Physical Therapy as Effective as Surgery for Torn Meniscus and Arthritis of the Knee, (Human) Study Suggests

Just One of Many Studies Published on This Topic-

My programs for conservative (no surgery) treatment are clinically and anecdotally successful. So, this means that clients and veterinarians do the work and get good results.

Physical Therapy as Effective as Surgery for Torn Meniscus and Arthritis of the Knee, (Human) Study Suggests –

“Surgery may not always be the best first course of action.

A physical therapist, in many cases, can help patients avoid the often unnecessary risks and expenses of surgery. To reinforce that, this study should help change practice in the management of symptomatic meniscal tears in patients with knee osteoarthritis.” Mar. 21, 2013 — A New England Journal of Medicine (NEJM) study showing that physical therapy is just as effective as surgery in patients with meniscal tears and arthritis of the knee should encourage many health care providers to reconsider their practices in the management of this common injury, according to the American Physical Therapy Association (APTA).

The study, published March 19, showed no significant differences in functional improvement after 6 months between patients who underwent surgery with postoperative physical therapy and those who received standardized physical therapy alone.

“This study demonstrates what physical therapists have long known,” explained APTA President Paul A. Rockar Jr, PT, DPT, MS. “Surgery may not always be the best first course of action. A physical therapist, in many cases, can help patients avoid the often unnecessary risks and expenses of surgery. This study should help change practice in the management of symptomatic meniscal tears in patients with knee osteoarthritis.”

According to lead physical therapist for the trial and American Physical Therapy Association (APTA) member Clare Safran-Norton, PT, PhD, OCS, “our findings suggest that a course of physical therapy in this patient population may be a good first choice since there were no group differences at 6 months and 12 months in this trial.

These findings should help surgeons, physicians, physical therapists, and patients in decision-making regarding their treatment options.”

Researchers at 7 major universities and orthopedic surgery centers around the country studied 351 patients aged 45 years or older who had a meniscal tear and mild-to-moderate osteoarthritis of the knee. Patients were randomly assigned to groups who received either surgery and postoperative physical therapy or standardized physical therapy. Within 6-12 months, patients who had physical therapy alone showed similar improvement in functional status and pain as those who had undergone arthroscopic partial meniscectomy surgery. Furthermore, patients who were given standardized physical therapy — individualized treatment and a progressive home exercise program — had the option of “crossing over” to surgery if substantial improvements were not achieved. In this situation, thirty percent of patients crossed over to surgery during the first 6 months. At 12 months these patients reported similar outcomes as those who initially had surgery. Seventy percent of patients remained with standardized physical therapy.

According to an accompanying editorial in NEJM,”millions of people are being exposed to potential risks associated with a treatment [surgery] that may or may not offer specific benefit, and the costs are substantial.” Physical therapist and APTA member Mary Ann Wilmarth, PT, DPT, MS, OCS, MTC, Cert MDT, chief of physical therapy at Harvard University, said, “Physical therapists are experts in improving mobility and restoring motion. The individualized treatment approach is very important in the early phases of rehabilitation in order to achieve desired functional outcomes and avoid setbacks or complications.”

Story Source:

The above story is reprinted from materials provided by American Physical Therapy Association. Note: Materials may be edited for content and length. For further information, please contact the source cited above.

Journal Reference:
Jeffrey N. Katz, Robert H. Brophy, Christine E. Chaisson, Leigh de Chaves, Brian J. Cole, Diane L. Dahm, Laurel A. Donnell-Fink, Ali Guermazi, Amanda K. Haas, Morgan H. Jones, Bruce A. Levy, Lisa A. Mandl, Scott D. Martin, Robert G. Marx, Anthony Miniaci, Matthew J. Matava, Joseph Palmisano, Emily K. Reinke, Brian E. Richardson, Benjamin N. Rome, Clare E. Safran-Norton, Debra J. Skoniecki, Daniel H. Solomon, Matthew V. Smith, Kurt P. Spindler, Michael J. Stuart, John Wright, Rick W. Wright, Elena Losina. Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis. New England Journal of Medicine, 2013; : 130318220107009 DOI:10.1056/NEJMoa1301408

WHERE DO I PUT THE ICE?

Where Do I Put The Ice?

I have read the homework and this is a dumb question, but I do not know where to put the ice on an ACL tear.

I would like to have an evalution to see what I can do to make my guy better. He has started limping more and I want to start using the ice. He does not seem to be in any pain at all and I do not have him on any meds except a chinese herb which is not helping. I will be setting up my work schedule tomorrow for the upcoming weeks. Is it possible for you to evalute my boy?

