590: Dr. Karin Gravare Silbernagel: Tendinopathy Research: Past, Present, & Future

In this episode, Associate Professor and Associate Chair at the Department of Physical Therapy at the University of Delaware, Prof Karin Grävare Silbernagel, talks about her research into tendonopathy.

Today, Karin talks about her historical perspective on tendonopathy, the future of tendonopathy research, and her presentation at the WCSPT. Is pain really worrisome?

Hear about tendon loading, chasing the shiny new objects, creating expectations with patients, treating different kinds of tendons, and get her valuable advice, all on today's episode of The Healthy, Wealthy & Smart Podcast.

Key Takeaways

• "If you just want zero pain, don't do anything, but that's really not what you want. You want to be able to move."
• "Sometimes in our eagerness to do good, we get a little crazy."
• "This is not a quick fix. This takes time."
• "Just because it takes longer, does not mean a tendon has poor healing."
• "Always have fun. If it's not fun, it's not worth doing."
• "It's a long life to work. Don't hurry to get to the endpoint."

More about Karin Grävare Silbernagel

Karin Grävare Silbernagel PT, ATC, PhD is an Associate Professor and Associate Chair at the Department of Physical Therapy, University of Delaware, Newark, DE, USA.

She is a clinical scientist with a strong record of mentoring clinical scientists (primary advisor for 10 PhD student – completed, and 8 current PhD students). Her expertise is in orthopaedics and musculoskeletal injury with a focus on tendon and ligament injury.

She has been a physical therapist for over 30 years and performed research for over 20 years. At University of Delaware, she is the principal investigator of the Delaware Tendon Research Group and the Delaware ACL Research Group. Her work has been directly integrated into the clinical guidelines for treatment of patients with tendon injuries. She has presented her research at numerous conferences and published in peer-reviewed journals (100+ published articles to date). She has also been invited to speak about her research at conferences nationally and internationally.

As the principal investigator of Tendon Research Group at the University of Delaware, she is working to advance understanding of tendon injuries and repair so that tailored treatments can be developed.

The Delaware Tendon Research Group is an interdisciplinary team focused on improving treatment outcomes for tendon injuries. Her research approach is to evaluate tendon health and recovery by quantifying tendon composition, structure, and mechanical properties, as well as patients' impairments and symptoms.

Her research is funded by the NIH, Foundation for Physical Therapy, Swedish Research Council for Sport Science, and Swedish Research Council.

Suggested Keywords

Healthy, Wealthy, Smart, Healthcare, Physiotherapy, Research, Tendonopathy, Pain, Injuries, Treatment, WCSPT, Education,

World Congress of Sports Physical Therapy

To learn more, follow Karin at:

Website: https://sites.udel.edu/kgs

https://www.udel.edu/academics/colleges/chs/departments/pt/faculty/karin-gravare-silbernagel

Twitter: @kgsilbernagel

@udtendongroup

Instagram: @udtendongroup

Facebook: Delaware Tendon Research Group

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Read the Full Transcript Here:

00:03

Hi, Karen, welcome to the podcast. I'm so happy to have you on and really excited to talk about tendinopathy research and treatment and clinical application. Super excited.

00:14

Thank you. I'm equally excited to be here to talk about my favorite topic.

00:18

Yeah. And later on, we will talk about, we'll give a little sneak peek to everyone about your topic. At the fourth World Congress is sport physical therapy in Denmark happening August 26, and 27th. So for those of you who want that fun sneak peek, you'll have to wait until the end of the interview for that. Because what we're going to start with is, I really want to know, the historical perspective of tendinopathy research and how it's been translated into the clinic. So us, as we spoke, before we went on 18 years ago, you wrote your thesis. And so you've got a really great vantage point to look back on, what what tendinopathy research was, where we're at. And then later on, maybe we'll talk about where you see it going. But I'll just hand the mic over to you. So you can kind of give us that historical perspective.

