Muscles and bones

Hello, Welcome and thank you for joining us. I'm Dr. Helen Lawal and I'm an NHS GP and I'm your host for today.

So the focus of today's event is musculoskeletal health, also known as MSK. So you'll hear me refer to it as MSK throughout as we go along.

So we're going to be looking at muscles, bones and joint health which are really commonly presenting conditions that can

affect us all at any point during our life. We've got hundreds of questions that you sent in.

So thank you for sending those in and we're hoping to address those during live interviews with our experts

and also in a quickfire round at the end we're gonna have a quick Q & A round right at the end of the event, so stick with us.

So first to make sure we're sitting comfortably we've got the help of Mike Livesey, now Mike is Bupa's specialist physio

Then moving on we'll be speaking to Dr. Petra Simic, Petra is the Medical Director of Bupa Global and UK Insurance,

and she's also a very experienced GP. So she's going to be giving us an overview of musculoskeletal health,

looking at common aches and pains and what we can do to manage pain and common conditions like arthritis, tendonitis, and osteoporosis.

Moving on, we'll hear from Bupa's UK Sports Ambassadors who will be sharing what we can learn from elite sports.

Then we have our second expert of the day joining us remotely, Judith Smith. Judith is Bupa's UK Insurance, Advanced Physio and Clinical Lead.

She's going to be discussing the importance of building mobility and getting started with exercise.

Then we'll have Mike again for a short demo on exercises we can do at home to prevent and treat common muscle, bone and joint injuries.

And finally, last but not least, we'll have Mr. Damian McClelland Now Damian is an orthopaedic surgeon

And he's also Bupa's Clinical Director of MSK. We're going to be having a really interesting discussion on the impact of surgery,

Why not always the answer, and how to prepare and get fit for surgery.

So to begin with, we've got specialist physiotherapist Mike Livesey, who's going to be showing us how we can sit comfortably.

Thanks, Helen. Hi, everyone joining us today, I just wanted us to get started with some simple exercises,

a little bit of advice about seating posture to make sure you're nice and comfortable. What we tend to see a lot of in clinic is

people coming in with spinal pain or shoulder pain because of poor seating position.

So where do we get started to help correct that? A good place to start is thinking about your spinal posture

and you spinal position and that supporting as much as possible. The spine as you know, has curves throughout the spine.

So if we can support them, and that will help offload the work that the muscles are trying to do to maintain that position.

If you're sat at home in an ergonomic chair with sort of ergonomic design, like I am, with a built in lumbar support,

make sure you're using it appropriately. You need to sit all the way back in the chair for that lumbar support to be in the right position.

That allows then the upper back to be in a much better position, the shoulders to sit back more comfortably

and the elbows dropped by our sides so we can get nice and close into the desk and the forearms to be supported.

If you're sitting at home on the sofa, use a towel or use a small cushion to roll up and just keep that support in that lower back.

But what happens if we don't have that is we slump, the shoulders drop forward, and the head comes forward and it goes a lot of unwanted stress

at the base of the neck. So try and get that spinal posture supported, helps you sit in a much better position.

Another good tip is try and get your feet flat on the floor. When we're rotated or feet up on the sofa or chair or legs crossed,

puts different stresses and strains on the knees and the hip. So it you're there for sustained periods of time that could start to become uncomfortable.

So feet flat on the floor helps knee and hip alignment alongside that spinal position keep you in a really good starting point.

A couple of simple things to remember though is movement. Get up, step away from your chair and step away from your sofa

for as much as you can. Don't stay for longer than 30 to 40 minutes ideally. If you can't get up and move around that much,

then do some simple exercises in your chair. So try and join with me, sit forwards at the front third of your chair.

I want you to sit up nice and straight, squeeze the shoulder blades together you might feel a bit of pull through the front of the chest that's quite normal.

hold that position for 10 seconds, and then relax. Again sit up tall. Second exercise, fold your arms across the chest

so your hands on your shoulders sitting straight and going to twist over one side as far as you can,

and then back to centre and then again the other side,

and back to centre. That's a great way to help mobilise that mid back and just get it moving if you are sitting for long periods of time through the day.

Roll and stretch out your neck by taking your ear down to your shoulder, feeling a stretch on the opposite side.

Hold for a few seconds and come back up and again even yourself out. Repeat it over to the other side and come back up.

Final movement is just simple turns over one shoulder, back to the centre and again repeat the other side.

Back to the centre. These should just cause a mild pull shouldn't be causing any pain.

So if you are getting anything like it might be worth seeking a little bit of advice from your physiotherapist.

But these are a couple of simple tips to go away and think about this morning, and get you started I'll be back with you

later with a couple of other exercise tips. So back to you Helen Thanks Mike, some really useful tips there.

So I'd like to start by welcoming Petra. Hello Petra, good to see you. So thank you for joining us today to talk all things MSK.

So let's start by exploring some of the common areas that tend to affect people when it comes to their MSK health.

So muscles, bones, joints and often it tends to be three areas at least that's what we've heard from customers,

arthritis, tendonitis, and osteoporosis that actually Bupa customers are interested to learn about.

I'm also hoping we can touch on pain management as well, because that's a big in something, which really impacts on the quality of life.

Sure Helen, well you know it's no surprise to you, you know that in practice, MSK conditions are really common.

