![[Physio Explained] Hip and knee OA rehabilitation: what do we currently know? with Dr Milly Bell](https://cdn-images-3.listennotes.com/podcasts/physio-network/physio-explained-hip-and-KSxpJ9-ah35-WX9UyZHF03z.1400x1400.jpg "[Physio Explained] Hip and knee OA rehabilitation: what do we currently know? with Dr Milly Bell")
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The GLAD program itself, from their 2025 annual report, just following three months after completing the program, knee pain reduced by 29%, medication reduced by 49%, quality of life increased by 26%, and walking speed increased by 14%.
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So even the increase in walking speed has implications for your overall health too, because there's a relationship between walking speed and early death.
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So if we can get people walking faster, then they're less likely to have an early death.
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There'll be some extra benefits for overall health, as well as being less likely to fall and those sorts of things too.
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What should first line management of knee osteoarthritis actually look like?
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Where does a program like GLAD fit within the treatment pathway?
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And what is the distinction between exercise therapy and physical activity?
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And why does it matter for people with knee osteoarthritis?
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Today we cover all of this and more.
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To do this, we are joined by Dr.
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Millie Bell.
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Millie is a physiotherapist, researcher and lecturer at La Trobe University.
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She completed her PhD exploring the barriers and facilitators to physical activity in people with knee osteoarthritis.
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And her research focuses on musculoskeletal health, physical activity promotion, implementation of science and digital models of care.
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Alongside her academic work, Millie continues to work clinically as a senior physiotherapist in orthopedic settings at Cabrini and Epworth hospitals, giving her a strong connection to the challenges clinicians face in everyday practice.
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You're going to love today's episode.
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I'm Sarah Yule, and this is Physio Explained.
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Well, welcome to the podcast today, Millie.
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Thank you so much for joining us.
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Thanks for having me.
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Let's start with current recommendations.
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When someone presents with knee osteoarthritis, what do the guidelines tell us should form the foundation of their management?
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Yeah, great question, Sarah.
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So Dr.
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Ali Gibbs recently published a systematic review in 2023 titled Recommendations of the Management of Hip and Knee Osteoarthritis, a systematic review of clinical practice guidelines.
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I think that's a really great starting point for us, where she included seven high-quality guidelines and then also 18 lesser quality guidelines.
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What the higher quality guidelines were consistently recommending is education, exercise therapy, weight management where relevant, and also use of non-steroidal anti-inflammatory drugs, sometimes referred to as NSAIDs.
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That's for hips and knees.
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These guidelines are based all around the world, and they all agree alongside GLAD, which is a good life with osteoarthritis Denmark.
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That's a program I'll refer to a little bit today.
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And essentially everyone agrees that education and exercise therapy should be the first line management for knee osteoarthritis.
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And those guidelines include the RACGP, Royal Australian College of General Practitioners, ACR, which is American College of Rheumatology, Aussie, which is osteoarthritis research society international, NICE, the National Institute of Healthcare Clinical Excellence, ULAR, which is the European League Against Rheumatism, APTAR, which is the American Physical Therapy Association, and the BMJ, which is British Medical Journal Rapid Recommendations.
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So everyone all around the world agrees that education and exercise therapy are absolutely important things to start with.
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Before we move on to the next question, I'm keen on your thoughts.
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How well does that current clinical practice align with those recommendations?
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Yeah, so I would say there are a lot of people out there who are doing a fantastic job of implementing those guidelines, but we also have a really long way to go.
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So there are lots of researchers out there who focus on implementation science and they're working really hard to try and make sure that we are actually following through on those guidelines, not just writing them up and putting them on the bookshelf.
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So a really great example of translating that into practice is the GLAD program that I referred to before.
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It originated in Denmark, which is the D, but we also have GLAD here in Australia.
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And GLAD is offered in 10 countries around the world.
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So I think it's really important that we try to refer to services like that.
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GLAD's not the only type.
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There are several other programs available, particularly in Australia, but also in other countries.
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And speaking to physiotherapists, I think if you see someone who comes in with neo osteoarthritis, whether you've diagnosed them clinically or whether they've come to you from a GP with radiographic evidence, regardless of the severity, everyone should be starting with education and exercise therapy.
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Fantastic message.
