Part 2: Dreaming In Orthopedic Prevention
Updated: Mar 5
In my last post I wrote about why we need a new approach to orthopedic medicine- a branch that consists of prevention. That post is sort of an outline of why the model of orthopedic health we presently find ourselves in doesn’t work. One thing I have learned from life, is that when you find yourself in a dystopia, it is really important to start a new dream. Start a spark with a new felt sense. In dreaming, I don’t necessarily take action. I am not “working” – I am allowing for the boundaries created by the current status quo to fall away. I notice what emerges, what is the felt sense in my body. In my heart, the dream I have is for well-educated consumers of orthopedic medicine, making empowered (rather than reactive) decisions around their health outcomes.
I want to share with you my daydreams about what orthopedic prevention would consist of (such as they stand at this moment- I am sure these will change. Please know that this dream is limited by my perspectives, and by my language).
What I dream for Providers:
1) Pure collaboration between different fields- with all disciplines respected and without hierarchical stratification (clinical psychologists, body workers, movement teachers are valued as much as MDs. Physical therapists collaborate with medical doctors, pilates teachers for best possible outcomes). Mutual respect between disciplines.
2) Multi-disciplinary educational experiences for providers (I don’t know if you are aware- but our continuing educational experience is largely contained by our profession- yoga teachers learn from yoga teachers, medical doctors learn from medical doctors. With respect to education, there is very little interdisciplinary sharing). For example: pilates teachers could learn biomechanics of the spine with tremendous outcomes- but because of this warehousing of information, they continue to learn from pilates teachers- which tend to encourage spinal motion over stabilization.
3) In insidious orthopedic pathologies, a bias toward initiating care with conservative care (education, biomechanics training, movement behavior modification) prior to the use of tertiary care (joint replacements, fusion surgeries).
4) Interdisciplinary teams, similar to the set up in Physical Medicine and Rehabilitation, focused on specific pathologies (e.g. osteoarthritis, persistent pain) to review interventions and process patient outcomes
5) Longitudinal movement science studies concerning prevention. (One of the greatest advances in cardiovascular primary treatment and prevention was initiated by the Farmington study- which has been collecting data related to lifestyle and cardiovascular health for 74 years! You can read about it here. We need this information in movement science too!)
My Dream for Movers:
1) To become more highly educated in understanding their role in creating more healthful musculoskeletal outcomes. Understanding- how do my thoughts and behaviors contribute to the progression of pathology or lessen the chances of pathology? Learn, how much do genetics purely play in to orthopedic pathology? How much do epigenetics- modified by lifestyle and belief choices- govern musculoskeletal outcomes?
2) To have a reliable movement specialist, educated in biomechanic science, to help them understand their current movement patterns and make modifications
3) To understand that pain is a biopsychosocial event- a willingness to look at the complex contributing factors that amount to sensory experiences with a variety of clinicians (including psychotherapists and psychologists)
4) To set movement goals related less to sensation and more to function. (e.g. to walk 5 miles when I am 85)
5) To understand that rest after injury is one of the greatest practices for healing you could give yourself
6) An ounce of musculoskeletal pathology prevention is worth a pound of cure- rather than focusing on surgery and injections, start with regular myofascial release sessions, biomechanics training and education, learning and creating strength and mobility
What this might look like in action:
You see a biomechanics/ physical therapist 4 times annually to check your fear avoidance beliefs around movement, your biomechanics with basic motion, mobility and strength.
Just like at the dentist! From these check ins, your provider might refer you for more extensive work up. (E.g. A provider may refer you to work with your MD for images as needed, and referral to clinical psychologists to identify and work with the psychosocial factors that influence pain prior to it becoming persistent). You are strong enough, you are mobile enough, you have solid biomechanics to pursue what you love in your movement.
Fitness and movement teachers are educated and on the same page with the basic principles of orthopedic biology and biomechanics. You attend classes once or twice a week depending on your interest and needs. There is no more confusion when we are all on the same page – no more my PT says this, my pilates teacher says that. That old he said she said takes a tremendous amount of energy away from progress. And we know enough to have solid answers we can all agree on.
Teachers feel comfortable about making referrals to PTs for quarterly assessments or medical doctors for further assessment. In this regard, preventative education starts where it matters most.
Bodywork, especially lymphatic massage and fascial mobilization, is practiced at regular intervals to avoid immobility across tissues. Clients are independent in how to best preserve fascial mobility on their own.
At one of your quarterly check ins, a behavioral health specialist can be present to identify thoughts/ perspectives, that may contribute to changes in your sensory processing. Again, this check in can lead to referrals (to neurologists etc.) as deemed necessary. Eating disorders/ overly controlled eating can be identified and appropriate referrals made to support your proper nutrition and mental health.
Of course, all of this takes money. In my dream (why not go big?), insurance moves toward supporting a preventative model of orthopedic medicine.
Companies cover orthopedically sound fitness classes, fascial massage and quarterly biomechanics check ins (similar to how dental insurance covers biannual check ins and cleanings). Dollars spent are shifted away from expensive surgeries, anesthesia, expensive imaging and injections toward much more cost effective primary care. An ounce of prevention.
I do not have solid numbers to provide a cost-benefit analysis of prevention vs what we have now. . What I do know, is that in the US we spend more on individuals with access to health-with only moderate outcomes to report. In other words, we could make the system much more cost effective than it presently is by focusing on more powerful, less expensive methods.
For example: a year of quarterly check ins with a PT, and monthly myofascial bodywork sessions at 60 minutes each year would cost an insurance provider about $1320.
A year of our practical strength classes- where we explore biomechanics, mobility, and strength, costs $1200.
A single MRI of the knee (depending on where you go for the imaging), costs about $8000.
An entire year of weekly PT sessions (which very few clients actually need) at $150/hour is $7500. The average cost of a knee joint replacement in the US (barring complications) is around $29,000 (with some costing as much as $70,000).
Post surgery, many clients continue moving in the same way they had prior to surgery- without changing movement patterns or establishing better education around joint preservation. They do not know to work on this. This is a huge loss, and often breaks down implants faster. Creating more pain and costly intervention.
Moving to a preventative model would not only save pain and suffering, spare joints, improve our mental health- it would also save health care dollars.
In this dream, we are at the center of our healing.
It doesn’t happen outside of our hands.
We are well educated, responsive and our actions and beliefs are the key to establishing healthful patterns around our aging musculoskeletal system.
I love this corner of our living room that looks out onto our back garden. I like to meditate and do yoga here if I cant actually practice outside.