Not a dumb question at all…for now, you may just place a pack directly on his knee, on the side, while he is lying down. Leave on the pack for 20 minutes, no towels or other barriers, especially if he has fur…that is enough of a barrier.

Yes, we may set up an appt. I have some openings next week, and I will write you mail this weekend to set up a time and day. Thanks-

Oh, and if he is limping, he is likely in pain.

It is common for most people, even people with medical training, to think for a variety of reasons I won’t take time to discuss here that the animal is not in pain, however the best demonstration that he is in a little pain, at the least, is usually limping.

I suggest you speak to the vet about getting an anti-inflammatory or another pain reliever, like Tramadol (used a lot here in Austin, TX), if you are open to that idea, and if you are not, we will talk about some other options when I see him for evaluation. There are usually not any combinations of even several non-pharmaceutical helps that will do away with the type of pain that is enough to make the patient limp. This means you usually need pharmaceutical drugs to help your pet feel better, feel less pain.

Also, if you do give a pain reliever for a day or two and the limping stops, that is another good clue that the limping has been due to pain. For more information on pain, please see my pain posts by searching the word pain in the search box.

I also highly recommend fish oil capsules…they are anti-inflammatory, for one, and good for many things. Look for a capsule with 1000 mg of oil or less and definite amounts of EPA and DHA, noted separately on the label. A good place to start is about 20 mg of EPA daily for every kg of body weight.

Deb

Goldendoodle Lame after Surgery for Osteochondritis Dissecans (OCD)

Goldendoodle Lame After OCD Surgery

My 8 month old goldendoodle had ocd shoulder surgery 10 weeks ago.  It was not arthroscopic, but open surgery.  He was still limping 4 weeks later, so he was opened up again for a second surgery on the same shoulder.  It has been five weeks.  He has been given the series of 8 adequan shots, which he just finished, and he limps as bad or worse that he did at the beginning. What can we do?  I am heartbroken.  My vet says he has ocd in the other shoulder as well, but I’m not about to do anything about it, until we can get our dog out of pain from his first shoulder.

hi! I just finished my last appointment and I’m on my phone right now voice texting you via email.
are you near me in Austin, Texas?
my first thought is this takes quite a while to heal and your dog needs more pain medication.
what meds is your dog on right now?
also, since this takes a while to heal, she should be doing specific short controlled walks and no extra activity around the house.
let me know what’s going on with these things-
Deborah

Deborah-

Sadly, I am not near you.  I live in Missouri.  We actually have 2 doodles.  They are brothers.  I think that might be part of the problem, however, the vet said that after 4 weeks of quiet time, that there are no restrictions on Cxxx (my poor puppy).  He can run like the wind with his brother, but walking slowly is a real challenge.  I could go on forever.  Are you in the medical field, or are you familiar with this problem?  I feel so bad for him.  Yesterday was a beautiful day, so he ran around alot.  Today, he walks almost like his leg is broken.  I give him 1/2 of a Rimadyl tablet, every few days.  I’ve heard so many bad stories about how that drug hurts his liver, so I hate to keep him on it. I also have some tramadol left over from the second surgery, but I didn’t know if it was okay to use it.  I really thought the adequan shots were going to be the miracle drug, but I don’t see any change at all.  I so appreciate taking the time to discuss this with me, as I am at wits end, and the thought of putting him through another surgery just sounds awful to me.  Thanks again for your response.   P

P-

Thank you 🙂 (for the kudos on the FB page)
So, from what you have said, everything I have posted on my WordPress website should answer your dilemma  even though this info is different from what you might have heard to do.
Cxxx needs pain relief and at least 12 weeks of no crashing around and very slow exercise protocol. No wild running. Read all my posts on pain after surgery.
Yes, I am very familiar, as you may have figured out by now, and I was blessed to have Grace Great Dane in my life for 10.5 yrs, and she had very bad OCD in one knee and mild in the other. That’s a longer story I haven’t written.
Anyway, in all my years of athletic involvement and now animal recovery, the biggest issue I have seen is lack of appropriate recovery time.
Get a harness and MAKE him go slowly, following any of my post-surgical homework assignments beginning at WEEK 1.
Use the Tramadol as if just after surgery, and see if that is enough to enable solid leg use during the very, very slow walks, and if so, you won’t need to use the nsaid for now. If you need to use the anti-inflammatory (nsaid), it is likely not going to do a bunch of damage. Usually vets don’t prescribe the meds without checking blood work anyway, and that was likely checked prior to surgery, at the least.
The bone was modified, and at the least the recovery time is 12 weeks. That is a general statement, but you will almost never, ever go wrong with strict control and specific recovery and rest.
I am currently working with two Goldendoodle sisters, and yes, they collaborate to damage each other.
This is a good opportunity to work on your being the alpha and doing some training. 🙂
Blessings-
Deborah