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And on the GLAD program, can you talk us through it and the treatment pyramid that it uses to conceptualize management of knee osteoarthritis?
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Yeah, absolutely.
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So if you haven't seen the GLAD pyramid before, I'd certainly recommend looking it up.
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Essentially, at the bottom of the pyramid, the first line treatment, which is recommended for everyone with neo osteoarthritis and hip, is education, targeted exercise therapy and weight management, if relevant.
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The second line treatment, which is through the middle of the pyramid, includes optional additions such as pain relief medication, maybe some manual therapy, possible braces.
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And some patients might use insoles and their shoes.
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And then the third line treatment, which is really only for a few people and kept as a last resort when non-surgical care isn't cutting the mustard, that's where we look at things like joint replacement surgery.
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And the reason we don't go straight to joint replacement surgery, well, one of the big reasons is it's very expensive.
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Another reason is you go through all of that pain, the possible health risks of a general anesthetic and those sorts of things, as well as the fact that not every surgery is successful.
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So you'd be kicking yourself if you'd had surgery and you hadn't tried non-surgical management first.
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And when I come back to your part of the question talking about what GLAD actually involves, so GLAD includes two education sessions alongside generally twice a week supervised exercise sessions for at least six weeks and often longer, some people go as long as 12 weeks.
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These can be held at your physioclinic, or some people do them via telehealth where they might be at home or where wherever they may be traveling.
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And GLAD includes neuromuscular exercises, which can sometimes also be referred to as nemics.
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It includes a focus on correct technique, postural control, building strength in your legs, balance and functional activities.
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And there are lots of different levels.
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So you can start really at the basics and then work your way up as you get stronger, more confident.
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The GLAD program itself, from their 2025 annual report, just following three months after completing the program, knee pain reduced by 29%, medication reduced by 49%, quality of life increased by 26%, and walking speed increased by 14%.
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So even the increase in walking speed has implications for your overall health too, because there's a relationship between walking speed and early death.
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So if we can get people walking faster, then they're less likely to have an early death.
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There'll be some extra benefits for overall health, as well as being less likely to fall and those sorts of things too.
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It's very compelling evidence.
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And I feel like just looking at that GLAD pyramid, it would do quite a nice job for patients of not necessarily demonizing any one treatment or another, but demonstrating where they might all fit.
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Yeah, that's right.
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And I think if you're a physiotherapist listening to this, our role is to educate patients about how to get moving and manage the pain so that they can gradually build up strength, including educating them about the fact that some pain is okay, but we don't want to push our patients to the point that they can't do any or activity or exercises for a week after doing a session.
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So that's why having supervised exercise when you're starting out is so important to build that rapport, build that relationship with your patients, build their trust in what you're showing them and make adjustments regularly, especially in the early days as they're adjusting to things.
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Compared to if you're a GP or a surgeon listening to this, then I'd urge you to make sure that your patients are having a really red-hot go at education, exercise, and possibly weight loss before considering surgery as a management choice.
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Severe knee osteoarthritis on a scan doesn't mean that you can't exercise.
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So certainly having that support in the early days is really important.
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And if you happen to be a person with knee osteoarthritis listening to this, I'd look up programs such as GLAD, which is which are offered in several countries around the world.
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Being able to do the program means that you're supported while you retrain your body, build up your strength, and support your knees or hips to do things that are important to you in life, whether that's getting out and exercising, playing sport, functional everyday tasks, playing on the floor with relatives or whatever that might be.
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That's great advice.
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So who might be an appropriate candidate for a program like GLAD?
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Anyone with neosteoarthritis.
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So as physios, we might we might see someone walking through the door, they come to you with knee pain, they might not even have the diagnosis yet.
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But that's where clinically, as physios, we can diagnose, and then often straight after that, we see patients added straight into a GLAD session and then do that for the full program.
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And then following that, a lot of patients, even if they were thinking they might have surgery, often change their mind.
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I actually, as part of my PhD, did a case report on a patient called Laurie, and he delayed the need for a knee replacement by five years.
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He was about to be on the table, he was convinced he needed it, and it was really just that he had the need for urgent heart surgery so that he could survive a total knee replacement.
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And we met in between that time, and I said, Oh, you've got to give Glad a go.
