Episode 1501 - Hip & knee OA: the unspoken battle

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Extremity Management division leader Lindsey Hughey highlights the four pillars of healthy living behaviors: mindfulness, exercise, diet, and sleep. These pillars are essential for improving overall health and wellness. Mindfulness involves helping patients become more aware of their beliefs and mindset towards their body, and providing them with strategies to think about their body in a healthier way. For patients with hip and knee issues, mindfulness should also involve reframing their mindset to view their bodies as having opportunities for improvement through strength and flexibility.

Exercise is crucial for meeting physical activity guidelines, which recommend 150 to 300 minutes of physical activity per week. The WHO recommends aiming for 300 minutes as it is more beneficial. However, prescribing physical activity for patients in pain can be challenging. The episode suggests starting where the patient is at and finding ways to infuse physical activity, such as starting with five-minute bouts. Therapeutic exercise is also helpful but may only result in small to moderate size effects on pain and disability due to variability in patient response.

Diet involves adding healthy foods to a patient's diet, rather than taking away harmful foods. This is especially important for those who have received negative messages about their body. Sleep is also crucial for tissue healing, and strategies such as sleeping in a cool, dark room and going to bed at the same time daily can help improve sleep quality.

Overall, addressing these four pillars may be challenging, but they are essential for improving brain tissue and making the body more resilient. The goal of mindfulness is to help patients become more mindful of their bodies and to frame their mindset in a more positive and proactive way. Meeting physical activity guidelines is a must, and therapeutic exercise can be helpful but may only result in small to moderate size effects on pain and disability. Adding healthy foods to a patient's diet and improving sleep quality are also crucial for overall health and wellness.

