we often hear statements about movement being medicine or if we could bottle physical activity wouldn't it make a great pill we hear a lot about the benefits of staying active but how do we operationalize that how much should we do of what particular type of activity finding the balance between overdoing this and maintaining joint function can sometimes be quite tricky we strongly advocate for the role of physical activity but often times we don't explain well how to do that the purpose of this episode of joint action is to dig down into that core treatment option
physical activity unpack it a little bit and hopefully make it so its practical suggestions that you can operationalize to identify the benefits but also hopefully give you tips around Behavior change and prescriptions for making this part of your daily life take exerpts from previous episodes in an effort to try to distill that information into one compact episode that will give you this information walking can be an excellent form of exercise and physical activity for people with ostearthritis in season 3 episode 14 we were joined by Grace low to talk about walking in its role it's
a loow impact and expensive and safe form of exercise for most people but despite the benefits many people with ostearthritis are simply not doing enough so we talked to Grace about walking and its role in preventing ostearthritis as well as the impact it has on progression of disease she gives us some advice about what people can do when they're currently not meeting the recommended exercise of physical activity guidelines and want to start walking more specifically how how many steps they should be aiming for and how they might track that I think at the moment the
community perception for many people is that too much activity is not good for their ostearthritis and the joint only has so many steps that it can use in its lifetime before it's likely to deteriorate but in contrast to that yours and other studies are really reinforcing the fact that this is not making the disease progress It's not making your symptoms worse if you've got symptoms and if anything the converse is that fair yes I entirely agree yeah yes so you obviously quite clearly demonstrated in this in that people that don't have knee pain that do
have osteoathritis at least radiographically in their knee that this might appear to play a little bit of a preventative role in the progression of the disease yeah why why do you think that it's having that effect so this is just conjecture because I didn't actually look at this specifically but I I really think that it's a you know it's easier to maintain your joint that it is to fight an uphill battle after you've already sort of lost your muscle mass and you've lost your strength and you've lost your ability to you know know where your
knee is very well the appropriate reception sort of aspect and so I think that it's about maintenance right the general idea that daily maintenance is H is the key I think you mentioned Grace that obviously people with ostearthritis uh I guess substantially under what the guidelines would recommend What proportion roughly based on the the literature that's out there in terms of the the percentage of people actually meeting the recommended guidelines for physical activity with ostearthritis it's like 10 to 15% so yeah lots and lots of room uh for improvement as as you said now tell
us a little bit about your study and what previous Studies have shown with regards walking in osteoarthritis and what you've actually found so there have been some small randomized controlled clinical trial studies that look at Short amounts of walking and they do find some benefit from the perspective of reducing pain and increasing function and decreasing the amount of pain medications that people use but they're very short-term studies and um they don't look at people over sort of several years or look at people's behavior over a longer period of time and so that is a big
difference to what we're looking at here so those small clinical trials did show benefit there is also a study that was done in Australia gets um reported a lot that looked at people who walked 10,000 steps as the cut off and what they found is that there were some MRI changes amongst people who exceeded the 10,000 step Mark that made people concerned that there might be some harm that's occurring in people who walked you know sort of a larger quantity and so I think that's really generated a lot of concern with respect to potential harms
that are occurring with walking yeah so let's dig in a little bit further and hopefully provide some more practical suggestions for people that do have ostearthritis and I appreciate that you know other Studies have looked at the volume of steps you've looked at minutes and the duration over which people have walked how do you find out if they are meeting the recommendations and if they're not what advice do you give to them in terms of starting walking so I guess to be honest I don't normally like strateg specifically about looking at overall physical activity guidelines
but I I feel like that our message here is to just get out and walk however you can and so I I don't think that there's actually enough data to really support giving specific recommendations about how much you should walk for your knoa but we already know that there's lots of physical activity guidelines for lots of other reasons and it doesn't seem harmful from an OA perspective so I guess that's the way that I would put it I think that it makes sense to sort of follow the guidelines that are already out there for physical
