Journal Club: Effect of running and walking on osteoarthritis and hip replacement risk

The article reviewed is WILLIAMS, P. T. Effects of Running and Walking on Osteoarthritis and Hip Replacement Risk. Med. Sci. Sports Exerc., Vol. 45, No. 7, pp. 1292–1297, 2013

http://www.ncbi.nlm.nih.gov/pubmed/?term=WILLIAMS%2C+P.+T.+Effects+of+Running+and+Walking+on+Osteoarthritis+and+Hip+Replacement+Risk.+Med.+Sci.+Sports+Exerc.%2C+Vol.+45%2C+No.+7%2C+pp.+1292–1297%2C+2013
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Design:

• This well designed article evaluated 74,752 runners and 14,625 walkers from the National Runners' and Walkers' Health Studies.  This is an unusually large number of runners and walkers evaluated, which is often a limiting factor in most studies.
• The runners and walkers were queried as to whether they were ever told by a physician they hip osteoarthritis.  This is an imperfect way of assessing the development of hip osteoarthritis, but as imperfect measures go, it is reasonable.  In some ways, this is a better measure than using a more "objective" standard like criteria based on x-ray or MRI imaging, since the correlation between imaging finding and functional limitations is imperfect, and for most patients, the only reason a physician would tell them they had hip OA is because they went to the doctor regarding a functional issue.  If I had a perfect measure, I'd want some form of functional assessment, but I do think this is a reasonable proxy.
• Another outcome measure was whether they reported having a hip replacement.  This is also a reasonably good measure- I don't know for sure, but I was assume that the correlation between reporting have a hip replacement and actually having a hip replacement is very close to 1.0.  Reporting bias is always a concern, but this is a case where I suspect the effect of reporting bias is negligible.

Results:

• As people age, they are more likely to both develop hip OA and get a hip replacement.  A bit of "no duh" result, but still useful to confirm.
• This effect of age was stronger for women than it was for men.  This confirms some other research (.... I'm thinking specifically of some of the aging/mobility research by Stephanie Studenski, one of my former colleagues from Pitt- http://www.upmc.com/media/experts/pages/stephanie-a-studenski.aspx), which is that people age, men are more frequently limited by medical conditions (like heart disease), and women  are more frequently limited by musculoskeletal conditions.
• Other factors associated with increased risk of either hip OA or hip replacement included: 
• Estrogen + Progesterone usage (notably, estrogen use alone did not, nor did menstrual status)
• Years of eduction (..... I guess a downside of being an MD/PhD)
• Intake of red meat (..... just what I need to hear on the 4th of July)
• Perhaps the most important finding in this study- the risk of hip OA and hip replacement went down the more someone ran.  This is an important finding, since I know many runners are concerned that their mileage is putting them at risk for developing arthritis.  It appears the opposite is true for the hips.
• A similar effect was found for walkers.
• The risk for hip OA and replacement was increased the larger the body size, as measured by body mass index.  Most, but not all, of the benefits of running and walking appeared to be related to the associated decrease in BMI.

Bottom Line: What does this mean for our patients?

• Running is good
• One of the theoretical concerns about running too much is that it may make one more likely to develop osteoarthritis or need a hip replacement.  Per this study, at least, the opposite is true
• Amongst the many benefits of running, it helps maintain a leaner body type, and this is likely one of the mechanisms that explains the protective benefit of running
• The article goes into the biology of cartilage.  In my opinion, much of that is in the realm of speculation and not assessed in this study, so this study does not do anything to alter our knowledge in those domains.  The study is valid regardless.

Prone Press Up

This may be single favorite exercise.  It is one of the most fundamental exercises in the Mechanical Diagnosis and Therapy (McKenzie) protocol, and is very similar to the Upward Facing Dog movement in Yoga.

I always do this exercise first thing when I get to my hotel room after a long plane flight, and it's very helpful for many patients who need to centralize their radicular symptoms (please see blog post about centralization- http://lakewass.blogspot.com/2013/07/centralization.html), or to help with low back stiffness while driving or flying on airplane (http://lakewass.blogspot.com/2013/07/tips-for-flying-with-low-back-pain.html).