You also said this in the other mail stream:
The Rimadyl doesn’t seem to take the edge off either. I give him a baby aspirin sometimes too. He was first diagnosed with pano. I knew something was wrong since he was 5 months old, but I was always told it was “growing pains”. We went to a different vet, who took xrays and found the divit in his bone. The Dr. said it was about the size of his thumbnail. When he went in the second time, he went in the backside and found more, some of the cartilage had taken hold, but some had not. I could explain more, but don’t want to bore you with details. Wish I could bring him in to see you. P

So, more replies for you…
Adequan is ok. In theory it is better than ok, however in my experience, very many animals do not respond notably to it. It is expensive for something that often doesn’t bring the expected relief. If you have a pet that doesn’t seem to notably benefit, then it is likely that he is not getting enough benefit to warrant the cost and potential drama of application. My Dane didn’t seem to benefit. Once in a while I see a pet that the owners REALLY think is benefiting from Adequan, so it’s likely a good choice for them.

Do not give baby aspirin along with another anti-inflammatory. It is very important to not double up on any nsaids (anti-inflammatories: Prednisone, Rimadyl, Deramaxx, Previcox, Metacam, Meloxicam, Vetprofen, etc…). They will be quick to give a bleeding stomach ulcer. Like I suggested previously, stick to the dog nsaid and let it do the work is is supposed to, use it as a good tool, and then he will be able to get off it for longer periods in his life. ALWAYS give an nsaid on a full meal, not just with a snack and definitely not an empty stomach. Tramadol may be given on an empty stomach, as may Gabapentin.

If you don’t give more restricted care and medication to the shoulder(s) now, the chance for arthritis increases, and since arthritis is likely at this point, take care and be gentle to let the body heal better.

I highly recommend Omega 3’s in fish oil, either by using sardines as part of daily food (reduce kibble accordingly and don’t make him fat :)), or using a good quality supplement. Find a supplement that contains about 400 mg of EPA in each capsule and start with one of those daily, moving up to 2 daily after about a week and after seeing that he adjusts in his gut (no squishy poop).

I also really like Xymogen DJD as a joint health formula.

I also highly recommend going grain-free in food and treats. Short story is that grains are difficult to digest and they are pro-inflammatory. End of short story. Substantial clinical research validates this.

Gotta go-
Blessings

Changing Pain Relievers for Pepper-Torn Ligament

Changing Pain Relievers for Pepper-Torn Ligament

Deborah-

Dr. L prescribed 2 weeks worth of Gabapentin and wants to have a check up with her on Feb 11th. He said that it is definitely a torn cruciate but will reassess for the meniscus at her check up.

Pepper is willing to put weight on her leg without any ice with the additional pain meds, and almost doesn’t ‘cheat’ at all on her walks! So far she may only miss 3 or 4 steps by cheating now, where before we were lucky to get her to get several good strides in a walk. She’s already even starting to use it a little on her own in the house. K said that he had good results with her walks when he sat and iced her knee for 30 minutes.

Her pill regimen now is 1.5 tramadol 3x/day, and 1 gabapentin 2x/day with the rimadyl at 0.5 2x/day.

I think that is all for now!
Jan 29

to B-

That is great!
So, do the five minute walks this week, getting success at weight-bearing, and then next weekend start her on the ten minute walks.
I think we can make some headway now 🙂
What milligram dose is the Gabapentin? 100 or 300?
Blessings-

D-

Its 100 mg. It’s still amazing to me the difference in her walks!

Jan 29

to B-
Good… That’s even a pretty low dose for her size, It’s just a better drug for her body chemistry, evidently, and it often works really well along with Tramadol.
I am very happy about this!

Hi Deborah,

Pepper is not getting any sleepier than normal with the added pill, but I’m not sure that I have seen much decrease in her limping. I forgot to mention that she has been out of glucosamine for about 1.5 weeks, so that may have a little effect. It finally came in the mail tonight so she will be back on track with that.

She is taking the new walk time well.

B

Hi B-

Overall, great info.

So, you gave one more Gabapentin along with the other pills? Twice a day or just once? Also, the Glucosamine could make a substantial difference. In the near future, maybe we can switch her to a natural anti-inflammaroty, Xyflamend, instead of the nsaid she is taking, after she is pretty stable for a while and not any additional lameness…

Deborah

Deborah-

We are giving her the additional gabapepentin with all the same pain meds.

I would definitely like to get her on a safer antinflammitory. Do you have any experience with bromelein? B

B-

B-

good…

yes, I have experience with it, and let’s talk about transitioning at my next visit. I feel it’s too soon right now because we just got to a better place, so let’s give her the stronger tools to keep getting better muscularly, and then we’ll transition her to biologically kinder interventions for longer term.

good? 🙂

Deborah- 

sounds good! 

