Good morning or afternoon depending on where you're joining us from. Welcome to our live session, The Big Picture of Musculoskeletal Pain and Obesity. As an introduction, my name is Paul Skolton and I'll be the session director and virtual moderator today. I'm an assistant professor of physical medicine and rehabilitation at the Mayo Clinic here in Jacksonville, Florida, and I'm fellowship trained in pain medicine. My clinical practice is focused primarily on spine but I do see a fair bit of musculoskeletal conditions as well. I'll be joined today by my colleagues Rikki Singh, Raul Rosario, Mark Hurdle, and Britt Moore, each of whom will be introduced as we move through today's session. Before I get started, I ask, as has been noted, that you please type any questions that come up along the way in the Q&A box at the left and we'll do our best to answer as many of these as we can as we go through today's session. So this program will explore a variety of important topics related to the treatment of musculoskeletal related impairments in obese patients. They can sometimes be challenging. Often weight loss through diet and exercise are recommended but barriers such as worsening pain, decreased endurance or strength may need to be addressed through rehabilitation or improved pain control to help patients achieve success. We will touch on each of these topics as well as the role of emerging therapies such as biologics and the treatment of obesity related musculoskeletal conditions but before getting into some of the details and challenges of treatment, I'll be providing some background information and also reviewing a few relevant studies that are important to consider as we develop treatment plans for these patients. I have no disclosures. These are our objectives and we'll address these as we go through today's program and I'd like to start by reviewing the concept of body mass index and as a reminder it is calculated by dividing a person's weight by their height in meters squared and obesity is defined as anybody with a BMI above 30 with anyone with a BMI above 35 being considered extremely obese. The obesity epidemic is a major public health concern and if we look at a map of the United States we can see that the prevalence of self-reported obesity varies with geographic location. Looking at the data over time we can see that there's been a clear trend towards increasing levels of obesity across the country. If we look at the most recent data here coming up in a second from 2018 we can see that there are now only two states Colorado and Hawaii as well as the District of Columbia that have prevalences of less than 25% and there are more states than ever with rates above 35%. The two main strategies for addressing this obesity epidemic are typically diet and exercise. Diet is going to be touched on by Ricky Singh in the next talk and I'll do my best to cover some of the activity principles in this talk. The CDC and WHO guidelines recommend 75 minutes of vigorous activity or 150 minutes of moderate activity in addition to two days of strengthening in a given week. As physiatrists I think we're really well positioned to help patients achieve these goals and in fact the WHO even recommends a consultation with a quote-unquote activity specialist if there are chronic functionally limiting conditions present that may limit their success in reaching these goals. In general I think it's our role to encourage patients that any or most activities are safe and that it is safe to gradually increase activity levels and also to emphasize the important emphasize the concept of start low and start low and go slow. Encouraging patients to do activities that they're already capable of doing and then very gradually ramping up intensity and duration over time so that they're able to have successful outcomes. So what exactly is moderate or vigorous exercise? These terms are really based on the concept of metabolic equivalence of task or METs where one MET is the rate of energy expenditure while sitting at rest or so-called sedentary behavior. Light activity requires somewhere between one and a half and three METs and includes activities like walking a slow pace or cooking whereas moderate activity which is where we start to see some of the more profound health benefits would be between three and six METs and includes things like doubles tennis or walking more briskly. Vigorous activity between anywhere above six METs includes things like jogging running or even shoveling snow. So how many people actually are reaching these recommended levels of activity on a daily or weekly basis? The answer is really not enough. If we look at the data somewhere between 13 and 58 percent of patients are meeting activity guidelines depending on the joint involved and whether or not activity is required to occur in a minimum of 10 minute bouts and keep in mind this is data from patients who have arthritis which is probably one of the most common obesity related diagnoses that we see as physiatrists. This data is also consistent with the CDC data that shows that somewhere between 15 and 30 percent of the general US adult population is meeting guidelines and the importance of increasing these rates really becomes apparent if we delve a little bit more into the mortality and morbidity associated with being inactive. So a lack of moderate to vigorous activity is a known risk factor for several chronic conditions including diabetes cardiovascular disease and stroke and is associated with over 5 million deaths globally each year. Furthermore high levels of sedentary activity tend to further increase this risk. So it's not only important to increase your levels of moderate to vigorous activity but also really important to decrease the amount of time you're doing in a sitting position no matter how little that may be. This concept as well as illustrated in the figure here on the right we're moving down the vertical axis which represents sitting time and to the right along the horizontal axis representing time doing moderate to vigorous activity overall tends to decrease the risk of all cause of mortality. If we think about activity in context of the WHO's international classification of functioning our role as physiatrists is really to help patients with their impairments so that they're able to partake in more activity and fully participate in society. Relevant to this classification system are two key terms capacity and performance. Capacity assesses one's ability to complete the task in a controlled often directly observed environment over a relatively short amount of time such as a six minute walk test whereas performance data is measured in real time in a patient's native environment oftentimes over far longer continuous periods of time using wearable accelerometers such as those post