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And he had improvements in he lost weight, he had improvements in physical activity, his pain, all those sorts of things.
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And he was sending me pictures of him walking around the cobblestones in Europe and playing with the grandkids and all of those sorts of things.
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So anyone who has knee osteoarthritis or anyone who comes to a physio with a sore knee and is diagnosed with that is absolutely eligible to do GLAD.
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I think we forget sometimes, or it can be easy to forget, linking the person and the outcomes with what we're actually seeing radiographically, which probably links to my next question, which you've already alluded to.
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We often assume that if we prescribe exercise and someone completes an exercise program, that they will naturally become more active.
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And we know that there are health outcomes associated with walking speed and physical activity over a lifespan.
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And these are two actually two quite different outcomes.
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What's the distinction between exercise therapy and physical activity?
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And why does it matter for people with neosteoarthritis?
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Yeah, great question.
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And I think a lot of people mix up exercise and physical activity.
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Even physios, a lot of the time, sort of lump them in together.
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So physical activity is any bodily movement that causes your skeletal muscle to work harder.
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So things like walking, it could be any sport, gym, playing with the dogs, even unloading your groceries and walking to the supermarket from your car, all of that is physical activity.
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It's this big umbrella.
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Exercise therapy is really targeted repetitive movements that are designed for a specific outcome.
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So in this case, we're talking about strengthening and supporting the knee, improving balance and helping out with functional movements.
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And the reason it's important to distinguish between the two, if I use GLAD as an example, GLAD is our exercise therapy part of the component.
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And so GLAD helps with pain, function, quality of life.
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It does all of those really good knee-specific benefits.
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But then GLAD itself doesn't actually increase physical activity.
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So a systematic review that I ran a couple of years ago as part of my PhD found that exercise, particularly walking and mixed exercise, if we think of the different types of exercise, can increase physical activity in the short term, but not really in the long term.
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And when we ran that study, there weren't that many studies that had long-term follow-up that included physical activity measures.
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So that may have changed since then.
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But when we looked at the studies that included just resistance programs, they didn't meaningfully increase physical activity.
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So they do have great outcomes for the knee itself.
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But overall health, we need something on top of the resistance programs or the exercise therapy for those overall benefits.
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And when we look at people with knee osteoarthritis, a lot of them have comorbidities.
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And that can be because over time, you know, if you've got a sore knee, one of the really common myths is, oh, well, you don't want to wear it out.
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So people become less active, and that actually gives less nutrition to the knee.
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So the pain continues to get worse.
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And then we see that compound with things like weight gain as well.
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Weight gain comes with inflammation and all of these, it's a cascade of unfortunate factors that make the knee worse, more sore, and you're losing the muscle strength from not being active.
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So by targeting the knee, that's addressing one problem.
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But then we also need to address physical activity as well.
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And often that needs to be with some behavior change.
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So a lot of physios are really good at building rapport with their patients, and that's a really important factor for behavior change.
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But we also need to meet our patients where they're at.
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So not all patients are ready to just snap their fingers and get active and get moving.
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Often it comes alongside, as I said, building rapport, educating about the benefits of exercise of physical activity independently and together.
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And as the knee starts to feel better, often our patients are more willing to look at other ways they can be more active too and build on that.
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And then we, when we are increasing physical activity, we are seeing all of those benefits, such as reducing the risk of comorbidities, as well as if you do have comorbidities, helping with the maintenance of them.
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So when we think of comorbidities, we're thinking of heart disease, type 2 diabetes, dementia, early death.
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That's a big one.
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So yeah, all of those sorts of things contribute as well.
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You've already answered the next question I was going to ask, which was around the for the physio listening that's already prescribing strengthening and aerobic exercise, what else can we start doing differently tomorrow to help those patients become more physically active?
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And I wonder if there's particular questions clinicians should be asking, or if how useful are step counts and wearables or activity targets in the picture of those outcomes?
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Yeah, I think that's a great question.
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My answer is there's no one size fits all.
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It really depends on the patient you're working with.
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I've had patients over the years who are super motivated and it's really just been their knee holding them back.
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And as soon as their knee feels better, they're out there, they're active, they're doing everything.
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I've also had patients who their knee's not too bad and it's feeling better now, but they're just self-described as I'm a book where I had a patient who told me once I was always pit last in PE class.
