Deborah Carroll's Blog, page 17

Fighting Foot Drop

“Brown prepares patients for challenges met in the community and at home by having patients walk on foam mats in the clinic and then on various surfaces outside.”

Employing these techniques in animal-other-than-human rehab is what I do and is highly successful here, as well–proprioceptive training that can also build nerve strength  For dogs and cats,  I utilize Orthovet footbed splints and Thera-Paws Dorsi-Flex Assist boots on a case-by-case basis.

FROM OUR PRINT ARCHIVES





The Foot Drop Fight
Early treatment and compliance with a home exercise program are essential.

By Rebecca Mayer Knutsen

Posted on: December 20, 2012
 

Footdrop

Foot drop, a general term for difficulty lifting the front part of the foot, can be a temporary or permanent condition. The condition signals an underlying neurological, muscular or anatomical problem.

A patient with foot drop due to weakness or paralysis may exhibit behavior such as scuffing her toes along the ground. Or she may develop a high-stepping gait so her foot does not catch on the floor as she walks.

Beyond the obvious frustrations and limitations that accompany this condition, these patients are at greater risk for falls. According to physical therapists, early treatment and patient commitment to a prescribed home exercise program is often the best approach for patients with this gait abnormality.

Gaining Control

The source of foot drop is most commonly a central neurological impairment such as stroke, multiple sclerosis or traumatic brain injury or a peripheral injury such as nerve damage stemming from knee replacement surgery.

“Controlling foot drop through strengthening, orthotics or a functional electrical stimulation foot drop system may address the instability of the ankle, limit the possibility of catching the toe during gait and increase safety and stability to decrease the potential of falls,” said Gregory A. Thomas, PT, physical therapy supervisor, Rehabilitation Center at Eastern Idaho Regional Medical Center in Idaho Falls, ID.

Therapists must conduct a thorough PT evaluation that includes a complete patient history and an assessment of range of motion, strength, sensation, spasticity, reflexes and mobility. Treatment varies depending upon the cause and presentation of the foot drop. Treatment options range from therapeutic exercises including ROM, stretching and/or strengthening to electrical stimulation and gait training.

“The first thing I do with a patient is determine if the dysfunction is central or peripheral,” explained Douglas O. Brown, PT, CSCS, manager of Raub Rehabilitation, Sailfish Point Rehabilitation and Riverside Physical Therapy, all part of Martin Health System in Stuart, FL. “Is it a brain injury such as stroke or MS?” Brown asked. “Or is it a pinched nerve in back or leg or damage from a hip surgery?”

Once the origin of the foot drop has been determined, Brown must determine if the patient is flaccid with no movement whatsoever. “If so, then the outcome /prognosis will not be as good as someone who exhibits some movement,” he shared.

According to Thomas, PT exercises for this patient population include range of motion exercises for knees and ankles and strengthening leg muscles with resistance exercises. And, stretching exercises are particularly important to prevent the development of stiffness in the heel.

“There are no exercises that are off limits to these patients as long as the ankle is stable during the exercise,” Thomas explained. “The exercises can be closed chained or open depending on the level of stability.”

“We have to focus on restoring normal movement patterns but also on stability,” Brown said. “Can the patient stand on one leg without swaying back and forth? It’s important that we remember the static part because these patients function on different surfaces in real life.”

Brown prepares patients for challenges met in the community and at home by having patients walk on foam mats in the clinic and then on various surfaces outside.

“If my patient’s goal is to be able to walk the beach in her bare feet, then we need to work on uneven surfaces,” Brown said.

The therapists need to understand a patient’s case 100 percent and treat each one as an individual. These patients need to be assessed on their own merits, according to Brown. “If I have a patient with a traumatic ankle injury from being run over by a car, then I may stay away from certain load bearing exercises,” he shared.

Enter the AFO

If a patient does not have functional use of his muscles, then an ankle foot orthosis (AFO) can be used to keep the ankle at 90 degrees and prevent the foot from dropping toward the ground, thereby creating a more even and normal gait.

The type of AFO used depends on each patient’s specific needs. Some of the types most commonly used include solid ankle, articulated ankle and posterior leaf spring and are most typically made of polypropylene. Articulated ankles allow for some ankle motion, dorsiflexion assist and partial push-off during gait and solid ankle AFOs are rigid and more appropriate if the ankle and/or knee are unstable. Patients typically need to wear a larger shoe size to accommodate these types of AFOs.

“As a physical therapist, I need to realistically fulfill the goal of a patient, which in the case of foot drop, is most typically to stop using an AFO,” Brown explained. “But there are other issues to consider aside from the annoyance of the device. I may need to worry about comorbidities such as diabetes and how the AFO may be causing skin breakdown.”