pictured here. In this data tends to quantify activity in a way that provides a far more accurate picture of what's going on in quote-unquote real life and can be very helpful in exploring some of the relationships between activity levels tissue injury and related symptoms as we'll see in the next several slides. So osteoarthritis as I mentioned is probably one of the most common obesity related diagnoses that we as physiatrists see and patients I speak to often have two key concerns the first being that their underlying arthritis or may become worse so they may have worsening cartilage damage and the second being that they're going to have increasing pain if they increase their level of activity. This study published last year by Dr. Javelin explores some of these important relationships and if we look at the figure at left we can see that subjects spent the vast majority of time doing sedentary activity here in the red bars with very little time spent in the blue bars or vigorous activity. This is very much consistent with what we see in the general population. They also looked at radiographic evidence from these knees and about 14% of this cohort did have radiographic progression of their arthritis but when they assess this and looked at the risk factors associated with that progression believe it or not the more time spent in moderate to vigorous activity was not associated with this worsening. So this would suggest that patients do not need to worry necessarily about further cartilage damage but that's not necessarily the entire story. So if we look at another similar study using the same cohort of patients that utilized MRI evidence rather than the radiographic evidence we see that they found there's still no progression of worsening cartilage damage when examined by MRI and that's depicted here in the middle row of the figure on the right. However high levels of activity were found to be associated with increased severity of meniscal lesions and bone marrow and plate edema patterns. So while the cartilage may not be impacted by increasing levels of activity there may be other at-risk tissues that need to be considered when we're developing exercise programs for these patients. In addition to considering damage to tissues as activity is increased we also have to take into consideration the patient's symptoms. This study looked at pain stiffness and function among patients with mild moderate and severe arthritis. Unfortunately the data don't demonstrate improvements in these symptoms with increasing levels of activity as we might hope although there are some trends that are interesting to consider. For example looking at the bottom left figure here we see that as activity increases in patients with the mildest OA or the blue OA there tends to be lower levels lower risk of worsening pain but in moderate arthritis or the red bar that opposite seems to be true. To me this suggests that we also need to consider the severity of any underlying musculoskeletal pain generators as we help develop personalized activity recommendations for these patients. Strategies to address some of the musculoskeletal barriers to increasing activity whether it be through rehabilitation, improved pain management, or even the use of biologics will be covered by my colleagues in the remainder of this talk. But first Dr. Murthy Singh is going to explore some of the dietary strategies that can complement the physical components to help combat the obesity epidemic. So at this point I think in the interest of time I'd like to go ahead and introduce Dr. Singh. He is the vice chair and associate professor of clinical rehabilitation medicine at the Joan and Sanford Weill Medical College of Cornell University and he's also the director of interventional spine at Weill Cornell Center for Comprehensive Spine Care. His talk for us today is titled food is medicine a guide to the anti-inflammatory diet. Thank you Paul. I wish we were in San Diego today but I'm here in sunny New York. You know one thing I love about this topic is it's not something we discuss a lot in clinical care and it's something I think we should. You know patients come in with knee pain and joint pain spine pain things like that and we focus on the imaging like you talked about in your presentation. We focus on their function very rarely do we actually get to sit down and talk about their diet and I that's my deficiency in clinic and I'm hoping with this presentation hopefully people take back some points on talking to your patients about what they eat and how we can improve upon that. So no conflicts of interest no related disclosures to this talk. Basically I want to discuss how food can play a role in joint pain specifically knee arthritis and spine pain and what strategies we can develop with our patients to understand nutrients food diet etc to improve their functionality. So we know arthritis is a leading cause of disability in the United States both in adults and children but what we don't really talk about is how food can lead to inflammation can lead to joint destruction and joint generation and this is where I've taken a recent interest in working with our Center for Integrative Health here at Weill Cornell in developing more of a comprehensive plan for these patients. So degenerative joint disease you know we use the word degenerative disc disease degenerative joint disease you know some of it's not disease some of it is just age related wear and tear but when there is an inflammatory component maybe there's something other than cortisone which we do use a lot unfortunately maybe there's something else we can offer these patients in terms of modifying their behavior to lead to less tissue destruction and promotion of collagen production and joint space within the body. So inflammation you know inflammation is sometimes okay you know we twist our ankle and our ankle will swell that's inflammation that's cells coming to a point of injury to help heal and recover sometimes that's okay when inflammation becomes chronic that's when it can lead to tendon and tissue destruction degenerative discs in the spine facet arthropathy and things like that and that's when the capsule and the joint no longer becomes lubricated it becomes stiff the capsule gets hardened and that leads to decrease function down the road. Some of the causes of inflammation are obesity which I will discuss in a moment certainly I can't underplay genetics and family history we know that very well in spine literature that genetics can play a role up to 40 to 60 percent of degenerative disc problems. Lack of activity like Dr. Scholten said, lack of moderate exercise, stress you know some stress is okay stress can allow us to perform a little bit better but again chronic stress can lead to more insulin production which is bad for the