Jared Powell:
Today's guest is Professor Kim Bonnell. Kim is a research physiotherapist and director for the Center for Health Exercise and Sports Medicine in physiotherapy at the School of Health Sciences, university of Melbourne. Kim is a true giant of physiotherapy research and has been involved in more clinical trials than many people have probably read. I've got Kim on today to talk about lower limb osteoarthritis, and specifically the role diet and exercise play as treatment. Kim has a wealth of experience and clinical insights making this episode an absolute must listen. Without any further delay, I bring to you my conversation with Kim Bonnell. Kim Bonne, welcome to the show.
Kim Bennell:
Thanks, Jared.
Jared Powell:
Kim, this is a real treat for me to be talking to you. As I just mentioned to you, I've been reading your work since I was a, a lowly student. Well, I still am a lowly student. I'm a PhD student now, but about 15 years ago, I, I graduated and I've been reading your work ever since. And that's, that's not to say that Kim, you've been in the game. Well, you have been in the game for a long time, but I have been reading your work for a long time. So welcome to the show. And Kim, tell me a little bit about who you are and, and what you do for the four people that that don't know or haven't read your work.
Kim Bennell:
Thanks, Jared. Yes. Well, I'm a physio and I graduated a little bit longer than 15 years ago, quite a bit longer than 15 years ago. And I am an academic physiotherapist at the University of Melbourne, where I'm director of the Center of Health Exercise and Sports Medicine in the Department of Physio. So we're a multidisciplinary research center and most of our research really has been around sort of lower limb osteoarthritis.
Jared Powell:
Awesome. And osteoarthritis, did you just sort of fall into that or was it a calculated move to, to get into that? What did you do your PhD on and, and tell us
Kim Bennell:
A bit about that. Yeah, my, yeah, so your PhD as you know Jared, it's not supposed to answer your burning question, it's a, you know, training ground. So I did my PhD on stress fractures in athletes. So, you know, with Peter Brookner and Karen Ka supervisors and Kay Crossley helping at the Olympic Park Sports Medicine Center. So it was nothing to do with osteoarthritis. And
Jared Powell:
That's a who's who of names though, Kim.
Kim Bennell:
Great. That's
Jared Powell:
A pretty good start. Yeah,
Kim Bennell:
It was great. It was great having, working with them all. And then I sort of did some more work in sports medicine and with Kay Crossley, she did her PhD and cell cow and others on sort of metallic femoral pain. And then we sort of thought, well, to get the big funding in Australia, you've gotta do major public health problems and sports injuries wasn't at that time in anyway considered major public health problems. So it's very hard to get funding for research in that area. So we sort of shifted to knee osteoarthritis and sort of started from there because it's, I have a lot of broad interests. I don't have one burning question, but osteoarthritis was, was interesting. Hadn't been a lot of work done on it. So obviously something where non-pharmacological conservative management is the core. So it sort of fits with physios and we sort of went from there.
Jared Powell:
Yeah, no, it's a, it's a really good research topic. Are you, so are you aian by background?
Kim Bennell:
I am, yes. Born, raised, yes. Staying in. And
Jared Powell:
Are you, are you a mad footy fan down there? I,
Kim Bennell:
Yeah, followed. We all follow the Collingwood, so we're big. Yeah. Okay.
Jared Powell:
Coming off good.
Kim Bennell:
My dad used to take me off there. We'd sit at Victoria Park and I'd stand on a little stepladder that he'd bring along and sit on that and watch many a game watch, just lose many a game. Grand final draw. Grand finals
Jared Powell:
. Yeah. Yeah. Geez. There's a, a calling would always seemed to be thereabouts, although you hadn't won a premiership for a while up until last year. So congratulations,
Kim Bennell:
. That was a good, that was a good day.
Jared Powell:
As soon as you got rid of Nathan Buckley, you seemed to win. So that was that was good, Kim. My notice, I was just looking at your research gate profile. You have an extraordinary H index of 110, and that's to put that into context that is rarefied and I don't know, there might be one or two people with a similar H index in the physio game. So that's sort of testament to, to your productive output and quality of output as well, because your work gets a ton of citations. And do you, do you enjoy being a researcher? How do you find that life?
Kim Bennell:
Yeah, look, I obviously started off as a clinical physio, did, worked in private practice couple years at hospital, then private practice. And then I sort of found myself, I I went and worked as a tutor at LA Uni there. And then when you are in that sort of academic environment, again, you, you, I did a, a master's prelim, like an honors year and I, I sort of was getting a little bit, I dunno, a bit tired of the, the constant in private practice. Another patient, another patient, another patient. And I really enjoyed the research. So I sort of moved into that area and you know, really enjoyed that. Ke kept up, had a private practice up until I started having children quite a few years ago. And then everything gets too much and something has to go. But I did do the private practice, so, you know, as part-time, 'cause I do think that does help inform research. Mm. But just when you mentioned my sort of H index, I mean really the key to that is worked with and collaborated with fantastic people that really much smarter than I am. Really good team. And so they're the ones that do all the hard work and oftentimes you are the lucky one that gets to stand up and go to conferences and promote the work, but really it's a big team effort.
