Surgery only recommended if other treatments don’t lead to improvements

Subacromial impingement syndrome (SIS), sometimes referred to as shoulder tendinitis, is a painful condition in which certain structures in the shoulder become compressed by bones in that region. Patients with SIS are usually managed with of a number of nonsurgical treatments, including rest, injections and physical therapy. In most cases, surgery is only considered for patients that do not improve after attempting several nonsurgical treatments. After surgery, physical therapy is typically recommended to help patients regain shoulder function. Although this approach is commonly utilized, there is no consensus about the most appropriate strategy, and little is known about the effectiveness of different types of exercise programs. It’s also possible that patients who have trouble returning to normal activities may require additional efforts to help in their recovery. For this reason, a high-quality study called a randomized-controlled trial (RCT) was conducted. In this RCT, patients with SIS who had surgery were randomly assigned to one of two treatments to determine which was more effective for helping them recover.

Patients treated with either physical therapy or usual care

Patients with SIS who had a surgical procedure called arthroscopic subacromial decompression were recruited for the study between 8-12 weeks after surgery. A total of 126 patients fit the necessary criteria and were randomly placed into either the physical therapy group or the usual care group. Patients in the physical therapy group followed a program that consisted of a combination of both supervised training sessions and home-exercise training. They received between 8-15 training sessions during the first eight weeks. Over the next four weeks, the frequency of these sessions varied depending on how patients responded, and they were told to perform their home exercises more regularly. Sessions lasted up to one hour each which consisted of aerobic exercise on a stationary bicycle, manual therapy performed by the physical therapist, and seven exercises that specifically targeted the shoulder. Patients were also instructed to become physically active at a moderate or high intensity for at least 30 minutes three times a week. Patients in the usual care group did not receive any specific treatments, but were told to continue the postoperative treatments recommended by the hospital. All patients were assessed before being assigned to their groups, and then again three and 12 months later for a variety of outcomes, including strength, range of motion and quality of life.

Following a course of physical therapy should be the norm after surgery

Results showed that after 12 months, patients in the physical therapy group improved significantly more than those who received usual care. This was based on better questionnaire scores showing that patients who had physical therapy had improved shoulder function and less fear about their condition than the other group. They were also found to be more physically active and had a better overall impression of the changes they experienced from treatment. This RCT, which is the largest study that’s ever been performed on the topic, clearly shows that physical therapy leads to numerous improvements for patients with SIS after having surgery. Based on these findings, physical therapy should be considered a necessary component of recovery following surgery, and it’s recommended that a treatment program similar to the one used here is followed to increase the chances of a positive outcome.

– As reported in the June ’16 issue of Physical Therapy

Completing treatment at home has certain advantages

Fractures of the hand are very common, and about one-third of these fractures involve the metacarpals, which are the bones between the wrist and the fingers. These injuries are particularly common in young adults, and they typically prevent patients from being able to carry out many basic tasks that involve the affected hand. The treatment for metacarpal fractures varies depending on how badly the bone is broken, and some patients choose to have surgery with the hopes of restoring their hand function more quickly. After surgery, physical therapy is typically recommended to help patients achieve these goals, and treatment can be given either within a clinic or through a home-exercise program. There are pros and cons of both approaches to treatment, but the main advantage of a home-exercise program is the fact that less time is needed and it can be performed at the patient’s leisure without needing an appointment. Unfortunately, there is not much research to support the use of home-exercise programs for metacarpal fractures. For this reason, a powerful study called a randomized-controlled trial was conducted to compare the two treatments.

Patients are randomly assigned to two groups and evaluated for 12 weeks

Individuals who fractured their metacarpal bone scheduled to have surgery were recruited for the study, and 60 fit the necessary criteria and were invited to participate. These participants were then randomly assigned to either the traditional physical therapy group or the home exercise group. Both treatments started two weeks after surgery, and the physical therapy treatment consisted of 12 30-minute sessions over the course of six weeks. Each physical therapist chose which exercises were to be performed, and they also instructed patients on how to perform these exercises at home. In the home-exercise group, patients were given a booklet with a set of specific exercises, which were to be performed for six weeks. Each day consisted of three exercise cycles, and each cycle consisted of 4-6 exercises and lasted 20-30 minutes. Exercises gradually progressed in terms of intensity as patients improved, and strengthening exercises were performed in the final two weeks. All patients were then evaluated for the flexibility, or range of motion (ROM) of their hand joints, as well as hand function and grip strength at weeks two, six and 12.