01:20

Thank you. And I think that, as we spoke about, too, I feel like I'm getting older because more and more my historical perspective kind of comes in. But I think it's important when I started as a physical therapist, so I started clinically in 1990. And when I started, we had in my courses and things you know, talked about muscle, you talked about ligament injuries, and all these things. And then the tendon was just this rope that went in between the muscle and the bone. And that was kind of it. And then when I started practicing, and I worked in Baltimore, and we worked a lot with with baseball players and things, and everybody had tendinitis was super undisciplined ages, tendinitis, Achilles tendinitis. So everybody had this inflammation in the tendon that we never really talked about. So okay, I felt like I was no dummy. I learned medical terminology. So I know itis was inflammation. So obviously, they had inflammation in this tendon, because that was the name was. So I thought our treatments then really, were treating the word. So we were really trying to rest because it was acute inflammation. We tried ice we did I onto freezes and fauna, for races, and they weren't allowed to load and all these kinds of things. And surprisingly, hopefully, some patients got better anyway. But that really sparked my interest into tendon in general, like, what is this? And then later on in the 1990s, that came up more and more research, Korean and Spanish started thinking about, you know, Achilles tendon would hurt more maybe when they were loaded, ie centrically and running, so maybe we need to train that and people are starting more thinking about how do we exercise and mostly maybe the lower extremity, tendon tendinitis. And then we had more research looking at if there was inflammatory components in the tendon. So if you took out cells and things too, there wasn't actually an acute inflammation. So this idea is maybe wasn't true. And that really opened the door for if it's not an acute inflammation, what do we do? So then in the late 1990s, beyond the curve is in Standish, it was another researcher knees and we're Tolman that looked at concentric versus eccentric loading. And then Hogan offense on in Sweden to started to have patients that were waiting to get surgery and he started like, okay, we're really going to load them, you know, we got a heavy load them, because maybe that's what they need, if not an acute inflammation, and started to see people get better if you actually load in them instead of resting them. At the same time we did our I started my PhD things, too, we started looking at, okay, should it be more overload, and we used our pain monitoring model versus the standard treatment that was, you know, circulation exercises, bilateral up and down, but not really trying to load it heavy. And what we started to see those exercise program that loaded more had better effect than the more like generic, protective things kind of things, too. So that's really when things started to change. Right. So I think the historical perspective is we didn't do anything. And we started to do things. And we had these huge jump in outcomes, which is brilliant. And our studies then was, you know, we were looking more at, you know, the Sylvan angle protocol, comprehensive, we use pain monitoring model to guide but also the loading and the exercises to kind of low beyond and not be worried about the pain because if the pain wasn't acute inflammation, maybe wasn't so worrisome, and loading the tendon was painful, but that was also the treatment. So we needed something to kind of understand how much could you really load. So we started with this exercises and being able to load and having kind of achieved this kind of change. I think that was really the the ultimate thing that happened in the late night. 90s, early 2000 And it was the combination of Korean and Spanish hooking out for some did we had programs and kind of moving that forward.

05:10

And there's something that you said in that? Well, a lot of what you said in there that I just want to pull out if we can. So, one thing that you just said is, is pain worrisome? And I think that's a really, really provocative question. Because if you ask the person living with the pain, yeah. And so how, as the therapist, if we're treating someone with a tendinopathy, let's say it's an Achilles tendinopathy, and the treatment induces pain, how do we communicate to the patient? That it's not as worrisome as you think it is?

