So I realize that I'm the last person to stop you from dinner on the beach or drinks at sunset. And knowing this group, maybe we should just end the talk right now. But really talking more about disability and arthritis. I'll speak again on Sunday about some legal implications of COVID, we'll kind of review public health law and emergency declarations, National Emergency Act, and then some cases coming out of COVID. So maybe that would have been better today, but we probably all had enough of COVID for one day. So maybe this is a good break. All right. So Dr. Swade, are you going to introduce Dr. Kenton, even though he's already started talking? I'm a man that needs no introduction. Yeah. All right. A legend in my own mind. Introducing a legend in his own mind, Dr. David Kenton, D-O-M-P-H-J-D-F-A-O-C-O-P-M. Originally from Missouri, Dr. Kenton earned a D.O. at Kansas City University of Health Sciences as an Army scholarship. In 1988, he completed a family practice residency at Southern Illinois University, and in 1999, he completed both an M.P.H. and a fellowship in occupational environmental medicine at the University of Washington in Seattle. Dr. Kenton added a J.D. to his CV in 2004 after graduating from Concord University's School of Law in Los Angeles and subsequently passing the bar. In 1990, he was a flight surgeon and part of the first Army medical unit deployed to Saudi Arabia as part of Desert Storm. He left the Army in 1992 to transfer to the Coast Guard. During his years in the Coast Guard, he was the chief of health and safety in New Orleans, a flight surgeon, and a general physician at Port Angeles, Washington, and chief of operational medicine for the U.S. Coast Guard Atlantic Area, where he provided professional oversight for 25 clinics with 150 providers and assets in Kuwait and Puerto Rico. For nearly three years, Dr. Kenton was the chief medical officer for the National Disaster Management System in Washington, D.C., part of the DHHS. In 2005, while Dr. Kenton served as the chief medical officer of NDMS, he had as many as 30 sites set up along the Gulf Coast to provide care for victims of Hurricane Katrina. Over the course of several months, the team has treated over 180,000 patients across the hurricane-ravaged South. Having retired from uniformed federal service, Dr. Kenton served as a vice president for medical affairs of Emanuel Medical Center in Turok, California, and director of medical education. He served as the medical director for Stanislaus County Medical Reserve Corps. He went on to assume the position of chief medical officer of Shasta Community Health Center in Redding, California. There he provided oversight of quality of care and professional leadership for over 25 providers and served as the chief academic officer for teaching health center operations. Dr. Kenton served as a health officer for Merced County before assuming the position of chair of primary care at California Health Sciences University in Clovis, California. He enjoys skiing, horses, as well as spending time with his family. In 2017, he completed a trip to Washington State where he drove his team of Clydesdale horses over 225 miles. I have no conflict of interest. Say what? Yeah, we can talk about that later. I have no conflict of interest. I don't think I'm going to discuss any legal issues during this presentation, but I'm not providing legal advice. This is only for educational value. So, we'll talk about what is osteoarthritis, what causes it. The kinetic chain, joint relationship, and then treatment and prevention. And when I say treatment and prevention, I'm talking about long-term disability. So, what is osteoarthritis? Let me back up just a little bit. The way this started is I have a disability. I'm 90% disabled from the VA, and I've had a hip replacement and a knee replacement. And my knee replacement was covered by VA disability. And I said, well, it just makes sense that because I've had a knee problem, it's had to have affected my opposite hip. So, I said my hip issue is contributory from my knee. Well, I went for an evaluation, and in the evaluation, the physician put in there, who happened to be a psychiatrist, there's no scientific evidence to suggest that the knee has had any implication on the hip. I said, well, that just doesn't make sense. So, I started looking into this, and I actually got an article published, and we're going to essentially review the article. It's in the Osteopathic Family Physician Journal, and that's in the bibliography here. So, you can basically pull this whole thing up online, read the whole article. But what is osteoarthritis? When you say that, what does that mean? Anybody? Degenerative joint disease. So, what does that mean? I mean, loss of cartilage. Okay. So, wear and tear, right? Early aging is kind of what we have described also in other settings. Overuse. When I was talking to, I was chair of primary care department, as Greg mentioned, in Clovis for a new osteopathic medical school there, and I was talking to the rheumatologist that was on faculty there, and she said, you've had a joint replacement. You've used your joints well. They've been well used. You've gotten a lot of service out of them. But osteoarthritis, that really doesn't say what osteoarthritis is. So, I kind of wanted to look at that. So, a little bit of background. Osteoarthritis is the leading arthritic condition worldwide. I mean, we see it all the time in primary care, right? And we also see it in occupational medicine. We spend, in this country, $15 billion a year in treating for osteoarthritis, and it's the second most costly disease. I think secondary to heart disease. So, certainly has a real impact. So, when I was looking at this, am I doing something wrong? Okay. When I was looking at this, I did a literature search. I went