Welcome back to the Healing Pain Podcast with Kirsten Ambrose, MS, CCRC
In this episode, we’re discussing how to treat individuals with osteoarthritis as well as how to promote public health campaigns for effective treatment. My expert guest is Kirsten Ambrose. Kirsten is the Associate Director for the Osteoarthritis Action Alliance at the University of North Carolina. She has a Master’s of Science and more than twenty years of experience managing multidisciplinary teams towards successful research conduct in chronic pain related disorders and public health action for osteoarthritis awareness. Her experience includes delivery of physical activity education and programming to individuals with various chronic pain conditions and disabilities. In this episode, you’ll learn all about osteoarthritis, what you can do to manage or prevent osteoarthritis, and how you can engage in effective public health campaigns for the treatment of osteoarthritis. Without further ado, let’s begin and let’s learn all about the care of osteoarthritis with Kirsten Ambrose.
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Osteoarthritis Across The Spectrum From The Individual To Public Health With Kirsten Ambrose, MS, CCRC
Kirsten, welcome to the show. Thanks for joining me.
Thanks for having me, Joe. I’m excited to be here.
We’re going to talk a lot about osteoarthritis. Both some of the intervention-based treatments, as well as some of the epidemiology behind it and why it’s important for licensed health professionals, as well as for others to start to turn their attention toward it. You do lots of great work at the Osteoarthritis Action Alliance. Give us a little bit of background on who you are in your career and how it’s led you up to this point.
My background is in Exercise Physiology from an academic standpoint, and perhaps like many people, I didn’t know what I was going to do with that. Once I graduated, I didn’t have a big plan. I found myself in a research group for fibromyalgia studying idiopathic chronic pain syndromes, that whole spectrum of conditions, fibromyalgia, temporomandibular disorder, the whole nine yards. I was in that for about fifteen years and had a lot of wonderful experiences. As much with research, given that I was not the researcher, I was as a clinical study coordinator. My path hit a wall at some point and I needed to decide where I was going to go next.
I decided that I wanted to take a little bit of a different tack from research. My very good friend, Leigh Callahan, who is the Director of the OA Action Alliance, she’s an epidemiologist, studying a lot of physical activity related to arthritis and population research in arthritis. She had a position opening up at the OA Action Alliance. The CDC and the Arthritis Foundation in combination started the OA Action Alliance back in around 2010 or 2011. It was with the arthritis foundation for many years and they had a whole shift in their programming. CDC brought it to UNC Chapel Hill where Leigh was. Leigh has a long history with CDC. She needed somebody to run the show with her. She knew I was looking and we ended up together.
You mentioned the University of North Carolina and Chapel Hill. It’s called the Osteoarthritis Action Alliance. Tell us briefly what is the aim of the Alliance and what are the typical members you are involved in it like?
We are a national coalition committed to elevating osteoarthritis as a priority in policy, both environmental and systems policy solutions to reduce the toll of OA. We were born out of the national public health agenda for osteoarthritis that originated in 2010. We updated it for 2020. It serves as a blueprint for the nation, but it is for us to operationalize through the Action Alliance to guide the nation with strategies from a public health perspective to address OA. Those strategies include things like proven public health interventions around physical activity, weight management, injury prevention, self-management education, as well as strategies to promote delivery of evidence-based programs that help with those interventions, strategies to promote alliances with different organizations or different entities, like insurers and healthcare systems or what to promote better care for OA and better coverage for OA.
We also have a strategy for addressing health disparities and improving health equity for musculoskeletal conditions, which we’re primed for in this country. Finally, for research, both surveillance, that is what a lot of the CDC does. We’re looking at the broader population, prevalence rates, incidents of arthritis in the country, as well as those organizations that fund to research like NIAMS, the National Institute of Arthritis and Musculoskeletal and Skin Diseases at NIH. As a coalition, we are mostly comprised of organizations across a broad swath of sectors. We want people at our table from healthcare, media, businesses, to community organizations.
Osteoarthritis does not discriminate, so we want to make sure that our public health actions are speaking to everyone. We want all of those people at our table to help guide what we do. We do also have a couple of individual stakeholders, whether those are healthcare providers or patients, people who have a way, youth athletes even, coaches to get into the weeds with us, guide our content development, and make sure it resonates with them so that we’re putting stuff out there that’s useful and not going to sit on a shelf.
It’s a broader public health approach to osteoarthritis. You mentioned stakeholders and other healthcare practitioners. What role do physical therapists play within the Action Alliance and contributing to the aim?
