Healthy Wealthy & Smart 443: Dr. Lars Engebretsen: Injury Prevention in Sport
LIVE on the Sport Physiotherapy Canada Facebook Page, I welcome Dr. Lars Engebretsen on the show to preview his lecture for the Third World Congress of Sports Physical Therapy in Vancouver, Canada. Lars Engebretsen is a professor and consultant at the Orthopedic Clinic, University of Oslo Medical School and professor and co-chair of the Oslo Sports Trauma Research Center.
In this episode, we discuss:
-Dr. Engebretsen's career shift from being reactive to proactive in injury treatment
-The importance of a team approach for injury prevention in sport
-Programs that focus on translating injury prevention research to coaches and trainers
-How to develop your research portfolio
-What Dr. Engebretsen is looking forward to at the Third World Congress of Sports Physical Therapy
-And so much more!
Resources:
Third World Congress of Sports Physical Therapy
Oslo Sports Trauma Research Center
For more information on Lars:
Dr. Lars Engebretsen is a professor and consultant at the Orthopedic Clinic, University of Oslo Medical School and professor and co-chair of the Oslo Sports Trauma Research Center.
He is also a consultant and former Chief Doctor for the Norwegian Federation of Sports, and headed the medical service at the Norwegian Olympic Center until the autumn of 2011. In 2007 he was appointed Head of Science and Research for the International Olympic Comittee (IOC).
Lars Engebretsen is a specialist in Orthopaedic and general surgery and authorized as Sports Medicine Physician (Idrettslege NIMF) by the Norwegian Society of Sports Medicine. He serves as chief team physician for the Norwegian Olympic teams.
The main area of research is resurfacing techniques of cartilage injuries, combined and complex knee ligament injuries and prevention techniques of sports injuries. He is currently the President of ESSKA (European Society of Sports Traumatology, Knee Surgery and Arthroscopy).
He is the Associate editor and Editor in chief for the new IOC-BJSM journal: Injury Prevention and Health Protection. In addition, he serves on several major sports journal editorial boards and has published more than 200 papers and book chapters.
Read the full transcript below:
Karen Litzy: 00:01 Hey everybody, welcome. Happy Saturday to everyone. For those of you who are on the Facebook page right now, welcome. I'm just going to check and make sure it's on. Yes. So we are live, which is awesome. As you know, we've been doing live interviews with speakers from the Third World Congress of sports physical therapy. And for those of you who, if you're on this page, I hope you know when it's going to be, but it's October 4th and fifth in Vancouver, Canada. And today I have the distinct pleasure and honor to be talking with Professor Lars Engebresten. So, professor, welcome. Thank you so much. And as we said before, I've been practicing that name for at least a week, so. All right. Chris Napier, welcome. We said welcome, to you, thanks Chris for being on. It's a little bit early. They're over in Vancouver. So professor, before we get started, can you please tell the audience and tell us a little bit more about you, your career trajectory, and what you're up to?
Lars Engebresten: 01:17 Yeah, I'm a professor at the University of Oslo Department of Orthopedic Surgery. And then I work, at the Olympic Center of Norway getting gold medals for Norway. And then I do work at the Olso sport Trauma Research Center, which I run together with Rollbar. And then I am a professor at the medical school and I work every other week for a couple of days in the Olympic national committee. So I have a very good combination or clinical practice. I still operate and I see patients quite a bit every week and research. I have many PhDs working on projects that I would say coordinated by myself.
Karen Litzy: 02:02 That's an amazing amount of work to do. It's like five jobs all rolled into one and I'm sure, although this is not what we're going to be talking about today, but maybe another time we'll have you talk about your time management skills. I mean, how you get all of that done because that's an amazing amount of work to fit in. But let's dive right into, since you just mentioned that you're still doing clinical work and research, so how being that clinician scientist, how important is that to merge your clinical work with your research work?
Lars Engebresten: 02:38 Well, you know, I think I found out very early in my career in orthopedics how important researchers, I was actually, you could tell this story I was doing in clinic as a resident, up in Trondheim where I did my residency and next door to me was one of the professors. And I had many patients with anterior knee pain. And I would ask him, what do you actually do with those patients? Cause they now see him a little bit strange now on them and then suddenly I operate and all that. So I said, yeah, what kind of operation do you actually do? And then it sounded, you see, I do a Mickey operation, like, elevating the tibial tubercle to reduce the load on the Patella site. And I said, oh, that's strange. How are they doing? And he said, oh, they all do very well.
Lars Engebresten: 03:35 And then I actually looked up 50 of those patients. I am in the hospital and then sure enough about one third did pretty well. One third was about the same and one third was much worse. Then I realized, you know, you can't really trust the old professors. You have to in the areas where there are some doubts here and there and what to do, you have to do research in those areas there. There's no way you can be a clinician in your university clinic without, doing that kind of research. So since that time, which was a long, long time ago, I've actually been doing all kinds. So both clinical and basic science research
Karen Litzy: 04:18 How does one inform the other? So how does clinical inform research and research informed clinical for you?
