Health Sciences Report Winter 2003

Orthopedics on the Move
By Susan Sample

Photos by Sean Graff

The U of U is the only institution in the Intermountain West offering orthopedic care in all eight subspecialty areas—and a new center to open in 2004.

Orthopedics and opportunity are synonymous to Harold K. Dunn, M.D. From the beginning of his career as a surgeon during the Vietnam War to his role as chair of one of the country’s top 20 departments, Dunn has foreseen the possibilities of orthopedics—and helped make them realities.

The new $34 million University of Utah Orthopedic Center is scheduled to open in October 2004. The 105,000-square-foot building, adjacent to the health sciences center in Research Park, will be a “one-stop-shop” for patients, featuring: 40 clinical exam rooms; outpatient surgical suites and patient observation areas; physical and occupational therapy exercise and treatment facilities; a therapy pool and rehabilitation programs; diagnostic radiology, MRI and bone-scanning capabilities; a pharmacy; and accessible parking.

One of the four floors will be devoted to education, including classrooms and a library for the department’s 20 orthopedic residents and 10 fellows. Another level will house the Orthopedic Bioengineering Research Laboratory, where investigators, working closely with clinicians, will continue studies to develop and improve treatments for patients.

“The fact that we are breaking ground today is a tribute to Dr. Dunn’s remarkable leadership abilities and his focused vision for the department,” noted U President Bernie Machen last June. “I know this has been a dream for him for many years.”

Orthopedics focuses on the muscles, bones, joints, ligaments, and cartilage that make up the musculoskeletal system. Once viewed primarily as a surgical specialty, orthopedics includes a range of treatments to restore and improve mobility, many of which don’t involve surgery. Two of the U orthopedic faculty are internists with specialized training to care specifically for nonsurgical problems.

The U is the only institution in the Intermountain West offering orthopedic care in all eight subspecialty areas: adult reconstruction, foot and ankle, hand and microsurgery, pediatric orthopedics, sarcoma service, spinal disorders, sports medicine, and trauma. It’s ranked in the top 20 programs nationwide by U.S. News & World Report.

Dunn initially didn’t choose to specialize in orthopedics. As a general surgeon in the U.S. Army Medical Corps, he was sent to Japan during the Vietnam War. “We were overloaded with orthopedic patients,” he recalled. “I started doing orthopedic surgery, loved it, and stayed with it.” After a residency in his home state of New Mexico, Dunn completed a two-year orthopedic residency at Baylor University College of Medicine in Texas, where he’d earned his medical degree.

“I wanted to go into academic orthopedics,” he said. “I planned to come to Utah and spend a year or two studying with Dr. Coleman [Sherman S. Coleman, M.D., first head of orthopedics], who had a reputation as an exceptional teacher and surgeon, but I never went back.”

Dunn joined the U in 1969 as an instructor—and the second faculty member—in the Division of Orthopedic Surgery, housed in the medical school’s surgery department. By the time Coleman stepped down in 1981, the division had five faculty members. Dunn, then associate professor, was named division chair.

“My vision was that we would have subspecialists representing the breadth of orthopedics, and they would be nationally recognized,” said Dunn. “That’s what I knew would be needed to deliver the level of patient care appropriate for a university.”

With 18 faculty members, the division was granted department status in 1995, and Dunn was appointed chair. The previous fall, he’d been named to the Louis S. Peery, M.D., Presidential Endowed Chair in Orthopedic Surgery.

In 1996, the department’s clinical visits topped 19,000, and the faculty performed 2,600 surgeries. An increasing patient population, coupled with the development and refinement of surgical procedures, continued to bear out Dunn’s prediction that the department needed to grow. Last year, 30 faculty members representing all the subspecialties saw nearly 27,000 patients in clinic and performed 4,400 surgeries.

Research efforts also have expanded. “Traditionally, orthopedics has been more mechanical. It’s been involved with fixing broken bones and replacing diseased bones,” explained Dunn, whose own research has focused on spine deformities and total joint reconstruction.