activity I think if you have a neoe arthritis using a choice of walking as um an activity to do is potentially additively beneficial so that's a good reason to choose that particular activity that's kind of the way that I would look at it and I think that to be honest we actually looked at people dichotomously like just yes no Walker and then also with some higher level of detail as far as how much people walked and like the volume of walking it didn't make anything worse there was a suggestion maybe that the the amount of
walking that people did might be a little beneficial nothing was statistically significant that's why we ended up leaving that part out of the paper but you know I think that a clinical trial to really look at the benefits of walking from a longer term perspective I think would be really great and I think you know really in this day and age where we have all these devices and we have our smartphones and they're tracking us all the time I mean this a really great opportunity to start thinking about how to mobilize those technology to get
people to be more active and to do more walking so great suggestions as you say I think the key thing here is actually having the motivation to get up and just start walking and you know I think that volitionally is probably the most important thing in the first instance and then you know set yourself some goals around what it is that you that you want to do and there are wonderful ways out there whether it be through wearables a smartphone or different things to track your activity now people with ostearthritis are often encouraged to exercise
inad Physically Active but what does the evidence say about running if you have neus you might be wondering if it's safe to continue so we're joined by Christian Barton Season 3 Episode 16 to talk about this really important topic one that I often get asked about and one that I think potentially may be Germaine to many of you so what's the relationship between running and neotis if you have neotis and you're a runner is it safe to continue running are there any specific populations of people that we might advise against running and what advice Christian
might give to someone looking to increase their physical activity or to start running what's the specific relationship here between running and if if you've got any data on it running loads or intensity and the development of knee ostearthritis yeah it's a it's a really really difficult question to answer and I think researchers grapple with this what we know from the research is that running is probably not detrimental to joint health both hip and knee osteoathritis for that matter and so I might just reemphasize what Christian's just said there running is not detrimental to joint health
because I think that's the key message I want to get across today and then I'll stop interrupting and let you continue no I think that's good David we could probably stop the podcast now except for the point that you made is that there's this common perception in society that running is bad for your joints and and so I think we need to dive deeper understand why what we're saying is really important and so when we look at the research there was a nice systematic review published in 2017 by um group and the names escaped me
for a second Al turn to jelly and so basically this looked at recreational Runners Elite Runners and then non-runners and so colls a lot of datas from about 30 different trials and it's cross-sectional and what it showed is the rates of arthritis of the hip and knee were much lower in recreational Runners and people always ask me what's a recreational Runner and the challenge with that is it's really vague in a lot of the research and so the best way to think about is probably someone who's running three or four times a week they might
be running five or 10 kilometers but they're not getting too competitive and so the the rates of arthritis in that population is around about 3 or 4% so it's quite low if we compare that to non-runners the rates of arthritis when they match for age and sex and a whole range of other things jumps up to around 10 to 11% and then if we look at Elite Runners so those who might be getting really competitive they're running internationally running in competitions for money and what we see in that population is that the rates jump up
to around 13% so recreational running seems like it could be a sweet spot for being not dangerous to your tissue Health but actually protective against a condition like ostearthritis we don't have great long-term perspective studies to look at this so we can only rely on some of this crosssectional research but nonetheless that is pretty compelling and certainly conflicts with the the common belief that running might be detrimental and one of the ways to think about why that might be the case is to really consider how tissue health is optimized when it comes to cartilage so
we we see in ostearthritis cartilage might thin over time and we also see changes to that structure now you mentioned going into space and we certainly do see that when people go to space their cartilage thins but people who sit on the couch their cartilage also thins faster as well what's really important to understand about cartilage and and osteitis is that the nutrients for the cartilage come from the sovial fluid and and that coval fluid needs a stimulus to turn over and and there needs to be a stimulus to to improve nutrient flow into that
area so when someone is inactive what actually happens is the nutrients called protog glycans in the collagen Matrix and think of your cartly like a sponge the the density or the concentration of those nutrients is less when you're not loading the joint and so what that means is the the sponge and this is what I talked to patients about isn't able to absorb water so easily so when we run and we do activities and we load our joints the water in that sponge or that cartilage is really important for allowing us to absorb loads and