05:53

Yeah, thank you for that question. And I think that's why the pain monitoring model that we've had, and really the pain monitoring model started with roll on to me who was my advisor, in patellofemoral. Pain, and that's when we applied it. And I think from the patellofemoral, pain, we kind of seen the same path, right? Just resting, it doesn't help you need to get strong. And then we will the tendons seems to be the same thing. And I think the pain monitoring model has been a lot of discussion is, you know, we go up to five is okay, and those things, to tell you the truth, I really don't care if it's five, or four, or whatever, I think it's that communication to the patient and communication that waiting for this pain to become zero, if that's the goal. And what I say to everybody was my lecture, and you might have heard that too, I'm like, Well, if that's the goal, I can tell the patient come in here, lie down on my nice little plants here in the office, you lie there, and I'm gonna go get a cup of coffee. And when I come back, you don't have any pain. So I've treated your pain, right. So I kind of start, I think, with the education. So the point is, if you just want zero pain, don't do anything. But that's really not what you want, you want to be able to move. So if you want to be able to move, you also need to get this tissue to tolerate more loading. And in order to do that, we actually need to load it. So we recover. So I spent a lot of time kind of explaining talking about this thing, so that there might be some pain when we're loading it, or without load, you're not getting anywhere. And what happened to a lot of people, they had some pain, the rest of it did last and they tried to do something a pain and they just D decline. And I talk a lot about hardening your tissues, right? This is loading, hardening of tissues. So the conversation is my goal with treatment is to increase the tolerance of your tissue over time, while keeping your pain level the same. So that's kind of the thing. So so your pain level, I'm fine with that you're not going to rupture, which is good thing to say for Achilles tendon rupture. That's like the big catastrophe. If that's not an issue, then we can follow it to and then we have the discussion. You know, above five, it's not good, or I don't know, you've seen Twitter, sometimes Twitter, that I use five, right? And I, I really don't care. I think the point is, there is a point of pain when pain goes from, it's uncomfortable to Ouch, I don't want it to be Ouch, I want it to be in five seems to be around in that round, right? And people can understand the difference in that. And it's, you know, you have the other conversation with the people that says, But I have really high pain tolerance. So this might not work for me. Well, you know, it's subjective. So I always tell them absolutely works even better for people like you. So, you know, sometimes maybe I'm a little silly, but that's. So I think that's kind of the point of really using it. So for me, the pain monitoring model is a way for discussing it and then using it. Some people feel like it's focusing too much on the pain, I actually think is does the opposite, right? Because it removes the worry. So I'm going to put a number on it. And it's just a number and everything else. And then we use training diary. So I use training diaries, you write down, you know, morning pain, worst, lowest everything else that you do. And then if I have three or four weeks, we can start comparing, and then people actually start seeing the numbers change with the activity, or the number stays the same. So I'm using it more of a of a descriptor, because if you just ask somebody you have pain, it's like they're gonna ask them what they did earlier. Right? And none of us remember, we don't remember how much pain was when we not painful. And so that's kind of how we using it in my description.

09:23

Yeah, I think thank you for that. I think that's great. And that also kind of answered my next question is how much load? How much can you load? How much load isn't? Is is enough? How much is too much? And I think you kind of answered that within that. But you want to expand on that a little bit or I feel Yeah, so I think

09:39

I think that's within the pain monitoring model too. Right? We're looking at that. But then you also have knowledge based on how the cells responds how the tendon response and I think that's where the next thing in the history perspective is now we're starting to see you know, which protocol is better. So now they're comparing Silvernail and offer zones or East centric loading, and it's all these. And really when you compare them, it's not that big of a difference. Right? The heavy slow resistance. I just say that you know who canal for some was in northern Sweden, he trained twice a day. I'm from Gothenburg and middle, we do once a day. And then you go down to Denmark, they did the three times a week for heavy slow, right? So Danish people are lazier than you know. But I think the point is, when you're looking at the data, actually, the outcomes are not that difference. You know, there might be some, you know, we can always argue that we're more satisfied with this. But when you're looking at the mechanical properties and things, you don't see that big of a difference anymore. And I think because I think you reached a saturation point, right? We've done no loading to loading now everybody does good. And I think for us as PTS now we're trying to manipulate more and more in that little realm, that for everybody, we might not see it when we do big studies comparing one group to the other, because I think we need to talk about individualized instead of precision rehabilitation and things too. So I think kind of that's where we're getting at. And they've been great studies coming on from unstuffy Agha Gordon Denmark from her thesis looking at moderate versus heavy and patellar tendon. And so I think that for the loading, you need to load them, you need to use the pain monitoring model, we need to do the progressive loading. But I as a PT would less worry about if I if you did two sets too little or five pounds to less, I think that's less of an issue.