The American Physical Therapy Association is one of our members. We know that they are also very strong proponents of evidence-based programs for arthritis. I believe they would consider themselves to physical therapists as primary care providers on the spectrum of primary care. They are seeing people who have a way front and center, treating them in a clinical care setting, as well as trying to facilitate outpatient care once their physical therapy sessions are over or even during or while they’re at home. We work very closely with physical therapists regarding OA across the spectrum from athletes who are recovering from injuries in a rehab setting to older adults who are either post joint replacement surgery or struggling with the mobility issues and things that come along with osteoarthritis.
I’m encouraging more physical therapists to get involved in public health initiatives with regard to many chronic diseases, osteoarthritis being one of them. Speaking of osteoarthritis, tell us from your perspective what is osteoarthritis and how does that differ from the common rheumatoid arthritis that we often hear about.
We get a lot of questions about the differences because people don’t know unless you’ve been diagnosed. People perhaps more often would be diagnosed with rheumatoid arthritis because of the nature of that illness. I’ll start there. Rheumatoid, as a distinction, is a systemic autoimmune disease. While it does affect the joints, there’s joint pain that’s characteristic, joint stiffness, those types of things. Rheumatoid gets much further beyond and also affects other systems. There’s more of an inflammatory component to rheumatoid arthritis. It’s a whole different type of disease.
There is a little bit of overlapping the treatments and I’ll get into a little bit more about this with OA, but physical activity and managing a healthy weight worked very well for rheumatoid arthritis. Osteoarthritis is very often considered a disease of wear and tear as we get older. It’s inevitable. We try to get away from that description at the OA Action Alliance and even at the Thurston Arthritis Research Center. We know that it’s far more complex of a disease process than simple wear and tear. Not everybody gets it. It’s not inevitable, so it’s more going on. Cartilage does break and wear away so that nice cushion that’s in a healthy joint is no longer there between the bones. The synovial fluid that’s also in a joint capsule can become inflamed or increase in amount to make up for some of that cushioning.
The ligaments around the joint can become lax and less supportive of that entire joint space. For example, the quadriceps muscle for a knee that’s affected by osteoarthritis weakens and is not supportive. You start to see problems with mobility. Structural alignment, whether somebody colloquially is knock-kneed or bow-legged back and puts a lot of strain on the joints over time. The main symptom for OA is joint pain. That’s the biggest one followed by stiffness. Sometimes stiffness will go away in the morning. If somebody gets up and feels very stiff but once they start to move, that can go away. Loss of range of motion, mobility issues are very common for OA, joint swelling, cracking, clicking, and crepitus in the joint space. All of that contributes to OA but it is very local to the joints that are affected.
I’m glad you spent some time talking about how osteoarthritis is not a wear and tear condition. That’s a very old way to look at the disease process or the condition. There are many people who are in their advanced ages of life who also have some osteoarthritis in their knee that lived very full active lives and have zero pain at all. It’s good that that’s part of the Alliance’s perspective with regard to the care and management of osteoarthritis. As we’re talking about the care and management of osteoarthritis, talk to us about some of the key points with regards to prevention for OA.
This went along with the wear and tear that people thought it was inevitable. I mentioned earlier in the show, OA can be prevented. The biggest things that work to prevent OA are managing heavy weight throughout life, somebody who has obesity or overweight. Losing weight will go a long way towards preventing the eventual development of OA. Injury prevention is very big as well. Somebody who is either an athlete. Even in high school, if you tear your ACL or meniscus, something like that, that can also set you on a path towards development. Not inevitable that somebody will get away but those are two very distinct areas that increase your risk. We know we can prevent both if we can prevent injuries either athletic injuries or from a fall. Fall prevention is also a big thing that we talk about and obesity, managing weight.
Along with that managing weight, physical activity is part of that. Is nutrition a part of the self-management of the prevention as well as treatment of osteoarthritis?
I mentioned my colleague, Leigh Callahan. She is participating as an investigator in a study that’s out of Wake Forest. It’s a collaborative study across the State of North Carolina that is looking at exercise and nutrition for managing osteoarthritis. This is a community trial that’s happening now that builds upon a more rigorous laboratory type study that already indicated that people who participated in both the diet and exercise group, as well as the diet group had better outcomes for their osteoarthritis in terms of both losing weight and some inflammatory markers. Exercise is beneficial. Nutrition and diet are extremely important.
I know that study. I believe it’s a meta-analysis or a systematic review you’re referring to. Is that right?
They could have participated in a meta-analysis but the one that I’m talking about is euphemistically called the IDEA Trial, a big trial in the State of North Carolina. Now, they’re taking that rigorous trial to a pragmatic community-based trial, eighteen-month of treatment, whether it’s diet and exercise to see what we can do practically outside of the laboratory.
