November 14, 2018 at 7:18 am #7043Eric MagrumKeymaster
Have a read post your thoughts; changes for patient management, communication from this high impact journal results (again).
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November 15, 2018 at 2:38 pm #7067jeffpeckinsParticipant
Did anyone else find this article difficult to read and follow, or was that just me? To begin, I don’t like the phrasing of arthroscopic partial meniscectomy (APM) vs PT to determine if PT is noninferior than the surgery. Why can’t it just be PT vs APM, with the possibility of PT being BETTER than surgery, not just “noninferior”? Not only do I think that this already puts PT in a bad lighting, it just makes the results and conclusions that much more difficult to interpret, with double-negative jargon such as “results did not demonstrate noninferiority at the 12- and 24- month time points.”
One thing that really struck me was the adverse events section of the paper. It reported that there were 9 participants in the APM group and 8 in the PT group that suffered serious adverse events (CV, neurological, or internal medicine conditions, venous thromboembolisms, or repeat knee surgery). I wasn’t able to gain access to the supplemental content which apparently stated what each adverse effect was, but what was PT doing that resulted in EIGHT serious adverse effects? Were people who switched from the PT group to the APM group, and then had to undergo another knee surgery included in this category? Can anyone else explain this?
The PT groups’ exercise protocol seemed to all be the same and all participants received the same treatment. Does anyone else agree that the PT groups’ results may have been different if the physical therapists were able to tailor their interventions to the patient based on severity, irritability, and patient tolerance for specific exercise?
Looking at the results and discussion, it seems to say that at 3 and 6 months, PT and surgery were comparable, but at 12 and 24 months, surgery had better results than the PT group. To me, that seems to say that overall surgery had better outcomes. However their conclusion states “PT was noninferior to APM for improving patient-reported knee function over a 24 month follow up period.” Either I am missing something, or their conclusion doesn’t match their results. I think a better conclusion could be that although APM showed slightly better long-term results when compared to PT, PT had comparable short-to-mid-term results and should be the first treatment choice in adults with non-obstructive meniscal tears.
November 18, 2018 at 8:16 pm #7079Matt FungParticipant
After reading this article I brought it up the findings to one of my patients recovering post meniscectomy and she was very surprised to hear the results and mentioned she never considered a conservative route. This was not a huge surprise to me and goes in line to what the article mentioned about APM being among the most frequently performed procedure in orthopedic surgery.
In my short time as a clinician I have seen the positive outcomes from both sides of this study. My biggest takeaway is that we as health professionals need to take the patient’s views into account when determining if surgery or conservative treatment is the best path for them. More often times than not these patients images are being ordered by orthopedic surgeons who read their results and are quick to recommend surgery. People usually want the quick fix for their pain so they don’t think twice about surgery, but what if patients do not want to get cut into? We need to advocate for our profession to patients and surgeons about the positive outcomes of conservative treatment for these injuries. Patients need to be properly educated about the different treatment options and involved in the decision making.
Jeff I agree that the objective and design of the study were interesting like you mentioned. Do to the nature of the study being a RCT they needed to control the variables which is most likely why each patient did not receive individualized treatment. That same thought crossed my mind when reading about the APM group and their intervention being simple HEP to perform individually.
November 19, 2018 at 5:35 pm #7081Cameron HolshouserParticipant
Jeff and Matt, you guys make great points.
This article would have been great for a patient I evaluated 2 months ago. The patient stated “if I have a tear in my meniscus, why am I coming to physical therapy instead of surgery” at the beginning of the session. Below are his MRI findings (which the patient brought with him to the evaluation). After the subjective and objective exam, the patient presented with symptoms consistent with meniscal and MCL involvement.
