Jared Powell:
Today's guest is David Hunter. David is a rheumatology clinician, scientist, and professor of rheumatology and medicine at the University of Sydney. David is ranked as the number one expert in the entire world on the topic of osteoarthritis, and it is no coincidence that I have managed to steal David away from his very busy day-to-day schedule for an hour or so to chat all things osteoarthritis. Osteoarthritis is a prevalent condition that can result in substantial burden for those suffering. But in my reading of osteoarthritis, I've noticed a marked discordance between what the evidence base suggests versus the sociocultural perceptions about osteoarthritis. In this episode, we do a sweeping 360 of the osteoarthritis landscape stopping at all stations along the way including terms such as bone on bone and whether these colloquial terms are helpful or harmful. We look at patho etiology of osteoarthritis. We touch on the treatment for osteoarthritis, including both surgical and non-surgical approaches, and we look at how we can reframe what osteoarthritis actually is if a patient were to have possible aran or maladaptive beliefs about what osteoarthritis is and isn't.
Jared Powell:
This is one of my favorite conversations today, and if I were you, I would grab a pen and a pad and take some notes along the way because there are many fascinating insights that David provides us with that I'm sure will have a substantial impact on your clinical practice. Before we start the podcast, a quick note from our sponsor, Clinico Clinico is a practice management software that's used by 65,000 practitioners worldwide. It's great for busy physios, which is why it's an endorse partner of the Australian Physiotherapy Association and the Chartered Society of Physiotherapy. In the uk, you'll find everything you need to run a successful physio practice in one place, like treatment notes, digital forms, online booking tools, customizable body charts, and much more. Clinico meets privately legislation for Australia, the uk, the US and Canada. So wherever your base, Clinico will keep you compliant.
Jared Powell:
Charitable donations in giving back are also a big part of Clinco. A minimum of 2% of all CLINICO subscriptions are donated to charity each month, which means more than than 1 million Australian dollars in total have been donated since Linco was founded. Shoulder Physio Podcast listeners get 60 days free. Signing up takes less time than this message. Visit clinico.com/shoulder hyphen physio. Without any further delay, I bring to you my conversation with David Hunter. Okay, Hello everyone. Thank you for joining me for another podcast today. I have a very special guest, the esteemed professor, David Hunter. David, welcome to the
David Hunter:
Show. Thank you so much for having me along, Jared. It's a great pleasure.
Jared Powell:
So David, firstly, I think this helps the audience get a sort of grasp or a grip on, on who you are. Tell me who you are, what you do, and especially what is a, what does a normal Monday to Friday look like for you?
David Hunter:
Yeah, so I guess first and foremost, I'm a husband and father of four kids and I try to make sure that family is very central in my life. I guess to summarize myself professionally, I'm a clinician scientist meaning I'm a researcher that also sees patients and the large focus of the research that I do is very much centered towards osteoarthritis and my clinical practice tends to mimic, mimic that. And so I work both in multidisciplinary clinics for osteoarthritis and work in a research context. And so I wear a few different hats. The primary hat that I wear is as what's called the Florence and Cope professor at the University of Sydney. I also have a staff specialist position at Royal North Shore Hospital, which is where I tend to do most of my multidisciplinary neuro osteoarthritis work. I'm the editor in chief of a journal called Osteoarthritis in College and the co-director of Sydney Muscato Ske Health.
David Hunter:
And so for a typical day, there is no typical day so, so so much. But in general I would see the only thing that's somewhat structured is I see patients a couple of days a week in outpatient clinics. And again, that's in a multidisciplinary clinic. So I get to work alongside physiotherapists, dieticians, occupational therapists psychologists and so on. And it's, it's a wonderful environment. We do basically group-based care of people who have knee and hip and hand osteoarthritis. So that's the only thing that's truly particularly structured. But most of my week is theoretically meant to be focused on research and a little bit of teaching. And when I say a little bit of teaching, most of the teaching that I do is largely directed towards post, post-doctoral researchers and PhD students who that I, who I supervise.
David Hunter:
And I, I run a research group of about 25 people, a clinical group of about 10 people. And so a lot of the work that I do tends to be very much focused towards human resource management and a research group that I have the privilege to work with targeted towards clinical osteoarthritis research. And so we cover the full gamut of sort of doing epidemiologic research, looking at why people develop pain looking at biomarker research, particularly around imaging and why tissue tissue structured changes matter. Do a lot of clinical trials, particularly in an area called disease modifications. So historically, you know, a lot of osteoarthritis trials have been targeted just towards symptoms. So we are also interested in not just targeting symptoms, but targeting the underlying structure, do quite a bit of health services research, so look at why people get the care that they get and how we can improve that. And we're increasingly do doing a lot more policy and advocacy work. So really just trying to change the way care is delivered and, and hopefully improved a lot for people who are out there who have osteoarthritis. So, long winded answer, but hopefully I covered all of the stems you gave me.
