Ep 49: Exercise and musculoskeletal medicine in rheumatology

In this podcast join Dr Daniel Fernando as your host, in discussion with Dr Raj Amarnani (Consultant in Sports and Exercise Medicine) as they consider the role of the field of Sports and Exercise medicine in the setting of the rheumatology clinic. Learn about the role of exercise in inflammatory arthritis and appropriate referrals for specialist input.

Thanks for listening to Talking Rheumatology! Join the conversation on X using #TalkingRheum or tweet us @RheumatologyUK.

BSR is the UK's leading specialist medical society for rheumatology and MSK health professionals. To discover how we can support you in delivering the best care for your patients, visit our website.

Transcript

00:00:00 [Speaker 1]

You're listening to the talking rheumatology spotlight podcast brought to you by the British Society for Rheumatology.

00:00:14 [Speaker 2]

Hello, and welcome to this talking rheumatology spotlight podcast on exercise, its role in rheumatology and a focus on the sub subspecialty of sport and exercise medicine.

00:00:25 [Speaker 2]

My name is Daniel Fernando, and I'm an IMT three doctor at Adenbrooke's Hospital in Cambridge, and I will be your host.

00:00:31 [Speaker 2]

It's my pleasure today to welcome doctor Raj Armanani.

00:00:34 [Speaker 2]

Doctor Amanani is a distinguished consultant in sport and exercise and musculoskeletal medicine at Central and Northwest London NHS Foundation Trust and a fellow of the faculty of sport and exercise medicine.

00:00:46 [Speaker 2]

He is the current president of the Royal Society of Medicine's rheumatology and rehabilitation section and is also advisor and trustee for the National Axial Spondyloarthritis Society.

00:00:56 [Speaker 2]

He is an honorary lecturer at Queen Mary University of London and a member of two EULA task forces currently developing international guidelines on physical activity and fatigue in rheumatic diseases.

00:01:08 [Speaker 2]

Alongside his NHS work, his career has seen him provide medical sport to a wide range of elite organizations, including the England and Wales Cricket Board, West Ham United, the Lawn Tennis Association, the Royal Ballet School, Super League Basketball, the Commons, and the London Marathon.

00:01:25 [Speaker 2]

Raj, it's an absolute honor to have you on the show today.

00:01:29 [Speaker 3]

Hi, Anna.

00:01:29 [Speaker 3]

Thank you so much for the really kind introduction.

00:01:31 [Speaker 3]

It's really great to be on board.

00:01:33 [Speaker 2]

Raj, we're about to talk about a topic that's I'm sure it's very close to your heart, and and and we're gonna we're gonna talk about exercise today, which is one of the fundamental pillars of of patient management in rheumatology, and there's so much we can talk about.

00:01:45 [Speaker 2]

But I wonder if you could first give us an overview of sport and exercise medicine and how you got involved in this branch of rheumatology.

00:01:52 [Speaker 3]

Absolutely.

00:01:53 [Speaker 3]

So it's it's probably one of the most common get asked in terms of what actually is sport and exercise medicine.

00:01:59 [Speaker 3]

Actually, we're we're actually working hard as a specialty to actually change our title slightly to sports, exercise, and musculoskeletal medicine because I think that better reflects the three pillars of what we do.

00:02:08 [Speaker 3]

So a big part of our component of our daily work is musculoskeletal medicine and managing really complex patients often presented with musculoskeletal pain from a nonsurgical perspective.

00:02:18 [Speaker 3]

Our second big pillar is, as you've rightly said, exercise medicine, and that is applies across complex diseases, but particularly in rheumatology, we have a big play here in terms of managing patients with chronic inflammatory conditions.

00:02:30 [Speaker 3]

And then finally, probably the smallest part of our specialty, it was becoming less and less, but one that most people associate us with, is team care.

00:02:37 [Speaker 3]

So working with the lead in athletes and in team environments.

00:02:40 [Speaker 3]

But, certainly, most consultants in my position work across all all three, pillars, and that's what makes our specialty quite exciting to work in.

00:02:50 [Speaker 2]

Understandably, with with sports and exercise medicine, a few of our a few of our listeners will be wondering whether you you obviously, you work with quite a lot of professional athletes in in in a broad range of of very famous sort of groups in in in sport in Britain.

00:03:03 [Speaker 2]

But do you also work with other sort of patient clients as well, with thinking about same professional athletes, even weekend warriors?

00:03:10 [Speaker 3]

Well, absolutely.

00:03:11 [Speaker 3]

I think our specialty encompasses both.

00:03:13 [Speaker 3]

So we'd see a lot of pediatric adolescent children who are active, and all the way up to people who are in their nineties.

00:03:18 [Speaker 3]

So, you know, we we see a whole range of people who wanna be active and also those who don't and those who have muscular skeletal complaints, who aren't athletes, who aren't active, but actually a lot of our role is using techniques like motivational interviewing, sharing the evidence and trying to understand how we get, you know, people becoming more active as a nation.

00:03:38 [Speaker 3]

But on the flip side, also people who aren't active get them better.

00:03:41 [Speaker 3]

How do we treat their complex musculoskeletal conditions that may not necessarily need surgery or may not be inflammatory in nature?

00:03:49 [Speaker 3]

That's exactly where our specialty sits.

00:03:50 [Speaker 3]

So we sit in that pocket, often getting referrals from primary care or rheumatology or orthopedics, so people with musculoskeletal complaints that, unfortunately, we haven't been able to get on top of or get a diagnosis for, and that's a lot of what we do.

00:04:04 [Speaker 2]

Excellent.

00:04:05 [Speaker 2]

Absolutely.

00:04:06 [Speaker 2]

And and like all of modern medicine, sport sport exercise and muscular speed and medicine has the disciplinary team to support the patient's journey.

00:04:14 [Speaker 2]

Is that right?

00:04:15 [Speaker 3]

Yes.

00:04:15 [Speaker 3]

Absolutely.

00:04:16 [Speaker 3]

So every environment I work in, we work very, very closely with all the allied health professionals and other medical specialties.