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They're just not that interested.
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And so for them, it's it's working with them to come up with their own idea of why they would be motivated to be more active, what's in it for them?
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And that's where I think shared decision making and shared goal setting with patients is so important.
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We can't come in and just say, right, well, this is what you need to do.
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This is what I've identified as is the problem, and this is what you need to do to fix it.
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We need to work together and look at whether we've got different goals and we need to work together to put them to achieve them all, or whether there's some overlap.
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But either way, it's working with your patient on an individual level.
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And sometimes that means taking a bit more time with them, you know, book them in for a longer session, or talk to them during the group exercise session they might be booked into.
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But it really is an individual thing.
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And I think also looking at some of the external factors is there anything you can help them with for that sort of thing?
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So support groups, things like park run, where you don't have to run, you can walk things like friendly gym memberships, or if they're part of a particular demographic, are they someone, are they an immigrant who wants to go and and bond with other people from similar backgrounds?
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Are they older?
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So they want to work with older people.
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Do they have a shared interest that has an exercise group that they can go and be a part of?
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Because I think it's it's really important to look for those sorts of things.
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And then I think the other thing is sometimes you can help people to make those changes, but how do you help them to maintain it?
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So I think the maintenance part is much more of an up and coming consideration where we look at Christmas holidays.
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It's a big time where everyone shuts down, people are entertaining, they've got the family over.
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I can't possibly find time for my exercise or my physical activity.
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So how can they maybe engage the family to help them with that?
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Or, you know, is it the weather we see over summer?
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We get really, really hot weather and people can't go out because they'll get heat stroke, or I've had patients as part of one of my own trials in Ballarat, and it's just freezing cold there in winter.
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So, you know, is it exercising in a gym for those periods of the year, or what is it that motivates people?
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It's a really great summary and a nice reminder that as physios, we really need to understand the barriers that have led someone to reduce their activity, or conversely, what might help us improve their activity and help them rebuild the confidence and capacity to participate in movement.
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Millie, thank you so much for that fantastic review.
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That was there's plenty of clinical gems in there as well.
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So thank you.
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My pleasure.
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I think my parting words would just be that the right care at the right time can change the trajectory of knee osteoarthritis and can also reduce the reliance on surgery.
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It's pretty powerful.
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Thanks, Sarah.
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Thanks, Millie.
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The GLAD program itself, from their 2025 annual report, just following three months after completing the program, knee pain reduced by 29%, medication reduced by 49%, quality of life increased by 26%, and walking speed increased by 14%.
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So even the increase in walking speed has implications for your overall health too, because there's a relationship between walking speed and early death.
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So if we can get people walking faster, then they're less likely to have an early death.
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There'll be some extra benefits for overall health, as well as being less likely to fall and those sorts of things too.
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What should first line management of knee osteoarthritis actually look like?
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Where does a program like GLAD fit within the treatment pathway?
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And what is the distinction between exercise therapy and physical activity?
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And why does it matter for people with knee osteoarthritis?
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Today we cover all of this and more.
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To do this, we are joined by Dr.
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Millie Bell.
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Millie is a physiotherapist, researcher and lecturer at La Trobe University.
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She completed her PhD exploring the barriers and facilitators to physical activity in people with knee osteoarthritis.
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And her research focuses on musculoskeletal health, physical activity promotion, implementation of science and digital models of care.
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Alongside her academic work, Millie continues to work clinically as a senior physiotherapist in orthopedic settings at Cabrini and Epworth hospitals, giving her a strong connection to the challenges clinicians face in everyday practice.
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You're going to love today's episode.
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I'm Sarah Yule, and this is Physio Explained.
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Well, welcome to the podcast today, Millie.
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Thank you so much for joining us.
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Thanks for having me.
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Let's start with current recommendations.
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When someone presents with knee osteoarthritis, what do the guidelines tell us should form the foundation of their management?
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Yeah, great question, Sarah.
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So Dr.
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Ali Gibbs recently published a systematic review in 2023 titled Recommendations of the Management of Hip and Knee Osteoarthritis, a systematic review of clinical practice guidelines.
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I think that's a really great starting point for us, where she included seven high-quality guidelines and then also 18 lesser quality guidelines.
