Ep 267: Clean air for musculoskeletal health, with Débora Petry Moecke

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[00:00:58] Hello, and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopedic and Sports Physical Therapy. It's great to have you listening today. How often do you think about the air quality in the clinic or outside when you're exercising?

[00:01:23] Perhaps you live and work in a part of the world where you're fortunate to have good air quality most of the time. For many people, though, that's simply not the case. Air pollution from wildfires is increasing, and it has serious implications for all of our health. Today, I'm joined by Dr. Deborah Petri-Mawiki, physical therapist and postdoctoral research fellow at the University of British Columbia's Department of Physical Therapy and the Center for Heart-Lung Innovation.

[00:01:51] Dr. Petri-Mawiki studies respiratory health and ways to improve access to healthcare. Today, we're tackling the clinic air environment and how to support clean air for health. Dr. Deborah Petri-Mawiki, welcome to JOSPT Insights. Thank you so much for having me. I think it's timely that we talk with you because in the Northern Hemisphere, the summer wildfire season, or what some people will know as the bushfire season, is pretty fast approaching.

[00:02:20] And as the climate's changing, we know that scientists have documented that these fires have been burning increasingly more land, they're getting larger, and they're getting more intense. None of this bodes well for our health, I don't think. Let's start by talking a little bit about what does wildfire smoke actually do to human tissues? Dr. Deborah Petri-Mawiki, Ph.D.: So the exact mechanism by which wildfire smoke causes health effects is not yet fully understood.

[00:02:48] Dr. Deborah Petri-Mawiki, Ph.D.: But studies in humans and animals exposed to wildfire smoke have identified oxidative stress and systemic inflammation as key pathways because many components of wildfire smoke can activate these pathways. Dr. Deborah Petri-Mawiki, Ph.D.: So wildfire smoke is known to generate more oxidative and pro-inflammatory components than chronic pollution from urban emissions, making it up to 10 times more toxic and harmful to the human body.

[00:03:16] Dr. Deborah Petri-Mawiki, Ph.D.: And while there are many pollutants generated by wildfires, such as carbon monoxide, nitrogen oxides, methane and volatile organic compounds, fine and ultra-fine particulate matter, commonly known as PM2.5, these are particularly dangerous because they can spread over larger areas and shadow more slowly than larger particles.

[00:03:41] Dr. Deborah Petri-Mawiki, Ph.D.: And these fine and ultra-fine particulates are also unique in their ability not only to penetrate the human tissue locally, which causes damage to mostly or mainly the cardiorespiratory system when they're inhaled, but also to be absorbed by the bloodstream. Dr. Deborah Petri-Mawiki, Ph.D.: Another important characteristic about wildfire smoke is its high temperature.

[00:04:04] Dr. Deborah Petri-Mawiki, Ph.D.: So this facilitates oxidation of smoke particles and beyond causing widespread inflammation throughout the body, wildfire smoke exposure can also suppress the ability of immune systems to clear up damage and can also lead to other biochemical changes.

[00:04:21] Dr. Deborah Petri-Mawiki, Ph.D.: So in addition to acute symptoms from short-term exposure such as dehydration, eye and throat irritation and cough, wildfire smoke exposure has also been linked to increased mortality, increased risk of respiratory and cardiovascular exacerbations for mental health and birth outcomes and cancer. Dr. Deborah Petri-Mawiki, Ph.D.: None of this sounds very good. Dr. Deborah Petri-Mawiki, Ph.D.: And I'm glad you mentioned briefly exposure to other environmental pollutants.

[00:04:51] Dr. Deborah Petri-Mawiki, Ph.D.: And of course, we're not singling out wildfire smoke as the only issue. Dr. Deborah Petri-Mawiki, Ph.D.: What we're talking about today is the particular challenges to the body of wildfire smoke and what we as musculoskeletal rehab clinicians might do to try to mitigate some of those concerns for patients and for ourselves as clinicians too.

[00:05:11] Dr. Deborah Petri-Mawiki, Ph.D.: I also heard you mention the PM2.5 and I think that number will probably resonate with people who have worn masks during COVID and anyone who's got a HEPA filter in their clinic or in their home. So we'll come back to, I think, some of these numbers and some of these concepts shortly. Before we get there though, Deborah, who's particularly at risk for poor health outcomes given exposure to wildfire smoke?

[00:05:41] Dr. Deborah Petri-Mawiki, Ph.D.: Several groups have been identified as potentially being disproportionately impacted and more susceptible to wildfire smoke, including seniors, children, women, pregnant people, indigenous populations, people living in remote areas, people with pre-existing health conditions, and also those with lower socioeconomic status. Dr. Deborah Petri-Mawiki, Ph.D.: And finally, people who work and play outdoors, so for instance wildland firefighters.