on Medline PubMed, and I looked at, is there an association? I mean, to me, it made biological sense that there should be an association, but is there an association between the knee and the hip? So, between 1981 and 2021, I found 68 articles that I reviewed in that search that came up for relevance, and we'll kind of discuss those articles. So, then when I got that information, and I guess, spoiler alert, yes, they are linked. The second search was, okay, then what's the cause of osteoarthritis, and is there a biochemical or a physical cause other than just overuse? So, I did another search between 2001 and 2021, came up with 538 articles. Most of those articles, when I came down to review them, talked about association, either genetic or weight, diabetes, those things, but it didn't speak to the cause. And as we all know, association is not necessarily causation. So, that when I made that second cut on those articles, it became much more selective. So, what does cause osteoarthritis? Wear and tear, repeated intense joint loading, high joint loading activity, these are kind of the things, you know, that we've talked about, we've seen. What I found was this study that's cited here, that they looked at articular cells, cartilage cells, and they applied shear forces to them, and what they found was inflammatory markers were then identified. So, it was not direct force, okay, but it was shearing forces on the joint that released the inflammatory chemical. So, that inflammation is then what causes the apoptosis or what results in early aging of the cartilage. So, with that, we can see that, okay, well, then osteoarthritis is obviously, it's not a weight issue. It's not because people are overweight and maybe they have a higher production of estrogen or some other factor that's affecting it. It's the actual shearing force on that, and we'll get into that a little more later. The second part of this I think that's important is the factor of kinetic chain. And I thought this was pretty common knowledge, but I'm starting to think that maybe it's not. And are people aware of that term, kinetic chain? Okay. So, this first came about or published by Franz Relox, and it's an application of force to the end of a fixed overlapping rigid segment connected by pin joints transmits the force to the next segment. So, what does that mean? Yeah. Okay, good, because if you did, I was going to explain it to you anyway. So, what it means is that if I have, let me see if I can get something. No, no. We'll kind of see it here. So, when we're walking, this is a good example. When we're walking and you have a heel strike, you have a force that hits here. This force gets transmitted up to the knee. It then gets transmitted from the knee to the hip and from the hip to the spine and so on. So, we can see that in here through the gate, we have transmission here on this side. And you can see where the force then goes from the ankle or the foot. It passes the knee because there's not a link there anymore and goes straight to the hip. And then there's a, when we get to this point, we're transferring the force from the right foot. Actually, I guess it's over here. From the right foot now, we're transferring to the left foot and we repeat the same process on the other side. So, there's a seesawing transfer of weight. Okay. Where we typically see this or the classic example is the balls. And you've probably all seen this where you pull out one ball and let it drop. And so, if we were to pull this ball back, it hits this ball and then this one hits this one. You don't necessarily see it, but the ball over here on this end swings out. So, that's all part, that's the real example of the kinetic chain. So, here we're seeing the same thing that I just described in the last slide. And we can see here, and this kind of, and probably at some point maybe Murray and I should do a lecture combined or a panel discussion because you can see here the impact of a sacro dysfunction is going to play, come into play when we're transferring these forces. Right? I mean, I can't do it in Boston, but I think in the future, it would be a great talk. And there's a lot we could do even with this towards the end. If you can't get the smothered ball. Yeah, or Chi Chin Chong maybe. Yeah, right, right. So, we know about the kinetic chain. Did I answer your question? Okay. So, we know about the kinetic chain. So, does this come into play? Do we have an explanation? We know what the mechanism is. Do we see it in biological application? Well, yeah, we do. In this article by Lee, range of motion of hip and ankle joints were significantly smaller in the OA group and were associated with limited range of motion of the knee. So, in this article, they're showing range of motion on one side is impacting range of motion on the other side. Or there's an association. That association then is explained through the kinetic chain. So, it all makes sense. So, then is there some other comparison there or something else that supports this? So, this article, non-random evolution of end-stage osteoarthritis of the lower limbs. They found in this study that they looked at five, almost 6,000 people, looked at patients with hip replacement, and looked at the likelihood of another joint replacement. Okay? So, now we should see another joint replacement. If we've got an injury at one, we're going to be transferring the forces to another joint. So, if our theory applies, then we should see an association here. They used rheumatoid arthritic patients as control because rheumatoid arthritis is not a force arthritic condition. It's an autoimmune inflammatory condition, right? So, if it was just a matter of joint replacement, then we should see no difference. And what they found is osteoarthritic patients are more likely to receive contralateral joint replacements, and RA patients showed no increase with laterality. So, this then, again, was support that the kinetic chain was coming into play, and the forces were having an impact on the joints. So, another article by Lamport, risk of subsequent joint arthroscopy in contralateral or different joint after indexed shoulder, hip, knee arthroscopy. Association with indexed joint demographics and patient-specific factors. Here, they looked at approximately 8,500 patients. So, pretty solid study, good numbers. Patients who had either total hip, total knee, or total shoulder. 