On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Adam Culvenor on the show to discuss ACL injury. Dr. Adam Culvenor is a physiotherapist, leader of the Knee Injury and Osteoarthritis Research Group and Senior Research Fellow within the La Trobe Sport and Exercise Medicine Research Centre in Melbourne, Australia. Adam’s research focusses on the outcomes of anterior cruciate ligament (ACL) injuries, in particular the prevention and management of early knee osteoarthritis in young adults following ACL injury and reconstruction.
In this episode, we discuss:
-The short-term and long-term burdens following ACL injury
-Why patient rapport is integral to effective treatment post-ACL injury
-Optimal loading strategies for non-surgical and post-surgical cases
-The latest research on prevention for early-onset osteoarthritis
-And so much more!
Resources:
Email: A.Culvenor@latrobe.edu.au
For knee injuries, surgery may not be the best option
A big thank you to Net Health for sponsoring this episode! Learn more about Four Ways That Outpatient Therapy Providers Can Increase Patient Engagement in 2020!
For more information on Adam:
Dr. Adam Culvenor is a physiotherapist, leader of the Knee Injury and Osteoarthritis Research Group and Senior Research Fellow within the La Trobe Sport and Exercise Medicine Research Centre in Melbourne, Australia. Adam’s research focusses on the outcomes of anterior cruciate ligament (ACL) injuries, in particular the prevention and management of early knee osteoarthritis in young adults following ACL injury and reconstruction. His work has identified important clinical and biomechanical risk factors for post-traumatic osteoarthritis, and he is currently testing novel osteoarthritis prevention strategies in young adults following injury in a world-first clinical trial. He has published over 60 peer-reviewed articles in international journals.
Adam has worked in teaching and research at universities in Australia, Norway and Austria and is a graduate of Harvard Medical School’s Global Clinical Research Program. His research has been awarded American Journal of Sports Medicine most outstanding paper 2016, Australian Physiotherapy Association Best New Investigator 2013 & 2017 in musculoskeletal and sports research, and Sports Medicine Australia best Clinical Sports Medicine paper 2019.
Read the full transcript below:
Karen Litzy (00:01):
Hey, Adam, welcome to the podcast. I'm so happy you're here. And I'm excited to talk about ACL injuries with you. So welcome.
Adam Culvenor (00:08):
Thanks very much for having me, Karen. It's great to be here and chat.
Karen Litzy (00:11):
So now the bulk of your research is in ACL injuries and not the mechanism of injuries for ACLs, but what happens after that injury? So before we get into, and we'll talk about the burden of ACL and optimal treatment and osteoarthritis and why that happens. But what I would love to know is why are you interested in this subject matter? Sort of, why did you make this kind of the centerpiece of your research?
Adam Culvenor (00:43):
It's a good, good question. So about 10 years ago, also, now I had done a couple of years of clinical practice as a physiotherapist in Melbourne where I'm based and was interested in pursuing a bit more of the research line into ACLs because we had a patient come to myself and one of my colleagues who was a young guy, about 35 years old, who had a very active, healthy life up to that point, he'd suffered an ACL injury about when he was 20 years old, he was about 35. Now it had a number of issues. He'd got back to sport without any problems, but then now about, you know, 10 to 15 years later, started having some pain, unable to do the things he normally would love to do. Couldn't go back and play anymore.
Adam Culvenor (01:33):
Sport couldn't start, couldn't really play with his kids. He'd seen an orthopedic surgeon, he'd had an Arthroscope, had a bit of a cleanup now going back to the surgeon and he was really in want of a knee replacement because he could no longer do the things that he wanted. And the surgeon basically said to him, you're too young to have a knee replacement go and see, Adam and Tom, our colleague. And so what we can do, and that really opened our eyes from a clinical perspective about these types of patients and this particular young guy had on x-ray most of his changes were actually in his patellofemoral joint. So in the patella and the trochlea, and that really set my mind up to go and look into the literature in this space and see what's out there in terms of not only osteoarthritis in these young people. And clearly it was very burdensome to this young guy, but also why are we seeing this in the patella femoral joint in particular and why is it causing so many problems? And so that really set us off for my PhD, about 10 years ago, looking into these medium to longterm outcomes, ultimately trying to help these people get back to do the things they wanted to do without the pain and the symptoms that come with osteoarthritis a lot of the time.
Karen Litzy (02:48):
Yeah. Oh, great story, that's a shame 35 years old. Gosh, that's so young. I can understand why that would really peak your interest because you don't want to see these patients coming into you or when you do see them, you want to be able to help them with the best evidence and best things that you can. So you had mentioned in your explanation there as to why this subject interests you, is that there is this sort of burden after having this ACL injury. So could you talk a little bit more about the burden of an ACL injury and subsequent surgery?
