This episode we identify common misconceptions surrounding knee osteoarthritis and bust common myths you might have. Ideas around: What is knee OA? What causes knee OA? What are the consequences of having OA? What is the symptom timeline? What are common non-surgical treatments? We also discuss the correlation between running and osteoarthritis. What some common symptoms are and if you can continue to run with OA. The answers might surprise you! Kevin Maggs is an instructor for The Running Clinic in the US, he helps deliver sound evidence-based advice to runners and medical practitioners alike. Link here for Kevin's twitter account: https://twitter.com/RunningReform Link here to learn more about The Running Clinic courses: https://therunningclinic.com/en To follow the podcast joint the facebook group Becoming a smarter runner click on the link: https://www.facebook.com/groups/833137020455347/?ref=group_header To find Brodie on instagram head to: https://www.instagram.com/brodie.sharpe/ To work with Brodie Sharpe at The Running Breakthrough Clinic visit: https://breakthroughrunning.physio/
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On today's episode, knee osteoarthritis misconceptions with Kevin Maggs. Welcome to the Run Smarter podcast, the podcast helping you overcome your current and future running injuries by educating and transforming you into a healthier, stronger and smarter runner. My name is Brodie Sharp. I am the guy to reach out to when you finally decided enough is enough with your persistent running injuries. I'm a physiotherapist, the owner of the Breakthrough Running Clinic and your podcast host. I'm excited to bring you today's lesson and to add to your ever-growing running knowledge. Let's work together to overcome your running injuries, getting you to that starting line and finishing strong. So let's take it away. I am really excited to bring you today's episode. I mentioned this at the end of the interview, but I'm really excited to deliver some really useful information. But there's certain type of information that can be completely on the contrary to what you currently believe. And it can just be a revelation. And this topic fits right in there for a lot of you. Kevin Maggs, he is an instructor at the Running Clinic. I was sharing my experiences with Kevin before we jumped on the interview. I actually attended one of the running clinic courses with a different instructor about three years ago. And so it was awesome to see that he's delivering the same course to other health professionals out there. He does it in the U S I had to travel to New Zealand to attend my course. And we delve in a little bit about how that course is ran and how evidence-based it is. And so for having Kevin as an instructor, you can just have the confidence to know his wisdom around the latest evidence is absolutely world-class. We cover a lot of osteoarthritis misconceptions, some surrounding what knee OA actually is, what causes it, what are the consequences, how long does it take to get better, and what some of the treatment beliefs are. We attempt to address all of this. and what it means for osteoarthritis for runners. I answer a couple of your Facebook questions and hopefully by the end of this interview, you feel a little bit more informed and have a bit of a revelation into some of your existing beliefs. Because like I said, it could be a complete game changer. Really, really excited to have Kevin on. Hopefully I can get him back to talk about some other topics because he's a world of wisdom. So let's bring him on now. Do you want to just talk to the audience and just let them know where your career began and how it's developed and where it is now? Yeah. Well, first of all, thanks for, uh, thanks for having me on. It's a pleasure to be on. I, uh, I listened to it and I like your podcast a lot. Um, yeah, so I grew up in Canada and I went to, uh, university of Waterloo for kinesiology. Um, my, uh, my undergrad professor for biomechanics was Stu McGill. It was a nobody at that time, but he's quite. quite well known now. I went to Chicago for chiropractic. And, you know, I always played a lot of sports growing up. I was on a lot of sports teams in high school and whatnot, but I never actually ran. I didn't start running until later on in life when I had a lot of patients come in with running injuries and it got me interested in running and wanted to relate to them. So I started running. So I've done a few full Ironman and quite a few marathons. I started working for a group called Rev3, which is a triathlon company. Traveled around with them for four years working on the pros. I became an instructor for active release techniques. And then in 2011, I took this course called the Running Clinic, which really radically changed the way I think about running as I think it did for you. You said that you had taken that course as well. Absolutely. And so it changed what I did. And so I started writing a lot of blogs and doing a lot of videos. And the running clinic contacted me and asked me if I wanted to become an instructor for them. So, I've been teaching for them for about four or five years now, which is so much fun because it's a very evidence-based course. And not only do I enjoy teaching it, but I learn a lot by teaching it. Like, you really have to be on top of your game when you don't know what kind of questions are going to be coming from the physios and the chiro's. orthopedic surgeons and podiatrists that are taking the course. So really forces you to stay on top of the research, which is, which is a lot of fun. I was definitely impressed when we started doing the course and my instructor JF was talking about, um, how up to date with the research they are and say every couple of months they look at what's been published and consider it with, um, the call, the course content that they have and just slowly over time, as more and more evidence gets released. they can slowly, slowly start manipulating the content. And yeah, it's not like one