Sports Medicine Physician Talks Ascend and Total Knee Replacement
In the spring of 2021, Roam’s VP of Health, Sujit Dike had the pleasure of sitting down with Dr. Rowan Paul, a sports medicine physician who has been working closely with Roam to develop Ascend. They were able to discuss the state of the knee osteoarthritis space, why he doesn't recommend total knee replacement to all his patients, and his excitement for new technology like Ascend. Highlights of the conversation can be watched/read below.
Professional Background
Sujit: Dr. Paul, tell us about yourself and your practice??
Dr. Paul: My name is Dr Rowan Paul, I am a sports medicine physician, I specialize in regenerative medicine, and interventional orthopedics, minimally invasive, microinvasive procedures that basically use your body to heal yourself. I have a whole host of different patients, I have treated everything from elite San Francisco ballet dancers to the Oakland athletic baseball team, Olympic athletes. But I also have a whole host of patients of all ages, including a lot with chronic knee pain, knee osteoarthritis, and problems with mobility. And really, my goal with what I do is to provide an integrative approach to help my patients get back to health, and get back to the activities and sports that they love to do.
Sujit: What differentiates you from other physicians?
Dr. Paul: I have a bit of a unique model. I made a decision a few years back that I wanted to move out of the network so that I could really focus on an integrated model. When patients come in with knee pain, for instance, it's usually not just knee arthritis, for instance. It's usually a complex health problem that has resulted in them gaining weight, becoming less active, maybe due to knee pain, and then accelerated deconditioning that results in more pain directly related to osteoarthritis, or other injuries.
Sujit: How is your approach different?
Dr. Paul: So my approach is much more integrated, I pull from different data sets, different fields. I come from a medical background, and then, sports medicine, and non-operative interventional orthopedics, so I really wanted to pull from those data sets, and at the same time that I am managing someone's knee osteoarthritis, I'm also thinking about them on a broader sense, as what is their metabolic health like, what is their weight, how is that contributing to their knee pain, and I try and optimize all variables, not just their musculoskeletal variables to give them the best outcome.
Patient Experience with Knee Pain
Sujit: What kind of patients do you see?
Dr. Paul: For patients, when they come in my door, because of the model that I have, they have typically already failed conservative care, and that might be nonsteroidal anti-inflammatories, rest, traditional braces, taping, physical therapy, cortisone injections, maybe even Hyaluronic viscosupplementation injections, and they come in and they are in pain, they're depressed, they are scared.
A lot of them are coming to me because they know, potentially, the next it might be a total knee replacement, and that really worries them, because they have inherent skepticism, or worry [about] their outcome.
You know, lots of them have friends that have gotten knee replacements and haven't necessarily been happy with it. So they are looking for alternatives, looking for options, maybe a bridge to surgery if they're not quite ready for it, and that gives me an opportunity to help them with regenerative medicine, and treatments that are still microinvasive, or non-invasive.
Sujit: Can you speak to their pain and what constraints they have due to the pain?
Dr. Paul: Yeah, most of my patients, they come in with significant disability, significant pain levels. So things that you and I would have no problems with, getting in and out of bed, getting out of a chair, in and out of a car, getting up and down stairs, these really have significant barriers, for patients to do these simple things. And so a lot of times, they end up boxing themselves into a very narrow, functional window, and, and that results in a lot more health issues, than if they were able to move naturally.
The Current Issue with Knee Osteoarthritis
Sujit: Based on your observations and experience in the knee osteoarthritis space, how big are the problems and how much of a need exists, to come up with innovative solutions in that space?
Dr. Paul: It's a massive problem. We have an aging population, and these are really patients, baby boomers that are trying to become active, or trying to stay active much later in life than historically. And so, there's a least, conservatively speaking, at least 20 million symptomatic knee osteoarthritis patients now. And that's probably a very conservative number….it's a huge problem because the number of knee replacements are skyrocketing, and frankly, there's not enough knee replacement orthopedic surgeons out there to do the number of knee replacements.
Sujit: 20 million seems like a huge opportunity. Are there any limitations to getting a knee replacement?
Dr. Paul: We certainly know that knee replacements are not perfect. Knee replacements, depending on the study you read, anywhere from 2 in 5, to 1 in 3, are not quite happy with the results. That is an unexpectedly high number, and so it really highlights the treatment gap between traditional conservative care and knee replacement, I think it's our duty, ethically as physicians, to really explore that treatment gap and find as many solutions as we can, until we know more about how to optimize knee replacement outcomes.
Limitations of Treatment Options for Knee Pain
Sujit: Can you speak on the limitations of conservative therapy and medications when it comes to addressing knee pain?