Jared Powell:
Comprehensive David, I would expect nothing less. So out of all those hats that you wear, if I may ask, is there, is there a particular hat you enjoy wearing the most or do you derive equal joy out of, out of all of them?
David Hunter:
So Jared, I've, as you can probably see on the screen, I'm balding. And so the more hats I wear, it's probably
Jared Powell:
Me, Me too, David. It's,
David Hunter:
It's probably, probably better for a little bit of head coverage . But no, I look, I, I enjoy the variety to completely frank with you. And from day to day, some things are more enjoyable and some things are more challenging, but that, that will often vary. And I, I wouldn't necessarily say that I enjoy one more than another. I actually enjoy the challenge of doing different things on a regular basis and not having, you know, an 8:00 AM to 6:00 PM clinic structure where I'm seeing, you know, 15, 20 people a day, I think my, my head would go into a mind spin after two or three days of doing that consistently. So I love the opportunity to teach, I love the opportunity to sort of work with that next generation. I love the opportunity to sort of push the boundaries on, on research and, you know, with the sort of new hats that I'm wearing around sort of co-directing muscato research at the University of Sydney and it's affiliated hospitals and also directing this journal that we're responsible for, that's providing new challenges, but also hopefully opportunities to influence and shape future careers and also the the research agenda of others.
Jared Powell:
And have you made a conscious decision to remain a clinician given, I assume you're being pulled in the direction of research more and more and more. And, and just for context, are you, when you say a clinician, are you, are you a rheumatologist? Is that, is that your occupation then?
David Hunter:
Yeah, so I'm a rheumatologist and I've made a conscious decision throughout my career to continue to have some clinical interface. And that comes about in large part because, you know, I think it's really important for me and the research that I do to have some relevance to the patient, patient population that I'm trying to serve. And if, if I, I think, extract myself too much from that, there is the capacity for weird people like me to go off and really abstract directions, and I don't, I don't wanna do that. I really wanna keep mindful and focused on the population that I'm, that I'm really truly trying to serve. It's becoming harder if I'm completely brutally frank with you, to, to have all of those hats and to serve them well. And the challenge is that the masters that I serve for each of those roles don't honestly think about the fact that you have those various hats and they just want you to perform at a hundred percent for every role that you're doing. And so that's, that's becoming harder. And it's similarly becoming harder to remain competitive, particularly in a research funding environment when you know that, you know, 50 to 60% of your time is dedicated to that activity, but you're competing against people who are doing that a hundred percent of the time. Yeah,
Jared Powell:
We can imagine. But yeah, so I, I really do respect people though who do remain clinician scientists, and it's a lovely term and I think it, it, it, it provides you with a, a much more well-rounded perspective on things, in my opinion, where I think in academia you can get stuck. And I'm being pulled into academia a little bit as well, but I am making a conscious decision to remain a clinician. Cause I think it, I almost think it's imperative to, to sort of have that, that plurality of perspectives almost. Do you plan on remaining in that, even though it is tough for you?
David Hunter:
Oh, definitely. Yeah. Yeah. And I, I would encourage you to continue to, to strive to continue to maintain those different roles and entities because it is so important as a researcher, particularly I think clinicians, clinical researchers, that they do keep some clinical interface because the stories that you hear from patients are so motivating, the challenges that they throw to me on a regular basis. So, you know, you know, David, why aren't you working in this space? Why aren't you solving this particular problem? It, it gives me pause for thought and gives me pause to actually think about the direction that we do, we move in. So, you know, I can potentially substitute it. So we do a lot of consumer focus groups and work with patients that have the disease, and they give us advice about the research that we're doing and the direction that we're taking.