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EPISODE TRANSCRIPTION

00:00 Dr. Lindsey Hughey, PT, DPT, OCS, FAAOMPTGood morning PT on Ice Daily Show, how are you? I am Dr. Lindsay Hughey, one of our lead faculty from our extreme management team coming to you live from Grass Valley, California. Kind of an atypical place to see you all, but I'm just finishing up teaching a course here with body logic. What a weekend and about to take off to Delaware a day of travel, but I'm so happy to be with you all this morning. Today I'm going to chat with you about hip and neo-a and really the unspoken battle we have with these folks when we're treating them. But before I dive into the topic at hand, I would love to review just briefly some courses that Mark and I and our extreme management team have coming up this summer. So our next offering is July 15th, 16th, we will be in Holmes Beach, Florida. And then July 22nd, 23rd, we will be in California again, but now we'll be in the southern part, almost the most northern part. So we'll be in Sydney Valley, California, and there are still spots in both of those courses. So we'd be delighted to have you with me. And then July 29th and 30th, we're going to be at Onward Madison. I think there's only one or two spots, maybe zero. Check it out though, because we are filling up because that's right before the CrossFit Games. And one of our faculty, Kelly Bempi, is competing in the CrossFit Games. So I'm going to teach that weekend and then stay the whole week and cheer her on. I couldn't be more pumped and a lot of ICE faculty would be there. So think about that as one of your weekends if you're wanting to go to the CrossFit Games as well and kind of make a week out of it. And then check us out on ptlnice.com in our extreme management division because we also have courses in August and then early September. But I'd love to unspoken battle. So in this episode, I want to briefly review what we know helps hip and knee away, which we in the last couple of years keep seeing studies that really just confirm exercise is the way. It's not injections. It's not surgery. It is exercise medicine. And just recently, a 2023 systematic review and meta-analysis on hip and knee away just came out out of the Lancet Rheumatology Journal reiterating this. The exercise is superior to no exercise. And kind of the challenge and this study in particular, its title was Moderators of the Effect of Therapeutic Exercise for Knee and Hip Osteoarthritis, a Systematic Review and Individual Participant Meta-Analysis. This involved 91 RCTs and they compared exercise versus non-exercise strategies and they included both knee or hip or included studies that actually looked at both or looked at each individually. And really the outcome measure is pain and disability, right? The number one things patients are coming to us for. And then the study just really reiterated the importance of therapeutic exercise. What we often just say exercise, but what this article defined therapeutic exercise to be was it involves participation in physical activity that is planned, that is structured, repetitive, and purposeful for the improvement or maintenance of a specific health condition such as osteoarthritis, right? So this has to be purposefully planned and it has is multimodal and in nature. This article not only reiterated that therapeutic exercise, in fact, that combination of multimodal treatment is helpful, but it also further demonstrated that we always see small to like moderate size effects or effect sizes as it relates to pain and disability. Meaning not really huge shifts and necessarily changing that patient's world and then implying it to the broad population because there's a lot of variability in patient response. We are just still missing the target here is what that's telling me, right? We're missing the target in this patient population because we're not even though we know exercise is the way, we're not reaching everyone. People are still going on to getting knee replacement. They're still going on to having pain and disability. And I believe it's because our focus is really misdirected and what the underlying battle here is. And it's not just about strength, range of motion, access. It is a much bigger underlying systemic issue because we're not even reaching the target. Because what is happening under the surface with hip and knee away is a really complex process. And while it's complex, I'm going to just unpack it for you in like a minute. But when we see folks that are inactive, not moving, and whether it's because they first started having pain and then they stopped moving or because of being sedentary, they started kind of developing osteoarthritis. What came first, the chicken here, but what we do know is there's this cyclic cycle where when you stop moving and you have underlying osteoarthritis, sarcopenia starts to happen, right? We start to see muscle wasting. With this inactivity in this sarcopenia in our tissues, we start seeing accumulation of visceral fat. And then macrophage infiltration throughout our body, hanging out, low grade. We see links to osteoarthritis and then this cycle where this leads to Alzheimer's disease. Our brain cells, our brain tissue starts to become unhealthy because of this low grade systemic inflammation. This starts to affect these immune cells are hanging out in our blood tissue. We have unhealthy blood. So we get atherosclerosis, right? We get buildup along our arterial walls. This starts to lead to insulin resistance and glucose just hanging out in our blood because it's not being uptaked as much as readily as it needs to because again, the blood is unhealthy and this leads to type two diabetes. We see cyclical links and then guess what? Then our blood no longer is oxygen rich. We see links to then anemia and osteoarthritis and this cycle of low grade chronic inflammation continues leading to other major diseases that affect our whole ecosystem. We know this, right? This is a like this cycle I'm describing came out in 2018 from school at L&T