[Physio Discussed] Alternative perspectives on osteoarthritis management with Prof. Ian Harris and Prof. Jeffrey Katz

In this episode, we have a discussion with Professor Jeffrey Katz (Rheumatologist) and Professor Ian Harris (Orthopaedic Surgeon) for an alternative viewpoint of Osteoarthritis. We explore:

• Pathophysiology and Drivers of change in Osteoarthritis
• The role of surgery in Osteoarthritis
• The relationship to scans/imaging, Osteoarthritis and pain
• The importance of weight bearing x-rays (Rosenberg view)
• Role of weight management and lifestyle changes in this population
• Timeframe for referring from Physiotherapy to orthopaedic surgeons
• Managing patient expectations
• Multidisciplinary treatment of patients with OA

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Dr Katz is Professor of Medicine and Orthopedic Surgery at Harvard Medical School and Vice Chair for Orthopedic Research at Mass General Brigham in Boston.  He is a practicing rheumatologist and clinical investigator with a focus on prevention and management of osteoarthritis and the role of surgical and nonoperative strategies in musculoskeletal disorders.

Dr Ian Harris is Professor of Orthopaedic Surgery at UNSW and Honorary Professor at the School of Public Health at the University of Sydney. A practicing orthopaedic surgeon with an interest in the evidence for surgical procedures and discriminating between perception and reality in surgical effectiveness.

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Our host is @sarah.yule from Physio Network

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Transcript

SPEAKER_01 0:04

What do we still get wrong about osteoarthritis? Particularly the relationship between pain imaging and structural change? When is conservative care enough? And how do we know when it's time to escalate management or consider surgery? And how can physiotherapists better navigate the grey areas between rehab, medical management, and surgical decision making? On today's episode of Physio Discussed, I'm joined by two internationally respected experts in osteoarthritis care. Dr. Jeffrey Katz is a rheumatologist, epidemiologist, and professor of medicine and orthopedic surgery at Harvard Medical School and Brigham and Women's Hospital. His work has focused extensively on osteoarthritis outcomes, patient-reported outcomes, and the effectiveness of interventions across the osteoarthritis journey. Professor Ian Harris is an orthopedic surgeon, researcher, and professor of orthopedic surgery at the University of New South Wales. He's internationally recognised for his work in evidence-based surgery, clinical decision-making, and evaluating the appropriateness and effectiveness of orthopaedic interventions. In this conversation, we explore osteoarthritis across the spectrum of care, unpacking what the evidence says about exercise, education, weight management, patient expectations, and long-term outcomes. We also dive into the challenges of shared decision making and discuss where physiotherapy can have the greatest impact throughout the osteoarthritis journey. If you're a physio wanting a broader understanding of how OA is viewed across disciplines and how we can better guide patients through the complexities of conservative care and surgical pathways, you're going to love today's episode. I'm Sarah Yule, and this is Physio Disgust. Well, Jeffrey and Ian, thank you both so much for joining me today. I think this is going to be a really valuable conversation for physios because osteoarthritis is one of those conditions that almost every clinician sees. So it will be great to explore the management of it from both of your perspectives. So I'd love to start broadly just on understanding osteoarthritis. You both work at the interface of research and clinical decision making. How do you currently conceptualize osteoarthritis in terms of pathophysiology, drivers of pain, and structural change? And what do you think clinicians still commonly misunderstand about it?

SPEAKER_02 2:26

So I think the general understanding of osteoarthritis is that it's a situation occurs that occurs when cartilage and other tissues in the joint fail. And they fail because of trauma, injury, or because of genetic program. You know, they they stop making the constituents they're supposed to make to keep cartilage healthy because of it, you know, there's a genetic program that everybody inherits that because of malalignment, because of obesity, or you know, combinations of those. But all of those lead to a mismatch between the sort of ability of cartilage to withstand load and the amount of load. And when load overwhelms the capacity, then the cartilage fails and the load or weight is transferred to the meniscus, which then fails and to bone, and bone hurts. And that process generates fragments, sort of, you know, as tissue is destroyed in the process, it incites inflammation, and the inflammatory process hurts. So bone and inflammation are sources of pain. There are variations on that, but that that's generally how this process is understood. I'll list a couple of myths. Ian probably has many others, but one is that many clinicians, and of course many people, patients, feel that in order to avoid joint destruction, you should rest. That there's no good evidence of that. In fact, there's very good evidence that exercise improves joint health and osteoarthritis. There's a myth that it's untreatable, that this is a wear and tear disease. You can't do anything about. There's a myth that surgery is very dangerous. It's actually joint replacement surgery, it is one of our safer operations, sort of an amazing operation. There's a myth that implants wear out, you know, in five to ten years. And they generally last, you know, over 20. So I'll I'll stop there, but there's a lot of misconceptions.