11:29

Yeah. And when you said individual, I actually just wrote that down individualized care as you were speaking, because if all of the different protocols have basically the same outcome, then does it come down to what can the patient do, given the constraints of their life? Or their schedule? Or you know, their job? So do you have someone who can do something three times a day? Or do you have does this person might do better three times a week with heavy slow resistance, or, you know, it really depends on what the patient can do. Because the best protocol, I would assume is the one that patient is compliant with.

12:12

And I think you and I have been around way too long for this too, right? So because, you know, when you started, when you were at least when I started when I was young, right? You were so excited for every exercise. So I guess kept on adding to my poor patients like removing something No, no, that's a really good exercise. And you're adding. And what I'm getting to is that if I can get you to do something consistent with two or three exercises, I'm much better off giving you two or three exercises that you do consistently, than trying to think that I'm going to give you a ton of things. And I have patients now that are you know, they they come back, they come back every four or five weeks and see me or they send me an email and they do their exercise, because I told them to do for Achilles like bilateral three sets of 15. And then do unilateral three sets of 15. And do that for your rest of your life. Like you're brushing your teeth, and I'm like, you could probably go down to doing them less, or you can do heavier in the gym. And some people don't go to the gym, they don't want to do that. So you kind of modify it to kind of get some of the exercises there too. So I think that I think the biggest key is that you need to load you need to do things. And then instead of getting too hyped up for all the specifics, I think that's really where we're moving forward. And I had I had a lady that you know, recently with insertional tendinopathy that had been to the doctor been to all these other clinics, and there's thrown all these things on or didn't get better. And then it was massaging it. And it was like dry needling and the instrument assisted and those kinds of things to me, she was just getting worse. And I'm like, Well, I just think you should do these three exercises once a day. And she's doing and she's like, I'm walking. I'm not limping, you know. So sometimes in our eagerness to do good, I think we get a little crazy.

13:49

Yeah, and that brings me to the next thing I wanted to talk about. And it's sort of the shiny new object syndrome that a lot of people will get. And we spoke a little bit about this before going on the air. And I said a lot of it is sort of the theatrics around different kinds of shiny new objects. So how how would you address that to say younger clinicians? In you know, obviously talking about tendinopathy

14:14

Yeah, so I think that that one thing and it's still hard, I mean, I teach Doctor physical therapy students and then they go out and they completely forgot what I said. Right? So I think there's certain things everybody wants to go to clinical course and learn something more hands on and something more specific but I think that to me, the attitude is what we really try to teach them is like what tissue is that? How does that tissue respond right? To start understanding the underlying mechanisms because then you have then you have an understanding to build the other thing on instead of not having the understanding and just thinking that you doing things and then then you might be changing the shiny objects without thinking about the mechanism. So I'm very much a mechanism person in to try to think about why would we do it, but you all No need to realize that just putting the hand on somebody is very, very strong treatment effect. That's not, that's the same as listening to somebody and paying attention. And I have a colleague Now Greg Hicks has done finishing a trial looking at strengthening specifically for low back and an older in the control group who got hot, hot pack and massage as the placebo control. And they did really well too, right. So even we have mechanism, we should not be afraid of doing things that might help the patient in that sense. But we the explanations and things for what you're doing, you got to be really careful for right. And I think that I have a great effect on my patients, because I think I have a good program. We know what we're doing. I know it works. But I'm also not under estimating that if you can Google me, you're going to get better just by coming seeing me because he's going to assume that at least I know what I'm doing. So, you know, I utilize that effect too. So you just need to thinking about what we're doing. And I'm very scared of chasing the shiny objects for the wrong reason, because maybe that shiny object would be really good for a specific reason. And if we throw it on everything, we've lost, what is good for?