23, almost 24% of patients had contralateral joint replace within five to eight years. And three, almost 4% had a different joint replace. So, here again, we're seeing that the contralateral is more likely to come into play once you've had one joint replacement. So, if we're looking at osteoarthritis, wouldn't it be, if we've got a patient who's had a joint replacement, we ought to be able to see, hey, this person is lining up, and according to this study, five to eight years, they're probably going to need another joint replacement. If we can't do something to correct the issue that's causing the sheer force, that's causing the inflammation, that's leading to the joint destruction. So, and that's preventing medicine, right? We're preventing disability. This is what it's all about. Again, another article, asymmetric knee loading and advanced unilateral hip osteoarthritis. So, 50 individuals, a smaller study, but they had their gait analyzed prior to total hip replacement. 10 to 23 months after surgery, 22 of the 50 were reevaluated. Others lost the follow-up in various different factors. Investigators assessed increased CIN peak, external knee abduction motion, which is associated with osteoarthritis, compared dynamic joint loads between contralateral and inflatable knees, peak external knee abduction movement, and peak medial compartment load were increased in the contralateral knee postoperatively. So, here we're seeing, even after surgery, they're having more loading to the other knee than compared to before. So, we're seeing something that's not, it's not getting corrected. The joint's getting replaced, but the forces have been transferred, and there's something in there that they're not going back to what we would call normal. So, part of this is probably explained by the Q angle. And do we remember Q angle from medical school? Just as a refresher, oops, sorry, sorry. The Q angle is measured from the knee to the hip, and it should be essentially straight or zero. But we have a decreased Q angle, and you see what this does, it puts, when that's not straight alignment, as it is here, we have this increased angle here. Oh yeah, make it kiss, yeah. So, the Q angle is increased, then we're seeing more joint space essentially here. So, what does this mean? Well, you can see when we have the decreased Q angle, then instead of the force being transmitted here across the whole joint surface, it's focused on the medial aspect of the knee. So, now instead of being flat, we've got an angle here, so the force instead of being applied vertically is going to be transverse to some degree, which is our sheer force. And the most common cause of knee replacement is deterioration on the medial side of the knee. So, I mean, here we are, we're seeing this now as it explains what we've been experiencing. Should I go back to this or just run it off? Yeah. Given that women have a greater Q angle by nature, okay? Yeah. But they have less in the way of knee replacement. Yeah. How do we explain that? Good question. And I don't have a good explanation for that per se. And it may come into play as to how the hips are placed over the foot, and it may also involve the foot, because everything, because of the kinetic chain, what happens here may, because of the alignment, may avoid the knee and go straight to the hip. So, do people who are naturally bowlegged have more knee replacement? That I can't tell you. I don't know. I didn't find that, and I don't know. But I know that medial deterioration is the most common cause for knee replacement. So, it's got to be the decreased Q angle in some way or fashion. Yeah, yeah, but the question obviously is, you would think that if somebody has, you know, a medial because they're cold, they get it more lateral if they're having increased human angle, but on the other hand, women, as I said, have a wider human angle because their hips are are wider evolutionarily, but they don't have knee replacements in the same relative numbers. It's because they're stronger. Well, yeah, that's the truth. You receive forces, humanity would have died out generations ago. So our traditional therapy, we send people to physical therapy, they get resistance training, weight loaded exercises, walking, bicycling, which involves repeated short arc motions. The short arc motions may decrease the mobility and continue to propagate the gait disturbance. And so perhaps we need to look at a different way or a different direction for physical therapy when we're sending people to therapy, either pre-op or post-op. And we have a similar, similar thing comes into play after sports injuries. So maybe there's a different paradigm. Maybe we need to correct the gait disturbances. I don't know if I have it in here, but we need to, there was another article that I found that showed that gait disturbances at the ankle propagated even after surgery, which led to knee replacement. So the real point that we should be looking at is to reduce shear forces applied to the joints. Okay, so how does that circle back to OMT? OMT to treat radical and myofascial somatic dysfunction, improve positional asymmetry and remove restrictions to the joint and range of motion. Well, that's almost the verbatim description