SPEAKER_03 4:36

But I know there are a lot of myths out there, and I I just echo what Jeff said about exercise and using the joint. And and I do know that a lot of the research says that Actually, people think that sport, things like that, oh, you you you're going to wear out your your joints. What does lead to osteoarthritis, particularly in my field in orthopedics, is injury. You know, so if you if you damage your knee by you know tearing ligaments, tearing a meniscus, you know, or if in my field, you know, we see fractures that involve joints sometimes in the ankle or the acetobulum, damage to a joint can accelerate this process and can lead to osteoarthritis. So that's commonly what we see. But using it doesn't do that. It's having you know a specific injury to it that does.

SPEAKER_01 5:26

Just building onto that, what's the mechanism behind that that damage driving the progression of osteoarthritis? Is it the the altered load bearing or as an orthopedic surgeon?

SPEAKER_03 5:38

I see it as a change in mechanics. You know, so when we see a you know a fracture with a step in it, it's very easy to see how the the load is concentrated on one point and that it goes beyond the cartilage's ability to withstand it and then it breaks down. And also if you have instability in a joint, if a joint is unstable, then it's not congruent the way it normally is. And so that alters the loads across it as well. So I I see it as a very mechanical thing, but that's a very orthopaedic view of things. And I'm sure there's other processes involved.

SPEAKER_01 6:12

Yeah, interesting. And Jeff, I just wanted to build on something you said earlier around obviously bone being a driver of pain. Why do we sometimes see the severe symptoms with relatively mild radiographic change? And sometimes you see the patient that has severe radiographic change with minimal pain.

SPEAKER_02 6:34

Yeah, it's a good question, something of a conundrum. But you know, a couple of things are worth noting. One is that is that x-rays, plain x-rays, can underestimate the amount of joint damage because they're capturing a three-dimensional situation with a two-dimensional picture. So, so so x-rays can show that there's joint space when, in fact, if one looked arthroscopically or at surgery, you'd you'd see it that and I think Ian could comment on this, but I think that happens fairly frequently where, you know, in the operating room, you know, joints look much worse. So that's so that's one possibility. Another, which I think is really important, is that if we take the knee, for example, there's a lot of knee pain, even in you know, middle-aged and older people who are at highest risk for OA, there's a lot of knee pain that's not due to osteoarthritis. And so, you know, people's x-rays can look perfectly normal if they have a bursitis around the knee or if they have a strained ligament or something like that. And then finally, you know, individuals really vary in the extent to which they perceive and report pain for a given sort of stimulus, you know, and there's a lot of experimental evidence about this because pain is complicated. And, you know, there are pathways that amplify the amount of pain that we actually perceive and report, and pathways that dampen. And those pathways are affected by the pain itself, but also by emotional and other input. So pain is very complicated and x-rays are imperfect. So it's no wonder that they don't correlate all that well or all that, you know, all that tightly.

SPEAKER_03 8:16

It's a common problem that because osteoarthritis is so common, we tend to just quickly jump to it as the as the diagnosis. I've seen so many cases where we've been fooled. You know, if somebody has a little bit of arthritis in the knee or or the hip and they've got pain, then surgeons often will just say, Well, studio arthritis will replace it. And then later the patient doesn't get better because they had a a back problem with the ridiculopathy, or they had another pathological process around the joint that wasn't detected. And the same thing happens too, where we think, oh gee, it's not, it doesn't look like very bad osteoarthritis. But as Jeff said, if you just get like the right x-ray or the right imaging, or a classic is in the knee not getting weight-bearing x-rays, because a knee cannot look too bad with a good joint space until you get an x-ray weight-bearing, or what's called a Rosenberg view, which which looks at a different part of the knee on weight-bearing. And then you can see that you know there could be almost no joint space all of a sudden. So there's a little bit of work involved in finding out exactly what's causing people's pain. And we shouldn't be too quick just to say osteoarthritis every time just because it's so common, because a lot of people have a bit of osteoarthritis, but they have other things going on as well.

