Neuromusculoskeletal Health and the Role of Physiotherapy

Key Takeaways

The Role of Physiotherapists in Obesity Management: Physiotherapists play a crucial role in addressing obesity-related musculoskeletal complications by improving mobility, reducing pain, and enhancing quality of life. Their expertise extends across the lifespan, supporting patients with varying physical capacities through evidence-based interventions.

Holistic Pain Management in Obesity: Effective obesity management requires a holistic approach to pain assessment and treatment. The Pain Catastrophizing Scale (PCS) can help identify maladaptive thoughts and behaviours related to pain, guiding personalised care. Addressing psychological factors and using patient-centred strategies improves functional outcomes.

Obesity as a Chronic Disease: Obesity should be recognised and managed as a chronic, relapsing disease. This approach emphasises improving physical function, quality of life, and long-term health outcomes rather than focusing solely on weight loss. Regular patient reassessment and self-compassion are key to successful management.

The Importance of Non-Stigmatising Language: Using non-stigmatising language is essential in obesity care. Compassionate communication fosters patient engagement, reduces bias, and supports effective clinical interactions, particularly when discussing pain and physical limitations.

Integrating Physiotherapy into Obesity Care: Physiotherapists are integral to interdisciplinary obesity care, collaborating with other healthcare professionals to address metabolic, mechanical, and psychological aspects of obesity. Incorporating pain assessments and functional tests, such as the 6-minute walk test, improves patient evaluation and treatment planning.

Next Steps and Future Considerations:

• Provide physiotherapists with specialised training on obesity-related musculoskeletal issues, including strategies for managing mobility limitations and chronic pain
• Foster closer collaboration between physiotherapists, dietitians, psychologists, and medical professionals to deliver comprehensive, patient-centred obesity care
• Incorporate standardised functional assessments (e.g., 6-minute walk test, sit-to-stand test) into routine practice to evaluate mobility and physical function in patients with obesity
• Investigate how obesity affects biomechanics and movement patterns to develop targeted physiotherapy interventions that improve mobility and reduce injury risk
• Conduct longitudinal studies to assess the long-term impact of physiotherapy interventions on pain, mobility, and quality of life in patients with obesity

Transcripts are auto generated, if you spot an error, please email enquiries@easo.org

Speaker 1
00:00 – 01:48
OK, brilliant, I think we’ll get started. So welcome, everybody, to March. March is EASOcon meeting, our webinars that we hold monthly, if not twice per month sometimes. And the EASOcons, for those of you who do not know, are a network of centres for obesity management. So the focus of these centres is on treatment and also on training of health professionals throughout Europe and globally. Today’s webinar is going to address neuromusculoskeletal health and in obesity and also how physiotherapy is a crucial part of the MDT when managing obesity. Today’s webinar is hosted in collaboration with World Physiotherapy, the European region, and we have a fantastic lineup. Before I talk through our, before I introduce Esme D’Arcy, I’m just going to talk through what our plan is for the next hour. So we’re going to have our welcome. I’ll be addressing physiotherapy and obesity management. Then we’ll have a patient perspective from Moira Murphy, from the European coalition of people living with obesity and also the Irish coalition of people with obesity and also the Association for the Study of Obesity on the island of Ireland. And then we’ll have Dr. Colin Dunleavy, who will address musculoskeletal health and function in obesity. And Colin is representing World Physiotherapy, European region and also the Adult Centre of Obesity Management in Dublin at St. Colmcille, Lochlam’s Town. So in my role as EASO secretary, I’m delighted to host this webinar for EASO and I’m also delighted to welcome Esther-Marie Darcy also to introduce the session. Also, Esther-Marie, over to you.

Speaker 2
01:55 – 03:15
Hello everyone and thank you. Thank you, Grace. My name is Esther Mary Darcy. I am the chair of the Europe region of World Physiotherapy and like Grace I’m delighted to work in collaboration in producing this webinar today. I was just thinking last night how timely it is. We’re which it began with the European Commission officially classifying obesity as a chronic disease. And we have the WHO forecast that Europe is facing a major obesity crisis by by 2030. So I think we are very well placed in the middle of the decade to to be holding this webinar and to be working together in Europe. And in. As Grace also said, I really believe that physiotherapists have a major role in the team in addressing the public health challenge that we are facing. The European region supports all efforts in terms of improving treatment and management. And in particular, I suppose we are supporting the education aspect to improve the education for

Speaker 3
03:15 – 03:16
health

Speaker 2
03:16 – 06:00
care professionals and particularly obviously as today for physiotherapists so that we have evidence based multidisciplinary care for people with obesity. So the region is delighted to be a stakeholder in an EU funded programme called Prominence. It’s a project that’s led out by our physiotherapy colleagues in the University College Dublin and it’s in developing an undergraduate or entry level module in obesity management, which will be rolled out right across the physiotherapy programmes throughout Europe. So I’m really very excited about this. It will mean that we have a minimum standardised curriculum content where the graduates will have a base level in knowledge, skills and competencies upon which to build once they graduate and that will enable them to contribute to their colleagues who are the seniors and the clinicians in addressing this public health challenge. So I think physiotherapists are well-placed and have been obviously to be part of the multidisciplinary teams throughout Europe. And I’ve noticed over the while that while we have a lot of physiotherapy colleagues working in academia, we actually have very few working in the clinical specialty area. And obviously, that is something that we need to address. And hopefully, this joint webinar will whet the appetite of many and also the prominence project will be delighted, will also do that. So I’m really delighted that we are co-hosting this and with my esteemed colleagues from Ireland with Dr. Grace O’Malley, who’s presenting obviously on behalf of ASO and to Colin Dunleavy, who is presenting on behalf of the European region of World Physiotherapy. And indeed, Maura Murphy, also from Ireland, from the European Coalition for People Living with Obesity, and will present from the perspective of a person who has received physiotherapy. I really hope in conclusion that all of you who are attending today will leave with some more knowledge or insights from the three speakers that will enhance the service that you provide. Thank you very much again, delighted to be here and to be collaborating with ASO. And I will hand you back to Grace for her presentation.

Speaker 3
06:01 – 06:01
Thank you.

