Healthy Wealthy & Smart Dr. Evangelos Pappas: The Latest Evidence on Athletic Knee Injuries
In this episode, Professor and Associate Dean at the University of Wollongong, Evangelos Pappas, talks about ACL injuries and surgeries.
Today, Evangelos talks about having difficult conversations around ACL injuries and surgery, some of the recent research that he has done, and the psychological effects of surgery versus non-surgery. What can physical therapists and associations do better?
Hear about continuing education, embracing digital health, and get Evangelos's advice to his younger self, all on today's episode of The Healthy, Wealthy & Smart Podcast.
Key Takeaways
- "For things to change, it cannot be done individually."
- "We need to tailor the treatment to them after we educate them."
- "Be more confident. Question things."
- "Don't worry. Everything will work out in the end."
- "Digital health is the future."
More about Evangelos Pappas
Evangelos Pappas is an experienced academic leader currently holding the Professor and Associate Dean (intoHealth) position at the University of Wollongong where he works on the development of the Health and Wellbeing Precinct at the Innovation campus. He has previously held academic appointments at Long Island University-Brooklyn campus (2002-2013) and at the University of Sydney (20013-2021) where he has also served as the Head of the Discipline of Physiotherapy (2018-2021).
His research focuses on the aetiology, prevention and treatment of serious athletic knee injuries such as those that involve the anterior cruciate ligament (ACL) as well as the long-term consequences of these injuries. He has published extensively in this area on research projects that utilize biomechanical, epidemiological and clinical approaches and he has been active on educating students, clinicians and patients on the latest evidence on the topic. He has disseminated his research with over 130 publications, primarily on athletic knee injuries but also more broadly on musculoskeletal injuries and disease.
He has been interviewed for his work on knee injuries and yoga injuries for newspaper articles and podcasts (Healthy, Wealthy, and Smart, and Knee Guru). He has taught extensively in the areas of musculoskeletal biomechanics, anatomy, orthopedic rehabilitation, clinical decision making, and digital health.
Suggested Keywords
Healthy, Wealthy, Smart, Physiotherapy, ACL Injuries, ACL Surgery, Recovery, Rehabilitation, Research, Digital Health,
To learn more, follow Evangelos at:
Website: https://scholars.uow.edu.au/display/evangelos_pappas.
Twitter: @evpappas.
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Read the Full Transcript Here:
00:02
Hey Evangelos Welcome back to the podcast. Always happy to have you on.
00:07
It's fantastic to be back, Karen on the regular since the days you were on satellite radio.
00:14
That's right. That's right. Since I was, I was doing this show out of a studio live every Monday at one o'clock. That's how it all started. And yes, your circle. That's right. And you were you were like one of the first guests and you keep coming back. Which, which only means that you keep doing really good
00:35
work. While you keep inviting me so well. And Matt,
00:39
and it's a good time, it's a good time to catch up and everything. So people don't know evangelists now used to work together in New York City. At on 57th Street, and actually, you know, we're as we're recording this, we're just a couple of days outside of 911. And I was with you on 911. That's where I was right. That's where we were. So someone asked me the other day, where Where were you on? 911? I could tell you exactly where I was. I was on 57th Street with working with you and and Mike and Amy and and that's exactly where
01:14
I was. That's right. Yeah, that's Tuesday. And then we went through all the trauma after that, which people are hearing now live in Australia. And people here asked me about my experience. And my response is that it's the closest I have you ever been to a warzone? So that's, that's the memories I have.
01:35
Yeah, yeah, I remember it very, very vividly. And, and now you're in Australia, and just publishing work like a fiend, paper after paper after paper, which is very exciting. And just so people know, we'll have all the links to all of your published works in the podcast in the show notes. But today, we're going to talk about your specialty. We're going to talk about ACL injuries. And we're going to talk about rehabilitation, whether you have surgery or you don't have surgery. So I think the the first question I have is when you're working with a patient, so they they they have an ACL injury, they come to see you maybe a couple days after, and they're kind of debating do I have surgery? Do I not have surgery? And they asked for your opinion, which happens all the time. So what what advice do you have for therapists listening, when people ask them that question, how do we answer that?