David Hunter:
But I don't think it's necessarily the same as, you know, getting in the clinic, laying my hands on knees and hips giving people guidance and advice. And, but he also hearing their reaction to, you know, what we're encouraging them to do and the changes that we're encouraging them to make as far as management choices are concerned. Because, you know, again, if I, if I tell someone in a guideline that, you know, this is what we would advocate for, but I don't listen to the reaction from the person who I'm trying to impart that to and don't listen to the, the fact that it's impractical in the circumstances or it's impossible in the reimbursement context. I, I'm missing the boat I think a lot of the time. So it's really, yeah, great to be in an ivory tower, but I think it's really important to get down into the coal mine or, or be, that's probably a bit of a dirty word at the moment, , to actually interface with patients
Jared Powell:
Directly. Yeah, you become a bit detached, I think if you remove yourself from that, from that clinical coal face. Again, dirty work. So let's, let's get into the number one reason. There's plenty of reasons why I got you here, David, but the number one reason I've got you on is because we wanna talk about osteoarthritis. And according to expert scap scape.com, you are the number one world leading expert on osteoarthritis. And that is a fabulous achievement. So congratulations for all your, I'm sure decades of, of hard work getting there. So, because you are the number one expert on osteoarthritis in the world, I want you to tell me is osteoarthritis, wear and tear.
David Hunter:
Yeah. So it's a great question and I just first wanna start by, I guess framing a little bit of the success that I've had and putting it in the context that's appropriate. So any success that I've had in the research context has been by virtue of the people that I've had the privilege to work with, particularly my team, but also the collaborators that I've had and, and the patients who've motivated me to, to do better. And so all of the kudos should go to them. It shouldn't, shouldn't necessarily go to me. But back to the, I guess the, the main gist of the question is about the terms that we use to describe osteoarthritis, their accuracy and how they're misleading. And so there's lots of different terms that are used to describe osteoarthritis including as you mentioned, wear and tear. Another one that's commonly used is degenerative, and oftentimes, at least visually, and when people stick up an x-ray, they describe changes like bone on bone and other things like that.
David Hunter:
So let's, let's talk about all of those individually, if that's okay. Sure. And then move and then move on and talk about why they're harmful and how best we frame this disease in a way that's actually helpful for patients to get positively engaged and, and motivated to do the changes that otherwise they need to do. So let's, let's talk about where and tear first. So wear and tear suggests that at least from a joint physiology and pathology perspective, that it's just a one way road towards deterioration. And that from the perspective of wear and tear, continued loading and continued engagement of that joint is likely to, to facilitate further deterioration of the problem. And so that to me is a complete antithesis, a complete myth, and it's completely wrong way to think about both the pathology, but also people's reaction to the descriptor that you've given.
David Hunter:
So every joint has the capacity for repair. And so when we're thinking at least from a path pathologic perspective about the joints themselves, when we think about the bone, the synovium, the muscle, the ligaments, and even the cartilage loading is helpful. And these are trophic organs that benefit from continued loading. The unfortunate consequence of use of terms like wear and tear is that patients often feel that their joint is vulnerable and as a consequence they don't want to load it because they're fearful that continued loading is gonna cause further deterioration. Similarly, the term degenerative suggests that this is an age related problem, which we know it does increase with age, but again, that it's just a one way street to continue deterioration. And when we know lots of cents in centenarian that don't have the disease and that potentially won't ever develop the disease, and it's certain characteristics that are about them that, that I actually find truly appealing and inspiring.
David Hunter:
So how did, how did this person live for so many years, live a really active and robust lifestyle, but don't actually have osteoarthritis? That's a whole lot more meaningful and important me than describing someone who's got the disease as degenerative and the fact that, you know, they're gonna continue to get worse in time. And, and likewise, you know, the bo the terms bone and bone and unfortunately a lot of my orthopedic colleagues tend to rely very heavily on the pictures that they see and radiographs and MRIs in particular and describe the disease based in those terms. Whereas it doesn't bear much, if any relationship to a person's lived experience of the disease. And I think to me that's the most critical element that we need to understand as, you know, what is a person feeling? How is a person functioning and what's their joint continuing to gonna be able to do?
David Hunter:
And you know, a lot of people, there's marked discordance about what we see on an x-ray and what a person feels and lives in terms of their experience. And that's what we should be focusing on is the pain that they're feeling, the function that they're limited in, but ultimately also the goals that they wanna be able to achieve. And when we use terms like wear and tear, degenerative and bone on bone, it discourages them from doing the things that we know their joint is capable of doing and the behavioral changes that we want them to do.
Jared Powell:
Yeah, be well said. Terms like bone on bone and wear and tear, they're almost part of our sort of common vernacular now in, in just culturally, aren't they? You see, we see, I'm sure you more and more you get people come in, I've got bone on bone, I can't do this because I've got bone on bone in my job as a, as a physio. It's often used as my surgeon who says, I've got bone on bone, therefore why should I be able to do this squat or knee exercise to assist the muscles around my knee? And it becomes a real barrier. So what, what, what did you, do you steer away from using these terms in your clinical practice? What other terms would you use to replace these terms?