In fact, they make up about one in five of the consultations that we see as GPs and then the most common joints affected are

backs, necks, shoulders, and knees and I'd say those are things that people come to us with pain in most commonly.

And certainly, the last year, I've seen a slightly different pattern and two broad groups of people coming to see us.

So we're seeing groups of people coming to see us who've increased their exercise really use the pandemic as an opportunity to focus on

their physical health, which is admirable and something that we really promote as doctors, but often they're overdoing things.

So we're seeing people that are gaining injuries, through taking up sports that maybe they haven't done for some years

or doing things too much and not listening to their bodies when they're getting aches and pains. So we're definitely seeing

groups of people coming into surgery who have injured themselves through doing new sports or using home equipment

incorrectly or unsupervised yoga. So they're developing joint aches and pains that we have to help them try and fix.

The second group of people we're seeing a lot is those who used to exercise more in their everyday life than they

perhaps realise. So their commute to work their jobs with they've been furloughed, and for those people that have been

shielding, their level of activity has dropped hugely. And that affects joints too, joints like to move and

mobility is really important. So reducing levels of activity have meant that some people have developed aches and pains that they

weren't expecting and either during the period of being more sedentary or when they go back to doing exercise people are

noticing that they're getting pains where they weren't expecting it or didn't have before.

So those are the kinds of things that we're seeing. You know, the human body,

we expected just to work and to do what we asked and we often don't think about what good condition we're in how much exercise we

should do, and slowly building that up and certainly rest and recovery are not things that we're always that good at doing.

So it's important that we really reflect on the exercise we want to do and make sure we do it in a in a graduated way.

I think we tend to take our bodies for granted don't we until something starts to go wrong and the aches and pains to creep in.

Absolutely. So talk to us about arthritis and by arthritis we mean osteoarthritis. So wear and tear arthritis.

Tell us more about that? Well wear and tear arthritis, osteoarthritis, again, incredibly common. If you've been diagnosed with it, you're

in really good company. I think it's again about one in five people over 45 will have signs or symptoms of knee arthritis but

the problem is that phrase wear and tear arthritis. So if you had a washing machine, and the engineer said it was suffering

from wear and tear, you're very likely to not want to use your washing machine as much because understandably you think well

the more I use it, the worse it will get but it's not the case with with osteoarthritis.

The important thing to try and resolve osteoarthritis, reduce its progression and improve

things like pain and function is keeping that joint mobile. So keeping mobile is really important. Offloading any excess

pressure onto a joint so particularly on the lower limbs if you're carrying any excess body weight that can really

affect pain and function on your knee or hip or ankle so if you are overweight, losing weight that can make a dramatic

difference to any pain you might be suffering with your arthritis

and strengthening and this is something that I think often we don't talk about enough so if we can strengthen the muscles

around an affected joint and sometimes the joint above or below, the stronger we get, the more it offloads that joint

and the better the joint functions, the less it degenerates and progresses and the better performance that you can get out

of the joint. So, those things are really important. Often I find patients feel a bit disappointed if they're

offered painkillers for their osteoarthritis but using painkillers can really help you function more normally and use

the joint more because it's less painful, and that in turn improves the outcome of your osteoarthritis.

So painkillers can be an important step. I think the other thing that may be a bit

misunderstood is how important surgery is and osteoarthritis because the vast majority of people will improve

with things like physio, strengthening exercises, graded exercise

and only a very small proportion of people will benefit from surgery in the long term.

What often happens when patients when they're in pain, and they've got arthritis or they are overweight and have been told to lose weight, how can I because I'm in pain? Or how can I

it's difficult to exercise? So hopefully our expert physiotherapist can guide us on how to approach exercise safely later on.

So talk to us more about tendinitis. What does it actually mean? And how can we really manage this at home or

even prevent it at home. So tendinitis is a different type of condition to osteoarthritis and you have to treat it quite differently.

Although as a patient, it might feel quite similar, because it's often a painful joint and the joint can feel quite stiff too.

But it's an inflammation of the tendon and the tendon is a tough bit of connective tissue that joins muscle to bone.

and essentially it's an overuse condition. It's when we've used a muscle group either over and over again for the same activity

and tired it or we've used a muscle group that's not strong enough for what we're asking it to do.

So it is something that sometimes you do need an expert like a physio to help you diagnose,

but the most important thing for tendonitis is rest. So where as for conditions like arthritis we might encourage

activity, for tendinitis, certainly at the beginning, rest is an essential part of letting that muscle group

heal and recover. And the next thing to do is to then kind of

recuperate the area. So if you've have tendinitis, that tells you something, it says something is not right.

Either your muscle group is too weak for what you want it to do or you're doing something in a way that irritates it. So you really

need to look at whether it's the ergonomics of your desk or your swing in tennis. Your tennis elbow is a tendinitis and going

to see a physio to see which muscle groups need strengthening to prevent it happening again because what I see in general

practice, and I'm sure you do, is people have episode of tendinitis, they recover and then six months later you see

them again and they've done no work in strengthening their muscle groups in between the episodes.

Painkillers can be helpful, anti inflammatories really useful. Sometimes the joint is so inflamed that the only thing that will help you

are things like steroid injections. But at the end of the day it's rest and then that kind of recuperation and

rehabilitation afterwards can prevent it becoming a recurrent problem. Actually, the body's really clever, isn't it? It's the

body's way of giving us a warning sign and saying, hang on a minute, something you're doing or not doing isn't quite right

here and I think it's really important to get help in those early stages. You're absolutely right and I think this is a real example of

when people say, "No pain, no gain." It's not the case when it comes to tendonitis. If it hurts, you must stop and change

what you're doing, there's no benefit from going through the pain, especially in a case of tendinitis.