body which I will discuss and age something we cannot modify but diet certainly where we can play a role in impacting our patients quality of life. So in thinking about inflammation you know what happens with obesity obesity leads to inflammation by producing a lot of these harmful cytokines such as the interleukins one and six tumor necrosis factor alpha and these cytokines kind of float around in the bloodstream and they focus on places where there is chronic inflammation such as joints such as a spine and that can lead to tissue destruction and cartilage destruction. So how can we intervene in order to decrease the production of these free radicals, decrease the production of oxygen within these joints to promote a more healing anabolic atmosphere versus catabolic and that's where diet really comes in. So how does diet and a healthy diet control joints so number one it's symptom reduction basically when you when we promote good diet and good eating habits in patients we're reducing that cytokine production that I mentioned earlier. Weight control is very important Paul mentioned BMI and BMI is great at looking at public health it's not really a great metric at looking at individuals you know we use the analogy of Arnold Schwarzenegger when he was in his peak bodybuilding years he was technically defined as class-one obese with a BMI of 30 so it's not pure and clean especially when you have a lot of muscle mass but looking at global health and population it is very helpful. In terms of immune support inflammation can lead to a destruction of your immune system so again promoting an anti-inflammatory diet can be very beneficial and chronic inflammation can lead to chronic illness so impacting heart disease cancer even psychological diseases can be impacted by the food you eat. So what happened with our nutrition you know basically in primitive humans there are mostly hunters and gatherers they either ate whole foods plant-based or wild game but with an increasing population we needed strategies on how to refine foods and process them so they can last longer and what happened with processing food we lost a lot of these micronutrients which I'll discuss in a moment and we lost a lot of fiber and this is kind of led to a destruction of the quality of food that we ate you know I remember growing up organic food was not something you needed to eat it was just a kind of a luxury item but now I feel with all the chemicals that we put into processing food some of the things you kind of have to eat organic in order to avoid those. Sugar is another thing that comes up a lot I talk about sugar and carbs a lot when we when we speak with patients with spine and joint pain simple measures like decreasing dairy decreasing sweets and carbs can lead to decrease inflammation of the body and most patients that do impact have those changes report back that they feel better in life. So things that can increase inflammation I mean a lot of you guys already know this but refined carbohydrates, sweets, french fries, soda, red meat you know again we need to live and I wouldn't say get rid of all of this because you know we all work and either your residents or med students trainees whoever you know we all kind of deserve this this break sometimes so it's just important to be mindful about what you're eating in order to minimize eating foods that increase inflammation also balancing your diet with food that decrease inflammation such as olive oil you know extra virgin olive oil is really great green leafy cruciferous vegetables almonds and walnuts fatty fish fruits and if you look at what a well-balanced anti-inflammatory diet looks like it actually looks very similar to a Mediterranean diet so Mediterranean diet always scores the highest in the healthiest quote-unquote diets along with dash and things like that but basically if you just look at this picture it's full of good oils good nuts fatty fish and vegetables and fruits so things to think about when looking at what kind of diet to emulate so when discussing the nutrient specific in inflammation the first thing that comes up is carbohydrates and the American diet typically is peaks and flows of peaks and valleys of insulin we eat a high carb-rich breakfast like a bagel especially here in New York your insulin goes up your blood glucose goes up your insulin chases it to shuttle all the glucose out of the bloodstream it goes back down you eat lunch again then a snack then dinner so all day you're kind of leading to this state of hyperinsulinemia and what happens with chronic insulin in the bloodstream these 10 signs the desaturases are on hyperactivity so linoleic acid gets converted to a rock arachidonic acid quickly because there's so much inflammation present in the body and with high arachidonic acid as we know that leads to prostaglandins and thromboxanes things that lead to pain which is why we usually treat inflammation with an anti-inflammatory such as either a steroid or non steroid but if we can prevent the surplus of arachidonic acid in the body by decreasing or improving on what we eat I think we can have some meaningful changes in the body in thinking the same thing glucagon actually does the opposite. Glucagon decreases the production of arachidonic acid, which leads to less inflammation in the body. Talking about fats, you know, we always talk about improving or increasing omega-3 fatty acids in your diet, which is true, but there's two real omegas, omega-6 and omega-3. So if you can look at this chart, I apologize, it's a little small, but you don't want a high omega-6 to omega-3 ratio. So if you look at some of these healthy fish, they're very high on omega-3s and not so high in omega-6, which is good. You compare that to bacon, and bacon is almost 20 to one omega-6 to omega-3. And what research has found is that if you eat a diet rich in omega-6, you're gonna lead to a pro-inflammatory state. Polyphenols, we've all heard of whole food, plant-based diets, you know, everyone can use a little bit more of this. What happens when we start cooking food and processing food, we eliminate a lot of these phytochemicals in the diet, such as polyphenols. And these are really good for you. We've known that they're important in maintaining a low inflammatory state in the body. So trying to eat whole foods is excellent. Unfortunately, our Western diet is the standard American diet, which is sad. It's very high in sugars, we know this. It can lead to increased risks of colon cancer, increased risks of heart disease. So it's really important for us as physicians, as healthcare providers, to inform our patients on eating healthy to maintain a good body and less inflammation. This is something I discuss with patients. And here at Weill Cornell, at the Integrative Health Center, we have a mediator release