paper is going to come out and change, radically change, but at least it's considered when compiling all the other evidence that's out there and then just slowly changing the narrative and slowly changing the advice and what they start teaching. So that was one component of the course that they go through at the start. And I was just really taken back by it. Um, it was really, really impressive stuff. And so, What got you, um, you know, the manuals change about four times a year. And the slides are four times a year too. So yeah, definitely keep up to date on the research. Absolutely. Would you find that over the last couple of years that you have been teaching, there has been much radical changes or has it just been slowly, uh, tweaking and slowly evolving? No, there's been some, some slight changes, some minor changes. What really happens is there's more. Um, more evidence of what we have been teaching more and more research comes out supporting what we have been teaching. And that's, that's interesting. Yeah. That's even better. Yeah. But I mean, there are, there are definitely are changes, but, uh, it's, it's a lot of reinforcement of what, what we have been teaching, which is great. Great stuff. And so what's the reason for, um, having the particular interest in osteoarthritis. Yeah, that's actually comes from teaching the running clinic because, uh, You know, obviously, you know, when you treat runners, you, I treat a lot of, a lot of my day is spent on lower extremity injuries. So I come across a lot of people with, with knee OA and hip OA and my approach was probably like most healthcare providers in terms of, you know, protect it, um, lessen the, lessen the inflammation and that's fine, you know, to protect it for a while to get it to calm down. But I think most healthcare providers have the attitude and I think most people have the attitude of continuing to protect it. But that falls into that idea of sort of the mechanical model of like, if you drive your car around a lot, your tires will wear out, your fan belt will wear out. And so people have the idea that if you run or you do a lot of work, there's... I think a lot of people feel that osteoarthritis, the cause is called wear and tear. really not what it is. And I think we'll probably get into that a little bit today. But, um, you know, I kind of view cartilage now as a muscle in terms of if you add a mechanical load to it, it will respond and it will become stronger. Um, you know, you have people with osteoporosis, like women with osteoporosis, they're told to do weight bearing exercise because your body takes the mechanical load and it converts it into stronger, healthier bone. And for whatever reason, we've always felt that cartilage is that way too. But now we have pretty good evidence that cartilage actually adapts to mechanical load. And the, the evidence is pretty overwhelming that, uh, people who exercise and people who run actually have a lot less knee osteoarthritis symptoms and pain and what not. Um, but then also people who have arthritis already, if you expose them to a exercise program, particularly one that involves some weight-bearing activities, including bouncing, there's a response in the cartilage that the cartilage actually becomes healthier. So it completely changed my viewpoint on that. And so, you know, it was quite exciting to me to have that viewpoint and implementing it over the years with patients with knee and hip osteoarthritis. I've seen incredible results that I never, never saw before. So it's just developed this big interest for me in that topic. Yeah, it can be an absolute game changer. And you did have this brilliant idea of discussing this paper and the title, the misconceptions and the acceptance of evidence-based non-surgical interventions for neo-A in 2019. I think it's a great idea because it does cover certain beliefs that people might have misconceptions people might have around knee osteoarthritis. And so I thought, um, it was a great idea what you came up with and it would be a good start to the interview if we just discuss these five different dimensions and we break down each section and then we'll just get into more specific questions. So, um, sure. You're happy with that? Yeah, that's, let's do it. Brilliant. So we've got, uh, the first one, the first kind of belief is about, uh, the identified beliefs. So what knee osteoarthritis actually is, uh, How would you explain that to people if someone was to come in with knee OA? Yeah. So in this paper, they interviewed quite a few people on a waiting list in Australia for knee replacement. My understanding is it's around 300 days. That's the waiting list to get a knee replacement. And so people have a lot of ideas about what it is. So they did lengthy interviews with these people. And every one of them felt that knee osteoarthritis, they use some description of bone on bone and that's how they identify what knee osteoarthritis is. And you know, it's a lot more than what you see on imaging. In fact, the correlation between imaging and pain is actually a pretty weak correlation. There's again, lots of studies on this, lots of systematic reviews on this, particularly with just, you know, x-rays. identity that people have with osteoarthritis, it's joint space narrowing and some bone spurs, maybe some subcontrast sclerosis, which means like some thickening of the bone around the joint. And the correlation with the severity of people's pain and the severity of what you see on the imaging is just not a very good correlation. So as a result of that, you know, when people say it's bone on bone, they're talking about this structural change that has taken place in their bone. But the reality is there's a really weak correlation there. So, you can take people with very bad looking imaging on an x-ray and they actually feel okay. They don't feel a lot of pain at all. And you can take people with a lot of knee pain and do x-rays and their knees actually look okay on the imaging. So, correlation isn't quite