Evidence based practice in physical therapy and the medical profession

Evidence based medicine/surgery/physical therapy

Spinal-fusionPhysical therapists and other clinicians follow the evidence… please

August 4, 2016

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Jon Keller Physical therapist

According to the New York Times Aug 3, 2016 Gina Kolata reports that…

The FDA does not regulate surgical procedures. A spinal fusion was tested in 4 clinical trials and surgery was no better than supervised exercise and therapy to help patients deal with their fear of back pain. This was according to the Spine Journal 2007 and the authors Mizra, Deyo et. al. Despite this information Deyo of OHSU said spinal fusion rates have increased quite a bit since this article in 2007.

.Now there are some cases where a fusion is appropriate of course. If a patient has intractable pain, consistent numbness down the leg and weakness from a pinched nerve, if a patient has compression on the nerve that is not able to be corrected except by fusion, and spondylolisthesis that is significant and in danger of getting worse.  But other strategies should be incorporated first.  The general order is anti inflammatories if the Dr deems appropriate, try exercises with a physical therapist and treatments with a physical therapist, perhaps a cortisone injection,  perhaps a microdiscectomy, perhaps a laminectomy,perhaps radiofrequency on the spinal nerves that are causing local pain, or perhaps a disc replacement.  Then the consideration of a spinal fusion may be appropriate if the orthopedic spinal surgeon believes it is necessary.

– A fusion is shown below. www.virginiaspinespecialists.com shows a picture below of a fusion.

Vertebroplasty or injecting cement into the vertebrae after it is fractured has been shown to not be effective at pain relief.  The procedure is performed usually after there is a compression fracture of a vertebrae.  According to a 2009 New England Journal of Medicine article by Kallmes et al. doing a sham treatment versus the actual procedure resulted in no difference of pain relief. The picture below is by painmd.tv

About 400,000 Americans have a meniscus surgical procedure a year on their knee. There is not a correlation of pain to meniscus tears according to the NY times article as cited above. There are many people that have a meniscus tear on an MRI of the knee but no pain. Dr Katz of Harvard did a study on meniscus surgeries and most said it offered little help. A meta analysis of  meniscus surgery showed that a sham treatment versus the surgical procedure didn’t show much difference at all in outcomes. Below is a picture of a meniscus repair.  From clinical experience I would say there are some cases that a meniscus repair would be effective and I have seen some be effective in helping the patient return to less pain and much less difficulty with their activities of daily living and sports.  But I have seen that with parts of the meniscus being removed that years later there is a much higher likelihood of quicker onset of arthritis in the knee that had the procedure.   Drugs.com shows a picture of a meniscus surgery

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