Adam Culvenor (03:27):
Sure. So I'm sure it goes through a lot of people's minds, as soon as they hear that pop or click, that if they know they've had an ACL injury, that's the initial burden is, you know, that worry of, I can no longer play sport. And often if you do go and have a reconstruction surgery, it's often the nine, 10, 12 months of extensive rehabilitation, as we know, and not going back to sport that often people find a lot of personal satisfaction and get a lot of mental health benefit from playing sport and from their peer involvement and social interaction. So it's that initial burden of the extended period out of sport. Some people do really well with great rehab. They can get back to their sport. They want to play at back to the same level of performance, but there's a certain percentage at about 50% of people we know in the evidence will develop longer term, not only persistent symptoms from a patient reported outcome perspective, but also ongoing functional limitations.
Adam Culvenor (04:26):
And ultimately the development of osteoarthritis be that on radiographs, on x-rays. And some of our work is which we can go into a little bit more detail in a moment is looking at the earlier changes on some more sensitive imaging like MRI to try and detect these types of people who might be more at risk of developing longer term changes. So as I said, some people do really well following an ACL injury, but rehab only, or surgery. And we can chat about the differences in the treatment options later as well, but about 50% of people at the moment. And the evidence suggests that they will have osteoarthritis within about 10 years of their ACL injury. So if we think of the typical patient is, you know, the adolescent or the young 20 year old patient playing sport, they rupture their knee only 10 years, 15 years down the track.
Adam Culvenor (05:16):
They're still only 30, 35. That young gentleman I spoke to earlier. And they've got a knee of essentially that looks like on imaging of a knee of a typical 70 or 80 year old. And we know that imaging findings on x-ray don't necessarily match up particularly well with what we see clinically. So that's not necessarily, you know, a sign that they're definitely going to have functional limitations on symptoms, but it certainly increases the risk of that happening. And that burden at a time when people often have really important family commitments and young family commitments work commitments, and they often still want to be active in participating in sport. And so when you bring all of those in to a knee that might not be has have recovered as well, following an ACL injury, you might still have some muscle weakness if that wasn't addressed initially and create the picture of more of a persistent pain problem, then you start getting into being quite a burdensome condition that we say these types of patients clinically come back in often five, 10 years following their injury.
Karen Litzy (06:20):
Yeah. And I can imagine along with that, persistent pain comes decreased activity, decreased movement, and we all know all of the sort of cascade of events that can happen when you're not getting an exercise. You're not getting in movement. You know, then you have risk of obesity, risk of diabetes mental health issues. So all of that stuff can kind of stem from, you know, this burden of an ACL, which, you know, for a lot of people, I don't think that even would flash in their mind when you're looking at a 20 something year old who just tore their ACL, because we know that population who does tear are usually pretty athletic.
Adam Culvenor (07:03):
Exactly. And that's the thing prior to their injury. They're often very healthy and, you know, never seen a doctor or never been to hospital before and having the ACL injury can often be that initial. Unfortunately, you know, the cascade where you become less physically active in, might not be able to get back to the sport. You really want to start putting on weight. And that increases the risk of all of these other conditions, as you've just said. And I think there was a recent article a research paper actually showing that having an ACL injury increased your risk of a cardiovascular disease by about 50% longer term. So for me, that was a real wake up. This knee is not just a knee, it's actually affecting the whole person. Exact reasons you just mentioned that it can spiral into, you know, less physically activity, the pain putting on and then being the increased risk of all of the comorbid conditions as well.
Karen Litzy (07:55):
Exactly. And now, so you mentioned a couple of minutes ago about treatment. So you could have surgery, you can not have surgery. So can you talk a little bit as to what the optimal treatment is after an ACL and how one comes to that decision, whether you're the clinician or you're the patient, how does that work?
Adam Culvenor (08:18):
And that's the $64 question. And so I can have extreme of the spectrum. You can have one end, you can have everyone has surgery. The other end is no one has surgery and the truth probably lies somewhere in the middle. So if we look to what the evidence suggests in the literature, there's very little high quality evidence comparing the two treatment options. There's really only one, what we call randomized control trial. That's compared about 120 people. Who've had an acute ACL injury and they were either allocated to having early surgery. So a couple of months of having the injury and then an extensive rehabilitation period I've nine months or so, and then the other group. So exactly the same rehabilitation. The only thing is they didn't have the surgery. And so the only difference between these two groups of patients was the surgery or not.
