He was to discuss the study Tuesday at an American Academy of Orthopaedic Surgeons conference in Chicago. Results were published online by the New England Journal of Medicine.
Posted January 7th, 2010 at 10:02 pm
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Physical Therapy’s Effects Equal to Surgery for Spinal Stenosis Symptoms
Physical therapy for spinal stenosis is as effective as surgery and should be fully considered as a first-choice treatment option, according to a new study that is the first to directly compare a single, evidence-based physical therapy regimen with decompression surgery among patients who agreed to be randomly assigned to either approach.
The study focused on self-reported physical function among 169 participants diagnosed with lumbar spinal stenosis (LSS) after 2 years, but it also tracked function measurements along the way–at baseline, 10 weeks, 6 months, and 12 months. Researchers found that not only were 2-year effects similar for the 2 groups (87 who began with surgery and 82 who started with physical therapy), the increase in function followed similar trajectories from baseline on.
Research was conducted between 2000 to 2007, and limited to patients 50 years and older who had no previous LSS surgery and had no additional conditions including dementia, vascular disease, metastatic cancer, or a recent history of heart attack.
The study, which appears in the Annals of Internal Medicine (abstract only available for free), was led by Anthony Delitto, PT, PhD, FAPTA, with coauthors includingSara R. Pilva, PT, PhD, FAAOMP, OCS, Julie M. Fritz, PT, PhD, FAPTA, andDeborah A. Josbeno, PT, PhD, NCS. The findings have been reported in Reuters, the Pittsburgh Post-Gazette, Medpage Today, and other outlets.
According to an editorial that accompanies the article (sample available for free), what makes this research important is that it restricted the nonsurgical approach to a single physical therapy regimen, and that participants—all of whom were prequalified for surgery—consented to a randomized treatment approach. Previous studies focused on surgical vs (mostly unspecified) “nonsurgical” approaches, and some allowed patients to self-select their treatment groups.
Editorial author Jeffrey N. Katz, MD, MSc, writes that the current study more accurately represents practice, in which “clinicians and patients must choose between surgery and a particular nonoperative regimen, rather than an amalgam of regimens.”
Those particular nonoperative physical therapy treatments administered to the participants included “instruction on lumbar flexion exercises including posterior pelvic tilts and supine knee-to-chest and quadruped flexion exercises; general conditioning exercises, including stationary cycling or treadmill walking; lower extremity strengthening exercises … ; lower-extremity flexibility exercises deemed appropriate … ; and patient education to avoid postures involving hyperextension of the lumbar spine,” authors write.
Most participants in the physical therapy group attended at least 1 of the 12 prescribed sessions, with two-thirds participating in at least 6 sessions. However, over half (57%) of the physical therapy group elected to have surgery at some point within the 2-year study window. While authors write that this crossover presents “a challenge in interpretation,” additional analysis revealed that even with this shift, “any differences between the groups were not significant.”
“From a clinical standpoint, Delitto and colleagues’ trial suggests that a strategy of starting with an active, standardized [physical therapy] regimen results in similar outcomes to immediate decompressive surgery over the first several years,” writes Katz in his editorial. “Taken together, these data suggest that patients with LSS should be offered a rigorous, standardized [physical therapy] regimen. Those who do not improve and ultimately consider surgery should be informed that the benefits are likely to diminish over time.”
Both the study’s authors and Katz agree that health provider-patient communication is key.
“Patients and health care providers should engage in shared decision-making conversations that include full disclosure of evidence involving surgical and nonsurgical treatments for LSS,” authors write, with Katz’s editorial arguing that “because long-term outcomes are similar for both treatments yet short-term risks may differ, patient preferences should weigh heavily in the decision of whether to have surgery for LSS.”
Surgery, therapy both prove good for knee repair.
After six months, both groups had similar rates of functional improvement. Pain scores also were similar.
Thirty percent of patients assigned to physical therapy wound up having surgery before the six months was up, often because they felt therapy wasn’t helping them. Yet they ended up the same as those who got surgery right away, as well as the rest of the physical therapy group who stuck with it and avoided having an operation.