Lars Engebresten: 04:28 Well, for me it's been like a, you know, I see patients, I follow a various teams. I'd done all kinds of soccer teams, handball teams, ice hockey teams and so forth. I see the issues, what kind of problems do patients have. And I see what we have to, give them in the form of various therapies or various surgeries. And I realized that we aren't really perfect. That there is a lot of research that remains to be done actually. So that's a general in general speaking the way, I've found out that this is something I have to do. And, when I was young I was doing all kinds of sports myself. And I also realized that, you know, when you got the injured really, we really didn't have that much of a argument for getting people back. And that was a long, long time ago. And now we're better, we aren't getting better, but, we still have a way to go. So the last, I would say, 30 years I've been working on the three different research areas. So I've been working on a cartilage issues, a ligament issues, and then later on the prevention of injuries issues.
Karen Litzy: 05:48 And you know, since you mentioned the injury prevention issues, let's dive right into that now. So, you've been involved in conducting a number of studies regarding, sports injury prevention. So what would you say are some of the common misconceptions around injury prevention?
Lars Engebresten: 06:10 Right. It's very difficult to get people really interested in that area because, you know, it doesn't really pay much on an individual basis. It does pay back to society because you get less injuries by doing it, but to the individual doctor or Physio, it is a difficult because of the payment schedule in these cases. In my case it was actually more specific at what made me change my attitude to this. So I was doing, all kinds of basic science and also can you go studies in the ligaments and tendons and then, you'll see them and they are very good. They were supposed to win the gold medal. Actually in Sydney. The star player had an ACL eight months at a time. And, which was a major issue of course.
Lars Engebresten: 07:17 And we operated on her and the most successful and she came back, Nora did not win the gold medal. Olympian bronze medal and she didn't really perform the way she was supposed to. And I realized then actually, that, you know, what we were doing was not really that great. I realized that she was on track for getting osteoarthritis pretty early after the surgery. And I realized, Oh, all my efforts in the, you know, ligament, design and, new ways of doing the surgery and stuff wasn't that great because I thought, you know, I should spend more time on how can I prevent these types of injuries at the same time as I treat them later on. But I kind of refocused towards prevention all these injuries after that incident.
Karen Litzy: 08:25 So getting back to this injury prevention, so based on our current knowledge of injury prevention in sports, what would be your recommendation or go to strategy intervention for injury prevention? So for example, is it exercise? Is it load management? Is it education?
Lars Engebresten: 09:05 The most important thing is to look upon this as a team effort. There's no way you as one person, I would be able to make a huge difference in this area because prevention is all the aspects that you mentioned. And therefore, you know, in our case, you know, also sports trauma research center, we are a quite a few people working in this field and there's no way that not one of us could make a big difference. Yeah. It's all about the team effort. Because you have to do research, just figure out whether your program is working. Secondly, you have to make people do it. And third, you have to look at results of it. And that really demands a manpower, budgets, long term studies in this area.
Lars Engebresten: 10:13 We've done a lot on randomized control studies showing the effect of these programs, but we still don't have perfect compliance, you know. What we have found out lately is that, we are changing our approach and it can be towards instead of travel around I get a mixture of some of this to athletes and stuff. We actually tried to teach the coaches in Norway anyway. The coach educational programs are now filming this prevention programs we have. So it's all about, I think parents and coaches, then the doctor or the physio doing it. So we have to be able to relate all the knowledge we have and to be able to implement it. And that is the biggest challenge at the moment.
Karen Litzy: 11:17 Yeah, that makes a lot of sense. Changing people's behaviors is not easy.
Lars Engebresten: 11:25 It's not, but you know, at least where I live and I'm sure also in the US, we have been able to stop people from smoking. Very, very few smokers left here. So we should be able to, you know, instigate the system where, if you are young and you're doing a sport, part of your sport is the prevention part.
Karen Litzy: 11:50 Yeah. And, and I think that that's great example that yes. Smoking, when I first moved to New York City, so many people smoke. Now it's a rarity mainly because of good outreach campaigns, via media and things like that. And sometimes they think that's where, injury prevention and sports injury prevention is just not getting its fair air time, I guess. Right. So when you look at mainstream media and news and things like that, they focus on the injury. So the professional player who gets injured or the collegiate player that gets injured, this is the injury. This is the surgery versus look at all the people who haven't gotten injured and why is that?
