What is an ounce of prevention really worth?

I am currently home with a stubborn cold that has morphed into some sort of other nasty thing. My voice is gone, and I am drained of physical energy. I am almost out of Netflix and reading options.

So I was so happy to see this article published today by the NY Times.

Why are so many teen girls still tearing their ACLs?

Back when I was a new PT, during the time I was studying for my OCS, I was working in a small town in a wealthy county in the Bay Area. I kept seeing one young girl after the other, as young as 11 years old, with season ending ACL ruptures and subsequent repairs.

I was distraught by the frequency with which these young ones were coming through our door- many were just in their first or second year of club soccer- and overwhelmed by the social and physical disconnection they endured as a result of their injuries.

Perhaps this was when my brain started to morph from a private Physical Therapist into that of a community health provider- understanding orthopedic pathology in the broader context of which it existed. I wanted to help athletes who were injured, true- but most importantly I knew we could reduce the number of girls sustaining injuries with the right kinds of warm ups. Simple, right?

A few years before when I was pursuing my doctorate in physical therapy, I had learned about a Physical Therapist out of Southern California who had developed a series of warm-ups that were proven to reduce ACL injury. The evidence behind her work was compelling.

And so I set out on what I thought (as a young and hopeful new professional) was to be the easy task of making my education and prevention services available to the community.

What I was met with, was not curiosity and an openness to learning about injury reduction strategies- I was met with a wall of resistance- from parents, and coaches and even a couple of athletic trainers (though I has a couple of great ATCs I got to know who were in support of implementing injury reduction strategies).

One of the down points of my attempts, was when I scheduled a meeting with a Crossfit coach (the athletes of this particular program were being sent to Crossfit in their off season and winding up with career and scholarship ending injuries) to discuss sports medicine prevention warm ups and research. I thought I would establish a connection interested in learning the best practice to reduce injuries (after all, it would be a great marketing sell for their gym). Instead the “coach” spent the entire meeting doing sets of pull ups, while I sat in a chair, in my business casual slacks, asking myself where had I gone wrong. In that particular meeting, the coach didn’t ask one question about how I might help him better help his students.

What was I not seeing? Why did the community and coaches and often parents not seem to care about the alarming rates of injuries their athletes were sustaining?

In reading the recent NYT article, I initially had a feeling of so much hope- what a wonderful representation of a great community resource that Physical Therapist Holly Silvers-Granelli has brough to the soccer community.

And also- so much frustration about how hard it is to get the message of prevention out in meaningful ways, to the community. In many ways, it feels like I have been singing/ screaming into a void for the past 20 years. Why indeed, when we have had this information since the early 2000s, are young girls still suffering needlessly, more often than is avoidable, with ACL ruptures? Why have our (my?) recommendations not landed?

We as physical therapists, have so much education and training we can offer communities- including but also, beyond how we are currently engaged to restore mobility after a loss. We are the movement experts within the health care field. We could intervene on monitoring strength, biomechanics, teaching optimal warm ups to communities, providing spinal loading education and pelvic stability to expectant mothers.

There are so many ideas that I have as to why prevention might be a difficult sell.

When you are not suffering, there is very low impetus for change, right?

I also let my mind wander in some of the darker cul-de-sacs of thought- if I had had the letters MD instead of PT behind my name, would I have been better received? If I had been better marketed or supported in my profession, or by my employers, how might the situation have turned out differently?

Perhaps it is our profession as a whole that is misunderstood.

In the hospital I currently work at, many of the other disciplines don’t know that we have our clinical doctorates and several of us are board-certified specialists. Physicians often assume our role is to “get patients up” (I know this, because sometimes they will linger at the door of a bed bound, dependent patient I am going to see for an eval, and wonder if I might do just this. Erm, probably not.). Patients often ask me if I had to get a certificate to practice, and many nurses are shocked that we have more than a bachelor’s degree.