00:04:22 [Speaker 3]

So I was having a think about this earlier, actually I think there's probably about 10 people in the MDT that we get involved with regularly, so we work with physiotherapists, occupational therapists, dieticians, podiatrists, soft tissue therapists, strength and conditioning coaches, particularly in an elite sporting environment, and then, of course, there are other medical and surgical specialties.

00:04:41 [Speaker 3]

So, of course, we have strong links with those rheumatology, primary care, radiology, neurology, the list goes on.

00:04:48 [Speaker 3]

I think that's a great thing again about our specialty.

00:04:51 [Speaker 3]

It's a really truly MDT specialty because we use everyone and work with everyone in that team to ultimately try and get the patient better, which is, of course, what we all try and do in medicine.

00:05:00 [Speaker 2]

Brilliant.

00:05:01 [Speaker 2]

Of course, Raj, our our listeners today come from all our areas of rheumatology, from every single profession, doctors, nurses, physios, and the entire MDT is actually listening in on this.

00:05:13 [Speaker 2]

And and, obviously, our our clientele is, you know, sort of, is everyone in the population with a with a rheumatology condition.

00:05:18 [Speaker 2]

But then this might be the most obvious question we've ever asked in a rheumatology podcast.

00:05:22 [Speaker 2]

But why is physical activity and exercise important in rheumatology?

00:05:27 [Speaker 3]

That's I mean, you know, like you say, it's a simple question, but, actually, it's such an important question to ask because, as you say, you know, every NICE guideline, every international guideline on most rheumatic diseases have exercise and or physical activity in some way, shape, or form.

00:05:41 [Speaker 3]

And I think everyone listening here knows the benefits of physical activity and exercise.

00:05:45 [Speaker 3]

I don't think we need to elaborate on that.

00:05:46 [Speaker 3]

I think what's really important to mention here with it is the nuances behind the difference between, firstly, physical activity and exercise, number one, and also differentiating the types of physical activity and exercise.

00:05:57 [Speaker 3]

A lot of my research and work over the last few years has been trying to answer that question.

00:06:01 [Speaker 3]

How do we differentiate between the various types of exercises and physical activity modalities?

00:06:06 [Speaker 3]

That's something we can certainly talk about.

00:06:08 [Speaker 3]

But also at the same time, you know, I think a lot of people are disheartened when their health care practitioner just says, oh, you should do more exercise.

00:06:15 [Speaker 3]

What does that actually mean?

00:06:16 [Speaker 3]

Or, for example, the other the other classic, which a lot of rheumatologists are guilty of and a lie should certainly be in this category was, you know, I'll refer you to physiotherapy, and we'll get you started on the exercise.

00:06:26 [Speaker 3]

Often, is it three to four to five month wait to see a physiotherapist?

00:06:29 [Speaker 3]

They're starting on the biology pretty quickly, and they're starting on the rheumatology when it gets pretty quickly, but, unfortunately, they seem to miss that window of those three to four months when, actually, they could be doing so, so much.

00:06:39 [Speaker 3]

What we do know from a lot of qualitative quantitative research is that, you know, there are lots of facilitators, motivators, and barriers to exercise and physical activity, particularly in those with in those with chronic conditions.

00:06:50 [Speaker 3]

But what we do know is one of the biggest motivators is when the the trusted healthcare professional, be that a rheumatology consultant, nurse, registrar, physio therapist, if they give patients the encouragement and the reassurance that exercise and physical activity is good for them, that uptake of it increases massively, and that's certainly something what I we spend a lot of time doing is giving people the confidence to actually say, Yes, you can exercise, but but this is how we go about it.

00:07:16 [Speaker 2]

Excellent.

00:07:17 [Speaker 2]

And I and I think that's really key to everything we do in rheumatology, isn't it, to start foundation?

00:07:22 [Speaker 2]

And as you rightly say, for all the wonderful drugs that we've now gotten and and treatment options we now have in rheumatology, exercise still forms the basis of everything.

00:07:32 [Speaker 2]

I think you've given a very nice overview there of of the main part of our podcast here today.

00:07:36 [Speaker 2]

I'm wondering if we can break that down a little bit.

00:07:38 [Speaker 2]

Let's say a patient comes into your clinic.

00:07:41 [Speaker 2]

How would you broach the topic of exercise with them?

00:07:44 [Speaker 3]

Absolutely.

00:07:44 [Speaker 3]

So I think the the best place to start really is to understand your patient, understand what makes them tick, what do they want to be able to do, and work backwards.

00:07:53 [Speaker 3]

So I think a lot of what we do is is very much functional medicine.

00:07:57 [Speaker 3]

So an 85 year old at home who's relatively independent with no package of care and is doing about their activities daily living, if they have a setback with a musculoskeletal rheumatic condition, what they want to get back to doing is very different from, say, a 20 year old who wants to go to the gym five times a week.

00:08:11 [Speaker 3]

So I think starting and then starting with that viewpoint of what they want to be able to do and what's important to them is always the easiest point because then you just work backwards from there.

00:08:20 [Speaker 3]

Once you've established that, I think it's then a lot easier to then determine what do they need to be doing, what do they want to be doing, and how do we go about doing this.

00:08:27 [Speaker 3]

So firstly, address try obviously, try to address the underlying medical condition first.

00:08:31 [Speaker 3]

So if they've got rheumatoid arthritis, if they've got axial spondyloarthritis, of course, getting on top of their medical management, certainly for rheumatologists in particular, is forms the bulk of their conversation of that consultation.

00:08:43 [Speaker 3]

But if you have two minutes just at the end of your consult, even if you start the conversation, the thought process around, actually, you know, have you thought about potentially incorporating this into your exercise program or into your daily activities or increasing your step count or potentially adding a bit more core or balance exercise?

00:08:58 [Speaker 3]

I think that two minutes at the end of a consultation, you'd be surprised how you can get.

00:09:03 [Speaker 3]

If you have the luxury of spending more time with the patient and actually you have at the end of your consult, that's when you can become a little bit more nuanced and specific.

00:09:10 [Speaker 3]

I can certainly talk about that in terms of how we quote unquote prescribe exercise.

00:09:15 [Speaker 3]

I think the the concept of exercise prescription has come in and out in favor over the years.