Technical note about the picture below: I have no idea why I am grunting so much, but that is NOT proper form.  Try to stay more relaxed and control your breathing

INSTRUCTIONS:
1. Lie on belly
2. Place hands next to shoulders like you are going to do a push-up
3. Take a deep breath in
4. As you breathe out, slowly arch your back upward
5. You may feel a point of stiffness in your low back- it is important to push through that stiffness
6. Lower yourself down so that you are completely flat again
7. Take a deep breath, and then repeat

Tips:
1. Make sure your pelvis stays on the table
2. If you have leg pain, your goal is to pull that leg pain into your back.  This may intensify your low back pain- that is ok.  This called centralizing your symptoms when you pull the pain out of your legs and into your back
3. You should feel your back start to loosen after 10-20 repetitions

When to do:
1. 20 repetitions every morning
2. 10 repetitions after any time that you have been sitting for prolonged periods (car rides, airplane flights, sitting in class)

Standing Back Extension

This is one of my favorite exercises, and I commonly recommend it to patients with low back to help centralize symptoms (please see blog post about centralization- http://lakewass.blogspot.com/2013/07/centralization.html), or to help with low back stiffness while driving or flying on airplane (http://lakewass.blogspot.com/2013/07/tips-for-flying-with-low-back-pain.html).

INSTRUCTIONS:
1. Stand with your back to a table, with the edge of the table just below your waistline
2. Make sure your feet are all the way back up against the table
3. Cross your arms in front of your chest
4. Take a deep breath in
5. As you are exhaling, arch your back backward
6. You may feel some stiffness- it is important to push through that stiffness.  Try to arch back a bit further with each repetition
7. Come back to neutral
8. Take a deep breath in
9. Repeat by arching backward as you exhale

Tips:
- Your goal is to CENTRALIZE your symptoms.  This means that you are trying to pull your symptoms away from your foot, leg, thigh, and buttock, and INTO your back.  Your back hurt more at first, but should loosen up after 10-20 repetitions

Tips for Flying with Low Back Pain

Flying is one of the toughest activities for patients with low back pain.

In some upcoming posts, I will include a few exercises you can perform on the plane, particularly standing back extensions, proximal hamstring stretches, and hip flexor stretches.

This post will focus on making sure you have sufficient lumbar support.  Most (.... and my most, I mean all) airplane seats are not designed with the low back in mind.  I suggest using a lumbar support when flying - I usually use a cylindrical roll they sell at the magazine shops, often recommended for the neck.

I often forget to bring a lumbar support with me, though, so what I then recommend is using magazines in the airplane as a makeshift lumbar support roll.  I am a big guy, so I usually need 4 magazines, which usually includes the in-flight magazine and Skymall from both myself and neighbor.

The pictures included here are intended to show you how to make the lumbar support roll.

Wall Centralization Exercise

On a previous post, we discussed centralization.  One exercise that can help with centralization is the Wall Centralization Exercise.  Often, patients benefit in performing this exercise under the guidance of a skilled Physical Therapist or Chiropractor familiar with the Mechanical Diagnosis and Therapy protocol (sometimes called McKenzie, named after the person who developed the protocol).

WALL CENTRALIZATION EXERCISE:

1. Lean against the wall with your shoulder against the wall (check with your doctor, PT, or chiropractor to make sure you are performing on the proper side)

2. Place your far foot firmly on the floor, and place your near foot (the side closer to the wall) over the planted foot, so that the near foot is not bearing any weight

3. Take a deep breath in

4. As you breathe out, slowly lean your hip into the wall

5. You may feel a point of stiffness in your low back- it is important to push through that stiffness

6. As you inhale, move back to the starting position

7. Take a deep breath, and then repeat

8. The goal for this exercise is to centralize the pain going down your leg, so that you will have less leg pain.  If this makes your back pain more intense- that is ok and expected.  After repeated repetitions, you should notice the back pain improve as well

  

Tips:

1. If you have leg pain, your goal is to pull that leg pain into your back.  This may intensify your low back pain- that is ok.  This called centralizing your symptoms when you pull the pain out of your legs and into your back

2. You should feel your back start to loosen after 10-20 repetitions

When to do:

1. 20 repetitions every morning

2. 10 repetitions after any time that you have been sitting for prolonged periods (car rides, airplane flights, sitting in class)

Centralization

CENTRALIZATION:

One approach to the management of radicular symptoms (sometimes called "sciatica") is called Mechanical Diagnosis and Therapy (MDT).  The goal of this program is to teach you how to prevent further exacerbations, and give you tools to use yourself so that if you have another exacerbation, you know how to treat it.