So moving on then to talk about osteoporosis, which is a very different type of condition. Talk to us more about that.

So osteoporosis just means porous bones, spongy bones

and I think it's important to understand a little bit about our bones and how they change through our lives.

So, our bones much like most of the cells in our bodies are constantly

renewing themselves and our bone regeneration as a child and

adolescent is amazing. It allows for us to grow and we've all seen children falling off their skateboards and their bikes and

the climbing frames, and they have a few bruises and they just jumped straight up again. So incredibly strong bones

when you're in that kind of growth phase. And then in adulthood, your bones continue to renew itself and actually,

you're although it's a constant state of renewal, you get a new skeleton around every 7 to 10 years, which I think is fascinating.

But from the age of 40 that bone regeneration slows down and everyone suffers a degree of bone density loss.

Now osteoporosis is just a phrase for low bone density and as a

condition gives you no symptoms until you have a fracture. So often you might not know you have osteoporosis until you have

a particular type of fracture and the type of fractures that we think about that are linked to weak bones are hip fractures.

So if you think about it, you don't hear about young people falling over and breaking their hips. It's very much a condition

of people as they get older. Wrist fractures, particularly if just falling from a stood up height and falling out onto an

outstretched arm. And for some people, if they lose heights as they get older or get a curvature of the spine that can

be a sign of osteoporosis, where the vertebrae are actually crushing down, which sounds very dramatic, but often with no pain at all.

So osteoporosis is a condition of thinner bones, making you more liable to fracture. The good news is that

although most of us will have reduced bone density as we get older, there are things we can do to reduce that risk.

So keeping a healthy BMI actually it's one of the few times as doctors we talk about being slightly overweight

actually reduces your risk of having and when you say BMI, you mean? Body mass index, so how much weight you carry on your body

and it's to do with that the harder the bones have to work, the stronger they get and that's also the case with what

we describe as weight bearing exercise. I think that's often misunderstood. I think people think that means lifting

weights and it doesn't it just means putting impact through bones. So even brisk walking, dancing, certainly things like tennis

or running are what we call weight bearing exercises and they can really help the bones to grow in a strong way.

Having a calcium rich diet, that's really important. So those are things you can do to really keep good bone health.

But there are things that you can't help. So as you get older, it reduces your bone density. If you're a postmenopausal women

not taking HRT, we know that that increases your risk of having osteoporosis. If you're someone who's always been very

lean, having a low body weight, that will increase your risk of osteoporosis as well smoking or drinking a lot of alcohol.

And anyone that's taken oral steroids for long periods of time, that will increase their risk. And if you've got a family history

of osteoporosis that can increase your risk and people often don't know about that, they'll know that their

mum had a hip fracture but no one quite explained to them that meant that their mum had osteoporosis and so having a

family history of osteoporosis can increase your risk. If you have a diagnosis of osteoporosis, the good news is

there are some really effective treatments and medications that you can take to strengthen your bones. If you think you've got

risk factors for osteoporosis, then it's a good idea to have a chat with your GP. You might benefit from a bone density scan to see

how strong your bones are. And if you are one of your loved ones that has had one of these fractures or is losing height

curving in the spine, it's probably again worth a conversation with your GP to establish does this person have

a reason for having the fractures something like osteoporosis and are there treatments that can prevent them

having a fracture should they fall again sometime in the future?

And finally, it'd be really great to get your thoughts on when is the right time to seek help, especially thinking of people who maybe they have a job or an occupation, which is you

know, being impacted by some of the symptoms they're getting and they want to prevent it worsening, so it doesn't impact

on their work. So this is quite common in general practice that people will present with joint problems that are affecting their ability

to earn a living. And what I try to impress upon people is the importance of getting help early that their bodies are as an

important tool as their laptop or their mobile phone and if it's not working properly and starting to niggle not to wait

for it to get worse because often treating these things early prevent them becoming such huge problems that they

have to pause work or take time off work or even stop work for a while which can have quite a dramatic effect on people's

ability to earn a living. Thank you I think that's really great advice and the key message there is really don't ignore your body, seek help

there is help out there and act quickly so that we can hopefully prevent some of these conditions developing and progressing

and worsening Absolutely. As part of Bupa's partnership with UK sports, we're going to

be hearing from some of the UK Sports Ambassadors, sharing their journey and also how they use injury prevention in their

daily lives.

I think one of the biggest things people neglect is mobility and flexibility. You know it's often time when a

muscle is pulled, it's probably because they've got into a position that their body is not used to. So if you can stretch

and do some form of mobility and flexibility every single day that is paramount for staying injury free, without a doubt.

I've been training now for 14 years, a long time and so far,

touchwood, I have never had an injury. So I must be quite good at injury prevention I don't know, or not training hard enough

One of the two.. I literally tore my cruciate ligament on Strictly I jumped

off the table and tore in the rehearsal and then it was hard to recover because like all the gym shut all the physio shut,

So I had to do my rehab on my own and I didn't realise how big of operation it was. Every day I'm like trying to learn about my

injury, like still now it's like year and a half after the operation, and like, I'm still managing my knee, like every day.

