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• W2120729279 abstract "The practice of sports medicine in 2011 is fascinating. The advancement of disciplines like tissue engineering has expanded our armamentarium tremendously. Along with the typical orthopaedic toolbox of metal plates, rods, methylmethacrylate, and polyethylene comes synthetic membranes, biologic scaffolds, platelet-rich plasma (PRP), and stem cell treatments. To some extent, we can already biologically replace several musculoskeletal structures; these fascinating developments were just wishful thinking a couple of years ago.As the areas of articular cartilage, ligament, bone, and muscle research progress, interesting and challenging clinical and ethical questions have arisen: when are these technologies appropriate for clinical trials and eventual human treatment protocols? Are clinical experiments justified? Are they ethical? How much laboratory or clinical outcome data do clinicians need to implement new approaches to chronic unanswered problems? Who decides if animal data or limited clinical trials are sufficient?These questions and many more confront the clinician when a desperate patient presents with a difficult clinical problem. At times, the issue is the timing: an elite athlete before a championship event without enough time for mainstream treatment protocols. Other times, it’s the severity or chronicity of the injury: a past high-level performer facing the possibility of the end of a career. Or it’s not even an athlete at all, just an “ordinary Joe,” medically uninformed, trying to avoid surgery or salvage an acceptable level of function. These issues must be carefully considered to protect the patient and the integrity of the health care system.These dilemmas force clinicians to decide on their type of practice and reputation. Are they knowledgeable clinicians who are up-to-date on the science and applicability of emerging technologies and therapies? Will they rely on solid research to make evidence-based decisions and recommendations for their patients? Or, are they willing to use unproven, untested forms of treatment to claim being “on the cutting edge” or for financial gain? In the United States today, sports medicine practitioners are granted a lot of leeway in their practice: some of this clinical freedom is understandable and justified. After all, medicine is an art—hopefully, one that is well based on scientific principles and clinical experience. This is where the door is open to treatments like PRP and stem cells. The clinical potential is apparent; these new treatments make sense. Applying the growth factors concentrated in PRP and pluripotential cells to musculoskeletal injuries appears to be a natural solution to perplexing problems. The question is, how far do we have to go past concept through research to recommend new therapies to patients and who should make those decisions? For example, is it ethical to allow a desperate, medically unsophisticated patient to choose treatments that lack medical evidence of benefit?These issues and questions came to me recently as I reflected on the treatment of a good friend and patient, John. John is well into his eighth decade of life, although you would never guess that by watching him work or by discussing business with him. He immigrated to the United States as a teenager and fell in love with America and all the wonderful opportunities it had to offer. With part of a high school education, a shrewd business mind, and plenty of hard work, he made his fortune. John is very active; he works many long hours on his feet and looks forward to dancing, golfing, and cycling. How he survived the past 20 years on his bilateral varus, degenerative, bone-on-bone knees isn’t quite clear. Over the years, I have encouraged him to decrease his weight and exercise regularly, and I occasionally help him through a few tough days with cortisone, fully anticipating his likely need for knee replacements at some point in time. Even though he never complains, John is always keeping his ears open to new treatments. To John’s credit, despite his lack of a formal education, he is quite worldly and spends a lot of time online. I have cautioned John in the past about the marketing of treatments on the Internet. Recently, a friend directed him to a website for a clinic in Florida that offered a “miracle cure” for arthritic knees. Partly because money is of no object to John, he flew to Florida for an evaluation and treatment. At a cost of $5000 per knee, he underwent bilateral injections of PRP and stem cells, fully expecting to regrow new articular cartilage surfaces and be “cured” of his arthritis. Unfortunately, John was vulnerable to promises of this miraculous approach, and he did not seek second opinions before his treatment. He says he felt better instantly after the treatment, causing me to wonder how long the $10 000 placebo effect would last. In my opinion, this is “boutique medicine” at best and fraud at worst. Even in the most imaginative medical mind, it is difficult to justify this approach.While John’s case is an extreme example, it emphasizes the critical role that clinicians play in the lives of patients and how vulnerability and desperation enter a patient’s decision-making process. This is where evidence-based medicine plays a critical role. The vast majority of our patients do not have the medical knowledge to decipher the treatment options. Our patients rely on us to guide them through these decisions. We must be able to truthfully discuss the “state of the art” treatments and the evidence for them. Without this scrutiny and honesty, whether someone is looking over our shoulder or not, the system breaks down.Looking ahead to the future, I believe that more and more treatment options will be scrutinized by third-party payers and, probably, the government. “Boutique” style medicine will be pressured. Evidence-based medicine will be forced on us by limited resources and bureaucrats. There is no way to avoid these changes. Health care costs will not be allowed to continue to spiral out of control regardless of the system: Medicare, Medicaid, or any other insurance plan. In actuality, many problems in medicine may be improved by the mandated guidelines and protocols. There will be less freedom for patients and physicians to choose treatments, but hopefully, some of the poor options will be eliminated. Many negative outcomes are possible when the bureaucrats decide clinical issues, but some problems may improve if we continue to migrate toward evidence-based medicine.Unfortunately, cases like John’s will probably persist; those with financial means and entitlements and those “exempt” from the forthcoming regulations by political processes will probably still have those options.As for John, I hope he does well. Anybody who has worked as hard and as long as he has deserves that. In spite of his experience with unfulfilled expectations, he made me promise that I’d look hard at these “miracle cures” and not be held back by “old thinking.” I promised him that I would keep looking." @default.
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• W2120729279 date "2011-10-27" @default.
• W2120729279 modified "2023-09-26" @default.
• W2120729279 title "Sports Science vs “Boutique Medicine”" @default.
• W2120729279 doi "https://doi.org/10.1177/1941738111425781" @default.
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