“But there’s a lot more opportunity now. We can genetically engineer cells to replace diseased cells and give new surfaces to joints or to replace ligaments. We can repair in a more natural manner. Of course, we’ll still always have to have biomechanics—something to support the body while it heals—but we’re always looking to new possibilities.”

Adult Reconstruction

Knee replacements are joining gray hair and bifocals as signs of middle age. Since 1988, the average age of an adult needing a joint replacement has dropped from 75 to the 40s and 50s.

“We’re seeing a 10-11 percent growth each year in joint replacements,” said Aaron A. Hofmann, M.D., professor of orthopedic surgery specializing in adult reconstruction, including total hip and knee replacement surgery, as well as partial joint replacement. “People are living longer, and they’re more active. Ninety percent of the patients we see have degenerative arthritis or osteoarthritis. Basically it’s wear-and-tear of the joints.”

Minimally invasive surgery (MIS) is helping decrease patients’ pain, as well as the length of their hospital stay, following joint replacements. “The surgical instruments are now smaller, so we can operate through smaller incisions,” said Hofmann, holder of the Louis S. Peery, M.D., and Janet P. Peery Presidential Endowed Chair in Orthopedics. “This eventually will take us to shorter stays. In the new Orthopedic Center, our goal is a 23-hour stay for hip and knee replacements. Typically, it’s been three to five days. We’re working closely with anesthesiologists to develop new protocols.”

Another new development in adult reconstruction is computer-assisted surgery (CAS). A computer monitor enables orthopedic surgeons to visualize patients’ leg bones, for example, so a knee replacement can be installed with greater precision. Hofmann developed software for advanced computer-assisted knee replacement surgery that is being tested in a national multi-center clinical study. The FDA-approved procedure is expected to be available nationwide by the end of the year.

“If an implant is placed more accurately, it will be more stable and less likely to wear out,” explained Hofmann. About 98 percent of the 200,000 knee replacements implanted in Americans every year still function well in 10 years. Hofmann hopes CAS will help boost that rate to 20 years.

Improving the materials used to create the surfaces of replacement joints also will lengthen the life of implants. Three materials are being used for the joint’s moving parts: plastics, metal, and ceramics. “All have advantages and disadvantages,” noted Hofmann. “The choice of material depends upon several factors, for instance, patient stature. Metal parts are available in smaller sizes.”

In the Orthopedic Bioengineering Research Laboratory, researchers test implants made of the various materials. “But they may not completely simulate real-life activities,” said the surgeon. He encourages patients to resume low-impact, non-jarring activities such as swimming, biking, hiking, and golfing. Hip or knee replacement surgeries have become so successful, however, that some patients push the limits, running and jumping. “Sometimes,” he joked, “we wish we could put a little pain back in to slow them down!”

Foot and Ankle

The admonition for muscles—Use it or lose it—reverses when the focus shifts to feet: Lose one, then you’ll realize just how much you used it.

“I hear that sentiment all the time. Our feet are our base,” said Timothy C. Beals, M.D. (pictured above), associate professor of orthopedics. As the department’s sole foot and ankle specialist, he also coordinates the amputee service. “That gives you respect to preserve them,” he added.

One of orthopedics’ newest specialities—“it’s exploded in popularity the last five years”—foot and ankle actually has a long history at Utah. Sherman S. Coleman, M.D., first chair of orthopedics at the U, defined the principles underlying surgical treatment for patients with certain neuromuscular abnormalities, according to Beals.

Beals chose the specialty for its variety. In a month, he may see 10 patients, mostly women, with posterior tibial tendon insufficiency, or “fallen arches.” The condition, whose cause is unknown, can be painful and debilitating. Treatment ranges from orthotics to surgery in which Beals cuts bones and transfers tendons to help restore strength and stability in the feet.

Broken heel bones, often the result of industrial accidents or car crashes, are common trauma fractures Beals treats. They’re also the most expensive in terms of workers’ compensation. “It’s due to the series of joints around the heel. It works like a screw,” he explained. If the bone doesn’t heal well, patients can lose their livelihood and, later, are at high risk of developing arthritis.