Jared Powell:
Yeah, absolutely. Especially with the clinical trials that you've conducted, I think you said before you've conducted well into the fifties, that that really is a team effort, isn't it? And you've all gotta sort of be pulling in the same direction. Yeah. Can you give us some, like, can you give us some insights, Kim, because yesterday as we're recording, this was World Clinical Trials day, and so this podcast will come out in a month's time and we can, I just wanna reflect on what it's like, given you've conducted millions of these things, like what, conducting a clinical trial, everybody's got an opinion on a published clinical trial, but what goes into actually planning, conducting, writing up a clinical trial? Can you give us some behind the scenes?
Kim Bennell:
Yeah, well, many years goes into that , people often don't realize how long it takes to do a clinical trial. And we've got so much better at doing them. We look back at the initial ones and obviously each time we are learning doing better and the, you know, methodologies and so forth. But really it's around, you know, we do a lot of thinking around, you know, is the research question important? Is it, because if you're gonna invest five years, oftentimes the trials really do take about five years, the big ones to go from start to sort of publication, which is a long time. So you really wanna make sure that it's a really important question that hasn't been answered before and is gonna make some difference to something. And nowadays you know, impact is a big thing where you need, we get judged on our research impact.
Kim Bennell:
So not just quantity anymore. And in fact there's much less emphasis on quantity. It's on quality and what, what impact is this work having in terms of knowledge or practice or policy. So a lot of thought goes into that. Then obviously the methodology's really important, you know, there's no point spending five years and you've got a trial that's flawed methodologically. So we are really lucky to work with some really good bias statisticians who, you know, again, make sure that the, that methodology is robust. So a lot of thought goes into to that and assembling the right team is part of that as well. As you said, multidisciplinary team so that you've got all the expertise could not, 'cause not everybody has, we don't all have the same expertise. So bringing in all that different expertise and then actually conducting the study, you've gotta make sure that you can, can deliver the, the study.
Kim Bennell:
So you need to have it, you know, powered adequately so you have a, a sample size that's appropriate. And then you've gotta, you know, are you gonna be able to recruit those people in the timelines? Are you gonna be able to train the physios, deliver that trial on time? And then, you know, then it's the, the analysis, writing up the paper and submitting it to an appropriate journal. So it all takes, yeah, a, a, a long time, but a lot of attention we pay to ensuring that they're the highest quality that, that we can make them.
Jared Powell:
And they always are. Kim, usually the, the papers that you are involved with the published in always in Q1 journals and always methodologically sound. I, I was mentioning to you before I read your shoulder trial, which is one of the only shoulder trials, which is compared exercise in manual therapy to a sham intervention. I think it was sham ultrasound or something like that. And it's really the only solid efficacy trial that we have in the shoulder pain literature. And it was the foundation for a Cochrane review that that came out a few years after your trial. And so it's sort of testament to the work that you do because it is solid, it's always well rated. So kudos to you. Keep going Kim. We need it. I wish she'd come back into the shoulder world a little bit more because we need you, but keep going in the arthritis area. Thanks. So I wanna get in
Kim Bennell:
. ,
Jared Powell:
You deserve it. You deserve it. So you, like I said you're in rarefied air. I was talking to Bill Vino the other day and he's got a sort of similar H index and you guys deserve all the credit that you get, so I'm not gonna take any, any humble
Jared Powell:
Attitude today. Thanks, Joe. So I want, I wanna get into your power RCT, which you can tell me what that acronym stands for in a minute. So this has just being published in the BJSM and it's a really interesting RCTI read it just a couple of days ago because it's only just dropped and it's a bit different. So usually when we look at knee osteoarthritis or, or really any musculoskeletal condition, we're looking at pain outcomes and disability outcomes, which are really important questions. This study here had a slightly different main outcome. So can you briefly tell us about the study, the aims of the study, the design, the main results, and then importantly, what are the clinical implications for clinicians?
Kim Bennell:
Yeah, thanks. And this was led by Dr. Kim Allison in our department and power, I have no, I've forgotten of all what that acronym stands for. . So, so I can't tell you. But basically the whole premise was that we felt that there's opportunities for physios to engage in extended scope practice around weight management because it's really hard for people to access support to, to lose weight. You know, oftentimes there's not dieticians available or they can't, people can't afford it, or they may have a sort of fear or stigma about going to a dietician. And we felt that weight loss is a key component of many of our chronic conditions that we would see, you know, osteoarthritis being one, but a whole range of other conditions as well. And so given that physios deliver exercise, which is one of the core recommended treatments and education, which is another core recommended treatment, and then there's weight management and as I said, ma many fewer dieticians than there are compared to physios.
Kim Bennell:
And we thought it was a really good opportunity to see if physios could extend scope practice into that, where they could integrate the exercise and the weight management together. And we've done, we've done some work some qualitative research with physios where we, firstly, where we showed that they lacked the confidence in their knowledge and skills around being able to, you know, have the weight loss conversation or even, you know, even have that conversation, let alone being able to support weight loss. But they did feel that, that it could be within their scope of practice. We also talked to patients about how would you find physios, you know, if, if physios were to do that, and they felt that that could be a role if they were sort of adequately trained and they could see some potential benefits of seeing sort of one person in sort of like a one stop shop.