Lars Engebresten: 12:33 Hmm. Yeah. You know, there are some good examples. For example, hamstring injuries, we have a pretty good way of reducing and reducing those by maybe as much as 75%. And even in the premier league in England, the best, very best teams, you don't really do those exercises. And it's really, really crazy cause the number one injury, keeping people out of premier league soccer is actually hamstrings, it's a very strange thing that I've not able to, and I think that's all about, you know, the coaches being involved and understanding how important is this.
Karen Litzy: 13:15 Yeah. And are you doing things in Norway? I know you said that now you're getting more coaches to come to lectures and things like that. So if there are people listening from other parts of the world, what sort of system are you using to get those coaches in?
Lars Engebresten: 13:32 Well, there, you know, almost every country has some sort of cultures of education and it's like level one, two and three and so forth. And, now we have introduced international programs, you know, all those levels. That's part of some sort of daily education is about prevention. And I think that's I must add a key in this area. We have shown that we are able to reduce the number of serious knee injuries for example by more than 50% in some sports that are really prone to those type of injuries. Team handball is a very good example. Basketball could be another one. So I think that education day is very, very important. But as I said, we are trying out new ways of getting compliance improved cause that's still an issue.
Karen Litzy: 14:30 You can have a great injury prevention program but if nobody does it.
Lars Engebresten: 14:36 Hmm. I know, you know what we are trying to do is to teach the parents. If you have a daughter, 12, 13, and 14 year old and if she plays soccer or team handball, the chance of having a serious knee injuries are very high and you can really take out insurance by doing a these kinds of exercises at the same time that you are training. So maybe spend 10, 15 minutes, three times a week on this that would be able to reduce the percentage risk for having an injury like that.
Karen Litzy: 15:13 Yeah, I mean from the standpoint of the clinician and the researcher just makes so much sense. We just have to get the coaches and the players and the parents and team organizations in schools and things like that on board. And I would assume that takes time and some effort and the incentives.
Lars Engebresten: 15:35 I think that in the US you have all the sports in schools, right? Whereas in the rest of the world, for the most part the sports are outside schools and community teams and stuff like that where it is a little bit more difficult to get this through. So there should be good chances in the US and Canada as well.
Karen Litzy: 16:01 Alright, well hopefully people listening to this will kind of take this to heart and go to their local high schools and middle schools and try and educate those coaches and parents. All right. Now you already touched upon this I think a particular patient case that you personally treated that caused you to reevaluate your whole treatment paradigms. And I feel like you touched upon that a little bit already. Do you want to expand on that at all?
Lars Engebresten: 16:31 Yeah, in a sense that, for me personally, it really changed me from, you know, doing surgery four times a week, four days a week, to spending more work in the research lab, trying to design exercises to help in preventing these kind of injuries. We have done a lot of work on looking at why are they happening and how are they happening. And our team here in Oslo has relatively good knowledge in this area and that has helped us in designing programs. It's taken a long time and takes your way from the OR and into a different environment and that has really put the major change in my medical activities.
Karen Litzy: 17:24 And are you happy with that change?
Lars Engebresten: 17:30 I am, I'm going to a meeting, for example now in a couple of weeks and I'm preparing for it in Pittsburgh on the ACL, various kinds of injuries. And that just tells you here all these, experts from around the world. They still attending as still the same question comes up. And again, there hasn't been a huge development, I would say, when it comes to serious knee injuries in the results of the treatment we have. So there, you know, the area that I'm interested in, this prevention area probably have still a lot to contribute to the field because you would, the surgeons haven't really caught on, at least not on the measure where of them. I would say in this, even though if you guys have done it, the physios have done it. The big story is still lagging behind a little bit.
Karen Litzy: 18:36 Yeah. And it's to me, what it sounds like I'm hearing from you, is it sort of forces you to be instead of a reactive doctor, a more proactive physician.
Lars Engebresten: 18:47 Absolutely. That's a good point. That's a difficult change.
Karen Litzy: 18:54 Yeah. Especially because you had a lot of training, but it's still, I mean, it's still all medicine and in the end it's helping the patient, which is the most important thing. That's why we do what we do. Right. As we said in the beginning, you're also a researcher. You have an impressive publication record, hundreds of peer reviewed articles. So if you kind of take a look back at all of those articles that you published, which one of your research projects or papers is most meaningful to you? So maybe it doesn't have the highest altmetrics score, but which one to you is like most meaningful?
Lars Engebresten: 19:40 For me that's very difficult to say actually because you know, not because I have some many, but more so because I have various fields and I've been very heavily involved in, there were some really important ones in a mechanism and I was working in the lab and then taken lab or to the OR. But I think that, overall the most important one is probably the one we did on, prevention of ACL injuries and team handball and follow, this for 10 years. I mean, you could see, you know, when we went in there actively and we were able to reduce number injuries and then we kind of stepped out and let the players do themselves, ramp back up, all the injuries. And then we really, reinforced our efforts and all of a sudden we were able to really reduced the number of injuries again and just shows us that if you really, put your mind to it, you can really achieve something. So that's probably the most important paper to come up with. Then again, you know, this is all about a team, a group, a team thing. It's not something I've done myself. Yeah. I've been part of the whole team, so really that's probably the most important.