Speaker 1
06:01 – 24:20
– Thank you. Thanks Esther-Marie. I just want to make sure that I my screen is moving OK. And of course, everything is starting to appear on my screen when I don’t want it to. So let’s close this. OK, perfect. That’s OK there. And for those of you who don’t know, so some of you may be new visitors at this QR code there to bring you to our website, also to World Physiotherapy and also to ECPO. So particularly for any patients or people living with obesity that are listening to the webinar, do make sure that you check the European Coalition of People with Obesity and also World Physiotherapy European Region. So I am tasked with discussing how physiotherapy is used in obesity management. And I lead the clinical team in one of our pediatric EASO cons, and that’s based in Dublin in Ireland. And I also work as a senior lecturer and a principal investigator at the Obesity Research and Care Group in UCSI, University of Medicine and Health Sciences, which is also in Dublin, in Ireland. We didn’t mean for today to be all Irish in terms of presenters, but that’s just how it turned out, unfortunately for everybody else. But hopefully you’ll get a good sense of why physiotherapy is important for patients. So I have some disclosures around funding. And a little bit about physiotherapists, for those of you who don’t know what they are. So there is a number of different titles used that might be physiotherapist. It might be physical therapist. It might be kinesiologist, depending on where you live in the world. They’re registered health professionals. In Europe, there’s over 38 national associations and globally there’s over 129 associations. There’s over 200,000 physiotherapists worldwide. Physiotherapists are the movement experts, so we develop interventions to maintain and restore people’s movement and their function. We do this through undertaking clinical assessments. We formulate diagnoses, we formulate prognoses, and we develop and implement therapeutic treatment plans. A cure code there for you, if you don’t know whether your country has a national association for physiotherapists, It’s worthwhile finding out in case you need to refer people to physiotherapists or if you’re a patient and you need to access one. So we work across the lifespan. So from neonates, so brand new babies and even from mothers who are who are pregnant. We also work to the very end of life. So through palliative care. And we work also across every range of capacity. So that might be at Olympic sports level in terms of performance and injury management or injury prevention all the way across the spectrum to someone who may have had a traumatic brain injury or a spinal cord injury and where their function is really inhibited. So it’s irrelevant, really, to physiotherapists what someone’s physical capacity is at baseline. Our goal is to get people empowered to move, to reduce some of the barriers to movement and to try and improve quality of life and well-being. In terms of obesity, we know that when we get an accumulation of adipose tissue in the body, if we get a lot of that adipose tissue, or if we get adipose tissue in areas of the body that we wouldn’t normally expect to find it, we get ectopic adipose tissue. And both of those, either excessive adipose tissue or ectopic adipose tissue can cause problems for how those certain cells function or the organ functions or that body system. And we know across the lifespan that obesity is related to a number of nearly 200 health complications. And some of these, many of these will emerge in childhood and they’ll continue to develop in adolescence and then they’ll progress in adulthood. So this figure just depicts a number of the different body systems that we have very strong evidence for in terms of obesity driving complications in these areas. So looking from one o’clock on the clock, we have neurological. So even in children and adolescents, we’ll have children with headaches, with blurred vision, who then are diagnosed with intracranial hypertension. We’ll have children and adults and adolescents who have a much higher risk of dental caries and periodontal disease. And we’ll have a much higher risk of cardiovascular disease, which, again, These complications can emerge in childhood, so high blood pressure, dyslipidemia, high cholesterol, high triglycerides and endothelial dysfunction. So where the walls of the arteries and and and the veins aren’t able to open and close as we would expect them to. We may we might have left ventricular hypertrophy. So the left ventricle of the heart gets larger and will then maybe have respiratory conditions. So again, in early childhood and adolescence and adulthood, we’ll see higher risks of asthma, higher risks of obstructive sleep apnea, impaired exercise tolerance, sleep disorders and poor outcomes with viral infection and then hypoventilation syndrome where the body cannot saturate in terms of oxygen levels. Again, we’ll have endocrine complications, so we’ll have polycystic ovary syndrome in adolescents and adults. We may have impaired glucose tolerance, delayed or indeed accelerated puberty in children and adolescents and higher risk of metabolic syndrome and type two diabetes. And we also have renal issues, so higher risk of enuresis. So urinary incontinence and leaking higher risks of gastrointestinal issues, of fatty liver disease, for example, or constipation, skin conditions, a canthosis, either cancer, psoriasis and then issues around function and participation and also musculoskeletal issues. And we’re going to really focus on these two aspects, the function, participation and musculoskeletal aspects. So physiotherapists work within across all of these different areas. And as I mentioned earlier on. Physiotherapists work across the life cycle and they’ll work within cardiac teams, within endocrine teams, within musculoskeletal orthopedic teams and any area of the body. Usually physiotherapists may be involved in trying to minimise impairment and maximise function. And we know that childhood obesity and adolescent obesity also increases the risk of adult chronic disease. So coronary artery disease, type two diabetes, stroke, osteoarthritis, infertility and adult obesity and certain cancers. And the work of physiotherapists is often through the lens of the World Health Organization’s international classification of functioning, disability and health. So most health professionals will be acquainted with ICD, which is the coding that’s used by WHO in order to code illnesses and diseases. Obesity is coded in ICD-10 as E66. And if you come from a more biomedical model, your focus usually is on the disease, the mechanism of that disease and how that manifests and usually how that manifests. The focus within the biomedical lens is on body structures and functions. So something’s not working properly. Blood pressure is up. Cholesterol is up. There may be an impairment in a certain system of the body or an organ or a cell. ICD extends or ICF extends ICD. So while we are very focused on what are the impairments at the cell and the structure and the level of the organ, we’re even more interested in, well, how does that affect the person? So how is their activity impacted or their tasks of daily living? And in turn, how is participation in everyday life affected? So we see a feedback loop where an impairment or where something in the body isn’t working the way we would expect it to impact how we live our lives and how we participate, and then also how we participate and live our lives impacts those actual impairments. Within the ICF model, we also see how the environment can impact how this disease of obesity manifests. So we know that even one person with a genetic predisposition to develop obesity, it may manifest differently living in one environment versus another. We also know that personal factors will have an impact on how the disease of obesity develops or how it affects us. So things like age, things like sex, and then also maybe life changes like puberty or pregnancy. These will all affect how obesity manifests. If you’ve never heard about ICF before, and this is the first time, please check out the QR code, which will bring you to the World Health Organization ICF learning e-learning page, and it’s well worth understanding this model. So this is more of a biopsychosocial model rather than a