Kim Bennell:
And then we produced a, a training course that we've now released free, it's called Edge Weight. It's on FutureLearn and it was a, it's a e-learning program about how to have the weight loss conversation and how to support weight loss. And we tested that in a randomized controlled trial and showed that it did improve physio's confidence in their knowledge and skills to be able to, to have this weight loss conversation and to, to live a weight loss. But we haven't tested can physios actually do that. So that was the premise of this RCT. And we used neo osteoarthritis as a model basically to test an alternate delivery model, an innovative delivery model. So we wanted to see whether physios could safely and effectively deliver a very low energy diet. So it was a diet with meal replacements, two meal replacements a day, and the third meal was a ketogenic meal.
Kim Bennell:
And so we wanted to see if physios, who we, who we'd trade up could do that. And so we had about six physios, so relatively some were experienced, but some were much less experienced, you know, relatively new grads a couple of years out. And we gave them some training, some a couple of practice patients. And then we had 88 patients that were randomized into receiving exercise only from the physios versus the exercise plus the weight loss program. And they saw the physios six times over six months. So it wasn't, you know, really intensive. And what we found was that the patients in the diet group, the weight loss group achieved an 8% loss of weight over the six months versus 1% in the con the exercise only group. And they had lower BMI, they had lower waist circumference. And so 76% of participants achieved more than 5% weight loss versus 12% in the control group.
Kim Bennell:
And in terms of achieving 10% weight loss, which is a big amount of weight loss 37% in the diet and exercise group lost it versus no, no, none in the control group. And there was no adver major adverse events. So we basically concluded that physios can safely and effectively deliver a, you know, very low energy diet protocolized diet. So I suppose for us, the implications are this could be a, a new sort of service delivery model's. Not saying it can, you know, we're gonna replace dieticians, but that there could be a role for physios to play to, to help support weight loss.
Jared Powell:
Yeah, absolutely. That's a lot of weight when you, when you think about it, up to 10% in some people that is, that's a, that's a solid amount of weight loss in six months. And what did, did you nest a qualitative study within that trial at all? Yeah,
Kim Bennell:
Yeah, we did. We haven't yet published that. That's still been submitted. But basically it was very interesting. A lot of the, we, we tested, we spoke to both patients and we spoke to all of the physios as well, and some of the physios could really see that it could be something that they could offer, but it, obviously the constraints are around reimbursement, you know, who's gonna pay, would the patients pay, how would you market it to patients and things. Someone who worked in a practice with a dietician in their practice felt uncomfortable about doing that because I think they felt that wouldn't be seen as a good thing in their practice, but others thought that it could be something that, you know, again, not for everybody. It's not, we're gonna say that everyone should do this, but maybe there are some pa some physios who might think that this is something that would be good.
Kim Bennell:
Perhaps rural physios or it could be, you know, this was done by telehealth, so it could be done by anybody anywhere. So the physios thought that the the patients, again, a lot of the, one of the quotes was that it was like a marriage that they felt that the two worked like a one stop shop, that the two worked really well, that they could see one person to, to get that. There was some, you know, one said that they felt that the physio was sort of reading a bit from the, like a script. So that, and and obviously we, you know, it wasn't a lot of training and they didn't get that many patients and you'd expect that after time that hopefully they get a bit more comfortable doing that. But overall there was mostly positive feedback from the, the, the patients saying that they felt it was really good, that they felt it was effective and that the, they were able to support that. There was some, again, comments that, that perhaps more training when it sort of deviated off what they knew because obviously we didn't teach them all about, you know, nutrition and everything. We sort of taught them this product wise program and we weren't trying to make them into dieticians. So, you know, there was a sort of a sort of a scope around what they knew and so that if they sort of veered off that their knowledge may have been less.
Jared Powell:
Mm-Hmm. Yeah, for sure. And what were the, were there differences in, in pain outcomes between the two groups?
Kim Bennell:
That's very interesting. No, there was no difference in pain and function between the two groups. Both groups improved, however, we didn't really power for that. Those were secondary outcomes. Our primary outcome was weight loss. We didn't power for that, although you would expect with 88 patients, you generally kind of, that's adequate for pain, not for function. But similar to what we found in our other trials where even though you add diet weight loss to it, and even though you get weight loss, the the extra benefits for pain and function are not, you know, they're not that large compared with exercise only. So, you know, exercise gives you good improvements in pain and function and you get some smaller additional benefits, but they're not really large. But obviously, you know, then people go, well, maybe we should do ex weight loss. But you know, obviously weight loss has all those other health benefits that we know of. Mm-Hmm. So, you know, to lose that much weight is great. And people obviously, when they lose that weight, it gives them a new lease of life, a lot of them.
Jared Powell:
Absolutely. It obviously it can't hurt. I was, I had, I've had David Hunter on the podcast before and but did he mention something about, has, has weight loss been shown to be a mediating factor in outcomes for osteoarthritis before? Am I remembering that correct?
Kim Bennell:
The amount of weight loss in, in our last diet trial, we did find that that was a, a mediated, so the amount of weight loss did, and there was, and there's also relationship in those who weight lose weight, the amount of weight you lose. So you know, I think if you lose in some of Steve Messier's work, you know, 20% or more, it does seem to have much greater benefits on pain and function. So it may be that the benefits for pain and function to get additional benefits, you know, you do need a lot more, but certainly still the clinical guidelines recommend, you know, at least 5% of weight loss. But probably aiming for 10% or more is what you should be doing to for, for sort of pain and function, additional pain and function benefits.