program. Basically, there are tests that can be done to show what you have a response to and increases inflammation in the body. And slowly you can eliminate those one by one. And we've seen patients are kind of receptive to, are sensitive to a lot of random foods. Usually it's dairy and gluten and carbs and coffee and things like that, but it could be chocolate. It could be tomato sauce. So this mediator release test can really tell patients what not to eat going forward. Eat rainbow, this is something I talk to my daughter a lot. And she's teaching me when I'm kind of not eating a rainbow to bring in whole foods and vegetables, cruciferous vegetables, like I mentioned, into the diet. Free radicals and oxygen radical absorption capacity is a measure of how antioxidant something is. So blueberries, pecans, dark chocolates, all these things are good. They can bring down free radicals in the body, which like I mentioned before, can lead to tissue destruction. So what is a good diet? Eating a variety of healthy foods, maintaining a healthy weight. We talked about weight and every pound extra in the body can lead to four pounds on your joints and seven to 10 pounds on your spine. So I tell patients, you lose five or 10 pounds in your abdomen, your spine is gonna be 50 to 70 pounds happier, and your joints are gonna be about 25 to 50 pounds happier. So five pounds can really make a meaningful difference in the body. Keeping joints lubricated, keeping the bloodstream full of oxygen and bringing that to different parts of the body is very, very important. Avoiding sweeteners. Basically the one thing we don't do well in medicine is prevention. We wait for patients to develop knee arthritis, to become overweight, to have pain. And then we like to intervene, especially us pain docs who like to put needles in things. But I think we're really doing a disservice to not educating our patients on eating nutrients that are rich and preventing pain. So we will, I'll entertain one or two questions before I pass it on Dr. Raul. One question was about vitamin D. Yeah, vitamin D is something we should talk about more. We've seen it in the literature, how a level of vitamin D can lead to less falls, but also less incidents of back pain. The problem with vitamin D tests in most labs is that normal number, we found it to be too low. I like to tell my patients to get that number higher than 40 or 50. Some labs say 30 is normal. So great question. Vitamin D is very important in getting sun, but also supplementing that as necessary. So if there's any questions at the end, we will entertain them. So let me pass it on to my colleague, Dr. Raul Rosario. Dr. Rosario is an assistant professor at the Department of Rehabilitation, Physical Medicine Rehabilitation in the Mayo Clinic at Florida. He did his medical education at the University of Puerto Rico, and he specializes in sports medicine. So hopefully he's enjoying better weather than me. Take it away, Dr. Rosario. All right, thank you, Ricky, for the introduction. Definitely the weather here in Raleigh is a little bit better than New York. I would like to thank also Dr. Sculton for coordinating this session, and APMNR for allowing us to speak about this important topic. So my presentation today will focus more on the conservative treatment options that we can use for knee osteoarthritis, which is the most common problems that we see in obesity with musculoskeletal pain. I have nothing to disclose, and the objectives would be basically going through the most common problems that we see in the musculoskeletal system with patients that are overweight, and discuss the conservative, non-interventional, and interventional options that we can offer these patients. So as you can see, obesity is associated to multiple problems in the musculoskeletal system, and this relationship is a little bit complex. It can involve the biomechanics, the diet, the genetics, the inflammatory factors, and the metabolic factors that the patient might have. But this presentation, we're going to focus on the genetic disease of the joint, especially on the knee. So osteoarthritis basically is a progressive degeneration of the articular cartilage. We noticed that there's some inflammation in the molecular level that we're learning that definitely there is involvement in that aspect, and we can see some evidence in the X-rays, and by seeing marginal hypertrophy and joint space narrowing, it's important to determine that the severity of the X-ray not necessarily correlates with the severity of the pain, or the decreasing function with the patient. So that's why it's important, I always say, we treat the patient and not the picture. We know that osteoarthritis is the leading cause of disability in the community, and there's a clear relationship of BMI in terms of developing the genetic changes on the knee, with some minor evidence on the hip. As we know, obesity can definitely affect the knee joint by affecting the forces. Obesity can increase the magnitude of the joint loading, it can alter the joint position, and can alter the joint alignment, and that's why we see sometimes that the patient have more evidence of arthritis in the middle compartment of the knee due to these changes in alignment of the joints. Definitely there's an association between BMI and the severity of the joint space narrowing in individuals that have virus alignment of the knees. So there's different treatment options, and the treatment option usually target the symptoms control. We're not changing the DC of the progression of the disease necessarily. And sometimes we can, and surgery is the only option in terms of improving the biomechanics of the knee and improve the function of the patient. So there's different guidelines that has been developed by different association and societies like the Ulster Arthritic Research Society International, the American College of Rheumatology, and American Academy of Orthopedic Surgeons. And we're going to review some of their recommendation in today's presentation. So first of all, as we discussed before, the first line of treatment is always exercise and a good diet. We should always emphasize the effects of exercise. We know that patients that are less active may develop early arthritis because the health of the cartilage is not optimal. So we know that exercise can have a role in keeping the optimization of that cartilage health. And motion is lotion. I always say that to the patient, and I kind of agree with that and try to selling exercise as an important aspect of their treatment. But it's important that you tailor the exercise to a specific patient. In theory, they need to avoid the high impact activity, which not necessarily will progress the arthritis faster, but it can flare the symptoms. So finding that good combination of aerobic