02:36
Well, just like with a lot of these questions, there's no easy answer. And obviously, you have to tailor the answer to the patient, their goals, their needs, their physical activity that they will use to do the physical activity as opposed to go back. And I have to say, it can be a somewhat heartbreaking interaction, because one area where we have not been doing so well, the physical therapy world, but also the orthopedic surgery world, is to be honest with our patients about what happens after an ACL injury. And I think the media has a responsibility here because you know, frequently they talk about the latest athlete who has come back stronger than before, after an ACL reconstruction, for example. And all that is incongruent with the evidence. So an ACL injury is a very serious injury, that in the majority of the patients can be a life changing injury. And we don't and it's difficult to say that to a 16 year old, it's difficult to add to tell them to educate them that, you know, not only you've missed the season, but that's the least of your worries, because you know, 15 years later, your knee has a very high chance of entering degenerative stage and developing debilitating osteoarthritis. So so we and I think, answering that question, do I need to have surgery should start with education? I guess, throughout this podcast, you know, you mentioned before, the research that we're publishing and you know, it is important to give credit to those who are doing a lot of the work and I'll be mentioning a lot of my PhD students and postdocs who are leading a lot of these work. So we I post supervise Andrew gamble, who is a amazing physiotherapist here in Australia, working on decision aids for patients who had an ACL injury and the younger than 18 year olds. So I think these are the tools that I really hope to see in the next few years that then allow the clinicians and the patients to navigate the different choices that they have. Have educate them, and then then make an informed decision. So if I were confronted with this question, I would ask tactfully, as I can explain that this is an injury that is serious, and that a lot of the treatments will probably be trial and error. So we don't know who does well with non surgical treatment. And who does well, with surgical treatment at this point, we just don't have the prediction models that that allow us to do a few tests. I mean, certainly not at two days, but even at three months after the injury, we just don't know who does well. And we'll be talking later about the three RCTs that have been published that give us some insight on the outcomes after ACL injury and the different treatment options that are available. But yeah, you know, I would educate the patients about the risk of developing new osteoarthritis, and I would also encourage them to consider other sports, because nobody wants to say that, as I said, to a 16 year old, who is playing soccer and wants to get on a scholarship to go to college. But yeah, if you had one ACL injury, you are your risk of suffering subsequent ACL injuries with everything this means for the health of the knee is is much higher. And again, that's the second area where we have failed as a profession to educate our patients. Try to redirect them, of course, it's their choice, if they make an informed decision that I love soccer, and I want to get back to it no matter what, then we'll support them to do that. But we have really failed to educate them about the seriousness of the injury and the advantages of switching to other sports that can keep you active.
06:54
And that's a really hard conversation to have. And I've been going through this over the past couple of weeks with a patient and the decision was made, she went back to the sport in which she initially injured which was soccer. After myself, her surgeon, a couple of doctors, they went for second opinions, everybody was of the opinion that it's not a good idea, and that your risk is much higher. And she said, I know the risks.
07:28
So it was three theta nonsurgically. And she went back to soccer, she enrolled surgery with surgery.
07:34
Okay, yeah. And she said, I know the risks, but it's what I do I want to do this. And she is 16 years old. She's a sophomore in college and high school. And she said, No, I know the risks. And if I tear it again, I that's, you know, that's on me. And I understand and I know what's going to happen, and I know what happens long term, and this is what I want to do. Yeah, and so you can't chain someone to the sideline, you know,
08:01
should Yeah, and you shouldn't either, you know, as long as they understand the race, I mean, we take risks every day, you know, people are doing really risky things, frequently, with a lot less reward than than playing the sport that you love. So, so Yeah, as long as it's an informed decision, and they're aware of the risks, then then I would be very happy to help them get back to this goal. When I tore my ACL, I did not have an ACL reconstruction initially, and I went back to play basketball. And you know, I was doing a PhD on ACL injuries, and it ended up being a terrible idea, long term, you know, with a subsequent injuries that I suffered, but yeah, well, you know, it's applied fine for for a few months. So, you know, you feel invincible, you know, when you do that. And, and I think that's the risk here can because I asked you whether this patient had an ACL reconstruction, because, yeah, obviously having an ACL reconstruction, going back to sports, it is a risky thing. But in some ways, it doesn't make sense. Frequently, patients have reconstruction exactly, because they won't go back to sports. But I do think with all this publicity in the last few years around non surgical options for people who have an ACL reconstruction, I believe that the pendulum sometimes is swinging way too far in the direction of that provides the impression that well, the ACL is not needed, you know, they're there. And then they isolate a couple of examples of athletes who play with no ACL. And then everybody believes that that's going to be the next person who's going to be in the news for that. And we do know that that just not the case. So I just, you know, one thing I can very comfortably say is that being ACL deficient and playing this cutting and pivoting sports at a high level isn't Other good combination, it does place your knee at a much higher risk of subluxation episodes, and then subsequent cartilage and meniscal injuries. And it does make a subsequent ACL reconstruction more difficult, I would say. So, yeah, one thing I will say is that if they're determined to go back to these high level sports, then then an ACL reconstruction is probably one thing to consider there.