People suffering osteoarthritis and rheumatoid arthritis frequently need foot surgery, as do those with neuromuscular abnormalities, such as those caused by Charcot-Marie-Tooth disease. In these patients, the muscles eventually weaken and nerves stop functioning, resulting in bony abnormalities and misshapen feet. Surgeons can transfer tendons to rebalance the foot, but the disease is progressive. The challenge is to project the rate at which muscles will be affected in order to determine the best location for transfer. Beals is working with Nicholas Brown, Ph.D., research assistant professor in the Orthopedic Bioengineering Research Laboratory, to develop computer-modeling techniques that will determine the best surgical location.

Another area of research that Beals wants to investigate is preventive surgery for diabetic patients. When they develop an ulcer on their foot, it can become infected and, later, may require amputation. “I’d like to do surgery to prevent the spots where they’ll develop ulcers. It would be a paradigm shift—surgery as prevention,” he noted.

As a subspecialty, foot and ankle offers not only variety but genetic variability, especially among ethnic groups. “If you look at X-rays, femurs are similar. Hands are similar. But feet are very different,” said Beals. “They’re still evolving.”

Spinal Disorders

Back pain is the number-two reason—second only to colds—people visit medical practitioners. At least 85 percent of Americans will experience an aching back at some point in their lives. Fortunately most won’t require surgery.

“Back pain can be caused by many things, ranging from arthritis to disk herniation to muscle injury,” explained Darrel S. Brodke, M.D. (pictured at left), associate professor of orthopedic surgery and director of the U Spine Center. “Muscle injury is most common, resulting from improper body mechanics. Treatment often starts with physical therapy and/or medication. Steroid injections may help ease the pain. Surgery may be required. But we have a discerning eye not to operate too soon. Many, if not most, of our patients don’t need surgical intervention.”

The three spine subspecialists in the Department of Orthopedics not only treat patients with injuries, but also receive referrals from throughout the Intermountain West regarding patients with complex spine conditions, including degeneration, deformities, tumors, infections, and trauma.

The U is one of 18 sites in the United States selected to test a new artificial disk beginning this past fall. In a randomized clinical trial that will run through winter 2005, patients will receive either the new chrome cobalt disk or the traditional single-level fusion used to replace disks that have deteriorated usually from arthritis. In fusion surgery, a screw-and-rod construct is used to stabilize the grafted bone surrounding the deteriorated disk. This prevents motion while the vertebrae heals and fuses. Disk replacement may avoid one of the problems of spinal fusion: adjacent-level arthritis, according to Brodke.

Artificial disks—“the forefront of spinal technology”—have taken longer to develop than hip and knee replacements due to the complexity of the spine: the spinal cord and nerves that thread through it, the multiple segments, and the load that the spine bears.

At the new Orthopedic Center and at University Hospital, surgeons will perform disk fusions and replacements, remove herniations, and perform cervical spine operations.

Hand and Microsurgery

The most developed orthopedic subspecialty—it has its own board certification—is arguably the most oversimplified, if judged only by the name “hand.”

“I consider us primary care physicians for the upper extremities,” said Douglas T. Hutchinson, M.D. (pictured at left), one of three U orthopedic surgeons specializing in hand surgery. “We take care of the entire arm below the shoulder: nerves, arteries, tendons, ligaments, skin, tumors, and bones.”

Hutchinson finds hand surgery fascinating not only for its variety, but also for the critical role of the arm and hand. “There’s so much delicate anatomy in the arm, because it’s such an important organ in our lives for working and expressing ourselves,” said the associate professor. “The development of the hand has secondarily caused development of the brain. Move your hand, and your brain works.”

For infants with congenital birth defects that result in a missing thumb, U hand surgeons “will create a thumb before the child is one year old, so the brain will develop as it should. That’s critical,” noted Hutchinson, president-elect of the University Hospital Medical Board. “The thumb is worth 40 percent of the hand.”

Because of the hand’s complex neurological aspects, the brain can magnify pain in the hand, causing depression in some patients. Often that’s compounded by cosmetic concerns, especially in patients with congenital deformities such as duplicate digits and thumbs, and syndactyly in which fingers are webbed together. These young patients are seen regularly by U orthopedic surgeons in pediatric hand clinics at both Primary Children’s Medical Center and Shriners Hospital for Children.