exercise, a good resistance strengthening training, focusing in some increasing the strength of the core and the pelvic and gluteus muscle is key to keep the knee control and dissipate those forces. And making sure that they need to do this exercise for at least 12 weeks to see any big difference. And hopefully they can continue to do that in the rest of their life. Weight loss, as discussed before with an excellent presentation by Ricky, is extremely important. It can prevent osteoarthritis. It can help relieve the symptoms, improve function and improve the quality of life. As discussed before, I tell the patient that every pound of weight that you lose is four pound of forces that your knee doesn't have to overtake. So even by losing five pounds, it's a big difference. So by creating short goals, it will help the patient try to achieve this small difference and give them symptomatic relief. Because if you tell the patient to lose like 30, 40 pounds, they're probably not going to do it because in their mind it looks very hard, which it is. Sometimes some patient may require some help and that's where the bariatric surgery can come into play. And sometimes we don't think this option is a good option, but definitely there's evidence that it can help with the physical function, musculoskeletal pain and arthritis, as seen in this study that reviewed 43 different studies. So it's something to consider in terms of trying to help the patient gain some weight loss. In terms of physical maladies, very limited evidence. I still, there's a role in the use to try to decrease the pain, but in the patient that is very obese, that the tissue is more deep, it may be more difficult to have benefit result from this. But in terms of the guidelines, there is sufficient evidence to recommend the TENS and therapeutic ultrasound as part of the treatment options. Moving on to more pharmacological management. I don't use a lot of medication in my practice. I try to find other options to decrease the side effects. Acetaminophen had been shown to be inferior to NSAIDs in controlling this pain and not superior to placebo. So most of the guidelines do not recommend this as a good option. NSAIDs, we know that it can help in the short term. In the long term, it's not recommended because it can increase the side effects, especially in patients that have other comorbidities. And if the patient is obese, the likelihood of having comorbidities is high. And there are some studies that duloxetine may have a role and some guidelines recommend that the use of 10 weeks of this medication has been superior than placebo to help with arthritis. Opioids is a big no in my practice. It has not been shown to be superior than NSAIDs to improve pain or functional scores. And the risk of taking this medication is higher. So the risks are not higher than the benefits. If you're going to consider this, there's some evidence in the use of tramadol, which is a weak opioid. It has less risk of developing abuse potential and decrease the respiratory system. So it's something to consider as an option for this patient. Topical treatment. There's a few topical treatment that can be considered like capsaicin, NSAIDs, and salicylates. I use topical NSAIDs a lot in my practice. I tell the patient that they need to use it three to four times a day for a couple of days in a row to see some evidence. In the obese patient, it can be harder to get some evidence due to the deeper structures that we're targeting with topical treatment, but these are always options to the patient to see if they receive good results. Bracing. There's some evidence that valgus offloader bracing can be effective in improving pain secondary to the amygdala comportment. And as seen in this study systematic review, it has not been shown to help with the function or quality of life, but definitely with pain. In the obese patient, it may be difficult depending of the large body attitudes to try to fit this patient, but it's something to consider in some population. And I have a few patients that respond very well to bracing in terms of managing their symptoms. Interventional management. The idea is to put the medication where the problem is, to try to decrease the side effects systemically instead of giving oral medication. It has been shown that it can help in this patient. Guidance definitely in the obese patient would be very important. And I think Dr. Hurdle may touch a little bit about this. The most common medication that we inject is corticosteroid. We know that can elicit some immunosuppressive and anti-inflammatory effects in the area. The dose that had been shown to be beneficial is an equivalent or higher dose than 50 milligrams of prednisone that usually we use Tramzinolone or Depo-Medrol, which is similar to the 50 milligrams of prednisone. We know that this effect would be short-term and if you use it more and more, it can decrease the effect. Also multiple use into the joints can be detrimental for the cartilage. So being conscious of do not over inject the patients and let them know that there's some effect in the cartilage. Study have shown in MRIs and in vitro that steroid injections can affect the cartilage health. And also the numbing medication, I'm switching now in my practice to use Ropivacaine, which is less chondrotoxic than Lidocaine and Bupivacaine. So it's something to think in terms of it can be useful. The way that I sell this is we're going to the injection so we can decrease the pain in the short term, but you can, so you can tolerate the rehabilitation, the exercise and improve the quality of life. Another option that we can use is Yaluronic Acid or viscous supplementation. Your knee produces Yaluronic Acid, Yaluronate, but when the patient have arthritis, this balance has decreased significantly. And that's the idea of adding an exogenous intra-articular Yaluronate in order to treat knee osteoarthritis. But there's some controversy in terms of the evidence. It remains debatable and uncertain. Some study says that it helps, some study says that it's not better than placebo. And that brings to the point that some guidelines do not recommend this as part of their treatment options. In my practice, I still use it. I have some patient that respond very well, not sure if it's placebo or not, but they're helping. So that's the idea of this, we're decreasing the pain so maybe they can tolerate better on exercise program. And that's the idea of offering these options. So basically the summary of my presentation is in this table. And you can go in this table in the different guidelines that are recommended. And remember, these are guidelines. You're trying to find which options is better for your patient and try to decrease the side effect of those options in order to get them more active, which is the main goal. And