SPEAKER_01 9:38

Obviously, highlighting the relevance of that patient workup and the differential diagnosis and the multidisciplinary treatment. So I suppose on that, how do you approach the patient clinically? And how should physios help guide those conversations without over-medicalizing, under-medicalizing, invalidating symptoms? What do you think is physios are best, a pathway the physios are best to follow?

SPEAKER_03 10:04

I don't know whether physios are any different to rheumatologists or or orthopedic surgeons, and they they still have to treat the patient the same way. They still have to find out actually what's wrong with them and don't jump to conclusions. And treating patients who have more uh you know, psychosocial reasons for pain as well. There could be other things going on in their life. It could be part of a messy compensation claim. These sorts of things can really obscure exactly what's causing the pain. But I don't know that physios have a different role to anybody else. It's up to all of us to you know treat the patient appropriately. We all owe them that responsibility, I think.

SPEAKER_02 10:48

I agree with that. And I think osteoarthritis, I kind of enjoy it because it's not a high-tech field. Blood tests are of little, if any, value. The MRI tends to lead you down the wrong path if you don't order it for the right reasons. X-rays are quite useful, but as we said, they can be insensitive. And it's really, you know, eyes and ears and fingers and and and just trying to understand what's going on in the patient's life. It's it's really like kind of good old-fashioned medicine. And I think that, you know, therapists and all the different stripes of physicians and physician assistants and nurse practitioners are all, you know, qualified to listen carefully and examine carefully. I like that. It's a very democratizing condition. You don't need to go to a fancy place with a lot of really crazy expensive antibody tests to figure out what's going on.

SPEAKER_00 11:43

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.

SPEAKER_01 12:05

In wildly surprising news, we're treating the person, not just the osteoarthritic joint. Absolutely. So, in terms of a patient with, say, earlier to moderate osteoarthritis, what does the highest quality evidence tell us about exercise and education and weight management? And where do you think the real-world translation of that evidence tends to break down?

SPEAKER_02 12:31

Well, you know, several society, you know, professional societies, the American College of Rheumatology, the Osteoarthritis Research Society, the Australian College of Physicians have NICE in England, you know, around the world have, and you Lars, which is a European society. So there's a convergence of evidence that some very simple things are really the bedrock, which is managing weight, being educated about some of the things that we're talking about, that, you know, activity is good, not bad, and managing weight, using simple, safe medications and exercising are really important. But with respect to, you know, weight management and exercise, they're sort of easy to say, hard to do. It's really the problems are behavioral. And so I think where the gap often occurs between what we know and yet what's really done is from a failure to appreciate that this is hard work for patients who have different barriers that have to do with just aspects of their personality and the and the rest of their lives. And but I think there's a growing appreciation of this. And I think, frankly, that physios are on the sort of front end. There's some really interesting research, some of which has been done in in in Melbourne and Sarah, that with you know Kim Benell's group where where physios have sort of partnered with behavioral scientists to provide physios with some basic tools for delivering some of the behavioral interventions that can really complement, you know, exercise prescription. I think that there's a growing understanding of that, you know, that we've focused on, you know, the medical and mechanical, but not necessarily the behavioral aspects of treating people.

SPEAKER_01 14:16

Yeah, absolutely. Anything to add there in?

SPEAKER_03 14:20

Completely agree with that. It is changing because there's a a lazy mentality that's been around for a while that we've been trying to correct, where patients who present for possible joint replacement surgery with osteoarthritis, now they may, you know, not exercise very much. They're often you're quite unhealthy, that they often have obesity. And we now have a lot better evidence than we used to that, you know, lifestyle changes or or what Jeff referred to as behavioral changes can really have a significant impact on the symptoms from the osteoarthritis. In the past, we've kind of said, oh, gee, you know, I think you should maybe, you know, exercise more and lose weight. And the patient said, Yeah, I tried that, but I I can't. And we go, okay, well, we'll do a replacement. And that's that's the extent of the conversation. And certainly I've it changed in the way I bring that up because for the patient, this is not just a reliable way of improving the symptoms from the osteoarthritis, but it can improve their health in innumerable other ways. Just exercise and weight loss alone for these patients, because these patients that they're not often young patients, these are middle-aged or older patients. We're talking about staving off diabetes or or improving the diabetes that they may already have, improving their cardiac health, mental health. It's just got such huge benefits. So we spell that out a bit more now, and we're more likely to involve other practitioners to reinforce this message. So I think that has changed. But unfortunately, patients want a quick, quick fix. You know, we we have to understand that it's not easy. And I think Jeff said something about it's easier said than done. But that's true, we have to recognize that, but it's still super important. And I would much rather have a patient improve their symptoms from weight loss and exercise than to have surgery. Because after the surgery, they still won't exercise and they still won't have weight loss, so they'll still be unhealthy. Their knee may feel a little better, but their general condition won't have improved.