do activities and over an activity that sponge actually thins out cu some of the water content comes out now if it's got a high con concentration of nutrients in it then it's able to absorb that water content really quickly and recover quickly so we can do the next activity if it's low concentration that it takes a long time to recover and we can overload very easily so that running stimulus or recreational running stimulus in my mind most likely optimizes that now this is me speculating and joining lots of dots together um I think there's a
lot more work we need to do in that space but certainly based on the evidence recreational running is probably in my mind protective against ostearthritis yeah no I think it's really important just to restate that that running does not appear to cause ostearthritis at least from a recreational standpoint at least based on the data Christian that you're just suggesting there the rates of development of ostearthritis are about four times less than if you're Sentry or or not active and I think that's really really important to clear up that misconception that this appears at least running
appears to cause osteitis which it doesn't now obviously it's potentially a little bit different as opposed to what we've just been talking about which is really the development of ostearthritis if you've got ostearthritis of the knee is it safe for people to continue running yeah and that's that's a really important question to consider and we have a lot less research in this space so we don't have great longitudinal studies prospective studies of people who have ostearthritis and and continue to run and what happens to their tissue Health The Limited research that we have would indicate
that probably doesn't cause more rapid progression in ostearthritis so that's really really important one of the things we know about or or starting to emerge about people with ostearthritis is I talked about the cartilage before losing some of its water content and that being important and needing to recover in someone who has established ostearthritis the recovery is slower so what actually happens is it takes longer for their cartilage health or or their cartilage to to reform and become thicker again so that doesn't mean that running's harmful what it means is we probably need to be
a little bit more sensible of how much we load so my common advice to people in the clinic is if you've got established ostearthritis and your tissue health is not as good as it could be and structurally has changed you might need to have more rest days so it might be wise for you to avoid running consecutive days too often so in clinical experience most people can run three times a week no problems and many people get away of running four or five times a week without too many issues there's very few people out there
who can run six seven times a day unless they've adapted to that over a long period of time so someone's got osto thus that's definitely the case they're trying to keep them away from from that side of thing so short answer to your question is I think it's quite safe to continue to run with ostearthritis but you need to have the preparation and capacity to do it so one of the important things that I often talk to people about there's two things to consider don't do too much too soon so if you get into doing
too much running you haven't run for a while you've got ostearthritis there's no doubt you'll get a pain flare so you need to build up your capacity and then once you're able to run use it or lose it so if you stop running and you have a few month mons off don't think you're going to be able to just go back and run what you were running and actually in a lot of people have established ostearthritis even two or three weeks off can make a really big difference to what their running capacity is and that
may be because of the tissue Health perspective may be because having really optimal muscle strength and power to support running activities and you might lose some of that quite quickly so it could be a range of things so it's definitely safe to continue running if you are running but just making sure that you build that capacity slowly over time and just don't do too much yeah it's really really helpful and practical advice I think particularly with regards ensuring that people tailor their activity according to what their current load is and make sure that they manage
manage that appropriately now I know you do a lot of or you spend rather a lot of time training other health professionals in running and running management and technique around that is there any particular group or health professional that you might Point people towards who are looking for specific advice over and above what we're giving today yeah absolutely I think you you need to find someone who's got really good exercise prescription knowledge so I talked to I mentioned that word mechanotherapy before so if you're seeing a health professional and going to them for a massage
or just taping and Hands-On treatment to help with your knee pain and they're not providing you advice and guidance on how you can optimize your muscle strength and power and and also tissue resiliency more broadly you're probably not going to optimize your capacity to do running so seeing an exercise professional is really important and so in Australia and most of the parts of the world your two common professions there are going to be physiotherapists and exercise physiologists they're probably the two key that you would see and you want to see someone who can give you
support and guidance around how to optimize your exercise prescription as well so you can get a lot out of doing two or three exercise sessions a week for 20 or 30 minutes you don't want to just grab some exercises off the internet because Runners World told you to do these three or four exercises it's often quite sensible to see someone who would be able to identify that you need to Target your quadriceps muscles for example and teaching you ways you can do that without stirring up your knee pain because there's different angles you can do