Jared Powell:
And maybe just spitball or hypothesize a bit here, how do you reckon losing weight may lead to a reduction in pain? Do you think it's a mechanical phenomena or, or a systemic physiological phenomena? What's the, what's the working mechanism behind weight loss and, and perhaps an improvement in pain and disability
Kim Bennell:
Function? Yeah, yeah, look, that's a good question. And it could be, you know, a few mechanisms could be a, a mechanical basis as you said could also be that we know now know that osteoarthritis is an inflammatory inflammation plays a key role in osteoarthritis. Whereas, you know, we used to think in the past that it wasn't that that was sort of ra but we know that inflammation plays a key role. And so you've got, with obesity, you have systemic inflammation and that can play a role in oa. So by losing weight, you're reducing that systemic inflammation. And then I think there's also that third sort of psychosocial factor that we know that weight loss, you know, has a relationship with people's self-esteem, their, you know, their mental health, other things like that. And so all of that, again, if you, you have improvements in that, that could help your pain experience as well, reduce that sort of pain experience that you have, you might be able to get out, you might do more get out, yeah. Be more social. So totally.
Jared Powell:
Yeah, that's good. It's a sort of multi-dimensional phenomena. As much things is in, in pain and musculoskeletal health, it's always so bloody complex. I wish it was easy for once. Kim, this is an anecdote. I have struggled in the past having conversations with people about overweight, obesity, losing weight, how best to approach it. It is somewhat of a, a stigma in, in our society and what's, I'm not asking you to solve this problem, but may maybe you could give us some, some ways in which you may have thought of or, or read or discussed where, how can a clinician in a busy clinic, you know, someone comes in with knee osteoarthritis, they are overweight or obese, you know, perhaps they are slightly resistant to doing exercise and, and maybe they've tried to lose weight in the past and they've struggled. Like what's the, what's the most appropriate way and respectful way of having a conversation about losing weight with a patient?
Kim Bennell:
Yeah, look and that's a really good question and we know, again, we've done some work and there's work from others as well that show that physios exhibit weight stigma as do other health professionals, as do the general society. So it's not, you know, we're not immune from exhibiting those unconscious or subconscious sort of weight stigmas as well. And it is difficult 'cause people think, well, if you're gonna bring it up, that might hurt that rapport. You know, it might damage that rapport. And also people, people's weight experience is very different as well. So you might say something to someone that they find offensive or they take, you know, and then someone else that doesn't. So it, it is a, it's a sort of a, a tricky one. And they may not expect physios to be bringing up, you know, if you, obviously if you're going to see a dietician, you're expecting that they're gonna talk about your weight, but they may not be expecting that the physio is gonna mention your weight and you know, especially if they haven't brought it up.
Kim Bennell:
But there's some ways I think you can do it, you can present it to the patient around and invite them to have the conversation. So rather than you having the conversation, so you could sort of, for example, say, look in, in terms of person centered care, look, we know that there are a number of different treatments for osteoarthritis that people can try. You know, it's really good for us to have some discussions, some education around exercise is one, like management can be one, there are some, you know, pain coping skills, training can be one. Is any of those something that you'd like to talk about? And then that kind of invites the thing they go a look, actually I wouldn't mind talking about my weight or, you know, yes, I know they might do that. You know, I know I need to lose some weight.
Kim Bennell:
And then that opens up the question of, of the, of the ability to go, well, you know, tell me a bit more about that and how so you can so do it in that way. So, because otherwise if you make the statement and go, well, you know, you need to lose some weight, they may not even think they need to lose some weight. So I think doing it in that way and explaining the different ways that, as I said that all the things, what we know about osteoarthritis, so it's kind of part of everything. And then they can pick up on something and you can take in from there or you can say, look, you know, as I said, if they have brought up about their weight or something, you could say, would you like to have a conversation about, you know, weight and what we might be able to do to help support, you know, see if that's something that you'd like to take further or get them to think about it for next time and you know, see if we'd like to talk talk about that next time or so.
Kim Bennell:
I think that's why. And if you, as I said, our our edge weight program on FutureLearn has modules that take you through how you can have a, a weight loss conversation and, and make that respectful. But it's always, it's also things like that you don't realize. It's also things about our advertising, you know, the kinds of people, our, our waiting room with the size of the chairs, a whole range of things that can, that can be done to make people feel safer. You know, if you're just having a curtain off area, the person probably, and there's people all around you, they may not be wanting to have a weight loss conversation where they know that someone next door can easily hear what you're talking about.
Jared Powell:
100%. Yeah. It's, it's setting wide really, isn't it? And that's a really good point that you make there to try and make that person feel safe and secure and the fact that they're being listened to and they're not being judged. And that's a, that's a really crucial part of it. So,
Kim Bennell:
So I just, one more point. I think the other thing is that people don't understand the complexity of weight. And it's not that the pe it's not that the person is lazy, that they just, you know, they're not doing their exercise and they're just overeating overweight and obesity. There's a whole range of factors that contribute to it. And I think, you know, making the person understand that it's not sort of not their fault and that there's all these different factors can really help again as well.