10:27
Yeah. And I think it's also important to consider as you're talking about, you know, the athletes that are in the news, it's important for people to understand that that's their job. That's their job. They have a team, they have a coach, they have a strength and conditioning specialist, a PT, probably nutritionist, you know, it's their job to literally work out and get stronger. So for the majority of clinicians, we're not seeing professional athletes, we're seeing someone who wants to play basketball on the weekend, but has a full time job and maybe can't work out and do the amount necessary on a weekly basis to get back to that level of sport.
11:11
Or absolutely, you know, having if we all replaced our job with the time we spend with rehabilitation, obviously, our body would be in different shape. But the thing here to to add to what you said, Karen, is that frequently, we hear about those few exceptions that played with the being ACL deficient. And we don't hear about all those who tried to return to sports, with no ACL and failed, and these are the majority. So yeah, just want to be clear, clear here is that the ACL is a very important ligament and then cutting and pivoting sports and ACL deficiently is not a good idea. Yeah.
11:55
100%. And of course, they don't talk about the people who tried and failed, because that's not newsworthy. That's not a news story. Although, I would argue that is the news story. That's yeah, right. Okay, so let's talk about you mentioned some of the research that has recently come out, in and so why don't you walk us through some of those RCTs and what you found and the people who helped you along the way?
12:23
Yeah, so it is an exciting time to look into treatment options for ACL injuries, because unlike a few years ago, we have some really good evidence that is coming out in the form of the randomized control trials. So just a couple of weeks ago, in the Lancet, one of the top medical journals, there was another RCT that was published by a group in the UK that looked at non surgical versus surgical treatment randomized so patients signed the form that said, I had you know, that they met the inclusion criteria that they had an ACL injury, minor meniscal injury, some of them but but nothing that required, you know, more expensive treatments and broken bones, and so on and so forth. And when they accept it to be in one of the two groups, either having an ACL reconstruction, or to try non surgical treatment with the option to obviously convert into surgery down the road. Now, the difference of these last trial that was published compared to the previous one is that they had chronic instability. So this is the group that that had the chronic instability, the better candidates in many ways for an ACL reconstruction, right. And it is impressing just like the other two trials. So the Canon trial that is the one that has the longest follow up at this point, and we should start seeing the 10 year results, hopefully soon from this trial, because we have seen the two and the five year results, and then they compare trial out out of the Netherlands, there is some impressive consistency in some of the outcomes. The last trial on the people who had chronic instability is different in that it showed statistically significantly better results in many of the outcomes in favor of the surgical group. But when you look at the difference, and you actually look at the statistics a bit more carefully, the difference it is statistically significant, but not but borderline in terms of its clinical significance. So it does confer an advantage on the average patient but probably not not the it's not a clear winner. We would say the other two studies. Again, you know, some minor differences between them. So the Dutch trial they found in some of the outcomes again, slightly better outcomes in the surgical group, but the cannon trial but in many of the other outcomes difference. And then the Canon trial actually found that there is no difference between the two groups. So when we look at the totality of the evidence out of the studies, there is a few outcomes here, a few back consistent messages. So one is that, if there is an advantage of the ACL for the ACL reconstruction is probably quite marginal. But also, and that ties in with what we're discussing at the first part of this podcast, Karen, when you look at the physical activity levels of the patient, it's very few of them sustain high physical activity level down the road. And again, that Canon trial provides a bit of evidence there, because it is a five year follow up a lot of the patients either by choice or because their knee, not happy with the health of the knee, do not return to their high level of cutting sports. Of course, as you would expect, there are some differences there. And the ACL reconstruction does indeed provide a more stable knee with a slightly better chance of returning to high level sports. But yeah, it is important to educate our patients about that, that you know, you and these are patients who are motivated, they are returning, they are enrolling into an RCT. So that is one key message here. The other key message and again that for us as physiotherapy as PTS, you know, it's important to keep that in mind is that from those who were randomized in the non surgical group, half of them end up having surgery.