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What the higher quality guidelines were consistently recommending is education, exercise therapy, weight management where relevant, and also use of non-steroidal anti-inflammatory drugs, sometimes referred to as NSAIDs.
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That's for hips and knees.
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These guidelines are based all around the world, and they all agree alongside GLAD, which is a good life with osteoarthritis Denmark.
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That's a program I'll refer to a little bit today.
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And essentially everyone agrees that education and exercise therapy should be the first line management for knee osteoarthritis.
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And those guidelines include the RACGP, Royal Australian College of General Practitioners, ACR, which is American College of Rheumatology, Aussie, which is osteoarthritis research society international, NICE, the National Institute of Healthcare Clinical Excellence, ULAR, which is the European League Against Rheumatism, APTAR, which is the American Physical Therapy Association, and the BMJ, which is British Medical Journal Rapid Recommendations.
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So everyone all around the world agrees that education and exercise therapy are absolutely important things to start with.
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Before we move on to the next question, I'm keen on your thoughts.
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How well does that current clinical practice align with those recommendations?
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Yeah, so I would say there are a lot of people out there who are doing a fantastic job of implementing those guidelines, but we also have a really long way to go.
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So there are lots of researchers out there who focus on implementation science and they're working really hard to try and make sure that we are actually following through on those guidelines, not just writing them up and putting them on the bookshelf.
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So a really great example of translating that into practice is the GLAD program that I referred to before.
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It originated in Denmark, which is the D, but we also have GLAD here in Australia.
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And GLAD is offered in 10 countries around the world.
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So I think it's really important that we try to refer to services like that.
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GLAD's not the only type.
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There are several other programs available, particularly in Australia, but also in other countries.
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And speaking to physiotherapists, I think if you see someone who comes in with neo osteoarthritis, whether you've diagnosed them clinically or whether they've come to you from a GP with radiographic evidence, regardless of the severity, everyone should be starting with education and exercise therapy.
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Fantastic message.
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And on the GLAD program, can you talk us through it and the treatment pyramid that it uses to conceptualize management of knee osteoarthritis?
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Yeah, absolutely.
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So if you haven't seen the GLAD pyramid before, I'd certainly recommend looking it up.
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Essentially, at the bottom of the pyramid, the first line treatment, which is recommended for everyone with neo osteoarthritis and hip, is education, targeted exercise therapy and weight management, if relevant.
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The second line treatment, which is through the middle of the pyramid, includes optional additions such as pain relief medication, maybe some manual therapy, possible braces.
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And some patients might use insoles and their shoes.
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And then the third line treatment, which is really only for a few people and kept as a last resort when non-surgical care isn't cutting the mustard, that's where we look at things like joint replacement surgery.
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And the reason we don't go straight to joint replacement surgery, well, one of the big reasons is it's very expensive.
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Another reason is you go through all of that pain, the possible health risks of a general anesthetic and those sorts of things, as well as the fact that not every surgery is successful.
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So you'd be kicking yourself if you'd had surgery and you hadn't tried non-surgical management first.
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And when I come back to your part of the question talking about what GLAD actually involves, so GLAD includes two education sessions alongside generally twice a week supervised exercise sessions for at least six weeks and often longer, some people go as long as 12 weeks.
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These can be held at your physioclinic, or some people do them via telehealth where they might be at home or where wherever they may be traveling.
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And GLAD includes neuromuscular exercises, which can sometimes also be referred to as nemics.
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It includes a focus on correct technique, postural control, building strength in your legs, balance and functional activities.
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And there are lots of different levels.
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So you can start really at the basics and then work your way up as you get stronger, more confident.
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The GLAD program itself, from their 2025 annual report, just following three months after completing the program, knee pain reduced by 29%, medication reduced by 49%, quality of life increased by 26%, and walking speed increased by 14%.
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So even the increase in walking speed has implications for your overall health too, because there's a relationship between walking speed and early death.
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So if we can get people walking faster, then they're less likely to have an early death.
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There'll be some extra benefits for overall health, as well as being less likely to fall and those sorts of things too.
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It's very compelling evidence.
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And I feel like just looking at that GLAD pyramid, it would do quite a nice job for patients of not necessarily demonizing any one treatment or another, but demonstrating where they might all fit.
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Yeah, that's right.