there. strengthened by the idea that you know if you take anybody with knee osteoarthritis, they're gonna have good days and they're gonna have bad days and you can't convince me that on the good days the structure of their knee has changed. The structure of the knee is gonna be the same day to day but yet they feel different day to day and a lot of that comes down to the idea of you know what actually does correlate with the pain and the symptoms of knee osteoarthritis really ties back into inflammation. So if we even look at MRIs and you look at the quality of the cartilage and the thickness and the volume of the cartilage, that doesn't even necessarily correlate well to pain, but things like synovitis and joint effusion and bone marrow edema are the three things that really correlate much better to people's symptoms. And so all three of those, synovitis means an inflammation of the synovial membrane around the joint, and then joint effusion means fluid accumulation in the joint and bone marrow edema means some fluid accumulation In the bone underneath the cartilage, but all three of those are tied in with inflammation And that's why people feel better and worse on different days Because it really ties back to the inflammatory part not the structural part. So this idea that It's bone-on-bone Doesn't doesn't really hold water because it's not It's not that simple. You know, you can take people with knee arthritis and give them some anti-inflammatory drugs and they'll feel a little bit better. And now anti-inflammatory drugs don't change the structure. So you know, it just it just strengthens the argument that it's not really tied to structure. But the problem with that is, as we'll see later, you know, with what people think about the timeline of how they're going to get better. They have a very pessimistic view of how they're going to get better because their doctor told them it's bone on bone. And obviously you can't grow new cartilage. So they get very pessimistic and they start to catastrophize about the whole situation. Yeah. Catastrophization is a huge one, especially if we know much about the brain and what the brain sends signals to the joints. If it does feel like it's in a significant amount of damage as well. And if you continuously, um, that thought and catastrophizing if you know it's bone-on-bone it's not going to get better it's always going to be like this I can't run I can't walk I can't do anything like this it starts to wind up the brain itself and produce more pain or become more susceptible to these fluctuations in pain and so you've identified with people that they have this misconception with bone-on-bone and the kind of structural damage if you were to have someone in the clinic who does have Neo A and let's just say they have a clean slate and no conceptions of what it is at all. How would you like to explain it to them? Yeah, in terms of what is causing the symptoms, I would certainly explain to them that it is an inflammatory process that's going on in there and it comes down to controlling inflammation. Now you can have all sorts of different things that influence the inflammation in the joint, whether it's tied to the activity level that they're doing, or they're doing too much. I think we'll probably talk about this as we go, but the biggest... thing that seems to be tied to the symptoms of developing the OA and also even the imaging findings on the OA is the fat content in people's bodies, which a lot of healthcare providers don't feel comfortable bringing up with people, which is frustrating because it's really tied in closely with the symptoms. So what we used to know is that one of the biggest modifiable risk factors for... symptomatic knee arthritis is people's BMI or the body mass index, um, which is a simple, simple equation of your body's mass and your, and your height and whatnot. So what we do know now is that it's a lot more than the total BMI. It's really, it's really the fat content in people. So you can have bodybuilders and power lifters and whatnot who have very high BMI's, but uh, but they don't have a lot of symptoms. But if you look at the fat content, fat in and of itself creates an inflammatory environment if you do. You look for blood markers of inflammation in people who have a high fat content. There's a lot of inflammation that goes on there. And since like what we talked about earlier, the inflammation is really what is tied into the symptoms. And you have somebody with a high amount of fat content. The number one goal at that point should be to lose weight. Um, so, you know, I'll talk to them about like, why are you feeling this? Well, you know, maybe losing weight is a good idea. Maybe doing some modified exercises is a good idea, but it's, it's really tied back to the amount of information in there. Yeah. And it could tie in well with this second point of the causal beliefs of what causes our way to start with. And I think you alluded to before that a lot of people would say, well, it's just wear and tear. Um, how would you like to address that misconception? Yeah. Again, uh, it's, it's pretty clear from a lot of different studies that if you're more active, you're going to have less risk of developing knee arthritis. Yeah. So it's quite on the contrary to what people do believe. Yeah. Quite on the contrary. Um, And that's pertaining to runners too. And I'm hoping we're going to get into that too, because runners certainly have one of the least incidences of knee arthritis. So, if you look at all the data there, it is certainly not a wear and tear type of issue. But then, again, even if you take people suffering from symptomatic knee arthritis and you start them on an exercise program, they feel better. And so, why do they feel better? If it was a wear and tear issue? we would be creating more wear and tear with more exercise. And there's a, there's a really good correlation to the amount of exercise that people do and the reduction of pain with, with people with symptomatic knee arthritis. And