Adam Culvenor (09:15):
Now the group who didn't have the surgery initially could have the option of having surgery later on if they had ongoing problems or symptoms, or desired to have the surgery later on, and they could cross over to the surgery arm. And what this study showed is initially this was published back in 2010 now. So we've not done this for over a decade, is that there's very little differences both at two years after surgery five years. And I think that the authors are about to publish their 10 year outcomes, but certainly the two and five year Mark, there's very little differences, whether you have surgery or not, in terms of pain symptoms, strength returned to sport the need to have more surgery, quality of life, and indeed radiographic knee osteoarthritis. So I was fortunate enough during my time in Europe, conducting a research fellowship recently to work with this group of researchers based in Sweden.
Adam Culvenor (10:07):
And we looked at the MRI outcomes in this population, as I said earlier, trying to identify people maybe earlier in the process initially after that ACL injury, to see if we can identify those more at risk of longer term problems, which might present opportunities to intervene a little bit earlier to stop that cascade of negativity and what we found really, interestingly, when we looked at the cartilage on MRI between the time of injury to two years and to five years, is it the group that had early surgery actually had more cartilage loss compared to the group that didn't have surgery and you sort of asked, well, why might that be? Because, and I think I haven't had an ACL reconstruction, I'm injuring myself, but I know from colleagues and working clinically that the ACL surgeries is almost a secondary trauma. Like you're going in there, you're drilling tunnels, you arthroscopically opening the joint.
Adam Culvenor (11:04):
You come out of surgery, having a very angry, hot red, swollen knee. And so I think that whole cascade of inflammation can soften the cartilage, can create a knee that's not particularly happy. And then when you go and potentially, you know, put that knee through load, maybe going back to sport and whatnot, then that might actually be related to the development of osteoarthritis more so than if you don't have the reconstruction. And so we've actually done a little bit more work on the return to sport type of thing. And, thankfully in a group with ACL reconstruction, it doesn't seem to increase the risk of osteoarthritis if you do go back to sport. So that doesn't seem to be the main things. That's a good thing for patients knowing that if you've had an injury or reconstruction, you can go back to sport knowing that you're not going to put your knee at more risk, but it's probably more the inflammatory markers, the secondary trauma of that that's reconstruction surgery that increases the risk even longer term as well.
Adam Culvenor (12:03):
So I think what I always tell my patients is that you should always trial a non-operative period. First, you can always go and have surgery later. And I think, I always say, you need to prove to me that your knee is unstable. So some people can do really well without having surgery because their neuromuscular and muscle systems can compensate for that ruptured ACL and the mechanical instability, the neuromuscular system, the humans are very clever. They can really compensate quite well, and they feel you don't need the ACL. If you're only going to perhaps not go back to that high level pivoting sport, where you put your knee at high stress, a lot of the time, then if you just want to run straight lines and play with the kids, then you're likely not needing to have the reconstruction. If for instance, you try a really intensive, progressive rehab strengthening program and you're starting to run, or you're starting to get back into a bit of sport and your knee starts to become unstable at that point at the level that you want to get back to, then that sort of probably instigates the conversation.
Adam Culvenor (13:12):
Well, maybe your knees actually not able to overcome the structural instability to the level of activity that you want to achieve. Maybe let's have the discussion of a reconstruction as a potential option, but always get them. You need to prove that your knee's unstable by going through this rehab and putting yourself through these activities. But it's not going to do well without surgery because we know that the outcomes that are quite similar for the majority of people if you have early surgery or even delayed surgery and doing a period of rehab, irrespective of whether you go and have surgery or not, will be beneficial, if you do go and have surgery. So that prehab, if you like. So that's, I think it's my take home is it's probably actually just educating the patient to empower them with the evidence because they're the ones ultimately that need to make the decision. And so presenting them with all the best available evidence and guiding them for the initial rehab stage often can change their mind that they need surgery once they realized they were actually doing quite well without it.
Karen Litzy (14:17):
And when you're saying to the patient, let's do a trial for a non-operative phase, so that you can prove to me that this knee is unstable. What kind of length of time are you talking about for that rehab process and knowing that it's going to vary person to person obviously.
Adam Culvenor (14:37):
Oh, of course, of course. So I think a period of two to three months is sufficient to provide an intensive strengthening program. Let the knees settle down initially and then actually start you know, within the first month and even two months getting them to start really loading their knee. That's the thing, if you actually don't have surgery and actually responds a lot quicker because you don't have any of the graft morbidity, you're not taking out some of the hamstring or the patellar tendon. There's no real reason why we need to be conservative about you know tearing a hamstring or whatever that might be cause of the graft or rupturing the graft because you haven't had the graft reconstructed. So it's different for everyone because different people will respond differently, but actually there's no real hard and fast rule with this because you need to rehab them to get them to a point where they're starting to do the activities that they want to get back to.