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And I think if you're a physiotherapist listening to this, our role is to educate patients about how to get moving and manage the pain so that they can gradually build up strength, including educating them about the fact that some pain is okay, but we don't want to push our patients to the point that they can't do any or activity or exercises for a week after doing a session.
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So that's why having supervised exercise when you're starting out is so important to build that rapport, build that relationship with your patients, build their trust in what you're showing them and make adjustments regularly, especially in the early days as they're adjusting to things.
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Compared to if you're a GP or a surgeon listening to this, then I'd urge you to make sure that your patients are having a really red-hot go at education, exercise, and possibly weight loss before considering surgery as a management choice.
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Severe knee osteoarthritis on a scan doesn't mean that you can't exercise.
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So certainly having that support in the early days is really important.
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And if you happen to be a person with knee osteoarthritis listening to this, I'd look up programs such as GLAD, which is which are offered in several countries around the world.
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Being able to do the program means that you're supported while you retrain your body, build up your strength, and support your knees or hips to do things that are important to you in life, whether that's getting out and exercising, playing sport, functional everyday tasks, playing on the floor with relatives or whatever that might be.
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That's great advice.
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So who might be an appropriate candidate for a program like GLAD?
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Anyone with neosteoarthritis.
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So as physios, we might we might see someone walking through the door, they come to you with knee pain, they might not even have the diagnosis yet.
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But that's where clinically, as physios, we can diagnose, and then often straight after that, we see patients added straight into a GLAD session and then do that for the full program.
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And then following that, a lot of patients, even if they were thinking they might have surgery, often change their mind.
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I actually, as part of my PhD, did a case report on a patient called Laurie, and he delayed the need for a knee replacement by five years.
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He was about to be on the table, he was convinced he needed it, and it was really just that he had the need for urgent heart surgery so that he could survive a total knee replacement.
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And we met in between that time, and I said, Oh, you've got to give Glad a go.
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And he had improvements in he lost weight, he had improvements in physical activity, his pain, all those sorts of things.
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And he was sending me pictures of him walking around the cobblestones in Europe and playing with the grandkids and all of those sorts of things.
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So anyone who has knee osteoarthritis or anyone who comes to a physio with a sore knee and is diagnosed with that is absolutely eligible to do GLAD.
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I think we forget sometimes, or it can be easy to forget, linking the person and the outcomes with what we're actually seeing radiographically, which probably links to my next question, which you've already alluded to.
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We often assume that if we prescribe exercise and someone completes an exercise program, that they will naturally become more active.
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And we know that there are health outcomes associated with walking speed and physical activity over a lifespan.
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And these are two actually two quite different outcomes.
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What's the distinction between exercise therapy and physical activity?
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And why does it matter for people with neosteoarthritis?
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Yeah, great question.
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And I think a lot of people mix up exercise and physical activity.
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Even physios, a lot of the time, sort of lump them in together.
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So physical activity is any bodily movement that causes your skeletal muscle to work harder.
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So things like walking, it could be any sport, gym, playing with the dogs, even unloading your groceries and walking to the supermarket from your car, all of that is physical activity.
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It's this big umbrella.
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Exercise therapy is really targeted repetitive movements that are designed for a specific outcome.
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So in this case, we're talking about strengthening and supporting the knee, improving balance and helping out with functional movements.
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And the reason it's important to distinguish between the two, if I use GLAD as an example, GLAD is our exercise therapy part of the component.
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And so GLAD helps with pain, function, quality of life.
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It does all of those really good knee-specific benefits.
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But then GLAD itself doesn't actually increase physical activity.
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So a systematic review that I ran a couple of years ago as part of my PhD found that exercise, particularly walking and mixed exercise, if we think of the different types of exercise, can increase physical activity in the short term, but not really in the long term.
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And when we ran that study, there weren't that many studies that had long-term follow-up that included physical activity measures.
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So that may have changed since then.
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But when we looked at the studies that included just resistance programs, they didn't meaningfully increase physical activity.
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So they do have great outcomes for the knee itself.
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But overall health, we need something on top of the resistance programs or the exercise therapy for those overall benefits.
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And when we look at people with knee osteoarthritis, a lot of them have comorbidities.
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And that can be because over time, you know, if you've got a sore knee, one of the really common myths is, oh, well, you don't want to wear it out.
