Physical Therapy vs Surgery for Meniscal Tears

 “I don’t deserve this award, but I have arthritis and I don’t deserve that either.” 
-Jack Benny

Before I dive into the findings of a recent New England Journal of Medicine study and how this connects to what is called “conservative treatment” (ie; non-surgical), here is a brief description of the medical terminology needed to understand the results and how this fits into your own treatment choices.

The two medical terms involved with this study are menisci and arthritis.

• Menisci are C-shaped cartilage structures within the knee joint which act like shock absorbers or cushions between the thigh bone (femur) and the shin bone (tibia). The menisci also provide stability with various motions of the knee including pivoting, twisting and squatting. Surgery for meniscal tears is the most commonly performed orthopedic surgery.
• Meniscectomy is surgically removing the torn part of the meniscus which takes out the “pain generator” and prevents torn pieces from breaking off and causing further injury
• Arthritis is a narrowing of the joint space associated with degeneration of the cartilage and bony structures of a joint.

Now to the findings of the study published in the New England Journal of Medicine, (NEJM, March 19, 2013 – http://www.nejm.org/doi/full/10.1056/NEJMoa1301408 ). This study indicated that physical therapy vs surgery is no different in efficacy for the treatment of meniscal tears among patients with mild to moderate arthritis. In this well designed study, patients with an average age of 56 were randomly assigned to either the conservative treatment group consisting of physical therapy or the surgical group which was treated with a partial meniscectomy. Further results showed that 30% of the patients in the conservative treatment group receiving physical therapy “crossed over” to get surgical treatment within 6 months. At 6 months and 12 months, the conservative treatment group compared to the surgery group indicated no difference on the WOMAC pain and function scales (http://en.wikipedia.org/wiki/WOMAC ).

Furthermore, as cited in my December 2012 blog article: (https://pursuitsports.wordpress.com/2012/12/14/huh-an-introduction-to-making-sense-of-what-your-doctor-is-trying-and-failing-to-tell-you/ ), shoulder MRI’s in the general population of asymptomatic patients show a high proportion of rotator cuff tears. Similarly,  35% of patients older than 50 will have meniscal tears seen on an MRI, and 67% of them will be asymptomatic (this means that patients do not report any painful symptoms). So, it is worth mentioning again the importance of the physical examination to determine if the meniscus truly is the origin of the pain and then correlating these findings with the MRI before considering aggressive or surgical procedures.

So, what does this mean for patients? General recommendations can emphasize non-surgical treatments for meniscal tears first, as long as they do not have mechanical symptoms (ie; locking, catching or giving way). If the patient shows no improvement after non-surgical treatments or has mechanical symptoms, then considering surgical management would be the next step.

Finally, what about regenerative injections to optimize conservative treatments? There is mounting medical evidence that regenerative injections can be helpful in patients with knee arthritis, so why not engage in this non-surgical treatment for meniscal tears? At present, there are no studies in this specific population of patients who have meniscal tears without arthritis, however, I generally tell patients who want to avoid surgery that we can try non-surgical treatments as long as mechanical symptoms (knee joint locking or catching) are not present. In this New England Journal of Medicine article, the study participants will be followed into the future in order to answer the question as to weather surgery on the meniscus leads to a higher risk of arthritis. If this turns out to be so, then it would be another argument to treat these injuries conservatively with physical therapy and regenerative injections.

For more information, please visit: www.pursuitsports.us
 

 

Medical Studies 101: How Test Results Can Shift Philosophies and Support Your Recovery

“Declare the past, diagnose the present, foretell the future.” – Hippocrates

Medical studies on various medical issues are used by doctors of all disciplines as guidelines for present and future knowledge. There are things like the WOMAC scale, percentages of “success”, and the scientific research base-lines which help determine results. These results can then be a tool for doctors which of course lend to helping increase patient recovery rates.

In this article, I would like to explain this behind the scenes world of medical research and how this relates to your recovery.

1.    Keep in mind that medical studies get funding for ailments that are the most common and most costly to society. Is it any wonder that celebrities spend so much time promoting medical causes that are important to them? Funding is unfortunately not readily available for less common ailments and diseases.

2.    In musculoskeletal medicine, many studies focus on knee arthritis, arthritis of other joints, and lower back pain because of the overall burden of these conditions to healthcare systems and the workplace. Some causes of these issues are genetic, while others are lifestyle-related.

3.    Even within each specialty (in my case, sports medicine), doctors do not always agree on approaches to treatment and how to decipher and implement the data obtained from the latest studies. Of course, more accurate data can mean better treatment, and a better recovery for patients.

4.    Fundamental differences in philosophy can hinder recovery. In osteopathic medicine, the body is seen as a “functional unit”. In other medical approaches, the body is seen as parts to be examined individually. For example, if a patient is experiencing pain in the lower back region, the cause might be from an area that is out of alignment at the neck, or muscles in the low back region that get “turned off” because of an injury such as an ankle sprain. Some medical philosophies would treat the lower back area only, while a DO would look at areas that may also be the reason for pain and discomfort. Again, these DOs approach the body as a “functional unit”.

Let’s talk about knee arthritis studies performed by several different hospitals, foundations, and research labs across the country. First, the WOMAC scale is a widely respected scale to determine pain – it stands for The Western Ontario and McMaster Universities Arthritis Index (http://en.wikipedia.org/wiki/WOMAC). This scale is used as a  measure of function and pain associated with knee arthritis and a standard base-line comparison to help understand what patients are experiencing and how to translate this valuable information into usable data. There will usually be 3 or 4 groups studied over an extended period of time, for example:

• Group 1: Patients who receive an experimental treatment or drug.
• Group 2: Patients who receive prolotherapy injections separated one month apart, followed up for evaluation for a full year from the beginning of a one year study period.
• Group 3: Patients who receive saline injections (a “placebo” group) during the same intervals as Group 2.
• Group 4: Patients who do regular physical exercises at home.