Karen Litzy: 21:00 Nice. And then what advice would you have for young researchers who are trying to develop their publication portfolio?
Lars Engebresten: 21:10 Yeah, I keep telling my coworkers in the hospital, that's not the university that although it is great to have patients and to treat them and see that they're doing fine. Still if you've been doing that for 10 years, you kind of get bored after a while if you don't really progress and develop yourself. So you have to be able to do some sort of research during your clinical work as well. I'm really trying to tell them some examples here and there, why I did this and that. And then it is absolutely possible to combine a missing clinical practice with some sort of research at least if you're able to work as a team. So you still as you know, have other orthopedic surgeons or in my case physios and trainers that you work with, which will enable you to do much more then you can do only by yourself. I think their whole, the most important advice is to, you know, if you look at your 10 last patients and you see and you really look, take a close look at them, then you realize that, you know, there are many things you don't really know. So there many things that needs to be researched. I had one young person come up to me a while ago saying that he was discouraged because there's nothing more left to research. That's all wrong.
Karen Litzy: 22:51 Yeah, everything's been done?
Lars Engebresten: 22:54 Everything has been done and you know, that is absolutely wrong there's so much left to do. So there's work for everyone.
Karen Litzy: 23:07 Yeah, I would think there would be. And now let's talk about what you're going to be speaking about at the Third World Congress on Sports physical therapy. So can you give us a little sneak peek as to what you're going to be speaking about?
Lars Engebresten: 23:20 Yeah, I see from the program that I'm going to talk about ACL or ligament injuries and a surgical treatment versus non surgical treatment. And that's something that we have been working on for awhile in Norway and also with other groups, where we have lots of research have been showing that in Norway we actually do about 50% of our ACL patients are having ACL surgery. The reason is that, you know, people that are not doing pivoting activities or pivoting sports they are completely able to continue what they're doing without having a reconstruction, things like that. The key there is of course, range of motion proprioception and strengths. And, if you are able to do that, then you can do well without having an ACL reconstruction. And even if you have an ACL reconstruction, if you don't do those kind of rehab are, you'll never be successful. That's probably what I would be talking about and some of the results we have from our area in the room.
Karen Litzy: 24:39 Sounds great. I look forward to it. And I think it is amazing that it's only 50% of people in Norway. I feel like in the US it's much higher. You probably know the figures better than I do. But just from an anecdotal standpoint, it seems like the moment someone has an ACL tear, they're having surgery regardless.
Lars Engebresten: 24:57 Yeah. I'll let you know. The point is nobody knows that in the US because you don't really, you know, how the numbers on people and not having a ACL injuries. It's very interesting because I been working with China actually on developing an ACL program for them. And you know, they have thousands of ACL injuries, but I have no clue on how many actually, because I think they have mostly injuries and China is not really being operated on, at least not until now. But you are right in your part of the world. If you have an ACL injury, you will be operated on automatically almost. And the same goes for central southern Europe. It's the same thing. And in Scandinavia, Sweden, Finland, Denmark, Norway. We're trending to operate only on the ones with the pivoting work and the rest we don't do so in Norway we have about 4,000 ACLs a year. You know, 2000 see surgery.
Karen Litzy: 26:14 Right. We'll see what happens as time goes on and people start to realize that maybe there are some other options. But I'm definitely looking forward to that talk in Vancouver. And are there any talks that you're looking forward to or people that you're looking forward to seeing?
Lars Engebresten: 26:32 Yeah, you know, I look forward to see some of the PT work on the new ways of getting people proprioceptively sound new ways, testing people for it, in sport, things like that. That is really something that interests me.
Karen Litzy: 26:50 Well, I have to say, I want to thank you so much for taking time out today. Is there anything we didn't cover that you have like a burning desire to talk about before we end?
Lars Engebresten: 27:00 No. I look forward to come to Vancouver. It's a wonderful city. I was there during the Olympic Games in Vancouver, and Whistler and also down in Vancouver and it was a beautiful area.
Karen Litzy: 27:16 Yeah, me too. The only time I've been to Vancouver was when I went to whistler to ski. I was only in Vancouver for as long as it took me to get off the plane, get into a car and drive up to whistler. So I'm definitely looking forward to spending a little more time there. But thank you, professor so much for taking the time out and speaking to everyone and Chris and everyone else that's watching. And Mario gave a thumbs up. Mario Bozenie, thanks so much for tuning in and hopefully we will see you all in Vancouver October 4th and fifth so thanks so much.
Lars Engebresten: 27:50 Thank you.
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