Both groups improve to a similar extent

After 12 weeks, results showed that both groups improved in all of the measurements taken. In particular, both the physical therapy and home-exercise group experienced similar improvements in grip strength and hand function, with no major differences found between them. The only significant difference between groups was for ROM of the fingers, as the home-exercise group scored significantly better than the physical therapy group after 12 weeks. These findings suggest that a home-exercise program may be just as effective as a traditional physical therapy program in helping patients recover from surgery for hand fractures. Patients who have fractured their hand preparing to have surgery may, therefore, consider both options after the procedure—and realize the importance of home exercise—to assist them with the recovery process and bring them back to full function as quickly as possible.

-As reported in the April ’17 issue of the Journal of Hand Surgery

Surgery for these injuries is becoming one of the most frequently performed procedures

The meniscus is a crescent-shaped piece of cartilage located between the thigh bone (femur) and the shin bone (tibia). There are two menisci in each knee, and their job is to stabilize the knee joint and absorb shock. Damage to the meniscus, which may occur either due to a single injury or gradually over the course of time, often leads to a lesion and eventually a tear of this structure. Meniscus tears are common, and surgery to repair these injuries is currently one of the most frequently performed procedures. New research, however, is questioning whether surgery is the most appropriate intervention for individuals over the age of 40 with meniscus tears. Evidence is suggesting that non-surgical treatments like physical therapy and exercise may be a smarter and safer approach for these patients. With this in mind, researchers performed a review of the available literature on the topic to investigate meniscus tears and determine the best methods for diagnosing and treating these injuries.

Investigators search through numerous databases for appropriate studies

Investigators divided their study into the following three domains: 1) risk factors, 2) diagnosis and 3) non-surgical treatments for meniscus tears. For each domain, they performed detailed searches of several major medical databases for high-quality studies that investigated the particular area of interest. This search led to 20 studies being included for domain 1, 12 studies included for domain 2 and 9 studies included for domain 3. The findings of the studies reviewed for each domain were then analyzed and compared to one another in order to draw conclusions about the most effective practices for managing and treating meniscus tears.

Patients with meniscus tears are encouraged to see a physical therapist first before considering surgery

For domain 1, low-quality evidence was found that suggested the following factors may all increase the risk for meniscus tears: being overweight, frequent kneeling or squatting, and activities that involve frequent stair climbing. For domain 2, the evidence suggested that the best way to diagnose a meniscus tear is to use a combination of the patient’s history, a physical examination and other diagnostic tests like MRIs and ultrasound. However, these additional tests should only be used if they are absolutely necessary, since they may not change the treatment prescribed and could increase the chances of surgery being recommended. For domain 3, the included studies supported a non-surgical approach instead of surgery for treating meniscus tears. This was based on the fact that moderate evidence showed no differences when patients were treated with physical therapy that included exercise compared to meniscus surgery. Surgery also did not lead to any added benefits when combined with these exercises.

Based on these findings, if you have knee pain that may be related to a meniscus tear, it appears that your best option is to see a physical therapist first and follow a course of exercise therapy. These carefully designed exercises will target your pain and functional limitations and work towards gradually building back your abilities in a natural and safe manner. But if this treatment does not lead to any significant improvements over time, you may need to speak with a surgeon to discuss other options to address your condition.

– As reported in the February ’18 issue of the British Journal of Sports Medicine

Combination of these two classes of drugs has not been thoroughly evaluated

Low back pain (LBP) is responsible for 2.4% of visits to the emergency department, which results in about 2.7 million visits annually. A significant number of these patients wind up with poor outcomes, with many having functional impairments or needing to take pain-relieving medications up to three months after their visit. There are a variety of medications available to treat LBP, with non-steroidal anti-inflammatory drugs (NSAIDs) being some of the most common and effective for some mild cases. Muscle relaxants are also considered beneficial for short-term pain relief, while opioids are commonly used for moderate or severe LBP; however, high-quality evidence to support the use of these drugs is lacking. The combination of NSAIDs and opioids in treating LBP has also not been adequately investigated, which led researchers to conduct a powerful study called a randomized-controlled trial (RCT). The goal of this study was to determine if adding a muscle relaxant or opioid to an NSAID would lead to any greater benefits for LBP patients.

Large sample of patients randomly divided into three groups

Individuals between the ages of 21-64 who had recently gone to the emergency room for an episode of LBP were recruited and screened to determine if they were eligible. This search led to a total of 323 patients being accepted to the RCT and then randomly assigned to one of three groups: the naproxen + placebo group, naproxen + cyclobenzaprine group or naproxen + oxycodone/acetaminophen group. Naproxen is an NSAID, cyclobenzaprine is a muscle relaxant and oxycodone is an opioid, while the placebo is an inactive pill used to compare results. All patients received 20 500-mg tablets of naproxen, which were to be taken twice a day, as well as 60 tablets of the other medications. They were instructed to take 1-2 of these other medications every eight hours, as needed, and if one tablet was sufficient for relieving pain in 30 minutes, they were told not to take the second. All patients were assessed at the beginning of the study and then one week and three months later for pain, functional impairment and healthcare usage.

