Great Medicine Needs Committed Patients

It's the unglamorous part of being sick. The patient has returned home from the hospital. The get-well wishes slow to a trickle. The flowers are wilting. Relief at coming home ebbs. And the hard part begins.

Hearts or brains, bones or joints, there's no pill or procedure to make physical rehabilitation happen on its own. It takes an educated, motivated patient. Russell Warren, longtime team physician to 2008 Super Bowl champion New York Giants and surgeon and chief emeritus at top-ranked Hospital for Special Surgery in New York, says that "patients can't be idle bystanders." The best hospital and the best operations are not enough.

Yet more than half of those who should be rehabbing don't stick to it, or even to their prescribed medications. And with healthcare delivery so fragmented, long-term outcomes that count on patients' work are mostly unmeasured and undervalued. Here committed athletes, whether injured in high school soccer or on any given NFL Sunday, can teach us something about staying with what can be long, dull, and rote.

Take those who rupture their anterior cruciate ligament, a collagen strut that weaves through the center of the knee, connecting the shinbone to the thighbone. Over 200,000 people tear an ACL each year. Most susceptible are athletes who engage in sports that require jumping, twisting, or cutting, like football, basketball, lacrosse, soccer, and skiing. Golfers, too, can get torn ACLs; witness Tiger Woods. Surgery returns athletes to their sport, Warren says, and also protects their knee from worse injury. The ACL is a stabilizer. Without it, the knee periodically gives way, eroding the cartilage that absorbs shock and leading to progressive degeneration and arthritis.

In a fairly elaborate reconstruction, performed mainly on more-active individuals, a torn ACL is replaced with a kneecap tendon or hamstring from the patient or a cadaver graft. To regain normal function, the operation is followed by six to nine months of intense rehabilitation. Physical therapy is the only way to reduce swelling, restore the leg's full range of motion, and build up the quadriceps and hamstrings, muscles that reduce load on the ACL and are critical to balance, strength, and speed. This takes hours of daily exercises and icing, plus visits to a rehab center two or three times weekly for monitoring and supervised workouts. Then come years of knee-strengthening routines, since the knee is still at risk for arthritis.

One of nature's surprises is that women are four to eight times as likely to rupture an ACL as men playing the same sport. It's unclear why—theories include hormones, ligament size, and how ladies jump. But no gender gap exists in the fierce determination to get back to what they love. And as in sports, grinding through the rehab process is a head game.

The trip back. Depression, a known deterrent to adherence, is something athletes struggle to overcome. Several patients at the HSS rehabilitation center told me of their utter despondence when they knew that the "pop" they felt was an ACL tear, their wavering confidence as they labored through rehab, and finally their elation as they saw real progress.

Maya Lawrence, a member of the U.S. World Championship fencing team, recalls that heartbreaking pop during a lunge in the last three seconds of a match she was winning. Now in the final phase of recovery, she credits much of her success to her therapy—and to her parents' steadfast presence. Environment, at home and at the rehab center, is important. The HSS facility feels more like a sports club, with gathering places for patients and therapists to converse and an adjacent cafe featuring healthful foods. It is an upbeat place, a beehive of social and psychological support.

Now apply this to cardiac rehabilitation. Twelve million people have known coronary artery disease. Their own efforts can keep it at bay, but few follow a diligent program of diet, exercise, and attention to blood pressure, cholesterol, and waist size. As with sports, studies show that a supportive environment, with a significant other who serves as coach and cheerleader, is almost essential to sticking with a program. But ultimately, it's the patient's own determination that really counts. Maya Lawrence says she's not invincible but will "still go out and fence with confidence" because she knows what she should and can do to stay strong. These young athletes mending their wounded knees show how the best patients drive the best medicine. That's true whether the affliction is sports threatening or life threatening.