Now, let’s talk about results. For example, cancer research study results are analyzed as follows: if a new drug or treatment method shows a 30% positive result, it is solid enough for future study and therefore for future funding. Over 30% improvement is called a “meaningful clinical outcome”. Results less than 30% are considered to have a “minimal clinical significance”. Of course, patients want a 100% positive result, right? But now you get the bigger picture of what might get more funding, more research time… or not.

Now, let’s talk about knee arthritis studies and the osteopathic approach. Thankfully, the WOMAC scale is very useful for understanding what a patient is actually feeling and offers an excellent standard for communication between doctors and patients. Furthermore just to reiterate: the osteopathic philosophy is to treat “the body as a functional unit”. In the case of knee arthritis, the thought is that it’s not just the knee-joint surface that is causing pain; it is also the surrounding soft-tissue support structures. Some of these support structures become worn out and develop laxity (looseness or weakness) with associated pain symptoms.

Traditionally, injections around the knee are poorly studied in past medical literature since many doctors will focus in on the knee-joint surface only. In contrast, prolotherapists over the decades have come to develop the practice of injecting these “extra-articular” structures (ligaments and tendons surrounding the knee-joint) because on physical examination, knee arthritis patients often have pain in these areas as well. Also, although ultrasound is an excellent tool for detecting visual defects, there are other “bio-mechanical” reasons for pain: lifestyle, mental attitude, posture, and overuse (every daily PC or Mac user knows what carpal tunnel syndrome is, right?). Osteopathic medicine “considers the entire body, not just where it aches.” This is key in a sound examination, an accurate diagnosis, an effective treatment, and a speedy recovery. It is also key when funding useful medical studies and correctly interpreting test results for the benefit of better patient recovery rates.

Why is any of this interesting to patients?

It comes down to a million-dollar question: Surgery or no surgery for knee pain? Surgical decisions such as joint replacement for severe knee arthritis are still common. Insurance pays for it, surgeons are good at it, people feel relief, and everyone is happy. But think about this for a moment: approximately 90% of sports and lifestyle related injuries do not need surgery. If test results show the effectiveness of prolotherapy injections for knee and knee arthritis pain without going to the hospital, would that not be preferable? Of course, sometimes surgery is recommended for some situations. AND, the non-surgical prolotherapy injection treatment is one method that works, medical studies consistently show this to be true, and patients can only benefit from this knowledge. Shifting from automatically going into surgery… to deciding on a non-surgical, alternative treatment method just makes sense. Medical Studies 101 says: think about this before making your treatment choices. Food for thought.

For more information, please visit: http://www.pursuitsports.us

HUH? An Introduction to Making Sense of What Your Doctor is Trying (and Failing) to Tell You

“They certainly give very strange names to diseases.” – Plato

When a doctor orders an x-ray, ultrasound, MRI (or any other test for that matter), it is done to help make a diagnosis of the patient’s problem after a thorough history and physical exam are performed. This in turn guides the treatment, and patients don’t need to have a medical certificate to recognize that “the treatment is only as good as the diagnosis”. When test results come back, patients want to learn what the findings mean and how this information can support their recovery – getting clarity is the first thing on their list. Unfortunately, patients are often introduced to a barrage of medical terminology which does not create more lucidity – in fact, they leave the doctor’s office feeling even worse with a bowl of murky information soup swimming inside their heads, not quite knowing what to do next. And finally, in addition to the daunting task of having to interpret medical terminology, patients are sometimes informed that there are other “unrelated” issues found on the x-ray or MRI… in areas where they aren’t even experiencing any pain!

So, what do doctors do with this information and how are patients supposed to process it?

Radiologists are trained doctors who interpret all of the imaging studies (X-rays, MRI’s, CAT scans etc.). In the radiology report handed over to an MD/DO, sometimes the words clinical correlation required will be included. Basically, this means that there may be some identifiable problems or what doctors call “pathology”, but they may not be clinically active or significant. Here is one of many examples, as cited in a general population study (J Bone Joint Surg Am 1995;77:10–5.): MRI studies were performed on “asymptomatic” patients – those who are not experiencing pain – and the results showed that 35 out of 100 patients  had at least partial tears of the rotator cuff. Similar findings were also seen in the lumbar spine – the lower back region – when general population MRI studies were again performed on asymptomatic patients.

The important part of the diagnostic process in musculoskeletal medicine is to not only correlate the physical exam findings with the x-ray or MRI, but to also look for any possible “bio-mechanical precursors” to the problem such as abnormal motion patterns of the shoulder blade (scapula) thus predisposing the patient to shoulder pain, or tight hip flexors leading to inhibition or inactivation of muscles that stabilize the lower back region.  In the orthopeadic paradigm, we diagnose a patient’s problem by reproducing their typical symptoms during the physical exam and then order the appropriate study – such as an MRI –  if the patient doesn’t get better with conservative measures such as manual or physical therapy… or if the patient is potentially a candidate for surgery. By linking the physical exam, patients’ complaints and the radiological findings, doctors can offer a more accurate, meaningful, applicable, and successful treatment to patients.

When this happens, clarity becomes the first thing patients experience… not the last.

For more information, please visit: http://www.PursuitSports.us