Neither added drug brings about any greater improvements than placebo

Overall, results indicated that neither the muscle relaxant nor the opioid provided any added benefit to the NSAID for LBP patients. This was based on the fact that measures of pain, functional impairment and use of healthcare resources were not different between the three study groups at the one-week or three-month check-in. Regardless of the group they were placed in, nearly two-thirds of patients demonstrated significant improvements in their pain and function levels one week later. Unfortunately, 40% of patients were still in moderate or severe pain and nearly 60% were still using medication one week later. At the three-month check-in, nearly one-fourth of patients were still in moderate or severe pain and using medications for it, but only 3% were still using an opioid. This study shows that opioids were not any better than a placebo for relieving pain in LBP patients. Despite their lack of effectiveness, opioids are still commonly used to address painful conditions like these, which has the potential to lead many patients to take a highly-addictive drug that may not even be doing much to relieve their pain. This is why you should strongly consider alternative options like physical therapy for your pain first before taking a dangerous medication that may only lead to further problems down the road.

– As reported in the October ’15 issue of JAMA

These addictive drugs have been commonly prescribed despite a lack of supporting data

Since the late ’80s and early ’90s, opioids have been commonly prescribed to individuals with chronic-or long-lasting-pain. Over the years, prescribing these drugs has become a standard practice that many doctors assumed was safe and effective, even though there has always been a lack of high-quality research on the benefits and harms of opioids. As a result, opioids have been overprescribed for pain on a massive scale, and at least 300,000 people have died of an opioid overdose since the epidemic started. The epidemic has brought light to the situation and raised questions about prescribing these drugs to patients with chronic pain, and current guidelines now discourage their use in favor of other, safer alternatives; however, studies are still lacking that evaluate the long-term effects of opioids on pain, function and quality of life. For this reason, a powerful study called a randomized-controlled trial (RCT) was conducted to compare opioid therapy to non-opioid therapy for patients with back, knee or hip pain over one year.

Veterans dealing with pain serve as the study group

Veterans with chronic low back pain (LBP) or moderate-to-severe hip or knee osteoarthritis were invited to participate in the RCT. These individuals were screened to determine if they were eligible, and 240 were accepted and then randomly assigned to either the opioid or non-opioid therapy group. Patients in the opioid group received a combination of different drugs at various times over one year that included morphine, oxycodone, hydrocodone and fentanyl. Patients in the non-opioid group received a completely different combination of drugs that included acetaminophen, non-steroidal anti-inflammatory drugs and lidocaine, amongst others. All patients were monitored regularly over one year, and at the end of the study they were evaluated for pain-related function and intensity of pain, both of which were assessed on a scale from 0-10 (higher score indicates more pain).

Opioids and non-opioids lead to very similar outcomes

Overall, results showed that patients who received opioids improved to a very similar extent compared to those who received non-opioids. In particular, the opioid group improved from a score of 5.4 at the start of the study to 3.4 one year later in pain-related function, while the non-opioid group improved from 5.5 to 3.3. Regarding pain intensity, both groups reported a 5.4 at the study start, but the opioid group improved to 4.0 and the non-opioid group improved to a 3.5. This means that the non-opioid group actually improved by 0.5 points more than the opioid group, which was considered a small but significant difference. In addition, opioid group patients experienced significantly more negative symptoms related to their medications than the non-opioid group. This is the first study to compare opioids versus non-opioids in the long-term, and it provides strong evidence that opioids should not be the first line of treatment for chronic musculoskeletal pain. Additional research is now needed to confirm these results, but this study is considered a major breakthrough that has filled a gap in the evidence on opioids for chronic pain. Determining the best way to prescribe opioids will continue to be a controversial topic, but these findings will likely be referenced in any related discussion. The study should also urge doctors to prescribe alternatives to opioids like physical therapy, which is a risk-free treatment that has been proven to help many painful conditions such as back pain and osteoarthritis. Patients should be aware that they can see a physical therapist directly, without a referral, if they are in pain and seeking out a safer alternative to opioids.

– As reported in the March ’18 issue of JAMA

Guidelines are necessary to assist doctors with treatment recommendations

Low back pain (LBP) is one of the most common of all sources of disability. More than 80% of people will experience LBP at least once in their lives, and it has become the number one reason people visit a doctor for pain that affects the muscles or bones. There are many treatments available for LBP, and it may be difficult for some doctors to determine which is the best possible approach for each patient. To help with this process, a number of guidelines have been developed, which include various recommendations that are intended to create the best possible outcomes for patients. Unfortunately, the quality of some of these guidelines is not very high, which can lead to medical professionals recommending treatments that are ineffective, expensive, or even harmful. For this reason, a team of researchers decided to conduct a study called a systematic review of all the treatment guidelines available. The goal of the review was to identify which conservative (non-surgical) treatments were found to be most effective for LBP and which should not be recommended.