David Hunter:
Yeah, I mean, so in general, I just talk about the pain that they're experiencing, the function that they're limited in. But really try to focus the conversation not on the x-ray appearance, not on the historical terms that are used to describe this but based upon, you know, you've got osteoarthritis, it's, it's a disease that's associated with the symptoms that you're experiencing, but these are the things that you have that have predisposed you to this and are stopping you from getting better. So whether that's the fact that they're sedentary, they're deconditioned, they've lost muscle string, they're carrying excess weight they're malaligned or there's some other modifiable factor that I can then get them just to singularly focus down on. This is correctable, this is modifiable. And if you work with the right hands and you work with the right people, there are many things that you can improve here that will improve your lived experience.
David Hunter:
I think it's really important to be honest with them, is that most of the things that we're currently doing to manage this disease, it's not about cure. And on that list I would include surgery. Surgery's not about a cure. And so when we're talking about, you know, educating people about the disease, getting them more active getting them to lose weight using adjunctive devices to help with the loading of the lower limb using analgesic therapies, it's about optimizing pain and function and treating the reasons that they've come along to see you as opposed to focusing down on things that will detract from the behavioral change that we, we otherwise wanna see. And so if you focus down on the, using terms like wear and tear, degenerative bone on bone, it's really gonna discourage people from engaging and it's really gonna inhibit your ability to meaningfully change their behavior. So focus down on what they're complaining of their pain, the function, the things that they can't do, work out what it is that they truly wanna be able to achieve. Tell 'em, you know, these are the things that I'm seeing on my history and examination that we can modify, that we can change, we work with the right people. There's a lot of things that we can improve. It's gonna take time, it's not gonna happen overnight, but those goals are attainable and we need to work together to achieve that.
Jared Powell:
That's great. So more sort of focusing less on the problem? Yes. Sort of re or yes, hearing them and validating that there is a problem, but focusing more on the solution, particularly with modifiable factors and, and being careful not to throw around too many throwaway terms. And we, we see this again and again and again in, in low back pain research with dis bulge for example. People tend to, patients latch onto these terms that we might forget about, we throw, we throw that term around, but that's the term that they latch onto. And I believe it's probably the same with with bone on bone because it's a coherent, it's visually it makes sense, they can model it in their mind. I have pain because I have bone on bone. And I guess that takes us really nicely into the next question. You mentioned in your answer, your fabulous answer, that there is a, there is a discordance between what we see on a scan and what we might see clinically or how a patient, a patient might present. So I know at university I was taught to look out for these, these cardinal signs of oa, you know, these bone marrow edema or sub condal sclerosis and osteophytes and joint space narrowing and all this, this kind of stuff. And I came out and I expected to equate a person's pain experience with what I see on a scan. Is that accurate, David, Is that wrong? And then what is the role of, of imaging in the D diagnosis of osteoarthritis? Yeah,
David Hunter:
That's a, that's a great question and a really important one. And it's a, it's an important focus of what is commonly a practice, what we call low value care in our community. So the large proportion of people who come along and see me in the clinic will often have an x-ray, but more frequently have an mri. And they'll usually say to me, Well, do you wanna look at my mri? And I more frequently they not say no. And that probably sounds a little bit counterintuitive to, for someone, cuz I spend a lot of my research life focused very much down on imaging for disease modification trials. But by and large, we don't have treatments at the moment that are gonna modify the structure of the joint. So there's not much point or value in my focusing down on the imaging changes that they might otherwise have in the joint.
David Hunter:
And more often than not, it's not gonna markedly alter the treatments that I'm gonna be advocating for that person, but it will be discouraging them from engaging in the treatments that I wanna pursue. Because if they've had an mri, they've had a tor meniscus, which is part and parcel of the osteo threat process, they'll latch onto that. And we know that that drives up rates of arthroscopy, which is just another form of low value care. So there's no positive advantage more often than not for this being done. The diagnosis of osteoarthritis is based on the signs and symptoms that a person presents with. So if they're over 50, they've got activity related pain, they don't have long periods of morning stiffness. More often than not they're gonna have osteo arthritis in the joint that's affected. So you can use the American college criteria, you can use European criteria you can use the nice criteria in the uk they're all pretty much the same.
David Hunter:
It's all based on symptoms and signs. And with that you've got remarkable sensitivity and specificity to make the diagnosis. And you only want to use radiographs if you really got a clear suspicion that this is something else. You know, this could be a rheumatoid arthritis, could be a psoriatic arthritis, could be gout, whatever it might be. But only if you've got a clear index of suspicion that that's the case. Because more often than not, the diagnosis can be made just based on those symptoms and signs. And getting the radiograph or getting the MRI is gonna dis discourage them from undertaking the activities that you otherwise want them to do.