and JOSPT just talking about the importance of if we don't get our patients moving and physically active, this low grade inflammation, it's just going to hang out there. And if we pair that with what we know is happening in our society at large, I don't just mean the United States, but globally, when we look to the WHO, right? The World Health Organization and you look at the top 10 causes of death, right? Guess what just got added to that top 10 list recently? Diabetes, diabetes, diaphragm, diabetes, right? And we have our folks with hip and knee osteoarthritis, not in pain, so they're not moving. And then this low grade systemic inflammation cycle, which leads to diabetes and things like Alzheimer's, which is also on our list of top 10 issues are things leading to death. We are dealing with metabolic disease with hip and knee away. We have to address the hard conversations around metabolic disease if we really want to impact our humans, our patients lives with hip and knee away. Think about most of your folks that have it. Most of those folks have diabetes on their past medical chart, right? We have an opportunity to not just impact joint health, right? But we have an opportunity to impact their blood, how their blood takes up sugar, right? And uses it for their body. We have an opportunity to ward off risk against developing Alzheimer's. We have an opportunity to work against leading towards anemia and sarcopenia. Our job is pretty huge here. So we have to do better. And I'll tell you, these conversations are so hard, right? But our society, we are, yes, living longer from a longevity perspective and lifespan, yet we're getting sicker. And you can look to the Who for data about that. I'll tell you at ICE, any faculty member, it doesn't matter what specialty division. Mine is in particular extremity management. We have pelvic health, we have CMFA, we have modern marriage with older adults, spine health, right? If you really ask each one of our faculty what we're really fighting against, what is ICE really doing? We are fighting against metabolic disease. We are championing and fighting for healthy living behaviors because we see this sickness in our society that we are getting more unhealthy, even though we're living longer. And it's because of sedentary behaviors. And we have to have these hard conversations surrounding how do we change these unhealthy living behaviors? How do we get these patients moving? Because again, it's not just about symptom management of their hip and knee pain. And it's not just about via exercise. It's really about infusing fitness into their life, into their tissue health. And when you think about that cyclical cycle I just described and that School.L article in 2018 gives a great visual. But this includes, when we think about fitness forward, we think about healthy living behaviors that help improve brain tissue, that help improve your blood, making your blood healthier. And we do that via cardiovascular physical activity. We want the ecosystems of our humans to be more healthy and more resilient. And really the best and most efficient way to think about how do we do this in the clinic, right? Because I mentioned this is a hard, hard conversation when we think about how we change patient lifestyles, how they eat, how they sleep, and how they move. The best way to think about this is through meds. Thinking about the four pillars. And med stands for mindfulness, exercise, diet, and sleep. When we think mindfulness for these folks that come in with hip and knee, or think about any patient you've ever had, what is our greatest responsibility here in mindfulness? When we think about mindfulness, I think we typically think about breathing strategies, taking a walk in nature, maybe journaling, some physiologic sighing, meditation. And yes, when your patients are stressed, yes, we want to give them this and give them those tools. And for our folks with hip and knee, this is fair game. But I'll tell you with these folks, when I say mindfulness, I'm thinking about how you frame their mindset, how you help these folks be more aware about what they believe, right? The folks that say, I had bad knees, my mom had bad knees, my great grandmother had bad knees, my great great grandmother had bad knees. They're the people that sit back, open up that hip angle, and you know you're about to get a long story that first visit, right? About this history. And this is deep ingrained beliefs, right? About their knee health. And we have to also acknowledge that this is probably deep ingrained lifestyle behaviors, right? When it comes to our food choices, our sleep choices. So there's some really entrenched shifts that we have to make. But we have to let them know, no matter what, like really let them tell us those beliefs, and then allow a reframe, a mind shift that these are knees that aren't bad, right? Please stop saying your knees are bad, Betty. Your knees have an opportunity, your hips have an opportunity, your hips have an opportunity to blank, right? To be stronger, to be more flexible. Your body has an opportunity to move more. Yes, we can help them manage stress with some of those techniques that I mentioned earlier, but it's really more about helping them be more mindful of how to think about their body in a healthier way, and giving them strategies to do so, right? So they're no longer a victim, but a victor. Exercise is that next, so we did mindfulness, and then exercise is that next pillar we have to address with these folks. Meeting physical activity guidelines. 