I love the multimodal approach to treating this condition. It’s a nut study and it sounds like that evidence-based work has been carried over into the Osteoarthritis Action Alliance.
That’s one of the functions that we serve. It’s to be that public health voice for the researchers. The Osteoarthritis Research Society International is a close partner of ours and they are, by name, very heavily focused on research. They are a professional organization of researchers. We provide that public health voice to take what they put out from a research perspective in the lab, the Ivory Tower Science that’s vital to what we do and gives us the credibility and the evidence that we need to put out the information whether it’s educational awareness messaging, developing new tools and resources. It’s a symbiotic relationship there.
In that IDEA study, I don’t remember all the details per se. You may remember some of the details but I believe the outcome was that people who engaged in a nutritional intervention as well as physical activity had better outcomes but also change inflammatory markers, which was important in that study.
That is true. The impact was greatest in those groups that had the dietary component compared to only exercise. IL 6 was the inflammatory marker that was highlighted the most, and that was reduced in that study as well as what fall out of the weight loss aspect of it is fewer compressive forces on the joint. Joint loading was reduced. A lot of the work that Dr. Messier has done out of Wake Forest has built upon this whole idea. One of his very early studies several years ago, found this nugget that everybody takes away.
What is important is that for every 1 pound of weight loss that translated into about a four-fold decrease in compressive forces or the sense of loading on a joint. If you lose 10 pounds, that translates to about 40 pounds of loss that you feel on your joints. That’s significant. For most people, 10 pounds is a reasonable amount of weight to lose. Any amount of weight is challenging. Obesity is complex as a disease itself but it matters. A little bit goes a long way in terms of weight loss, reduction, and inflammation.
You mentioned obesity, which is a chronic, non-communicable disease, gets a lot of attention. Why is it that osteoarthritis does not receive the same attention?
It’s one of the casual reasons why we exist. We want to bring osteoarthritis up into the conversation. We know that when we talk about obesity, 1/3 of people who are overweight or have obesity also have arthritis. If we look at other chronic comorbid conditions, cardiovascular disease, and diabetes, almost 50% of the people who have those conditions also have arthritis. A lot of these conditions traveled together. People who have OA are extremely likely to have upwards of 3 to 5 additional chronic conditions.
Where this matters is that the treatment strategy for physical activity and weight management overlaps with all of these chronic conditions. What gets forgotten is that joint pain can be a barrier to physical activity. If that’s not getting discussed in a clinical care setting, the doctor is not asking the patient, the patient is not volunteering that joint pain is a problem then no physical activity will happen. We don’t help our hearts and our blood sugar. They’re all intertwined and we need to make sure that people understand how they’re linked.
We know that physical activity is beneficial for promoting health and for promoting healthy lifestyles for those living with osteoarthritis. Sometimes, people are scared to exercise because they don’t want to injure themselves and cause what they would identify as more damage. What do you say to people who are fearful of moving their body, exercising and be more physically active when they’re living with osteoarthritis?
It’s a common question that we get or a common concern that we hear. It’s understandable. Whenever you are physically active, you might experience a little bit more joint pain. Nobody wants more pain and don’t want to make your disease process worse. We know that physical activity may not prevent osteoarthritis. There isn’t any convincing data that says that it will prevent osteoarthritis. Once you have it, there’s also not convincing evidence that physical activity will make your arthritis worse. In fact, the opposite is true. That physical activity helps with the disease. It helps your symptom management. What you’re doing is keeping your joints mobile, keeping the range of motion as full as you possibly can, reducing stiffness, and you’re countering all of those symptoms I described in the beginning. Keeping your muscles and ligaments strong to support the joint that’s affected and helping to reduce some of the inflammation.
We talked about the IDEA Trial and we know that diet is a big part of that but exercise in general for anybody has an effect on reducing inflammatory markers. It’s very important that way. Exercise will help people maintain strength, and you also help to maintain balance, improve agility, which will help prevent falls. There’s so much that gets tied up with exercise and the biggest advice to give somebody who hasn’t exercised ever or in a very long time is to start low and go slow. Nobody is talking about running a 5k or joining the gym. A small amount of weight loss can have a significant impact on joint pain. Small amounts of physical activity can have a significant impact on both your overall health as well as improving joint pain symptoms. A short amount of time, light amount of weight, walking is easy. Theoretically, everybody knows how to walk and it takes very little equipment. It doesn’t take much but it will go a long way.