Jared Powell:
Ok. So I just wanna reiterate that the diagnosis of osteoarthritis is a clinical diagnosis and an x-ray or any other radiological imaging is not required for a routine diagnosis of osteoarthritis.
David Hunter:
Absolutely correct.
Jared Powell:
Wonderful. That's what I want to hear. And so do, do, I'm gonna come back to this, this discordance between what we might see on and imaging, whatever imaging we want to use. And the experience of pain. Is that, does that apply across the spectrum? So if you have severe osteoarthritis, is that, is more, is that more related to a pain experience or is it a, is it across the
David Hunter:
Spectrum? It's pretty much across the spectrum. The discordance is less the more severe structural diseases. So, but there's still marked discordance in people with endstage radiographic disease. And despite all of our best efforts to better understand and tighten that relationship between that symptom experience and the structural change using MRI and other sophisticated imaging methodologies, there's still a marked discordance even in endstage disease. And I think that really to me emphasizes the important influence of other psychosocial risk factors in a person's symptoms. And so the concomitant presence of, you know, depression, stress, and anxiety, which we know is present in about 30% of our patients, the fact that this disease is more common in people from lower socioeconomic groups that we know is influencing their expression of pain and disability the concomitant features of sensitization, none of that can be characterized on imaging. And so, and we know that they play a really important role in the person's symptoms and disability. So it's not surprising that the discordance is marked albeit slightly less discordant in more severe disease. But, you know, I can spend my life studying imaging, but it's still not gonna tell me why a person feels the way they do.
Jared Powell:
Yep. Perfect. David, something's just come to me while I've been, while I've been listening to you. A common bit of rhetoric that I hear reported to me secondhand by patients is that their surgeon says that this is only gonna get worse over time. We may as well replace the knee or replace the hip knee. You know, you've already got stage three osteoarthritis, it's a matter of time before blah, blah, blah, blah, blah, blah, blah. Is there, is that an accurate statement? And I'm, I haven't heard a surgeon say this specifically. Some, some might have, But is, is that, is that a bit of rhetoric we should sort of veer away from as, as per the other labels that we've been talking about?
David Hunter:
Yeah, definitely. Definitely. I mean, I, I have a lot of patients that come along to me and tell me the same story that they've seen. The surgeon, the surgeon says, Well, you're gonna need a joint replacement at some time, so why, why not get it done sooner, the sooner than later? And I really wanna stress that that is completely inaccurate. So there's lots of different trajectory studies that have been done and osteoarthritis looking at the prognosis of the disease. And for the vast majority of people, the prognosis and the trajectory of symptoms is a very, very flat one over many, many years, up to decades. Similarly, from the viewpoint of the natural history of osteoarthritis, the underwhelming minority, so whether it be knees or hips, ever have a joint replacement in their future. So at this point in time, if we look at the natural history of disease, about 10% of people during their lifetime will require a joint replacement.
David Hunter:
And I think the common community perception, the common perception amongst many clinicians is that a joint replacement is inevitable, both based upon the fact that the trajectory of symptoms for the vast majority is flat. We know based on large epidemiologic studies that very small proportion of people ever require a joint replacement. I think the most important thing you can do for patients is basically to say, look, you know, prognosis is generally very favorable in most people. A small minority people might need surgery in their future, but by and large there are lots of things that you can do to help with the disease and that's what you should be focused on. And the prognosis is generally very
Jared Powell:
Good. Yeah. That, that is contrary to the, the, the common belief, I believe, where it's a progressive disease and it's only gonna get worse over time. So that is a real breath of fresh air. So let's talk about treatment a little bit where I could talk about natural history all day. I, I love that as a topic, but I wanna get into treatment cause that's important there. You were involved in a trial that's recently been published to a little bit of controversy called the START trial. It's, it's not controversial because of the study itself, but the results it produced, particularly in the physiotherapy community who are obsessed with strengthening and think that strengthening cure all. So this, this trial, and it may do, but this trial was interesting. It compared three groups. I believe David, you'll know more than me, but I'll attempt to summarize it, a high intensity strength training group, a low intensity strength training group, and then an an intentional control basically. And then tell us, David, what, what were the results and, and kind of what, what was the point of the trial in the first place and, and then what are the clinical implications of the
David Hunter:
Trial? So the rationale for doing the trial in the first place is I think there's a perception that the stronger you are and the more intense the training that you do, the better the outcome is gonna be. And this, this study, , I think put that to bed pretty clearly and basically showed no difference at all between the intention control, the low intensity strength training group or the high intensity strength training group. And just, so just to give some people some sense of, of what that meant. So at the first intake, the participants in the trial were asked to do one repetition max exercise. They identified what that was. And for the high intensity strength training group, basically they were asked to do three sets of eight repetitions at about 75% repetition max. The low intensity group was three sets of 15 repetitions at 40% repetition max.