Pediatric congenital surgery is considered one of the subspecialty’s “ultra-specialized aspects.” Others include brachial plexus surgery, which focuses on nerves in the arm and neck area, and microsurgery. U specialists can reconstruct and transfer tendons, and move bone from one part of the body to another, such as implanting bone from the fibula to the hip to help prevent arthritis of the hip, explained Hutchinson. “Essentially it’s microsurgery of the blood vessels to keep the bone alive.”

At the new U Orthopedic Center, the hand surgeons will continue to treat patients with chronic problems, as well as trauma, from throughout the Intermountain West. They also have an annual goal to travel outside the United States to train surgeons and perform needed surgeries. Last year, they worked with a Nepalese surgeon who has become the first hand surgeon in his country of 24 million people.

“Extensive instrumentation is not required for doing hand surgery in developed countries. Most of our procedures use tissues of the body, rather than mechanical or industry-developed devices,” noted Hutchinson, who, along with his colleagues and fellows, has volunteered in Bolivia, Brazil, and Chile. “It’s education.”

Pediatric Orthopedics

When Peter M. Stevens, M.D., says, “pediatric orthopedics is like 3-D tic tac toe,” he’s not referring to a game in the clinic playroom.

“You have to think longitudinally and plan for subsequent problems: what you do now to treat a child may have an impact later,” explained the U of U professor. “With adult fractures, a common problem is that they won’t heal due to factors such as poor blood supply, noncompliance, diabetes, even smoking. Children often heal very quickly, but there may be deformities that have to be corrected later after they’ve grown.”

Stevens and four other U of U orthopedic surgeons see patients at five pediatric subspecialty clinics—general pediatric, fracture, oncology, hand, and spine—every week at Primary Children’s Medical Center. Four additional pediatric orthopedists treat patients at Shriners Hospital for Children in Salt Lake City.

“Children have different needs,” said Stevens, looking beyond the clinic’s toys and diaper-changing stations. “Many of our patients have disabilities and complex medical problems. It’s easier for their parents to go to one place to see consultants and therapists.”

At the subspecialty clinics, the orthopedists treat both congenital problems and trauma. Children may suffer growth-related problems due to conditions such as scoliosis, or require neuro-musculoskeletal treatment as a result of premature birth. The proportion of trauma cases continues to rise. “Valley demographics,” surmised Stevens. “Rapid growth and large families—and they all seem to have trampolines.” The Intermountain West’s outdoor lifestyle, especially the increased use of ATVs, is another factor, he said.

While surgery may be the best treatment for many patients, Stevens noted that “education is a large part of what we do. We’ll see patients two to three times a year during their active phases of growth—from about age 10 through their mid-teens—to screen for recurrent problems and detect new ones.”

While adults are degenerative, children are regenerative: new problems may not appear for many years following treatment, a situation Stevens likens to an “extended warranty” for pediatric orthopedics. Because of lingering concerns, more medical students are choosing other orthopedic specialties.

For Stevens, however, the opportunity to treat children—and their siblings, when the problem is genetic—over many years is gratifying. “There’s a lot of surprise in pediatric orthopedics. That’s part of the challenge—and the fun.”

Trauma

When the AirMed helicopter arrived at University of Utah Hospital with a 15-year-old girl thrown from a car, Thomas F. Higgins, M.D., was in the Emergency Department. Five years ago, he might not have been.

“There’s a more holistic approach to treating trauma patients now,” said the assistant professor of orthopedics and trauma specialist. “Musculoskeletal care and rehabilitation are considered an integral part of a patient’s overall recovery. When Trauma 1 patients arrive, an orthopedic representative is there, along with the ER physician, general surgeon, and neurosurgeon. We used to be called after the initial triage.”

Advanced surgical techniques helped contribute to trauma becoming a subspecialty. For instance, Higgins used a newer technique to treat the 15-year-old girl who shattered her hip. With fluoroscopy, he was able to make a 1 cm incision and insert 135 mm screws into her pelvis. The X-ray machine isn’t new, but only recently have orthopedic trauma surgeons used it to remotely manipulate fractures and injuries before making significantly smaller incisions.