[00:06:08] Dr. Deborah Petri-Mawiki, Ph.D.: There are actually various factors contributing to this disproportionate risk, which includes biological and physiological differences across life stages and or the presence of comorbidities, as well as an increased likelihood of exposure due to location and or occupation. Dr. Deborah Petri-Mawiki, Ph.D.: So, for instance, access to masks or air filters or purifiers, as we were talking about, and even healthcare.

[00:06:37] Dr. Deborah Petri-Mawiki, Ph.D.: I just also wanted to mention the indigenous populations and why they are disproportionately affected. Dr. Deborah Petri-Mawiki, Ph.D.: And this is due to a series of structural inequities, actually, that are linked to lower socioeconomic status, higher rates of chronic health conditions, and even limited housing infrastructure. Dr. Deborah Petri-Mawiki, Ph.D.: And beyond the factors, many indigenous communities are actually located in rural and remote areas closest to forests that work. Dr. Deborah Petri-Mawiki, Ph.D.: Yeah, it's complex, isn't it?

[00:07:06] The research team you're part of is doing a lot of work, particularly in indigenous communities, to explore, work with communities to come up with solutions to help improve health outcomes for these populations, and very much driven by the decisions of the community as opposed to people coming in and telling the community what to do.

[00:07:27] Dr. Deborah Petri-Mawiki, Ph.D.: And I wonder, Deborah, talking about indigenous communities specifically and their particularly increased risk, and of course healthcare and how healthcare services are delivered is very much involved in planning and evacuation plans for communities, which is a nice segue, I think, into let's talk about musculoskeletal rehabilitation and clinicians and what we as clinicians can do to help mitigate some of these exposures.

[00:07:55] Dr. Deborah Petri-Mawiki, Ph.D.: Let's start by talking about why should clinicians care? Why is this an issue for specifically the JOSPT community who are active in musculoskeletal rehabilitation and delivering those sorts of services? Why should our listeners care or think about how wildfire smoke is going to have a larger impact on their clinical practice into the future? Dr. Deborah Petri-Mawiki, Ph.D.: That's a great question.

[00:08:18] Dr. Deborah Petri-Mawiki, Ph.D.: And I think one reason is that rehabilitation clinicians often provide care to people who are more vulnerable to a personal exposure, including those with persistent underlying conditions such as heart and lung disease. Dr. Deborah Petri-Mawiki, Ph.D.: And also people who work and play outdoors. Dr. Deborah Petri-Mawiki, Ph.D.: I talked about firefighters, but even outdoor athletes would also be more at risk.

[00:08:40] Dr. Deborah Petri-Mawiki, Ph.D.: Fire skin directly influences how most post-college clinicians, rehabilitation clinicians prescribe exercise therapy, how they manage outdoor sessions, and also how they maintain a safe clinical environment. Dr. Deborah Petri-Mawiki, Ph.D.: Given that, as far as smoke exposure is more likely to exacerbate underlying conditions or even trigger adverse responses in healthy individuals during physical exertion, heightened vigilance for suitable physiological changes,

[00:09:08] finally incurred respiratory distress, particularly among the vulnerable population, is critical. Dr. Deborah Petri-Mawiki, Ph.D.: So first clinicians need to know who is most at risk and then pay extra attention to things like heart rate, respiratory rate, dyspnea, oxygen saturation, chest pain, all these signs and symptoms that we learn about during our training. Dr. Deborah Petri-Mawiki, Ph.D.: And also just know when to refer to medical care.

[00:09:37] Dr. Deborah Petri-Mawiki, Ph.D.: So like some of us, we already do that in our routines in clinical practice. Dr. Deborah Petri-Mawiki, Ph.D.: But it's important to be more vigilant during wildfire season, especially if you live in an area where you know there's potential. Dr. Deborah Petri-Mawiki, Ph.D.: Yes, absolutely, which is the perfect segue to talk about the practical things that clinicians can do in the clinic.

[00:10:00] So you mentioned this is something that certainly people who are working in areas that are particularly susceptible to wildfire are going to have more and more front of mind. Dr. Deborah Petri-Mawiki, Ph.D.: So if I'm in an area that's at higher risk of experiencing wildfire air pollution, how might I think about setting up my clinic, planning the work around mitigating some of the worst health outcomes of patients and me as a clinician being exposed to wildfire smoke in day-to-day life?

[00:10:29] Dr. Deborah Petri-Mawiki, Ph.D.: I'll start with doing wildfire events. Dr. Deborah Petri-Mawiki, Ph.D.: So during wildfire events, in addition to monitoring the outdoor quality, clinicians are also encouraged to use sensors to monitor the real-time indoor quality in their clinic and aim to keep EM 2.5 levels below 12 micrograms per cubic meter.