13 studies are analyzed in the review

Researchers searched through 10 major medical databases for studies that included guidelines on the best treatments for LBP. They only accepted studies that targeted adults and/or children with guidelines on conservative treatments or treatment protocols for LBP. Out of 2,504 studies identified, 75 were assessed in greater detail, and 13 of these fit the necessary criteria for the review. All accepted guidelines were then analyzed in detail and compared to one another to determine which treatments are best for LBP. The quality of each study was also assessed and given a rating to indicate how reliable their guidelines were.

Education, activity, and therapy are all central to effective treatment for LBP

The results of this study identified a number of treatments that were recommended by all of the guidelines reviewed. For acute LBP (pain that has only lasted for up to six weeks), the following recommendations were found in all the guidelines: advice and/or education, returning to activities or staying active, acetaminophen (Tylenol) and a hands-on form of physical therapy called spinal manipulation. The same treatments were also recommended for chronic LBP (pain that lasts for longer than six weeks), and additional recommendations for specific back exercises were found in the guidelines as well. The researchers also reported that of the 13 guidelines reviewed, 10 were found to be of high quality. Finally, it was pointed out that a recent study challenged the effectiveness of acetaminophen for treating acute LBP, which calls this recommendation into question. Based on these findings, it appears that education and advice, staying active, physical therapy that includes spinal manipulation and performing specific back exercises are the most commonly recommended treatments for LBP based on available guidelines. The fact that most of these guidelines were of high quality also indicates that their recommendations are strongly supported and reliable. Medical professionals treating patients with LBP should, therefore, consult these guidelines and recommend treatments accordingly in order to produce the best possible results.

-As reported in the February ’17 issue of the European Journal of Pain

Knee condition is one of the leading causes of disability in the country

Osteoarthritis is a painful condition that develops when cartilage breaks down over the course of time. This is why it’s often called “wear and tear” arthritis. Osteoarthritis can occur in any joint in the body, but the hips and knees are affected most frequently. Knee osteoarthritis is a very common condition that affects more than 10% of the adult population, and it’s considered a leading cause of disability in the U.S. Conservative (non-surgical) treatment that includes physical therapy is typically recommended as the first line of treatment for knee osteoarthritis, but surgery may be necessary for patients that fail to improve. Total knee replacement is the most common surgical procedure used to treat these patients, and it often leads to successful outcomes with less pain and better knee function afterward. Before getting to the point when surgery is needed, knee osteoarthritis patients may undergo a variety of different treatments. There is a set of treatment guidelines from the American Academy of Orthopaedic Surgeons (AAOS) that all doctors should be following when making these decisions, but many doctors continue to prescribe treatments that are not recommended. To get a better idea of what types of treatments doctors are prescribing knee osteoarthritis patients before surgery and how much it’s costing, a study was conducted.

Large database examined for patterns in treatment recommendations

A large database used for recording information on patients who had a total knee replacement surgery served as the main source of data for the study. Researchers identified 86,081 patients who fit the necessary criteria for the study and examined the treatments that they received prior to having surgery. Based on the guidelines for treating knee osteoarthritis, they chose to analyze the use of eight treatments, which included physical therapy, braces, injections and both over the counter and prescription pain medications, including opioids.

None of the top three treatments used are supported as effective

Results showed that in the year prior to having knee replacement surgery, most patients (66%) received at least one of the analyzed treatments for their knee osteoarthritis, which cost an average of $506 per patient. The three most commonly used treatments were corticosteroid injections, hyaluronic injections, and opioids. For the injections, one of two different chemicals—either a corticosteroid or hyaluronic acid—is injected directly into the knee to reduce pain. In total, these three treatments accounted for about 43% of the costs associated with managing knee osteoarthritis; however, none of them are recommended by the guidelines as effective interventions for this condition. In addition, the hyaluronic injections were responsible for approximately 30% of patients’ costs, even though the guidelines strongly recommend against using them. This shows that many patients with knee osteoarthritis are being given treatments that are not recommended, which could cost them more and do not even lead to successful outcomes. Patients dealing with knee osteoarthritis should, therefore, seek out only treatments that follow the AAOS guidelines, which will help them experience the best possible outcomes and avoid surgery unless it is completely necessary.

-As reported in the January ’17 issue of The Journal of Arthroplasty