16:37
So when you look at and when we read this paper, it's it is important to actually keep that in mind, because you look at the outcomes for the non surgical group. But we have to keep in mind that half of these patients in this group had surgery had an ACL reconstruction. So when you look at obviously, if you take those out, which again, that kind of takes away some of the advantages of the RCT, you cannot just remove that group and then just compare the group that's stuck with a treatment with the treatment allocation of the non surgical treatment with the other group. But yeah, you know, it is in the canon trial, I did a little bit of that. So it is important to look at all these different comparisons. But that is another consistent message from both of these trials that you know, a lot of half about half of these patients, they switch treatment, and they end up having the ACL reconstruction. Now, this does not mean that they're happy with the ACL reconstruction, obviously, you cannot undo the ACL reconstruction. But but it does demonstrate that they were not very happy with the outcomes that they got from the non surgical treatment. So that is important to keep in mind as we are looking at this evidence.
17:55
And in these trials, are they also taking into account sort of the psychological effects of surgery versus non surgery? And maybe the expectations of what one might have? I you know, I don't know. Because I know I've had people who were kind of on the non surgical route and doing very well and then just said to me, you know, I can't live with the fact that there's something torn in my body, I can't do it. Can't do it. You know, they're like, from a psychological standpoint, I can't do it. I realize I'm doing everything I want to do and can probably continue to do it. But I need to have this corrected. Right. So there is always that kind of psychological component. And, you know, to your point earlier, what you see in the media, I think can sway people.
18:43
Oh, absolutely. Yeah. See, to put it simplistically, the patients who tear their ACL, they frequently feel that they want it fixed rate. And they believe that if they go to the most expensive surgery and the one who is treating the professional athletes, and have tons of physiotherapy with somebody, again, who is famous as a physiotherapist, that they will get the best outcome. So so doing more treatment is really going to fix that in many, you know, in many other parts of our lives. They work like that, you know, if you do buy a very expensive car frequently is better than you know, use very cheap car that you can buy from your neighbor. But in healthcare, it frequently doesn't work like that it didn't maybe not the best treatment and, and we spoke about that in a bit more detail in an editorial that we wrote in sports medicine about three years ago, Joe Zadra, who is doing amazing work as a research fellow now within the equivalent of the NIH here in Australia called the NHMRC. And he's looking at this MCs called supervising Andrew gamble that I mentioned earlier, you know, doing a lot of work in this space. but it is about that it's about the expectations that either people have intuitively that, yeah, well, I tore something, I'll go fix it as soon as possible. And that will make it good. Versus the evidence which, you know, the reality is that frequently things break in the human body and cannot be fixed, not to the same in the same way as before. And the ACL is definitely one example here.
20:26
Yeah, and I think the hardest part about the rehab process is oftentimes managing those expectations.
20:40
But also thinking that, you know, and when we were working, you know, in midtown Manhattan, then you would frequently have patients who would see some of the very famous surgeons and the expectation, either explicitly or implicitly, will be that that, you know, everything will be as good as before. And frequently, the clinicians isolate one fact like one laboratory study that showed that the graft is stronger than the original ACL, and serve that to the patient that that that doesn't help with these expectations. So yeah, it is it is a bit of a challenge the error in creating these expectations in the healthcare system that doesn't help achieve that.