MRI left knee:
1. “Free edge tear of the posterior horn of the medial meniscus which is smaller than normal, likely related to a prior tear but no displaced fragment identified,
2. Discoid lateral meniscus without tear
3. Sprain vs low grade partial tear of the ACL
4. Partial tear of the semimembranosus tendon with muscle strained associated with posterior oblique ligament injury,
5. Strain of the MCL with probably tearing of portions of the coronary ligament “
I stated to the patient: Conservative management with physical therapy has similar outcomes to meniscal surgery, and if we’re not making any progress, then I would refer you back to the doc. Even if surgery is appropriate, those who have conservative management prior to surgery have better outcomes anyway, so it’s a win-win. But we need to at least try PT for a minimum of 6-8 weeks to see some changes.
Many of the physical therapy related journals recently have published findings stating that conservative management has similar outcomes to meniscal surgery. This article is really nice to compliment the PT journals who have lower impact factors (i.e. BJSM impact factor 7.8) to JAMA which is 47.7. This is definitely a nice article to back up our recommendations for pro-PT versus the patient taking our word for it. I would use this article in the future for this type of patient to help patient buy in to conservative management. I will still bring this up to this patient when I see him next time.
Any thoughts on this patient or patient education?
Luckily, this evaluation was during mentorship hours, so Mike was able to help me through this case.
November 20, 2018 at 9:56 am #7082Erik KreilParticipant
Jeff – Matt – Cam
I agree that this article standalone will appear to take a halfhearted look at the effectiveness of PT in its role in conservative management before surgery; but I think this viewpoint actually adds to the already saturated bank of research supporting PT’s potential superiority.
Existing research, to my knowledge, supports marginal superiority of PT > meniscal repairs in instances without mechanical blocks. With this article, we can make a stronger argument to support the utility of PT before surgery by stating that we’re non-inferior (or comparable, more like). APM surgeries cost around $4 billion, so if PT is comparable then this definitively should be the primary recommendation rather than introducing an expensive trauma (surgery) to the patient.
Cam, your case example is probably one of the most common discussions PTs have with patients who’ve experienced an injury-related event. Ultimately, the medical world is going to need to start using the existing bank of research as real-world guidelines to guide patients into the right doors (PT vs surgery vs specialist). PTs are fighting an uphill battle against cultural norm, so it’s more important than ever for PTs to be fluent in the current literature. I’d take an approach similar to yours, and maybe even go over the article in-person to make my viewpoint less of a “claim.”
November 25, 2018 at 9:00 pm #7100CaseylburrussParticipant
Hey all. I don’t really have much to add however reading through this discussion chain it reminded me of a conversation I was having with one of my patients who recently was seeking my opinion on conservative versus surgery for a SLAP tear. By the way, this guy should not get surgery.
I won’t bore you with all the details of his injury etc. however after giving my professional opinion (lets try PT first), he hit me with a question that kind of stumped me. His question was along the lines of “So are you telling me I’m going to have to do all these exercises and stretches for the rest of my life to feel better in order to get to where I want to be with my shoulder and do what I want to do?” making other comments like “if I get surgery it sounds like more work up front but less work in the long run”
I realize without a lot of detail it is hard to give me super specific advice on what to say but wondering if anyone has had similar interactions or discussions with their patients? Cam, what would you say to this guy if he had similar questions about his knee. For example, maybe after his therapy session with his exercises he feels and moves better but to him that’s an hour out of his day he is dedicating to his knee. Relaying the “first line therapy” idea to the patient with evidence, like this article, is great to have however what I hadn’t thought about is what are these conservative people at 24 months follow-up still doing regarding their HEP? Are they still dedicating a lot of their time to their exercises versus those who had surgery and are 2 years out. I wish I had better insight or experience to better communicate with my patients on what their management will need to be in the long run with conservative management. Just some food for thought.
November 28, 2018 at 8:28 am #7131Jon LesterParticipant
This discussion resonates with right now in particular. I’ve been treating a guy with what appeared at first to be a partical RTC tear from a traumatic traction injury (caught himself from falling from a roof). At IE, he was actually the one advocating for conservative tx before I got the chance to bring up the conversation. He wanted to avoid further imaging, sx, and any other medical management, which I thought lined us up for a pretty successful bout of conservative care.