My first real experience of injury was when I was 14 I had

a double stress fracture in my lower back I had to do a rehab. When I was 18, I tore me cartilage off the bone on my

wrist had a surgery and had to do a rehab. When I was 21 I snapped my ankle ligaments had a surgery and had to do a rehab.

At this point, I'm sort of used to the process. It never gets easier But it's right. This is real. What can I control?

That's what you do you, you control the controllables. You try and just focus on that. Everyday I can do my rehab,

There's always some positive that you can take out

It was straightaway drummed into me that you always get a good warm up, always get a good cooldown, always have the

recovery you need between reps. So it's something that I've just kind of carried with me through through my years. And you know,

so many people just want to "I have done my session now" "I'm off, I'm done". Always do stretching, always make sure

that you've done those little things because it makes such a big difference.

We have physios that are based here full time so that we can use that as much as we want. Obviously, for my conditions,

it's important to us that when I can I get really stiff joints and to have that opportunity to use the physios is massive.

When I'm working with the physio, a lot of the exercises that we do with them in the gym is like helping

prevent injuries because like I'm trying to get stronger and that will like therefore hold my legs in position better and I

won't get that tear or anything like that. If I'm the stronger am like physically the less likely I'm going to get an injury.

I know gyms are open now and we all can't wait to get back in but don't just run in and go straight to the benchpress machine.

Go in, do a little stretch, do a little warm up. So maybe you know, little run on the treadmill, a slow one.

I think just be very aware of your own fitness levels. I had physio every week when I wasn't injured and it that was a

preventative. It was sort of making sure that, certain areas where I get tight I keep loose.

If you've got any kind of injuries or little niggles always go to professionals you know don't try and self treat it

because it can only make it worse. For you have to learn how to manage your body and yeah,

still learning. It's really great to hear from Will, Nile and Hannah there,

sharing their experiences and learning as elite athletes. and also from their point of view on how important physiotherapists

were in, getting them fighting fit and ready, and how important it is for us all to take care of ourselves.

So now here's your opportunity to take part in our poll, and the option should come up on the screen in front of you.

So what one thing do you want to focus on to improve your muscle, bone and joint health?

Is it to lose weight? Start exercising? seeking help for an existing issue? changing your diet or all of the above?

Next I'd like to welcome Judith, who's Bupa's Advanced Physiotherapist and Clinical Lead.

So Judith, we've had lots and lots of questions on mobility and strength. So can you share some tips on really how the audience and people at

home can use exercise to help them build up their mobility and strength? Yes, thank you, Helen. That's a really great question to start with

as strength mobility plays a crucial role in keeping muscles, bones and joints healthy and preventing injury.

Strengthening activity is as important as aerobic exercise. but recently a study showed that only 30% of people actually

meeting both the aerobic and muscle strengthening guidelines and we are least likely to meet the strengthening component.

Strength is often referred to in fact as the forgotten guideline in comparison to the much better known recommendation for aerobic exercise

and the Physical Activity Guidelines tell us that muscle strengthening activities should be completed on at least

two days per week for the major muscle groups including the legs, hips, back, and shoulders. As well as balance and

flexibility activities to build strength and mobility. Adults should be physically active every day, reducing the amount

of time spent sitting and breaking up long periods of not moving, such as desk based rolls of activity.

Being active can can have an enormous benefit on the overall health and it doesn't need to be difficult or expensive.

Whatever your situation, there are some simple ways to get started and improve your health in way that is right for you. You can start to aim

for small bouts of 10 minutes of brisk activity throughout the day and what we're aiming for is about 150 minutes of moderate

exercise over the week plus the specific strengthening exercises.

If you're new to strengthening, shortly, Mike will show us some easy ways to get started and just remember

that it's never too late to start increasing your strength. In fact, one study showed us that after a 12 week strengthing

programme for a group of 90 year olds, they were able to double their muscle strength. The fit principle gives us four ways to

progress the amount of activity that we do. So fit stands for frequency, intensity, time and type. Frequency, this means

increasing the number of times per week that you're active. Intensity, walking a little bit faster, cycling a little bit harder,

digging harder in the garden, and time, increase the amount of time that you spend on each of the exercises and then

the type. So if you're comfortable with the exercise that you're currently doing, try something a little bit more demanding. This is especially important after the events of

last year where people have experienced deconditioning due to reduced activity levels. Make sure also that you find an

activity that you enjoy the chances are you'll stick to a new activity if you're enjoying it and don't worry if it's not

the most taxing to start with. Because the best activity is one that you will actually do. Start gradually give yourself small

goals and set realistic targets and you'll soon see the positive effects of exercise without overdoing it.

That's brilliant Judith. I think that's really really good advice and love fit, frequency, intensity and time, it's a

really easy way to remember and like you said, it's about building exercise into your day to day isn't it, it shouldn't

have to be a chore and 10 minutes here can really work. I think the key really is to find something that suits you that

you enjoy. And that you can incorporate into your daily life, whether that be an active commute, you know, walking

instead of driving to work, and even things that we don't think about like gardening and things can actually count towards our

physical activity. Absolutely and also increasing with strength, gardening is

a fantastic exercise because it's going to give you both the aerobic component and the strengthening part is often missing

Just clarify you use the word aerobic there just explain to us what the different main differences between aerobic

and strengthening exercise. So when we're working on aerobic exercise we're wanting to

increase our heart rate slightly. So you should feel slightly out of breath, you should be needing to take a rest

to complete a full sentence. So you know that you're getting a little bit of a sweat perhaps. and your heart rate is slightly

increased. Strengthening exercises and more for loading the bones and strengthening the muscles so they can be they

don't need to be things that you do in a gym. They can be things that you can do at home using your own body weight, doing squats

working more on the function of the muscle. You mentioned that about the 150 minutes that we should all

be aiming for 150 minutes of moderate intensity exercise a week That sounds like quite a lot. Can we build up to that gradually?

