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Mechanical Tissue or _____ Injury: What is at fault?

2/6/2014

3 Comments

 
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In recent years, Physical Therapy research has emerged that compares surgical interventions to placebo surgeries. For certain conditions, there is now fairly substantial evidence that surgical intervention is not always necessary despite what is considered standard societal practice. The most recent example of this is a December 2013 article written by Sihvonen et al, that investigated arthroscopic surgical menisectomy compared with placebo surgery for individuals with degenerative meniscal tears. The results were pretty interesting! In a recent post by Leonard van Gelder at Dynamic Principles, he discusses the reasons behind why this appears to continually be happening & gives several good examples of when conservative management is either more successful or equally successful as surgery. 

Questions you need to ask yourself: 
-If patients have similar results in surgery vs. placebo surgery, what is at fault in the patient? The mechanical system cannot solely be the answer. The answer lies in the patient's belief system regarding tissue healing and surgery.
-How should this change the type of education you give a patient regarding certain conditions?
-How do you manage a patient that strongly believes surgery is the answer (after a disc herniation for example) despite knowing that surgery is not always the best course of action. 

(As Leonard discusses in his post, we are well aware that certain conditions require surgical intervention. By no means are we saying surgery is a bad thing. We are simply bringing light to certain conditions that respond positively from conservative management.)

3 Comments
Jeff Abernethy
2/10/2014 02:03:12 am

The true reason for a placebo is to see if a patient has benifit when no procure is conducted at all. This study was not a true placebo. The patient had surgery. Surgery is a procedure. I speculate that the patient may have actually experienced true physically and mechanically improved as a result of the trauma and recovery from the sham procedure. Is it the the removal of the meniscis or the act of creating a healing response in patients that works? As PTs, we may be better equiped than orthopedic surgeons to get most "meniscis tears" back to full function, although, some cases of mechanical block, clearly need surgery to clear.

Reply
Leonard Van Gelder link
2/15/2014 12:08:54 pm

Hello Jeff,
While the Sihvonen et al, study did include lavage, a placebo study by Mosely et al. in 2002 specific to OA, not meniscectomy only utilized cutting the skin as a placebo with excellent results between groups http://www.ncbi.nlm.nih.gov/pubmed/12110735. Although not related to a complete menisectomy, the average arthroscopic debridement does include cleaning up meniscus fraying along with other loose tissues.

Specific to meniscectomy. both Katz et al (http://www.nejm.org/doi/full/10.1056/NEJMoa1301408) and Herrlin et al. (http://www.ncbi.nlm.nih.gov/pubmed/17216272) showed physical therapy is equivical to meniscectomy which despite a lack of a placebo without lavage, makes it questionable whether removal of a mechanical block is necessary. Albeit, as always, there are specific cases where this may be necessary.

Reply
Jeff Abernethy
2/16/2014 10:15:28 pm

Thank you for your reply and I agree with your comments. I am certified to perform Dry Needle Therapy and one of the speculated theroys behind why we see improvement during Dry Needling is that we create a miro lession and generate a healing response by the body. The Mosely study you reference may be affective simply by creating a lession and the body has a natural response to recover. In doing so, the body heals all neighboring areas in distress. Pretty cool stuff, but more than a placebo I think.

Reply



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  • Home
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  • Online Courses
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    • Return to Sport Essentials Course
  • Resources
    • Newsletter
    • Business Minded Sports Physio Podcast
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    • Residency Corner
    • Special Tests >
      • Cervical Spine >
        • Alar Ligament Test
        • Bakody's Sign
        • Cervical Distraction Test
        • Cervical Rotation Lateral Flexion Test
        • Craniocervical Flexion Test (CCFT)
        • Deep Neck Flexor Endurance Test
        • Posterior-Anterior Segmental Mobility
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        • Sharp-Purser Test
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      • Thoracic Spine >
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        • Thoracic Compression Test
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      • Lumbar Spine/Sacroiliac Joint >
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        • Alternate Gillet Test
        • Crossed Straight Leg Raise Test
        • Extensor Endurance Test
        • FABER Test
        • Fortin's Sign
        • Gaenslen Test
        • Gillet Test
        • Gower's Sign
        • Lumbar Quadrant Test
        • POSH Test
        • Posteroanterior Mobility
        • Prone Knee Bend Test
        • Prone Instability Test
        • Resisted Abduction Test
        • Sacral Clearing Test
        • Seated Forward Flexion Test
        • SIJ Compression/Distraction Test
        • Slump Test
        • Sphinx Test
        • Spine Rotators & Multifidus Test
        • Squish Test
        • Standing Forward Flexion Test
        • Straight Leg Raise Test
        • Supine to Long Sit Test
      • Shoulder >
        • Active Compression Test
        • Anterior Apprehension
        • Biceps Load Test II
        • Drop Arm Sign
        • External Rotation Lag Sign
        • Hawkins-Kennedy Impingement Sign
        • Horizontal Adduction Test
        • Internal Rotation Lag Sign
        • Jobe Test
        • Ludington's Test
        • Neer Test
        • Painful Arc Sign
        • Pronated Load Test
        • Resisted Supination External Rotation Test
        • Speed's Test
        • Posterior Apprehension
        • Sulcus Sign
        • Thoracic Outlet Tests >
          • Adson's Test
          • Costoclavicular Brace
          • Hyperabduction Test
          • Roos (EAST)
        • Yergason's Test
      • Elbow >
        • Biceps Squeeze Test
        • Chair Sign
        • Cozen's Test
        • Elbow Extension Test
        • Medial Epicondylalgia Test
        • Mill's Test
        • Moving Valgus Stress Test
        • Push-up Sign
        • Ulnar Nerve Compression Test
        • Valgus Stress Test
        • Varus Stress Test
      • Wrist/Hand >
        • Allen's Test
        • Carpal Compression Test
        • Finkelstein Test
        • Phalen's Test
        • Reverse Phalen's Test
      • Hip >
        • Craig's Test
        • Dial Test
        • FABER Test
        • FAIR Test
        • Fitzgerald's Test
        • Hip Quadrant Test
        • Hop Test
        • Labral Anterior Impingement Test
        • Labral Posterior Impingement Test
        • Long-Axis Femoral Distraction Test
        • Noble Compression Test
        • Percussion Test
        • Sign of the Buttock
        • Trendelenburg Test
      • Knee >
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        • Dial Test (Tibial Rotation Test)
        • Joint Line Tenderness
        • Lachman Test
        • McMurray Test
        • Noble Compression Test
        • Pivot-Shift Test
        • Posterior Drawer Test
        • Posterior Sag Sign
        • Quad Active Test
        • Thessaly Test
        • Valgus Stress Test
        • Varus Stress Test
      • Foot/Ankle >
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        • Calf Squeeze Test
        • External Rotation Test
        • Fracture Screening Tests
        • Impingement Sign
        • Navicular Drop Test
        • Squeeze Test
        • Talar Tilt
        • Tarsal Tunnel Syndrome Test
        • Test for Interdigital Neuroma
        • Windlass Test