SPEAKER_01 16:32

Certainly, as a clinician, it's so powerful to be able to talk to all of that evidence. And I feel I have noticed over the last decade a changing rhetoric around exercise and weight loss being listed as an adjunct rather now it's a it's a necessary pathway and a very much an embedded part of treatment options given to a patient. So, do you think we as clinicians are waiting for too long now to refer? Or do you think we're pulling the trigger too early? What do you notice in clinical practice?

SPEAKER_03 17:08

I think patients still get referred fairly early. And I'm really talking about Australia, but it's an easy thing for GPs just to refer somebody with a sore knee and an x-ray that shows some degree of osteoarthritis to an orthopedic surgeon, and then they don't have to make the decision. And so the problem I have is what the surgeons do about it, is whether the surgeons pull the trigger and do surgery or not. I don't mind them being referred for an opinion. I think that's fine. It's it's the opinion that I have a problem with sometimes. And I think, yes, in it in Australia and possibly in the US, based merely on population rates alone, that those two countries are certainly more aggressive than the average country in doing knee replacement. And I see personally, anecdotally, you know, many patients who've had a knee replacement and don't get better. And when you look at what they had the knee replacement for, you really got to question why they had it in the first place. So I think that there's there's still a problem there. Yeah, I think uh yeah, I I guess to summarize, I don't have a problem with them being referred early. I have a problem with them still these days being operated on too quickly.

SPEAKER_01 18:30

That makes sense.

SPEAKER_02 18:31

Yeah, I think there's two parts to what Ian is saying. One is, was it the correct operation for the correct problem? And it goes back to what we were saying before that sometimes, you know, people have pain. They have archery arthritis, but their pain is in part from other areas. And so that that's a surgery that's tested to fail because it was not correct. And another is when is it right for the patient? And my sort of view is that that it's a preference-based decision and it'll it'll be different for every patient. What's the surgeon? I think the surgeon has a really important job in saying, you know, I think a joint replacement would help you if you wished to have it, right? And that that's actually requires a lot of judgment. But I think surgeons are great at that and really can discern who's going to benefit. But then whether the patient really wants to have it now, have it later, not have it, has a lot to do with how they feel about risk and and also, you know, whether it's interfering with their valued activities. And, you know, some patients don't really want to or need to, you know, be all that active. And, you know, something about OA is if you sit down, the pain tends to go away, you know, if away of the of the hip and of the knee. So I think it's perfectly appropriate for one patient who's walking, you know, two miles, but really wants to be able to, you know, take long walks with their dog and get back to playing certain sports to have their knee replaced. And another patient who's only walking two blocks, sort of saying, you know, I'm not ready yet, because they don't really have a desire to walk more.

SPEAKER_01 20:04

I mean, that makes sense. And it's it's sounding like you've got a great framework, which I, from the clinical end, patient, from the physioclinical end, patients do tend to respond well to of having their own decision-making framework, knowing that you've got your your multidisciplinary team around you guiding you through that process. Do you think there are any particular markers or patient characteristics that make you think that surgery is more or less likely to help?

SPEAKER_03 20:32

As a general rule, and again, this is an on-average comment, not a comment for every individual patient, but we've shown with some of our research that on average, the lower the severity of osteoarthritis on X-ray, the worse the results. So there may be some people who who don't have severe osteoarthritis who benefit for sure. And there may be people who have severe osteoarthritis who don't benefit. But on average, we've shown that it's actually a fairly strong predictor, particularly for knee replacement surgery, is that the lower the severity of osteoarthritis, the less happy the patients are with the results. And I guess when you think about it, it kind of makes sense because knee replacement is such a dramatic operation that it can take someone with terrible, you know, severe osteoarthritis and no cartilage left and restore them to good, smooth movement in the in the joint. But obviously, the difference between pre-op and post-op isn't going to be that great if they weren't that severe to start with. So it really kind of makes sense when you think about it, but we have been able to show that, you know, statistically with larger numbers.

