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[Physio Explained] Managing multimorbidity: evidence-based physiotherapy with Professor Soren Skou

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In this episode with Soren Skou, we discuss multimorbidity and the impact this can have on us as Physiotherapists. We discuss:

  • The implications of multimorbidity on Physiotherapy treatments
  • Evidence for different exercise therapy interventions in this population
  • Quality of life in this population and how Physiotherapists can impact this
  • Strategies to encourage behaviour change in this population

👉🏻 Learn more about Physio Network’s Research Reviews here - https://physio.network/podcast-skou

Søren T. Skou is professor of exercise and human health at the University of Southern Denmark and head of the multiprofessional research and implementation unit PROgrez in Region Zealand Denmark. He has vast research experience within the field of exercise as treatment of chronic conditions and multimorbidity. His main interest is to advance clinical care of people with chronic conditions through evidence-based treatments developed, evaluated and implemented in a close, interprofessional collaboration between patients, clinicians and other stakeholders.

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SPEAKER_01:

The challenge with this is that both in research but also in clinical practice, we are highly specialized. We're really good at treating individual index conditions, but we're not that good at treating people with multiple conditions. And the challenge for the individual is obviously that they have to seek different healthcare providers for different healthcare problems. It's kind of a part-time job for them. And for the healthcare sector, it's not a good thing either. It's both costly. And at the same time, for the healthcare practitioner, it can become a bit challenging to try to balance all the information that the patient has from other healthcare providers. So it's really a challenge for now and for the future, one of the biggest in the healthcare system.

SPEAKER_00:

On today's episode of Physio Explained, I'm joined by Professor Solens Go, a world-leading researcher in osteoarthritis, chronic disease management, and the founder of the internationally recognised GLAD program. In this conversation, we explore the important topic of multimorbidity. We look at what it is, why it matters, and how we as physiotherapists can best support this large and often complex patient group. We discuss the latest evidence and recommendations for managing multimorbidity, the role of physical activity and exercise, and practical strategies for applying this knowledge in clinical practice. This is a hugely relevant episode for anyone working in healthcare, and I encourage you to listen right the way through. I'm James Armstrong, and this is Physio Explained. Saran, welcome to the Physio Explained podcast. It's great to have you on, and we're really looking forward to this topic, something a little bit different and but also really, really important. So thank you for your time today. Yeah, and thank you very much for inviting me.

SPEAKER_01:

I'm looking forward to it.

SPEAKER_00:

We're going to talk about multimorbidity. And the best way of starting this is with a bit of a definition. So introduce this to us. So multimorbidity, what is it?

SPEAKER_01:

So multimorbidity is basically two conditions or more in the same individual. It has been identified or defined in many ways in the literature, but the most common ways, and also the way WHO defined it, is two or more conditions in the same individual.

SPEAKER_00:

This is a something we're going to see in a lot of patients that we see. So why is this important from your background and the things that you look at from a point of research and also clinically? Why should we be interested in multimorbidity?

SPEAKER_01:

Well, a few years back when I started focusing on multimorbidity, my interest was sparked by the fact that many individuals with one chronic condition, for example, osteotitis, also have other conditions. In fact, we know that it's more common among people with chronic conditions to have two or more than only to have one chronic condition. And the challenge with this is that both in research but also in clinical practice, we're highly specialized. We're really good at treating individual index conditions, but we're not that good at treating people with multiple conditions. And the challenge for the individual is obviously that they have to seek different healthcare providers for different healthcare problems. It's kind of a part-time job for them. And for the healthcare sector, it's not a good thing either. It's both costly. And at the same time, for the healthcare practitioner, it can become a bit challenging to try to balance all the information that the patient has from other healthcare providers. So it's really a challenge for now and for the future, one of the biggest in the healthcare system.

SPEAKER_00:

And the importance of it. What's the effect of it? So from a point of view of a physiotherapist treating a patient, what's that importance, the effect of seeing someone with a multimorbidity? Yeah.

SPEAKER_01:

You know, we could uh spend 15 minutes only talking about the problem. There are so many very important facts about multimorbidity to consider as a physio. First of all, as I said, it's very common. It's about one-third of the world population who has it. And also, among people who have two more conditions, it's more common to have poor function, poorer quality of life, depression, polypharmacy, which means that you take five or more different medications at the same time, hospitalization, and early death as compared to having one or compared to having non-chronic conditions. For some, this might be something that are a population they see every day in clinical practice without even considering it. And I think that is where the major and important point about multimorbidity comes in for fishers. What we see from qualitative research from around the world, and also something we have done, is that patients with multimorbidity have a higher treatment and disease burden than people with one chronic condition. And that means that if you as a fisher provide or recommend exercise, for example, for a person with low back pain who has at the same time depression or a heart condition, the treatment burden might overload them so much that they're not able to attend to the exercise therapy that we propose to them. So although it might be the best for them to go through a, let's say, 12-week program, two exercise sessions a week, you might be able or at least have to adapt the program to them to ensure that the treatment burden isn't too high and at the same time obviously consider how to progress with the exercise and adapt the other treatments they receive.