Adam Culvenor (15:37):
And at any point in that step ladder of increased physical activity demands that they might fail or start having, you know, severe giving way episodes. Then that's the point that you might have that conversation with someone, but if you're running and you start giving Y and these people want to go back and play elite football, then clearly maybe you're not getting, being able to run without a stable knee. You're probably not going to be able to play football with that with a stable knee. Then that might be the point where you revisit, you're running no problems and you tried playing football and it starts giving way, but really you actually just want to run, right? Playing football is just something you tried, but didn't really want to do. Then you probably don't need the structural stability. If you just want to run off another thing, I like to set a patient's, is it like a seatbelt?
Adam Culvenor (16:28):
Is it, we all wear a seat belt when we drive, but very rarely do we have a crack and we rely on that seatbelt to keep us safe. So if you're someone who walks around and might run, then the ACL is a bit like a seatbelt, is that you actually don't need that seatbelt on because you're not having a crack. You're not putting the need through that real pivoting type movement to rely on it. So unless you're going to go back to a high level sport and, you know, put your knee through those pivoting jarring mechanisms of movement, then you probably don't need that seat belt. You don't need that ACL to protect the knee. Does that make sense? Yeah,
Karen Litzy (17:06):
That's perfect. That's really great. And it sounds to me like when, if you're the clinician working with this patient during, let's say this non-operative trial period where they have to prove, again, the instability, every single person is different. So what you're going to be looking at is different meaning, right? So if I just want to be able to play with my kids, I wasn't a runner before I don't really need to run. I just want to ride a bike or, you know, you want to put people through the things that they want to be able to do. And that would kind of be the way you would test for that instability. But are you also using sort of standardized tests when it comes to seeing if people have the stability in the knee?
Adam Culvenor (17:54):
Exactly. so it's really a goal based discussion with the patient come. The desires of the return to activity comes is driven by the patient. And as clinicians, you know, it's good to have that discussion to then work out, you know, what level do we need to get at, but certainly there's a number of standardized clinical tests and really great patient reported outcomes that we can use with these patients. So the very common ones are the strength tests. So if you have the resources, you know, a dynamometer, an isokinetic dynamometer in the clinic to look at the three range of quads and hamstrings strengths and making, you know, the criteria we typically use in the literature is meeting 90% of the strength compared to your uninjured side. Now, there's obviously some pros and cons about doing that.
Adam Culvenor (18:44):
And the other tests are typically hop tests. So single leg hop, as far as you can, with a balanced landing site, decide hop tests. There's a number of different tests we can use to try and assess the stability, the functional stability and confidence of the knee. Having said that though, we've actually just done some work I've led by Brooke Patterson here as part of our team, looking at the limb symmetry index, which is the ACL rate constructively comparing to the, I mean, delayed and what we found sort of between one and five years after their reconstruction is that often the non-injured leg isn't that healthy gold standard cause that often deteriorates because it's a period of an activity, you be back playing the sport you’re back to. So that's sort of the crisis in capacity. So it's not that reference standard that we should necessarily be comparing our rate constructed.
Adam Culvenor (19:44):
And so there's been a couple of other bits and pieces that people have looked at alternatives to this type of measurement. And whether it's, if you have say someone initially after injury, it's a great opportunity to start doing these tests is actually the estimated pre-injury capacity. So to estimate that it's best to try and do it as soon after injury as possible, given that patients might have some fear and confidence, you know, respect that obviously, but actually trying to do a hop test quite early before that other leg has the chance to start decreasing in capacity because often the limb symmetry index overestimates, what the reconstructive legs capacity actually is. And so they're the functional type of measures that I think we should be using in this patient population, not only to assess outcomes, but also patients get in my experience really like seeing their improvements and getting feedback about having, going along their journey totally. And then an objective test of strength or a hop test they can see right in front of their eyes, how far they're hopping and if they are improving and if they're not, then why not have that conversation. And so that can be great for adherence motivation because this journey of a rehab, irrespective of whether you have a reconstruction or not, can be quite long and tedious, it can be boring. You're sitting there doing strength exercises, you know, any type of motivation to get people to continue is going to be beneficial.