New methods of fixation, such as less invasive plating systems, also have resulted in improved surgical techniques. Expectations surrounding outcomes have been raised as well, said Higgins.

Although orthopedic trauma surgeons treat fractures and injuries of the pelvis and joints throughout the entire body, their patient population isn’t as widespread. “Trauma is not a random disease. It preferentially strikes young people,” noted Higgins. “It’s the leading cause of death from birth to age 40. Those are the people who are on the job site, driving motor vehicles, and involved in sports like skiing, rock climbing, and motocross.”

The two trauma specialists in the U Department of Orthopedics often are involved in their patients’ care beyond the initial surgery. The physicians may treat badly injured patients for 12 months or longer, especially if reconstructive surgeries are necessary. Since her accident in summer 2002, the car accident patient has undergone orthopedic surgery to graft her femoral nerve. In the future, she may need further hip reconstructive surgery.

“Trauma patients are frequently young people who have their entire lives in front of them. There are few areas of orthopedics where you have such a significant chance to make a huge difference in a young person’s life,” said Higgins. “They arrive in terrible condition, but have massive potential for recovery and long-term function.”

Just last spring, he received an invitation to the high school graduation of a patient he initially treated three years ago. “She was in a car wreck and had life-threatening injuries to her head and pelvis. Later she made the high school volleyball team, and now, she’s headed off to college. That’s neat.”

Sarcoma Service

Understanding the biology of diseases that affect the musculoskeletal system, especially cancers of connective tissues, is the goal of R. Lor Randall, M.D., assistant professor of orthopedic surgery and director of Sarcoma Services.

“Our forte in orthopedics has been biomechanics, but we’re reaching limits in what we can do with plastic and metal,” said Randall, who also is chief of the Sarcoma Array Research Consortium (SARC), a molecular lab located in the University’s Huntsman Cancer Institute. “We need to understand problems at the biomolecular level.”

At SARC, Randall is investigating molecular gene profiling to better categorize and treat sarcomas, using samples of soft tissue tumors sent from across the country. Recently he received funding to study “antisense” genetic interventions, which are anti-sequences of DNA that bind to a sequence of gene messengers, thereby inhibiting expression of certain genes involved in sarcoma formation.

There are 90-100 different cancers that occur in bones and soft tissues, which, although rare, have a high mortality rate. They account for some 15 percent of childhood cancers and 1 percent in adults. Randall is able to surgically treat some of these cancers; he might perform a tumor resection and reconstruction to cure certain types of tumors. Other times, surgery is only palliative. “If a tumor has spread to or from another part of the body, and the bone is so eaten away, I may replace the bone or strengthen it with an implant.”

Among his clinical research projects, Randall is investigating kyphoplasty for patients with metastatic bone disease of the spine. If the tumor has destroyed the spine, he can restore the height of the vertebrae with a bone-strengthening device. Not only does the procedure restore strength to the spine, but the bone cement may actually kill the tumor.

He also is testing radio-frequency ablation, a minimally invasive technique in which a special probe is inserted into the tumor and sends heat waves that destroy cancerous tissue. Randall was the first orthopedic tumor specialist in the Intermountain West to use these techniques.

For every patient with a malignant connective tissue tumor, Randall estimates that there are 200 noncancerous counterparts. Often the benign tumors can be very challenging as these growths can be debilitating. Fibrous dysplasia, a developmental abnormality in children and young adults caused by a cellular defect, affects multiple bones and can lead to crippling deformities. Neurofibromatosis type 1, a common dominantly inherited condition, can cause benign tumors, or neurofibromas, throughout the nervous system, gradually invading muscles and joints.

“Being able to relate to my patients puts my life in perspective,” noted Randall. “Being able to help them is an honor and a privilege.”

Orthopedic Research

Few of us need a computer to show that shoveling snow involves lifting and twisting. But the spine simulator, designed and built by a team at the Orthopedic Bioengineering Research Laboratory, measures not only the biomechanics but also the kinematics, or three-dimensional motion, of different activities.