21:23
And so where do you think? Or where or what do you think physical therapists can do? Better to help manage this? Because like you said, oftentimes, yeah, you cherry pick some research that follows the narrative that perhaps you're hearing from the patient, but I guess the question is, Is it okay to be truthful? You know what I mean? I know that sounds like, of course, it is, from like a moral standpoint, of course. But if you have a patient who really wants to hear something, it also then becomes, hey, if, let's say, and this goes into a whole other thing that you may not have the answers to. But if you're a physical therapist that owns a practice, you know, Peter O'Sullivan will often say what's good for wellness or what's good for the patient isn't good for business. So if you have a patient who just wants to hear this, and you want to stay in business, you know, I'm not advocating to compromise the patient's health or anything like that, but,
22:28
but yeah, definitely, but yet compromise is part of our daily life as clinicians and you know, I am speaking from a position of privilege here as an academic, you know, so I certainly don't don't, I'm not trying to take the higher moral ground. But I do understand, obviously, the challenges, I mean, not only financially, but also the fact that if you are the party pooper, who is telling your 16 year olds that, well, you're not going to you should not get back to soccer. And then they go across the street to somebody else to another big surgeon or a PT, who tells them I've had all of my patients when back to the previous activity level, who are you going to go with? You know, it is intuitive. So, yeah, I certainly understand the challenges. And you're correct, but I don't have the answers. And I think the four things to change, it cannot be done individually. So you know, individual physiotherapist can are not going to change this. There's so much inertia in the system. So I do think that collectively we should. Yeah, well, the the, there are associations that have made statements for specific things that I've seen recently read one, the Hospital for Special Surgery, where they tried to place the evidence around ACL repairs, which are, you know, there are some surgeons who are doing them, and they may have a place. But again, the evidence shows that they do fail at the higher rate and an ACL reconstruction. So maybe it's a question and a place where associations can play a more major role. But certainly people who teach continuing education courses. And that's not different for a lot of the other pathologies that we see. We certainly want to educate our patients and you wouldn't tell your patient who had a total knee replacement that they shouldn't be running marathons, you know, 20 marathons a year, that just wouldn't wouldn't make sense. So why do we do that for our patients who have an ACL reconstruction? It is obviously that they're younger and it is but you know, we don't want to get them goes back to clinicians traditionally being viewed as the Guru's who. Just use marketing techniques to talk about the outcomes that they have. And if you're good at If you're good at selling that to your patients, then you do get Vizier. But you there are ethical issues there, as you pointed out, the reality is that there is a lot of work for everybody. So we don't have to do that. That's my sense. And of course, you don't have to be able to sleep comfortably with our conscience, you know, being comfortable without conscience at the end of the day. But one thing that I've seen, and that's, you know, probably a bit different, but related to this discussion we're having Karen is this turf wars that still exist between professions. I mean, I've seen that in Australia, you know, quite obviously, here in that a lot of the some of the physiotherapist they are trying to throw as much mud on the ACL reconstructions as they can. And they are probably over utilized. We had a debate here a few months ago with an orthopedic surgeon, as part of a debate that the sports medicine in Australia are organized. And the consent, one of the things we agreed on is that ACL reconstructions are probably over utilized, and the outcomes are not as good as we're telling patients that they are. But at the same time, we should not completely disregard ACL reconstruction because it does have a place and it does provide a more stable knee. And we should avoid this turf wars where physiotherapists are trying to convince everybody and utilize the evidence to their advantage, demonstrating that ACL reconstruction don't work. Well, of course, there's two big surgeons, they are cherry picking some of the outcomes showing that it does work, that the truth is in the middle, in that thing, to change things, we should work with the other professions, and make sure that we're all on the same page. Because there is quite a bit of evidence that is emerging. And it actually says a few things that are good for some professions, but a few things that aren't good for the same profession. So
27:04
yeah, so doing your best to give all sides to the patient. And then ultimately, like you said, in the beginning of the podcast, it's the patient's decision. It's not our decision. It's not the doctor's decision, it's the patient's decision and what they feel like they're going to do moving forward from movement and activity perspective and what they need.
27:27
That's exactly right. We do tailor the treatment to them after we educate them. But But I really hope that again, that goes back to all of us joining together and those of us who do research, that in the next few years, we can develop some algorithms that will tell us who is a better because of everybody's is, has the same chance of success with each one of the treatments. I had patients who have been ACL deficient, some of them bilaterally, and they're skiing hard and dancing and playing sports that you would think that we'll be able to, there are these examples. And of course, there are the examples for those who have an ACL reconstruction, and they forget that their knee ever had an injury. So there's good outcomes in both sides. But we really have to do work to and to do these studies, they're very expensive, you know, they're very, very difficult to do. And you do need very large sample sizes. So it will have to be multicenter and multinational, I will say collaborations that that. But that if we all joined our forces together, and we say that in the next five to seven years, we should develop good algorithms reliable algorithm that then can tell you, when you tore your ACL, what are roughly your chances of being successful with no surgical treatment, then yeah, I think that will be a good outcome for everybody.