Karen Litzy (21:14):
It's always, one of the biggest complaints is, gosh, these exercises, when do we get to the X, Y, Z, you know, that you see on, on Instagram or on YouTube. And I was like, you know, you're a month in buddy. This is it.
Adam Culvenor (21:28):
Exactly. And I think as physios and the evidence suggests that, we're very good at doing the early stage of the rehab because patients are probably more compliant at that point as well. But there's evidence actually coming out of Australia that less than 5% of people who have had an ACL reconstruction, so less than 5% actually go through a period of rehab beyond six months and include and return to sport type training. So I think whether it be a lack of understanding from a clinician standpoint, or also that, you know, financial and motivational points of view from the patient after six months of like, I've had enough, I'm out, I've good enough. I don't need that extra, you know, icing on the cake to get back to sport. They tend to drop off. And that's when not having that really high level agility capacity returned to school at top training, you increase the risk of re rupture. And that obviously is a devastating impact for these patients and increases the risk of longer term negative outcomes as well.
Karen Litzy (22:27):
Yeah. And I know here in the United States, not so much in other parts of the world, but insurance will oftentimes cut people off at three or four months.
Adam Culvenor (22:36):
Okay. So it's different everywhere. Yeah.
Karen Litzy (22:38):
So it's like, okay, so the person can walk and run and then, then what do they do? You know what I mean? So it kind of depends on your clinic model and things like that. But I mean, I've been lucky enough that I've been able to stay with my patients for 12, 13 months and upward. So it's been really great to be there the week they are out of the OR to getting them on the field and actually doing things that are going to, you know, mimic their soccer, their football place. So, but it's, yeah, there's so many obstacles. It seems.
Adam Culvenor (23:25):
Totally. And I think there's some really great evidence coming from Scandinavia that for every month that you delay the return to sport up to nine months, it actually reduces your injury risk by 50% that's mind blowing for me. So not only, you know, it was it from a rehab point of view, but actually from a range, point of view, having that nine months will actually you know, reduce your risk substantially of re rupturing when you do go back to sport. And I think that is why it's so heavily on people's minds when they're first going back to sport. That fear that's a huge impact psychologically for these types of patients. And I think often an ACL injury can happen. So innocuously, like you've done this movement a thousand times at training before, so why this time and that fear of, Oh, it wasn't a major blow when I first did it, like it wasn't someone running across and really hitting my knee. It was, I was on my own. And so what's stopping that from happening again. And that's that, I think that feeds into the fear of what could happen anytime again. Yeah. So I think I often try and say to patients while you injured your ACL, initially let's get your knee back to better than it was before you injured it, to prevent it from happening again. Because once we know once you have one injury, the biggest risk factor. So the biggest risk factor for a second injury is having a first.
Karen Litzy (24:51):
Exactly, exactly. And I've quoted that that study of that nine months reducing 50%, especially when you're working with kids who think I'm fine. Now I can walk. And I was like, listen, this, and you have to have that conversation with the child and with the parents. And once the parents hear that, they're like, okay, like we get it. Even though her physician was onboard, like you're not playing until you're one year out from surgery. I mean, wherever it is on the same page, but it's hard to keep. It's hard to keep everyone on the same page, but being able to use the literature and say, listen, I'll send you the study here it is.
Adam Culvenor (25:34):
When actually pulling it's actually for some people it's not in needing to encourage them, it's actually needing them to pull them back. That's where your education and clinical reasoning and discussions with patients will differ quite a bit is that some people are so gung ho in their rehab and they just want to get back to sport. You actually have to, as I said, pull them back, whereas the opposite might be true for some alpha people. So it's really interesting how different people respond differently to this type of quite devastating injury.
Karen Litzy (26:03):
Right. And how they respond, how you can use, like you mentioned the study of Scandinavia, how we can use that study with both of those extremes of people, right? So the people who are afraid and the people who are gung ho, so again, it's having this good rapport with your patient and their other stakeholders to kind of get them through safely through their rehab. But now we talked about it earlier on and that's osteoarthritis. So 50% of people will develop some sort of osteoarthritic changes in their knee. So what do we do about that? Are there prevention strategies? What can we do?
Adam Culvenor (26:54):
So this is something that we've been looking at for a few years now and obviously you know, we'd love to be able to have a treatment to stop this from happening, but we're not actually there yet. There's a lot of really nice longitudinal studies investigating risk factors for the increase prevalence of osteoarthritis in this population. And there's a number of risk factors that we can start informing how we might treat these people initially as well. So the number one risk factor is having a combined injury with a meniscus tear or a cartilage lesion. So if you have not only an ACL injury and very rarely, is it just an ACL injury, it can often be combined with a meniscus tear, cartilage lesion, bone marrow lesion, et cetera. So that more severe sort of type of injury will automatically put you at risk longer term of having osteoarthritis.
