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SKEPTOID BLOG:

Physical Therapy as Good as Surgery?

by Stephen Propatier

March 20, 2013

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Donate There has been a widely reported federally funded study showing arthroscopic surgery is no better than physical therapy. This is a absolute unequivocal truth. Within a certain point of view. When it comes to science reporting there are always issues with narrative versus facts and science versus story. Since I specialize in orthopedics I felt it necessary to review this article and help people understand where the writers got it right and where they got it wrong.

The Washington Post, among others, has written a story indicating physical therapy is far more effective than arthroscopic surgery. The details are factually true. Like many science news stories the facts are minimized and the narrative is accentuated to make the story more catchy. "You might not want to rush into knee surgery. Physical therapy can be just as good for a common injury and at far less cost and risk, the most rigorous study to compare these treatments concludes. Therapy didn't always help and some people wound up having surgery for the problem, called a torn meniscus. But those who stuck with therapy had improved as much six months and one year later as those who were given arthroscopic surgery right away, researchers found."

The overall narrative in the news has been compelling. Doctors are doing unnecessary surgery when simple physical therapy will cure you. Very alternativ-y. Again a gross oversimplification of a complicated problem. The reality is that this study is neither groundbreaking nor new information to orthopedic surgeons.

To give you a common frame of reference, I will review some simplified definitions for orthopedic treatment and procedure.

Knee Arthritis-in the orthopedic setting simply wear and tear to the cartilage of the knee. More factually it is osteoarthritis. Arthritis literally means joint pain and is a description not a disease.

Knee Arthroscopy-surgical procedure, two small incisions in the front of the knee where a light source and a camera is inserted through one incision. Through the other incision a surgical tool is inserted. This is to visualize the knee structures and perform surgical procedures.

Meniscal tear-A tear to the soft cartilage of the knee, a common injury. Common in degenerative knees as well as acute injury. The meniscus is a C shaped cartilage. There is one on the inside of the knee called the medial meniscus. There is another C shaped cartilage on the outside portion of the knee called the lateral meniscus. Some studies have show that as much as 40% of people over age 55 have some damage to the meniscus.

As an overview of the research, I will review the pertinent findings. This was a nationally funded study, had several different orthopedic centers. A large number of patients were evaluated in a well-controlled double blinded study. Success was judged by patient satifaction. I think that this was a good piece of research. It is consistent with prior research. That physical therapy is as least as effective as arthroscopic surgery especially in knees that have significant osteoarthritis.

The reasons for this are well understood by orthopedic surgeons, but not well understood by the public. Often the reports talk about repairing the meniscus. That is not factually true. Surgically the torn cartilage is removed and the remaining cartilage is smoothed. In osteoarthritis most of the articular cartilage is damaged in some way. There is usually significant cartilage loss. In the case of severe osteoarthritis there is no cartilage left, only exposed bone. Even in moderate cases there can be very little healthy cartilage to work with at he injury site. Removing cartilage from the knee and smoothing the small amount of remaining cartilage does not have good success rate. By the same token a young healthy knee with "normal" articular cartilage has a very good success rate removing a torn fragment.

This is not a eye opening moment for orthopedic surgeons, but it appears to have spurred discussion in the news media about the effectiveness of arthroscopic surgery. It is well-known that knee osteoarthritis is a poor prognostic indicator for arthroscopic surgery. For the last six years in my practice I have encouraged patients with degenerative arthritis to avoid arthroscopic knee surgery. Prior arthroscopic research indicated a 1 in 10 chance of improvement with significant degenerative changes. Plus 1 in 5 chance of making your pain symptomatically worse.

This study is in line with what other research has shown us. In my practice for the last six years I have spent many hours discussing this fact with patients. More often than not, patients wish to pursue surgery due to the simple fact that they misunderstand the problems of osteoarthritis and meniscal tears. Patients like surgery, especially arthroscopic surgery. It's a short stay in the hospital, it promises a quick fix, people have high expectations. They fail to grasp the concept that you can leave a torn meniscus alone and have no pain. I spend a great deal of time encouraging patients to avoid arthroscopic surgery and pursue conservative measures, especially in cases of knee arthritis.