00:09:20 [Speaker 3]

I think, traditionally, we were thought we should be telling people what to do and and and write down a prescription for them, and then went the other way where people thought that was too paternalistic, and, actually, we should be encouraging people to do any activity that they like.

00:09:32 [Speaker 3]

And I think there's probably a fine balance in between in the middle somewhere, and, actually, some people do do benefit their prescriptions.

00:09:38 [Speaker 3]

Some people do benefit from actually saying, let's try x, y, and z, whilst other people are more functional and more adaptive in nature.

00:09:44 [Speaker 3]

And I think, again, knowing your patient is so key for that.

00:09:47 [Speaker 2]

I I totally agree with this.

00:09:49 [Speaker 2]

And and, also, this is a a conversation that we're having with every appointment, isn't it, and then over a series of appointments.

00:09:56 [Speaker 2]

And, I understand that, you know, this is this is something that we need to regularly check-in on patients and and and sometimes to adjust what we originally sort of prescribe for them or what we originally discussed.

00:10:05 [Speaker 2]

I guess many of our listeners would be expensive patients who who perhaps struggle to obtain data activities of daily exercise and physical activity.

00:10:13 [Speaker 3]

Yeah.

00:10:14 [Speaker 3]

Exactly that.

00:10:14 [Speaker 3]

And and we know that so there are, of course, I'm sure many of the listeners tuning in, you know, are familiar with the chief medical officer of physical activity guidelines.

00:10:22 [Speaker 3]

For those of you who who aren't, this was published a few years ago, and it's pretty much broadly adapted globally by most international consensus statements.

00:10:29 [Speaker 3]

But generally speaking, they say the average adult should have approximately one hundred and fifty minutes of moderate intensity exercise per week split up into a few sessions or seventy five minutes and more vigorous intensities.

00:10:41 [Speaker 3]

On top of that, ideally, most people should be doing two strength sessions per week.

00:10:45 [Speaker 3]

Again, when you when you when you say that to a patient, that can seem really daunting, and I think people who are pretty sedentary and don't do any exercise, certainly going from zero to that is really difficult.

00:10:55 [Speaker 3]

But, you know, for those who are close to that or who want more kind of evidence based guidelines, that's certainly where we start because, ultimately, we know that that seems to be the sweet number for most people to aim for at least and eventually get to.

00:11:08 [Speaker 3]

But, ultimately, when you look at all the studies in terms of actually who benefits from telecoidosis, that initial kind of going from zero to fifty minutes almost is when people have the most exponential rise in terms of benefit.

00:11:19 [Speaker 3]

Those who people who already exercise, you know, 120 to 140 a day or a week, sorry, That extra ten minutes doesn't make as much of a difference as the first ten minutes of those who go from zero to 10.

00:11:29 [Speaker 3]

And I think, again, adapting how you present that information and understanding what the patients are currently doing is really important.

00:11:35 [Speaker 2]

Perfect.

00:11:36 [Speaker 2]

So, Raj, we're now we're now getting into the the evidence base here now for for the exercise that that we're prescribing for our patients.

00:11:43 [Speaker 2]

For others out there, particularly some of our rheumatologists in clinic, what are some of the guidelines or some of the the the key seminal works in the field that that they can possibly refer to for their own knowledge and and possibly even to quote for their patients?

00:11:56 [Speaker 3]

Yeah.

00:11:57 [Speaker 3]

Absolutely.

00:11:57 [Speaker 3]

So I think a a really good starting point here is the 2018 new law guidelines on physical activity.

00:12:02 [Speaker 3]

So, again, this is now relatively outdated.

00:12:04 [Speaker 3]

We are, myself and a lot of colleagues around Europe, are now just putting together the 2025 guidelines, which should be published hopefully towards the end of this year, if not early next year, and it's been presented by myself hour next year, so if anyone is attending BSR, please do come for the physical activity SIG, which I'll be joining in April.

00:12:21 [Speaker 3]

So just a quick plug for that.

00:12:24 [Speaker 3]

But, essentially, yes, the guidelines for 2018 still are there.

00:12:27 [Speaker 3]

They're still of very much relevance.

00:12:29 [Speaker 3]

The 2025 will just update the exit the evidence that's come up over the last seven years.

00:12:34 [Speaker 3]

But certainly alongside that, there are many patient facing resources that are super helpful.

00:12:39 [Speaker 3]

So we know that each of the patient charities, the National Axial Spondyloarthritis Society, Arthritis UK, AMRA, they all have brilliant resources that have physical activity guidelines, recommendations, exercises, videos, patient resources.

00:12:52 [Speaker 3]

And I think myself in clinic, often I when I first started doing this, I found myself a bit overwhelmed with how much was available out there.

00:12:59 [Speaker 3]

I think we've gone very quickly from having nothing to loads of loads of websites.

00:13:03 [Speaker 3]

I think my advice around that is find one that you like, find one that you feel comfortable with, and find one that you feel that you can explain to patients.

00:13:10 [Speaker 3]

Because ultimately, sending someone a link or showing them a website is one thing, but going if if you spend that extra minute just showing opening up the website and connecting them what you're referring to and and showing them that you know what you're talking about, actually, you become familiar with those results yourself, Gives the patient so much more confidence, and, actually, their uptake of them doing those exercises or rehabilitation is so much helpful.

00:13:32 [Speaker 2]

This is really sound practical advice, Raj, that we can use in our everyday clinics, isn't it?

00:13:36 [Speaker 2]

And I'm I'm gonna pick up on that point you said earlier about prescribing exercise.

00:13:41 [Speaker 2]

And I know you sort of touched upon this in in the last question, I guess.

00:13:45 [Speaker 2]

In terms of the the evidence base, do we give greater weighting to particular exercise, such as endurance versus strength training?

00:13:53 [Speaker 2]

The evidence based sometimes talks about aerobic versus aquatic exercise.

00:13:57 [Speaker 2]

What is your opinion on on on this?

00:13:59 [Speaker 3]

That's that's such an important question, Daniel, and I really, really wish we knew the answer.

00:14:04 [Speaker 3]

So we know, you know, of course, there's many different types of exercise, but broadly, we kind of split them up into four main main groups.