Jared Powell:
Yeah, I'm glad you brought that up. It's a, being overweight or obese is a, a truly bio-psychosocial phenomena with a huge genetic role as well. So Exactly. So yeah, glad you brought that up. And we're not, we're not, we're not here just judging people who, who happen to be overweight. However, I think it's important as exercise-based professionals and you know, someone in the healthcare space to have these conversations that will improve someone's overall health and that also might improve their, their knee pain as well, which is a win-win. So moving from that one, Kim, there's a, there's another study which I wanna chat to you briefly about, which was at a slightly different theme but on exercise as well. And this was led by Kendall Marriott and I'm gonna read the title here. It's called, are the Effects of Resistance Exercise and Pain and Function in Knee and Hip Osteoarthritis Dependent on one, exercise Volume, two Duration, and three adherence to the Exercise Program. And this was a systematic review and meta-analysis. And I read, this is just published this year too, I believe, and I read it a couple of months ago and it was a really surprising paper to me. So do you mind just briefly outlining and overviewing the paper and then, and then I'll get into some of the things that I found interesting. Yeah,
Kim Bennell:
Well this was work that was led by Kendall Marriott and Monica Ley and her team over in Canada. And I was just, they just kindly invited me to be part of it. So I'm not claiming I did you know, hardly any of the work. 'cause It was a huge, huge undertaking that they did. They did a systematic review as you said and over and found over two 80 studies, which for those who have done systematic reviews and meta-analysis, know that's a huge amount of studies to include in there because you've gotta extract all the data you've gotta go through. And that's enormous amount of work.
Jared Powell:
It, it triggers me just thinking about it, Kim, because in the shoulder literature when we do a systematic review, we have like four or five studies that we include sometimes one. So that's a monumental amount of studies to include in a meta-analysis. I don't that's when you need a big team.
Kim Bennell:
Yes, exactly. So they did a huge amount of work and they confined it to exercise or resistance exercise. So it wasn't all types of exercise, it was randomized control trials in knee and hip osteoarthritis. The majority of the literature is in knee not hip, and they had included any comparative group so they could compare it against no exercise or no treatment as well as any other treatments there. And the, this is kind of the, where the, the kind of interest is at the moment in exercise in a way. 'cause We know that, that basically there are benefits when you compare it to no exercise or no exercise comparators. But we don't know a lot about the optimal dosage. You know, we do in other conditions, you know, if you've got, you know, if you wanna improve strength and you should do this and this and this and so forth.
Kim Bennell:
But we actually don't know for neo osteoarthritis and hip osteoarthritis about optimal dosage. So what that was, what they're trying to do, they're trying to pull all the studies together to see if they could answer some of those dosage questions to help us, to help clinicians better prescribe exercise to patients. And they really didn't find that any of the things that they looked at predicted or, or associated with differences in outcomes, which I don't know it, I suppose it's in one way not necessarily surprising because they, there's a lot of heterogeneity in the studies, so they, they have different timeframes. They, even though they're doing resistance exercise, there's different types of different exercise prescriptions and it doesn't, it's sort of similar to what some of the other studies have shown as well. And so we, it sort of didn't show that the, the, the dosage was sort of, we couldn't work out from it what the optimal dosage was. And I think you were gonna mention about adherence in that as well about the
Jared Powell:
Yeah, that's the fascinating one was to me that adherence percentage or levels or, or compliance was not related to clinical outcomes, which was, it's somewhat confusing 'cause we always hear the old trope thrown out there that the best exercise is the one that gets done for a particular patient. But does this study kind of challenge the actual, the doing of the exercise to some degree now, you know, perhaps doing 10% of your home exercise program is sufficient for one person, you know, because they might, might just subtly improve their confidence, might subtly reduce their fear and that may have a big effect on their pain, whereas others need to do 90% of their prescribed exercises and they may get a true physiological effect, they might need to get a little bit stronger or, or something. So perhaps it's really individual and maybe that gets washed out in a meta-analysis. But can you have any, do you have any sort of preliminary thoughts on, on the adherence outcome?
Kim Bennell:
Yeah, look again, the adherence feel, that's, again, it's an issue. So firstly, there's no real gold standard in how to measure adherence. And adherence is measured. I think there was a systematic review that looked at how adherence was measured and it was about 70 different ways and measures of adherence. So everyone's measured it differently, but mostly it's done with self-report, like a diary. And we know that they can be inaccurate. And p Nicholson, one of our PhD students a few years ago looked at the, she, she hid accelerometers into ankle weights that we sent home with the patients and then she got them to keep a log book and she was able to compare what they said they did with what they actually did. And the relationship wasn't really that good. So, you know, there's, there's inaccuracy in getting self-report measures. So that's not one aspect that it's hard to measure. So, you know, your measures can be inaccurate. But
Jared Powell:
That's fascinating that I, I hadn't, I I've not heard of that study. That is, that's really cool because it's becoming more common to, to give accelerometers to people when they're doing the weights to actually quantitatively measure how much they're doing. But measuring the difference between self-report and actual is a fascinating I'm
Kim Bennell:
And you say they didn't know they were there and what Yeah, what we also did in that study was that she looked at the relationship between adherence and outcomes and this was around, this was a, a trial there and there was no relationship. So again, it sort of showed similar results to what Kendall Marriott found in the systematic view that there didn't seem to be a relationship. And we always do say, oh yes, there's a relationship between adherence and that, but in actual fact it's not well established at all. And it's, again, for reasons, like you've said, one, as I said, the adherence measures themselves being poor, but also we don't really understand the mechanisms by which exercise may be having its effects. And I suppose you, if you're thinking that there's gonna be this relationship that's sort of presuming perhaps more of a physiological effect, you know, if you do more, you improve your strength more and therefore you get be better benefits.