16:12

Yeah, if you beat me to it, I was just gonna say also people probably come to you knowing your background, and the work that you do. So they're coming in, like primed, like, this is she is the expert, I'm in the right hands. I know, this is gonna, you know, this is a person who's going to help me and that's a huge part of the rehab process is that trust that you have in the practitioner and that therapeutic relationship, but it also sounds like you're giving realistic expectations, and describing realistic expectations to your patients, which, again, takes time. And I know a lot of therapists like why only have a half an hour with them, how can I how can I spend 15 or 20 minutes talking to them? So what would you say to that kind of a comment?

17:02

Yeah, and I think that's another thing that happens over the years. Like, I feel like I do less and talk more, but that might be just my personality, too. But, but I think that that's without that understanding, when you start that therapeutic alliance or understanding why you're, as you're doing, you're not going to get anywhere. And patients and especially patients with tendon injuries and tendinopathies. I mean, it takes six months to a year, I tell them that right away, it takes six months a year, you can do what I say, I'm pretty sure you're gonna get really well, you might not be 100%, I'm gonna get you definitely to 80 or 90%. If you don't do what I say, we can meet here in a year again, it doesn't bother me. Right? So it's handy because I think when I was younger, I tried to take on the problem and I I'm handing it back right away. I'm like, doesn't bother me if he doesn't do don't do it, you know, you can just come back to understanding and I think the other part from from the young clinicians were tendon injuries is the biggest thing is, this is not a quick fix. This takes time. And what you see a lot with the younger clinicians or maybe younger, my younger self, too, is like your to do treatment for two, three weeks, and they're not there yet. And then you get worried. And when you get worried the patient get worried. And then you start changing things. And then then they get more worried because you don't seem like you know what you're doing right, you know, it's setting the expectations. This is what you're going to do. It's not any cool exercises, this is going to take time, and having the training diaries that I follow over time and they say, You know what, I don't think much of happening. I'm like, Well, you weren't here three months ago, you could only walk one mile, but the pain of five. And now you're jogging for miles. I'm like, I think that's a pretty good improvement. Right? So having those to kind of working on and I think that's really, really important.

18:45

Yeah, and my next question is, is are all tendons created equal? So we sort of alluded to an Achilles tendon and a patellar tendon or we can talk about, you know, a golfer's elbow or tennis elbow. So when we're talking about all these different tendons, are they all created equal? And can we kind of throw the same treatments at each one, regardless of the part of the body?

19:10

Yeah, so again, it's kind of the same thing that attendance is a tendon in certain tendons structures, right? But all tendons are meant to connect muscle to bone and allow for mobility and that help us however, the design of those tendons are also meant for what they're good for. Right? So the Achilles tendon is the biggest tendon in the body because it's generates a lot of force and helps us move it move. patellar tendon is a little bit different isn't big, but it also tries to help change the angle of force around the knees. So then we put a patella and so all of a sudden we have compression and tendons are not very good for compression. The rotator cuff is more of a flatter tendon, that has a lot of curvature and the compression there is a problem right? So the flatter tendon combines more. Spread the force versus around tendon they kill As tenderness and then you're thinking about tendons in the hand, right, they are really long and thin, to be able to manipulate the fingers really gently build up the force gently. So they have different functions. And soon as you have different function, the tendon has to be slightly designed differently, which makes if it's designed differently, the treatment or the loading might be needed to be very differently. So I think one of the biggest thing is a tendon is really good for tensile forces, but not a good for compression forces. So for example, the rotator cuff, when you're talking about these overload tears is usually an inferior kind of compression that slowly degenerates, a tear. And the Achilles tendon is nothing like that at all. It's a high load, that kind of happen because you pull it apart just like Play Doh, you pull it apart from two different ends, and it kind of can rupture. So I think those are really, really important. What we also see as the lower extremity tendons seem to respond fairly similar. They're not as high in central sensitization indexes and don't have those things versus differently when you're looking at upper extremity tended to So there are definitely differences. So you need to kind of thinking about the basics, that it's not probably an acute inflammation that we need to treat it and then you need to start thinking about what does this tendon do? Is it being compressed as a flat? What are the other structures? Right? So Achilles tendon, you know, that is Achilles tendon. The real problem is, it's right there. There's not much else. That's why I study it, because it's easy to study versus the rotator cuff. We talk less about rotator cuff tendinopathy. And we talk more about shoulder pain, right? More because we not so sure. Is it purely the tendon? That's the problem and other things