“With the spine simulator, we can take a cadaver spine [see photo above] and move it through a range of motion that mimics that of the human spine and simultaneously tests different kinds of treatments in lateral bending, flexion and extension, axial rotation, and axial compression,” explained Kent N. Bachus, Ph.D., research associate professor of orthopedics. “This results in huge improvements for patients in the clinic.”

The department’s research is carried out at four sites. Bachus directs the Orthopedic Bioengineering Research Laboratory, located in the U Biomedical Polymers Research Building. Roy D. Bloebaum, Ph.D., research professor of orthopedics, directs the Bone and Joint Research Laboratory. Located nearby at the Salt Lake Veterans Affairs Medical Center, the lab’s focus is microscopic: researchers study the mineral content of bone, for example, and how bone grows into porous implants. The Movement Analysis Laboratory, directed by Bruce A. MacWilliams, Ph.D., research assistant professor, is located at Shriners Hospital for Children. David E. Joyner, Ph.D., supervises the Sarcoma Array Research Consortium (SARC) lab at Huntsman Cancer Institute (see pg. 21).

At the bioengineering lab, the focus is biomechanics. Orthopedic devices recently developed by U of U faculty members, as well as private companies, are tested. Existing devices that have been modified by U researchers and faculty also are evaluated.

Most of the equipment used for testing has been designed and built by the U researchers, assisted by 10 graduate students in bioengineering and 10 medical students and residents. As Bachus noted, “If it doesn’t exist, we want to develop it.”

Next to the spine simulator is a knee simulator built by the U design team. Used to test devices for sports medicine and adult reconstruction, it mimics motion of the knee on all planes. A hip simulator calculates loads that can be withstood by cadaver hips or femurs implanted with different fixation devices, such as screws or plates, which is valuable information for an orthopedic surgeon specializing in trauma.

The development process can take from months to years. Two U orthopedic surgeons—Christopher L. Peters, M.D., and Daniel S. Horwitz, M.D.—wanted to improve the design of fixation devices for multi-part fractures to the tibia. Their options—a metal plate screwed to one side of the bone or a two-sided plate attached to both sides of the bone—each had disadvantages. They met with the bioengineering researchers at the lab and worked on a design compromise. The researchers tested a prototype on the simulators; the surgeons implanted the modified plate in patients’ legs. Five years later, they’re working together to follow up on how well the bones healed.

In the future, Bachus anticipates that increased collaboration between the bioengineering research lab and the department’s new molecular lab will lead to exciting possibilities. “As cellular and microscopic research in orthopedics develops, we’ll see more collaboration and a greater understanding,” speculates Bachus. “I think cellular and mechanical bioengineering will morph into something different than we have now and answer different questions than either has in the past.”

Sports Medicine

While they’re available to help treat 270 University of Utah student athletes who participate in 12 varsity sports, the sports medicine specialists in the Department of Orthopedics focus most of their attention on recreational and high school athletes in the community.

“There are thousands of people in the Salt Lake valley who compete with themselves: the 35-year-old tennis player, 42-year-old jogger, 60-year-old backpacker,” said Robert T. Burks, M.D., professor of orthopedics and director of the U Sports Medicine Center. “It’s more visible when we help a teen return to the basketball court after an injury, but it’s just as important to get the 70-year-old golfer with a shoulder injury back onto the greens. Taking a week off is a big deal.”

Sports medicine encompasses much more than separated shoulders or torn anterior cruciate ligaments, according to Burks, who holds the Mary Scowcroft Peery Presidential Endowed Chair Established by Louis S. Peery, M.D., in Loving Memory of His Mother. “It can include everything that keeps athletes from doing what they want to: asthma, diabetes, eating disorders, intestinal absorption problems, rashes, eye injuries. In fact, the non-operative cases are increasing.”

Two internal medicine physicians specializing in sports medicine have joined Burks and another orthopedic surgeon to help provide non-operative care. Amy Powell, M.D., the newest member of the U Department of Orthopedics, is especially interested in caring for female athletes. “There are a host of medical problems, along with musculoskeletal ones, that are unique to females,” noted Burks. “For instance, girls who train excessively can delay the onset of their periods. We want to focus on the special issues and needs of female athletes, so we can help them maximize their potential to play, yet prevent injuries.”