Adam Culvenor (27:46):
That's not that exciting because as clinicians, we can't do much about that. It's not really modifiable. So we're really trying to identify some factors that might be modifiable that we can address. So things like BMI being overweight, we know increases the risk of osteoarthritis longer term not only after injury, but in people of older age who have the traumatic type of osteoarthritis what's coming emerging from the literature more and more is the quadriceps weakness. So quadriceps in particular the muscle weakness in that muscle and also the functional impairments. So we talked about hop tests and in a balance in your muscle control a little bit earlier. So they're actually starting to become more and more prominent as risk factors for the medium and longterm outcomes for osteoarthritis. So we've just published a paper in the British journal of sports medicine, which looked at this exact question.
Adam Culvenor (28:44):
So do functional outcomes. So typical tests, we might use to clear someone to return to sports, a hop tests and strength tests. Do these actually have a relationship with future osteoarthritis? And what we found is, so this is a one year we tested them. And then at five years we measured their osteoarthritis on MRI. So quite sensitive measure of osteoarthritis, but also an X ray. And what we found is we combine a lot of these tests together into a test battery. So side to side hop test, single leg forward hop test. If you have a poor outcome at one year in these tests, then you're more likely to develop osteoarthritis at five years down the track. And so there's other studies that show quite similar findings in this space as well, which is really, I mean, it's upsetting because they're more at risk of osteoarthritis, but it's quite encouraging as clinicians.
Adam Culvenor (29:34):
This is our forte. We can actually do something about it in the initial stages of rehab. And again, this can be a great education motivational tool to say on this test, you're not achieving at a level that you need to achieve. This is not only going to put you at risk of reinjury. The research shows that this is actually going to increase your risk of developing arthritis. And we need to be a little bit careful about how we inform our patients about this. Cause as I said, some people can be really fearful and terrified about reinjuring and worried about what it is going to look like. And so presenting them with, Oh, you're going to be, you're going to have arthritis in 10 years as well. Might not be quite the right moves to allay that fear at that point in that patient.
Adam Culvenor (30:16):
Whereas other people having a knowing that information can be really motivating to try and get them feedback to the best possible condition that it can be. So again, it's very personalized how we educate our patients, but I think it's really important to educate them along the journey about that increased risk of OA and encouragingly. There's some, some really positive signs that we might start to be able to modify that risk with some really great rehab, getting back to the strengths, getting back to improving function in our clinical work as well. So I think that's really, really exciting moving forward.
Karen Litzy (30:50):
And that's great news for physical therapists because this is where we live, so wow. We can really make a difference in someone's life by good comprehensive rehab within that first year after ACL injury. And again, that's, regardless of whether they have surgery or not, is that correct?
Adam Culvenor (31:08):
Exactly. Yep, exactly. And as I said earlier about the return to sports, so we've also done some research which should be published shortly, hopefully looking at the fact that again, encouragingly, if you have an ACL injury or reconstruction and then decide to go back to these pivoting type sports, some people say, well, you shouldn't go back to that. You know, the high impact sport, because that's going to put your knee at undue stress and you're going to have more arthritis longer term, is that what we've found is actually that's not the case. So we can be confident that we can give these people you know, the advice to go back to sport. If that's what they really want to, for their quality of life and mental health, they do drive a lot of social pleasure from playing sport. The good thing is, is if you have a great functional and strong knee, then that's not going to put your knee at further risk by going back to sport. Sure. It's going to perhaps increase your risk of re injury compared to sitting on the couch at home. I heard that from a lot of mental health and also physical health being physically active and involved in sport has so many more benefits to our general health as well.
Karen Litzy (32:11):
Absolutely. And now can we, if you don't mind talk about the patient that I think a lot of physiotherapists are going to see, and it's like the patient that you saw 15, 20 years after their ACL. So we're not, we're not seeing them one to five years, but now we're seeing them 10 to 15 to 20 years later. That's when a lot of people are going to come to us with knee pain. So what can we do for these patients? Do we want to look at these hop tests in these patients? Does that make a difference? What happens then? Cause that's a big bulk of our population.
