“Unfortunately in our field, there often is acceptance and use before there is data,”
When I came through my training, I never saw patients over 40 who required a ligament reconstruction of their knee. I rarely encountered a 70 something lifting as much weight as me in the gym… and 90 year old ex-presidents were not jumping out of airplanes.
People are more active than ever. Marathoners, Ultra-marathoners, tri-athletes, and plain old folks who are spending countless hours in the gym or exercising at a far greater pace than ever before. Unfortunately, the tissues of a 50 yr old, are 50 years old. The tissues of an 80 yr old tri-athlete are 80 years old. As we age, our ability to withstand repetitive stress diminishes. With these changes in our tissues… injuries are bound to occur. The older the participant, the more intense the exercise — the more frequent, and potentially more debilitating the injuries. Not only are people trying to remain active longer, and not only are they pushing harder… but they do not want to stop. They do not want to alter their exercise pattern to accommodate their tissue tolerance.
I understand that. This is much more than a desire to exercise. Many patients’ emotional and psychological well being is directly tied to their ability to exercise.
Don’t try to tell a 75 yr old marathoner that their days of running long races at a reasonable pace are over. They simply will not hear you… they will leave your office — they will ping Dr. Google and they will end up chasing a potential remedy and pay whatever it takes to maintain their active lifestyle, regardless of the lack of strong evidence that the treatment they chose works.
- but at what cost?
- With expectations of what result?
- And what proof do they have that it will work.
Most will not care. They will do whatever it takes in their quest to get back on the road.
Some may be reasonable and will listen to me as I explain that the status of their joint, their desired activity and the available treatment modalities do not fit. Many will roll their eyes and leave… fairly unhappy that a simple cure is not available. Many will seek out an unproven treatment and not objectively look at the data available. The patient does not bear all the fault in these instances. The sports medicine community has promoted many procedures or injections without concrete proof that the techniques work. Take PRP for example. There are nearly 20 systems available to prepare the PRP… and each will give the physician a sample that is slightly different than the other systems will. How can we assess the efficacy of such treatments if we’re not comparing apples to apples? There is some literature to support the use of PRP… but not nearly enough proof to use it as often as it is being used.
This article from the NY Times is worth reading and touches on much of the issues I just outlined.
I love the field of Sports Medicine and Orthopedic Surgery. I truly enjoy helping many people return to an active lifestyle to support their physical, emotional and psychological well being. I do not enjoy telling someone that there is nothing that we can do to enable them to return to the activity they desire. I will offer comfort, support, knowledge and empathy towards to their plight.
But I clearly understand that they will be hitting Google within an hour to find someone who will offer them exactly what they’re looking for… a miracle.
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Nick Dawson says
Howard, nice thoughtful post.
This is a good example of thinking empathically about your patients.
I often think in terms of “frames” – the different perspectives we have depending on our role and circumstances. You do a nice job of framing the data-driven perspective.
From a patient’s frame, is there a chance to meet in the middle? As you point out, if someone has been active into their 70s, its pretty understandable that they’d like to remain active. How could providers offer a data-proven path to helping them return to some level of activity, before they seek something potentially unproven and dangerous?
Howard J. Luks, MD says
Thanks Nick… There’s absolutely a chance to meet in the middle. Once I have a clear understanding of the patients goals… and the patient has a clear understanding of their disease we can move forward to formulate a plan that seeks to achieve a satisfactory balance.
Thanks a lot . Its really healpful :) .
Renda Wirtjes says
A very interesting post.
i met an over-40 guy yesterday, sitting on the sidelines in a boot. cause? he said, “i was just doing too much. i hurt something in my ankle and didn’t know it.” some good has come of this. he’s doing new exercises, more upper body strengthening exercises now. and when he gets back on his feet, his overall routine will be more well-rounded. so i guess there’s a silver lining here. seems so easy to fall into the habit of only one kind of exercise.
Howard J. Luks, MD says
Thanks for stopping by and sharing Liz
Dr Pullen says
Undoubtedly aging Americans have expectations for their physical capacity that would have been considered exceptional a couple of decades ago. Still often older bodies just break when put in activities they are not trained or capable of successfully accomplishing. I’m almost 60, exercise regularly, and enjoy active recreation but I know better than to pretend I’m still a teen. We need to recognize the realities of growing older.