“There are patients who would like to get better in a `fix me’ approach” and surgery may be best for them, said Elena Losina, another study leader from Brigham and Women’s Hospital.
However, an Australian preventive medicine expert contends that the study’s results should change practice. Therapy “is a reasonable first strategy, with surgery reserved for the minority who don’t have improvement,” Rachelle Buchbinder of Monash University in Melbourne wrote in a commentary in the medical journal.
As it is now, “millions of people are being exposed to potential risks associated with a treatment that may or may not offer specific benefit, and the costs are substantial,” she wrote.
Surgery costs about $5,000, compared with $1,000 to $2,000 for a typical course of physical therapy, Katz said.
One study participant – Bob O’Keefe, 68, of suburban Boston – was glad to avoid surgery for his meniscus injury three years ago.
“I felt better within two weeks” on physical therapy, he said. “My knee is virtually normal today” and he still does the recommended exercises several times a week.
Robert Dvorkin had both treatments for injuries on each knee several years apart. Dvorkin, 56, director of operations at the Coalition for the Homeless in New York City, had surgery followed by physical therapy for a tear in his right knee and said it was months before he felt no pain.
Then several years ago he hurt his left knee while exercising. “I had been doing some stretching and doing some push-ups and I just felt it go `pop.'” he recalls. “I was limping, it was extremely painful.”
An imaging test showed a less severe tear and a different surgeon recommended physical therapy. Dvorkin said it worked like a charm – he avoided surgery and recovered faster than from his first injury. The treatment involved two to three hour-long sessions a week, including strengthening exercises, balancing and massage. He said the sessions weren’t that painful and his knee felt better after each one.
“Within a month I was healed,” Dvorkin said. “I was completely back to normal.”
Rehabilitation Within A Day of Knee Replacement Pays Off.
Starting rehabilitation sooner following knee arthroplasty surgery could pay dividends – for both patients and hospitals. Commecing physical therapy within 24 hours of surgery can improve pain, range of motion and muscle strength as well as cut hospital stays, according to new research in the journal Clinical Rehabilitation, published by SAGE.
Mindful of the trend towards discharging patients from hospital more rapidly after surgery in recent years, physical therapy and public health researchers from Almeria, Malaga and Granada in Spain set out to investigate whether an early start to physical therapy would improve recovery from knee arthroplasty surgery. They compared patients who began treatment within 24 hours of surgery with those who began 48-72 hours after their operation in a random, controlled clinical trial. Each group comprised over 150 patients aged 50-75.
The post-operative treatment began with a series of leg exercises, breathing exercises, and tips on posture. By the second day walking short distances with walking aids was added, and in subsequent days this was built up towards adapting to daily life activities, such as beginning to climb stairs on day four.
On average, those beginning treatment earlier stayed in hospital two days less than the control group and had five fewer rehabilitation sessions before they were discharged. An early start also lead to less pain, a greater range of joint motion both in leg flexion and extension, improved muscle strength and higher scores in tests for gait and balance.
Health systems are currently subjected to strong economic pressures, and a cutting the length of hospital stays has become a priority. Other benefits of early mobilization after this surgery are fewer complications such as deep vein thrombosis, pulmonary embolism, chest infection, and urinary retention. With hospital-acquired infections such as MRSA also a serious concern, a shorter hospital stay might also lower the risk to patients of contracting this type of secondary infection.
“Orthopaedics, especially knee replacement surgery, is one area that may lend itself to accelerated discharge,” says author Adelaida Mª Castro Sánchez, from the University of Almeria. “We therefore postulated that early rehabilitation after total knee arthroplasty could accelerate the capacity of patients for daily life activities, and reduce their hospital stay.”
Osteoarthritis is estimated to affect around three quarters of over 65s in developed countries, and when it affects the knees it can be intensely painful, affecting the gait and leading to deformity. As a result, replacing the knee joint with a surgical implant has now become a routine, but major, surgical procedure.
Source: Medical News Today
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