biomedical model. And it really fits well with the disease of obesity because we go beyond just thinking about what’s happening at a cell level and how life is affected for people living with obesity. I just want to use a couple of examples to extend that idea of ICF and just make sure that you kind of understand what I’m talking about here. So if we take the respiratory system for example, we know that people with obesity will have a higher risk of impaired cardiospiratory fitness, so their lungs may not be working in the same way, their FEV1 may be reduced, they may have higher shortness of breath or more increased shortness of breath and more fatigue. So at the level of the cell and the organ we know that the lungs are affected. In turn the activities of daily living may be affected so that the person tires more easily and they may find it much, much more difficult to move with higher intensity movement and it costs their body much more. And what that might result in for a child for example or an adolescent is not being picked on a school team. For an adult it may mean that they may choose to drive a car rather than walk to work or walk to try and get a bus because walking may be quite difficult. Let’s use the musculoskeletal example. So again, in in children, particularly before or around puberty, if they have obesity, they may have a higher risk of bony malalignment. And what that means is as the skeleton is developing, if we carry extra weight, we often have increased loading on the inside of the knee and it can cause the knees to grow out. So we get knock knees. And this can lead to a change in how the biomechanics are manifest, so how the child grows and also how they are walking is affected. So in turn, this can affect their activities of daily living. It may make their movement less efficient. Again, they may tire more easily and physical activity and movement is hampered by discomfort. And then that may then impact the child’s participation. So they may reduce their participation in sport or walking may be more uncomfortable. So they may be looking to to get in a car more to cycle more indeed. One more example in terms of painful joints, so we know that people living with obesity will have a higher risk of back pain, knee pain and foot pain. Again, main maybe due to the mechanical loading, but also there’s there’s evidence to suggest that there’s also an impact of the hormonal and inflammatory milieu that often can occur with obesity, which can impact pain. So if somebody is having extra pain in their back, their knees or their feet, often certain movements will exacerbate that pain. And it can mean that someone will try not to move as much and they may stay out of P or sports. So using the WHO ICF model, we can start to really think much more holistically about how our patients present, what type of assessment they need. So if someone is not moving as much as you might like them to, it’s not enough to just tell them to move more. We need to understand that there may be biomechanical or other anatomical issues that need to be addressed to be identified and to be treated first. And a little bit more about the musculoskeletal complications, because obviously during childhood, our bones are developing, so how our bones develop during childhood is absolutely vital for the rest of our life. In adolescence, we reach our peak bone mass, and that means that we develop the most bone that we’ll ever have in our life just around puberty. So if we don’t optimize that, we are at a disadvantage later on in life. So making sure that our adolescents have the most bone and the strongest bone that they can have during adolescence is very important for long term bony health and for osteopenia and osteoporosis prevention. This is really important in terms of obesity management medicine. So if you have adolescents that are using obesity management medicines, you have to consider their bone and their muscle. We know that some of these medicines will have an impact on sarcopenia, so that can in turn affect bone health. So be very careful and cautious about prescribing these medicines and monitoring muscle and bone health. So children with obesity, adolescents with obesity and many adults with obesity will have a higher risk of pain and chronic pain. They’ll have a higher risk of bony fractures. They may have impaired dynamic balance. So this is when they’re standing or moving and balance can be affected. There may be reduced muscle strength, higher risk of orthopedic anomalies or how the bones develop impaired gait. So walking can be impacted and impaired cardiorespiratory fitness. So how the heart and lungs work, moving takes more energy. So there’s an increased energy expenditure in movement and people with obesity can fatigue more and there may be an impaired quality of life also. And often people have lower movement confidence, so particularly if there’s been a lot of stigma or teasing and throughout someone’s life, when they move, they may get more red in the face, for example, they may be breathless. It might be slow for them to move. It takes more energy that can create a cycle of potentially teasing and bullying, which then affects someone’s confidence and may make them less likely to move in front of other people or to engage. The the plain film x-ray on the right is of a slipped upper femoral epiphysis. So this is where the the top of the hip slips off the neck of the femur. And we have a higher risk of Sufi as well during adolescence and childhood for those living with obesity. So a couple of slides before I finish, so just on what physiotherapy ads and really why it should be an essential part of MDT management. So physiotherapists understand how a disease impacts on the life of the person, not just at the cell and function and organ level. They’re thinking about quality of life and participation, regardless of what someone’s baseline capacity is, whether they’ve had a spinal cord injury, whether they have a rheumatological condition, whether they have obesity. It doesn’t matter. We conduct expert clinical assessments, so we’ll conduct clinical exercise testing, cardiorespiratory exercise testing. We’re thinking about the 24 hour movement cycle, so movement throughout the day and the evening and sleep also. We’ll we’ll be conducting gait assessment, neuromusculoskeletal assessment, lymphedema assessment and then cardiorespiratory assessment. So what’s the mechanics of the lungs and blood pressure management as well? Based on your holistic assessment, then you’re developing an evidence based treatment plan, and that will involve therapeutic exercise, pain management, maybe manual therapy, a rehabilitation plan addressing any of the obesity related complications that present for that person and also for prevention of frailty and sarcopenia and sleep hygiene and training and ultimately to build fitness function and self-management and provide the person with practical skills. So while we do educate and give advice all the time, We’re teaching people practical skills on how to manage their obesity. Physiotherapists are also champions for evidence based practice and research. They’re a key liaison for other members of the team around physical function and fitness and functional health. We train other health professionals. We address implicit and explicit bias. And we’re off because of our work throughout the disability field. We’re often key advocates for supporting inclusion and accessibility, which is really important for people living with obesity. And then again, we’re also obviously augmenting and emphasizing public health nutrition guidelines also. So I’ll leave you with this question. WHO ICF, one of the key aspects of activity would be jumping and jumping is moving up off the ground by bending and extending the legs, such as jumping on one foot, hopping, skipping and jumping or diving into water. That’s how we define jumping. If jumping is not possible, does your patient or do you yourself have a disability? So using the ICF model, if someone cannot jump, they can they can basically be described as someone who has a physical disability. You need to think about that for your patients. Does your does your patient have access to physiotherapist? And if they don’t, why not? So I shall leave it there and then we’re going to come to Mora next. So I shall stop sharing my slides.