Brown aims to improve his patients’ optimum function and quality of life while decreasing the fall risk. “Once a patient tells me his goals, I need to determine if they are realistic,” he told ADVANCE.

The goal of physical therapy with these patients is to use the least restrictive device, according to Thomas. “If there is active movement at the ankle and we can strengthen it back to normal, then a temporary brace can be used for support and to increase safety,” he stated. “If the foot drop is more long standing, a custom fitted AFO may be needed.”

In the last 10 years or so, AFOs have improved in quality and function, according to Brown. In fact, he says, some AFOs are made of carbon fiber and elicit a dynamic action instead of keeping the foot rigid while going through the swing phase of gait.

Another option is a foot drop system that applies electrical stimulation in a precise sequence, which then activates the muscles and nerves to lift the foot and bend or extend the knee. This type of device assists with a more natural gait, reeducates muscles, reduces muscle loss, maintains or improves range of motion and increases local blood circulation.

The foot drop device allows a flexible ankle during gait to obtain a more normal walking pattern. A good alternative to bracing, the device’s gait sensor adapts to changes in walking speed and terrain, allowing the patient to walk easily on stairs, grass and carpet.

Brown recently treated a 37-year-old woman with early stages of MS. He put the FES foot drop system on her and it helped her walk normally for the first time in years, bringing tears to her eyes.

“FES can help patients develop great gait patterns and fire muscles,” Brown observed. “FES shows the potential for improvement and the patient can rent the device themselves to wear all day instead of an AFO. The technology is helpful but the device isn’t for everyone. There is a better response with central foot drop as opposed to peripheral lesions.”

The device works well when the peripheral nerve is intact. Patients with a peripheral nerve injury-from diabetes or trauma-who have no palpable muscle contractions may not see improvements. “If the damage is peripheral nerve, then a FES foot drop system will not work in correcting foot drop and a passive AFO system will have to be used,” Thomas shared.

If the patient’s spinal cord has been interrupted in any way, then retraining the muscles would be a very difficult-and maybe even impossible-endeavor.

An AFO remains the appropriate solution for patients with lower-extremity edema, unstable ankle stance or cognitive impairments that interfere with operation of a foot drop system.

Complying at Home

For this condition, patients typically go to therapy for about 45 minutes, two times a week, according to Thomas. “If a patient is going to make gains, however, it’s imperative that there is good compliance with a home exercise program,” he shared. “The patients who have the greatest success are the ones with a solid work ethic outside the clinic.”

Brown’s approach to ensure compliance with a home program begins with the patient’s first evaluation. “I tell them how important the home program is and that participation is crucial,” he shared. “I put them on the spot and I go through the exercises the first day and then send them home with illustrations. I say I will quiz them during the beginning of the next session and will ask them to demonstrate the exercises I assigned.”

With this approach, Brown knows whether or not they’ve followed through based on their familiarity with the exercises. “I give additional exercises and instruction during each session,” he said. “And that’s how I make sure that they are compliant. It usually works because patients come prepared because they don’t want to fail.”

When it comes to foot drop-and really any PT-related injury or diagnosis-Brown stresses the importance of seeking care with a physical therapist as soon as possible. “I don’t want to see someone with foot drop after 6 months,” he stated. “Once a patient is medically stable and safe to treat, they need to be sent to PT.”

Brown recalls seeing a patient with foot drop after having a stroke one and a half years earlier. “There was a lot less I could do for her compared with what I could have done right after her stroke,” he said. “It’s crucial to treat these patients as soon as possible with exercise, stretching and weight bearing.”

Rebecca Mayer Knutsen is senior regional editor of ADVANCE and can be reached atrmayer@advanceweb.com.

 

Filed under: Atrophy and Building Muscle, Cognitive and Neurologic Situations, Deconditioning, Exercise Heals, Ligaments, Neurological, Range of Motion Exercises, Tarsal Joint (Ankles), Tendinopathy Tagged: dog nerve damage, foot drop, nerve damage, Orthovet splint, patellar tendon, radial nerve damage, sciatic nerve damage, tarsal joint, Thera-paws dorsi-flex, tibial nerve damage

Terrier Lame Many Weeks After Knee Surgery

3/11/12

Last week I evaluated another dog with persistent disuse & pain after CCL surgery ( for torn ACL / CCL).

Here is a copy of the synopsis I sent via email to the owner and to the vets. I had already made a phone call and left a message with one of the treating vets.

As promised, here is a bullet point email synopsis of our visit today. I am also sending a copy to Drs. Txxx, Exxx, and Wxxx since they have all been treating Dxxx. As I texted to you, I did contact Dr. Txxx after our visit, and I left a vm for her, trying to detail what I thought was going on with Dxxx. She and I subsequently texted a bit and she noted that she gave Dr. Exxx a heads-up since he is the one who did the surgery and since you may be contacting them tomorrow.

