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Dreaming in Orthopedic Preventative Medicine

Updated: Mar 2, 2023

I keep noodling on the idea that orthopedic care is largely reactive. We have an injury, we go see our doc, they prescribe (meds, rest, surgery, therapy). We undergo said treatment. And we wash and repeat the cycle. Where is the education? Where is the prevention? The lifestyle change? The accountability?

When injuries are traumatic (after a car accident, a slide tackle in soccer) this cycle may work well.

When injuries occur insidiously- without an event, which is the vast majority of outpatient injuries- this cycle of care is too short sighted. With the amount of knowledge we have in the biology of healing, biomechanics, and pain science, we should be able to intervene with the progression of atraumatic injuries.

There are branches of medical care that do a fantastic job of preventative education and care- cardiology and dentistry come to mind (I am sure there are more examples).

In dentistry, we learn to care for our teeth and gums to make them last through our lifetime. When I met my most recent dentist he said to me "I am here to ensure your teeth are functional into your early 90s". I love this. This is my most heart felt goal as a clinician, with the clients and students I work with. I would say "I am here to ensure you can maintain- as best possible- functional mobility well into your 90s".

Cardiologists have also transitioned into working preventatively to stop the progression of atherosclerosis and other progressive cardiovascular diseases before life sparring surgery is required.

Cardiology works with other fields- dieticians, exercise physiologists- even yoga teachers- to help teach clients to improve the health of their vasculature and heart.

One of my friends had a wonderful cardiologist who recognized her type A personality and lifestyle, and urged her to explore parasympathetic practices such as yin yoga. Amazing.

I understand that part of the reason movement scientists are unwilling to publish and talk openly about injury prevention, is the scientific rigor has simply not yet been established on the topic. One of my mentors who is extremely successful in movement science research and publication, spoke with me about the difficulty in attaining enough numbers of participants, enough strength of results, and securing funding for the prevention research.

But here is the thing- we are having an escalating crisis in orthopedic medicine, where people are turning first to joint removal/ replacement rather than starting with basic biomechanics. This is tantamount to starting a cardiology plan not with medication or lifestyle change, but with bypass surgery. While I understand that scientists may not want to go out on a limb, clinicians have to at least put in the best possible practice we can (which included prevention and education). Given the amount of suffering and lack of awareness we encounter, we have to try.

Joint replacements are a billion dollar industry in the US- they use up a tremendous amount of health care dollars. And though they treat the underlying offensive cartilage surfaces (by lopping them off) they do nothing to help movers change the lifestyle that caused the joint wear and tear in the first place- the poor mobility, strength and biomechanics that led to joint devastation. They also don't last forever- 15, 18, 20 years is the life expectancy of most replacements. At the clinic where I work seeing orthopedic patients part time, people are returning after replacing their replacements, and the surgery the second time around is quite challenging.

Its not as though joint replacements don't have a place in orthopedic medicine. They just should not be a first point of care. Osteoarthritis, similar to atherosclerosis, is a slow moving disease. It requires the exacerbation of inflammation (most often with predictive causes of shearing across joint segments) over and over and over again. Why are we not intervening when arthritis is at an early stage in its process? Why don't we assume most people have some degree of this brewing, and teach good biomechanics and postural alignment, successful strength and stabilization prior to end stages of the disease?

While most Americans know they should get a certain number of minutes performing cardiovascular exercise, flossing daily, eating less saturated fats for the health of their teeth and hearts, how many people know that quad dominant movement patterns are destructive to patellar and tibiofemoral cartilage? How many people think about their hip moment angle as a measure of safety in weight bearing activities?

It is as though the literacy related to healthful movement is just not there.

I propose that we ask more from the field of orthopedic medicine. Physical therapists alone cannot create a whole new arm of preventative medicine. We will need to stand on the shoulders of the biomechanists who have forged the movement science, and also collaborate with orthopedic MDs and neuroscientists specializing in pain science. Similar to the interdisciplinary approach that was so successfully employed in cardiology and dentistry, we will need to join together for the greater good- less suffering, less fear, better patient understanding of physical medicine, less expensive end stage interventions in orthopedic medicine. This switch to prevention will yield better results with less suffering. Ultimately, isn't the reduction of suffering why we are in medicine in the first place?

Fascial mobilization, joint mobilization, functional hip strengthening, supplements and activity pacing are all part of Chana's daily life as she gets frosty faced, given one of her caregivers practices orthopedic preventative medicine. Prevention attempts to ameliorate pathology, but could never prevent aging.

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