Monday, November 10, 2014

Sports Medicine Expert Series

Recently I was asked to participate in a Sports Medicine Expert Series.  This series was put together by Howard Luks, MD – Chief of Sports Medicine at University Orthopedics, Professor of Orthopedic Surgery at New York Medical College and nationally recognized expert in the area of ACL reconstruction.  This series was developed to provide five professional opinions from some of the top orthopedic sport medicine physicians in the country and from some of the national leaders in the area of physical therapy and athletic training.  The physician participants included:

  • Dr. David Geier @DrDavidGeier
  • Dr. Jeff Berg @DrJeffBerg
  • Dr. Derek Ochiai @DrDerekOchiai
  • Dr. Steve Mora @myorthodoc
  • Dr. Scott Slattery @sportscaduceus

The physical therapy and athletic training participants included:

  • Julie Eibensteiner, PT, DPT, CSCS @laurusrehab
  • Trent Nessler, PT, MPT, DPT @ACL_prevention
  • Sylvia Czuppon, PT, DPT, OCS @czuppons
  • Anja Goebel, MA, ATC  @ACL_not_again
  • Darin Padua, PhD, ATC @DarinPadua
  • Jesse Dimick, PTA, ATC @Jdimick

Not that I would consider myself an expert at anything, but to be included amongst such a prestigious group is truly humbling and an honor.  Throughout this series, we were asked to respond to a series of questions.  Included in here is a reprint of each my responses to those questions.  If this is a topic of interest, I would encourage you to check out Dr. Luks full series by clicking here.

Are all Ortho surgeons created equal when it comes to ACLRs?  Do some have better results? Does volume matter?

Throughout my 17 year career as a physical therapist, I have been blessed with the opportunity to practice throughout the country.  That said, I am not a surgeon nor do I profess to know what it takes to be good surgeon versus a superior surgeon.  However, I have been honored to work with a wide variety of surgeons with varying levels of experience, a variety of approaches and varying techniques.  All of them have their merits and are skilled practitioners.  But, as a physical therapist, when it comes to rehabilitating the ACLR patient, we do see a variety of outcomes among physicians.  Just like there are physical therapists that have better outcomes, there are also surgeons who have better outcomes especially when it comes to ACLR patients.  Based solely on my experience, what I tend to see four common factors among surgeons who have better outcomes. 
1.      Empathy – this tends to present itself in several different ways but most importantly that they listen to the patient.  This is critical for the optimal outcome and the patient experience.  Those who possess will tend to want to educate the patient and the family on what is expected and the process.  As one surgeon commonly says “If this were my daughter, this is what I would do”.  In essence they treat you like family or your child as if they would their own.  This results in them not only educating to elevate fears but also in setting realistic expectations in a way that is comforting and not devastating.  They are also approachable when patients have to ask the hard questions or post-surgical problems arise.  They do not become defensive or evasive.  I also tend to believe that it is this empathy that also drives them to want to be the best at what they do for their patients and hence constantly drive to hone their skill.  Most importantly or just as importantly, this adds to a positive patient experience.  The psychological impact of the patient’s experience plays a key role in the patient’s motivation with recommendations, perception of progress, confidence in the surgeon and ultimately drives the final outcome achieved.  How do I know if my surgeon has empathy?  What does your gut tell you after your visit?  Do you feel good about the experience, did you like your physician and did you feel like he listened to you? How is their bed side manner?  Do you feel well informed?  What kind of reviews have they gotten online and by your insurance company?  If you know someone that has used them, what is their frank feedback?     
2.      Volume – to quote Einstein “Only one who devotes himself to a cause with his whole strength and soul can be a true master. For this reason mastery demands all of a person.”  To master a skill requires a constant pursuit of excellence and practice.  I don’t want to pretend to understand what it takes to be a master surgeon, but what I do know is that to master any skill requires practice, practice, practice.  To master the art and complexity of Brazilian Jiu-Jitsu, for example, takes 10-15 years and hours and hours of practice in a day.  When applying that analogy to orthopedic surgery and especially ACLR and when considering the complexity of the human body, the complexity of the surgery and biomechanics, to master this skill requires a lot of practice.  The master always has some innate level of skill that only some have but a master never becomes the master or gains their full potential unless they practice.  Unfortunately in this business, this means lots of volume or lots of ACLR surgeries.  How do I know if my surgeon has that experience?  Look at their resume or CV online.  What does their clinical bio say?  Do they list ACLR as one of their specialties?  Ask them how many ACLR they do a week, a month or a year?  Do they have any specialty training (sports medicine fellowship)?
3.      Evidence based practice – most surgeons will be well versed in the research but few are leaders and innovators in the research.  Sadly, so much of what is published today in the literature will take 5-10 years before it becomes as standard of practice.  To be the standard of practice means that it is adopted by the majority of those practicing and hence what is the norm.  Do we want the norm in our outcomes or superior?  Innovators in the field tend not to be just well versed in the research but follow it closely, dissect it for clinical applications to their clinical setting and become the earliest adaptors of the most clinically sound research techniques and protocols.  Many times they are also the innovators in education on the topic (papers, articles, blogs, conferences), in the research (doing research and publishing papers related to the topic) or driving the education in their field (through teaching conferences for their colleagues or educating future surgeons in medical school or fellowships).  How do I know if my surgeon practices evidence based practice?  Look at your surgeons CV or bio.  Do they list any papers they presented or research they have done on the subject?  Do they list any specialty conferences, books or scientific committees they presented at related to ACLR?  Have they be sought out as an expert in this particular area?  Ask them what the current research says in this area and how they approach.
4.      Great surgeons believe in great physical therapy – I am not saying this just because I am a physical therapist but because great surgeons also know that great physical therapy is a critical component to achieving the optimal outcome.  Great surgeons know the right therapists in their area to aid them in achieving optimal outcomes.
Keeping in mind I am not a physician but when I am looking for a surgeon, this is some of the things I recommend when looking for the right surgeon for my ACL deficient patient. 