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So people become less active, and that actually gives less nutrition to the knee.
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So the pain continues to get worse.
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And then we see that compound with things like weight gain as well.
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Weight gain comes with inflammation and all of these, it's a cascade of unfortunate factors that make the knee worse, more sore, and you're losing the muscle strength from not being active.
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So by targeting the knee, that's addressing one problem.
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But then we also need to address physical activity as well.
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And often that needs to be with some behavior change.
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So a lot of physios are really good at building rapport with their patients, and that's a really important factor for behavior change.
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But we also need to meet our patients where they're at.
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So not all patients are ready to just snap their fingers and get active and get moving.
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Often it comes alongside, as I said, building rapport, educating about the benefits of exercise of physical activity independently and together.
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And as the knee starts to feel better, often our patients are more willing to look at other ways they can be more active too and build on that.
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And then we, when we are increasing physical activity, we are seeing all of those benefits, such as reducing the risk of comorbidities, as well as if you do have comorbidities, helping with the maintenance of them.
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So when we think of comorbidities, we're thinking of heart disease, type 2 diabetes, dementia, early death.
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That's a big one.
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So yeah, all of those sorts of things contribute as well.
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You've already answered the next question I was going to ask, which was around the for the physio listening that's already prescribing strengthening and aerobic exercise, what else can we start doing differently tomorrow to help those patients become more physically active?
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And I wonder if there's particular questions clinicians should be asking, or if how useful are step counts and wearables or activity targets in the picture of those outcomes?
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Yeah, I think that's a great question.
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My answer is there's no one size fits all.
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It really depends on the patient you're working with.
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I've had patients over the years who are super motivated and it's really just been their knee holding them back.
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And as soon as their knee feels better, they're out there, they're active, they're doing everything.
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I've also had patients who their knee's not too bad and it's feeling better now, but they're just self-described as I'm a book where I had a patient who told me once I was always pit last in PE class.
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They're just not that interested.
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And so for them, it's it's working with them to come up with their own idea of why they would be motivated to be more active, what's in it for them?
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And that's where I think shared decision making and shared goal setting with patients is so important.
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We can't come in and just say, right, well, this is what you need to do.
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This is what I've identified as is the problem, and this is what you need to do to fix it.
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We need to work together and look at whether we've got different goals and we need to work together to put them to achieve them all, or whether there's some overlap.
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But either way, it's working with your patient on an individual level.
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And sometimes that means taking a bit more time with them, you know, book them in for a longer session, or talk to them during the group exercise session they might be booked into.
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But it really is an individual thing.
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And I think also looking at some of the external factors is there anything you can help them with for that sort of thing?
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So support groups, things like park run, where you don't have to run, you can walk things like friendly gym memberships, or if they're part of a particular demographic, are they someone, are they an immigrant who wants to go and and bond with other people from similar backgrounds?
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Are they older?
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So they want to work with older people.
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Do they have a shared interest that has an exercise group that they can go and be a part of?
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Because I think it's it's really important to look for those sorts of things.
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And then I think the other thing is sometimes you can help people to make those changes, but how do you help them to maintain it?
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So I think the maintenance part is much more of an up and coming consideration where we look at Christmas holidays.
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It's a big time where everyone shuts down, people are entertaining, they've got the family over.
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I can't possibly find time for my exercise or my physical activity.
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So how can they maybe engage the family to help them with that?
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Or, you know, is it the weather we see over summer?
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We get really, really hot weather and people can't go out because they'll get heat stroke, or I've had patients as part of one of my own trials in Ballarat, and it's just freezing cold there in winter.
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So, you know, is it exercising in a gym for those periods of the year, or what is it that motivates people?
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It's a really great summary and a nice reminder that as physios, we really need to understand the barriers that have led someone to reduce their activity, or conversely, what might help us improve their activity and help them rebuild the confidence and capacity to participate in movement.
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Millie, thank you so much for that fantastic review.
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That was there's plenty of clinical gems in there as well.
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So thank you.
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My pleasure.
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I think my parting words would just be that the right care at the right time can change the trajectory of knee osteoarthritis and can also reduce the reliance on surgery.
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It's pretty powerful.
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Thanks, Sarah.
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Thanks, Millie.