00:14:09 [Speaker 3]

So like you said, we have aerobic or cardiovascular exercises.

00:14:12 [Speaker 3]

We have strength training.

00:14:13 [Speaker 3]

We have flexibility exercises, and then we have balance and core.

00:14:17 [Speaker 3]

I think, ultimately, a combination of all four is needed for most people.

00:14:22 [Speaker 3]

Now a lot of my research in the paper we did a couple years ago was trying to do a meta analysis to try and compare, particularly across inflammatory rheumatic diseases, not as much as the connective tissue diseases where the recent Ebola last, but growing, to try and compare between exercise programs area.

00:14:38 [Speaker 3]

Unfortunately, the the the data is so heterogeneous.

00:14:41 [Speaker 3]

The patient reported outcomes are so different.

00:14:43 [Speaker 3]

It's really difficult to compare what an optimal exercise is.

00:14:46 [Speaker 3]

But then it made us actually ask the question, is that really necessary?

00:14:50 [Speaker 3]

Because, ultimately, between those four exercises, the deficits that patients will have will vary from person to person.

00:14:56 [Speaker 3]

And, actually, if you're forcing someone who loves to do aerobic exercise to all of a sudden change their program and do more flexibility work, although that in full, they may not do it.

00:15:05 [Speaker 3]

But ultimately, you know, finding a way to combine all four but adapting it to your patient is incredibly important.

00:15:11 [Speaker 3]

I think when you come to talking about exercise prescription, again, you know, if you look at the textbooks that have traditionally on exercise prescribing, they break it down into these four principles called the FIT principles.

00:15:21 [Speaker 3]

So that stands for frequency, intensity, time, and type.

00:15:25 [Speaker 3]

That essentially gives you, you know, the the the guide to basically prescribe any type of physical activity across those four domains because, ultimately, it's trying to say how frequently you should do an exercise, how intense should you do the exercise, which I'll talk about in a second, what how, often you do it, so what timings you should do it, and what type of exercise you should do between those four pillars.

00:15:44 [Speaker 3]

Now with intensity, again, one of the more common questions I get asked is what you know, coming back to the CMO guidelines is what is moderate intensity exercise and what is vigorous intensity exercise?

00:15:52 [Speaker 3]

So people who have, you know, wearables, garments, you know, Oura rings, things like that, and look at things like heart rate variability and predict maximum heart rate response, I think, certainly, if you wanna get into nitty gritty of that, there's ways to differentiate between moderate and vigorous.

00:16:06 [Speaker 3]

But for each person, a really easy task is the talk sing test.

00:16:10 [Speaker 3]

What that essentially is is moderate moderate intensity exercise is a point where you're doing physical activity to a point where you can have a conversation, but you can't sing.

00:16:18 [Speaker 3]

So that's essentially when you know your point where you're, you know, moderately out of breath.

00:16:22 [Speaker 3]

Again, that will vary from person to person.

00:16:24 [Speaker 3]

That will vary on comorbidities.

00:16:25 [Speaker 3]

So, again, you start a hard and fast rule, but for your average person, that's a really easy way to differentiate.

00:16:30 [Speaker 3]

Okay.

00:16:30 [Speaker 3]

Am I short of breath enough to call this moderate intensity exercise?

00:16:34 [Speaker 3]

Vigorous intensity exercise is more that you can't have a conversation or sing enough to to call it vigorous intensity exercise.

00:16:40 [Speaker 3]

So that's kind of a hard and fast sort of rule that you can try and use to to differentiate intensity of exercise.

00:16:48 [Speaker 2]

And this is something our patients will will readily understand in clinic as well, and it's something that they could readily sort of apply to their everyday life.

00:16:54 [Speaker 2]

So So that's that's really useful to to to hear about.

00:16:57 [Speaker 2]

And and now we're thinking a little bit more about how how excited it's going to to impact the patient and and what they will experience.

00:17:04 [Speaker 2]

And I I guess some careful counseling is needed here, isn't it, Raj, as to as to what patients should expect?

00:17:09 [Speaker 2]

And then the the follow on question to that is patients obviously come in with with a variety of different symptoms in rheumatology, pain, fatigue, joint stiffness.

00:17:19 [Speaker 2]

How is exercise going to modify a lot of these factors?

00:17:23 [Speaker 3]

That's a really important question, actually, Daniel, because ultimately there is a fine line between overmedicalizing exercise but also on the other side encouraging people to be active, and I think, you know, the evidence so far across rheumatic diseases, as seen in the 2018 guidelines, our paper a couple years ago, and a sneak preview for the 2020 guidelines, is ultimately almost every type of physical activity and exercise across rheumatic diseases essentially works, so there's good evidence that it helps pain, helps fatigue, helps sleep, helps mood.

00:17:52 [Speaker 3]

I could go on there.

00:17:53 [Speaker 3]

The benefits really are enormous with physical activity and exercise.

00:17:58 [Speaker 3]

But what's tricky to then outline is how you then apply that evidence to the patient sat in front of you in clinic because ultimately you can show them all the evidence in the world about, you know, how Nordic walking, for example, or hydrotherapy or yoga or tai chi is really good for their rheumatoid arthritis or axial spondylosis.

00:18:13 [Speaker 3]

But again, actually getting them to try and take it up, try and do it, and actually try and, give it a chance for their symptoms is really tough.

00:18:20 [Speaker 3]

And those barriers, like you said, of pain, fatigue is going to be really tricky to to overcome.

00:18:25 [Speaker 3]

But the question is how do we do that?

00:18:27 [Speaker 3]

I think working in a team, working with your physiotherapist, working with your specialist nurses, working with sports and exercise medicine.

00:18:33 [Speaker 3]

I think this is exactly what we do on a day in, day out basis, and sometimes, you know, I've worked in rheumatology clinics where I've had to, you know, take patients who are pretty stable on their medication, who just want to be active, and, actually, the consultation with me is probably more than potentially a ten minute conversation about their medication that they're pretty stable on.

00:18:48 [Speaker 3]

And I think using the these resources and team around you can be can be really helpful and invaluable for those type of tricky nuances in terms of, exercise prescribing and conversations.

00:18:59 [Speaker 2]

Absolutely.