Take this for the anecdote it is, but I see hundreds of knee osteoarthritis patients a year with this problem. For the last 6 years I have almost universally recommended avoiding arthroscopic procedures and trying physical therapy for this condition. 6 years not 6 days. Despite that patients are often resistant to physical therapy. Frankly put they feel like I'm giving them a job to get rid of their knee pain. Surgery has the lure of "pill treatment", a quick simple fix to their problem. The surgery is a fix not a cure. There is no effective method to restore cartilage currently. Patients often express frustration because my partners refuse to consider arthroscopic surgery in arthritis cases. They wish that the physician would at least consider trying it.

The story in the television media has been presented falsely as "arthroscopic surgery is no better than physical therapy". Given what I've written you can see that this is actually a very complicated statement. This should not be decided by your television news man nor the science beat writer at the Washington Post. This is a discussion that has many nuances to it. This is why you pay your orthopedic physician a great deal of money for his knowledge and his experience. The training and continued medical education give him or her the ability to determine a good candidate for arthroscopic surgery versus a poor candidate. This is old news to us. Maybe that is why it was published in NEJM not an orthopedic journal.

In my opinion, and it is supported by the research, arthroscopic surgery should never be the first treatment option for a meniscal tear. Patients should always be encouraged to pursue physical therapy first. No matter what your age, the severity of the injury, or your level of pain, physical therapy can have success. That does not automatically mean that surgery is universally useless or that therapy is universally good. Media presentation, both in print and television has been giving a false impression.

Always remember that getting your medical advice from your TV is generally a mistake. Science is not one study, good science is multiple lines of good evidence.

Stephen L. Propatier MS, NP

DNS voice recognition technology and software, please excuse minor grammatical/typographical errors.

References:


Usefulness of knee arthroscopy for diagnosis of knee pain in pediatric patients: comparison with preoperative clinical diagnosis.


Hagino T, Ochiai S, Watanabe Y, Senga S, Saito M, Wako M, Ando T, Sato E, Haro H.

Arch Orthop Trauma Surg. 2013 Mar 19.






Arthroscopic Excision of Solitary Intra-articular Osteochondroma of the Knee.


Kim JI, Kwon JH, Park YJ, D'Almeida VR, Soni SM, Nha KW.

Knee Surg Relat Res. 2013 Mar;25(1):36-39. Epub 2013 Feb 27.







Results of Arthroscopic Partial Meniscectomy for Lateral Discoid Meniscus Tears Associated with New Technique.


Lee CH, Song IS, Jang SW, Cha HE.

Knee Surg Relat Res. 2013 Mar;25(1):30-35. Epub 2013 Feb 27.







Review of Meniscal Allograft Transplantation Focusing on Long-term Results and Evaluation Methods.


Lee BS, Kim JM, Sohn DW, Bin SI.

Knee Surg Relat Res. 2013 Mar;25(1):1-6. Epub 2013 Feb 27.







Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis.


Katz JN, Brophy RH, Chaisson CE, de Chaves L, Cole BJ, Dahm DL, Donnell-Fink LA, Guermazi A, Haas AK, Jones MH, Levy BA, Mandl LA, Martin SD, Marx RG, Miniaci A, Matava MJ, Palmisano J, Reinke EK, Richardson BE, Rome BN, Safran-Norton CE, Skoniecki DJ, Solomon DH, Smith MV, Spindler KP, Stuart MJ, Wright J, Wright RW, Losina E.

N Engl J Med. 2013 Mar 18.








Arthroscopic Evaluation of the Accuracy of Clinical Examination versus MRI in Diagnosing Meniscus Tears and Cruciate Ligament Ruptures.


Navali AM, Bazavar M, Mohseni MA, Safari B, Tabrizi A.

Arch Iran Med. 2013 Apr;16(4):229-32. doi: 013164/AIM.008.







In vitro electro-mechanical characterization of human knee articular cartilage of different degeneration levels: A comparison with ICRS and Mankin scores.


Abedian R, Willbold E, Becher C, Hurschler C.

J Biomech. 2013 Mar 7. doi:pii: S0021-9290(13)00074-2. 10.1016/j.jbiomech.2013.02.004.








Arthroscopic treatment of symptomatic paralabral cysts in the hip.


Lee KH, Park YS, Lim SJ.

Orthopedics. 2013 Mar 1;36(3):e373-6. doi: 10.3928/01477447-20130222-29.







Effect of Evidence and Changes in Reimbursement on the Rate of Arthroscopy for Osteoarthritis.


Holmes R, Moschetti W, Martin B, Tomek I, Finlayson S.

Am J Sports Med. 2013 Mar 4.



PMID:
23460330

[PubMed - as supplied by publisher]


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by Stephen Propatier

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