Kim Bennell:
But in actual fact, the studies that have looked at that don't show that that, you know, that's a huge predictor or a, or a mechanism. There's some evidence that it does have some mechanistic effect there, but there's a lot of other unexplained variability in terms of what, what is explaining these benefits. And again, as you've mentioned, it may be that it's not a linear relationship at at all anyway. You only just need to do a little bit and that's enough or it's a curvy linear, you know, it's okay up to, there's a relationship up to a certain point and after that more doesn't necessarily mean better. So I think we, I mean I think we know that you've gotta do something, but I think what the literature is showing is I don't think we need to be sticking to the precise, you have to do it x times a week and this many and this to get benefits.
Kim Bennell:
I, I don't think the literature is showing that there is some evidence from another systematic review that showed, and I think it was in the the hip and it was only for one measure like function that if you did a CSM concordance, like if you follow the recommendations for dosage for a CSM, that you got better outcomes. But again, not consistently found. And we've been looking at that from another one of our system. We're updating the Cochrane review and we haven't yet found that either. So I don't think there's that strong relationship there and I think it relates to a whole range of factors. But I think it just means if people can do something, they're gonna have some benefits. And again, that's a good, I suppose message because sometimes people think, oh, the physios told me I have to do it, you know, I don't know, three times a week this many sets this many reps and if they're not doing it, it's a bit like the all or nothing, oh then I might as well stop because I'm not able to do it.
Kim Bennell:
But if you have that message, we'll just do something. If you only manage to do it once a week, this week, that's okay because again, setting some more realistic targets may still be beneficial. And Rana hin and I have got a study that we're just about to start where we are gonna compare one exercise only, one strengthening exercise versus I think it's gonna be six strengthening exercises to see whether the number makes a difference. 'cause There's some evidence to show that you can still get benefits that were similar from just one exercise only and you didn't need to do six different lower limb strengthening exercises, which that's gonna have implications in terms of time and making it much easier for patients to do.
Jared Powell:
That'll be an amazing study, Kim. We've got similar in the shoulder. Chris Littlewoods done some work where you do one resistance exercise twice a day versus a whole usual care where you go see the physio and acupuncture, this, that, and the exactly the same outcomes after a period of time. If I was a betting man, which I am most certainly not if, if my wife is listening to this, I reckon there's gonna be no difference between the two groups. But fascinating to see the outcomes. I've got about a million questions I wanna ask you in response to all of that, Kim. So you kind of mentioned, you were alluding to basically this assumption that a lot of clinicians have and maybe a lot of researchers have, that there should be a dose response relationship between the amount of exercise that you do and that should result in proportional better outcomes the more that you do.
Jared Powell:
But we're really not seeing this, this biological gradient or or dose response. Some people might need to do a little bit, some people might to do a hell of a lot, but it doesn't, it's not this simple curve where the more you do, the better you get. Like if you're taking a particular medication or something, or in other areas where there is a a dose response relationship in musculoskeletal pain, that doesn't seem to be, I just published a critical review on exercise for shoulder pain and we found there was no dose response relationship between high volume or high load exercise and clinical outcomes versus low load or, or low dose exercise. So it seems to be across the board as well. So it it's quite interesting. So it, and as you said, it makes us think about, well what is the active ingredient? What is the mechanism of exercise?
Jared Powell:
And maybe the mechanisms could be different from patient to patient, right? Depending on, on what they may need that some person may have a psycho psychological mediator in response to exercise. Some people might need to be reassured, some people might feel better by seeing a clinician and that may help them, then some people might need a true strengthening program in order, but, but perhaps that strengthening program is still mediated by confidence or something else. So it really is a bit of a, a shallot's web as it were into we, we have no idea on how this thing works. And you've mentioned strength in osteoarthritis a couple of times. I think, who was it? Was it hold, was it Melanie Holden who did a study, or was it , I dunno how to pronounce that. Who found that only 2% of outcomes in osteoarthritis related to strength gain? So it only predicted 2% of the effect. Yeah,
Kim Bennell:
That was Jo. Yeah, you're right. It was Josh and, and Mel was on the study. They looked at ipd. So individual patient data, meta-analysis from all the trials that are in the exercise, exercise trial bank and are able to sort of pull all those and again, didn't find much there. Yeah, so,
Jared Powell:
So it's a, it's a, it's a veritable mystery as it is in most conditions. A lot of work's been done, a lot of, finally we're doing mediation analysis consistently for musculoskeletal pain and what we're finding is how these things work are very different to our preconceived notions of how our exercise works, which is interesting. So there, that's a, that's a fascinating study. Thanks for your, thanks for your thoughts on that. I'm gonna link all of this in the show notes. I want to get finally just do a little bit of a sort of quick fire, rapid fire hot seat round of questions here in regards to osteoarthritis. You can take as long as you want to answer these questions. So is there a difference between seeing someone and treating someone with osteoarthritis if we see them in person to face-to-face versus telehealth?