00:19:01 [Speaker 2]

And just to round off this particular segment of this podcast, obviously, it's great if our patients can can comply with with some of the the things that we recommend them, to do.

00:19:10 [Speaker 2]

But what about those patients who feel a little bit discouraged or or start to go off exercise, and suddenly we're we're losing exercise as a as a pillar of management in their condition?

00:19:19 [Speaker 2]

How do you approach that in the in the, say, the third or fourth consultation that that they've come into?

00:19:25 [Speaker 3]

It that can be really difficult, and I think I think, again, it comes back to actually, you know, have we lost them because we've potentially overmedicalized them?

00:19:32 [Speaker 3]

And I think there's a differentiation between physical activity and exercise that that sometimes gets a bit lost.

00:19:36 [Speaker 3]

So I think physical activity, we know, is any any movement, essentially, that requires energy and and force, and, actually, the studies that look at the difference between physical activity and exercise, whilst exercise is a bit more prescriptive and intentional, really, the benefits are seen across the board.

00:19:50 [Speaker 3]

So, you know, with those types of patients, do we need to really draw things back and say, actually, okay, you know, exercise isn't for you, but, you know, would potentially just being a bit more active in your day to day basis help?

00:20:00 [Speaker 3]

So, for example, increasing your step count by, you know, 500 steps a day or, for example, adding a bit of balance to your day.

00:20:07 [Speaker 3]

So, you know, when you you will have heard of this all the time, but simple thing, you'd be surprised that, you know, how much this small advice goes a long way, so you're getting off at the bus stop a bit early to get a few more steps in, taking the stairs where you can, balancing on one leg when you're brushing your teeth or popping the kettle on.

00:20:24 [Speaker 3]

For for a lot of people who start to lose their balance as they get a bit older, adding a little bit of proprioceptive exercise a long way in terms of their longevity and abilities to maintain their activities of daily living.

00:20:33 [Speaker 3]

So I think with those types of patients, really drawing it back to actually just to keep a little bit more active day in day out can make a big difference because again, you know, it's an in agel, analogy, but essentially, you know, some is good and more is better, and whatever that more is for them is gonna be so variable.

00:20:50 [Speaker 3]

So I think understanding that, and drawing it back down to the real basics can be really helpful.

00:20:57 [Speaker 2]

Personally, I'm finding this re really, really helpful for for my practice as well.

00:21:00 [Speaker 2]

I think a lot of what you're saying is is is some of the basics that that, you know, we we can always be doing better at, and and things that we can we can be offering our patients.

00:21:10 [Speaker 2]

Brilliant.

00:21:10 [Speaker 2]

So on that foundation, we're coming into sort of the final segment of this podcast, really.

00:21:15 [Speaker 2]

And, Raj, you and I had a little discussion before we we started this podcast, and and we were discussing about, referrals, from sort of general rheumatology to sports and exercise and medicine, drawing together what we've already talked about in this podcast.

00:21:27 [Speaker 2]

And we've come up with our we've come up, haven't we, with our top three referrals to to sports and exercise meds.

00:21:33 [Speaker 2]

And perhaps we can go into each of those, Pat.

00:21:35 [Speaker 2]

And if you can give a couple of comments about sort of what are the sort of things you encounter and and perhaps some of the things you'd like to hear from us when when we're giving you the referral, and then how how this impacts your your sort of management.

00:21:48 [Speaker 2]

So perhaps starting with the first one, and and we've got here, MSK pain, often of unknown origin in in a lot of our patients.

00:21:55 [Speaker 3]

Yeah.

00:21:56 [Speaker 3]

Exactly.

00:21:56 [Speaker 3]

So I'd say the vast majority of referrals we get, especially from rheumatology, but also from primary care and orthopedics, patients with musculoskeletal conditions should be either haven't been able to diagnose or manage.

00:22:06 [Speaker 3]

So I think particularly from rheumatology, it's often the ones that come from primary care to rheumatology with the query inflammatory arthritis or connective tissue disease that the rheumatologist is obviously very aptly either ruled in or ruled out.

00:22:17 [Speaker 3]

But ultimately, regardless of whether they've ruled in or ruled it out, I think sports medicine very much has the role to play there.

00:22:23 [Speaker 3]

So, for example, if they've ruled in an inflammatory arthritis and, for example, they have a patient with an axial spleen arthritis, differentiating between how much of their pain and functional limitation is secondary to their inflammatory condition, how much of it is biomechanical, how much of it is postural, how much of it is muscle overload, how much of it is postural.

00:22:41 [Speaker 3]

I think there's loads of facets, as we all know, that can that contribute to pain, particularly musculoskeletal pain, and I think a lot of rheumatologists will obviously very aptly treat their inflammatory condition.

00:22:52 [Speaker 3]

But if the patient then has persistent pain after that, it's really difficult then to tease out where that pain is coming from.

00:22:58 [Speaker 3]

The other thing, of course, is, you know, central sensitization and fibromyalgia is, you know, very common in patients with inflammatory arthritis.

00:23:04 [Speaker 3]

And, you know, when I do my rheumatology clinics, again, depression issue is really tricky.

00:23:08 [Speaker 3]

So this is where I think sports medicine has a real role to play in terms of doing things like diagnostic ultrasound, functional assessments, comprehensive musculoskeletal assessments.

00:23:17 [Speaker 3]

A lot of my clinics are forty minutes long, of which twenty to twenty five minutes of it is musculoskeletal assessment plus or minus ultrasound.

00:23:24 [Speaker 3]

So we really take our time in trying to assess those muscle deficits and where the pain or symptoms may be coming from.

00:23:30 [Speaker 3]

So those are the ones that, you know, we've rolled in inflammatory arthritis.

00:23:34 [Speaker 3]

On the flip side, the other ones who then rule out who, you know, who've had a rheumatic condition ruled out, for example, was just, again, even more so a reason for them to come to us because, ultimately, they still have symptoms.

00:23:43 [Speaker 3]

They still there was a reason they were referred in the first place, but clearly, with rheumatology, we haven't been able to give them a diagnosis.

