So for example, doing fairly low load mobility type exercises is not going to present a challenging enough stimulus to cause muscle strength adaptation in maybe that younger OA person who may be quite active.
SPEAKER_00:Today we discussed strengthening and the effects that might have on knee OA. We looked at previous research and why the results weren't so strong and then what the current research is telling us. We spoke to Claire Minshall. Now Claire is one of the most highly respected and research active rehab professionals in the UK. She treats a lot of knee OA in gym settings and around strengthening. She had some wonderful knowledge to share with us. Now make sure you stay to the end of the episode where Claire starts exploring what type of exercises to prescribe and exactly how she does that in a meaningful way with her patients. I hope you enjoyed this episode. My name is Michael Risk and this is Physio Explained. Welcome, Claire. Thank you for joining us.
SPEAKER_02:Thanks so much for having me on. It's really an honor.
SPEAKER_00:Thank you. And the first question we were going to cover was there was a previous assumption that strength training may not have been effective for NeoA. Where did that come from and did you find that in some of your research?
SPEAKER_02:Yeah, so a few years ago I did a systematic review which investigated the application really of the principles of resistance training in the management of knee osteoarthritis. And these principles of training are looking at specificity, overload, progression, something that we know a lot about in sports performance and sports medicine. And to be honest, I thought it'd be well translated into the osteoarthritis research. So we followed the normal procedure for conducting a systematic review. Over a thousand papers we looked at, which transcended to 34 being included into the systematic review. And then when we looked at the methodologies of these papers, which are all, you know, kind of gold standard, randomized control trials that look at, and each and every single one of those papers said they were applying a strength training protocol or program to investigate effects of that on management of knee osteoarthritis. These methodologies, I think only one paper came reasonably close to applying what we would typically understand as a strength training protocol. So to give you an idea, the strength training ranged from extending the knee against a rolled up towel for maybe 20 repetitions with no determination of real intensity or progression through to kind of one of the better designed ones, requiring quite a bit of equipment, but there was an isokinetic protocol. I think it was 10 repetitions and all manner of exercise in between. And then the way in which there's a whole array of determining what intensity was or not. So reps and sets were determined without, let's say, reaching failure. or calculating, let's say, a percentage of a rep max. Some did, some didn't. Some were set at an intensity of 10, sorry, 70% of a 10 rep max. And then, you know, rest wasn't considered in a lot of the papers or indeed written in the methodologies, which we know if we're doing, you know, kind of strength training in particular, we need a decent amount of intercept rest. And progression as well was not addressed by each and every one of these papers. So only one paper really came close to delivering what we would understand as a strength training protocol.
SPEAKER_00:And what was the result of that systematic review with such a wide range of strength protocols?
SPEAKER_02:Yeah, so there was no point doing a meta-analysis at that stage because, you know, if you think about the heterogeneity of protocols there, at that stage, At that time, which that was published in 2017, there was no wonder really that there was this question about whether or not resistance training, strength training had an effect on the management of symptoms of knee OA because I don't think we're even close to getting a homogenous approach to strength training or resistance training. And there's such an array of interventions that there's no way we can answer that question. So we're bound by the research that has gone before. So if we've got a study that's doing knee extensions against a rolled up towel with an arbitrary number of of repetitions with no real progression built in or measurement built in compared to something that's actually a little bit better where they're doing maybe resistance band exercises to something that's maybe a little bit better, which is using an isokinetic dynamometer. You know, how can we possibly conclude that it has an effect when we're bundling all this research together? So I think there's a real... So the conclusion basically is that the principles of resistance training weren't consistently applied across the board of these studies. So there wasn't attention paid to specificity. So what is strength really? Do we understand what that is? And then the overload required to elicit that strength adaptation. And then assuming that you get those two things right, your patients will progress, get better. So we need to building progression within an exercise program or resistance training program such that we can maintain that continued adaptation. So that wasn't consistently done across the board, very poorly done. And a lot actually didn't report adherence either. So we don't really know how much of a mixed bag of this exercise that was being done and how much that contributed or didn't to any of the results that we saw earlier.