Adam Culvenor (32:54):
You're exactly right. And it varies about again what their goals are, but often if they're 10 to 20 years down the track and they've got osteoarthritis, we can look to the literature in the osteopath writers field. And in that space, it's very, very compelling evidence that exercise therapy and education provides the strongest effect for pain and symptoms and function in this population. And so that's almost reassuring that it's quite similar to what we're seeing in the early post-operative or post-injury stage is that whatever level on the spectrum you are post-injury and the development of osteoarthritis, essentially your treatment's going to be quite similar where you're developing the strength that underlies everything that we do in day to day activities. And indeed, if we want to get back to sport and also the functional capacity, so ask for the, what they want to do, what they can't do because of their pain and symptoms and make it a really goal oriented treatment.
Adam Culvenor (33:54):
And I think it's really important to also ask them what physical therapy have they actually done. A lot of those people come to us and they've seen five different surgeons and they've got different opinions. And when you actually question them and interrogate them, they've actually never had a gym program or they've never done any strength training. And it's like, well, of course you're having a few problems. So let's start you from the very basics. And not, you know, not flare them up by going too hard, too fast, but actually educate them around the importance of strength and functional control that the knee will benefit a lot from that. As well as from a function symptomatic point of view and start building on their strength, capacity and functional capacity to be able to meet whatever goal that they want to get back to. So I don't see it as being a totally separate patient from the post-injury one to the osteoarthritic, it's on a spectrum. And a lot of the treatments going to be very similar in principle depending on what their goals and their goals might change over time. So the treatment can as well.
Karen Litzy (34:58):
Yeah. Yeah. Well, thank you for that. That's great. Now, can we talk about the study that you are currently undertaking at La Trobe University. So can you tell us a little bit more about that? What is it and what are your goals for it?
Adam Culvenor (35:18):
We're super excited. Pardon the pun. So this is a project that's really stemmed from over the last 10 years of our work. Looking at identifying those risk factors, as I've talked about earlier to then be able to get some funding. So we've got some funding from the Australian government health and medical research council to perform this really world first randomized control trial, to see if we can actually prevent early osteoarthritis and improve symptoms and function through an exercise therapy intervention. So in essence, we're going to get a whole lot of people, about 200 people who are one or two years following there ACL reconstruction. So they've had that initial period of rehab to get better. Cause some people do really well. We need to remember that, that some people do great following the injury and surgery and don't need more intervention longer term.
Adam Culvenor (36:14):
So we want to try and capture the ones that have some ongoing symptoms and functional impairments. Haven't got back to doing what they want to do at one year post op to two postop at a point where they should be able to do those things and because they are going in out by some of the research, that's just, those people are more at risk of developing longer term problems. So we want to capture those at high risk and we're going to separate them into two different groups. In our clinical trial. One group will get a really intensive physio therapist, led exercise therapy program. So a lot of strengthening, agility, neuromuscular control, education, around physical activity you know, loading of the knee return to sport. And then that's over a period of four months initially. And then the other group gets what we're trying to say is usual care.
Adam Culvenor (37:06):
So very little intervention, they get a little bit of education and some booklets with the types of exercises I could do if they want to essentially, which is what they'd probably get it from their GP or their surgeon. Similarly, am I going to then assess their needs and their general health and symptoms and function from baseline and that changes over four months. And then also look at the changes up to 18 months as well because the MRI is one of our main outcomes looking at early collagen changes, which is our osteoarthritis marker. And some of these can take a little while to show up. So if you have an MRI on one day and then go and have an MRI the next week, chances are, you're probably not going to see much difference. So we need that period of, you know, 12 to 18 months to be able to see an effect of our exercise therapy intervention.
Adam Culvenor (37:56):
Whereas the symptoms of function we're expecting to be able to improve quite a bit within the first four months, which is going to be the most intensive period. And so yeah, our hypothesis is yeah, is that there's really strong, intensive, progressive rehab program strengthening, getting nice knees back to better than what they were before is going to be beneficial for their symptoms, function, general health quality of life, but also hopefully be able to show that that's actually preventing the early changes that we see on MRI or indeed maybe slowing the changes. So we know that cartilage thickness decreases. So we have a loss of cartilage, bone marrow lesions can start developing also for small osteophytes and bony spurs can start developing over a course of one or two years. And so we want to see if there's a difference in the development of those features in the two different groups. So we are ready to hit, hit, go on this study and a little bit delighted with COVID effecting us at the moment as well. So we're really excited to get going on this study and hopefully be a really impactful research project, moving the field forward and empowering clinicians to say, we actually can make a difference in this space for these patients.
Karen Litzy (39:07):
Yeah. I love it. Well, I look forward to when you guys can actually get started and maybe 12 to 18 months from then. So it sounds like a great study. And like you said, it's something that can be so empowering for physical therapists or physiotherapists to then pass on to their patients and kind of transfer that power from the physio to the patient to give them a greater sense of wellbeing, which is exactly that's what we do, right. That's why we became PTs or physios. So before we sign off, I have a couple other things. Number one. What are your biggest sort of takeaway messages for the listeners?