Unknown Speaker
24:24 – 24:26
Thank you. Thanks very much, Grace.

Speaker 4
24:26 – 25:20
Thanks for that. And thanks for the invitation to speak here today on behalf of the patient. And from when did my journey with obesity start? It started at 10, being overweight. And by 33, I was finished with sport because my life changed. I was playing basketball up to 33 years of age. I loved basketball, very fit, but still at around 16 stone. And then moving on to, sorry I have to save something here, moving on then in my life, different things happen. I wasn’t as active as I was before. So by the age of 50, when I was referred to the weight management clinic in St Colmcille in Lochlandstown and to the multidisciplinary team, the one I feared the most was the physiotherapist. What was the physiotherapist going to do to me? was he or she going to put me onto a running machine or something, because I could only get from my car to the building, and that was a struggle as it was. I was now 28 stone, and I was thinking

Speaker 3
25:20 – 25:21
— well, I didn’t

Speaker 4
25:21 – 32:39
know I was 28 stone on my first visit until I was weighed in. I thought, “What am I going to do?” And then Colin Duleavy walked in and chatted, and was really friendly, and I kept thinking, “No, I’m not going — no matter what he asked me to do, I’m not doing it,” went into his office, and I could see the running machines and everything, and then all he did was put a clip on my finger and took me for a walk. Now I had a big wall around me about walking that I literally would drive to everywhere I needed to go. As Grace said, you don’t want to go on public transport when you’re a certain weight, so you do use a car for everything. So Colin brought me up for a walk up around the Weight Management Clinic, and I thought I might get to the car if I’m lucky. Halfway up that little bit of a hill, I had to stop. Halfway up the hill, I had to stop, and then he continued on, kept chatting to me, and walked me around the car park. I kept thinking, I’m going to die, I’m going to die. But I didn’t, I actually didn’t. I actually was getting better as I was walking along ’cause Colin was great at chatting away to me, making me feel comfortable, chatting away about anything and everything, and giving me little hints and tips on the way. But coming down that hill, going back into the unit, I was totally elated because that wall was broken down for me. I realized I could walk, when I looked at the car park, it looked like Crowe parked me. But actually walking around it and getting back down to the unit where the admission was, I couldn’t believe the elated feeling that I had. I can actually walk and I didn’t realize it. That wall was built on me. As a physiotherapist, that was essential for me to move on and to start a new quality of life from that moment. Two years attending that clinic, I had Eimear and I had Colin and they were both brilliant physiotherapists. The physiotherapist was, you know, I saw the doctor and I saw the nurse, and physiotherapists was giving me a means of more mobility, which is exactly what I needed. I wanted more mobility, because when you get to a certain weight, you know, you can’t jump. As you said, I can’t jump. I’d be afraid to jump. So I know I can’t do that. But I was delighted with what I learned and how I could manage doing simple exercises that empowered me to help me to do to do better. And there was zero negativity, zero blame. And I thought it would fall and all, but I didn’t fall. And along the way, somewhere, Colin told me, if you lift the front of your feet, you will fall. Which made a huge difference to me as I went along. As I go on holidays and everything now, I don’t fall over anymore because I’d forgotten to lift the front of my feet. I was obviously, you know, shuffling along, which I didn’t realize. So twenty four, twenty twelve, I had my bariatric operation ten stone down. And of course, you think that you can run and jump, as you said, and do everything. I couldn’t stop myself crossing my knees was a big thing, running and jumping and getting up off the chair the whole time, delighted myself, but didn’t realize that I was a lot older and definitely I was having pain pain. So again, I mean, he was definitely in a bad situation. So I had to have a knee replacement done. And after I had the knee replacement done, I was on the crutches for quite a while. But within two weeks after when I was leaving the hospital, I couldn’t lift my leg off the bed for the physiotherapist. I kind of felt a failure and a lot had to do probably with the way he was talking to me. So then two weeks later, I had an appointment down in Kirk and Shannon with a physiotherapist who walked me between parallel bars, had great, you know, great, what you call, you know, gave you great joy and told you you were doing really well, you know, boosted your confidence. And then she said, have you any problems? And I said, I can’t lift my leg. Oh, she said, really? And she went out and she rolled up a towel, lifted my ankle, put it under my ankle and said, try lift your leg now, up wet my leg. So it’s these little tips and hints that we get from our physiotherapists that are gold dust to us. And I think the physiotherapist is one of the people that we in our lives that we visit more often than we visit anybody else, bar for our chemist, because really you go to your physiotherapist nearly every six weeks. And I still try to go to the physiotherapist every six weeks. And thankfully, Colin and Eimear and Katie and them, they come on to our, what’s called our support meetings every third week and they give a group of us, we got a Zoom license during COVID and that enabled us to reach people we could never reach before. Like people who couldn’t even leave their homes because of stigma, stigma being a very big thing, you know, get out of my way, you’re in my way, you’re too big, you can move over, lose weight, all of these things said to you that stop you from going out into the public. And like as Colin said, people who had never even gone outside their back door. You just asked them to open their door and look out into the garden, which led a lot of people to actually go out walking out in their garden for the first time. That’s how basic we’re talking. I’m not talking about jumping, I’m not talking about doing huge exercise. I’m talking about the basic stuff to get back from level zero where we are, or where most of us are. Like even Yvonne, one of our colleagues, she had a rotary cuff problem. Seven years, she couldn’t actually put on her bra and she attended a good few of the sessions with the Waitrose clinic with Colin Eamer and she was able to put on her bra. She couldn’t believe it. She was absolutely delighted. That’s what she was. So we definitely, you know, I moved to Ballina then in 2020, of course, during the Covid, broke my arm admiring my gutters and ended up with a physiotherapist again in Carrick and Shannon or in Ballina, who also gave me great joy and gave me great, great praise. You’re doing really well. Here’s another exercise for this week. My arm is totally better lifted up. No problem. So it’s what the physio, how the physiotherapist makes you feel. And to be honest with you, like a lot of our meetings, people say, I’ve talked to physiotherapists. It’s not working for me, but I tell them it’s not working for me. And I’ll ask them, have you anything else to help me with? So it’s a continuous thing. Unfortunately, we can expect an awful lot. We really think that our physiotherapist is totally going to fix us. So we have to get it into our own heads that we might get 80% back of what we lost. We might get 100% back. That can be a very difficult thing because our expectations are very high, particularly when a physiotherapist sorts something out for us. We think, oh, they’ll do something else for me now. That isn’t always possible. So we have to we have to realise that as well. So we do. You know, so I think the physiotherapist is very important in your multidisciplinary team. And as I said, even privately, we go a lot of us go to physiotherapists because we know that they keep us mobile, that they help us to stay mobile and they encourage us. It’s the way you make us feel, the way you talk to us, non-stigmatising language. I went to, I had a very bad breast, what do you call it, event that I didn’t like. I had to go to the unit and I didn’t like the way it was treated. Same hospital. I went to a physiotherapist because I’m now walking a little bit like a penguin and he was younger than me, so I had some sort of bias about his age, which I was surprised at. And he was brilliant, sent me for an X-ray. And then when I came back from the X-ray and he had the results, he pulled the chair over beside his computer and said, now have a look. We can we can make a plan, make a plan. And that’s fantastic. So it is. So all I can say is that these people keep looking after us. Don’t give up on us. But remember, a lot of us can be at that base level that we, you know, small, small start and we will build up on it and don’t give up on us. We are very, very motivated people. Thanks very much.