21:40

add a lot more structures around it than just the Achilles tendon. That can adjust the Achilles. Sorry, but yeah, yeah. Yeah. So the little, a little more complicated area of the body will say, yes, yeah. So, you know, I think it's great to sort of look at that historical perspective. And I love that you kind of talked about where we are now, where do you see research moving towards, in the tendinopathy? field?

22:12

So now we're getting little bit into what I'm going to talk about in Denmark, too. But I think, yes, so one of the big things that we're really working on, is that, okay, I felt like we kind of reached this point, we're doing really well with everybody. But again, you know, if you look at average, with a big group, we're still not 100% On average, right? Some people aren't 100% recovered, versus some people are not. And why is that and we can't manipulate the treatment anymore. I need to figure out who do I treat how right we've been there in other areas, too. So really, what we're doing in our in our research now is really trying to use various statistical models and larger group data to really first evaluate, we'll be starting to call a tendon health, I'm really proposing that tendinopathy might be more of a biological disease, more like you're talking about knee osteoarthritis, there used to be just wear and tear, and now it's a biological disease, I think tendinopathy need to be considered the same way. And the reason I say that is because it's not just that the tendons structure had changed, or that you have pain, there's so many other variables related to it, like you have personal factors too, like BMI or diabetes affects them in differently cholesterol do so you have the metabolic factors, you have the personal factors, right. And you have, you know, the fear factors, and all these kinds of things play a role. So we call that our tendon health model. We really started with function, structure, pain and symptom, psychosocial factors. And then I realized it was a person too. So we actually have personal factors. And based on that we're trying to figure out are there different? Because you can't, we can in clinic, you can treat every person in singular, right? But, but we need to also to have more of the precision health understand what we do in the health system understanding are the various groupings. So who should we treat how to be very efficient. And that's some of the research that we're working on now. It'd be looked at my PhD students try and handle and found like, we have different groups, we have what we call activity dominant, which might be the one so we see a lot of them, the runner's active, they don't have a lot of symptoms, they don't have a lot of deficits, tenant is not that bad. versus group that we've called structure dominant, that are heavier, they have really horrible looking tendon, that poor function. And then we have a group that we call psychosocial dominant, that maybe the worst are not the best, but they're people with higher fear, decreasing function, but the tendon might not be so bad. And when we started thinking about that, well, now you can understand maybe how you can treat them a little differently. And then we can start looking at how should we treat them based on looking at randomized controlled trials because from a researcher perspective, if I threw all of those in, and I do the same treatment, some of them might benefit a lot and some of them don't and then the treatment is seared out right. There is no difference. But then I lost Ask the benefit for the ones that might benefit and I lost learning from the ones that didn't benefit the needed something else.

25:07

Fascinating. And you're going to be talking about this in Denmark.

25:12

Absolutely. And we have new data, how it changes over time and all those kinds of things. Yeah, well

25:18

don't give it all away. Now. Will we want people to go to Denmark to see you present this live? Demo? Yeah. Yeah. I mean, it sounds fascinating. I love the idea of a tendon health structure. And I love how it's it is, seems to be evolving to be more about the whole person, not just someone with a tendon injury. Yeah. Right. Because like you said, it could be like, two people can have the same injury. It could be one could be a postmenopausal woman who has the same injury as a young 30 Something male runner, maybe they both have an Achilles tendinopathy. But are you going to treat them exactly the same?