[00:10:50] Dr. Deborah Petri-Mawiki, Ph.D.: Then they must keep windows and doors closed, use heating, ventilation, and air conditioning systems in recirculating mode, and also use portable air purifiers with high efficiency. Dr. Deborah Petri-Mawiki, Ph.D.: So, in addition to the outdoor quality, the air conditioning systems, are also ensuring that the air conditioning systems are not overcrowded as this can reduce the ventilation efficiency.

[00:11:17] Dr. Deborah Petri-Mawiki, Ph.D.: Another thing that's important to have in mind is regarding outdoor exercise therapy sessions. Dr. Deborah Petri-Mawiki, Ph.D.: So, studies have shown that one hour of high intensity outdoor exercise results in particle deposition levels comparable to those typical Dr. Deborah Petri-Mawiki, Ph.D.: So, this means that exercising outdoors during outdoor season exponentially increases the risk of smoke exposure and its negative health effects.

[00:11:45] Dr. Deborah Petri-Mawiki, Ph.D.: Tracking real-time air quality using systems such as the Canada's Air Quality Health Index, which is also called AQHI, Dr. Deborah Petri-Mawiki, Ph.D.: And knowing when to modify activity or completely avoid outdoor activity based on CM2.5 levels is crucial. Dr. Deborah Petri-Mawiki, Ph.D.: AQHI is based on the observed relationship of nitrogen dioxide, ozone, and fine particulate matter.

[00:12:11] Dr. Deborah Petri-Mawiki, Ph.D.: So, it provides a number of 1 to 10 that indicates the level of health risk associated with local air quality. Dr. Deborah Petri-Mawiki, Ph.D.: The index will describe the level of health risk associated with the number as low, moderate, high, or very high. Dr. Deborah Petri-Mawiki, Ph.D.: And then it will also suggest steps that can be taken to reduce exposure. Dr. Deborah Petri-Mawiki, Ph.D.: So, it comes with a health message for both people that are more vulnerable and then regular non-advasive people as well.

[00:12:40] Dr. Deborah Petri-Mawiki, Ph.D.: There are other sources or other websites such as the IQ Air and also the Purple Air, which have sensors across the globe, and they provide direct measurements of atmospheric PM2.5. Dr. Deborah Petri-Mawiki, Ph.D.: And this is helpful because studies have actually established a threshold for exercise safety based on the PM2.5 level.

[00:13:02] Dr. Deborah Petri-Mawiki, Ph.D.: And most sources, they actually generally agree that levels above 50 micrograms per cubic meter represent poor conditions for exercise and require adaptations, while levels above 150 micrograms per cubic meter are likely to be hazardous to exercising outdoors. Dr. Deborah Petri-Mawiki, Ph.D.: Those numbers are scary. The one hour of exposure outdoors is the equivalent of 10 hours of exposure if you're not exercising.

[00:13:31] As someone who does quite a bit of outdoor activity, that's something I need to keep in mind. And I guess it also makes me think when there's a smoke event, we start to get worried about, should I even leave the house? And for patients coming into the clinic, they're, of course, going to have some sort of exposure outside directly. But it seems like perhaps what's key here, Deborah, is focusing on the higher intensity activities.

[00:13:58] So if you're someone who's exercising outdoors, moving that exercise indoors, and then when you're in the clinic thinking about if you've got people exercising in the clinic, what sort of an environment have you got for them to access in the clinic? Have I got that right? Dr. Deborah Petri-Mawiki, Ph.D.: Yeah, yeah. You got that right. And there are, like as I mentioned, there are different thresholds.

[00:14:18] So for what the AQHI would call moderate or even high, but mostly moderate, which is levels above 50 micrograms per cubic meter. This is when you don't necessarily need to move inside. If you can, that's better.

[00:14:37] But there are other things that you could also prioritize, such as exercising early in the morning or late in the evening, exercising in open space away from traffic, using proper protection, so using high efficiency math, hydrating, which is really important. And also just reducing, as you were saying, reducing the intensity of your exercise and potentially the duration.

[00:15:01] Sometimes when it's above 150, you can look outside and you'll see that the conditions are not great, that the sky is a bit smoky. But in times when you cannot see, it still could be dangerous. So that's why it's so important to have a look at those PM2.5 levels and really check those websites. Yes, and certainly those of us who have been in smoky environments will know you can smell it. As you say, you can see it.

[00:15:30] And I feel like a lot of weather apps on our smart devices now have got quite good at building in those alerts into the app. So you might go and check the weather and then you get the alert about the air quality at the same time, as opposed to having to go to another app or another website. I want to also come back to the monitoring air quality indoors in the clinic. Is that buying a CO2 monitor or is there a special monitor that you need to have that also monitors the PM2.5 levels indoors too?