exercises in different types of exercises you can do if your quads to help that it might be that you need to Target your hip or your calf muscles a little bit more and build some capacity there you may already be really strong but you don't have the ability to generate Force quickly to absorb loads of running so you might need some guidance on building in a plyometric program into into your training and building the capacity and really simple piece of advice for both clinicians and people out there who are Runners going back to that mechanotherapy
concept you don't need a high volume of exercise loading to stimulate tissue changes so as an example in running the first 90 seconds you'll get osteogenic changes stimulated and after that you can run a marathon and there's no additional benefits to your bone density and if we think about trying to build up resiliency of muscles and building muscle strength and power you really only need to be doing three sets and they're only going to go for 20 or 30 seconds so around 10 repetitions but they just need to be appropriately progressed and loaded in terms
of intensity and rate of force development and you can build muscle capacity by doing that which makes you more resilient at running so we mentioned the the myth about running a NE ostearthritis we actually put a series of these in bjsm led by James Alexander who's a master student I work with one of the other myths for runners is that endurance-based resistance training is more beneficial than high resistance and and low comption so really thinking through that and talking to your heal professionals about that important so find that expertise and I think the other thing
you can seek out which is probably maybe less important but can be really important in some instan someone who can give you some good coaching and guidance around your running technique as well and that's really helpful so there's some key things we can look at from a running mechanics perspective that we can change and manipulate to reduce stress on your need but you really need to get guidance from someone who knows what they're doing so you don't cause yourself another injury and I'll use a really tangible example for runners out there with knee pain a
lot of people are told to change their strike pattern so get away from landing on your heels and go to a non- rear foot strike pattern now logically that makes sense for your knee because you're going to reduce the knee joint loading and people often find it quite beneficial but if you don't have the capacity in your calf and in your foot and ankle you're going to cause yourself a stress fracture or an Achilles tendon issue or a plan of heel pain issue and so seeing someone who can if that's something you want to change
who can guide you through the process of building that isue resiliency and capacity to do it is important and then adequately coaching you and instructing you to to get there as well is important as well that's superb advice and hopefully very practical and something that people out there can Implement and it's tremendous tremendous news that based on the existing evidence that running is safe for people with NE ostearthritis and it doesn't appear to accelerate progression now obviously that's the blanket rule of thumb but are there any particular populations of people that you would advise against
running I think really anyone can run almost I mean as we get older certainly as we get older and more frail we will lose the capacity to run at some point in our lives if we're lucky enough to to get to that age I've seen and people who work in similar principles to me with running R training and exercise who work with brain injury patients and spinal cord injury patients and it's so impressive watching what they do and I've learned a lot from the neurological literature around how to manage Runners so when it comes to
muscular scal injury quite traumatic car accidents severe OA pretty much anyone can be brought back to some form of running and even if it's 1 or 200 meters for that stimulus to help with tissues is is really helpful one of my favorite patients is an 83 year old gentleman who come and saw me at the age of 79 he hadn't run for a few years he was considering a joint replacement surgery if we grade his ostearthritis he's got medial tibiofemoral away grade three on a Calin Lawrence some reasonable Patel FAL joint away as well now
we've got got him back to running and he's now 83 he comes and sees me every 3 or 4 months and all he ever complains about is he can't run fast enough he doesn't have pain anymore he's completely fine from a pain perspective and he does three or four runs a week he does a park run every couple of weeks and he does a long run on the alternate fortnite of 10 to 15ks so I always like to use him as an example for people way if he can get back to running and and run
really well and I've got a 40 or 50y old middle-aged person in front of me there's no reason their body can't adapt over time to be able to run so that's really important the caveat to that is some people will occasionally need a short period of time away from running and it's often off the back of them doing too much running so if we do too much running we can develop a condition called relative energy deficiency and that can lead to all sorts of Health implications um for female athlete Health but also males and females
when it comes to bone health as well and so in some of those instances we actually need to take them away from running a little bit and try and address some of those health issues and working with medicos to help with that side of things and dietitians and then there's also the group who and saw a lot of this in lockdowns that go crazy just do far too much running and end up with quite significant Bono Dema and this is really common in P telal joints so you might see someone who and I've seen this