00:23:48 [Speaker 3]

And I think ultimately, coming then to us for a diagnosis and subsequent management is really helpful because, of course, the accesses we have to in terms of imaging, in terms of injection therapies, you know, not just steroid, but things like PRP, shockwave, high volume, nerve blocks.

00:24:03 [Speaker 3]

There's a whole host of things that we we can potentially offer.

00:24:06 [Speaker 3]

And then also, you know, of course, working with our physiotherapy colleagues.

00:24:09 [Speaker 3]

We know our physiologists are incredibly invaluable when it comes to musculoskeletal pathology, but this is why we work so closely with them.

00:24:15 [Speaker 3]

You know, almost every patient I see, I've seen almost in tandem with physiotherapy or have conversations with physiotherapists because ultimately what we do very much complements each other and I think that's certainly, again, for those patients that have ruled out have a have a rheumatic disease ruled out, certainly, you know, I would love for rheumatologists to think the first person for them to send to is us.

00:24:34 [Speaker 2]

Brilliant.

00:24:34 [Speaker 2]

And we might come back a little bit to the interventional treatments.

00:24:38 [Speaker 2]

We've obviously listed this as number one on our list of of but also perhaps one of the most critical sort of categories of of of patient conditions that we've we've patients and patient conditions that we've dealt with.

00:24:48 [Speaker 2]

Mhmm.

00:24:50 [Speaker 2]

Thinking also to your particular clientele and your particular experience, because as well as sort of the everyday rheumatology patient, you also deal with with, say, professional athletes and professional athletes and rheumatoid out in advance.

00:25:00 [Speaker 2]

So how big a problem is this particularly for for this group of patients, and what do you counsel them on particularly if their pain doesn't get any better?

00:25:10 [Speaker 3]

It's it's a really difficult conversation.

00:25:12 [Speaker 3]

Right?

00:25:12 [Speaker 3]

The one thing because sports medicine as a specialty is so new, it was only recognized in The UK in 2005, is that the evidence base we have for a lot of our treatments is growing.

00:25:22 [Speaker 3]

I mean, they're not non existent and they have fluctuated over the years, but we are growing as a specialty in terms of our research, our evidence base, and the treatments we can offer.

00:25:30 [Speaker 3]

And year on year, we have new treatments coming out that certainly, you know, do show promise.

00:25:34 [Speaker 3]

And I think often what tends to happen is they they start almost at their lead level because we know that, of course, with elite athletes, often time is of the essence and ultimately getting them back to performing at the level that they need to means that means that you have to make sometimes difficult decisions on treatments that may not have always the best evidence outcome, but counseling them and actually understanding the rationale for doing them with environment and using the broad MDT around you can be really helpful.

00:25:59 [Speaker 3]

And often what we find is then if it's been proved in that environment, it then trickles down to to everyone else.

00:26:03 [Speaker 3]

And certainly, that's how a lot of the treatments we've used, we do use at the moment in the NHS and and not just in any environments, have happened and have occurred.

00:26:12 [Speaker 3]

And I think that's often, unfortunately, where things start.

00:26:15 [Speaker 3]

But, you know, that it's it means our specialty is exciting and it's growing, and there's a lot to lot to be excited about in that sense.

00:26:22 [Speaker 2]

I mean, this is absolutely fascinating.

00:26:24 [Speaker 2]

And this is this is really the the doctor's perspective on all the sporting events that there are out there publicly to to the and and and that people watch and enjoy every day.

00:26:33 [Speaker 2]

This is something that we we see on a on a regular basis, and and and the thing that sort of concerns us the most, I guess, and and the things we and probably the reason why we do this specialty.

00:26:42 [Speaker 2]

Mhmm.

00:26:43 [Speaker 2]

Moving on to the next category.

00:26:45 [Speaker 2]

We listed number two as being primary tendon pathologies.

00:26:49 [Speaker 2]

And could you tell us a little bit more about that?

00:26:51 [Speaker 3]

Yeah.

00:26:52 [Speaker 3]

So I'd say probably in in your general sports medicine clinic, I'd say forty to fifty percent of patients we see generally have secondary tendon pathology.

00:26:59 [Speaker 3]

I think a lot of what I do as well is trying to differentiate is that a true just isolated tendon pathology or or is this an inflammatory enthesopathy?

00:27:06 [Speaker 3]

So is this an seronegative spondylolaryngitis that we're missing?

00:27:08 [Speaker 3]

So I think a lot of it you'd be surprised how many we end up picking up because, of course, that is a hard diagnosis to make in the first place, but often ultrasound, the history and the location of the pain can certainly help with that.

00:27:18 [Speaker 3]

But if it is indeed a primary tendon pathology, I think often they tend to grumble for a long time.

00:27:24 [Speaker 3]

Tendon issues are very difficult to come over, especially primary tendon issues because we know, you know, tendinopathy, tendinosis, tendinitis have been used interchangeably for many years now.

00:27:35 [Speaker 3]

And I think teasing them out really depends on how we then treat it.

00:27:38 [Speaker 3]

We know tendinitis by definition is a more inflammatory process around the tendon.

00:27:42 [Speaker 3]

So whether that's inflammatory signal in the tendon sheath or within the parotenol itself can differentiate between how we manage it versus a chronic tendinopathy.

00:27:51 [Speaker 3]

So these are tendons that you when you see an ultrasound, look horrendous.

00:27:54 [Speaker 3]

They look grumbly.

00:27:55 [Speaker 3]

They look, you know, they look out of shape, quote unquote.

00:27:58 [Speaker 3]

And for those of you familiar with ultrasound, you'll be able to appreciate actually what versus a non healthy tendon looks like.

00:28:03 [Speaker 3]

But, again, you know, using programs like eccentric loading, shock wave therapy, injections for more of your chronic crumbling tendinopathies, and differentiating between the two is a lot of of what we do, really.

00:28:13 [Speaker 3]

But you can see, again, how very nicely that ties in with physiotherapy because often people with a tendinopathy issue will see seek a physiotherapist.

00:28:20 [Speaker 3]

They'll try a few months in rehabilitation.

00:28:22 [Speaker 3]

And, unfortunately, if that then doesn't work, they often come to us for diagnostic confirmation number one and then discussions around injection therapies, which is, again, a big part of what we do.