Absolutely and that's where we starting with if you start with small bouts of 10 minutes of brisk activity throughout the day.

That doesn't need to be done every single day but it's good if you can do a little bit every day. Just as you said bringing it

into your commute so that can be using the stairs at work instead of using the lift. Getting off the bus one stop early and doing

an extra 10 minutes walking in the morning. Just gradually building up with small bouts of activity to be able to bet over

the whole week do a 150 minutes. Some great ideas there and I know we've got Mike coming up

later and he's going to be doing some demos and exercises we can do at home as well. So moving on your physiotherapist, tell us

why sometimes seeing the physiotherapist before seeing the GP is actually the best option for patients?

Yes that's right. A big shift has happened recently in health care of the last few years. Physiotherapists now recommend as the first

point of contact when it comes to bone, muscle and joint problems.

This model is taking pressure off GP services as musculoskeletal issues can take up to 30% of GP appointments.

So seeing a physiotherapist first can be the best and the quickest routes to treatment, as it allows people to get straight to

the professional whose expertise is focused on bone, muscle and joint systems.

Physiotherapists are the third largest group of qualified health professionals, after doctors and nurses and

qualified to train, assess and treat undiagnosed bone, muscle

and joint conditions. A physiotherapist will spend time assessing and diagnosing and will also be able to give you

expert advice on how to begin managing and treating your condition right from the start. If needed, physios can also

refer to specialist services such as orthopaedics, and they're skilled in deciding after the assessment and

discussion with you, which is the most appropriate treatment path for your particular problem. A physio will assess

soft tissue injuries such as sprains, strains, sports injuries,

as well as arthritis and joint problems. Problems with tendons, spinal pain, such as low back pain and neck pain

and sciatic pain. Seeing a physiotherapists first for these conditions will give you faster access to diagnosis and you will

get exercises and treatments straightaway. It's been demonstrated that rapid access to physios can actually reduce

the amount of time people need to take off work and it's an effective way of preventing acute problems from becoming

longer lasting problems. And in some circumstances, actually seeing a physiotherapist after they've diagnosed your problem,

you're confident enough, they may be able to give you advice and exercises to manage your recovery yourself at home.

So as a GPI must say that physiotherapist really don't get enough credit and you could wait potentially weeks and weeks to

see a GP and in that time, he could have seen the physiotherapy and they could have sorted you out.

So moving on then. Bone mineral density, is it just an age thing or is it

something that actually we can we can work towards and do something to prevent and manage in our younger years too?

Yes, absolutely, our bone density is 90% developed by the

time we're 20 years of age and the actual reaches a peak by 30. So being fit and active in your younger years is the best way

that you can maximise your longer term bone density. From 30 years onwards the bone strength will naturally start to

decline over time. And at about a rate of about 3–8% per decade

of your life. That might sound like a bleak picture but it is part of the natural ageing process and the good news is

that bone density loss can be significantly slowed down by lifestyle choices. Bone is the living tissue and it can be

improved by exercise and weight bearing exercise as Petra describes earlier which involves staying on your feet, working

your bones against gravity. Such as brisk walking, dancing, jogging, aerobics alongside the strengthening exercises are

particularly good at improving bone density. The other lifestyle changes that you can do yourself to influence have

healthier bones are things like your diet, reducing alcohol intake, stopping smoking altogether, these can have a

significant negative effect on your bone health and for women,

especially around the time of menopause when oestrogen levels fall.

This can play a crucial part on the regulation of bone production and turnover. So at this time, it really becomes

important to keep your bone strength up by exercise and

lifestyle. I think especially for the postmenopausal women when we see a big drop in bone mineral density, around that time, it is

okay to ask your GP for trial HRT as well because we know that's a really effective way of slowing the progression of the

bone mineral density in postmenopausal women as well. I think the lifestyle stuff is great, isn't it, but sometimes

it is also important to consider what our medical options are as well. Absolutely. Brilliant, thank you so much. Such really insightful stuff there

Over to you Mike.

Hi again, everyone. So just wanted to discuss with you a little bit about injury prevention and a couple of tips

and exercises that are useful when you are exercising. Couple of injuries are impossible to avoid things like slips, trips

and traumatic injuries. However, we see a lot of people in clinic coming in with overload injuries where they train too much and

they've exceeded what their body can tolerate. So a couple of things to help avoid that is a warm up. So anything before your

activity to encourage blood flow, encourage heart rate and oxygen to the muscles in really important. The aim of a good

warm up is to help prime those nerve endings and those muscles so we get a better relationship between them and they perform

more effectively, which result in better and more efficient movement. Better improvements in your balance and your

coordination. So a couple of great exercises to go away with are things like squats exercises. So let's start off

with that. So you start with your feet shoulder width apart. Nice and comfortable, soft knees, you're going to sit

slowly down by bending your knees and your hips into that squat position. Keeping the weight into the back in the

heels where possible. It's good to have your arms out in front because that will encourage you to distribute that weight A little bit further back. Try to keep your chest high to the back

straight as well and avoid any unwanted stresses. Don't squat too deep and make sure it's comfortable. A great progression

on from that exercise is coming into a split squat or what we commonly will know as a lunge. So with that you're going to

stride with one leg forward, one leg back. It's really important

to help maintain your balance with it. So what we want to try and think about doing is keeping the knees straight with this movement. We're going to slowly bend both knees down to about 90

degrees if that's comfortable and then come back up and repeat so we're looking for the knees to stay in line with the front

portion of the foot so your second or your third toe. You can make this more challenging by offsetting your balance by

folding your arms or raising the arms up high.