hopefully eat better, which as discussed before is the main thing. Before we finish, I want to talk a little bit about the total knee replacement in this population. As we know, this is an option that patient that have knee osteoarthritis or arthritis in the hips can undergo. But we know that BMI more than 40 are more likely to experience serious complications during and after surgery than patient that have a more normal weight because this patient also have other comorbidities. Usually they have cardiovascular disease, type two diabetes, obstetric sylipidemia that increase the risk of having complications. And that's why some surgeons do not do surgery if the patient have a BMI more than 40 and some of them more than 35. So after they have the surgery, obesity can increase the implant and prosthesis complications. It can loosen up the components and increase the failure of their replacement. And it can develop some dislocation, especially in the hip. So the take home message of my presentation is basically that knee osteoarthritis is extremely common in the obese patient. We have different options to offer the patient that the idea is to control their symptoms so they can tolerate better nutrition and exercise program. And if they end up having a total knee replacement, the outcomes are less. So definitely regardless if they need or want a surgery, they need to do a weight loss program. So these are my references. So now I'm going to switch it up and I can free to answer questions at the end. So I have the pleasure to introduce the next speaker with Dr. Mark Hurdle. He's a consultant in the Department of Pain Medicine here at Mayo Clinic Jacksonville in Florida. His areas of interest are musculoskeletal ultrasound and spinal intervention. So I'm happy to introduce Dr. Hurdle. And I'm happy to answer questions at the end. Thank you. And I'd like to thank the Academy as well as Dr. Scholten for being generous enough to invite me to speak. I'm going to try to change things up a little and look at things from the perspective of the interventionist or the surgeon. And this will give a little bit of a fresh perspective to physicians who don't typically do interventions. And for those of you who do interventions, I'm going to delve into the effects of radiation and the potential risks with different interventions we offer. So I do consult for Avanos. I don't think we're conflicting at all in our discussion today. And I am on staff here at Mayo Clinic in Jacksonville. And I'd like to thank all of you who have muted the NFL in the background, wherever you are. I know it is around one o'clock. So what are our goals today? We want to kind of go over the challenges of obesity for doing image-guided interventions and discuss kind of which modality or which imaging may be best for different patients or different joints. We're going to touch on radiation safety, things to consider. And we're also going to kind of touch on technical considerations of different treatments. And also, what are some more aggressive interventions that one can consider if their BMI is too high for surgery and they're not participating or able to participate in physical therapy. So this was a case report. I think we wrote in the archives at least a decade ago or maybe eight years ago. So this is a lady who was sent, when I was in Rochester, who was sent to us from rheumatology because she had myofascial slash fibro-like symptoms and they wanted knee joint fluid to check for Lyme disease so we could definitively rule out other interventions, excuse me, other diagnoses. Obviously, typically when you aspirate a knee, you palpate the patella and you can go into patella unguided and drain fluid. Well, I couldn't really palpate her patella well So we ended up doing an ultrasound guided knee aspiration and sent it off for joint analysis and she was in fact Lyme negative. So this patient had been to radiology and it was too painful to be done under radiology where they're basically going down to us and just palpating around and it was done attempted in an unguided or palpation guided setting. It was also not successful. So these are the type patients we're dealing with. So when you refer to someone try to think okay what modality is appropriate and you know how can we get it done. So choosing a imaging modality obviously in the spine where we do a number of interventions here in the pain clinic a slight difference you know millimeters can make a really big difference. You can be intrathecal versus epidural versus intravascular. With ultrasound as a lot of you know the deeper you go or the deeper you're trying to see a clear image the harder it is because you lose accuracy and you lose precision with the depth. Under fluoroscopy or under CT you can get to the greater depths with some accuracy but you're also having to expose the patient and therefore yourself to greater vascular excuse me greater radiation exposure and you're also obviously injecting contrast. So for superficial interventions I always try to consider ultrasound first. For deeper interventions in my larger patients a lot of times I'll skip right to flora and in fact I always you know try to remind my colleagues who don't do interventions it's always good to at least look at the tissue where we're targeting. Back in Rochester I was sent a patient with a significant PANUS you know to do an ultrasound got a hip injection you know I retract the PANUS and there's a large fungal infection so might want to look at the tissue first and then obviously you've sent somebody for piriformis injection and they have a lot of soft tissue back there it becomes very challenging to do a piriformis injection if they have you know too much soft tissue in the area just because of the depth. Now what's the correlation between obesity or larger size and radiation exposure? So this was a study or looking at patients who are getting ablation for AFib and there was a 75% higher dose exposure to patients in the obese category compared to normal weight and overweight. So that means 75% higher radiation for both the patient and therefore for the interventionalist doing the procedure. So it's good to keep that in mind and this is a study I think out of RIC the impact of BMI on fluoroscopy as far as time duration of epidural steroid injection so multi center study and the conclusion was that basically obesity correlated correlated or BMI correlated more directly with fluoroscopy time than you know levels done and approached. So you could do bilateral or if a trainee was involved the highest correlate was BMI. Now when doing these interventions the goal is always to have the target area with a C-arm as close to the image intensifier or camera as possible to eliminate scab. The problem is the larger the patient the longer you have to the longer needle