Adam Culvenor (39:55):
So I think the biggest thing is probably when you first see the patient, whose had an acute ACL injury in front of you and they're devastated. They often might come into your rooms and have heard particularly here in Australia. Our media is very centric on if you've had an injury, you need reconstruction because the elite athletes tend to have the reconstruction and I want the best treatment. And therefore I need a reconstruction is actually having a conversation with them and saying, presenting them with the evidence as I spoke about earlier. And there's no problem trialing a period of non-operative management for a couple of months, because that's going to be a great help if you do go down and have surgery afterwards. And it's, I think the reality is that a lot of people given the opportunity to do is to not pretty, very happy, actually can change their mind over the course.
Adam Culvenor (40:45):
And I realized actually, my knees gone really well. I actually don't need to have surgery where I was. I thought I would. So that's instead of just going gung ho into surgery, I think the evidence is very clear that a period of non-operative management is beneficial. Most patients almost all. And then the second key take home for me is, is during a postoperative or post-injury rehabilitation is actually working these patients intensively and progressively, I think we tend to shy on the side of being a little bit cautious, particularly after they've had a reconstruction, we worry about the graft rupturing. And of course we have to respect the surgeons requests of what we need to do with the patient from a restriction standpoint. But I think there's evidence growing now that we can be a lot more intensive early on and progressive with our exercises and looking to the strengths and conditioning research like these guys are trained specifically to develop strength and conditioning programs.
Adam Culvenor (41:46):
And I think as physios where we're pretty good at it, some better than others. And I think meeting the American college of sports medicine, you know, criteria for strength gains is actually, you need to work really hard. You need to get sweaty, you need to actually be working at an intense level. And so unless we put our patients through that, those sort of levels of intensity, we're not going to see the best outcomes that these patients can then can achieve. So there my two take homes is I think try non-operative period of rehab initially and revisit that along the course of the program. And then don't be afraid to actually build a lot of strength in those people because that's going to be beneficial. So they short term prevent re injury and the longterm of preventing arthritis, likely down the track as well.
Karen Litzy (42:31):
Awesome. And then number two, next question is, and it's something I ask everyone knowing where you are now in your life and in your career, what advice would you give to yourself right out of a physiotherapy school?
Adam Culvenor (42:51):
Ooh, good question. I'd say don't worry so much about things. Things will work out. I think in the research I'll probably have my research hat on a little bit, is often clinicians who want to start in research or even researchers who want to continue in research is that the funding can be really you know, tricky and really competitive and can often make and break careers. But I think some general, you know, I'd tell myself is don't worry too much about that. Just link up with good people and strong mentors. So, and I think finding, I'm sure you've had other guests say this as well, but finding good people who can mentor you really well and put your interests or your goals in your career sort of forward to their collaborators. So you can meet new people and open doors.
Adam Culvenor (43:46):
I think I was always worried that it wasn't gonna be enough doors opening, but I've been really lucky in my career that I've been surrounded by a great team throughout and doors have inevitably even though I don't expect them to keep opening. And so having the being in the right place at the right time is important, but you can, you can help to create more instances of being in the right place and more instances of being in the right time by putting yourself out there and meeting new people and surrounding yourself with really good mentors.
Karen Litzy (44:20):
Great advice. And number three, last question. Where can people find you?
Adam Culvenor (44:25):
Peak pool can find me in my lantern at the moment I'm up? No. So I'm have a Twitter account @agculvenor. My profile's on the Latrobe sport and exercise medicine research center page at Latrobe university. So we have a blog at our research center with a lot of really nice impactful easy to digest, short blogs, short videos, infographics designed for clinicians designed for patients. So you can take them off the blog and give them to your patients so I can not recommend that resource highly enough. And then my email, feel free to email me. You can find that email address on the La Trobe website page as well.
Karen Litzy (45:13):
And, we'll have all the links to that at the show notes for this podcast over at podcast.healthywealthysmart.com. So we'll have a link to your Twitter and to your page at Latrobe and also to the blog. So people want to get those resources, they can, and we'll also put in links to the papers that we spoke about today so that people can go and kind of read those papers as well. So we can link up to all of that. So, Adam, thank you so much was a great conversation. I appreciate your time.
Adam Culvenor (45:44):
That's been fantastic. Thanks Karen.
Karen Litzy (45:46):
You're welcome. And everyone, thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart.
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