SPEAKER_01 21:46

And can I just clarify, Ian, is that in terms of patient satisfaction or pain ratings or both?

SPEAKER_03 21:53

Everything. Patient satisfaction, pain, uh, and function.

SPEAKER_01 21:57

That makes sense. Anything to add there? Jeff?

SPEAKER_02 22:01

I think that observation is really robust. And hips are a little bit different, but in the knee, you don't quite get a normal knee at the end. There are some restrictions in terms of motion, some restrictions in terms of kneeling, for example, for some patients. And so if you start with a knee that functions extremely well and only gives you pain with very demanding activities, that person really needs to value getting back to those activities to make it seem worthwhile because they, with the new knee, they're going to have some new annoyances, you know, even if they get a pretty good pain result. Whereas the person who has really excruciating pain with a block of weight bearing, they're going to get better. They're going to get better even if they end up a little stiff, you know, their motion's not fully restored. You know, they they start so limited that that you can feel pretty confident they're going to improve. So yeah, I think that I think it's harder to to make a for the patient and the physician to make a good decision when they're functioning at a very high level. Doesn't mean it's the wrong decision, but it really means clarifying expectations carefully.

SPEAKER_03 23:06

Yeah. I I often use, say, like the Oxford knee score or something like that. And I I say to the patient, well, a good, a good knee replacement will give you an Oxford score of where 40 is perfect score, where your knee's fantastic. You know, a good knee replacement will give you a score of 35 or 36 out of 40. Now, if you come to me with an Oxford knee score of 10 or 12, which is terrible, and I give you a knee of 36, you're going to notice a huge difference. If you're coming to me with an Oxford score of 35 or 34, the best I can offer you with a knee replacement is maybe 35 or 36. You know, that you're not going to notice the difference. You're already at a point where you're equivalent to somebody with a good result after a knee replacement. And that's why, uh particularly for knees and not for hips, because they do not give you a normal knee. And it's another thing I often say to patients. I often say a knee replacement is not a normal knee. It will not feel like your other knee. It's a good knee, but it's not a normal knee. And they often they often don't get a full flexion after a knee replacement. That's pretty standard. And so they need to understand that this is not a we're not just making everything go away and restoring them to someone with a native knee. It doesn't work like that.

SPEAKER_01 24:28

I mean, my next question was going to be how do you navigate unrealistic patient expectations? But I think that outlines it in a really objective way that I'd imagine most people would be quite receptive to in in terms of how they organize the outcome of what a knee replacement might look like.

SPEAKER_02 24:44

Yeah, it's really helpful to have patients articulate, because they often can, you know, so what do you think life's going to be like, you know, after you get your new knee? You know, and they may be spot on, in which case, you know, that's very reassuring, but it may not be correct at all. I think sometimes patients underestimate how much better they'll they'll be. And that's one of the reasons I think why some patients delay. Oh, I've heard terrible things about it that doesn't take your pain away, that I'm still going to have this and that, you know. So expectation clarification is useful for both the hesitant patient and the kind of super eager patient, because they they both may be a little off base.

SPEAKER_01 25:24

Yeah, absolutely. Absolutely. I think those are all incredibly valuable points. Ian, I just wanted to touch on something you spoke of before, just around the less severe the radiographic OA, the worse the results with joint replacement. How do you make objective the radiographic results as objective as possible to a patient? Because I think there's an element of radiography that patients are probably putting into Chat GPT or they're putting in the report. And as we know, every clinician sometimes reads the report slightly differently and interprets different things from the images. And probably for that less to moderate, there's obviously a spectrum of subjectivity. But do you have objective measures that you're looking at?

SPEAKER_03 26:13

For sure. And but particularly for orthopedic surgeons, they love looking at x-rays and measuring things off them. I try not to get too caught up in it because as Jeff said, it's not always a you know perfect correlation. But when you do have, you know, clear, obvious signs that it fits with the patient, that then it normally works. But yeah, I normally explain the x-rays to them. I show them their x-rays, and you know, we look at all the changes of osteoarthritis, but you know, in particular, we look at narrowing of the joint space because when you have an x-ray of a of a pelvis and it's got both hips on it, it's very easy to show the patient what's happening on one side of the hip compared to the other side of the hip. And you can they can see very clearly, any patient can see how the the gap between the ball and the socket is narrowing, and you can show them osteophytes and you know, or they may have other avascular necrosis or other changes that that lead to osteoarthritis, and you can point all these out to them. And you know, I I I think it's always helpful for patients to understand the condition that they have. That's what we normally do. Your question is do we look at any particular feature? Well, I think joint space narrowing is a is a big one, but we look at all the features of osteoarthritis, sclerosis and cysts, and we also look at deformity in the knee in particular. Patients can have quite severe deformity associated with osteoarthritis, which can just on a mechanical basis alone make it quite difficult for them to walk. And we can show them the malalignment and what it's due to and things like that.