I’ve seen him 5 times up until yesterday and he was making decent progress at first. He was able to reach his forehead with his R hand after not being able to lift it beyond 60 deg elevation at IE. He was having a somewhat easier time doing ADLs – was able to eat with his R hand, get dressed slightly easier, and wash his left arm with his R hand. However, over the past three visits, he has developed significant mm guarding, N/T in his fingers, shooting pains throughout UE, and other signs of possible nerve originated symptoms. At this time, we had made no progress over the past 2 weeks and the pt appeared to be getting more painful as these shooting pains worsened. I suspected that he might have a brachial plexus traction injury or something similar at his IE, but it wasn’t until more recently that it became more apparent.
Because of the new onset of symptoms, he began to worsen within session too. Anything I tried made him more painful and he was noticing more difficulty with the ADLs described above. I had the discussion with the pt about how it did not appear that conservative management was appropriate for him at this time due to his onset of neurological symptoms and worsening of UE ROM/strength. We decided yesterday to refer him back to his referring physician for further consult. It was a joint decision and he was definitely on-board because he knew that his recent deterioration was a good reason for some form of continued medical management outside of PT (e.g. imaging, pharmacological intervention, etc). He is still on my schedule moving forward but we plan on changing his appts as appropriate based on his consult.
This was my first time having to refer someone who “failed” conservative management. I’m curious if anyone else would have kept treating him, referred him earlier, or done similar to what I did (ride it out for a few visits and then refer). Let me know your thoughts.
November 28, 2018 at 2:57 pm #7132Cameron HolshouserParticipant
That is definitely a hard question to answer because the patient makes a valid point. Attached is an article that BJSM published not too long ago titled, “Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline.” I really like this article because it has some nice graphics that are researched based but also easy to explain to patients. One graphic compares the long term benefits, short term benefits, and short term harms of conservative vs surgical management. Their study found that there was no difference in long term benefits in pain or function (1-2 years) between the two approaches. Arthroscopic surgery had more favorable results in short term benefits (< 3 months) in pain and function yet arthroscopic surgery had increased harmful events such as DVT and infection compared to conservative management which had no adverse events. Not to mention the cost of imaging and the surgery itself which is much more expensive than conservative management. This article is somewhat biased towards conservative management in my opinion but it does give valid points that we can mention to patients with this diagnosis. So going back to your patient’s question Casey, you could potentially show him that yeah you might feel better in the short term with surgery but there is no different in long term benefits and there is a higher risk of adverse events with surgery. As for the exercises every day comment, you could say that you don’t have to perform the exercises every day once your function/pain is normal but you’ll know how to self-manage your symptoms in the future.
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December 6, 2018 at 8:47 am #7172Erik KreilParticipant
I love how clear this article makes its point, and the graphics can be great tools to visibly support our discussion with a patient who has no background knowledge (and may have a predisposition toward surgery). As a clinician, having knowledge of good studies like these are tools on the table that we can use to help shape a person’s understanding of the proverbial scales when it comes to comparing one option over another; that being said, we have to remember the power of perception.
Not everyone will look at a visual diagram or respond to the recitation of research equally, we have to parallel with the patient for the tool to be effective. A good example is a new patient I had yesterday. He begins the evaluation simply communicating that he’d had poor experience with PT prior, and he’s frankly unsure if we can help him with his diagnosis (s/p axillary lymph node removal resulting in gross paresthesia and local hypersensitivity to his triceps). He’s basically asking for concrete evidence, and Laura and I were able to show him a desensitization protocol and some research demonstrating how we can be effective. For others, this might not mean as much, and it’s our job to recognize that we’re not just a clinician talking to a patient. Every treatment is a human interaction between people, and we can be more effective if we take the time to understand our patients and tease out important viewpoints for their care.
Casey, it might be helpful to just continue having an open but intentional conversation to see his viewpoints. This can be a foothold for more conversation and potentially more effective discussion.
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