The key concept in an MDT program is the concept of CENTRALIZATION.

 This means that you want to pull symptoms out of your foot, leg, thigh, and buttock, and INTO your back.

- This process is called centralization because you are moving your symptoms toward the center of your body

- The goal is to move disk material away from your nerve root

- Sometimes when you perform this initially, it may actually make your back pain worse.  That is ok.  Eventually, in addition to pulling pain into your back, the goal is to make your back pain disappear.

- If the pain, instead of going into your back, goes AWAY from your back and into your buttock, thigh, leg or foot, that is called PERIPHERALIZATION.  That is not a good sign, and suggest that the disk material is pushing on your nerve root.

Sometimes, after your symptoms have improved, your therapist may work on additional strategies to help strengthen your core and prevent you from an exacerbation.

- These exercises are sometimes called LUMBAR STABILIZATION or CORE STRENGTHENING exercises.

- These are very helpful exercises. However, the concept of centralization is still the priority, because if your symptoms start to peripheralize, than means you may soon have an exacerbation of your symptoms.

- Please let your therapist or chiropractor know if you start having peripheralization, as that means you need to shift the focus back to centralization.

Anti-Inflammatory Diet

This diet was developed by my colleague Trasey Falcone, DO, and is helpful to bring down systemic inflammation.

Anti-Inflammatory Diet
Goal: Decrease foods that lead to inflammation and pain, and optimize intake of healthy protein, fats, and carbohydrates.

General Guidelines:
- Increase daily intake of a variety of colorful fruits (2-3 servings) and vegetables
- Eat good protein sources at every meal
- Minimize or eliminate trans fatty acids, and partially hydrogenated oils
- Minimize or eliminate high-glycemic index foods
- Try to purchase organic fruits and vegetables and free-range meats whenever possible

Proteins:
- Use organic or free-range meats when possible
- Nut butters (almond, cashew, macadamia)
- Beans and grains (soy, millet, quinoa, lentils, and other beans)

Proteins to avoid or limit:
- Avoid charring/browning proteins/meats
- Minimize large fish such as tuna and swordfish because of mercury
- Avoid farm-raised salmon because of PCBs
- coconut, canola, or olive oil for cooking

Fats:
- Sources of omega-3 fats: flax seed oil, sardines, ocean salmon, walnuts
- Dietary supplement of high EPA/DHA fish oils (purified to eliminate mercury,
- Use dry-roasted or raw nuts

Fats to avoid:
- Eliminate deep fried and breaded fried foods (french fries, chicken nuggets, etc)
- Avoid all partially hydrogenated oils and trans fats
- Decrease saturated fats (ice cream)
- Avoid highly heated fats (crispy bacon and french fries)


Carbohydrates:
- Colorful fruits (berries, pomegranate, apples, pears and citrus fruits)
- Vegetables (organic when possible)
- Cruciferous vegetables (detoxification) broccoli, cabbage, cauliflower, kale
- Fiber-rich vegetables: chard, spinach, celery, squash, zucchini, cucumber
- Onion family: Onions, leeks, chard, garlic, chives
- Consider juicing organic vegetables to improve intake of phytochemicals
- Beans (soluble fiber and protein): Kidney, black, pinto, garbanzo, etc
- Use high-fiber, high-protein breads (3-5 gms)
- Use whole grain carbohydrate sources: quinoa, millet

Carbohydrates to avoid:
- High-glycemic index foods such as cookies, cakes, scones, muffins, potatoes, sugars, white rice, enriched pastas, white breads
- Try to avoid artificial colorings and diet beverages with aspartame
- Minimize and avoid foods containing ingredients that have MSG

Other Anti-inflammatory Foods:
- Dark chocolate (in moderation)
- Red wine (optional- and in moderation)