David Hunter:
And the attention control is literally just about education, about the disease and what they can do to manage it. And we really found no statistically or clinically meaningful difference between any of those three groups. And I guess for, you know, a health professional community group that's out there, you probably say, Well, you know, you didn't do this right, you didn't do this well. But the reality is it was a well conducted rigorous trial, but everybody was treated the same. And so that everybody was given the same exercises to do, irrespective of their deficits, irrespective of their, you know, their clinical profile, irrespective of the other things that are going on in their life. And I think as clinicians, hopefully we're a little bit more intuitive than that, and that we try to identify specifically what's wrong in this person as far as deficits that are concerned, as far as modifiable factors are concerned.
David Hunter:
And we try to tailor our treatment to the individual. It helps to underpin I think a lot of research that's coming out at the moment that suggests, you know, there's no difference between standard quarter decept strengthening versus neuromuscular exercise. We can get the same effects through yoga or tai chi or through cycling as we can through targeted strengthening exercise. And to me, the most important thing is that we identify what's, what deficits a person has, what's correctable, what other modifiable factors they have, But probably most importantly, what we can get a person engaged in doing longer term that we know will help modify their symptoms. And so I wouldn't discourage people from continuing to improve a person's strength if they have some deficit that needs correction, but try and best in the approach as to how you approach the individual to make sure that you're targeting the problems that they have, and then tailor your treatment so that it meets what their, what their interests, what their preferences, and what their goals ultimately might be. And so I know I can't say that directly from the trial itself but you know, if we educate people and we get the same effect as a high intensity strength training group it basically says that if you give people information and you encourage and support them through the process, they're likely to get better.
Jared Powell:
Yeah. The fact that the, that the two strengthening interventions didn't outperform the attention control was, was very interesting to me. And, and, and it's not to say that exercise, you know, is still good for a lot of other, it's not just about pain. You know, exercise is very good for a number of other sort of secondary benefits. But that was a really fascinating finding. So why, why do you think that is, David, Do you, do you think these people just received a bit of information or education about their disease and felt perhaps a little bit less worried or had less catastrophizing thoughts? And we're just speculating here, What, what, why do you think that they did comparably well versus the exercise interventions?
David Hunter:
Yeah, so my, my good colleague and friends, Steve Messier, who's run now, a number of these different trials is incredibly effective at imparting wonderful attention control interventions that essentially give people a lot of information about how best to manage their disease. And what we find in most of the attention control groups that we've, that we've used in the past is that they lose weight, that they get strong, that they get more active by virtue of the fact that you're telling them about what should be beneficial for their disease. Now in the intervention groups such as in star, the high intensity group doesn't necessarily get the same education, but they do get benefits from the high intensity strength training group, but the, the, the high intensity strength training, but they don't necessarily get the benefits that they might otherwise get from losing weight or taking medication or modifying activity.
David Hunter:
And the various other interventions that the attention control group did get advice about. And the other piece here that I think is so important for clinicians to hear is that patients for deem a benefit just from the contact that they have with the health professionals that are, that are seeing them. And so Kim Bonnell and others have done wonderful studies, basically, and this isn't to detract from the important role physiotherapists have, but basically to say, you know, you go and see your physiotherapist, they're gonna get better just from the fact that they've had some interaction with, with the clinician. They don't necessarily need to do anything. And again, I don't want people to walk away with a message that, you know, I don't want people to be active. I don't want people to be strong. We do, we know that that benefits people, but they just get benefit just from interaction and talking about what they're feeling and hopefully having a good ear to listen to what, what, what it is that they're suffering from
Jared Powell:
Bloody oath. And I don't think that detracts from the role of a physio or any clinician. I think that's a, a powerful role to serve. And then if you can get them to do a little bit of exercise on top, what's the worst that can happen? It's, it's, it was a really well conducted trial. And from memory, I haven't, haven't read the paper since it's probably came out and I should've, David apologies. But I think one of the outcome measures was whether the interventions changed joint forces, Was that right?