[00:16:00] Debra, what would you suggest there? What clinicians could do in preparation for before the smoke pollution is around, right? So I feel like that goes in line with what you were just asking in terms of how to monitor the indoor air quality. And there are a few things that clinicians can do if they know they live in an area that's at risk of smoke exposure.

[00:16:23] So the first thing would be to really seek and share information to ensure that everyone within your clinic knows how to monitor and interpret outdoor and indoor air quality, how to monitor patients more closely, as well as how to keep the clinic's indoor air clean. Kind of developing those ESCO fees and having some training could be extremely beneficial.

[00:16:50] And then the second thing, as you were mentioning, is ensuring indoor air quality through sensors and monitors. It doesn't have to be like super high tech. You can buy for as cheap as 50 bucks on Amazon. So yeah, it's just any monitor that will give you CO2 levels and more importantly, PM2.5 levels. This is how you can then.

[00:17:14] These are the values that we do currently have established thresholds for, as well as the air purifiers. You know, so remembering there is the 13 or higher reporting efficiency reporting value to have in mind. These often come with filters and the filters must be changed. So each filter has its own frequency of changing the filters, but mostly they recommend at least once a year. And then again, back to the masks, right?

[00:17:39] So I feel like having masks to offer to patients, especially because some of them will still exercise or be outdoors during the last pair seasons. Is it an N95 mask you're looking for, Debra? Exactly. Yeah. Okay. Yeah. So not just the, sometimes you see people with a scarf over their face when they're, I see them sometimes riding their bikes to work. That's obviously not enough. Needs to be a better quality mask.

[00:18:10] Yeah, that's right. So we have the N95, we have the CAN95 and the KF94. These are the three models that have been most recommended. Okay. Excellent. So we've been talking about the clinic environment. Now I want to zoom out as we start to wrap up. Let's zoom out to the policy level. You touched on this a little bit, I think, when you talked about clinics having policies and standard operating procedures and making sure that everyone's aware of the policies in place for exercising outdoors.

[00:18:39] For ensuring the indoor air is clean. Let's talk about what can happen as these events continue to get worse. And all of the scientific literature suggests that these are getting worse and will continue to get worse unless something drastically changes in the world.

[00:18:58] What else needs to happen then at a policy level to help us ensure as safe environments as we can for patients, for athletes, for people who like to spend time outdoors and for musculoskeletal rehabilitation clinicians?

[00:19:13] In light of what I said before about training and creating those kind of ASCOPs for the clinic, I feel like developing emergency response plans can also help clinicians quickly organize their work when wildfires demand this rapid shift of how care is delivered. Because these events can be unpredictable.

[00:19:34] Because these events can be unpredictable, although we are more and more aware and we monitor outdoor quality more often still, it can, like, it spreads super fast. So you never know. So having those type of emergency response plans in place can be super helpful. So, for example, a suggestion would be to start thinking ahead of time about questions such as how will the clinic address surges in patient volume or staff shortages? What should we do if care gets disrupted?

[00:20:04] Or even how can we support evacuated patients from close by area? I also talked about seeking knowledge. So pursuing knowledge about disaster response, the incident command system, evacuation experiences, and also just how the healthcare system responds to these events. It's a good way to prepare.

[00:20:29] Another good way of doing it would be creating a community of practice with other sites and other healthcare professionals to kind of debrief after a lot of our event and shared experiences of what worked well, what didn't. I think this can certainly contribute to improve future responses as well. Another thing that I think it's important is just revising cancellation policies to minimize unnecessary exposure.

[00:20:56] So if it's not crucial for your patients to come into the clinic physically, and sometimes, as I mentioned, these events are unpredictable. So if they have to cancel less time, less minutes, try to be, do you considerate all these things that we have been talking about? And also just consider offering virtual appointments. So telehealth is also something that many, many clinics have already been offering to their patients.

[00:21:23] And it's definitely an alternative for going care during large-parasmo events. So if you have the structure, or even if you don't, thinking about that, about starting something like that within your clinic for when it happens. Debra, this has been such a good blend of practical, local things that we can do as either individuals to protect ourselves, to help protect the patients we're working with, to help ensure healthy clinic environments.

[00:21:51] And then also what we can do as advocates within a larger health system and a larger population. I'm really glad that you've been able to get us out of our silo of musculoskeletal practice. It's good to think a bit more broadly about population and public health. Dr. Debra Petri-Moyki, thank you for joining me today on JOSPT Insights. Thank you for having me. It was my pleasure.

[00:22:42] Thanks for listening to this episode of JOSPT Insights. Be sure to follow us on Twitter, we're at JOSPT, and Facebook, we're JOSPTOfficial. Talk with you next time.