Kim Bennell:
Okay, so study led by ran human in our group and just published in the Lancet was the first non-inferiority design. So set up to show that there was, or to test the hypothesis that there was no difference. And we found that there was no difference between the care delivered by physio and it was exercise and education and physical activity and the physios delivered at in person that same program or they delivered it via telehealth and outcomes were non-inferior between the two groups in terms of pain and function, which were the primary outcomes. And then there were a whole range of secondary outcomes and some of them actually favored telehealth in terms of convenience and satisfaction and, and obviously, you know, distance travel and so forth. So that sort of shows that you can deliver that program, you know, deliver that sort of care non in non-inferior. But obviously if you wanting to, you know, in some conditions it's not gonna be possible because you might have to have some hands-on or some assessment that you can only do in person if you're trying to, you know, test someone's ligaments or so forth. But for that particular treatment and that condition, you can certainly deliver that
Jared Powell:
Good. So you can do face-to-face or telehealth depending on the condition. And the person that seems to be following the general trend that we're seeing in musculoskeletal pain where telehealth doesn't seem to be, is not inferior to face-to-face care. And that may be challenging again, some notions that what is the role of perhaps hands-on? And I hate having these hands-on hands-off debates, but, but maybe that isn't the crucial aspect for some conditions that we once thought.
Kim Bennell:
Yeah, well we certainly weren't testing hands on, you know, hands on with saying if you deliver this program that you don't need to do hands on, doesn't have hands on, it can be done equally.
Jared Powell:
Yeah. Awesome. So what about, what about exercise? Now? Exercise is getting, is getting a bit of grief in terms of small exercises, poor quality evidence. Really when we look at the systematic reviews, a lot of it's coming out there as low quality to very low quality evidence. We are unsure of the mechanisms underpinning exercise. Often when we compare exercise to a realistic sham, there's no difference between the two. So exercise is getting some grief in the literature. Should clinicians move away from exercise or should we continue to prescribe it? Albeit we don't really know how it's working. Yeah,
Kim Bennell:
Yeah you're right, there's a lot of discussion around that. But I think it depends on what the question is and from a patient's perspective, they're wanting to know if I go and see someone, if I've got pain and I go and see someone, am I gonna be any better than if I don't do anything? And when you test exercise against that, then it's effective. You know, patients do show improvements that we would deem to be sort of moderate in size, so it is effective there. But then when you start looking at, as you said, compared to sort of sham some other we did turned off ultrasound and you know, discussion with the physio and so forth, there was no difference but both groups still had improvements. So I suppose the patient doesn't really care that much. You know, if they, what aspect of it is causing their improvement?
Kim Bennell:
Is it the fact that they've gone and seen a caring physio who's chatted to them, made them feel better or is it the fact that they went there and got some exercise and that did it, they don't probably care about that. They just wanna get better. And so I think, you know, I don't think we should be saying no, we shouldn't be doing exercise. Also, as we said, we know exercise has a whole range of other benefits as well. So you know, treating the person holistically doing exercise and being more physical activity is gonna be better them than us just sticking on some sham ultrasound to their knee. So I
Jared Powell:
Agree. I a hundred percent agree. Good. Okay. What about, so we've discussed weight loss. Should we be routinely discussing weight loss for the appropriate person who is overweight or obese? Or should we be readily referring to a dietician? Should physios be upskilling immediately? What do you reckon?
Kim Bennell:
Yeah, look, I think I think every encounter with a healthcare professional should be an opportunity to to, to treat that person holistically and you know, if it's appropriate to, to you know, give them some support around that or you know, talk to them, invite 'em to have that conversation. And then from there it can be, well, you know, these are some options. You could go and speak to your gp, you could see a dietician, you could. So I think it's around giving them options. But certainly I do think yes at, at those touch points and that's what the, some of the guidelines recommend as well that, you know, all of these encounters with a health professional should be opportunities for, to improve the person holistically. I do think physio should, you know, it doesn't, I think to help them upskill in how to have that conversation so that it is easier and they don't feel daunted by it. Yes, I do think that would be good. They don't necessarily have to deliver the weight loss support, but at least being able to bring it up in a sensitive way and way that's empathetic and have that, that chat I think, you know, is, is gonna be good. Any clinician. Perfect.
Jared Powell:
Yeah, agree. Imaging,
Kim Bennell:
Imaging in OA there, the guidelines recommend that imaging is not used X-rays and MRIs, et cetera are not used in routine diagnosis of OA because it makes no difference to the person's treatment choices or you know, you can't monitor response. So for anyone you can make the diagnosis on clinical clinical grounds alone and an x-ray is only recommended if it needs to be used to rule out, exclude some other conditions.
Jared Powell:
Beautiful surgery. So I hear, have I seen Kim a trial that's come out recently comparing knee replacement to non-surgical treatment from
Kim Bennell:
That, that one was out a couple of years ago. Okay. Yeah. By Soren from SCO from Denmark and their group there and showed that it was superior to conservative care that included exercise, but obviously much greater sort of side effects and more severe side effects than, than nonsurgical care. But so surgery isn't, I mean surgery is good for the right person but you know, there's too many times where patients are having surgery and they haven't even tried optimal non-surgical care. So they haven't done a exercise, they haven't tried any of that. So it is appropriate for appropriate people.