Dxxx is able to walk on sx limb and often chooses not to do so. He is 2-4/4 lame; 2 at a walk and 4 when faster. He is quite atrophied in L thigh, especially lateral. He is 7/9 PBS with substantial fat pads over both hips, adding to the deformed appearance of L hind. Fluid sac exists at L lateral stifle and you said the vets were aware of it and it was deemed a fluid collection related to suture. Mild to moderate effusion in L stifle, and I worked with owner so that she could feel it and become accustomed, able to tell in the future if/when it subsides. Dxxx has not consistently been receiving pain meds recently.

At this time out from surgery I would expect Dylan to be consistently using L hind and atrophy to be (mostly) resolved, no effusion.

1) Begin dosing analgesic this evening. You may use Metacam as previously directed and so long as his liver values are fine. You may use Tramadol as scripted on the bottle. We discussed the mechanisms of both drugs and the potential benefits/drawbacks. If his lameness is not resolved using these analgesics and/or possibly using the Gabapentin that you also mentioned he has been scripted, then you are to contact the vets no later than 2 days from the time of pain med dosing to discuss the possible use of antibiotics. I have seen many cases like this that have persisted in lameness and had mild effusion (or no effusion) in which existed a low-grade, latent, painful infection. In these cases, depending on the antibiotic the vet chose to utilize, the lameness was mostly or fully resolved within two days, usually at the end of one day. Given Dylan’s dynamics, it is highly possible that this is what is occurring. The vets in other cases have chosen to dose the meds and not tap the stifle joint because the meds are relatively easy and the joint is then not disrupted nor the chance of new infection introduced. I touched on these ideas with Dr. Txxx, and I do not know what she passed on to Dr. Exxx, however they are welcome to discuss it further with me and will likely want to have a look at him if they have not seen him in a while. Please do not hesitate to call them sooner than two days, and I’m sure they will be glad to talk with you or see you.

2) I recommended you follow this link: http://rehabilitationandconditioningforanimals.wordpress.com/category/homework-suggestions-for-functional-rehab/ to my “Homework for After Knee Surgery” and read it thoroughly. Begin working Dxxx at week 1 two days after most of the lameness has improved. Again, I expect the disuse to resolve with either pain meds or antibiotics or both, and in my experience it will resolve within two days of the medication that hits the problem.

3) Follow this link: http://rehabilitationandconditioningforanimals.wordpress.com/category/qa/ to Q&A about limping and knee pain after surgery.

4) Follow this link: http://rehabilitationandconditioningforanimals.wordpress.com/2011/07/30/water-treadmill-is-definitely-not-necessary-for-rehabilitation/ to more on joint pain, water treadmill, and rehab work.

5) Slowly reduce treats and a small amount of pm feeding. Measure the food he receives currently so that you are able to control the amount you reduce. Losing the extra fat will help with his function and protect his joints. Lots of research exists regarding this.

6) Begin giving ~200 mg EPA and ~100 DHA in fish oil daily. This amount may be doubled. You may use the brand you have or some from (the clinic).

7) Please keep me posted regarding his progress with the different meds. We will recheck in one week. In the future I intend to discuss massage. I believe acupuncture and laser therapy could help him, at least for the next 6-8 wks, as he resolves these issues. I expect him to be able to follow the homework protocol as written for the first 4 weeks after pain management and then we will discuss the program for weeks 5-8. After that, it is up to you, should he be improved and doing well, as to whether or not you would like further, more dynamic, homework.

Thanks again!

Blessings-

Deborah

AND, here is the owner’s follow-up report I received via email just a bit ago:

Hi Deborah, I was about to send you a quick text, when I saw this email (one I, Deborah, wrote asking how Dxxx was doing). Yes, Dxxx started antibiotics on Friday, and wow, what a difference. I saw almost immediately the change. Yesterday, almost all his walking was done with his leg down. I can really tell a difference. Thank you so much for getting us on the right path. I look forward to seeing you Tuesday.

He continued to improve and over about 3 months time he was equally muscular in both hind and had lost the extra fat he was carrying.

 

***

I have very many stories like this one, and I just now had time to share this one.

Hope it helps-

Filed under: Infections, Knees (Stifles), Lameness and Limping, Ligaments, Pain

Warm Up More Productive Than Stretching…

I’ve been reading studies on this topic for several decades, and the consistent evidence is as Dr. Mirkin presents it (below). Every opportunity I get to work with competitive dogs, I press this info home to the human clients. Ball stretching before an event is more destructive than helpful. Coming out of a crate and trotting around just a bit is not usually enough of a warm up. Dogs should perform better in events with at least a quarter mile slow jog warm up with a few sprints worked in. This would also be beneficial prior to training drills as well. Just the basics…

Dr. Gabe Mirkin’s Fitness and Health e-Zine

April 7, 2013

Stretching Before Exercising Provides Only Flexibility

Whenever I see someone stretching before running,

cycling, tennis, swimming, or any other sport, I worry that

the person doesn’t know much about training.