Speaker 1
32:39 – 33:24
Maura, thank you so much. You’ve summarized some fantastic points around pain, around being able to do the really important things in life, like dress ourselves, get out, do the things we want to do and the importance of the fear of falling, which I think often isn’t really talked about, particularly as people are aging. And also how obesity treatment like surgery will impact many, many aspects, but we’re aging at the same time. So mobility issues are always still something we have to consider. So thank you so much. Really appreciate you being here today. And we’re going to move on to Colin next. He’s going to speak about musculoskeletal health and function in obesity with more likely a focus on adulthood. Thanks, Colin.

Speaker 5
33:29 – 33:33
Hello, am I on? My mic’s on and everything. Can everyone see the slide? Yeah, we’re good to go.

Speaker 3
33:33 – 33:34
Maura,

Speaker 5
33:34 – 41:15
thanks for that. I know, Maura, a long time, you’re very generous with your words, Maura, I appreciate that. Maura’s fantastic. There’s a bit about Maura’s story that does maybe come back into the theme of this. So, Maura, I might ask for your input in just a few moments, if that’s okay. Now, if I can get my screen, my slides to go on. Okay, so again, thank you for inviting me to speak, and thank you for all the participants for giving up their time and listening to us. Again, the focus is on musculoskeletal health and physical function. And for me, the main thing that we need to do is to make sure everybody understands the problems that we’re dealing with. And I think that’s the biggest issue for me in the context of working in a centre for obesity management. And I’ll frame the presentation around a patient’s story. And I’ve just put in the little subheadings maybe just for our imagination is digging a foundation to build a house and maybe building a house there. There’s a lot of parallels I think that we can draw from when we’re thinking about obesity and how to manage obesity, health behaviours and what drives the chronic disease in the wrong direction. For anybody who’s got a child with dyslexia or possibly dyslexia yourself, you know that that can be a difficult issue. Back in the 1980s when I was in school, certainly we didn’t know that, nobody mentioned that word. I think some aberrant behaviours that come on and the consequence of those aberrant behaviours socially are there very evident and everyone will know what these images, I suppose, are bringing up. Ultimately, the child with dyslexia does not feel good about themselves and possibly gets into a lot more trouble than they should have, and it’s all built on a frustration and a lack of understanding. So, there might have been in the 1980s, children with dyslexia might have been put in the corner and made feel very bad, in a kind of a tough love type of, “You need to get better, so we’re going to punish you until you get better.” where now we know that’s all absolute nonsense, we cannot think like that and luckily I think the majority of people will have good experiences with their children in school, but that isn’t the case and there’s so much positivity and strategies to overcome that difficult dyslexia. I don’t know, is it a disease? I wonder if anybody can help me out with that. I’m not sure. It’s certainly a dysfunction. So I think the parallel I’ll draw from is that obesity has been in a very similar space. We, as Esther Mary said at the start, it is well recognised as a chronic disease for a very long time. We have clinical practice guidelines since 2022. And just some really important points and phraseologies that we must understand before we get going is that this really is a physiological problem. It’s a dysfunction within our homeostatic system of your body detecting a problem or an excess temperature or increased water or not enough water in your body, having a system of a control centre and an action that urges you to address that problem. That is what the disease of obesity means, is that in that context, the adipose system is dysfunctional and it’s laying down as Grace alluded to, laying down adiposity where it shouldn’t be laid down and at a rate that it shouldn’t lay down and that can drive a whole milieu of physiological harm. So the real issue is, and again, Rana, from you, Grace, how that presents then outside the medical model is that people’s relationships with their body, what happens to their body under the same environmental factors or even more stringent environmental factors will be completely different from one person to the other because of their physiological dysfunction. However, we might talk about the dysregulation of appetite, body weight and energy systems, but oftentimes the thing that will land most is, “Oh, it’s an appetite. Your appetite’s off.” And that’s certainly in the media recently with Wachovia and Ozempic, that’s the, “I’m listening to the radio and certain TV presenters,” and that’s the bit they focus on, because that’s the blame. The blame is behind you and your appetite, and not what’s driving, and not what’s behind and not the physiological dysfunction and hormonal imbalances that people with obesity have that present in an appetite regulation problem. And with most people, with an awful lot of people that we present to our service, they don’t have an appetite regulation problem. They have the other parts of the problem. So we do talk about obesity presenting with slightly different physiological pathways. So we don’t talk about obesity. We talk about obesity because the pathophysiology is different between one person to the next. It’s really important for us to understand that. So let’s talk about Sarah. Sarah is 45 year old lady. She has a BMI of 48 kilograms. She’s metabolically well. She reports being tired, poor sleep. She has chronic bilateral knee pain. She works, she has a child. She reports a lot of stress. She avoids physical activity because it makes my pain worse. And I don’t get anything good. Nothing good comes out of there. No joy there. And that has squeezed her participation. She doesn’t leave the house. We leave the house four days a week. So when we saw Sarah, this is, I suppose, a little bit of a brain splat as to what we think about and what what we as physios, I suppose, try to cover in our assessment, and because they’re all, we feel them, all these areas are linked. We’re focused on pain, I suppose, today. So that’s one of the main focuses of this presentation is. But I suppose from there, you can see that it’s a bad news and it’s a good news story because you cannot over focus on one particular area in isolation, that these things have to be looked at with a broad map. That’s the bad news. And the good news is that if we can start to get these cogs to turn, one thing generally turns another thing and you can accumulate and have a positive experience from managing one aspect of it. And if you really focus on that, the whole picture can get better. So digging a foundation, I suppose the main thing that we have to do with Sarah is make sure she understands what she’s, the pictures that she’s faced with because of the, the, the mixed messages that she gets from the media, from her social group. The internet is a complete crazy place for this. Although I have to admit it is slightly better now