00:28:33 [Speaker 2]

And for and for all the rheumatology trainees or would be trainees out there, this once again emphasizes the the importance of history examination and and investigations in that order and going into great detail on this.

00:28:44 [Speaker 2]

But could we also perhaps take a little brief detail to consider the anatomy and physiology of of tendons and and collagen, and and and how how does this factor into your clinical decision making?

00:28:55 [Speaker 3]

Oh, yes.

00:28:55 [Speaker 3]

So tendon pathology is one of those things that, you know, again, our understanding of tendons have increased massively over the years.

00:29:01 [Speaker 3]

So when I did my masters a few years ago, one of my, professors who is a, I would say, a tendon guru and a whiz when it comes to understanding tendon pathology, actually started her career as a vet.

00:29:13 [Speaker 3]

And actually, a lot of the research we know about tendons have started from from the equine models.

00:29:18 [Speaker 3]

What we do know about tendons is that, generally speaking, the collagen fibers tend to respond to load.

00:29:23 [Speaker 3]

Compared to muscle injuries, compared to bone stress injuries, compared to ligament injuries, tendons are one of the few tissues in our body that respond really well to loading, especially eccentric loading.

00:29:32 [Speaker 3]

And I think that's often where chronic tendinopathies start and we have lots of rehabilitation protocols that vary from tendon to tendon.

00:29:39 [Speaker 3]

For example, Achilles tendinopathies, patellar tendinopathies, glute medius tendinopathy, so, you know, that overlap with trochanteric bursitis and trochanteric pain syndrome, certainly vary in terms of how we load them, but ultimately load through tendon really is is an important thing that we do in terms of helping that tendon healing and and endurance and structure within the tendon.

00:29:58 [Speaker 3]

And often you'll see actually if you do sequential ultrasound is that some of those fibers within within the tendon look a lot healthier as you tend to load it.

00:30:06 [Speaker 3]

Now the UNCS we use to try and help tendinopathies very much stem from symptomatology.

00:30:13 [Speaker 3]

So depending on how inflamed and angry and aggravated the tendon is, that may respond better to injections than potentially loading at certain points in their rehabilitation pathway, but also shockwave therapy.

00:30:25 [Speaker 3]

So shockwave therapy, of course, we're all familiar with it when it comes to polarizing kidney stones, but for many years now for tendon issues, shockwave therapy has become a very mainstay, treatment modality.

00:30:35 [Speaker 3]

Again, we probably don't have too much time to go into the details and science of it.

00:30:38 [Speaker 3]

It's something we use, and it's very much a, a low risk, high reward type treatment.

00:30:43 [Speaker 2]

Brilliant.

00:30:44 [Speaker 2]

And that nicely brings us on really to the to the to the third most common referral that you receive, which is which is really for interventional treatment, isn't it?

00:30:50 [Speaker 2]

And you've just touched a little bit upon the upon shockwave therapy.

00:30:54 [Speaker 2]

Extracorporeal therapy is another term for it, I guess.

00:30:57 [Speaker 2]

But how about also platelet rich plasma?

00:30:59 [Speaker 2]

And and when do when do we consider that in in our patients?

00:31:03 [Speaker 3]

So that platelet rich plasma is, again, it it's been around for a long time now.

00:31:06 [Speaker 3]

I'd say at least so it started initially as autologous blood injections, and then the then the researcher run actually trying to isolate the platelet plasma section of the of the injector, has become in favor for the last kind of, I would say, ten, fifty.

00:31:21 [Speaker 3]

PRP, again, has come and gone in waves.

00:31:23 [Speaker 3]

I think people were really excited about it when it came out, and there were big multicenter control trials, that essentially disproved it for certain things like Achilles tendinopathy, and certainly we do use it occasionally when suddenly nothing else has worked.

00:31:36 [Speaker 3]

Generally speaking, the consensus at the moment with PRP is for tendinopathies and, in certain indications, osteoarthritis.

00:31:43 [Speaker 3]

The evidence base is growing.

00:31:45 [Speaker 3]

European guidelines from last year did suggest PRP could be considered as part of your treatment pathway for knee osteoarthritis, and that has come and gone in favor over the last year since those guidelines came out.

00:31:56 [Speaker 3]

But I'd say to cut a long story short, vast majority of the time, it's a consideration for chronic tendinopathies, partial tendon tears, and potentially osteoarthritis.

00:32:05 [Speaker 3]

Brilliant.

00:32:06 [Speaker 2]

And that really concludes our top three, doesn't it?

00:32:08 [Speaker 2]

So MSK pain of sort of unknown origin in a lot of our patient groups, primary tendon pathologies, and interventional and referrals for interventional treatments.

00:32:18 [Speaker 2]

And now and, Raj, just to just to close off this segment, obviously, you know, for for all the the rheumatologists out there, any other sort of referrals that you'd be very happy to sort of provide advice on or or to receive, particularly in in this in this sort of sports, exercise medicine, and musculoskeletal medicine sort of section?

00:32:33 [Speaker 3]

Absolutely.

00:32:33 [Speaker 3]

So I think I could I think we've already touched about this, but I think the three areas would be, you know, if there's musculoskeletal pain that we can't really explain, number one.

00:32:40 [Speaker 3]

If you have a patient with a rheumatic condition where actually their disease process doesn't necessarily match their symptomatology, number two, you have a patient with rheumatic condition that wants to be more active, wants exercise advice and guidance, but they're unsure where to start, number three, and like you said, interventional treatment.

00:32:56 [Speaker 3]

I think, you know, all of us are skilled in doing ultrasound guided interventions.

00:33:00 [Speaker 3]

I would never go back to doing landmark now, unfortunately, after after being, upskilled in ultrasound.

00:33:05 [Speaker 3]

I think, certainly, you know, if there's any if there's any concerns around that, I know Ruben D'All just wants to have a conversation.

00:33:10 [Speaker 3]

I think every sports medicine consultant I know is friendly, is willing to pick up the phone and and have a conversation.

00:33:16 [Speaker 3]

So, those would be probably the big four, I would say, in terms of referrals.