you have to use and you have to try to fit the needle between the image intensifier and the patient and it's more challenging. And there's a fairly direct correlation between the size of the patient and how much radiation is involved and here you can see the thickness of the patient in centimeters correlates quite directly on the right with the exposure of radiation. And here you can see on the left all the little arrows of kind of scatter you have more scatter with larger patient and then if you have to turn and get a lateral or an oblique you have even more radiation exposure again for both the interventionalist and the patient. And this is you know how when you took your driving test many years ago there's always the shock video of drinking and driving. Well this is the equivalent of radiation overexposure shock video or a shock picture of what can happen. You know you can have burns of the skin or large tissue deficit. I think I've seen this here once at this institution and it was in fact a patient you know who's you know very large and they were trying to cardiac trying to resuscitate him during a cath and he had too much radiation exposure. So it's it's pretty rare but kind of a take-home point as far as you don't want to overexpose them to radiation. So as far as the interventionalist is concerned the main source of radiation is the patient himself or herself. So what do you want to do? You want to minimize your time in front of the patient or being exposed to the radiation. You want to maximize the distance from the patient which means going behind a shield or taking a few steps back and you want to utilize a shield whenever possible. So what are the treatment options? You have these obese patients and this is kind of well spelled out spelled out by my colleagues. You know if they're over 40 BMI everyone's kind of you know hesitant to operate on either the spine, the hips, knee. You can do gastric bypass, monitored diet, you can increase your exercise intensity but again most of our surgeons have a criteria for BMI of below 40 specifically because the outcomes can be worse as Dr. Rosario discussed. There is increased risk of revision and there's overall poor outcomes and most importantly it's technically harder to do you know a spine injection, a knee injection or knee surgery, spine surgery on these large patients. So as far as treatment options one option that's kind of become more popular recently is radiofrequency ablation and it's radiofrequency ablation of the joint nerves specifically to allow a patient to be more active and decrease their weight so they can in fact go for knee replacement or hip replacement. It can also be used retrospectively because patients haven't had adequate pain relief from the joint replacement. Here's just a nice picture of genicular nerves where they lie medial superior and medial and lateral of the knee and inferior medial genicular nerves that we target when we do ablations. And ultrasound or fluoroscopy can be utilized to kind of position these needles with the target of ablating you know specifically medial medial and lateral genicular and inferior geniculars. And this can be done under ultrasound specifically when the patient has a stem in the femur and you can't really see in the lateral view where your needle has been placed. In addition hips can also be targeted for radiofrequency ablation specifically the branch obturator branch of the articular branch of the obturator and the femoral nerve. And this is a study looking at radiofrequency procedures to relieve chronic hip pain and kind of what we found is unfortunately there's no placebo controlled study but there is significant relief eight days to 36 months. Obviously we want to get at least you know six months of good relief to consider this a viable option. So in conclusion radiofrequency treatments for sensory denervation of the hip has potential to reduce pain secondary to degenerative conditions. Obviously we consider this when we've kind of gone through the previously mentioned interventions including visco supplementation corticosteroids and oral anti-inflammatories. Unfortunately there are no randomized excellent randomized control studies that prove this. And obviously a pool therapy is always an option but the patient has to be healthy enough and willing and able to get to the pool and get in the pool without too much pain to initiate a pool based therapy program. And that's a quick overview of the interventionist perspective for pain for obesity or dealing with obesity. Next I'd like to introduce Brittany Moore. She was at Mayo Clinic Jackson excuse me Mayo Clinic in Rochester and did her pain fellowship there and now she's back in her hometown in Kansas City working in apex orthopedics. But she's also the team doctor for Avila University and also does some consultant for a ballet company. So without further ado I'd like to introduce Dr. Moore. Awesome thank you Dr. Hertel I appreciate it. So get myself centered here. We are going to be talking about orthobiologics and obesity. A brief overview of the talk going forward. I'm just going to give a quick overview on terminology that I'll be using. So with orthobiologics there are non cell-based orthobiologic injections PRP amniotic products where we're using growth factors to influence the underlying environment and there are cell-based orthobiologic injections BMAC and fat where we have similar growth factors as the non cell-based but also have live cells that work through higher level cellular influences to modify the environment. So if you look through the orthobiological literature you find that BMI and weight are often factors that just aren't considered. On my own informal review of key papers I found that a significant amount of papers that are otherwise very well done completely don't mention BMI or body weight in patient description or exclusion criteria. When BMI is touched upon the overweight group is regularly included obese groups less commonly included and morbid obesity just very rarely included. I did not find a single paper that provided subgroup analysis of results by weight or obesity and so all of this is to say that orthobiologics is a giant quickly growing field. There are so many areas we have not explored and the effect of weight and obesity on clinical outcomes is one of those unexplored areas. So considerations during patient selection. The most important thing for chronic musculoskeletal conditions OA refractory tendinopathy is that you discuss with the patient a multimodal management strategy. We've talked about this already in previous talks. I add it here because it's an easy thing for you as a provider to not discuss particularly when the patient's coming to you asking for orthobiologics. I think it's worth your time to discuss realistic goals of