multiple times in the last couple years particularly they've gone and started trying to run 150 200 km a week off a reasonable base but it's just becomes too much and they've got this Bono D that just doesn't settle down so in some of these cases we do need to give them a period of rest away from running so they can actually get some recovery but at some point they be able to go back to running so long term I don't see very many reasons people can't run again really really positive and hopefully stimulates a lot
of people out there to at least if they're contemplating being more active not fear being active in that regard now Christian we may have already touched upon some of this but what advice practical or otherwise would you like to give for people out there with ostearthritis looking to increase physical activity or start running so we've talked about running being safe and the key is to to really just look at trying to get back to running if that's something you really want to do I think what's important is really simple concept you need to be able
to walk before you run so if you've been sitting on the couch and doing no physical activity don't just go out and start trying to run so in a lot of people what I'd encourage them to do is start a walking program and it might just be doing five or 10 minutes walking each day and then you if you can build that up over over the space of one two three months to be doing 30 minutes each day then every second day you might start to integrate some running into that and you can start to
do just a couple of minutes at a time and slowly build that up and that's a really senseful way if you do nothing else don't worry about all the exercise stuff I talked about don't worry about looking at running mechanics you'll probably be okay doing that you might take longer to adapt if you want to make it more efficient then alongside doing that walking based program what you would try and do is work with an exercise professional and address any strength or muscle impairments that you might have to to try and ensure that you've got
optimal capacity to run and before you start running it's often sensible to start with some simple hopping skipping jumping type program to try and build up a little bit of capacity so again low volume but gradually increasing your your intensity of loading so you're building that tissue resiliency so your curtilage is not going to complain if you do five or 10 jumps on the spot every couple of days it's going to be fine and that's a nice way to reduce your fear of that impact loading and then if you can work with an exercise profession
you sensibly increase that loading and get to the point where you're doing decent hopping and petrics you'll really build that capacity to get back to running now in the short term if you're just going for a walk each day you probably not getting your heart rate up as much as you'd like to or your General Health would benefit from so what you might do is take up something non impact initially so looking at some cycling swimming those types of activities but even then you still need to be careful about how quickly you integrate into that
so the key is to not do too much too soon and one of the best ways to monitor that with a history of NE ostearthritis is not to avoid pain because we have to be honest we we none of us can do exercise without some form of discomfort and without pain that's just what happens and what pain is is a protective mechanism to stop us damaging ourselves now in the context of ostearthritis or long-term muscular little condition we become sensitized and what that means is we don't have a high pain threshold like many people think
they have they actually have a low pain threshold but a high pain tolerance putting up with lots of pain and what happens is simple activities and even thinking about activi start to become painful so we can't avoid pain it's not possible what we need to do is monitor the response after an activity that's really important so we don't want to see pain escalating during an activity or a new exercise and then ideally it settles within one or two hours after that activity definitely 24 hours later we'd like to see that we're back to our day-to-day
symptoms so if it normally hurts to walk down the stairs we don't want to see that pain increase walking down the stairs if it normally hurts to squat down we don't want to see that increase so if we can do that and gradually increase our loading you'll be off on the right track and that's probably a really important process to go through I think that's probably a really helpful point just to clarify obviously that shortterm pain that you're talking about that may persist for an hour or two after the activity is probably fine so if
you're out there and you've been wondering about how to stay Physically Active hopefully this gives you some tips and tricks for doing so the intent here is to try to promote positive behaviors to really put core treatment options for osteoathritis in your hands so you can operationalize them we're hoping you found the content of today useful look forward to your ongoing support thank you so much for listening and between now and when we next speak please do take care of [Music] yourself thanks for listening to Joint action with David Hunter if you like our show
and want to know more visit www . joint action.in if you have any questions you can email us at helljoint action.in and follow us on Twitter at joint action org this podcast was hosted by David Hunter edited by Vicky dwang music produced by Jordan Hunter the information posted on this podcast is not intended to diagnose treat cure or prevent disease anyone seeking medical advice should consult the health professional [Music]
