Joint Lab: Optimising recovery from your knee replacement – Neil Welch

Watch this video of Neil Welch, Head of SSC Lab discussing ‘Joint Lab: Optimising recovery from joint replacement’.

This video was recorded as a part of  SSC Online Public Information Meeting focusing on the Hip and Knee.

Lorem ipsum Neil Welch is Head of Lab at SSC Sports Medicine.

Good evening everyone, my name is Neil Welch – Head of SSC Lab Services at the Sports Medicine Department in the UPMC Sports Surgery Clinic in Santry. I would like to spend some time talking to you about your health, your fitness, and rehabilitation. In particular, the journey we may take throughout our lives, how that journey can change depending on our circumstances, and hopefully give you an understanding of how important it is to try and adopt some activities whether it is fitness, personal training, or organized activities to help maintain your fitness throughout your lifetime.

The first thing I want to start by saying is everybody’s journey is different we all have our path that we follow throughout our lifetime. I don’t want to come across as judging anyone for the number of activities they do or don’t do. The aim today is simply to help you understand the impacts of the paths that we do follow and to give a little bit of guidance hopefully to paths that guide each of us to better health.

When I talk about fitness and health, I am going to split it into 3 categories. The first is Musculoskeletal, this is the health of the muscles and the bones and joints within the body. The second subject we are going to touch on is our cardiovascular fitness, the health of your heart, lungs, and pulmonary system. Then as a general health element, we will discuss your BMI and body fat percentage. To help us through this journey, I want us to try and imagine that we are either a twin or we have some twins and we are going to step through a fitness journey with this pair here. We are going to call them Jack and Sarah. Being the good parents that we are, we guided them through their early years and into some activities so like GAA, camogie, hurling, soccer, rugby, athletics, some organized sports for our children that we are always keen to do as parents I think, to promote physical activity.

By doing this we cover several positive developments in their physical developments. The first is around optimizing skeletal Health. So we stepped forward a bit into our 50/60s osteoporosis and osteopenia the elements we want to try and avoid. We avoid these by having healthier bones essentially and higher bone density and bone mass. Physical activity in childhood could be a way to protect ourselves in that going forward. So what this study demonstrated were the activities that we may undertake have a massive difference in the challenge that they offer the body. We can see from this graph at the very bottom is the amount of force that the body has to cope with while standing still, that dotted line while walking and then the spikes and ground reaction force, that the body has to cope with while running and during a landing task which we might also equate to decelerating change direction during field sport are all very different and very often the impact loads that are sustained during running and field sports are castigated being a negative thing, and they can be if we do too much of them, so if we have children who are very active and are training every single day and sometimes a couple of times a day, we can give them too much and we can get bony stress responses but for the most part these kind of impact loads are health and the body changes itself to be able to cope with so the bones become denser and they become stronger. By asking Jack and Sarah to pop down to their training sessions we are helping to strengthen their bones and limit the chances of these issues later on in life.

We often adopt physical activity and promote it amongst our children, to promote healthy body weight. We know that obesity particularly well throughout the whole population icon the rise and pediatric obesity is no different. This systematic review looked at studies around obesity in children and whether youth sports do anything to prevent it okay and then the results of this study are inconclusive, so we can’t say certainly that exercise is going to prevent obesity in childhood it seems like it’s a much broader topic and nutrition plays a much bigger role or as big a role as an exercise in preventing it. So moving away from junk foods and high sugar foods seem to be as or if not more important than exercise for saving off weight as youngsters. We also know as well that physical activity reduces cardiovascular risk factors in children, so a healthier heart and lungs, and circulatory system leads to fewer complications in children and this then carries forward into later life in part because we take on healthy lifestyle choices and habits so we maintain a lot more physical activity when were more active were young, so when we think back to jack and Sarah there’s a whole heap of benefits were given to both of them just simply by bringing them down to sport and helping them to participate inactivity.