so, you know, all these factors really tie into the idea that it's not a wear and tear issue. It was more of a inflammatory issue. Very good. And we can move on to, I guess, the third one, which is consequence beliefs. Yeah. So that's a, it's an interesting one because, you know, people, um, people think the consequence of, of doing more exercise is going to create more wear and tear. And so it ties back into the other one and it's very difficult to, to get to the point of saying, okay, You know, the patient has to be on board with us, but you want to start to explain to them that you want to start doing some step ups. You want to start doing some maybe jogging in place, maybe some jumping rope, maybe some strengthening. And if they are still back in the previous beliefs that it's bone on bone and it's a wear and tear, then the consequence belief of doing more exercise is going to be this, you know, cognitive dissonance where they're going to say. Well, I don't want to do that because it's aware and territory. So the whole idea of before you get into any, any prescription of rehabilitation, we have to sort of clear up the idea that it's not aware and territory because the consequence beliefs of people is that the consequence of exercise is going to make it worse. I think they can also, they can also be misled if let's just say they have moderate to severe away and they have a big day where they're up and about the moving around, they're on their feet a lot. And by the end of the day, they're quite flared up. and they've obviously exceeded what the capacity of that joint is, but then they can associate, okay I've done too much walking, therefore a little bit of walking might flare it up as well. So there might be misled by symptoms and in the relation to activity, but in reality low levels of activity that don't flare up symptoms is actually a very positive thing. Absolutely. And then if relatives or other... people who see those symptoms and can correlate those symptoms, um, might draw the same conclusions that they have as well. Yeah, absolutely. Uh, I've, I've experienced a lot of that, um, in terms of, you know, somebody comes in and they've got, I had this one gentleman come in with, with a really bad knee away. He was actually coming in for his back, but he mentioned that he was going to be getting a knee replacement in like six months. And I suggested that maybe we can start, uh, you know, an exercise program leading up to running. And he was obviously a little hesitant of that, but he was, he was set for a knee replacement anyway. So he said, you know, I have nothing to lose. That's fine. So he started them on a very light program and uh, he, he tolerated it well. And then we eventually got him to running and he was running, you know, it wasn't much, it was like a mile or two every day, which was totally fine with me. I don't want to necessarily make him start running a marathon. It was just a little bit of impact on the joint that we wanted to gradually expose him to. And he said he was going up and down stairs without pain now. And it was the most consequential thing that he had done for his knees because he had a lot of injections, Sinvisc and Orthovisc type injections like Tylen cartilage injections, as well as steroid injections. And he said the exercise program and the running helped him more than anything else before. And so then he goes home for Thanksgiving and, uh, and his daughter is there. Who's a nurse and he's putting on his running shoes to go for a run. And she, uh, she proceeded to chastise him for going out for a run because he has knee arthritis and how dare you go running because part of me. How dare she give you that advice. And then, so he said, you know, actually, I think this is going to be a good program for me and seems to be working so far. She's like, where did you get an idea like that? And he said, my chiropractor. And so she obviously gave a big eye roll for the word chiropractor. But he stuck to it because by that point he was a believer because he saw the results. But yeah, I mean, at the beginning, yeah, I mean when you're surrounded by friends and family that may not, that may not agree with that, it's, it's tough to, it's tough to implement that. Yeah. And that's why you have to bring out a study like this that addresses all these misconceptions. Yeah. Let's talk about timelines. So if I have knee osteoarthritis and it's like a moderate severity, aren't I just doomed for life until I get a knee replacement? Right. So that's the other misconception is that people, people had those ideas. People had some really wild quotes that, you know, that like I'm at the end of my line and you know, I'm doomed for this. And the, the interesting thing is, is most of those, beliefs came from the orthopedic surgeons that they saw and the primary care doctors that they saw and even the physios that they saw which was not encouraging to see that. But we have really good studies that are showing if you implement an exercise program and a weight loss program, over the course of years these follow-ups are going. the reduction in knee replacements in the intervention groups, in other words, the people that get the weight loss and the, uh, and the exercise is around 40%, 40% reduction in, in knee replacements. So yeah, I mean, they're definitely not doomed if you start implementing a program like that. I mean, you may still need a knee replacement. I'm not saying that this is like the cure. Obviously people, some people will greatly benefit from a knee replacement. Um, but my belief is and this is what is outlined in all these international guidelines is that if you're gonna do that, you're gonna go for a knee replacement without trying weight loss and exercise first. That is a big mistake and everybody should be trying that first. And there was a really good paper, it was by Messier where they had people go through a weight loss program. And if there was a 10% reduction in weight loss, which isn't that much, 10% reduction equated to on