Pepper will need refills on everything by the end of next week. I didn’t realize that he changed her dose of the Rimadyl. He changed it to 1/2 tab per day and she was taking two 1/2 tabs per day.

B

Feb 24

B-

Good-

That’s a step in downsizing, and what you need to look for is more lameness with less drugs. I realize you are now giving more Gabapentin…has there been less lameness with that? And then look to see if there is more lameness with less Rimadyl.

She won’t need the same drugs/doses “forever”, but once we get on the upside of the pain, there is no sense in removing the drugs before the rehab work is done, so I do it in increments, looking for more muscle and function production and less lameness.

I’m sure that makes sense 🙂

Blessings-

And, as for switching to a natural anti-inflammatory,

Remember that Omega 3’s are anti-inflammatory (whereas the other Omegas are pro-inflammatory), and you also mentioned that you were going to get more of the Glucosamine/Chondroitin/MSM joint formula Pepper was using before you ran out. Both of those are good to implement now and for the duration of her life, as you probably know.

Like I said in the email I just wrote, the vet reducing the amount of the nsaid is a step in downsizing, and what you need to look for is more lameness with less drugs. I realize you are now giving more Gabapentin, too, than you previously were…has there been less lameness with that? And then look to see if there is more lameness with less Rimadyl. In the older dogs with torn ligament and torn meniscus, we have consistently gotten better pain relief with an nsaid, Tramadol, and Gabapentin all together in moderate doses. This always seems to work better than trying to eradicate pain with high levels of just one or even two drugs. She won’t need the same drugs/doses “forever”, but once we get on the upside of the pain, there is no sense in removing the drugs before the rehab work is done, so I do it in increments, looking for more muscle and function production and less lameness.

I often remind people that once we get to the good pain relief with the least lameness we are thoughtfully able to accomplish, then we need to stay there while the functional drills progress (so long as blood work supports that). Often then along the way less lameness is realized, less pain, because the muscles build and the joint settles down and other positive things are taking place. It is only after good, consistent success with exercises and drills that we want to play with reducing the pharmaceutical medications. Often, then, if there are no conflicts, I encourage some of the older dogs to get on Xyflamend, which I have found beneficial and have been using more and more recently in conjunction with a local vet who is well-versed in herbs and knows there are no conflicts. I have personally used the product for a couple of years now as part of an anti-inflammatory regimen for my body as well as for some joint and muscle pains.

You asked about bromelain as a natural anti-inflammatory, and I’m aware that the internet is full of testimony toward Wobenzym N, a popular supplement that contains bromelain and other protease enzymes and that it has been around for quite a while. I tried it for a bit in the 1990’s. The approach is different in Wobenzym N than Xyflamend, and maybe both would eventually be good for her, but they are also not cheap (neither one), so I usually start now with Xyflamend due to the advance of research into some of its components and because I really, really like tumeric/curcumin 🙂

My finding is that (unfortunately?) there is not any one natural remedy that has the impact on greater pain, like Pepper has and like most of my patients have, that pharmaceuticals have, and I have found that a combination of natural substances, like Xyflamend and/or Wobenzym N and Omega 3’s and Glucosamine/Chondroitin/MSM at the forefront, works best for long-term maintenance.

There definitely isn’t one natural compilation along with interventions from us, like massage/ice/heat/laser, that will take over in a situation like this, with torn meniscus and with her ongoing pain that we’ve had a difficult time finding the right combo of pharmaceuticals to address. I have found this out over time and through very many cases, even in thinking of allowing for every being having slightly differing biochemistry. In time, though, and with thoughtful progress, we should be able to transition to more natural aids without also putting a huge dent in your schedule for the day!

I had a client at one time with a quite elderly mid-sized dog, and he did not want to use any pharmaceutical interventions. This dog appeared quite painful and was very, very stiff from arthritis. I had him doing a regimen of massage and ice and I did laser therapy. He also used several neutraceuticals (Omega 3’s, joint formulas), and I also recommended Epsom salt baths (rinsing very well after). These interventions, along with some others, did little to quell the pain, yet the time investment was around 3 hours daily. I finally talked him into dosing the trial of Rimadyl the vet had given him, and his pet was notably substantially better by later the first day. Unfortunately for the dog, I don’t think he continued with that medication and he fell off of pursuing rehab interventions.

I won’t take time here to get into windup pain or concepts of getting on top, over the top, of substantial pain and minimizing the reactivity. I think we are on a good path with Pepper so long as she continues to show improvement. Keep me posted!

Blessings-Deborah