SPEAKER_00:It's not inspiring pushing your leg against a towel. So I'm not surprised there's no adherence. We can make it a little more exciting, I feel. Was there any result to that? So even though it was such a wide array of protocol, do you think that was a reason behind the results not being favorable?
SPEAKER_02:So, I mean, we didn't do the meta-analysis on the effects because we felt that it was pointless in that respect because we wouldn't make a sensible conclusion. So the methodologies were so heterogeneous, then... it wouldn't make sense. Now, there were systematic reviews kind of out at the time, meta-analyses, and I'm pleased to say that more recent research is much better in attending to these principles of training and thinking about what is strength or what is the focus of that exercise intervention and then build the program around that focus such that we meet our objectives. So in terms of the... there was no reason really to amalgamate those data. And the papers that might have done that, if we reach a conclusion where we can't say it does or it doesn't, then we can see if we look back at the research that shows that heterogeneity in methodological approaches, then it would make sense that we wouldn't have a conclusion because some of them are not doing strength training interventions at all, whereas others might be.
SPEAKER_00:So take me to what's come out recently. There's probably two questions in this. I'll let you pick where we start. But has there been a better review with different outcomes or have we at least reached an agreeable dosage of strengthening for NeoA? I
SPEAKER_02:think we're still answering those questions and I think maybe still asking those questions. So there's obviously some great programs out there. And some of the challenges as well are to deliver these at scale as well, aren't they? So we know osteoarthritis is hugely prevalent in most populations, extremely costly. And we want to maintain people's activity levels, if not increase them. And, you know, these people are generally older. And I know that's coming for me, I think, in not too many years' time. So I'll use older loosely. But the relationship potentially between muscle weakness and other factors like dependency and even all-cause mortality, there's a need really to keep people active. And actually, I think there's a strong rationale to preferentially strength train these populations. So in terms of the... the programs that we've got and the things that are out there, there's some really great research. And even thinking about, I think I'll come back to that question of what is it that we're trying to do. If we think that muscle strength is important, then we need to design our protocols to elicit that. If we think, you know, some exercise of some description with Education is likely to have a good effect. So here in the UK and expanded to Europe, we have something called escape pain, which addresses that quite nicely with education plus exercise. However, I think when we're thinking about that, that broader population of people with knee osteoarthritis or starting on that trajectory, I think we would need to pay attention more to the exercise interventions. So for example, doing fairly low load, mobility type exercises is not going to present a challenging enough stimulus to cause muscle strength adaptation in maybe that younger OA person who may be quite active. versus somebody who's fairly inactive, sedentary, and they're really at that kind of end stage of the disease. So I think we really need to think about the aim, as I said, of the exercise intervention and how we start to properly train those different aspects of muscle function.
SPEAKER_00:You were mentioning high load when we were emailing each other. You were mentioning a heavy load. So I'm assuming we're speaking to that point of, we do want to increase muscle strength. And then there's this thought train that, well, do we actually need muscle strength to decrease pain? Where do you sit on that? Do you think we should be going heavier? Is there any research for that? Or are these lower load plus education getting the results you would expect?
SPEAKER_02:That's a great question. And I don't think we've really got the answer. I know there's certainly a big camp for people that Advocate for some exercise, low load. We don't need high intensity. Educate people on pain and that can have a great effect. And I don't necessarily disagree with that. But what I do think we should do is not be dismissive of the benefits of high intensity training. high load training for particularly that older population. Now, when we think about older populations, there's a lot of fear around loading older populations because maybe you view them as fragile, they're older, they're less capable, you don't want to cause pain. But in terms of seeing research that shows, I'm yet to see a paper that has progressively loaded an older age group and had a lot more adverse events than in a younger population. Because we're not comparing absolute weight. So what I can lift is not going to be the same as what a 70-year-old can lift. It's relative to them. And I think a fantastic example of that is Belinda Beck's work in the Lift More trial, where it's not neo-weight. It's actually osteoporotic populations. They program high intensity. So we're talking over 80% of one rep max here. So 80 to 85% one rep max. Things like deadlifting and squatting and overhead pressing. And I think that's a fantastic example of being able to do that in a population you might... viewers even less able to do these exercises compared to Neoway. They're osteoporotic. The results speak for themselves. The abilities of these individuals is great to see. So if you can manage to see the snippets on YouTube, do look at them. They're fabulous. It will challenge your hesitancy straight away. But the consequences of falls have been less. Fewer falls have positive effects on strength and for mineral density. So would we get that same level of adaptation if we were doing really submaximal loading and much lesser intensity? And I think we shouldn't naturally assume older people can't do things. And I think we should automatically consider those protocol or those heavier loads and resistance training on a par with any assumption or any consideration of exercise program because of the need to combat sarcopenia, the effects of muscle weakness that we see or relationships with or cause mortality even as well as dependency and particularly in the management of these conditions.