Again it makes you look more unstable, engages a little bit more muscle through your trunk and through your core. So they're really good for

hip and knee warmups in order to get you moving if you do any lower limb exercises. Then another brilliant one for hips

and the backs, again to get strong and get moving, so you can use this to strength as well as the wall is a bridge exercise.

So we're going to lie on our backs with our feet bent up well our knees bent up sorry and our feet on the floor.

So you're going to have your kness bent comfortably, about shoulder width apart and you're going to raise the pelvis up off the floor

and then come down. Avoid any pinching or any pain through the back or through the hips. And you can hold the position for a

few seconds or longer if you want to get some strength benefits from this exercise and then come back down.

While we're on the mat a couple of other really good exercises, a couple of yoga stretching is fantastic for sort of hit and low back

mobility. So again, if you stick in these areas, these can lead to injuries as well. So start in a four point kneeling position.

and we're going to sit back onto our heels, bringing the hips back, bringing the chest and the head down slowly to the floor

and you'll feel comfortable stretching the lower part of the back and maybe into the hips. And then you're going to come

out of that stretch back to that start point and repeat and you can hold the stretch for as long as you want in order to help

improve that flexibility in your lower back and in your heads. I think the final tip to just go away with, is again a bit of a

core and a hip exercise in this four point kneeling position while you're on the floor. It's called a superman exercise, I'm

going to come down on to four point kneeling and I'm going to stretch opposite arm and opposite leg away from the body.

So back nice and straight and we slowly move away with arm and leg and back in trying to keep the trunk as still as possible

throughout the movement. Again, should be comfortable. If we get any pain in shoulder wrists or hands, then just ease off that

exercise. It might be a bit too challenging for you to start with. So think warm up, prepare the body for exercise and get

stronger, It's a great way to get tissues nice and robust, so they're less likely to injure. Okay Helen, back to you.

That's great. Thank you, Mike.

So next we have Damian. Damian thank you for joining us today. You're an orthopaedic surgeon. So I thought might be useful to start with. When is surgery the

right option? And also, are there any instances when it might not necessarily be the best option for the patient? The vast majority of people that get referred with a

musculoskeletal problem are not candidates for surgery, most people can be managed with non surgical options. So when we see

somebody we've accurately diagnosed them with appropriate investigations and examination, the next stage to do is consider

what we can do with that person. And it's always a joint discussion with the patient obviously how we manage that problem.

So the first option always is to do nothing if they have a diagnosis, and they just came because they were a bit concerned that we had a particular problem, and their fear

has been assuaged, then we can just leave it. Then option one is to do nothing. Option two is physiotherapy. So if somebody

has a joint related issue, or balance related issues, such as an unstable shoulder, then you can have physiotherapy,

physiotherapy can balance the muscles around a particular joint, help with the pain and therefore avoid the need for surgery.

If there's a local problem, such as an inflammation such as subacromial impingement say, and there's a bit of a bursitis

then you can treat that temporary problem with an injection. So you have injections to help either with

diagnosis and or with treatment. So that's the third option and it's only when you've exhausted those that you come to the final option

which is surgery. So surgery is a last resort is what you're saying and in some instances?

Yes, unless there's an urgent reason to move to surgery such as a fracture or a tumour or something like that, then yes,

people tend to move down, the algorithm of less invasive, less risky

down to the more risky and obviously, when you've exhausted all the less risky options you come to the surgical procedures. So the first option always is to do nothing if the

patient has a diagnosis and they've been concerned that they may have had something more serious. But in actual fact when the diagnosis has been made, they haven't. If they're happy

to live with the symptoms they have, then we can leave it at that and do nothing. That's option one. Option two is

physiotherapy, so in many cases, if people have, say, an unstable shoulder, then it just requires some balance around the muscles

of the shoulder if they haven't had a traumatic injury. Then they can go to physiotherapy, the physiotherapist can balance the muscles around the shoulder and that can solve the

solve the problem. Option two. Option three is injections. Injections fall into two main categories. The first is the

treatment and the second is a diagnosis. So if you have pain around a particular joint and you're not quite sure where the

pain is coming from, you can use the injections as a treatment for targeted treatments with ultrasound

guidance or image guidance. And that can help to diagnose the problem and also can help to treat the problems. So if somebody

say has inflammation around the AC joints, you can inject it and that can help to treat the issue as option three, it's only when

those three options have been managed or used that you come on to option four, which is the surgical option

So surgery is often a bit of a last resort then for some patients? Yes, it's a last resort for most cases of elective presentation.