SPEAKER_00:

And do you think some of the reason they may maybe spend more time with us is because we're not taking that into account very well?

SPEAKER_01:

I think in general, fishos are really good at considering other conditions. We are trained to do rehab for people with chronic conditions and actually have usually more time with the patient than some healthcare providers do, for example, doctors. So I think we're good at it, but I think we can be better. And I think the healthcare system in general should be better to adapt to people with multimobility. But the challenge is when do we need to adapt? I guess all of the listeners would know that if you have, let's say, asthma and eczema as compared to having depression and a serious heart condition, is not the same. But both are multimobility. And that's where the challenge comes in, because you, as a fissure or any other healthcare provider, need to start the conversation with the patient and try to figure out is this a patient, a person who needs a multimorbidity approach, or should we continue with the single disease framework that we use where you're focusing on one condition? And then finally, I think this is important as well. If we decide to go with the multimorbidity approach, then we'd need to inform the doctor or other healthcare providers that the patient has that we are taking a somewhat different approach to their overall health conditions.

SPEAKER_00:

Okay. Yeah, absolutely, absolutely. So making that sort of conscious decision early on and what's the most appropriate for that patient. So the evidence around this and recommendations, what does it tell us about how we manage multimorbidity?

SPEAKER_01:

Yeah. We have, as researchers, been really good as with the healthcare system to have a silo-based approach, which means that many researchers have actually excluded patients who have more than one chronic condition from the research. As I said earlier on, that is challenging, as most people with chronic conditions will actually have two or more conditions. So we're excluding the majority of people with chronic conditions from our research. That unfortunately also means that the evidence we have isn't that convincing. We do not have that many trials in this space, and those that we have are not really showing any major benefit for quality of life, which is the most important outcome for people with multimobility according to core outcomes. So a few years ago, yeah, six years ago now, we took the most recent Cochrane systematic review and used that as a framework for what we wanted to do as physics. And it had a really brief sentence that we took as the suggestion to focus on exercise therapy. As it said, our findings suggest that future research should consider targeted patient health behaviors such as exercise, not based on evidence, but based on kind of indications from available evidence at that time. And that was also aligning with a James Lindeline's priority setting that was developed in 2019, which said that among the 10 top priorities among patients, healthcare providers, and decision makers was identifying the most effective and cost-effective and acceptable exercise therapy interventions for people with multimorbidity.

SPEAKER_00:

Are you struggling to keep up to date with new research? Let our research reviews do the hard work for you. Our team of experts summarize the latest and most clinically relevant research for instant application in your clinic. So you can save time and effort keeping up to date. Click the link in the show notes to try Physio Network's research reviews for free today. And the question about is there any particular exercise that's better or good, or what are the recommendations around that?

SPEAKER_01:

So one of my colleagues who was hired in our EU-funded project called Mobilize Alestrobica did a systematic review some years ago now, where he, together with us as the team, tried to identify is there any type of exercise that is better than others for people multimobility, or are there combinations of conditions that might identify as better targets for exercise therapy? And what we found out in that systematic review was that yes, exercise therapy seems to be effective on a range of outcomes like functional outcomes and psychosocial outcomes. And it also indicated that serious adverse events were more common among those who did not undergo exercise therapy as compared to those who underwent exercise therapy. But it wasn't possible to identify one type of exercise that was better than any other. And what, at least for us, that led to was to develop a program that was directed both towards what we know is effective and also focusing on patient preferences. Because as with any type of chronic condition in multimorbidity, if you want the effect, you need people to do it. So preference was also guiding us through the development of a program.

SPEAKER_00:

And also that long-term behavior change as well, isn't it? Yeah, for sure. For sure. Do we see a correlation between those with multimorbidity and achieving, say, for instance, the WHO minimum physical activity guidelines?

SPEAKER_01:

I think that's very important. We actually see, and this is based on obviously on more cross-sectional data, but what we see there is that more people with multimorbidity are inactive, and the more conditions you have, the less physically active you are. And this is particularly important among people who have a combined mental and somatic healthcare condition. So, some people with depression, for example, on top of a heart condition or low back pain. And at the same time, other factors that were important among people with multimorbidity for a lower physical activity level is BMI, is mental health, and also if you live alone and whether or not you're working or not.