Speaker 3
41:15 – 41:16
years

Speaker 5
41:16 – 41:20
ago. So I’ve been doing this job since 2008. And when

Speaker 3
41:20 – 41:21
in

Speaker 5
41:21 – 45:37
previous times, when I searched the internet looking for, you know, eat less, move more, debunk it, it would pop up everywhere in a very positive way. Whereas when I was just yesterday, when I started to look and put the same slide in, it is starting to go, you know, being a bit more exercise and eat less, move more. Why “Boy, eat less, move more, doesn’t work for obesity.” There’s a thankfully, some slow messaging maybe help us to unwind that difficult place. But she will certainly have been present with strong elements of stigma. And I’ve done this to myself. She came in, she was talking about her wear and tear on her joints. And then we kind of look down and try to maybe address that in a very early stage. One of the first things I will do, and the reason for that is if we don’t get this foundation dug, if we’re not on the same page, I just don’t think we get anywhere. I think that’s a really shaky, the house doesn’t stay up for long. And we must debunk and have a good sense of a reason for the things that we want Sarah to engage in. Making sure she understands what we mean by disease. What most people think, what Sarah will have thought will be, “Oh yeah, I’ve heard that, obesity is disease. That means, for me, that means that I’ve made myself like this, so therefore I get sicker.” That’s the logic that most, I would say most people, patients will present as. We must bring that back and present it in a way, the disease means that your body is trying to get bigger and bigger because it thinks it’s too lean and it doesn’t have enough adiposity or fat tissue on it and it keeps on driving that system up. And if you look at your friends who are lean and in the same circumstances, or these, as you say, they’ll eat more than you do or they’ll exercise less than you do, but yet their body remains lean. And making sense of that, drawn from those strong observations in the person’s life. And again, it’s a tough one to get across because they’re so stigmatised. And to get back from that model of, I’m putting the fuel in, so therefore I should be using the fuel to this other way. No, it’s much more complicated. It’s how your physiology works. That’s a long way. And I don’t think it lands straight away. And it just takes several goes and reflections and parallel examples to get some bit of progress there. And I think it’s really, really important that we do that because ultimately that will empower the patient to understand what the problem is and stop that frustration that they feel. That’s a whole other world. Let’s go back The focus of this was talking about pain, that we know that people in our service have high percentage of, or high prevalence of chronic pain, biggest ones being your knees and backs. And we also know that you can improve and modify those pain scores, even in the absence of significant weight change, which is again, a good thing. Just, I suppose, if you look back in here, actually this previous paper, this is 2017. And I’m just embarrassingly look at the word obese in there. So obese isn’t a word anymore. That isn’t a word, you don’t define people by a disease. So obesity is a disease, it’s a problem within the body. That person is still a person, they’re not an obese person. So just look for your own language in that, make sure that that word is a dead word, we don’t use it anymore. Back to Sarah. So she looking at her pain scores and the way that we will accumulate and build up a cluster to look at her pain and how it affects her. We do a numerical rating scale. What’s the worst has been

Speaker 3
45:37 – 45:38
in out

Speaker 5
45:38 – 49:24
of 10 over the last two weeks. How often would you have it? Have it daily. She would have a daily more than 10 times. It doesn’t have a rest for a long period, but as soon as she starts to move again, she got pain. So things that make it worse, certainly stairs. No obvious observation and deviations, et cetera. That can be tricky to look at anyway in terms of any oedema, particularly around the knee. And we look at functional tests, how she performs in those, five times sit to stand test. And that is a metric that we use around grading for sacropenia risk. We look at the timed up and go test. We also do a six minute walk test as Amora was talking about there. Her main language that she was using, yes, there was an X-ray and it shows wear and tear. It’s very structural, that biomedical model and how that is presented to her. And what she thinks and she feels is, “I have pain because I’ve damaged my joints. I’ve done this to myself. It’s now, it’s not safe to move anymore. It’s wear and tear.” That’s what they were told. So if I move more, I’m just gonna get more wear and tear. So obviously that isn’t something that needs to happen. Plus, if you dig deeper, she feels, well, I’ve done, I deserve this. I’ve done this to myself. I’m the one who’s, you know, all those very negative thoughts that are echo chambers in her head. And what have been said to her, you know, the knees of an eight year old. You know, unfortunately, we hear that. And wear and tear, bone on bone, bones are crumbling. You know, you’ve heard all these things that are presented from a biomedical model, this is what it looks like. These are so destructive to Sarah and how she’s gonna manage her pain. So it takes an awful long time to unwind those images that Sarah or a patient like her might have. And they’re certainly, all they do is, I think they amplify any maladaptive coping strategies. And that’s one of the things that we’ve done over the last few years is maybe embrace and try to objectify that. So we found the pain catastrophizing model very useful here. This is a quick test to do. I’m sure some in the room will be very familiar with it. If a patient’s score is greater than 30, we’ll say that’s a clinically relevant score in terms of their maladaptive thoughts and feelings and possibly behaviours because of the pain, background noise and how they feel about it. So it’s an easy thing to do. And again, in our context, at least, we found it very useful. Sarah’s score was 36 out of 52. So that put her into that category. And again, we weren’t surprised about it. It semi-objectifies it for us because we’ve heard the language that she’s presented her problems with. We’ve just got a couple of little in-house audits that we’ve, just to give you a little background as to what the PCS typically might show you. This was for a group of 105, just a little audit we did maybe two years ago, and just simple categorizing people into low scores and high scores. you can see that despite the, there’s no significant difference in age, gender or BMI on these little subgroups, but the numerical rating score seems to be reported higher. The knee pain seems to be reported higher. Now they may be that’s because they’re worse or that they just perceive them as worse. And I think that’s where we would probably