If somebody has a fracture, obviously, then that that's got a more of an emergent treatment option as a different treatment

path then. But for the elective procedures, yes, it's always a last option. And what are the processes that and procedures that patients

will go through in the run up to surgery and after surgery? In general, the patient needs to be prepared for the surgery and

you can do that in two main ways. You can prepare them generally and you can prepare them specifically. In general,

if they're waiting, say for a knee replacement and common procedure that gets done in the UK, and they need to be healthy

for the anaesthetic. So they can contact the GP they can find out

if the medication is okay if the blood pressure is being controlled if the thyroid function is is satisfactory.

So all those general things we can optimise their medical health before they come in for the anaesthetic and then

specifically around the joint that they're having operated on. So if they can get some so called prehabilitation. So they

can have some physiotherapy before their operation to optimise the muscle function that will be looking after the

knee replacement once it's in, then that can hasten the recovery for them after the operation and if they contact

the physiotherapist, they'll be quite happy to provide them with some exercise regimes and perhaps weights that they can do

in the meantime. As long as it's tolerated. So the weeks and the months in the run up to surgery are actually really important for the success of the surgery itself?

Absolutely. A bit of time spent in the preparation can pay dividends later. Absolutely. And how about after surgery, what support and rehab is

available for patients after the operation? After the operation, we have a number of different available

options. You can get physiotherapists involved beforehand. With the physiotherapy teams reviewing

you, you would have been able to identify if you had any particular requirements for your home circumstances. So perhaps

your bed may need to be brought down in short term or seat raises for toilets, things like that. Those kinds of

interventions can be assessed preoperatively and it makes the post operative recovery a little bit easier.

And actually, I guess surgery is just the beginning anyway, isn't it? It's about then helping and supporting patients to

live a better life and higher quality of life after surgery and adapt at home

Absolutely. Surgery is just a tiny part of the whole process and it starts from when the diagnosis is made, and then

is the run up to that process of the surgery, and then afterwards the run off afterwards to make sure that all the follow up is

okay the physiotherapist improving and their patients recovering, that's the level that they hope to achieve.

And for the audience at home, is there anything else that they can do in addition to what you've mentioned in the run up to an operation?

I suppose general things that they could do. We've already mentioned that going to general practitioners to make sure that medication is ok. Make sure that the current treatments for

the medical conditions are optimised but also you can pop to see the dentist so if you've got a bit dodgy tooth for a while

and it's occasionally gets infected or flares up and that can be a source of infection potentially for a joint

replacement. So you need to go see a general practitioner. If people have podiatry problems, perhaps it can see a podiatrist.

get any bunions or any things that are causing recurrent infections. Those are the things that we mainly worry about with

joint replacements. So surgery is one of a number of different options when looking at MSK problems. And actually it presents a real opportunity

doesn't it to review your general health and get a number of different things sorted when it comes to health?

Absolutely, it's a real opportunity to take a good look at yourself and sort things out at the same time. Thank you, Damian. That was really really insightful.

My pleasure.

So now this is the opportunity for the questions you've asked to be answered. We're going to do a quick fire round with our experts. So starting first on lifestyle, diet and supplements.

So Judith, I'm gonna come to you first, how do you deal with muscle and leg cramps at nighttime?

So leg cramps are really common and usually harmless. They can happen at any time but often happen at night when you're

resting. The pain happens when the muscles shortened rapidly and often only lasts a few seconds, it can be really

unpleasant to experience, but generally nothing to worry about. Cramps commonly affect the muscles of the calf and the

foot. During the cramp, you can try to gently massage the muscle

move the affected limb if possible, try to encourage the cramp to pass. After the cramp there is often muscle soreness,

you can use heat massage again just to try and allow that muscle soreness to wear off. They do become more common as we

age, so helping things with drinking plenty of fluids keeping well hydrated, avoid alcohol, and keeping the muscles

flexible and strong. There are some medications that can affect cramps. So if cramps are becoming problematic and

regularly disturbing your sleep. It may be worth discussing this further with your GP.

Thank you, Judith, I think that's gonna be really helpful because it's one of those things that can really impact on quality of life. Next, a bit of a controversial one for you,

Petra, what do you think of glucosamine? Well I get asked this quite commonly in practice and I think the

short answer is, we haven't been able to prove that it really helps anyone. There's been lots of studies done on glucosamine

but some of the higher quality studies show that the effects of glucosamine are exactly the same as if you were taking a sugar

pill or a placebo. So although some people really are absolutely certain that taking glucosamine has helped their

joints. My advice is if people want to try it, they may try it. But if they're not seeing any benefit, after a couple of

months there is no point in continuing to take it and people be better off spending that money on a Pilates class or

seeing a physio or doing some kind of exercise regime, than continuing with the medication because there's no good evidence

that it makes a significant difference. And what do you think of supplements in general? Well, I think if you've been advised to take supplements

because you have a very restrictive diet, or you have

vitamin deficiencies is obviously very important. However, for most of us, if we've got a well balanced diet,

we're getting plenty of sunlight and exercise there's very limited evidence that taking supplements benefit our bones

and certainly nowhere near the benefits we get from regular exercise, strengthening exercises and keeping mobile so

as far as I'm concerned, unless you're advised to for medical reasons, it's probably not worth it.

And vitamin D is one of the common vitamins that has had a lot of media attention in recent times. Damian coming to you.

How important is vitamin D for bone health? Vitamin D is essential for bone health because it facilitates

the absorption of calcium from the gut into the metabolism.