SPEAKER_00:

This is something we may not know, actually. It just came into my head. Do we then see those with multimorbidities who do exercise more achieve a better quality of life than those who have multimorbidities who don't exercise very much and have a low physical activity? Is there a correlation there?

SPEAKER_01:

First of all, it's important to say that the review we did was followed by other reviews from other international researchers. And it also sparked several randomized control trials trying to investigate the effects of exercise therapy and self-management support. As you say, self-management and long-term behavior is very important. And we recently published our trial in Nature Medicine, which showed that among people with multimorbidity, it was possible to improve health-related quality of life through an exercise therapy and self-management program. And I think future trials that are coming out in the future years would show the same. I don't think at this stage we're able to say whether the difference or the effects are larger in those with lower physical activity level, but obviously it seems reasonable that the effects from exercise would be larger among those who are less active to begin with.

SPEAKER_00:

Is there a focus to say but the research needs to look at maybe that subgroup analysis around this is going to be huge, but what combinations of multimorbidities do better with certain things? And it's a never-ending question, really, isn't it? Because there's such a vast variety.

SPEAKER_01:

I think it's important what you're asking there. And I think for the future, not only for multimorbidity, but for people with chronic conditions in general, it's about identifying subgroups or preference-based programs that makes people continue to be active, also after a supervised program, either digitally or in person, or booster sessions, or just providing support to continue exercising in the community. So I think there are really many important areas to pursue here. And we'll doing we'll be doing that and others as well. And I, you know, if you invite me again in 10 years, I hope we'll be even better at identifying who, you know, which conditions and how, which type of exercise should we provide for the individual patient.

SPEAKER_00:

Definitely. And I suppose, as you said earlier, it's that scarcity of research, hopefully, with that focus and ability to then include what you said there is a majority of our patients with these multi-morbidities to allow us to be able to see more data and be able to pick this apart a bit. And in terms of physical activity, the effects, obviously, we've said there with effects with people with multimorbidities. Is there anything more to add on that in terms of for physios listening to this, the advice that you would give them when thinking about exercise and prescription for these this population?

SPEAKER_01:

You know, the first step would be to identify what are the resources, what are the treatment burden and even disease burden, which is about how much does the individual and combined condition affect your daily life. Identifying what is it actually that the patient wants and also what is possible, and then set common goals together with the patient. And again, I think this is what fishers do. But what should be different when they go to practice tomorrow after listening to this program would be to consider multimorbidity more than they would typically do now, and perhaps set some goals together with the patients that seems less optimistic or less uh you know progressive, but might be better for the individual patient in terms of their treatment and disease burden. And just giving one example, instead of asking a patient to do exercise supervised twice a week for 12 weeks, if this is not something that is realistic for the individual patient to do, then it would be better just to help them improve physical activity in daily life, giving them simple advice and talking to them about what is it that motivates you and how can we ensure that you change your behavior over time. And then the end goal might be to exercise twice a week for 12 weeks, but don't start there if the patient hasn't got the capabilities or resources to do that due to their multimorbidity. Because as I said, it's kind of a part-time job for some. And adding two times more a week for 12 weeks is not much, but if you add it to a part-time job as a patient, then it's a lot.

SPEAKER_00:

And that's a really good point, isn't it? And we do do this a lot, especially with our when we're looking at focal single things, it's we're good at recognizing how to progressively build people up and set realistic motivational goals. And it's just as you said all along, being aware of that multimorbidity and that being a part-time job as a patient.

SPEAKER_01:

And in particular, in people who have combined somatic and mental conditions, it seems that the mental part is very important. And also a second thing that that we have identified is that the more pain sites you have as a patient with multimorbidity, the worse your well-being is. So depression and anxiety and other mental health care conditions and the number of pain sites were something I would at least, you know, assess as part of the initial conversation with the patient.

SPEAKER_00:

Brilliant. Or giving you as much information as you can to deliver a patient-centered, motivating, long-lasting intervention at the end of the day. Yeah. Doran, this has gone so quickly. I can't believe I'm just looking at my watch now. We've already come to the end of our conversation. And as you said right at the beginning, we could talk about this for a lot longer than 15 minutes. And in that case, I think we definitely need to get you back on. Perhaps a little quicker than 10 years, though, I think.

SPEAKER_01:

Yeah, yeah, yeah. At least uh hopefully, I'd say that we'd be able to say more just in uh four or five years, but we could talk about this subject again from another perspective. So feel free to invite me.

SPEAKER_00:

I think that would be wonderful. I think that's something that we're definitely going to look to do, and I'm sure the listeners will be keen to hear more from you about this subject. So, Sirin, thank you so much for your time and uh have a good rest of your evening. Thank you very much.