26:01

Yeah. And I think that's when we need to start thinking about this, some of the programs are maybe the same, but how do you modify them? And what are the expectations? And then what are the other things that you can add on to that, to really make sure that we get more people up to 100%, and really try to focus on them. And as a researcher, sometimes those things get lost. And that makes that's concerning to me.

26:26

But I for one cannot wait to hear that talk in Denmark. Now. Before we start wrapping things up here, what advice maybe give three tips, if you want to give more or less whatever you want. But what would you give to what tips would you give to clinicians who are treating patients with tendinopathy? Injuries? I don't know if I want to say injuries, if that's quite the word, but diagnoses let's say, so what are your top tips?

26:59

So my top tip is to kind of think about what that it is the structure and that structure responds differently than muscle structure and bone structure to thinking about it from that from the tissue level when you're designing the treatment program. And I think the number one is tendon takes longer to recover than other tissues. So setting that expectations right away. I mean, it's a clear indication when you're looking at hamstring injuries, is it purely muscle or is it more proximal with a tendon is clearly evidence to show that it takes longer. So if you have that expectation and sitting down to explain, but just because it takes longer does not mean a tendon has poor healing, it has very adequate healing is just healing that takes a little longer. And sometimes I even explain that that is a good thing. Because a tendon can last you for a very long time. Like for marathon runners, the Achilles tendon rebounds you so you can run a whole marathon, if your muscle was doing that, you'd be fatigued way earlier, and you wouldn't be able to do it. So the low metabolism is beneficial. But this is the rehab, it's going to take your time. So that's one of my biggest thing and taking time to kind of thinking through that. The other piece of advice is do not panic. And my clinician in our clinic, they tell me back to others what I say because I always tell the patient right away, you're going to get better. This is going to take time, and you're going to have setbacks. And I want to tell clinicians that to the patients are going to have setbacks, they're going to come but don't panic when they have setbacks. You know, it just is what it is. And if you set the expectations right away, the patient's going to come in and have a setback. Now they're like, Yeah, I have my setback. But you told me I would eventually have it right? Instead of not expecting them because then we react on a dime, oh, they're worse today. What am I going to do? And what am I to change? Like, no, this is part of life that goes up, it goes down and moving. So I think those two things, and along with really using the pain monitoring model, and training diaries are my key things.

29:04

Great advice. And I love that do not panic, because they know when you're panicking, yes, right? The eye you know, they see it in your face. And like you said, you start throwing everything in the kitchen sink on there. And they're like, Well, wait a second, what just happened here? I thought you said I could just do this. But I always tell patients like this is not a linear journey. It's not like you're going up a roller coaster and it's going to be linear and perfect. Like it's going to go up, it's going to dip down, it's going to come up maybe dip down but not as much and then you're gonna go up again and you know, it's a little bit more of a squiggly line and that's okay. And people really do appreciate that because setting expectations is paramount. I always feel like if I do nothing else, if they hear nothing else, at least they have an idea of what to expect. So that it's not crazy. Just

29:59

And I think the training diary to me, I use it for any patient for anything, I think that was really key too, because that calms all of us down. Let's see, let's go back here five weeks, wherever we're at what you were doing. And then we can see the pattern. And I even had one person that gave me like an Excel spreadsheet, and a color coded the pain. And if you looked over like a year, you can see that red and orange decrease and the green was increased, you know what I mean? Those are the patterns that you want to see. And it's hard to see those in your daily life. So that's why I think that's really important.

30:32

Yeah, that is a dedicated patient. Yes,

30:35

I do. But yeah,

30:38

yes, well, right. Right. But well, this was great. Where can people find you? If they have questions? Maybe you're on social media? Where can people find you?