50, 150 to 300 minutes, right? Of physical activity is a must. And the WHO acknowledges that 150 is on the low end, right? That we want more towards 30, which means 300, excuse me, which means 30 minutes at minimum, but probably 30 to 60 minutes of physical activity five days a week. If they're doing higher intensity exercise, right, 75 minutes is fair game. But this is so tough, right? Because these patients are coming to us in tons of pain. So what do we do? How do we get them moving? And this is the hard part, right? If Betty can only walk three to five minutes, and it's painful for her to just make it into your clinic, and she needs a rest break, it's hard to prescribe, okay, 30 to 60 minutes of activity a day. And so we have to start where they're at and figure out ways to infuse physical activity. Maybe initially that's that five minute six bouts, right? And some of you are like, Lindsay, you're freaking crazy. My patient, Betty's never doing that, right? Maybe we start off small at 50%. Maybe the first goal is just five minutes, three times a day, right? We have that dose, and we see her response to movement. The real key part is we figure it out. It doesn't matter. It doesn't have to be walking. It could be dancing to music, right? It could be calling, Betty could be calling her grandson and going for a little walk so she's a little bit distracted. It could be marching in place. It could be an exercise video. It could be linking them to their community. It doesn't matter what it is. You have to figure it out. And it is hard, but you have to partner with that patient and figure out a way to get them moving. And then that's not enough. It's not just the physical activity piece. It's then adding in strength, flexibility, endurance, neuromuscularity, right? Kind of the things in our wheelhouse and figuring out what really helps their tissues feel better. That also respects irritability. In extremity management, we talk a lot about the rehab dose, which is an irritability respecting dose. And that part is really key in these folks because you need that initial buy-in, right? Our CEO, Jeff Moore, says we manage symptoms to maximize fitness. If you don't first get that modulating buy-in window of opportunity by dosing exercise well to show patients that actually exercise, right? You do about an exercise and then you retest some maybe knee flexion, knee extension, hip flexion, or maybe how fast they're walking and show them, right? Oh, wow, you're now moving faster. Oh, wow, you now have more motion, Betty. That's awesome. You have to give them that show me moment. So our test retest strategies have to illustrate that exercise is medicine. Exercise is the thing making tissues feel better, right? Not just our manual therapy. So that's a big thing that we can do to help with this exercise pillar. And then diet, right? This is probably the hardest one and these folks have been told they're obese and they need to lose weight and that's not the answer, right? Please don't say that to those folks, right? They've heard that time and time again. They've heard it from providers that haven't even looked up from their chart or from their computer to look them in the eye. What I want you to do is a weight neutral strategy where we add resistance training. We add things that increase basal metabolic rate and then start chatting about things they can add like half their body weight in ounces of water, right, for a diet and then maybe adding a little bit more protein, right, for tissue healing and to help as they continue to increase their exercise activity level, right? So it supports their activity level. Talking to them when they're open to it, eating more plants, right, more colorful, diverse diets. That's kind of where we go with our diet discussion. It's not right away take away the soda, take away the bowl of ice cream because you're going to lose buy in with those folks, right? And we know the harmful inflammatory effects of sugar but with these folks that have been told a harmful message about their body already, let's add to these folks with hip and knee away before taking away. Sleep is our final pillar so we've talked mindfulness, exercise, diet, sleep and I'm pushing my time limits a little bit here. Sleep, we need to help our folks work on sleeping better, right, in a cool dark room that's 60 to 65 degrees. Use blackout curtains, go to bed at the same time daily. Those are just a few of our strategies that we really love to help with quality of sleep, right? While seven to nine hours is ideal and I would love sleep quantity on board for tissue healing, work on sleep quality before quantity first with these folks. And again, yes, these pillars, addressing these pillars are hard and no, we can't address them all at once, right? We'll dose our education just like we dose exercise. But we have to have the hard conversations with these folks. Behavior and lifestyle change, I mentioned earlier, they are hard but they have to occur to make our society healthier. Diabetes was just added to the top ten killers of our world, not just the United States. That's a big deal and most of our folks with hip and knee away have diabetes so don't miss that link, right? Fitness forward is not just about lifting heavy shit with your friends. Although barbell medicine is a key part of it, right, because it brings on intensity for our tissues and that pumping effect for good healthy blood, right, and it tends to make a patient feel pretty bad ass when they start getting heavy. But we are here to wage war on metabolic disease with our hip and knee away. It is plaguing our system, it's plaguing our country and our world. Hip and knee away is associated with diseases like diabetes and Alzheimer's. It will not go away without engaging the hard, it will not go away without engaging the hard conversations and the hard behavior change. We have to wage war here and we as physical therapists that have that experience, as our patients, probably have the greatest opportunity to wage war on the underlying tissue inflammation that is there in these folks, the sedentary lifestyle that's associated with that pain and the poor mindset of I have bad knees. Take this opportunity with your folks this week to address one of the pillars, mindfulness, exercise, diet, sleep. I suggest starting with the M and getting some buy-in with the E. Thank you for your time this morning everyone. Joining me in Grass Valley in an atypical spot here. It's been a pleasure. Have a great, happy Tuesday.

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