average a 50% reduction in symptoms. And then the more weight they lost, the more symptom reduction that there was. And if you implemented exercise on top of that, there was even more reduction in symptoms. So. I mean, I think a lot of people, when they hear all you should exercise and lose weight, I don't think they quite understand the effect sizes of what these interventions can do. And they just think, yeah, it's going to reduce it a little bit maybe, but these are quite large effect sizes. Yeah. And the fifth, um, topic that covers in this article was treatment beliefs. And so you did mention the effects of weight loss and the importance of strength training. Um, should be within the right advice of a health professional to work out what dosages and what type of exercise is most suitable. But is there anything else that we haven't covered so far that we want to address when it comes to treatments? Yeah, I mean, I think there really should be a little bit of counseling that goes into it because people do have a very pessimistic view. You know, I mean, we're in this age of the biopsychosocial approach, and I certainly am a big believer in that. I am certainly not an expert in it, so I try not to meddle in something that I don't know what I'm doing. But yeah, I think, you know, a team approach to this where you can get a nutritionist involved and you can get a physio involved or in my case a Cairo, as well as some sort of counseling. to deal with the pain I think is a good well-rounded approach. I mean, you know, same with nutrition. I mean, I know enough about nutrition, but not enough that I would feel confident, you know, doing that as an intervention for my patients. I refer out for that. But those three are really the three pillars of how I would go with that. But, you know, along with getting patients on board with that is going back to the previous topics that we talked about where in this particular paper, the participants of the study had a really negative view of physio and exercise because their beliefs were that you can't grow new cartilage. So what's the point in doing all that? And it's just going to flare it up. So again, you have to sort of go through it step by step and go through... All of these beliefs individually before you get to the saying, okay, this is what we're going to do. You know, if somebody comes in with Nearthritis and I say, okay, we can start, you know, an exercise program that may end up in running, people are going to think you're crazy. Um, so if you, if you sort of address those initial issues first, then you're going to have a much better buy-in. Yeah. Cause I think people create this image of someone running and the impacts involved with running. And if it's just bone on bone and there's no cushioning or there's no like smooth gliding of the joints. it can be a very negative image that people portray. And we've covered all the five kind of dimensions of those beliefs now. And like you said, someone might need a knee replacement moving forward, but I think the overarching message here is as long as they are well informed of the evidence and the research that's out there and they don't have any misconceptions before considering a knee replacement. And if they are well informed, then they're most likely going to consider um, non surgical interventions first, um, with a bit more of a calmed down idea. And the treatments being like weight loss, exercise and the right education, um, can help sort of swing them in the, the other direction. Hopefully they do become a part of that 40% that avoids surgical interventions altogether. Right. Yep. And unfortunately a lot of this starts with the primary care doctors and there's, there's quite a few different studies on the attitudes and beliefs of primary care doctors towards knee osteoarthritis. And unfortunately, in these papers, the primary care doctors are the ones propagating these misconceptions a lot, which is really unfortunate. And you know, they rarely refer out in these studies. And when they do, 70% of the time, it's to an orthopedic surgeon. So they're going straight away for the surgery. And in this one paper that was actually done in Australia, when patients presented to primary care doctors with knee osteoarthritis, the referrals to physios comprised only 3%, it was like 3.5% of the time a primary care doctor would refer to a physio. Which is really, yeah, because who's better equipped? to manage a rehab program. I mean, it's the physio. So, yeah, unfortunately, you know, when a patient does come into a physio office or a chiropractor office with knee osteoarthritis, you know, a lot of these misconceptions have come from the primary care doctor, which is unfortunate. It is very unfortunate, but it's gotta be such a huge task to try and change the whole. idea around OA to like every GP that's out there because they are the first point of contact for a lot of these people. And to try and change what they've been taught, their whole ideology, it's got to be a monstrous task but I think it's slowly getting there or there are a lot of doctors out there or some doctors out there that share the same beliefs as you and hopefully if we start to identify them, then we can start referring clients to them. just to gain some of that reassurance for them. Wouldn't that be, wouldn't that be interesting? Yeah. It's a monstrous task, but, um, yeah, it's something that needs to be done. Yeah. Um, you know, if, if I think if they were in, in these papers where they interviewed them, a lot of their reasoning is, uh, that they don't believe that exercise will help and they don't believe that weight loss will help, which is unfortunate. Yeah. And the other thing is that they don't know how to implement it. Right. And even if they have that really ingrained belief, I don't think like a pamphlet or an information session will convince them otherwise either. Right. Yep. But you know, there was a paper by a best week in 2012 that was outlining the outcomes of, of knee replacements. And, uh, it