David Hunter:
Yeah,
Jared Powell:
Yeah. And, and did, did they,
David Hunter:
Yeah. So no. So no difference in symptoms, no differences in joint loading between the, between the groups that were studied. And obviously, you know, the hope here is that the stronger you are potentially that the less loading that would be going through the primarily affected medial compartment, but that wasn't found.
Jared Powell:
Yeah. Something that I, for the first 10 years of my career as a physiotherapist would say to every single person with neo osteoarthritis or patella femoral pain knees in general, for some reason, was that we've gotta get your quads, your calves and your hamstrings strong. So we, so the force is distributed away from your knee to your muscles somehow. And I don't know where I learned that. Is that wrong based on this study or what about the body of evidence? What does it say?
David Hunter:
The body, the body of evidence would suggest that it's not wrong, but it's not changed by virtue of a high intensity intervention versus another person who goes off and does their own types of care. So I think it's still important from the viewpoint of impulse loading, particularly in a person that has impaired proprioception, you know, joint that's otherwise affected by osteoarthritis, that the muscles around the joint be stronger, so that hopefully some of the, the abnormal or aran forces that go across a mechanically deranged joint can be dissipated appropriately across hopefully a better functioning joint. So I would still encourage you to say it's important for the perticular muscles to be strong and to hopefully reduce loading by virtue of that. But what this study suggests is that by virtue of high intensity strength training, that doesn't provide a benefit over and above the low intense strength training
Jared Powell:
Group. Yeah. And, and that joint loading forces aren't a mediating factor of recovery particularly correct in this study.
David Hunter:
Yeah.
Jared Powell:
Did, did you do a sec? Is there a secondary mediation analysis to this study coming? No,
David Hunter:
Not, not done. Yes, there will be, but it's not been done. Yes.
Jared Powell:
I, I, I love those studies. Okay. So let's go into the role of weight loss and lifestyle programs in osteoarthritis. Is it as simple as saying if you lose 10 kilograms, your pain experience, your pain symptoms, your function is gonna go down or go up by X amount? Or is there more to it?
David Hunter:
There's a hell of a lot more to it, unfortunately. I, I wish it were that simple. But, you know, I guess just to outline what the evidence is at the moment. So again, you know, a wonderful study that Steve Massier, myself and others did called the IDEA Study, which was published in JAMA now close to a decade ago, where we got 450 people randomized to diet and exercise, diet or exercise. And over the course of 18 months, the diet and exercise group lost 10% of their body weight through caloric restriction and exercise. And with that 10% weight reduction in their symptoms improved by 50%, and about 40% of them got into what you'd otherwise call a low, low pain or remission type state where their pain is less than one outta 20. And they stayed like that for a good two to three years.
David Hunter:
But I think the key point that probably needs to be emphasized here is that it was a really intense intervention and, you know, a lot of health professionals were involved in imparting that it wasn't simply just a message given to the patient, Go and lose weight, come back in a few months and tell me that you've lost weight and you'll feel a lot better. They really need to be supported through that journey, and it needs to be done in a way that makes sure that they, they have a dietary plan, they're given appropriate advice, they're counseled through it, they're monitored, they're carefully supported. It can have great effects, but simply by giving the advice itself, most people don't necessarily have the wherewithal to go out and do anything with that information unless you give them the mechanism to do so. There are great resources around the world to help support people through weight loss, and I would really encourage people to pursue that because it has massive clinical implications if they can get it off and keep it off.
Jared Powell:
Yeah. But I have a huge problem when a clinician says, you need to go and lose weight, and this will help your knee pain or your back pain and your hip pain, and then give zero support, zero resources to help that individual. And I'm sure if I was an individual that needed to lose weight and I heard that from my physiotherapist, I'd walk away going, Well, what the, what the go, what am I, how am I gonna do this mate? You know, like it's easier said than done when there's social driving forces there as well, you know what I mean? It's complicated.
David Hunter:
Yeah, no, it's not. And again, you know, when I'm sitting in front of a person, I really say to them, Look, it's really easy for me to say here, sit here and say, lose 10% of your weight, and I appreciate it's fully hard for you to go out and do that, but this is what we are gonna do together in order for you to have the mechanisms to support that. So again, you know, working in a multidisciplinary clinic, I work alongside dieticians that help people through that process. There are other programs that are out there called Healthy Weight for Life that's supported by most health insurance funds in Australia to ensure that people with knee and hip osteoarthritis can actually get to a weight loss target of about 10%. And we've shown now and at least one study that that's quite effective In doing so these days. There are also, you know, a range of pharmacologic options that can actually help people to get to weight loss targets, but it's really important, I think that people be aware that just losing the weight on its own is not as effective as if they're doing the exercise at the same time. So when we compare diet to diet and exercise in combination, we don't get the same effect just through diet alone. So it's important that they do some strength work and activity at the same time to get the maximal benefit.