So it allows the calcium to enter and then be applied to the bones. So it actually strengthens the bones over

A period of time. If you don't have enough sun exposure which is a good source of vitamin D or if you don't have if you have a

dietary deficiency of Vitamin D, then this can lead to significant medical issues

Regardless of whether we have an MSK case or not, I believe the advice is all of us should be taking vitamin D supplements over the winter months. Is that right?

Yes, there's there's been some suggestion that the sunlight in the UK is only good enough between the summer months to

provide enough vitamin D for our day to day bone health. Brilliant. Thank you. So moving on then to mobility and pain

management. Judith, we're going to come back to you on this question. What's your best advice for maintaining muscle

bone and joint health as the body ages and gets older, Just keeping active including 150 minutes of aerobic exercise

a week, minimum two days a week including some strengthening exercises for your bone, muscle and joint health. Take a healthy

diet and lifestyle, maintain a healthy weight, avoid smoking and reduce alcohol intake and remember that it's never too

late to get started on strength and aerobic exercises. Just brilliant. Thank you. We've got some great questions coming

in here. So Damian, how can you prevent knees from clicking and grinding when walking, really common, it can be a bit sort of

disheartening when it happens. I'm not sure we can actually prevent it from clicking and grinding necessarily but clicking can occur and be not

much of a problem so you can get a bit of soft tissue catching behind the kneecap and as long as it goes away, then we tend

not to worry too much about those. Grinding can be more of a problem. So if you look at the back of the kneecap,

patellofeoral joints, the kneecap is shaped a bit like a keel of a boat and runs on the front of the femur against two of the parts

of the knee joint called condyles. The muscles on the inside of the knee have to be balanced with the muscles on the

outside of the knee and that allows the kneecap to then glide between those two condyles. If the muscle on the outside which are commonly stronger

than the muscles on the inside they tend to pull it over starts to cause some abnormal rubbing If that grinding persists an doesn't recover with

physiotherapy or doesn't improve with physiotherapy, then it may require treatment from from orthopaedic surgeon.

Okay, great explanation there. Thank you. And then Judith coming back to you does physiotherapy always have to be

delivered face to face for it to be effective? So remote telephone or video consultation is often a great

starting place for physiotherapy assessment on treatment. During an assessment up to 70% will involve taking the detailed

history from you with the onset of your problem, mechanism of injury, detailed questions about your symptoms and how to respond

to certain activities throughout the day. Now all of this information can be captured remotely and the physiotherapist

might also ask you to perform some simple movements to demonstrate how your joint moves for example and which activities

you're struggling with. At this stage the physio will be able to give you some advice and exercises that you can try at

home to see how that your problem responds over time. The physio can then also follow you up with another remote call.

If you're not progressing as expected or there is not a clear cut diagnosis, it is possible to move to face to face after

assessment for more detailed examination. Thank you and of course most of the work with physio is done at

home by the patient in the home rather than face to face with the expert. So moving on then a lot of us have spent a lot more

time working from home in recent times. It's really difficult, isn't it when you spending so long sitting you can feel really

stiff in the hips and achy in the neck? What can people do to avoid these sorts of issues and injuries?

I think you have to remember to try and keep natural breaks in the day. So we those of us who have gone to homeworking in the

last year realise how much we moved. Whether it was just getting to work, whether that be walking to your car or walking

to a tube or a bus. And then how when we were at work, how much movement we did in our natural day, whether it was speaking to

a colleague or going into a meeting or performing our job itself. So if you are working from home, it's really important

to include lots of natural breaks, and to go up and downstairs a few times and to introduce walking, if you can

during your day. So where you're not commuting, perhaps to go out for a walk first thing in the morning at lunchtime or at the

end of the day or ideally all three can really help if you're doing meetings or conversations with people if you can do them

whilst you're walking has a really great way to get some movement into the day. And perhaps also look at your

ergonomic setup. So a laptop on that on a dining table might be fine for a week or two but a few months later, that may not be a

great way to be set for your posture and your shoulders and your neck. So making sure that if you've got a desk setup at

home, you've done that as ergonomically as possible and even think about standing desk I think they're a great a great

option for people. Thank you. A personal favourite minor walking meetings as well either on the phone and then scheduling it in a walk or

trying to meet a colleague face to face think they're a great one to get up and get moving. Right Damian coming to you

lastly then. Frozen shoulder can it be caused by an activity? So when we are doing a lot of sitting, can that bring it on

and you know can being at home and not being my usual routine actually precipitate it? The honest answer is No one knows what causes a frozen

shoulder. So, it could be it may well be, but we don't really know. It was first described in 1934 by a surgeon in the States

called Codman and he described 12 particular features that he'd noticed with what we now know is frozen shoulder. Starts

insidiously usually with an aching around the shoulder and it becomes inflamed. Because it's inflamed, we tend not to

move it. The shoulder surrounded by an elastic capsule that stretches which allows us to have the best range of motion of

any joints in the body, but doesn't dislocate that often compared to the amount of times it's move. With the

inflammation because you don't move it because it's painful that elasticity starts to shrink and that's what

causes the stiffness in the frozen shoulder and over a period of time, it will settle down by itself, but most people

who attend our clinics can't cope with that time taken to

recover by itself, so they may require some treatments. Thank you. Thank you to all of you some really useful insights

and advice for our audience at home. Thank you for joining us today for our musculoskeletal event.

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