was a, it was a review and they came up with the figures of somewhere between 10 to 34% of knee replacements have an unfavorable outcome. The average of 20, 20% of knee replacements have an unfavorable outcome. So one in five, which isn't, it's not great. So to me, if you're not attempting the weight loss and the counseling and the, and the exercise prior to that, you're kind of missing the boat. Cause once you get the knee replacement, you know, there's no turning back at that point. Yeah. We need to move on because I've got a couple of other questions written down. Sure. Just quickly, uh, what are some like early signs or symptoms of osteoarthritis if someone is going through some knee pain? Yeah, generally just pain. I mean, the, the first sign is going to be pain. Like I was saying earlier, I mean, you certainly can't go by imaging. That is not the way you should be diagnosing, um, knee osteoarthritis, just generally stiffness and pain. Uh, that's progressively worsening. If you're fine and all of a sudden one day you wake up with knee pain, it's mostly unlikely that would be knee osteoarthritis. But progressively worsening stiffness and pain is certainly suspicious of knee osteoarthritis. You know, what we've been talking about so far are all the modifiable factors. The biggest factor for developing knee osteoarthritis is genetics by far. Uh, but the modifiable ones, you know, we can help, but if you have a big family history of knee osteoarthritis, um, and you're having progressively worsening pain and stiffness in the knee, then that would be worse than dusting. Okay. I'm glad that you mentioned stiffness because if we're trying to differentiate, uh, worsening pain that's associated, let's say if it's patella femoral pain or ITV, that sort of stuff, that's not usually associated with stiffness. And so, um, Yeah, like you said, if there is pain, if there is stiffness and it's slowly, progressively getting worse, then it can be an indicator, but don't go for imaging straight away. Next question, what's, is there much of a link? I will sort of touch on this already. So there isn't much of a link between knee OA and running. Are there any kind of stats that we can refer back to when we're talking about the prevalence of knee OA? Yeah, so there actually is a link between me away and running, but it's an inverse link. Ah, very true. Contrary to what a lot of people think. Yeah, I mean, there's certainly lots of stats on that. Kate Timmons has an article in 2016. It was a systematic review. So they looked at lots of studies that have already been done. And these studies went anywhere from less than five years to more than 25 years of running. And it showed that runners have about 54%. less risk of having a knee replacement compared to non-runners. So, I mean, again, that's a huge effect size. It's tough. I mean, that's a study where it's an association. We can't necessarily say that running caused that. You know, perhaps there's a survival bias in that, but, you know, there's another paper that shows that the incidence of knee osteoarthritis in recreational runners... is around three and a half percent, whereas non-runners, it's about 10%. So, those are associations. But there was another study where what they did is they looked at 58-year-olds. On average, they were 58 years old and they followed them for eight years. And at the beginning of the study, the runners had a little bit more knee arthritis than the non-runners. But 18 years later, the non-runners had a lot more knee arthritis. than the people who were running. And so you certainly can't say that running causes arthritis. There seems to be a pretty big trend that running is associated with less knee osteoarthritis. And again, you could say, okay, well, one of the biggest factors for developing symptomatic knee arthritis is fat content and runners have less fat content. So maybe that's why they have less symptomatic knee arthritis or maybe the people who have knee arthritis drop out of running. And so that's why it's like that. So we can't really conclude from those studies that running is the cause of why people have lessening arthritis, but it is a strong association. But there's a couple studies, one by Ruse, that showed if you take MRIs of people and you look at something called the glycosaminoglycan content, which is a compound in the cartilage that, do you ever have people who get hyaline cartilage injections with like Cyndisc or orthobis? Basically that's what they're injecting. but your body can intrinsically make those glycosamino glycans. And so they took MRIs, a special type of MRI called the de-GemRec MRI, and they looked at people's knee cartilage. And then after, um, after a certain amount of time of exercising in the, in the intervention group, which included like jumping rope and running in place, the glycosamino glycan content in their knees was much greater than the people who weren't doing that. So that is, that's something where it's not association. You can use, weight-bearing activity as an intervention to improve the quality of the cartilage. And then with running specifically, there was a study by Van Ginkle that did the same sort of thing where they took people who were not runners and they started half of them on a running program. And at the end of just 10 weeks, those people had significantly more glycosamyl glycane content in their cartilage than the nonrunners. So there's definitely an inverse relationship with running and knee osteoarthritis and it seems that running... seems to stimulate the cartilage to be healthier. And I think it's going to be very encouraging for you to say those sort of stats and those design studies as well, to get someone who's 58 with mild signs of OA and if they continue running, that actually helps improve outcomes. Or it's what the studies have shown because you can easily see a 58 year old who's running, getting a little bit of knee pain and finds out to have early signs osteoarthritis. And they say, all right, game over. My