Don’t Blame the Structure – The Role of Belief and Movement in Orthopedics

**Updated 2/16/14**

The purpose of this post is to have a central link on this blog which will contain brief summaries of the growing evidence demonstrating a continued need for us to examine the role of belief and movement interventions prior to pursuing surgical interventions for many common orthopedic conditions.

Please let me be clear that there are certainly clear need for surgical intervention for the management of symptoms, even in the absence of medical necessity. In fact, the structure may be involved and may have initiated the output from the brain, but may not necessarily be responsible for continued symptoms. However, the emphasis on structure has resulted in a growing trend towards excessive, unnecessary, expensive, and risky surgical procedures for the management of pain and movement dysfunction. These procedures are occurring despite clear evidence indicating that just because a “damaged” structure innervated with nocioceptors is removed or “repaired” and the patient feels better and/or moves better, the structure itself does not fully explain for the existence of the symptoms, nor does it fully explain for improved symptoms. The advent of placebo surgeries and increased number of true randomized controls for surgical intervention have opened a whole new realm of understanding of the role of structure in the human body.

This post is incomplete as it stands and will be constantly updated. I welcome any and all recommended additions to it, with the hope that it will grow into a stand alone section of the blog itself:

Arthroscopic Debridement for Knee Osteoarthritis
First, the landmark study by Moseley et al. which started it all in 2002 which showed that both  arthroscopic debridement (‘cleaning up”) and lavage (‘washing out’) were no better than placebo surgery for moderate to severe osteoarthritis: http://www.ncbi.nlm.nih.gov/pubmed/12110735

Second, Kirkley et al. addressed some the questions brought about from critics about the pain measures from the Moseley et al. This study compared arthroscopic debridement and lavage to physical therapy and conservative medical therapy and found again that  neither arthroscopic debridement nor lavage provide any additional benefit over physical therapy and conservative medical therapy: http://www.ncbi.nlm.nih.gov/pubmed/18784099

Third, Herrlin et al. found that arthroscopic debridement with physical therapy was no different than physical therapy alone: http://www.ncbi.nlm.nih.gov/pubmed/17216272

Fourth, Katz et al. looked at individuals with a meniscal tear and evidence of mild-to-moderate osteoarthritis on imaging found that arthroscopic partial meniscectomy with physical therapy had no better outcomes that physical therapy alone: http://www.nejm.org/doi/full/10.1056/NEJMoa1301408

Finally, the 2nd edition of the “Treatment for Osteoarthritis of the knee” from the American Academy of Orthopaedic Surgeons officially states “We cannot recommend performing arthroscopy with lavage and/or debridement in patients with a primary diagnosis of symptomatic osteoarthritis of the knee.” and their first recommendation in this association statement was “We recommend that patients with symptomatic osteoarthritis of the knee participate in self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education; and engage in physical activity consistent with national guidelines.” with the following clarifying statement written within the recommendation that “The exercise interventions were predominantly conducted under supervision, most often by a physical therapist”.

Arthroscopic Meniscectomy
Most recently (December 2013), Sihvonen et al. compared  arthroscopic partial meniscectomy for patients age 35-65 with degenerative meniscal tears without knee osteoarthritis with placebo surgery and found that their outcomes were no different: http://www.nejm.org/doi/full/10.1056/NEJMoa1305189?query=featured_home

This is in agreement with earlier studies which also showed that arthroscopic partial meniscectomy followed by supervised exercise was no better than supervised exercise alone:
http://www.nejm.org/doi/full/10.1056/NEJMoa1301408 – (May 2013)
http://www.ncbi.nlm.nih.gov/pubmed/17216272 – (2007)

Spinal Fusion for Low Back Pain
A study which followed up on previous randomized controlled trials of spinal fusion versus exercise and behavioral therapy for chronic low back pain found that there no difference in outcome after 10 years and there is no evidence for continued deterioration of symptoms in the absence of surgical intervention. Making strong suggestion for avoiding fusion due to the increased risks of surgical intervention for spinal fusion: http://www.ncbi.nlm.nih.gov/pubmed/24200413

A meta-analysis of  666 patients (402 cases) over 4 randomized control trials demonstrated no benefit of spinal fusion over conservative treatment. The authors concluded the evidence was so strong that no further research was necessary: http://mobile.journals.lww.com/intjrehabilres/_layouts/oaks.journals.mobile/articleviewer.aspx?year=2014&issue=03000&article=00002

No different in outcomes between conservative treatment and lumbar fusion after 10 years:
http://www.ncbi.nlm.nih.gov/pubmed/24200413

Vertebroplasty
Multi-center trial which compared vertebroplasty to a simulated procedure (placebo) without cement for OSTEOPOROTIC SPINAL FRACTURES. The capital letters are for the fact that for the simulated procedure, those vertebrae are still “not secured” or “healed”. Despite this, outcomes between groups for pain and pain related disability were similar at 3 months. The authors did an excellent examination of cross over effects, well worth reading the full text: http://www.nejm.org/doi/full/10.1056/NEJMoa0900563

A similar study design was performed which also confirmed that the fractures were unhealed via MRI and expanded the follow-up to 6 months. Similarly no benefits for vertebroplasty over sham was noted: http://www.nejm.org/doi/full/10.1056/NEJMoa0900429

Miller et al. discuss verbroplasty and the placebo response here: http://pubs.rsna.org/doi/full/10.1148/radiol.11102412

A meta-analysis of these two studies concludes that the hypothesis of the possibility of a specific subgroup benefiting from vertebroplasty is unlikely to have unique benefits from vertebroplasty: http://www.bmj.com/content/343/bmj.d3952