Now we are going to step up upon a scenario, so we imagine jack who’s active and enjoys his football, come across some tricky times with injury, he’s unable to rebuild rehabilitate himself to a position where he can get back, he didn’t rehabilitate here but that ends his sporting journey, he gets to a stage where it is not worth him picking up the niggles and he stops playing sports and that’s probably a fork in the road that a number of us watching tonight have stumbled upon. Sarah on the other hand stays fit healthy, enjoys a sport, stays engaged with it, and continues playing sport throughout her adult life. So we end up with this little fork in the road, so what happens there. We think first of all around our musculoskeletal system so muscular strength is really important for reducing all-cause mortality which might come as a surprise to you but this is a large review study so there are over two million or approximately two million participants worth of data over 38 studies essentially the strong you are in the lower and upper body the lower risk of all-cause mortality in the adult population so essentially you live longer and this association was higher among females. So again if we think back to Sarah and Jack and by removing some of the strong stimuli that we might get with exercise we maybe predispose them to further issues in adulthood, similarly we remain active ourselves again maybe we are doing ourselves a disservice in terms of our longer-term health and we know that as we age we lose muscle mass anyway this is a process called sarcopenia and the example here is an MRI of the thigh and we can see on the left-hand side the muscle mass so that’s the grey elements around the white bone at the center now the white ring around the outside is subcutaneous fat, so it’s the fact that you have just sat below the skin. In the second image, we can see how that changes so the muscles mass reduces and the amount of the percentage fat we have increased and then graph on the right-hand side is it just indicates how the number of muscle fibers reduces throughout our lifetime so that’s the battle was trying to have as we go through the aging process. Activity can influence this, here we have an MRI slice of the thigh with a 40-year-old triathlete again the white thigh bone in the middle and the grey muscle around it, and a very thin layer and a tiny layer of fat around the outside. Then we have our 74-year-old sedentary man as an example so again we can see how the size and the quadriceps are reduced and the amount of adipose or fat tissue that can exist around the quads then. We can also see an example of a 70-year-old triathlete and we can see the difference in condition.

There are also cardiovascular effects and exercise benefits without going into too much detail, we reduce our risk of cardiovascular disease and cardiovascular mortality. The elements on there you will recognize are our reduced resting blood pressure and reduced blood pressure as well also reduce resting heart rate. So again lots of positives to remaining physically active. The dotted lines are those who didn’t do exercise and the black lines are those who did exercise throughout the 12-week intervention. The lines going down indicate that they lost weight. It doesn’t matter what diet you take as long as you run a deficit you will lose weight. In the future those who did not exercise gained weight. So we see these graphs here, they have split this up into an a and b, one for smoking and non-smoking. I think it’s worth noting from the data that we have and the changes in risk when we adopt certain lifestyles. So broadly speaking this is the world health organization, we know that maintaining a healthy weight and maintaining physical activity, reduce our chances of type two diabetes, cardiovascular disease, We reduce falls in depression, dementia and there’s a certain healthy body healthy mind element to that joint and back pain and cancers reduce just by simply being more physically active. We talk about being more physically active, so what does that mean, essentially we look at the bright green on the left-hand side and we think of this as being our cardiovascular fitness, so exercise that gets us out of breath, a bit sweaty. 75 minutes of vigorous-intensity exercise or 150 minutes of moderate exercise is going to lower those risk factors. Reducing our sedentary lifestyle so sitting less and getting up and moving around more and then some form of strength exercises like the gym or yoga to build strength at least two days a week.

That brings us to what we do here at the UPMC Sports Surgery Clinic to try and help individuals with their health and fitness. My job as the Head of Lab Services is to try to introduce testing and rehabilitation or training interventions for everyone and wherever they are on their fitness journey. We think that offering information and education is important for shaping your rehabilitation from surgery and injury. Within the fitness realm offering testing services to ensure that your exercise strategies are doing what they need for you. It is simply to give you an understanding of where your current fitness and strength levels are currently and to give you guidance on what you need to work on. Our rehab lab testing is what we do for our injured patients for example if you were jack and injured your ankle you would come in for some isokinetic testing, so we measure the strength of his joints to hip knee, and ankle to try and understand where he was weak and we might need to work on. As well as getting some biomechanical information, to understand anything in the individual’s movement that they might need to change. Fitness lab, we can do vo2 max test to measure cardiovascular fitness, we measure body composition, upper and lower body strength measures, and explosive strength measures and we also give you an individualized strength and conditioning program to target your needs. We are starting our Health lab service which is more tailored to weight loss, we measure your resting metabolic rate, blood glucose monitoring, blood inflammatory monitoring, and body composition. Thank you for taking the time out to watch this and I hope it has been informative.