28:51
I mean, that would be a really good outcome for everybody. And would make I think would allow the patient, the therapist, the doctor to move ahead with this, maybe some more confidence in that they're making the right decision, because we're human beings and everybody. So I mean, I second guess what I'm going to have for lunch. I mean, I can't imagine like, you know, to have a surgery or to not have a surgery, it's a big decision. So there's a lot of like, second guessing. And now earlier, you had mentioned continuing education. So we're gonna pivot to that for a moment because you're speaking Friday and Saturday, the seventh and eighth of October at the Paris lower limbs Summit. So do you want to give the folks a little sneak peek as to what you're gonna do? I mean, you don't have to give away everything you can like tease like, Oh, I'm going to talk about this research that I've never spoken about before. So if you want to tease that a little bit, go ahead.
29:48
No, I have nothing to hide in other things you were publishing, as you said, so everything is out there. And again, if any of the listeners want to read the paper, it helps with putting you to sleep, I would say the methodology section, please feel free to email me and I'm happy to share some of the work that we have been doing. So yes, I'm going to Paris in a few weeks for the lower extremity Summit. As yawns are there pay a has been organizing this conference has been postponed a couple of times because of COVID. But it is happening right next to the, to the tower there to the Eiffel Tower. And you know, the these guys are really professional, they, the I was told that the tickets for that conference were sold out in 24 hours. So that just demonstrates the hunger that exists in Europe about high quality, continuing education. So they have invited a lot of really, really smart people. But because they're French, and they're very modest, they also invited average people like myself, to balance out the intelligence level there. But yeah, a lot of great speakers, I'm really excited to listen to everybody else speaking, to be honest, and I will be speaking on the topic of surgical versus non surgical treatment. So if you haven't been paying attention in the last 10 minutes, probably the message is there. So but I will be providing obviously in much more detail on the RCTs that have been published. And also, some of them are cohort studies that have been published again, you know, my message will be that not everybody benefits the same from all the treatments and that there is a wide spectrum of outcomes. But there are a few things that have emerged from these three RCTs that are quite consistent. So yeah, if you if you are in the in Paris, in the beginning of October, I don't think there are any tickets left. But you'll see us partying somewhere in one of the local clubs there in the evening. But I'm really looking forward to this conference, which will be the first one the first time I'm going out of Australia since the COVID pandemic and the first international travel. So that's gonna be interesting.
32:08
Yeah, it's a big deal. It's a big deal. It's I've been out of the country twice so far, once to Monaco for the IOC and then to Copenhagen for the Fourth World Congress and sports pt. And they it was both amazing conferences, great information. But the best part was kind of seeing all those colleagues that you haven't seen in a long time. And I'm sure that's one of the things you're looking forward to, as well.
32:37
Oh, absolutely. Yeah, the social part of this conference will be very interesting, too. But yeah, the scientific part. So and the good thing about not having been at a face to face conference in three years is that there's so much many more things that you have to learn now, because all this research that has been published over these years. So yeah, please come and say hello, and if you haven't tickets for the lower extremity Summit, love to hear from you.
33:08
Perfect. And then where can people find you outside of Paris? Let's say they just want to get some of your research. ask you questions. Where can people find you?
