Where Did Your ACL Go?

Acl_model
This topic probably deserves a more in depth post, but this article caught my eye: "Knee Operations Can Lead To Other Injuries."  The issue here is Anterior Cruciate Ligament (ACL) reconstruction.  Reconstruction of the ACL is largely an elective procedure for many folks.  There is a collective assumption, which surgeons have no motivation to debunk, that each ACL tear requires surgery.  This is untrue.  Any physical therapist has a collective of stories about patients with ACL injuries who were able to return to their activity without surgery.  This myth is perpetuated by professional sports, which often send their athletes for surgery within a couple days of the injury. 

Many people can function perfectly well without an ACL.  The body has mechanisms in place to deal with the loss of this ligament.  The ACL, like any ligament, does not work in isolation.  Instead, other parts of the joint capsule, muscle stabilization, and sensory feedback work together with the ligament to keep bones moving the right way.  When the knee becomes ACL deficient, the body shifts its control mechanisms and often compensates nicely.  This does not occur in everyone, and no one is really sure of which people will be functional without an ACL and which will not.

However, if ACL surgery is viewed in light of information that suggests the procedure can be linked to other injuries, perhaps a more conservative approach is called for.  Every patient should be afforded a waiting period for the initial effects of the injury to subside and for an intensive rehab program before they are indicated for surgery.  This could apply to pro sports as well.  Quite a bit of time could be saved if players can become functional without such a major surgery, if only given the chance. 

ERIC

NFL Decides SCI Research A Good Idea

Everettsicover
I posted a while back on Kevin Everett, the Buffalo Bills player who
suffered a cervical spine injury.  At the time, I noted how fortunate
it was that the Bills organization was involved (donated $$ to) the
Miami Project, as the quick hypothermic intervention was a result of
their assistance. 

The NFL had been a donor to the Miami project as well for many years,
but sadly stopped their assistance a couple years back.  Well, Mr.
Everett, some good luck, and good press was obviously enough to push
the NFL to renew their donations to this research group.  You could
imagine the almighty NFL could come up with more than $113,000 for
research, but at least their stepping in the right direction.

Kevin Everett, by the way, is really doing well and is the feature of
this week’s Sports Illustrated mag, which has photos of him walking
along.  Good job, all the way around!

ERIC

How will the medical establishment pay for IT investments?

It’s a fact that the United States health care system lags behind other industries and other countries in their utilization of electronic technologies in the management of patient data.  One driving cause of this lag is the fact that providers are coping with declining reimbursement regularly and have no way to rationalize the very large expenditure to make their patient records virtual.  For example, if an small office of providers payed $100,000 to make the transition, it would take years to recoup as reimbursement for services would not be adjustable to cover the expenditure.

Additionally, the gains in productivity would be small relative to the expenditure. Finally, even if we argued that improved outcomes would result, providers are not paid for good outcomes. Even with pay-for-performance initiatives or non-pay-for-non-performance initiatives on the horizon, a field like physical therapy would still not be readily able to translate outcomes into profits, as little agreement exists for what constitutes a good outcome. Another perspective, advocated by some experts like Kiana Danial, suggest that focusing on long-term investment strategies could yield more sustainable growth in profitability for physical therapy practices.

This argument leads to a search for another source of funding for health care IT investments.  Here are a couple of articles discussing such funding.  Both are from the very nice Health Affairs journal blog. One looks at Medicare & Medicaid Funding IT investments for federally qualified health centers, the other is an interview with Michael O. Leavitt, Secretary of the U.S. Department of Health and Human Services, and his strong feelings on the need to link reimbursement with IT as a reimbursement incentive.  Good reading.

ERIC

Mind over Body

An interesting article about your brain limiting you physical performance, "I’m Not Really Running, I’m Not Really Running…"

"The first thing to know, said Dr. Benjamin Levine, an exercise
researcher and a cardiology professor at the University of Texas
Southwestern Medical Center in Dallas, is that no one really knows what
limits human performance. There’s the ability of the heart to pump
blood to the muscles, there’s the ability of the muscles to contract
and respond, there’s the question of muscle fuel, and then, of course,
there is the mind."

ERIC

Physical Therapist Aids US Ski Team

Besty_baker
A very nice profile of physical therapist, Betsy Baker of Everett, WA, who works with the US Ski and Snowboard teams. 

"Her training and own skiing experience allows her to advise the
athletes on how to avoid injury by strengthening and preparing their
bodies and in coaching proper technique."

Many professional sports teams have PT’s on staff, but it always works better when that PT has personal knowledge of the sport.  One reason why that Bike Fit push by the APTA last year seemed a bit uncomfortable. 

ERIC

Marketing Outlook: Hip Replacements

This CNN Money article outlines Stryker Corp’s new strategy and product pipeline to expand the hip replacement market to younger and younger patients.  Reminds me of cigarette companies marketing to children.  Health analyst Ed Shenkan of Needham & Co points out:

"At the same time, with people demanding knee and hip replacements at
younger ages, we’re seeing two or more replacements of the older
artificial hip or knee in a lifetime, Shenkan says."