SPEAKER_01 27:45

That makes sense. Anything to add there, Jeff?

SPEAKER_02 27:47

Yeah, I think one of the things that this conversation made me think about is this observation in spinal stenosis, which is a totally different condition, but but it's it's there there's research that has was done, you know, quite a number of years ago that showed that the outcome in terms of pain and function of spinal stenosis tends to be better when the stenosis, the amount of narrowing of the spinal canal is worse. And you know, you might you might not suspect that because you'd think, wow, the tighter the stenosis, the more likely there is to be nerve damage that might be more permanent. And but it turns out the tighter the stenosis, the better the outcome. And I I've always imagined that it was probably because, and this is sort of a more difficult problem in back pain than in hips or knees, but there are similarities that the question is, what else is going on beside the problem that you're operating on? And when somebody has really mild stenosis, but a lot of pain in their back and in their butt and it or in their leg, but the imaging is not that impressive. You you kind of have to worry that it's not due or due entirely to stenosis. And you know, when it's really severe stenosis, it's more likely that that's the culprit. And I I think that's partly what what we see too. One of the things that I do, I'd be interested, Ian, if you do this as well, is in the hip when patients are really, really limited in terms of their pain and their physical exam supports hip arthritis, but the x-ray just isn't that severe. And the hip is an area where the the plane radiograph really can underestimate, you know, just because it's this this spherical three-dimensional structure reduced to two dimensions, is that we'll arrange to have anesthetic injection in the hip, which is kind of like a hip replacement for an afternoon, you know, to really put the hip to sleep. And just to try to really clarify that. And it's actually useful for patients, also, I find. I usually try to arrange it so they can, on the day when I'm seeing patients, so they can come back and see me when they've had their anesthetic and kind of talk about it. It's a traumatic intervention. But when it doesn't help at all, then I think everybody's learned something, you know, that ooh, maybe we don't want to replace that hip. And I I do that in the knee as well.

SPEAKER_03 30:01

Yeah, I think injections can be used. We often use them for various conditions diagnostically. You know, injections are often overused a little bit therapeutically, particularly in the spine, where you know the evidence for them isn't as great as we it's certainly not reflected by the number of injections that we do in society, which is huge. But diagnostically can be helpful. And I agree that the hip can fool you. We've all seen many patients who have a hip x-ray that doesn't look that bad, but on clinical examination they clearly have pathology that's isolated to the hip. You know, this is not coming from their back, this is not radiating from somewhere else. There's something inside their hip causing severe pain. And so sometimes we just do further investigations. And you know, I've seen patients who have a fairly good-looking x-ray, but they'll have some huge chondral flat where a whole piece of cartilage has sort of come loose and causing terrible pain in their hip. So yeah, you've got you've got to find out what's causing it. But the hip often does trick you with a with a good-looking x-ray.

SPEAKER_00 31:09

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SPEAKER_01 31:30

And I'm curious, what does your management look like when you do have those patients that invariably have some lumbostenosis, a little bit of hip arthritis, they've got some back pain, they've got some hip pain. Do you go after the back first? Do you go after the hip first? Where do you go?

SPEAKER_03 31:47

This is a really good question because patients often don't come to us with a single pathology, do they? They've got a little bit of everything. And you do have to be mindful that pain often radiates from proximal to distal. So hip pain can often be coming from the back, you know, knee pain can be coming from the back or the hip, etc. And yeah, you have to try and isolate it. Clinical examination, Jeff's already mentioned, you know, diagnostic injections, these are some of the things that can guide you in the right direction. Having said that, I have seen many patients who had lumbar spine surgery who have severe ostearthritis of the hip, and it was never picked up in the first place. The spine surgeon did it. I've seen many cases like that. And I've been caught myself where I used to do spine surgery. I don't do that anymore. Spine surgery, you know, I once had a patient come in and it was an older lady, and she had uh terrible pain radiating down sort of the buttock and the thigh, and and her spine x-ray was a complete mess. You know, it was it was all over the place. And I said, Oh, gee, I really think you know maybe this needs a bit of work. And so I just referred her to one of my colleagues who also did spine surgery because I didn't do it anymore. And the letter I got back a few weeks later was that Mrs. Smith has done extremely well since her hip replacement. Because I I completely miss the fact that all her pathology was actually coming from her hip. That was a that was you know a real wake-up surprise myself that I'd missed that, but it happens.