running career is done. Um, when if they're educated with the right type of information, they can actually, um, be more encouraged to continue running because that helps improve longer term outcomes. Right. Yep. Exactly. So if they start having knee pain, I would probably go back to, it probably ties into something that they did recently where they change something, either change their shoes or their form or their running volume or their speed. And it just aggravated the knee, right? Which is fine. Like it's just. That's because they just did too much too quickly, but then they go get an X-ray and then somebody tells them that they have knee arthritis and then now that's in your brain. Um, but if we can just tie it back to look at, you're fine. You just did too much. Let's calm it down and then you can gradually build it back up. Yeah. It can be very dangerous if put in the wrong hands, uh, conscious of time. I might cover, um, a few of these Facebook questions that have come in. Um, and then we'll see how we go for time afterwards. So I think we kind of address this anyway, but Naomi asks, there was a question, what's the difference between knee away and like a, an actual like inflammatory type of injury. And she puts as a, um, example, her knee cracks naturally when she squats down without pain compared to when her knee stops cracking, but she actually feels quite stiff. So, um, that's interesting, isn't it? Yeah. Uh, so, so the, the knee cracking and grinding, I mean, in, in healthcare terms, you know, this, we call it crepitus. And there's really no correlation with Crepitus and who's going to get knee osteoarthritis or who has knee osteoarthritis. That's pretty well established. There's a woman out of the UK, Claire Robertson, did a great blog post on that with lots of research. Physiotutors did a great video on it out there. I think Tom Goom had a blog on it with Claire as a guest, but it's pretty well explained. If you have... knee grinding or popping or cracking or wherever you want to describe it. And it's painless. You tend not to worry about it too much, which, you know, can sometimes seem like you're blowing the patient off. But you spend time talking to them and going through a proper exam and reassuring is really the key reassuring them that it's quite normal. It's just a normal process of aging and it doesn't mean anything sinister at all. you know, hopefully you can reassure people with that. Perfect. And one more Facebook question from Mareika. And she asks, are there any specific running shoes you advise patients use? What type of attributes you want that shoe to have if they do have neo-A? Yeah, that's a really big topic, isn't it? If they have neo-A, so if they have neo-A, that's a, that's a completely different question. And if they don't, but generally what we want to do with people with symptomatic knee away is continue to have them running, but maybe lessen the load on the knee a little bit so they can continue to run while it's, you know, while it's in an irritable state. If we can lessen the load on the knee so that they can run without irritating it, that's our main goal. So there's pretty good research that, like with quite a few studies that show that if you get into sort type of shoe, one that sort of mimics the way you run barefoot, there's a natural thing that happens in most people where you increase your cadence. So in other words, you increase the number of steps that you take per minute, which means that if you're running the same speed, you would by definition be shortening your stride. And when you do that, it significantly lessens load on the knee. And from again, a lot of different research studies, it actually lessens the symptoms as well. It's important that you go to somebody who knows what they're talking about and we don't want to just blanket tell everybody with knee osteoarthritis to go into a more minimalist pair of shoes because when you do that, you are definitely lessening the load at the knee in most people, but you're going to increase the load on the foot and the achilles and the calf. If you make that change too rapidly, you're going to be at risk for injury somewhere else, which obviously we don't want. So that type of change has to be done really gradually. And then there's a certain cohort of people where you put them into a minimalist pair of shoes and they don't actually increase their cadence or land softer, they actually end up landing harder. So it's on a case by case basis, but for the most part, around 70 or 80% of people when they're put in a very minimalist pair of shoes, in other words, very little cushioning, you tend to land softer. by increasing your cadence and just sort of cushioning your landing a little bit, which really lessens the load on the knee. If someone does have a low cadence, um, shoes aside, can they continue wearing the same shoes, but then just work on increasing their cadence slightly. And that way, they're not at risk of, uh, a lower limb injury, like in the foot or ankle. Um, and still reducing loads to the patella femoral joint. Absolutely. And that's why you need to go to somebody who knows what they're talking about, like yourself. where you can get someone on your treadmill and do a gait evaluation and look at things like what's called loading rate, which is how hard they're landing on the ground, like how much noise it makes, as well as the cadence and start playing around with it. You'll have some people where you ask to take shorter steps or increase their cadence and they can do it. And there's other people who have a really, really hard time doing that. They can't figure out how to do it. And it becomes very cognitive and it sort of ruins the running experience for them. So in that situation, you can maybe take the shoes away and see how they run without any cushioning and see if it naturally increases their cadence. And if it does, then they may be a candidate for the minimalist type of shoes. But you're absolutely right, Rody. If you take somebody