orthobiologic injections and how we can use our typical conservative management approach as a foundation to optimize those goals. And so my quick spiel I give to patients when I'm talking about orthobiologics is there is a foundation of management where the literature shows that the most improvement can be made and that is if you're overweight to lose weight and two to perform regular strengthening exercises to support that joint in question. On top of that we can sprinkle any number of things with orthobiologics being one of those things that can provide further pain relief and benefit potentially. In my obese patient population I take the time to have a discussion with them about weight loss as well. The person's likely heard that weight loss discussion from their primary or other specialists. Often it's in vague terms related to health kind of vague health outcomes. I like to phrase it that hey you're obese you have knee OA or whatever it is. Remaining overweight will likely not progress that away but it will make you more symptomatic and weight loss is the one thing that we know will make the largest improvement in your pain and function and this is something that the other presenters have all touched upon and so I like to phrase it just a little more optimistic kind of standpoint and again those are things that other presenters have touched upon. Often at this point in my conversation the patient will say that makes sense I know I need to lose weight I want to be active but because of my pain I can't be active and when you consider it from that standpoint there's a strong argument to be made that orthobiologics actually may be ideal for this patient population. And why is that? One there's a large association between obesity and diabetes. Loading a diabetic patient with a bunch of steroids is just not ideal. Orthobiologics are a steroid sparing approach. Two often these patients aren't surgical candidates for joint replacements because of their BMI. Well orthobiologics are an option where we don't have strict weight cutoffs. And three orthobiologics when effective last on the order of months to even years compared to steroids that generally are going to be lasting weeks to maybe months. What are some considerations to discuss during the procedure? There is concern that cell-based injections EMAC and FAT may be less functional in an obese population. It's important to note that this data comes from bench studies not clinical outcomes. The pro-inflammatory environment of metabolic syndrome has been shown to have negative impact on MSCs. Specifically it causes reduced proliferation rate, reduced ability to clone, and altered expression of surface antigens. MSCs in obese and those with diabetes also have increased apoptosis and limited multipotency. We know all of this is true when we look at the cells in a petri dish in the lab but we don't know if this affects clinical outcomes. So when I'm counseling patients it's very much the same discussion I have with obese population as I do with the older individuals. Your cells may be less functional because you have a higher BMI than normal. We don't know if that relays any significant clinical differences. Another thing to consider is are you able to safely obtain the injectate you're trying to obtain? Specifically for bone marrow aspiration the majority of us probably do bone marrow aspiration under ultrasound assistance but not true guidance because you need fluoroscopy for that. Obesity is a risk factor for procedural complications in particular increased side effect of hemorrhages. I use the expert opinion from my prior place of work at Mayo that in BMI's of 50 or higher I sent those patients to my colleagues who can do a bone marrow aspiration under fluoro to reduce that side effect or risk of hemorrhage. Lastly as Dr. Hertel was discussing it's important to consider how are you getting to the target? Palpation guided injections are less accurate than guided injections and larger body habits worsens this baseline inaccuracy. So particularly with expensive orthobiologic injections I think it's critical to use guidance whether that be ultrasound or fluoro. With the obese population realize that ultrasound can be limited particularly with deeper structures and so when you're evaluating someone for an orthobiologic injection it's critical to do a pre-scan to ensure that you can visualize the target before you take their blood, draw their bone marrow, get their fat and distill it down to that orthobiologic. What are some considerations post procedure? So post procedure there are many factors that can potentially optimize the result of an injection. Most of these are theoretical meaning there's no studies evaluating their efficacy but I bring them up as consideration that may influence outcomes. And one thing that I talk about is offloading particularly after cell-based injections for the lower extremity. I will offload with non-departure weight-bearing for a period of time after the injection to limit the mechanical stress on the live cells. In the obese population however I do worry about the increased risk of DVTs if I'm telling someone to reduce their weight-bearing and so I counsel my patients about this potential risk that we can just forego any frank weight-bearing restrictions or maybe we can do more isometrics range of motions to potentially limit a DVT risk that they are at somewhat higher risk for. Another thing that you can consider post-procedure is what's called a booster injection. Again there's no real evidence in the literature that supports booster injections have better outcomes and what a booster injection is is it essentially refers to a therapy injection that's done at some interval after your initial orthobiologic injection. Usually I use this in patients who've had some improvement but overall an underwhelming response that kind of 6, 8, 12 week time frame after the injection but if you are wanting to throw everything you have at the patient to optimize all potential outcomes you could consider doing this as a low-risk potentially beneficial thing to do particularly an obese population. If I was going to add this as part of my standard protocol I'd probably do it at six weeks post the initial orthobiologic injection. So in summary one obesity is often not considered or accounted for in the orthobiologic literature. In vitro studies show MSCs are less functional in obese populations but there really aren't any in vivo studies showing inferior outcomes in obese populations. Lastly you need to be more thoughtful about your typical approaches in the obese population. All right that is the conclusion of my talk we will go to the Q&A session.

musculoskeletal pain

obesity

weight loss

diet

exercise

rehabilitation

body mass index

activity levels

osteoarthritis

orthobiologics