Dr. Paul: A lot of patients come to me and they are looking for options. Most of them have tried anti-inflammatories like Ibuprofen and Aleve and it may work short-term, but not long-term. We certainly know that there are side effects from long-term non-steroidal use and... they include ulcers and GI bleeds and heart attacks and strokes, and so patients are becoming much more savvy to this now. Some of the common injections like Cortisone and Hyaluronic Acid are... typically used as well, in this kind of earlier, stage Osteoarthritis, but at some point, repetitive use of Cortisone is certainly not helpful, certainly hyaluronic acid can be helpful but, it's a bit unpredictable in late-stage Arthritis so, they're looking for additional options beyond this, and certainly short of knee replacement.
Sujit: What are some of the key outcomes and emotional factors of dealing with patients with significant knee pain?
Dr. Paul: One of my key outcomes for my patients is, I want to get them back to mobility. Mobility is the key to health. If we can get people moving, we're getting them back to health, and... that should be a huge priority... in health care, in general. When I treat them, and I take that pain away, or substantially reduce it, it's like the skies open up, the sun comes out, and you see their smile again, you see that, kind of, like zest for life again, patients just-it-they become, who, they really are, instead of being a patient defined by pain.
Dr. Paul’s Thoughts on Ascend Smart Knee Orthosis
Sujit: Well said, let's switch gears to Ascend. What differentiates Ascend in your mind and what excites you about this product as a physician?
Dr. Paul: Ascend is a really exciting device because it's giving patients options where they had no options before, short of knee replacement. It provides them with an innovative, lightweight, custom fit wearable, that allows them to be active, and to do things that are easy for you and I, but impossible for them otherwise. And that might be something as simple as walking on the beach, potentially walking up and down stairs, going for a walk with their family up and down hills, maybe even traveling again for the first time in years. I have several patients who would love to fly to Europe and walk on cobblestones but they can't because they're scared that that's just going to flare up their knee pain, they're gonna get stuck.
Sujit: Who would you prescribe Ascend to? Why not just prescribe them to undergo a total knee replacement?
Dr. Paul: Ascend is a very useful tool for my patients, who have failed all conservative care and are not quite ready for knee replacements. They are in a treatment gap, where they may not want knee replacements, maybe they're not candidates for knee replacements for, metabolic reasons, cardiovascular reasons, maybe they're obese, maybe they're too young. These prosthetics have shelf lives and for some patients it may wear out in 10 years, for some it's 20 years. But regardless if you're a 50-year-old getting a knee replacement, there's a very high likelihood you're gonna need a revision surgery. And we know that that second revision total joint is always more complicated than the initial, total joint replacement.
Sujit: How can this new technology improve the way you treat your patients?
Dr. Paul: We're at a very exciting time in technology where we have the ability to make devices that actively sense, provide support to allow you to move in a relatively seamless way. And the data that the sensors provide gives us so much more information for both the product development, the understanding how patients live. One of the problems that I've always had as a physician is I see patients in a very, kind of, snapshot way and I have no idea what they're doing when they go home. And when I see them back, you know, I'm, I'm trying to get them to remember what they did in the last six weeks, potentially, and most people don't remember what they've done in the last week, let alone the last six weeks. So there's a lot of recall bias, so one of the beauties of this device is it provides some rich data that we can use to better healthcare outcomes, as well as improve the device itself.
Sujit: What are some of the consequences of less mobility? Why is it so important that patients properly address their knee pain?
Dr. Paul: Mobility is critical to patient health. I think if a patient can get back to movement then they can exercise. And if they can exercise, they can be much more healthy. And that results in some very tangible health benefits, such as weight loss, uh, improvement of hypertension, improvement in their lipid panel, or cholesterol, perhaps a reduction in heart-attacks and strokes. We know certainly that mental health is, certainly positively affected, patients are able to go back to their friend circles and do activities that they couldn't otherwise do. Helps them become much more meaningful members of society, being more productive.
Sujit: What would you say to your fellow physicians about Ascend?
Dr. Paul: I mean, knee replacements are going up and up every single year. Knee osteoarthritis is a massive market and it's only going... getting bigger. $135 billion, considerably, and that's a 2010 metric. I think the number of joint replacements are somewhere around 700, 000 per year. And they're at a cost of about $40,000 to $70,000 depending on where you're getting it. So that's a huge opportunity for technology to come in and prevent some of these knee replacements. If we prevent 5% of these, that is a massive cost saving to the system. And, uh, that's a very considerate number. I think Ascend is potentially useful for a much higher percentage of these knee replacement candidates.
To learn more about knee pain or Ascend, visit www.ascend.health or call us at (415) 481-6400 or email us at hello@ascend.health
Medical Disclaimer: Ascend is registered with the FDA as a Class I medical device. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare providers.