of, now I'm blanking, not muscle energy, but myofascial release, right? If we're improving the range of motion. So perhaps there's a number of things that we could do to the knee, the hip and the ankle that would improve function of the myofascial tissue and improve the range of motion, the long range of motion, which theoretically at least could decrease the progression of a leg. So any other questions or comments? Dan? Does it matter in this interview which in person? Yeah, good question. Yeah, the question was, did the study show any difference? Did it make any difference if they had the knee replacement first or the hip replacement first? And no, it didn't make any difference. So if they had a hip replacement, they were more likely to have a knee replacement on the other side, or if they had a knee replacement, they were more likely to have a hip replacement on the opposite side. So good question, because you might think, well, the forces haven't been transferred. Yeah, Jeffrey? Did you go and jack up the psychiatrist? Not yet. The question was, did I jack up the psychiatrist that said there was no scientific evidence to support relationship between the knee and the hip? No, I haven't done that yet, yeah. I guess I just wonder, you know with sheer force, however, maybe some other sites are more affected by sheer force based on family email, family genetics, things like that. No, they didn't look to that. These were culture counter sites, so I think they're probably pretty genetic. I don't know. I'd have to go back and look at the article again. And at least when we look to, there is some, I mean, there's some, I don't know, I don't want to say that there's genetic link, because I don't know that it's genetic, but there's familiar links to osteoarthritis. So if your parents had osteoarthritis, then, you know, you may be at higher risk of having osteoarthritis, but if your parents had a habitus that created an increased angle, which resulted in increased sheer force, then you're more likely to have that same body build, right? So is that genetic? I guess it is, but it's not exactly. But again, I didn't see literature to that, so I can't speak to it, but it makes biologic sense, at least to me. Any other questions? Okay. Yeah. Okay. So the article we're discussing here, one of the people here in the audience read an article last night that said that the people that had back pain, okay, and they took an anti-inflammatory long-term. Okay, so the ones that didn't take a non-steroidal had higher inflammatory markers three months out but had a lower risk of developing chronic pain as opposed to those who took a non-steroidal to begin with. I don't know. I haven't seen that. It'd be an interesting article to read. How many, Pete? How many, how big was the study? Okay. All right. Yeah. I mean, there's a, this is a, you know, I mean, we've been dealing with this for centuries, right? Osteoarthritis is not new and we don't really have any good treatments other, I mean, fortunately, we've got joint replacement. My grandfather homesteaded in, was born in 1867. His family, when he was a child, homesteaded in Western Kansas. He lived in a sod house as a child. He drove cattle from Texas to Montana. So you know, if he had gotten to the point with his hip that I got to, I don't know, in the, at the same age, in the early part of the 20th century, joint replacements weren't that common. You know, I mean, people, it was basically the end of your life. I mean, we were talking about this earlier, Murray, I think with your mother living to be almost a hundred or a hundred and two, oh, grandmother living to be almost a hundred and two. But, you know, my great, great grandfather, he lived to be 102 and survived for a while. Yeah. So you know, people back then, the life expectancy was 40 or 45, right? Because when, you know, it was a tough life and when you wore out your joint, there was no, there was no other option, right? You couldn't get food, you couldn't work. So that was pretty much the end of your existence. Is there any questions from, from the virtual universe? All right. Thank you. Yeah, John. I didn't see anything about the spine and that wasn't part of the search. I was looking at lower extremity. So, and I was talking to my orthopedic friend who did my hip and my knee about this. And, you know, at some point, can I back up? We go back to the gate. Okay. Okay. So, you know, the, the force is transmitted through the lower extremity. They see saw back and forth. And if we, if we look at this, you know, where the force is going to be a sheer force here as we've got this sort of teeter totter, okay, there's an impact or there's potentially have an impact. But once it transfers to the sacrum, everything up the sacrum is straight in line. So the force, I would think the force here is going to be the same regardless of what happens down there. So, yeah, I mean, people get degenerative joint disease, right? It's essentially the same process and it probably depends or has a big impact, at least theoretically, would be on stature and posture and because your posture is going to determine the sheer force is applied to your spine. Yeah. And I don't, I haven't, I haven't done a review of the literature, but my impression just from practices that the majority of, of, of a spinal OA is in the lumbar sacral region. But I don't know. That may not be true. I'm just sort of, just, I mean, and low back pain is so common, right? All right. Well, that concludes our day. I want to thank everybody for their participation. We'll be on the same time tomorrow morning and it's the same Zoom number and password that we'll be using tomorrow as well as Sunday.

disability

osteoarthritis

kinetic chain

joint replacements

VA benefits

gait disturbances

osteopathic manipulative treatment