SPEAKER_01 33:18

Absolutely. Any thoughts there, Jeff?

SPEAKER_02 33:21

Yeah, those are people who I usually get a hip injection on. And because you can't really the provocative, you know, injection in the spine is is just less reliable. You can do an epidural and the patient just may not improve, even though it is really spinal stenosis. Sometimes you're quite convinced that it is both a combination of spinal stenosis and hip osteoarthritis. I think that's often the case. And in those circumstances, the wisdom I've always heard, in which I tend to do, is to, is to lead with a winner. You know, if somebody really has is uh sufficient pain and functional limitation to warrant surgery, and you really think that they may require two operations, I'd always lead with the hip. It's just such a great operation, and it often makes a big difference. And then people can sort of put up with so yeah, lead with a winner is a good principle. The hip's a winner.

SPEAKER_01 34:14

That's a great point. I mean, you we certainly see patients that have both, and the injection in in either the lumbus spine or the hip gets rid of some symptoms, but not all. And it makes sense to to address the biomechanics of the hip first to improve the way the lumbar spine loads.

SPEAKER_02 34:32

I mean, sir, I one of the questions, Sarah that we saw in in advance that I'll just re refer to because it relates to this is this idea of, you know, how could management be sort of better? And and I think that like this middle-aged to older individual with pain in their butt, pain in their groin, some back pain, and a great deal of functional limitation who's like not able to do the things they want to do, you know, around the house with their grandkids or in, you know, as they're winding up their careers, that the ideal person to see that person would be somebody who's comfortable with the various pathologies that we've already talked about, who's comfortable with kind of some of the behavioral and exercised and PT approaches. And that might be a surgeon, it might be a non-surgeon physician, it might be a therapist, but but often that person is hard to find. And I think in Australia, there are more, I would say, you know, non-surgical physicians who are really interested in these musculoskeletal problems. In the U.S., it's kind of a dying breed. Surgeons would like to operate. The rheumatologists look for, you know, crazy antibodies and you know inflammatory conditions, and primary care doctors are overwhelmed and just don't have the patience or the knowledge to sort through this. And some orthopedic practices are hiring PAs or non-surgeon physicians and sometimes PTs to manage the, to take sort of primary control of these patients. And and I think that's a a really important role, but there's often not somebody doing that. And it's it's a particularly in the US, I think it's a real problem that we have for musculoskeletal patients. I I don't know, Ian, if that's sort of if if that person i is more readily found in Australia than than here. It's possibly more than one person.

SPEAKER_03 36:30

And in particular in in back pain and spine conditions, we've learned a lot from other areas of medicine where multidisciplinary care is more usual. And I've I'm old enough to have seen that happen with cancer care over the decades, where uh in the old days, if you got referred to a medical oncologist, you got chemotherapy. If you got referred to a surgeon, you had the lump taken out. If you got referred to a radiation oncologist, they gave you radiation. Where all three possibilities would have been reasonable treatment, instead of meeting together and working out the best thing, people just did what they do. And I think the same thing can happen for back pain. So, what I've seen in the back pain world is some surgeons I know who are specialist spine surgeons now have clinics where the patients are basically screened with the process of seeing a physical therapist, sometimes uh or a rehabilitation physician and a psychologist, even. And then for the surgeon, I guess they're being a bit selfish because then they only have to see the patients that have gone through this process and probably more clearly have a surgical indication. But to have a patient with a complex condition such as back pain, and for people to sit around a room and and give their different perspectives, I think is much better for the patient than just seeing a surgeon or just seeing a physiotherapist, etc.

SPEAKER_02 37:59

Yeah, I agree. And I I think here too, but but here, I mean in the US also, it it is in back pain where you do see that more often, I think, multidisciplinary clinics, less so in lower extremity practices, sports practices, and some, but not not often enough. And but I think some of the concepts are really the same and that it would be good for patients, but you know, organizationally, how it relates to reimbursement schemes, those become complicating factors.