Jared Powell:
Yep. But certainly not a first line intervention. No, good. You sort of touched on it a few times. Key aspects of education and lifestyle advice for you. Obviously physical activity, weight loss, if if necessary. What else do you counsel people about in regards to osteoarthritis? Do you talk about the prognosis? Do you talk about, well you know, physical activity isn't gonna wear your knee joint out anymore. Is there any particular go-to bits of advice that you go to?
Kim Bennell:
Yeah, so there's a lot of work now on changing the narrative around OA and Samantha Ley from Queensland as sort of leader of that work in Australia and around the language that we use. And we've also done some RCTs on the effect of changing the language. And so use avoiding terms like wear and tear degeneration, you know, worn out and bone on bone, avoiding all of those because those give people this sort of negative opinion about, makes them think that there's nothing much that they can do and so they're more likely to opt for a joint replacement or some of your biologics like stem cells and things that PRP and things that aren't really proven and they less likely to wanna do exercise. So changing that language around there to give them sort of hope and optimism that there's things that they can do and that that that OA is a condition of sort of where there's some changes in the knee joint, but we know that the changes don't relate to how the person is experiencing it. So what we do is we that's why we don't need an X-ray really. We just treat here what we present with the symptoms and that there's things that they can do to, to manage it. So really changing that narrative around, as I said, treating OA as a worn out old car that, you know, nothing can be done except to replace the joint.
Jared Powell:
Yeah, the old bone on bone trope needs to go in the bin. I think so Kim, that's epic. I highly recommend everybody reads that work of Samantha Bosley Barnsley that you just mentioned. It's, it's, it's a real eyeopener and I'll link that in the show notes as well. Kim, is there anything interesting that you're working on right now that we should keep an eye out for?
Kim Bennell:
Yeah, so as I said, that's the study that we are doing with the one versus six exercises. We've also got a study with Medibank called Better Hip, where we are looking at a physio delivered exercise and a dietician delivered weight loss program for people with hip away because most of the research has been in the knee and we know that knees and hips are not the same and they can respond differently. So that'll be interesting as well to see whether we get the effects. And we've also just finished a study looking at the effects of weight loss in hip OA because most of the literature that shows that weight plays a role shows it in Neo A, but the, the relationship between weight and hip OA is much less. And so it may be that hip that weight loss at the hip doesn't really have the same effects that we may see it at at the knee. So that that's gonna be coming out soon.
Jared Powell:
Interesting. How come the hip hasn't had as much research done relative to the knee? Is it just less of a disabling condition? Yeah, no,
Kim Bennell:
It's, it's, it's interesting why, I mean it's obviously less not as prevalent but yeah, no, most of the FO focus has just been on the, the knee and I think oftentimes the, the, the hip, they seem to progress faster to hip joint replacement from the time that they get it, you know, the symptoms and that seems to be a bit more rapid than you see at the knee where they kind of can rumble on for quite a long time. I think that could be one reason, I dunno about your experience with that Jared, but yeah, that's
Jared Powell:
Absolutely every the, the threshold for getting a hip replacement seems to be so low these days probably 'cause it seems to be a very effective procedure. But am I right in saying there's no clinical trial comparing hip replacement versus non-surgical treatment out?
Kim Bennell:
No, none that's out there. Yeah,
Jared Powell:
So that's interesting. Like we're getting these, we've got this idea of effectiveness based on probably case studies and anecdotes. Yeah. Which is curious, right? Because it seems to be a fairly untouchable procedure. Yeah,
Kim Bennell:
It is much, it does seem to be much lit, much simpler, easier doesn't it? And less complications compared to the the knee, which is a bit more of a harder joint. Yeah.
Jared Powell:
So what, yeah, maybe we don't need to progress into a clinical trial because it seems to be a pretty effective procedure, but that would be interest interesting to see anything
Kim Bennell:
So out there that have been underway, not yet publish, so.
Jared Powell:
Alright, good, good. I'll watch this space. Alright, Kim, I've taken up enough of your time. Thanks for your expertise. It's been a really good chat. We, so you're not all, you're not all over social media so they can find a lot of your work on the chem Twitter page or X page these days. And that's at CH HSM Uni me. What does chem stand for? Again?
Kim Bennell:
It's the Center of Health exercise and Sports medicine and at our website there, we've got heaps of resources for patients and clinicians as well as all infographics of all of our studies and whole range of resources, free resources that we've produced for patients that clinicians can refer as well, like pain coping skills, training programs, education programs online for patients, you know, four week progress. So there's a whole range of, of resources that we've tested in RCTs and that have made freely available for clinicians and patients and
Jared Powell:
Yep. Highly recommend checking that out. And that's based out of Uni Melbourne? Yeah. Yeah. That Awesome. Kim, thank you very much. Thank you
Kim Bennell:
For listening.
Jared Powell:
Great talking. Listen to this episode of the Shoulder Physio podcast with Kim Burnell. If you want more information about today's episode, check out our show [email protected]. If you like what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rating or review. It really helps the show reach more people. Thanks for listening. I'll chat to you soon. The Shoulder Physio Podcast would like to acknowledge that this episode was recorded from the lands of the Ang people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning, and working from every day. I pay my respects to elders past, present, and emerging And celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