Jared Powell:
Yeah, so that's a really key point. So is it, is it, is it, if you lose weight, is it the mechanical factor of that there's less weight perhaps going through the joint? Or is it the systemic metabolic effects of losing weight and becoming fitter and increasing muscle mass, so and so forth?
David Hunter:
It's a, it's a combination. So, you know, again, great data from the IDEA study, but we did demonstrate that cy inflammatory molecules like cytokines such as I L six came down through weight loss. And that weight weight change mediating changes to I L six was related to a person's pain improvement. So it is partly the systemic inflammation that goes with people who carry excess weight predisposing to further deterioration, but by all means, it's still also the mechanical load. And so for every kilogram that a person loses, there's about four kilograms less loading going through the me epithermal compartment. So it does play a really important mechanical loading response. And so for every kilo a person loses, obviously it has a huge influence on both the mechanical loading, but also that circulating inflammation. And so, you know, to that end, you know, you want, you want to change the body composition and by that reduce the amount of fat tissue, but also at the same time hopefully at least maintain the the muscle composition and muscle strength.
Jared Powell:
Yeah, really well, really well answered quickly, what is the role of joint alast for let's say knee and hip osteoarthritis? Now, I know that's a big question, I'll try and make it a bit more specific for you, is firstly, are these surgeries effective? And I think I know the answer to that. And then when should we consider these surgeries?
David Hunter:
Yeah, so joint replacements is a wonderfully cost effective procedure done for the right person at the right time. And I guess the key point in what I've just said is the right person at the right time. So ideally it's done, done in a person that has end stage radiographic disease, has persistent symptoms despite appropriate other treatments. And that's often where times out, I think our health system fails. So about 80% of the time I see people in the public hospital who've seen a surgeon who've been put on a wait list, they haven't had any appropriate treatment before they've seen the surgeon. So they haven't had the exercise, they haven't had the strengthening work done. They haven't lost weights, they haven't been provided with adjunct therapies. And so, at least for me, it's critical that we provide patients with that opportunity. And there's now randomized trials comparing people that have gone off to surgery, comparing people that have had more appropriate conservative management. Those people that have conservative management, about two-thirds of them at two years say, Look, I've done completely well, I still don't need surgery. I mean, our health system should be better at supporting people through the process of losing weight, getting more active, getting stronger, and supporting them through that, as opposed to, you know, getting expensive imaging, getting the really expensive surgical intervention done. And, but unfortunately our health system's not necessarily as supportive through that process as they should
Jared Powell:
Be. David, this is all music to a physiotherapist ear. We're gonna, we're gonna induct you as an honorary physiotherapist, so thank That's beautiful. Finally, before I let you go, I know you're a busy man, This is the most important question, so, so spend some time on it. What book are you reading right now? Why are you reading this book? Or what TV show are you watching right
David Hunter:
Now? So, I'll give you an answers for both, for both Jared. But at the moment I'm reading a book called Mastery by Robert Green, and it basically just tells about the lives of masters and the journeys they've been on, and the, I guess the life lessons that could be imparted to everybody trying to become an expert in their field. Cuz you know, like everybody, I'm still trying to learn, still trying to improve. And so that for me is a vehicle to hopefully continued improvement on that. It's a, it's a slog. So for anybody who's gonna go and pick it up and just say, this is gonna be easy going, it's a bit of a slog, but it's, it's well worth it. And I literally just finished that one yesterday. And I guess in an effort to address both of those questions I'm watching at the moment with my beautiful wife show called House of Dragons, which I would assume half of your listening audience is probably watching as well at as well at the moment. But it's, it's a lot of fun.
Jared Powell:
It's intense, isn't it?
David Hunter:
Yeah.
Jared Powell:
Alright, David, thank you very much.
David Hunter:
Absolute pleasure, Jared. Thank you for having me along.
Jared Powell:
Thank you for listening to this episode of the Shoulder Physio podcast with Professor David Hunter. I hope you got just as much outta this episode as I did. If you want more information about today's episode, check out our show [email protected]. If you liked what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rating or review. It really helps the show reach more people. Thanks for listening. I'll chat to you soon. The Shoulder Physio Podcast would like to acknowledge that this episode was recorded from the lands of the Turang people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning, and working from every day. I pay my respects to elders past, present, and emerging, and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
