This is a simple way to categorize approaches to fixing an orthopedic issue: surgically invasive, other invasive, and not invasive. You always want a diagnosis first, and since clinicians in orthopedics diagnose with different approaches, a second opinion is warranted if you are not pleased with your options or progress. (I diagnose primarily via a method of repeated movements, which, on the whole, is more helpful than diagnosing via imaging.)
We all know what surgery is. In my opinion it should be the last resort. Among the many reasons why, surgery (or intentional trauma) should be picked last because of the relative risk. The “other invasive” group includes prolotherapy, PRP, cortisone or any other injection, stem cells, dry needling, pharmaceuticals/supplements, and so on. Things that generally penetrate or enter a person’s skin/body. In the category of “not invasive” are movement, clinician techniques like mobilizations, various modalities such as heat and ice, and others.
Each category has pros and cons. What I find encouraging in this day of costly high-tech alternatives is that an expert program based on movement will still fix most problems! -- Laura
There is absolutely a time and place for joint replacements. While it’s every patient’s decision, I believe it’s best to explore conservative measures first - if for no other reason than risk alone. An individual’s determination should be based on a collection of facts and viewpoints.
It’s typically true that, when compared to replacement, therapy 1. poses less health risk 2. mandates less time off work 3. costs less 4. instills more self-efficacy 5. hurts less. Of course in the right patient group, it also provides superior outcomes. Within 5 visits I can usually arrive at a prognosis. With a poor prognosis (ie there’s too much structural compromise to improve), presenting the option of a surgical consult makes sense. If a patient explores therapy and a replacement is indicated, little time or money is lost in that endeavor if the therapist is skilled at arriving at a prognosis early.
“How can a person with a given diagnosis of OA who’s been recommended a new knee do well with therapy?” I treat a patient with joint complaints just like everyone else. I diagnose the patient based on a history and movement exam and treat accordingly. Most diagnoses do well with therapy, but in some cases it becomes clear that surgery is needed. -- Laura
Yes, it matters if you had surgery last week. It may or may not matter if you had surgery years ago. It also matters if you fell last week, if you had the flu, if you have vertigo, if you have an inflammatory disorder, and so on. Your entire history can matter - and your surgical history is simply one piece of that history I consider when I determine the most appropriate questions to ask you as well as the appropriate ways in which to move you. Given how people often have lots of things going on health-wise, it takes expertise to know what is relevant and not get bogged down with extraneous minutiae (which can eat up your precious time with patients quite quickly).
The biggest overarching error I see with clinicians treating patients specifically for postsurgical rehab is that they assume the surgery indeed addressed the true problem. Resultingly, they fail to both ask questions and move patients in ways that are diagnostic in nature. I make my own diagnosis - which may be a straightforward diagnosis of “postsurgical” - and treat accordingly. There are a lot of postsurgical patients out there whose surgeries did not resolve their underlying issues, which makes this way of thinking imperative if you want a successful outcome. --Laura
Imaging can show plenty of things that are not related to people’s complaints. You need to move people to understand their problem. I am not against imaging when used under the appropriate circumstances. But imaging people’s spines (who have no red flags) before moving them to arrive at a diagnosis is plain wrong. Stenosis is quite normal with aging and is present on images of people with zero pain. Therefore, we know stenosis is not an automatic pain generator. If you have complaints and imaging shows stenosis, it holds that something else could be causing your pain. We don’t know until we move you. In my experience, the large majority of patients who have come to me saying another clinician diagnosed them with stenosis have done very well with therapy. In most of those cases, therefore, something else was causing their symptoms and their initial diagnosis was incorrect.