Role of PT/AT PRIOR to surgery

There has been some debate on the whether or not there is a role for the PT/AT prior to surgery.  Although the studies may not be completely clear, there several “key roles” to for the PT/AT prior to surgery that do have a significant impact on the patient and outcome.  These can be categorized in three areas

1.      Maximizing pre-op range of motion, inflammation control and strength.  Those who have better range of motion, less swelling and improved quad control pre-operatively tend to regain it quicker post operatively. 
2.      Patient education. This not only helps to help expedite their recovery but can also help to elevate a lot of anxiety.  This is a critical part and can include lots of things including:
a.      Education on the process – educate the patient and care giver on what to expect after surgery.  Educating on proper positioning in bed, use of CPM (if being prescribed) & post-operative instructions (icing, range of motion, quad sets) that can be performed the day after surgery prior to seeing the PT for the 1st post op session.
b.      Education on use of assistive device – if they are going to be using crutches, setting them up with proper fitting crutches and how to ambulate with PWB (partial weight bearing) or WBAT (weight bearing as tolerated) and how to navigate stairs or curbs safely.
c.      Educate on what to expect in their first PT visit when they come in.
3.      Reassure the patient.  It is vital for the PT/ATC to instill confidence in the patient in whoever is performing the surgery.  Encouraging them and reassuring them will not eliminate fear and anxiety but it will decrease it.  

All that said, there is the unspoken psychological aspect and positive influence this also has on the patient.  If there is one thing that is often undervalued in ACLR, it is the impact that psychology has on the patient and outcome.  Considering, there is a positive psychological impact to the visit.  The PT/ATC should never undervalue the impact they will have on this pre or post-surgery.

We hope that you found this blog insightful and useful.  Stay tuned next week as we conclude this Sports Medicine Expert Series.  As we stated previously, stay tuned and if you like what you see, SHARE THE PASSION!  It is the biggest compliment you can give.  Follow us on Twitter @ACL_prevention and tweet about it.  #DMAOnTheMove and help us spread the passion and #movementonmovement #PT #ATC #ACLChat.
Build Athletes to Perform…Build Athletes to Last!™
Trent Nessler, PT, MPT, DPT:  CEO/Founder ACL, LLC | Author | Innovator in Movement Science and Technology.  Dr. Nessler is a physical therapist and CEO/Founder of ACL, LLC.  He is the researcher and developer the Dynamic Movement Assessment™, Fatigue Dynamic Movement Assessment™, 3D-DMA™, author of the textbook Dynamic Movement Assessment: Enhance Performance and Prevent Injury, and associate editor for International Journal of Athletic Therapy & Training. For more information, please see our website at

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