SPEAKER_00:There's something about the expectancy violation and the empowerment of going a little bit heavier and doing some of those compound movements you mentioned. And I think if you can do that without adverse effects, which the research is not showing any, then it's a good place to go because it's such an empowering narrative for a patient of that age to lift and do a compound movement. So I'm biased that way. I was going to ask you, Where do you start? Like quite clinical question. Let's say you have a 60 to 70 year old Neo A in front of you. And if your bias is to head in that direction, there's no reason we can't start with low load, I'm assuming, or a really meaningful exercise for them. But how do you then progress that?
SPEAKER_02:Yeah, it's great. And I agree with you as well. So when we're not in lockdown, which we are here in the UK, I run a 12-week program for NeoAid individuals, and most of them are clearly over 60. And a lot of them haven't been to a gym before. And I run this out of a gym. And it's a pretty intimidating environment to be in. So, honestly, I don't care what they do in the first session. I just want them to come back for the second. So... It's all about making them feel confident and comfortable in that environment and understanding what they want to get out of this process. So what are their goals? Where are they headed? Is it that they, you know, a good example, a couple of patients, one wanted to be able to do or continue to do their cross-country walks, which they were limited in doing. They wanted to be able to play with their grandchildren. And once you understand that and you're able to frame the exercise within their goals, understand their barriers, their perceived barriers and how they themselves might be able to work around that. I had one patient who used to travel an hour and a half on a bus with his wife to come see us in the gym because he got so much benefit from it. And his wife did her own thing in the gym as well, which was great. You start with something that they feel comfortable with. And literally that program, we're all centered around kind of knee extension, hamstring curls, and leg press. Each and every person is going to be limited in what they physically think they can do and physically their symptoms. And we modify the exercise to maintain the specificity, not to reduce the load when they're fully in the program. But as I said, I don't care what they do the first session. I want them to come back for a second. And then likewise, second, maybe we kind of ramp it up a little bit. And maybe, you know, I think I've been kind of tagged with poo-pooing the three sets of 10. But if that's something that it's easy for them to remember and it means that they're going to come back, I don't mind that at all. But we will get specific quite quickly. And usually within a couple of weeks, we're getting these people doing five rep maxes on knee extensions, on hamstring curls, and maybe even leg press as well. Now, that might not be full range, and it might be one leg is less than another, which is fine, but we're kind of getting up into those ranges, and we see tremendous strength gains, reductions on pain, reductions in analgesia, and people kind of getting back to what they wanted to be able to do. And the point you were making right at the beginning about these compound movements, most of these people will do a deadlift, at the end of that program. Now, I'm not saying it's a five rep max deadlift, but when they walk into the gym and they see somebody perhaps doing that, that is so far off their radar. They're never in their wildest dreams, could even imagine doing that, nor would they ever want to do that. And when they do do it, oh my goodness, you know, they feel like you're saying, they feel so empowered. And, you know, I mean, I get warm and fuzzy inside, but they, you know, they take a lot from that.
SPEAKER_00:They do. It's really exciting. I think you see a transformation in their being. A smile usually comes across their face. It's really rewarding. That was a really practical pearl there, Claire, that I really loved the framing of the exercise towards their goals. So I think we're going to leave it there. And thank you so much for your time.
SPEAKER_02:Oh, it's absolutely my pleasure. Thanks so much for having me on. Thank you.