30:51

I am on social media at kg silver Nagel, I think I'm on Twitter, is the main one is that but I also run the Delaware tendon research group, and attend them on a ligament research group. So on Twitter, we also have the UD tendon group. We're also on Facebook, and we're also on Instagram. And I'm easily found the University of Delaware and Department of Physical Therapy to please feel free to reach out and connect with us, you know, on the social media and those kinds of things that we're doing. And I'm very excited to discuss these clinical things.

31:26

And if you don't mind, can we talk a little bit about the Delaware attending group because you guys have some projects that you're working on to do you want to tell the listeners about those projects? In case you know, you need recruiting or you need volunteers? So go ahead.

31:42

Yes, we always need volunteers. So we actually have we have a lot of ongoing studies, but one of the big ones that NIH funded right now is we're looking at comparing men and women with Achilles tendinopathy. So we're up to 145 recruited patients out of 200, we had a little dip around COVID. So we're actually providing treatment for anybody that is around the Delaware Philadelphia area, please feel free to reach out or send your patients. We're also have ACL studies ongoing. One of the big ones also been relating to tendon is looking at the recovery from patellar tendon grafts to see how they change over time, how does that tend to actually recover? And could that if the doesn't recover fully, can that explain some of the deficits that we do see their ACLs injuries to we're also hoping to soon start more of looking at insertional, Achilles tendinopathy, with treatments we have. And one study with shockwave treatment, we have studies that we're hoping to start now looking more at metabolic factors, and getting a little blood draws and those things. So we have on our website with all of those things going on. So if anybody's interested, please feel free to reach out or look at our website.

32:53

Perfect. And we'll have a link to that at podcast at healthy, wealthy smart.com under this episode, so one click and we'll take you right there. So before we end, I have one question. Question I asked everyone and knowing where you are now in your life and in your career, what advice would you give to your younger self, and you can pick which ever age of your younger self you

33:14

would like. So I'm going to pick myself before I even went to PT school, because one of my mantras is to always have fun, and I will stick to that now. And I'll stick to that younger because if it's not fun, it's not worth doing, even if it's research and those things. So do anything that's fun. But I was did not want to go to school in Sweden, I wanted to do sports medicine wanted to go to the US. But I was very worried that if I didn't get in, when I was 20 that I wasn't going to go to PT school because it took four years and then I would be too old when I graduated before I was ready. So I wasn't going to go luckily I got in and I stayed on. So I think to to my younger self. It's a really long working life. So just keep on having fun and plugging along and learning more things. And I have taken the really long path to academia with the clinician for many years and doing those kinds of things. So that I'm happy for so I'm glad I got in and didn't say I wasn't going to do it. Because who cares if I was 2425?

34:14

Yeah, and that's so young. Yes, but isn't it funny when you're 1819 20? You're like, Oh, forget it. I'll be an old person by then 25 behind the eight ball when of course, now that were a little older, we can look back on that and be like, Oh my God. Yes. And

34:34

I mean, it's like it's, it's a long life to work. Don't hurry to get to the endpoint, right? Enjoy it get experienced during that time, because as I tell our students, I've had a lot of fun during my years and worked with sports workers, clinician travel, research, academia, you know, you got to have fun.

34:53

Absolutely. Well, and on that note, I want to thank you for coming on the podcast and having such a fun conversations. Well, thank you so much. And everyone, if you want to get a chance to see current speak live, then join us at the fourth World Congress, a sports physical therapy, it is in Denmark and August 26 and 27th of this year. And not only will you get to see speakers like yourself, but there's also going to be great networking, activity breaks, things like yoga, or running or walking tours, paddle paddleboarding, all sorts of fun stuff. So it's again, not going to be quite your average conference, and a lot of it is going to be clinically focused and clinically based. So I think that's really important. I think a lot of times people think, Oh, we go to these conferences, it's going to be researchers just talking about their research and how's that going to affect me clinically? Well, this conference is all about that. So I think, right? Absolutely agree. Yeah. So come join us in Denmark. Again, thank you so much for coming on. And everyone. Thank you so much for tuning in. Have a great couple of days and stay healthy, wealthy and smart.