Of the orthopedic injuries that do require surgery, about 80 percent are performed with arthroscopy. An incision, often so small it doesn’t require stitches, is made near the injured joint, whether it’s a knee, foot, ankle, shoulder, wrist, hand or elbow. The tube of the arthroscope is inserted, and magnifying lenses inside the tube transmit images of the joint’s interior onto a screen. The surgeon can examine the patient’s joint, diagnosis problems, make repairs, and even transplant meniscus, or cartilage.

“Arthroscopy clearly has made the biggest distinction in sports medicine as a subspecialty,” said Burks. “It’s less painful for the patient and cosmetically better, since small incisions mean less scarring. The rehabilitation is typically quicker. The diagnosis is more complete, and the problem can be treated at the same time, without an additional surgery. It’s pretty much the standard of care for many orthopedic conditions.”

Rehabilitation is not only essential for recovery, but, for athletes, it’s usually welcome activity. “A large number of our patients are pretty motivated,” explained Burks, who, like the other U sports medicine specialists, leads an active life: running, biking, playing golf, and camping. “They already have exercise plans; they eat reasonably; they want to get back out on the field or the court.”

Physical Therapy

The “negative work” of Paul LaStayo, Ph.D., P.T., promises to be a positive move, bridging programs in the College of Health and School of Medicine.

LaStayo joined the U health sciences center faculty last summer as an associate professor of physical therapy and adjunct associate professor of both orthopedics and exercise and sport science. In the new Orthopedics Center—being constructed next to the Health Professions Education Building that houses the Division of Physical Therapy— he’ll conduct research aimed at improving the performance and recovery of patients suffering from musculoskeletal problems.

“The location of the Orthopedic Center is wonderful for us,” said R. Scott Ward, Ph.D., P.T., associate professor and director of the Division of Physical Therapy at the College of Health. Like the orthopedics department, “we’re interested in movement, function, and biomechanics. The opportunities for collaboration in clinical trials, training, and teaching will enhance patient care—and be good for both faculties and students.”

LaStayo’s research on negative work recently was published in the Journal of Gerontology, where it was lauded for its novel clinical application that may help “combat the epidemic levels of sarcopenia (muscle wasting) in our aging society.” When a load placed upon a muscle exceeds the muscle’s force production, it contracts outward or lengthens. These eccentric muscle contractions result in “negative work.” Think of hiking downhill and feeling the muscles in your thighs producing force and stretching with each step.

Over time, muscles will increase in size and strength as a result of negative work—with an added advantage. Your heartbeat is slower during negative work, because it requires less oxygen. Your perception is that negative work involves less effort, resulting in what LaStayo terms the “high force, low cost” of negative work.

Working from this premise, the physical therapist theorized that an elderly population whose cardiac conditions made them “exercise-impaired” would benefit from an eccentric training program. For 11 weeks, a group of frail elderly subjects exercised on a custom-made eccentric ergometer, powered by a motor that moved the pedals in a backward rotation. The subjects slowed the pedals through resistance, or negative work. The comparative group participated in traditional weight training, using free weights and weight machines.

Results showed that the negative work group increased their muscle size and strength significantly more than the traditional weight-training group, and they reported that the exercise was relatively effortless. In addition, tests showed that their balance improved, and their risk for falls lessened as a direct result of the large increases in leg strength and size.

Muscle wasting is a major concern as it “often puts elderly persons at high risk for serious life-threatening falls, the most common cause of injury-related death in persons over 75,” according to LaStayo.

Likewise, muscle atrophy is a problem faced by many patients following surgery to repair the anterior cruciate ligament in their knees. Beginning in January, LaStayo’s lab will investigate how negative work affects the performance and rehabilitation of orthopedic patients at the U Sports Medicine Center. “If we can minimize atrophy after surgery, patients can recover normal movement patterns—whether for daily function or sports—more quickly,” noted the researcher.

At his lab, LaStayo and his colleagues will extend clinical studies to elderly patients following other orthopedic procedures and to those suffering neurological problems.

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