Inappropriate imaging, excessive specialist referral, and lack of physical therapy referral for Low back pain
A recent study on trends in the management of back pain examine the treatment of back pain from January 1, 1999, through December 26, 2010. The researchers found a worsening trend in the management of back pain inappropriately referred for imaging and specialists when they should have been referred to physical therapy first: http://archinte.jamanetwork.com/article.aspx?articleid=1722522

Non-surgical intervention of atraumatic full-thickness rotator cuff tears
A multicenter study of 452 patients who are treated with physical therapy first rather than initiating surgery for full-thickness (complete) rotator cuff tears found that 75% of the patients after 2 years opted not to have surgery due to a satisfactory outcome from physical therapy alone: http://www.ncbi.nlm.nih.gov/pubmed/23540577

Achilles Ruptures treated non-operatively have equivalent outcomes to operative interventions
A randomized study of 144 patients with an average age of 40 revealed that non-operative treatment of achilles ruptures had no difference in functional strength, range of motion, calf circumference, functional scores, or re-rupture rate between groups. In addition, a greater number of soft tissue complications were noted in the operative group: http://www.ncbi.nlm.nih.gov/pubmed/21037028

Is ACL reconstruction the best management strategy for ACL rupture?
A systematic review and meta-analysis of ACL repair versus non-operative repair demonstrates poor available evidence for ACL interventions as a whole, but that current evidence appears to indicate that a non-surgical intervention should be attempted prior to considering surgical intervention. http://www.thekneejournal.com/article/S0968-0160(13)00199-3/abstract

MRI detection of disc herniation has no indication on outcome and is associated with lesser sense of well-being
In a study which examined both surgical and conservative treatment of sciatica and lumbar disc herniation, the presence of disc herniation on MRI after 1 year had no association with the outcome. 85% with the presence of disc herniation after 1 year of treatment still had a favorable outcomes: http://www.ncbi.nlm.nih.gov/pubmed/23484826

This is in agreement with previous research which revealed that not only was MRI findings not representative of the patients symptoms or outcomes, but that knowledge of the MRI findings resulted in a lesser sense of well being: http://www.ncbi.nlm.nih.gov/m/pubmed/16244269/

Surgical Scraping for Achilles Tendinopathy
In a study of patients with bilateral chronic achilles tendinopathy, surgical scraping performed on one side (the most painful side). Despite having expected to need a second surgery for the opposite side, 11 of the 13 patients had full resolution of symptoms bilaterally after unilateral scraping. Many already had full satisfaction bilaterally within the first 6 weeks. The authors make a good discussion why they believe these improvements were centrally mediated, not mechanically oriented: http://www.ncbi.nlm.nih.gov/pubmed/23193327

No difference in outcomes between arthroscopic acromioplasty and supervised exercise for shoulder impingement syndrome
A randomized control trial of 140 patients with shoulder impingement syndrome showed no differences in pain or function at any point over a 5 year follow-up. Furthermore, surgical intervention was not considered cost effective and the recommendation was that structured exercise should be the treatment of choice for shoulder impingement: http://www.ncbi.nlm.nih.gov/pubmed/23836479

Shoulder Impingement Syndrome and Central Sensitization
A trial which compared 17 age matched patients awaiting arthroscopic subacromial decompression to a matching asymptomatic control group and identified a significant proportion of these patients presented with notable central sensitization. Those with the most pronounced levels of central sensitization had significantly worsening outcomes at 3 months post subacromial decompression than those with lower levels: http://www.ncbi.nlm.nih.gov/m/pubmed/21464489/

Examining peripheral and central mechanisms in shoulder pain
Why does my shoulder hurt? A review of the neuroanatomical and biochemical basis of shoulder pain: http://www.ncbi.nlm.nih.gov/pubmed/23429268

The pain of tendinopathy: Physiological or Pathophysiological: http://www.bodyinmind.org/wp-content/uploads/Rio2013.pdf

The central nervous system e An additional consideration in ‘rotator cuff tendinopathy’ and a potential basis for understanding response to loaded therapeutic exercise: http://www.ncbi.nlm.nih.gov/pubmed/23932100

Multiple abnormalities of the hip are normal imaging findings in asymptomatic individuals, including labral tears
In a random sampling for 45 volunteers (60% males) with an average age of 37.8 y/o, MRI imaging revealed “Labral tears were identified in 69% of hips, chondral defects in 24%, ligamentum teres tears in 2.2%, labral/paralabral cysts in 13%, acetabular bone edema in 11%, fibrocystic changes of the head/neck junction in 22%, rim fractures in 11%, subchondral cysts in 16%, and osseous bumps in 20%”: http://www.ncbi.nlm.nih.gov/pubmed/23104610

Cervical surgery with physical therapy versus physical therapy alone resulted in similar outcomes after 2 years
Although surgical intervention demonstrated a more rapid improvement in the first year, these differences were no longer present after 2 years. Due to the decreased risks and decreases costs, physical therapy was recommended prior to considering surgical intervention: http://www.ncbi.nlm.nih.gov/m/pubmed/23778373/

MORE TO COME..

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About Leonard Van Gelder

Leonard Van Gelder is a physical therapist, athletic trainer, therapeutic pain specialist, and strength and conditioning specialist. Leonard has strong interests in pain science and the use of Therapeutic Neuroscience Education (TNE) and manual therapy based on the body Neuromatrix model in his rehabilitation and performance enhancement approaches. Leonard also develops strategies for injury prevention and sports performance enhancement. He is a clinical scientist and occasionally contributes to scientific literature through authorship in peer reviewed publication and serving as a peer reviewer. View all posts by Leonard Van Gelder

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