33:21
Well, physically, they can find me in Google and Gong, just this beautiful place, an hour and a half south of Sydney. So I am the Associate Dean for a developing health and wellbeing precinct here at the University of Wollongong. That's my day job. My evening job is research and I do have 11 PhD students in a very large network of collaborators that I have been working with. We are growing our team here at the University of Wollongong. So if you are in Australia, and you want to do a PhD and ACL injuries, please talk to us. So we have a lot of very interesting abs and a lot of problems that you can help us solve. And then as a busy father and husband I do how I try to save some time for social media. So I'm on Twitter at EV Pappas tweeting all the great work that my PhD students do and occasional some political commentary there. And yeah, on LinkedIn, evangelist Pappas, so
34:25
perfect. So we will share all of this information with people so if they want to get in touch with you with questions and things like that one, click at podcast at healthy, wealthy smart.com And you'll be able to find evangelists very quickly. So before we wrap things up, one more question. Given where you are now in your life and career, what advice would you give to your younger self? I know you've answered this before because you've been on the podcast before but give another give another piece of advice. Oh, don't
34:53
even remember if I have answered it and what I say Yeah, well how young Um, I mean, it could be age myself, or is it professional advisors, life advisor,
35:06
life, it could be anything, you know, it could be right out of PT school, it could be, you know, when you're in New York toiling away and at NYU getting your PhD or, you know, whatever, whatever you
35:19
guess, yeah, I would give a different made, I will give different advice to different parts of my personality in different parts of my life. Certainly, when I did move to the United States, I did my undergraduate in physiotherapy in Greece. That was in the late 90s. And that was when I did a master's degree at Quinnipiac University. And and, again, the a lot of the continued education back then was around myofascial release and cranial sacral therapy. And so I do remember myself, struggling with a lot, I mean, trying to get as much knowledge as possible and not questioning a lot of what was presented then. So so that's one piece of advice, question more. But I think I speak for other people when I say that. Obviously, we now we know that a lot of these treatments are not based on on a lot of evidence, and even the mechanism that were proposed to be based on they have been proven, understandably not not very valid. So yeah, quite question a bit bit feel more confident, feel more comfortable question more. I do remember, there was this conference in Las Vegas where I went, and as they commonly do in this continuing education courses, they take somebody from the crowd, and they say, Well, let's look at their pelvis, and if it is aligned, so So the instructors immediately says, As soon as they expose the PSA axis of that participant, you know, say, Oh, wow, obviously, you see that, and then everybody around so home, wow, as everybody would see something really obvious, it was not obvious to me, but then I looked around. And eyes, see that thing, I couldn't see anything, you know, it was not even wearing my glasses, and I was too far. So even if there was something there. So yeah, I think, you know, being a bit more confident to question things, that's what I encourage my students nowadays, and thankfully, these newer generations are a bit more brave, and question skeptical and questioning things, so you can't fool them very easily. And that makes me very optimistic about the future. And when I was doing my PhD, and you know, working with you, Karen, that website, physical therapy, back there, you know, obviously, a lot of fun and learning from each other, but challenging times to, in many ways, you know, trying to balance everything and do a PhD full time at that time. So, so the advice I would give myself back then is that don't worry, everything will work out at the end. So yeah, but the advice I give myself now, and then maybe that's a good idea for you for another podcast is that digital health is the future. So that's obviously a large topic. And we can open this discussion up in different podcasts in in different episodes. But one of the great things from the pandemic is that a lot of the things that then there are quite a few things that are wrong in our profession, they seem to be addressed. And there is companies that are aggressively moving into the space, and democratizing which is the catchy word that we have been hearing the last couple of years physical therapy, and that's not gonna, you know, it cannot turn back the clock. So I do think that 510 years from now, a very big part of physical therapy services will be delivered in a in a digital environment. And I think we should embrace that instead of fighting it as a profession. And we should try to look at the advantages of this approach.
39:09
Yeah, I agree. There's, like you said, you can't do you can't want to let out of the bottle the genies out of the bottle, you can't step it back in and the quicker we can embrace it and, and find ways to perhaps make it a little easier for physical therapists across the board around the country and around the world to be able to utilize digital assets I think the better so I agree with you on that one. Well, Evangelos thank you so much for coming onto the podcast again. And I guess now we'll schedule another one for digital health. We could do like a digital health panel you know, have like a couple people have a series Yeah, it's a good idea to I'm up for so you don't you love how guests come on, and then they immediately booked themselves for another work. That's great. It's perfect.
39:58
So when is the past Oh, well. Invitation.
40:02
Maybe after we'll let you go to Paris first. When you get back from Paris, you let me know. Yeah, yes. All right. Well, yeah, if you're still if you're not too jet lagged. Give me a few days. Yeah, we'll give you a couple of days. But again, thank you so much. So great to catch up with you and to see you and thanks again for coming on.
40:21
Oh, thanks for the opportunity, Karen. And Lovely to see you again. And then speaking to, you know, going back to the satellite radio day, so obviously, things have changed rapidly for you and you deserve all this access as you are doing great work, educating the profession.
40:38
Thank you. Thank you. I appreciate that. And everyone. Thank you all for tuning in. Have a great couple of days and stay healthy, wealthy and smart.