Scenario one. Your image shows stenosis. We move your spine and, despite the bony stenosis your image shows, you respond well to movement(s) and your symptoms resolve. [majority of cases in my experience]
Scenario two. Your image shows stenosis and, after we move you for several visits, it becomes clear that the stenosis is related to your symptoms. We discuss how we need just a couple weeks of specific movement to see if we can change any correlated soft tissue stenosis and impact your symptoms. We know that there is bony stenosis on the image but we still don’t know if bone or soft tissue is the real issue. Soft tissue we can usually change with movement, bones we cannot. After a few weeks your symptoms decrease or resolve so that no further intervention is desired/needed. [fewer cases]
Scenario three. Same as number two except, after the couple weeks of specific movement, your symptoms are unchanged. At this point we can integrate different strategies in therapy with goals of minimal to moderate overall improvement of symptoms - or you can have a surgical consult with the goal of more significant improvement. [fewer cases]
The point is we don't know which scenario applies to you until we move you. -- Laura
Osteoarthritis (OA) is prevalent with aging. So is gray hair. And wrinkles. OA is a form of joint degeneration, just like gray hair and wrinkles represent types of degeneration. But we think of hair and skin changes kindlier, accepting them as normal, harmless parts of getting older.
OA, on the other hand, gets a bad rap – a painful rap – when in fact it can also be normal and harmless. An association between OA and pain is unfortunately widely believed. If someone’s knee hurts and a knee MRI shows osteoarthritis, we quickly blame the osteoarthritis for the pain and tell ourselves that it can’t be fixed (unless we have surgery). When our head or skin hurts, do we automatically blame our grays or our wrinkles?
It is clear OA doesn’t necessarily cause pain because we find plenty of OA in people without pain. In fact, a person over 60 undeniably has OA somewhere in her body. Pain in a joint may be from OA, but it may also be from an irritated nerve, a dysfunctional tendon, or a misalignment in the joint – which are all typically very fixable! Expert McKenzie clinicians identify (and then treat) the true cause of someone’s pain. -- Laura
The article Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial reveals no difference between the fake (or sham) surgery and the real surgery.
This type of shoulder surgery, know as subacromial decompression (SAD) is unfortunately still prevalent in the U.S. In this research study, both the sham surgery group and the real surgery group had something important in common: in both groups the shoulder joint was irrigated. Essentially the joint was power-washed. I believe this to be the key part of the intervention, the reason why both the fake and real surgeries provided the same results.
What I find in the clinic is that many joints have a piece of debris obstructing the joint's motion and causing pain. In the extremity joints this is thought to be a piece of fat, cartilage, bone, tendon, or similar. Of course, this can be effectively "power-washed" with repeated movement, too. My job is to find the movement that moves that piece of debris out of the way. My patient's job is then to perform that movement throughout the day and temporarily avoid movements in the opposite direction.
If you have been contemplating shoulder surgery, please read this study and/or contact me with any questions. Hopefully medical providers will no longer suggest this as an option. -- Laura
Check out how the US compares to other nations in terms of back surgery prevalence. Most are unnecessary! A McKenzie evaluation and treatment usually does the trick - and saves the patient from a lot of stress, risk, lost time, and cost. -- Laura
Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up
This study comes from the BMJ, formerly known as the British Medical Journal. I've included the conclusions here and a link to the entire study. This shows once again that surgery for orthopedic issues should be a last resort. -- Laura
BMJ 2016; 354 doi: http://dx.doi.org/10.1136/bmj.i3740 (Published 20 July 2016)Cite this as: BMJ 2016;354:i3740
Conclusions and policy implications
The observed difference in treatment effect was minute after two years’ follow-up, and the trial’s inferential uncertainty, as shown by the 95% confidence limits, was sufficiently small to exclude clinically relevant differences. Supervised exercise therapy showed positive effects over surgery in improving thigh muscle strength, at least in the short term. Nineteen per cent of participants allocated to exercise therapy crossed over to surgery during the two year follow-up, with no additional benefit. No serious adverse events occurred in either group during the two year follow-up. Our results should encourage clinicians and middle aged patients with degenerative meniscal tear and no radiographic evidence of osteoarthritis to consider supervised structured exercise therapy as a treatment option.
Find the entire article here: http://www.bmj.com/content/354/bmj.i3740?utm_content=buffer795ae&utm_medium=social&utm_source=facebook.com&utm_campaign=buffer
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