Speaker 3
49:24 – 49:25
hint

Speaker 5
49:25 – 51:22
at it. and a big change in their quality of life and how they feel about living life. This is also on the PCS, another little in-house audit, this time of 140. We just did this one last year and looked at how, so these people have the same pain in their NRS and they have same frequency, same intensity, no significant difference amongst those, same AIDS, same BMI, no significant difference there. And you can see how we feel that that cross-sectional view for what it’s worth will reflect their risk of being stuck at home a little bit more, their quality of life being a bit more diminished and lowered. And in terms of their functional scores, that their functional scores, the timed up and go takes a little bit longer, and their citizen takes a little bit longer. So we do feel it’s a very important part of of showing that cumulative effect of dysfunction and maybe maladaptive thinking. So it’s definitely worth our time, we feel, trying to defuse that bomb. Very difficult because it’s very intracted and maybe has the way that their pain has been presented to them has caused a lot of fear. So maybe feeding into this red arrow picture here. So a bit of fear, pain catastrophizing. Strollway and I’ve put in the works are where the obesity stigma and that deeper feeling that I have pain because I have obesity and my body is bigger. And ultimately, I’ve done that to myself, that misguided belief that that person has done it to themselves, because that’s what they’ve heard. That’s what they’ve heard from their social groups and maybe even from their from their interactions with health care professionals. And that leads to an avoidance, deconditioning, hypervigilance,

Speaker 3
51:23 – 51:23
and their

Speaker 5
51:23 – 53:21
effects on mood, where my life is going, what I’m able for. You can see it’s a runaway train that gets really intracted and stuck. And this is what we try to do. We try through conversations and understandings to move them a little bit more, to lessen that fear, to be on a journey of acceptance, thrown in our own little trigger words. Motion is lotion. This joint’s the best joint you’re going to get. Let’s move with them. Explaining how feelings work. Sometimes I find that I like the DIMMS and SIMMS model for anybody who doesn’t know what that is. It’s just a general look at how you manage the sensations that enter your mind from your body. So the DIMMS bit is there’s a danger here. I’m afraid of this. You or the Sims feelings like everybody’s sitting on the chair. Now you forgot about the pressure between your bum and the seat. That’s a safety model. You don’t feel threatened by that. It’s a good, so the brain goes, yeah, that’s fine. Don’t worry about that. Whereas if you’re hypervigilant and there’s a problem here, you’re gonna kind of feel every bump in the road. So working along that line, it’s a difficult thing to do and it takes time and it takes the right person and it takes the right therapist for the right person possibly. And it’s similar to that, we must also then balance the experience and the acceptance of pain with living with pain and my values, things I want in my life. This is, we only get one chance at this. Let’s try to move with this and accept that there is this noisy passenger in my car and that I, sorry about that, I’m not just gonna cut, thank you, thanks a lot. And that there is a holistic approach. And again, just like I showed earlier on with all those little cogs, that we are thinking about not just in isolation, but how it fits with everything else, stress and sleep and stigma and understanding and compassion for myself and the language I use to myself.

Speaker 1
53:22 – 53:24
We’ve one minute left, Alan does say no.

Speaker 5
53:24 – 55:11
Oh, OK. So we have a YouTube channel. We do some strength work as well. Sarah’s outcome, her again, making sure that Sarah knows that this We’re talking about activity. We’re not, for the first time ever possibly, we’re not chasing calories. This isn’t what we’re doing. Obesity does not work like that, that you burn calories off and then your body becomes lighter. Your body physiologically resists weight loss and has some very clever tricks up its sleeve to resist that. So you’re doing, you’re encouraging activity to keep your physical function high. That’s the goal is protect your physical function. and you’ll achieve that and that your 20 year self will be delighted with you because you’ve done your strength work now, because you’re keeping your ability. Her outcomes were good. So we managed in her case, and one of the reasons we pulled her out was her thresholds for sit, stand and tug got back into where we wanted it to be. And she started on sleep apnea and so on. So we’ve believed that we’ve built this house well because we dug the foundations. Sarah was, Sarah’s case was, oh, she got it. She got it really early. She understood, oh, hang on, this isn’t my fault. And that in itself, just lifted such a psychological burden from her shoulders that enabled her to do things. Oh, I’m the one who matters here. Let’s, this is the fight I’m in. Let’s get myself strong. Let’s get myself, let’s protect myself and my life. This is a snapshot of what we try to do. The first things first in our early timeline is make sure she understands what obesity is. We need that to develop self-compassion. Now she can engage with us and yes, we’ll look at function and all the other,

Speaker 3
55:12 – 55:12
the

Speaker 5
55:12 – 56:12
menu of physio things. Easy wins early on is a motor control for your low back pain. That can, if for the right person, that can be very helpful as well. We do other work around this. We mentioned sleep apnea. Recurrent cellulitis is a big problem for our patients. So we do lower limodema assessment and garmenting, etc. In the middle, it’s important to come back to, “Fellas, you’ve heard it two or three times now. What’s landed? What’s different? Is there an acceptance of this as a problem that’s outside your control that you’re trying to manage and influence?” And hopefully we’ll have support her with CPAP as that can be a tricky journey too. at the end of her time with us, maybe six to nine appointments later, we’ll reassess, look how things are going and what’s the road ahead. It’s not going to be rosy in the garden. This is a chronic disease and it requires chronic disease management strategies. Thank you. Thanks very much for listening.

Speaker 1
56:13 – 56:41
Thank you so much, Colin. We have a couple of minutes left, so if anyone has any questions, please raise your hand or put them in the chat. If they come come into the chat, it’s very useful because if we get a lot of them together, we can come back and respond to them another time. But please do let us know if you have any thoughts, queries, insights. Looking through all the participants.

Speaker 5
56:48 – 56:49
Still in silence there.