You mentioned overall health. One of the things we know is as you move, you start to improve your mood or your mood becomes elevated the more you move. There’s an aspect of an elevated mood that is accompanied by a physical activity that has an impact on osteoarthritis as well.
On the opposite side, people who have chronic pain often have depression, anxiety, and feel stress over the inability to complete their daily activities, work, or all of that. Sleep can be affected by any pain condition including osteoarthritis. Physical activity has that counterbalancing effective boosting mood, helping to improve sleep, improving overall health and fitness, and overall disease risk profiles for all of the other conditions too that could be exacerbating away.
People are often concerned about joint replacements. They see that as a potential option. If they’ve been diagnosed with some type of OA, they see it as the only option for them. What is the Alliance’s perspective on joint replacements with regard to osteoarthritis?
We would argue that it’s the last option. It should be the end-stage disease option when you have exhausted all other options or your disease condition has progressed to that point. Unfortunately, we have no drugs unlike rheumatoid arthritis I described in the beginning to change the disease process for OA. All of the treatments whether we’re talking about the non-pharmacological, physical activity, weight management, self-management education, disease education, NSAIDs, or joint injections, work to a point to manage symptoms. At some point though, perhaps somebody gets far enough along the path that they have no other option, that’s a discussion to have with a doctor. At the OA Action Alliance, what we promote are those behavioral interventions, physical activity, weight management, injury prevention, self-management education, and other nonpharmacologic therapies as the first line of defense.
In fact, the American College of Rheumatology also includes in their guidelines for the treatment of hand, hip, and knee OA that they updated in 2019. They strongly recommend physical activity and weight management as nonpharmacologic therapies. That’s what we promote as well. We know that people may go on to a joint replacement but also keeping in mind that joint replacement is extremely invasive. It’s very common now. Perhaps, patients get a false sense that it’s nothing. It’s outpatient or one overnight. My friends have had it. It might be the thing for me, what’s the big deal? It’s extremely invasive and it is not for everyone. In some patients, it’s not even better than physical therapy. It is a consideration for you and your doctor if you’re the one thinking about it. It’s not to be taken lightly.
With the number of comorbidities that often exist with osteoarthritis, electing for a surgery like that has a significant risk for it. It doesn’t always come out rosy the way we see it on pamphlets and things like that. It’s a significant surgery and there’s some risk involved in it. There are potential side effects and for some people, a longer rehabilitation period depending on what their health is like going into the surgery. We look at this as the last option for people with osteoarthritis. I know the opioid epidemic has had an impact on the Alliance and now we have a COVID pandemic here in the United States. How has that impacted with the work you’re doing at the Alliance and the public health outreach and initiatives that you’re all working on?
The opioid epidemic or the COVID epidemic or both?
Let’s start with opioids first and then we’ll transition into the Coronavirus.
As we all know, opioids are a significant issue in this country right now. For me, Action Alliance is not something we focus on because we focus on behavioral interventions and public health interventions. However, we can’t ignore the opioid epidemic. We know that patients are seeking solutions, people have pain, they don’t want pain. Opioids, in general, have a place. It’s narrow. For a select bunch of people in a certain circumstance, they do work well. Opioids notoriously don’t work that well for chronic pain conditions. They’re not the first line of defense for those types of pain. Chronic pain doesn’t respond very well. Not often terribly much better than NSAIDs over time. You might get an initial relief from an opioid but it doesn’t last. That cycle of physiologic dependence and tolerance to the drug changes over time. They’re not the best choice for OA. We try to discourage that. I’ve seen a lot more conversation about non-opioid therapies and making sure that those are available whether it’s from an insurance, Medicare, Medicaid perspective, or in the conversation. Let’s be looking at other therapies.
Let’s transition to the Coronavirus pandemic and how that’s impacted. What’s happening in healthcare in our country as well as how it’s impacting our ability to reach to people?
It’s had a funny impact in many ways. The obvious ones are it’s been challenging for people. Requiring people to stay socially distanced, this puts challenges on seeking healthcare and getting pain medications. Transportation issues become a problem if you can’t get close to people. People’s jobs have gone away. Healthcare coverage or the ability to pay for healthcare is challenged. Gyms and fitness facilities, senior centers, all of these places where people congregate, churches, that very often provide evidence-based programs or other services are closed, or people aren’t able to go there. This has challenged a lot of people’s ability to maintain not their everyday lives, but care for their OA.