SPEAKER_01 38:28

I couldn't agree more. I think it's very easy, and we particularly see it with patients that have multiple joints or multiple pathologies. It's very easy for them to get lost in the web of opinions and in the going down, getting different opinions. And it's really helpful if you've got a central team that can tie it all together through the framework of what do we think is driving this? Will this intervention help with these symptoms as well? So if we were zooming out a little bit, I'd be keen on both of your thoughts. If we were designing the ideal multidisciplinary pathway from scratch, what do you think, if anything, needs to change over the next five to 10 years to make that possible?

SPEAKER_03 39:15

Well, I guess what you're asking is what should change? Like what should we be doing better to manage patients with osteoarthritis? Yeah, I think there needs to be a more streamlined way of progressing these people through the possible treatment options because at the moment it does tend to jump a little bit depending on the primary care physician. So in Australia, it's different to the US. So you can't see a specialist in Australia, whether it's a rheumatologist or an orthopedic surgeon, unless you go to your GP and get a referral. So they're the gatekeeper. And so a lot of it depends on them because they're the first point of contact. And it's either a GP or a physiotherapist. But some GPs will refer to physiotherapy, some will refer to have a favorite rheumatologist next door, and some will have their favorite orthopedic surgeon across the road. So I think that needs to be considered, and perhaps there needs to be more thought put into a model of care or a management pathway of how these patients step through these things, because a lot of them could receive quite effective management before having to see a surgeon. And in Australia, it costs them a lot of money just to see the surgeon. And often that surgeon just sends them away and says, Well, you don't need a knee replacement, go back to your GP, and without giving them a lot of structured alternatives, either. So I think the whole pathway from first pain to more severe pain and onwards needs to be thought out a bit better and needs to be managed a little better than it is at the moment, because at the moment it's it's really ad hoc and it depends on the primary care physician and their reaction. And they often the easy reaction is refer this patient to an orthopedic surgeon. It'll stop. Bypassing a lot of effective treatments sometimes.

SPEAKER_01 41:10

Yeah, absolutely.

SPEAKER_02 41:11

Yeah, I I I agree, Ian, and I think the same happens here, compromised to some extent by the fact that at this moment, about 20 to 30 percent of individuals, say in Boston, who wish to have primary care doctors can't find one. So we have a terrible shortage of primary care physicians and they're overwhelmed. And so they're doing a lot of referring because there's, you know, they don't have time. I do think that structural, you know, economic structural factors make a big difference. To some extent, it's it's sort of easy to land on a air pathway model, such as Ian outlined for cancer patients. It's a beautiful model. It it does require that the reimbursement system works for everyone involved. So, you know, we have some patients are covered by plans that provide capitated care where a health system is given a certain number of dollars for the year and they have to take care of those patients. They then are fully incented to, you know, have group classes have people practice at the top of their licenses to not send patients to surgeons until they need operation, unless for, you know, kind of diagnostic purposes, because surgeons tend to be very, very good diagnosticians, but to get somebody rolling, you know, with back pain or knee pain, you wouldn't see a surgeon first. But again, it requires creating a structure where you can do things like see groups of patients and have that make sense in terms of the economic model. In more typical fee for service models, there's no way of charging for a group. You know, you charge a patient's insurer when they come to see you. So it's very limiting. It seems like a simple, you know, obstacle, but it's actually a very important obstacle. And so some of the most innovative care that we see in diabetes and in cancer, and I suppose in musculoskeletal are in these prepaid environments where the incentive is to really take care of patients thoughtfully and efficiently, and the the solutions flow from there. And they tend to look a lot like the models that we've been, you know, talking about here.

SPEAKER_01 43:25

Well, it's nice to know we're on the right track.

SPEAKER_02 43:28

Well, maybe, right? I mean, you know, in a in a FIFA service model, it's hard to make a case for a diabetes education class, but they're incredibly successful. And the patients, the peer interactions that they get, the kind of allyship that they form is invaluable, but the economic model doesn't support it in many instances. So I think sometimes we know the right thing to do, but we're not incented to do it.

SPEAKER_01 43:54

That makes sense. Well, Jeff and Ian, this has been such a valuable conversation. I think there are so many nuances around pain and imaging and timing and individual patient goals. And I think today's discussion has really highlighted the importance of collaborative evidence informed decision making across all of these disciplines. So thank you both very much for your time and insights today.