If you start thinking of your exercises divided into two categories, one of them is around cardiovascular health, exercises where you get out of breath and sweaty, these exercises look after the heart and lung function. That becomes more biased as we age. The other categories to maintain muscle mass would be resistance exercises, these would be elements if you were a member of a gym where you might simply use some of the machines in the gym for the lower body exercises like the leg press and the leg extension are excellent for maintaining muscle mass.

In the upper body, especially in females, we see more of a loss in muscles mass and strength in females. Pushing and pulling exercises again there are machines. The exercises should be tough enough so they feel a bit sore. If you do strength exercises twice a week you can maintain and even gain more muscle mass. It is also very healthy for the joints and tendons as well, there is good evidence emerging of this.

Similar to what I was saying and without being an expert on the hormonal changes and systematic changes that join them during menopause. I’d say first of all if you have any severe symptoms then chat to your GP first before engaging in physical activity, but as a general rule doing stuff where you feel comfortable doing it would be a good guideline initially.

Then to just do what you can, if you go through periods where it is a real struggle through symptoms and pain then you just do what you’re able to and you’ll find there’s very often a certain psychological benefit to doing some exercises as well that might even give a little bit of a lift during periods where there’s more pain or symptom.

My first taught there is about the range of motion in the hip. If you are sitting in a kayak you would need 90 degrees plus of hip flexion, so if you can get your full range of hip flexion back then it shouldn’t be a challenge. Then there is a cardiovascular component to kayaking and a bit of strength loss with the upper body so I would be thinking from a cardiovascular perspective, you might be reliant on the bike, to begin with, to maintain their fitness and upper limb strength you can maintain again relatively straightforwardly in the gym, to limit the strength loss you will have from just not doing kayaking anymore. The main limiting factor would be I would expect a hip range of motion

Getting advice and finding a physiotherapist that you trust to give you some guidance on that and some things you will be surprised by how much you can do relatively early on the following surgery, the area that takes the longest period regaining the loss of muscle through that will have occurred following a long period of pain preceding the surgery and then also the surgery itself that’s what we find its re-gaining the size and strength of the muscles around the knee joint that is always the slowest.

What you are trying to do before surgery is minimize the muscle loss or gain as much muscle as you can beforehand but also there is a challenge there in that depending on symptoms, you don’t want any of your exercises to flare up lots of pain or symptoms around the hip as you want to preserve as much range of motion before surgery as possible.

Oftentimes when you exercise into pain you kind of speed the loss of strength anyways, so exercises in particular for your bum, the back of your bum so exercises like a glute bridge, for example, banded clam exercises for the side of the hip and then basic hip flexor exercises as well, anything that doesn’t cause pain but makes the muscle work hard is going to give you as much benefit as possible. You might find you can do more than this before your surgery, you might speak to someone before to get a more challenging strength program, which puts you in a better place before the surgery.

This can be quite dependent on and Gavin might expand on this, depending on what the knee is like before surgery and the period that there’s been a loss of flexion for. So if its been 5 years and you have only had 90-degree knee bend, then it’s unlikely that you are going to restore full flexion compared to the other side, so unfortunately I think it’s a how long is a piece of string kind of scenario there but you would expect whatever range of motion is going to come back, you should have that restored certainly within 9 months following surgery.

To make an appointment please contact 01 526 2030
Date: 8th March 2022
Time: 6:30 pm
Location: Online
This event is free of charge