00:33:20 [Speaker 2]

And now just to close off our podcast, you've touched on this actually a little bit earlier, but we're we're now due with some new guidelines.

00:33:26 [Speaker 2]

It's an activity and exercise.

00:33:28 [Speaker 2]

I'm wondering if you can just share this a bit because you're actually sort of part of that process as

00:33:32 [Speaker 3]

well.

00:33:33 [Speaker 3]

Yeah.

00:33:33 [Speaker 3]

So unfortunately, I can't say too much at this stage, but I think what I can say is that the evidence base is growing.

00:33:38 [Speaker 3]

I think the last seven years we've seen a huge explosion of really good quality research of exercise and physical activity across rheumatic diseases, so I think the overall message remains really optimistic.

00:33:49 [Speaker 3]

What we are seeing more of is the use of wearables and actually coming to new age technology in terms of how we track physical activity and exercise, and I think there will be there will be guidance on that about how we how we use that in terms of our day to day, management.

00:34:03 [Speaker 3]

And then the last thing to say, really, is actually we we we are gonna put out more information on actually how do we eventually do a meta analysis.

00:34:10 [Speaker 3]

So we talked about earlier is how do we compare between physical activities, and what is the optimum exercise for each person?

00:34:17 [Speaker 3]

I think we are heading there.

00:34:18 [Speaker 3]

We still don't have an answer yet, but there will be some updates on kind of how we start approaching that in terms of standardizing studies and outcome measures.

00:34:26 [Speaker 2]

So watch this space is basically the the the the answer then, and then I believe there's there's the upcoming twenty twenty five EULA guidelines as well that may be in process at the moment potentially?

00:34:36 [Speaker 3]

That that's exactly it.

00:34:37 [Speaker 3]

Yes.

00:34:37 [Speaker 3]

Exactly.

00:34:38 [Speaker 3]

So those are the ones we are we are involved.

00:34:39 [Speaker 3]

There's about 25 of us on the on the, on the group at the moment.

00:34:43 [Speaker 3]

We've had a last kind of review of the, of the submission, and hopefully should be out pretty imminently.

00:34:50 [Speaker 3]

So yeah.

00:34:50 [Speaker 3]

So, again, just another plug.

00:34:52 [Speaker 3]

If you are at BSR in 2026, please do come along for the physical activity's sake, and we'll be talking about it there certainly.

00:34:59 [Speaker 2]

There you go.

00:35:00 [Speaker 2]

So that's for our listeners right there.

00:35:01 [Speaker 2]

Additional events that's upcoming at the time of this podcast.

00:35:04 [Speaker 2]

And, also, just to signpost viewers to the to the rest of our spotlight as well, where we've covered a few of some of the things that Raj has mentioned.

00:35:12 [Speaker 2]

I thought if we can just finish off this podcast just because we got a lot of listeners out there, a lot of people thinking about HST applications, thinking about CCT, thinking thinking even further than that.

00:35:23 [Speaker 2]

To start off with any advice you have for rheumatology trainees out there considering a career in sports, exercise, and muscular skeletal medicine?

00:35:32 [Speaker 3]

Absolutely.

00:35:33 [Speaker 3]

The biggest piece of advice would be find what you're interested.

00:35:35 [Speaker 3]

So, you know, sports and exercise medicine has those three pillars, and it may only be that one of them appeals to you.

00:35:41 [Speaker 3]

So maybe only the exercise aspect of it or the team care aspect of it or the musculoskeletal aspect of it.

00:35:45 [Speaker 3]

I think finding what interests you, number one, is the best place to start.

00:35:49 [Speaker 3]

There are loads of resources online in terms of diplomas from the faculty of sport and exercise medicine, so they have diplomas in all three of those pillars.

00:35:56 [Speaker 3]

If you want more qualifications, that's certainly a place to start.

00:36:00 [Speaker 3]

But also attending things like our conferences.

00:36:02 [Speaker 3]

There's online educational resources from the British Association of Sport and Exercise Medicine, or BASM.

00:36:07 [Speaker 3]

We also have our national conference every year in November.

00:36:10 [Speaker 3]

And, and, again, there's a whole host of accesses, resources online.

00:36:14 [Speaker 3]

Similarly, I'd be very happy to have a chat with anyone who's interested.

00:36:17 [Speaker 3]

I'll be at BSR.

00:36:18 [Speaker 3]

I'm sure you'll be able to find my email online.

00:36:20 [Speaker 3]

If you have any questions, I'm very happy to answer and and help any of my colleagues who are interested in the specialty to find more opportunities and get involved.

00:36:29 [Speaker 2]

Excellent.

00:36:30 [Speaker 2]

And lastly, something that's perhaps a bit more overlooked, how about for new consultants in rheumatology and and sports medicine?

00:36:37 [Speaker 3]

Yeah.

00:36:38 [Speaker 3]

So being a relatively new consultant myself, I think it's certainly there's a lot to learn in terms of how our specialty integrates with each other.

00:36:44 [Speaker 3]

I think rheumatology and sports medicine have such a great overlap to play with each other, and I think we we need to work together more, we need to find more hospitals that have both departments, which is sadly there there's not many of, and again finding your feet when it comes to developing the best career you can for yourselves is tricky, it's tricky.

00:37:03 [Speaker 3]

I'm still finding out how to navigate that at the moment.

00:37:06 [Speaker 3]

But, yeah, if anyone has any any tips or thoughts, again, please do come and find me at BSR, and we'd be happy to have a chat.

00:37:14 [Speaker 2]

Raj, thank you very much for joining us today and and taking us through this fair topic.

00:37:18 [Speaker 2]

And thank you to everyone who has joined us today listening to this talking rheumatology spotlight podcast on exercise.

00:37:24 [Speaker 2]

We hope it's been had had both refreshed and advanced knowledge to take back and implement in your clinical practice.

00:37:30 [Speaker 2]

So thank you.

00:37:31 [Speaker 3]

Thanks so much again, Daniel.

00:37:32 [Speaker 3]

It was great to be on board.

00:37:35 [Speaker 1]

Thank you for listening to talking rheumatology spotlight brought to you by BSR.

00:37:40 [Speaker 1]

Please do rate, share, and subscribe through your favorite podcast app.