Speaker 1
56:50 – 56:51
– Absolutely. – So

Speaker 5
56:51 – 56:55
that they couldn’t understand my action. So they’re still trying to work out what I was talking about.

Speaker 1
57:01 – 57:07
– Were any of the other comms teams present? Do you guys all have access to physiotherapy on your team?

Speaker 5
57:10 – 57:15
– I wonder even, is there pain assessments done across? There

Speaker 3
57:15 – 57:15
is other

Speaker 5
57:15 – 57:24
evidence showing that pain as an independent variable can influence do in terms of their obesity management and body weight management.

Speaker 1
57:29 – 57:47
So for AMICOMS members, is everyone asking about pain in some part of your assessment? Hopefully.

Speaker 5
57:49 – 57:52
Maybe there’s food for thought there, Grace. I think so.

Speaker 1
57:52 – 57:54
Yeah. Okay. We’ve no questions. So,

Speaker 5
57:56 – 57:56
oh, we

Speaker 1
57:56 – 57:58
have one from Eimear O’Malley. What steps,

Speaker 5
57:58 – 57:59
no relation

Speaker 1
57:59 – 58:18
of mine, what steps can we take to help support more helpful language among health care professionals for pain? So I suppose the, yeah, so language guidance is really important in general for language and obesity, but then for pain specifically, Colin, I’ll let you take that one.

Speaker 5
58:18 – 58:29
Great. And I might do with more if that’s okay, because there’s one bit that you talked about your pain progressing. Was that before when you were playing basketball or kind of afterwards?

Speaker 4
58:30 – 59:13
I know no pain, any pain that I had from playing basketball would have been dealt with a bit of liniment and a bandage and all the rest of it. You just wanted to get back on the court within two weeks. You didn’t want to be sitting on the bench. So it wasn’t like up to 33. We find that an awful lot of people don’t have problems until they’re into their mid forties, even with their, that they don’t even seek help for their weight until they’re in their mid 40s or heading for 50 because before that you have a lot more mobility and then something happens and you don’t have it anymore. But what you said there about pain seemed to be worse after you lose a lot of weight, that’s probably because we were moving more. I was just thinking that has made total sense to me from what you said there. That’s a great one I picked up today. Now I know why I have more pain because they are moving more. That’s good.

Speaker 5
59:14 – 59:45
Well, sometimes that can be the way certainly. And I know this is the other ironic bit that we didn’t get down into is after, if there has been a weight loss intervention like surgery or the new medications, that the people maybe might make the assumption that the pain goes away. Maybe it’s, we’re not seeing that exactly. So we’re seeing And some, it does certainly help. And there’s a big piece of the jigsaw, but surprisingly, some people can get pain after

Speaker 3
59:45 – 59:47
significant

Speaker 5
59:47 – 59:58
weight loss that they mightn’t have had before. And we think that may be because they might be losing a little bit of muscle and the joint might not have enough support around it. And yes, you might be using it in a way you never used before.

Speaker 3
59:59 – 59:59
Yeah. And you’re not,

Speaker 4
01:00:00 – 01:00:11
you’re not sitting as much either. You’re moving more as well. So you’re trying to keep going and trying to keep your mobility up. You don’t want to lose what you’ve gained. You know, your new quality of life, you certainly don’t want to lose it, you know?

Speaker 5
01:00:11 – 01:00:12
Yeah, exactly.

Speaker 1
01:00:13 – 01:00:44
And we might just take one last question before we finish. I’ve answered one about an ongoing follow up with our services. So in our comm, it’s up to 16. So after that point, we can’t follow them up. But primary care can. And Colin, you could maybe type an answer there in terms of your adult follow up. And the other question is, in addition to the sit to stand and the time to go, do you recommend any other tests? So you’re this person, Fabio is using six minute walk test and hand grip test, and both of those would be used

Speaker 3
01:00:44 – 01:00:46
very well. We use them as well. They are very

Speaker 1
01:00:46 – 01:00:47
validated. Yeah.

Speaker 3
01:00:47 – 01:00:48
Yeah.

Speaker 1
01:00:48 – 01:01:02
And the other test that we’d use, Fabio, is then clinical exercise testing as well. We might use either a bike test or a treadmill test. But again, you’re you’re trying to decipher what’s cardiorespiratory exercise testing versus what’s a functional capacity test.

Speaker 3
01:01:02 – 01:01:03
Depending

Speaker 1
01:01:03 – 01:01:05
on the level of the person, you might choose one or the other.

Speaker 5
01:01:06 – 01:01:51
We don’t do, we do those Fabio, we do six minute walk tests, certainly, and hand grips, certainly particularly very useful for screening for sarcopenia. We don’t do any exercise tests, we toyed with the idea and Maura alluded to when you came first, we did have a treadmill and we did do an attempt at a study looking at VO2 max, for example, in a subgroup. But our patients are maybe further down the line, typically in terms of the severity of obesity. We just found that the limitation to their ability was their pain and their function. So we couldn’t ramp up enough for those standard VO2 max tests. So we don’t do any of that stuff, but we do just that functional view of it. And that serves us, I think, generally well.

Speaker 1
01:01:51 – 01:02:37
Yeah. So it’ll all depend on the client group you’re seeing, but basically you have to assess for pain, you have to assess for function, you have to assess for mobility regardless of the age. I think we’ll close it there. Please do send in any other questions you have and for those listening back, please always reach out. We have our Eco Congress coming up in May on the 11th to 14th in Malaga in Spain. Please join us. And then we also have the Physical Activity, Fitness and and function working group of EA. So of which myself and Jean-Michel Aupere chair. So there’s always activities and resources as well provided. So thank you so much for being here today. Thanks to all our speakers. Thanks to Dr. Colin Delevy. Thanks to Esther Marie Dorsey. Thanks to Maura Murphy. And thanks to Lisa for being such a

Speaker 2
01:02:37 – 01:02:38
fantastic coordinator.

Speaker 1
01:02:38 – 01:02:40
And thanks to everyone for being here.

Speaker 3
01:02:40 – 01:02:40
Take care.

Speaker 2
01:02:41 – 01:02:41
– Thank you.

Speaker 1
01:02:42 – 01:02:42
– Thanks everyone.

Speaker 3
01:02:43 – 01:02:43
Bye.