On the flip side, I would say the good thing that’s come out of it is an increase in telehealth. Telehealth has expanded during COVID with coverage for healthcare as if it’s a regular visit. That’s been a good thing and has increased access for people to seek certain levels of care. The expansion of drug delivery, pharmacies that deliver medications to people by mail, people being able to get their groceries by mail, all of these are the pro-con. It’s been an interesting challenge. From our perspective, we’re frequently focus on physical activity for people with OA and managing weight, we know that COVID can have a lot of detrimental effects on people’s ability to be active or challenge people’s mental-emotional wellbeing.
It can even challenge stress-eating behaviors and get people to dispense with their healthy eating behaviors or they’re not able to get to the store to get healthier foods right now. There are all of these challenges that come with it. We’ve tried to respond. A couple of ways we have curated along with the Osteoarthritis Research Society International. The Osteoarthritis Foundation International based out of Spain joint action down in Australia and us. We’ve come together to curate a collection of resources that we’ve all shared on our respective websites. That addresses physical activity, emotional wellbeing, pain management even and healthy eating behaviors.
We’re trying to bring those resources to people. One step further through the Action Alliance, we have long been proponents of one specific evidence-based program called Walk With Ease. It’s an Arthritis Foundation program. Traditionally, it’s delivered in a group setting with an instructor and a self-directed format. The group instructor settings aren’t happening. Very often community-based organizations deliver those programs, whether it’s parks and rec, senior centers or area agencies on aging, they are not able to do that with COVID. It’s important during this timeframe.
That’s one thing that we’ve promoted. We have a patient portal that people can come and sign up for the program for free, get a very extensive guide book to help them through this six-week walking program. People can walk outside, be socially distanced, and safe. They’re learning at the same time to walk safely and comfortably with arthritis. We also recognize that there are a lot of people that can’t walk safely outside, perhaps they don’t live in a community that has sidewalks or where their personal safety is even there. We’re mindful of that. We’re taking parts of the Walk With Ease Program to try to pull out those things that people can do on their own at home, inside their home, or inside their apartment like stretching, strengthening exercises, balance exercises, education to try to keep people moving along while the COVID pandemic is going on.
It was a great program. It has been used for many years with good outcomes by lots of different health professionals and lots of different community organizations. Hopefully, we can bring that back or find a way to even bring that online with more telehealth so people can stay active and keep moving because we know that physical activity has a tremendous impact on osteoarthritis. Kirsten, it’s been great speaking with you. You’re a wealth of information with regards to osteoarthritis. Tell everyone how they can learn more about the Alliance and learn more about you.
Our website is very simply OAAction.unc.edu. You can go there and find all kinds of resources based on the education that I talked about. We have policy resources and monthly webinars. You can find out all kinds of things about us. All of our resources are free. We are primarily funded by CDC and some other grant funding. What we want to deliver to people, we want it to be freely accessible, and taken up by people by all means. Come, learn, participate in any way, whether you’re an individual with OA or an organization that you want to come, join us at our table. We have social media platforms, almost all of them that are popular, Facebook, Twitter, Instagram, the whole nine yards. You can find all of that as well as you sign up for our newsletters. For everything that we do, you can find it all on our website.
It is a wonderful organization. I recommend everyone check out the Osteoarthritis Action Alliance at UNC Thurston Arthritis Research Center. It’s a fantastic organization. They do have a ton of excellent handouts and pamphlets, whether you’re a practitioner or you’re someone who has chronic pain and osteoarthritis. Make sure you check out OAAction.UNC.edu. Make sure to share this episode with your friends and family on Facebook, LinkedIn, Twitter, wherever people are hanging out, talking about chronic pain, and how to overcome it naturally. I’m Dr. Joe Tatta, it’s been a pleasure. Thank you, Kirsten.
Thank you.
Important Links:
- Osteoarthritis Action Alliance
- Kirsten Ambrose
- Leigh Callahan
- American Physical Therapy Association
- National Institute of Arthritis and Musculoskeletal and Skin Diseases
- Thurston Arthritis Research Center
- IDEA Trial
- Osteoarthritis Research Society International
- Walk With Ease
- Facebook – Osteoarthritis Action Alliance
- Twitter – Osteoarthritis Action Alliance
- Instagram – Osteoarthritis Action Alliance
About Kirsten Ambrose, MS, CCRC
Experienced Associate Director with a demonstrated history of working in the health wellness and fitness industry. Skilled in Nonprofit Organizations, Coalition Growth, Proposal Writing, Fundraising, Patient Education, and Writing. Extensive history in Research Administration in multidisciplinary academic research centers focused on chronic pain. Strong program and project management professional with a Master of Science (M.S.) focused in Exercise Physiology from The George Washington University.
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