and you just ask them to take shorter steps and a faster cadence and they do it with ease, then there's absolutely no need to go to a more minimalist pair of shoes where you may expose them to... to, uh, you know, an injury somewhere else. Okay. I think that answers Marika's question quite nicely. And there's a massive debate with shoes and, um, whether like certain types of shoes, reduced load or increased load or, um, that whole topic. So we won't open that can of worms. We have, we have five different studies where you compare regular running shoes to hokas, which is like maximum cushioning and the loading. rate goes up in the Hocus compared to regular shoes. So, I mean, it's a trend though, right? It's not every individual. So you really have to take everybody as an individual. Very true. Um, thanks for those guys submitting those questions. Let's talk a little bit on what we know about HIPAA because I know there's not a lot that is studied compared to NIOA. There's a whole, you know, blanket of research around knee OA and not a lot about the hip, but is there any comments that we can make with what research has shown so far? Yeah, it's very similar to the knee. You're absolutely right. There isn't nearly as much research on hip OA, but it really does come down to the same thing. We know that if you add an exercise intervention, people generally do better. We know that it's tied into inflammation. So weight loss is certainly a good. option for that. So I really wouldn't make any, any significant, uh, recommendations that are different for hip away versus me away, except for obviously the type of exercises that we would give, but exercise and weight loss is certainly the, uh, the big way to go there. Yeah. So we're still following the same concepts. Exactly. Very good. We're almost about to wrap up. Is there any other message or any other tips that we haven't covered today? Uh, that you want to address to this population? No, I think it's just, it really comes down into, you know, making sure that, that you don't get told how you should feel by somebody. When they take a, when they take an image and they, you know, they make comments about, oh, this is really bad and you're going to need a knee replacement in two years or five years or. you're gonna be coming back to see me for a knee replacement those comments aren't helpful and I think people just need to Do their best to determine for themselves how they feel rather than how an image Tells them how they should feel or how their doctor tells them how they should feel try to keep a positive attitude There is hope you can do simple interventions like weight loss and exercise to help mitigate the symptoms and Try to try to put the naysayers out of your mind Yeah. Unfortunately, the way it is like a lot of people, uh, the orthopedic surgeon's opinion trumps all others. And if they're told, yeah, I'm going to be seeing you in two years for a knee replacement and they've got that in the back of their mind moving forward. It's just so detrimental. And it can be a very dangerous slope for a lot of people. And unfortunately it's just the way it is. Like if a physio has to give them sound advice, they'd probably just, um, disregard it or, think, Oh, you've just, you just want me to come back seeing you, or you just want me to exercise. That's all you know. And not taking on board that advice because they have received that information from the surgeon. But I think you talking about these sorts of things and looking through the research and we actually have, um, studies that have shown, uh, and a lot of population sizes that have shown the outcomes if they were to take certain measures, uh, could be very encouraging for people. And Yeah. Anything else you want to add for that? Yeah, no, I just hope this podcast help people get through that, you know, cause they are inundated with that information. So hopefully your podcast will help. Yeah. Fingers crossed. Kevin, is there any social media platforms or websites and things you want people to, to go to, to learn more about this or learn more about you? I mean, if you're a healthcare provider, as you found out, I would certainly recommend taking the running clinic course. I think it's not. I'm obviously biased because I teach it, but I think it's, uh, it changed the way I practice. It changed the way you practice. Very, very good for that. If you're, if you're not a healthcare provider, um, yeah, I mean, there's definitely resources out there, uh, that, you know, certainly on Twitter, um, they can follow you, they can follow me. My, my Twitter handle is at running this form. I try to put things out there that aren't too technical. Um, and yeah, just search around for more positive viewpoints on things like that. Yeah. Great. I want to thank you for taking the time to come on, uh, sharing your knowledge and just like shining a light on a very misunderstood condition. And I get really excited when I talk about this because it's, it's quite on the contrary to what people do believe in conceptions that they do have. So teaching them the complete opposite. and can be very reassuring for a lot of people. So helping out provide providing that reassurance and diminishing like that helpless kind of mentality that some people can have with Neo A they do feel quite helpless. So I want to thank you for coming on sharing this wisdom and hopefully reassuring all of those people. Yeah. Thanks for the opportunity, Brady. It was, it was fun and keep up the good work on your podcast. It's great. Thanks for listening to another episode of the Running Smarter Podcast. I hope you can see the impact this content will have on your future running. If you want to continue expanding your knowledge, please subscribe to the podcast and keep listening. If you want to learn quicker, jump into the Facebook group titled Become a Smarter Runner. If you want tailored education and physio rehab, you can personally work with me at brea Thank you so much once again and remember, knowledge is power.