Melbourne in Australia are doing a lot of leadership in this work. And I'm really grateful for the work that you are all contributing. Mel, you have a leadership role in clinical education and in physio work in elite sport, in women's elite sport in Australia.

[00:19:28] So, how has that role and the research you do and your training and your practice as a physiotherapist all interacted to inform what you do now? How do you work? How do you take all of this information and work with the athletes with whom you're working and the clinicians you're mentoring? Firstly, how lucky am I that my clinical life gets to influence my research life and vice versa?

[00:19:56] It's so cool because it's not often you get to really work on things that you actually are passionate about and really love. So, I feel very lucky. That's the first thing. But yeah, working in that elite space with the women athletes, I've learned a lot. And something we learned very early when we set up our program was that the girls wanted to know about everything. They wanted to know why.

[00:20:25] So, we had to incorporate a lot of that education in. They wanted to know the why. They just wanted to know. So, I think that got me thinking and we had lots of chats in our research group about, yeah, maybe this comment and we're missing a few things here.

[00:20:46] And it's interesting with our coaching staff, for example, in that elite space, they're majority males who have worked in a majority of male elite sport throughout their lives. And they've come across to the women's program, which I love. And, yeah, they often comment how different it is in the women's space to the men's space and little things like that. Like, you tell the boys, go and do this drill.

[00:21:15] And they go, okay. And you tell the girls, go and do this drill. And they say, yeah, but why are we doing that? What's that for? Why do we need that? So, it's that next level of wanting to know the why. Okay. Mel, as we wrap up, if you could convince people who are listening to us today to change one thing about the way they practice based on all your research work, what would that be?

[00:21:41] I think it would be just adopting a socio-gendered lens to the work you do. So, what do I mean by that? I mean checking your biases to see if there's anything in your practice that might need to change or that you need to be aware of.

[00:22:01] And becoming aware of potential gendered barriers and enablers to care for your women patients because they are there. The women are telling us that they're there. So, I think as practitioners in the clinic, we need to be self-aware and then more broadly aware. Adopt that social gendered lens when you're in the clinic. I think that would be very impactful.

[00:22:29] I think that's a great place for us to finish our chat today, Mel. You've left us with some teasers of what's coming in the future. And again, thank you for all of the work you and your colleagues are doing in this space to help us as clinicians better support the women and girls with whom we're working in clinical practice. Melissa Haberfield, thanks for joining me on JOSPT Insights. Thanks so much, Claire. Thanks for listening to this episode of JOSPT Insights.

[00:22:58] For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice, subscribe to JOSPT Insights on Apple Podcasts, Spotify, TuneIn, Stitcher, Google or your favourite podcast app. If you like JOSPT Insights, help others find us. Tell your friends and colleagues and rate and review us. To keep up to date with all the latest JOSPT content, be sure to follow us on Twitter, we're at JOSPT, and Facebook, we're JOSPT Official.

[00:23:28] Talk with you next time.