We are movement experts. We are the only medical field in western medicine with our doctorates and training to advise on rehabilitation exercises including biomechanical techniques and training across virtually all pathologies. I instructed gross anatomy with a prominent medical school and a private PT school- and the anatomy taught within PT school blew the doors off of what the MDs learn.

There are, of course, other obvious logistical reasons that impede prevention research such as funding. Prevention studies notoriously need large sample sizes, which require more funding to run.

There is not a lot of financial drive in medical research, to reduce the consumption of medical services, and there is a large financial burden to run studies that can clearly demonstrate positive prevention outcomes.

It is also difficult when you have a license, to practice in creative and unusual ways (outside of PT typical scope of practice).

I have noticed that for other licensed professionals (such as MDs or nurses) this is not so tough-one of my favorite MDs moved from being an internist into a boutique wellness practice but therapists seem to have a hard time reimagining our potential roles within our communities. When people do make a leap in a different direction, it is often into tech sales and not in a direction of transforming interactions with people.

I am an advocate for evidence based practice- but the truth of the matter is that large bodies of evidence on the topic of movement to prevent injuries just does not exist.

We may not have a study to define an exact intervention to avoid injury, but we know from biomechanics research (such as that provided by Chris Powers) that when people have improved motor learning and strength- they often can avoid both non traumatic and traumatic orthopedic injury.

We know the pathogenesis of osteoarthritis – and we can help improve joint stability and muscle control across joint segments.

We know enough to use our best judgement and all of the years of skilled training to come up with a best practice movement intervention for pathology reduction for athletes and non-athletes.

I recently was at a conference suggesting small case studies as a best practice solution when large randomized control trials (the gold standard of medical research) are not available on an intervention.

I think this is particularly important in the field of physical therapy, where, unlike pharmaceuticals or surgical implants, the potential negative outcomes of a movement intervention tend to be far less grave- and I think worth the attempt given the amount of traumatic and non-traumatic injuries we could potentially stave off.

I have an open hearted relationship with research- as soon as it comes into existence, I will read it and employ it. But I cannot let the lack of research limit intervening when I know I can help. If we as PTs silence ourselves in this way, we let trainers, Crossfit coaches, yoga instructors, pilates teachers be the voice of fitness.

Maybe because of this early experience with ACL ruptures, or because of my background in buddhist philosophy/ meditation of looking deeply and my strong desire to reduce suffering, I continue to pursue orthopedic pathology prevention on a community level.

When I tell colleagues, advisors and friends what I am up to now- they usually just smile and give me a bit of a blank look and wouldn't I like instead to move more deeply into academia?

I wonder if they feel I have sold myself short by offering community education and fitness focused on pathology prevention. Or - committed the sin of all sins in our profession- that I am providing care that is based on intuition and my years of clinical evidence- instead of clinical practice guidelines.

But when I look at orthopedic pathology I can’t help but take a 40, 000 foot view. I can't go back to seeing 8 (to 24) patients a day, all with tendinopathies and ACL/ meniscal tears.

My brain will start wondering  something such as “this is the fourth patient with osteoporosis you have seen in two days. What is the general awareness in the community about exercise and osteoporosis?”

To this day, there is a larger clamor for my rehabilitation skills following injury, than for my orthopedic pathology prevention strategies. There is a need for education strategies to reduce OA progression and osteoporosis progression. At this point, I am just putting one hand on my heart, and my head down like a buffalo and going it alone.

I continue to try to modify and adapt my teaching style to improve the efficacy of my message. And of course to use common sense, and promote the safest possible interventions among the clients with whom I work.

I am professionally alone in my passion and delivery of preventative movement education and care. I would love to connect with other like minded PTs (please email me if you feel the same way I do!). I am buoyed in reading stories of therapists like Silvers- Granelli, who use our training to provide care at the community level, and attempt to intervene before- rather than after- harm has come to our clients. Go PTs- may we use the next decade to evolve beyond what we have been, and reimagine what we can use our brilliant education and training to become in the future.

Happy moving + preventing

xxTrina

My dog, hating the Hollywood sign