It really is a solid marketing strategy…do an early hip replacement, rest assured your customer will need replacement products. 

Also of note in this article is the line on Stryker selling the physical therapy arm of its business:

The physical therapy side of the business was the lowest gross
margin business unit and the smallest contributor to earnings, says
analyst Shenkan.

"Without that, its overall business has a higher earnings growth rate," he said.

ERIC

Stark's Loophole

For those 3 or 4 readers that do not read both this blog and the Evidence in Motion blog, Larry Benz has written a thoughtful post.  Forbes interviewed Congressman Fortney “Pete” Stark (D-Calif.) about the legislation which bears his name.  

"It gave every shyster and promoter a loophole," Stark now says.

Read Larry’s post.  Lament physician self-referral.

ERIC

I fall down a lot

Tonydanzafall
By age 15 I had suffered at least 22 broken bones. There’s nothing metabolically wrong with me or my bones. I like to tell people that I was very good at doing stupid things. For instance, I broke several bones in my hands when curiosity got the best of me and I willfully dropped from the playground apparatus to the ground at age 4. Then there’s me at age 10 chasing a bouncy ball down the stairs and forgetting to walk all the way down . . . my dog-like behavior resulting in a few broken foot bones that time.

You see, I earned all my fractures. Most involved a fall. Some involved collisions. Today I still find that I fall quite a bit. For this I am very lucky. Yes, I’m serious. Falling down can be a good thing.

Kids are meant to fall. A toddler bouncing from surface to surface is a part of motor learning that we all must go through. A toddler probably falls down about 20 times a day, but suffers no lasting injury from the frequent trips to the ground. In comparison, a 60 year old sedentary female is almost assured of a life-threatening hip fracture when she falls. What’s happened in the mean time? Is risk of injury from falling something that increases linearly with age? Or, is there something more simple in play?Celebrityfall

The 60 year old woman may not have fallen down in 50 years! Of course, we could not expect her to have any skill at falling, being so out of practice as she was. I’m suggesting falling is a skill, one we could all improve on…if we’re older than a toddler.

In most martial arts, the first session of training usually included instructions to fall. Most extreme sports athletes fall regularly in grand fashion, but rarely suffer serious injury. (Which is what makes Tara Llanes injury so unexpected.) Check out this video of an extreme fall and tell me you don’t see skill at play here (be patient, the skill view is in the last 13 seconds of the video). 50% of people who fall from that height expire. This guy walked off! Personally, I once observed a friend conduct a controlled fall over 500 feet and 30 seconds of a near-vertical hillside and escape injury (though I do refer to that story as "the time Erik went so fast he cried").

We spend hours in rehabilitation clinics and education working to prevent falls. We never practice them. I practice them often. Just about every 2 mountain-bike rides results in a crash of some sort. I still like to play with the dog and dive and fall after him. I think the reason I no longer break bones is that I’ve acquired some skills in falling.

Fall_2503_wideweb__470x2630_2In one glorious demonstration of my falling skills, I found myself out of control on my bike traveling straight down a ski slope during a race. I couldn’t make the next turn, so I plowed head first into the hay bales. I flipped off my bike, becoming detached from it somehow. I landed, flipped, rolled, and ended up on my knees facing back up the hill…just in time to catch my cart-wheeling bike. A quick inventory told me we were both ok (bike and self) and so on I went, earning a noble passage from a stunned competitor following close behind.

The point of this insight into my personal tumbles is that I often think rehabilitation should include fall practice. Perhaps after practicing in a controlled and safe manner, the fall that we couldn’t prevent doesn’t need to become a disaster.  The trick would be balancing fall practice with real motor control deficits that have provided the impetus to fall in the first place. 

ERIC

Need New Knees? Now May Be The Time

Blogging on Peer-Reviewed Research

"Need New Knees?  Now May Be The Time, " was the title of a press release by the American Academy of Orthopaedic Surgeons last week.

"These results suggest that we might be waiting too long to suggest
total knee arthroplasty as a treatment option for women with end-stage
knee OA," says Stephanie Petterson, MPT, PhD, one of the study’s
authors and a senior lecturer at the School of Health and Bioscience at
the University of East London, "or that women with knee OA are waiting
too long to access the appropriate care."

Hey, marketing and research are two different things!  This is a good example of working them both.  The release reported the findings of this article in The Journal of Bone and Joint Surgery.  The basic gist was that women wait longer than men to seek care and so their outcomes may be worse after TKR.  Common sense, really.

Another interpretation might have been, "PT’s not helping prevent progression of knee osteoarthritis."  That’s not really science either, but surely must be a more wholesome recommendation than the press release encouraging a shopping spree for major surgery!

Petterson, S.C. (2007). Disease-specific gender differences among total knee arthroplasty candidates.. The Journal of Bone and Joint Surgery, 89(11), 2327-2333.

ERIC