STRETCHING BFORE EXERCISING WEAKENS MUSCLES:  Two

recent studies show that stretching before competition and

training weakens muscles.  Stretching prevents you from lifting

your heaviest weights or running your fastest miles. It limits

how high you can jump, and how fast you can run (The Journal of

Strength and Conditioning Research. April, 2013; The Scandinavian

Journal of Medicine and Science in Sports, April, 2013).

Stretching weakens muscles by almost 5.5 percent.

The longer you hold the stretch, the more strength you lose.

Holding a stretch for more than 90 seconds markedly reduces

strength in that muscle.

Stretching reduces power: how hard you can hit a

baseball or tennis ball, how fast you can swim, run or pedal,

Stretching also does not prevent next-day muscle soreness, and it

does not prevent injuries.  On the other hand, warming up helps

to prevent injuries and helps you to run faster and lift heavier.

HOW MUSCLES MOVE YOUR BODY: Every muscle in your body is

made up of thousands of individual fibers.  Each fiber is

composed of sarcomeres, repeated similar blocks, lined end-to-end

to form the rope-like fibers.  Each sarcomere touches the

sarcomere next to it at the Z line. See the diagram at

http://www.drmirkin.com/public/ezine120912.html

Muscles move your body by contracting, a shortening of

each muscle fiber.  Muscles do not shorten (contract) equally

throughout their lengths.  Muscles contract only at each of

thousands of Z lines.  It is the cumulative shortening of

thousands of Z lines that shorten fibers to make muscles contract

and move your body.

HOW STRETCHING SAPS STRENGTH:  When you stretch a muscle,

you pull on the muscle fibers and stretch apart each fiber at the

thousands of Z lines.  This damage occurs only at the Z lines

throughout the length of the muscle fiber, to weaken the entire

muscle.

PROLONGED STRETCHING LIMITS THE ABILITY OF MUSCLES TO

STORE ENERGY:  Muscles are like rubber bands. They stretch and

contract with each muscle movement.   This constant stretching and

contracting stores energy.  For example, when you run, you land on

your foot and the muscle stops contracting suddenly.  The force of

your foot striking the ground is stored in your muscles and tendons

and this energy is released immediately to drive you forward.

Your foot hits the ground with a force equal to three

times your body weight when you run at a pace of six minutes per

mile.   Up to 70 percent of the force of your foot strike is stored

in your Achilles and other tendons.  This energy is released by

your muscles and tendons to drive you forward for your next step.

Stretching decreases the amount of energy you can store in

muscles and tendons and therefore weakens you and you have less

stored energy to drive you forward, so you have to slow down.

STRETCHING SAPS SPEED AND ENDURANCE:  Elite college

sprinters were timed in 20 meter sprints, with and without prior

multiple 30-second stretches of their leg muscles. Both active

and passive stretching slowed them down (Journal of Sports

Science, May 2005).

STRETCHING DOES NOT PREVENT NEXT DAY MUSCLE SORENESS:  A

review of 12 studies published over the last 25 years shows that

stretching does not prevent muscle soreness that occurs 8 to 24

hours after you exercise vigorously (The British Journal of

Sports Medicine, December 2011; 45:15 1249-1250).  Researchers in

Australia reviewed five studies, involving 77 subjects, to show

that stretching does not prevent next-day muscle soreness.

(British Medical Journal. December 2007; 325:468-70 and 451-2).

STRETCHING DOES NOT PREVENT INJURIES:  A review of the

scientific literature shows that there is no good evidence that

stretching prevents sports injuries (Clinical Journal of Sports

Medicine.  March 2005).  Muscles and tendons tear when the force

applied to them is greater than their inherent strength, so

anything that makes a muscle stronger helps to prevent injuries.

Strengthening muscles helps prevent muscle and tendon tears, but

stretching does not make muscles stronger. This review showed

that stretching does not prevent shin splints, bone stress

fractures, sprains, strains or other arm and leg injuries.

Filed under: Ligaments, Muscle, Stretching and Warm-up, Stretching and Warm-up Tagged: agility, canine competition, canine stretches, flyball, high jump, long jump, lure course

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

Certified Canine Rehabilitation Practitioner

Certified Strength and Conditioning Specialist

http://www.rehabilitationandconditioningforanimals.wordpress.com

http://www.facebook.com/AnimalRehabConditioningMember: American College of Sports Medicine, Capitol Area Veterinary Medical Association, International Veterinary Academy of Pain Management, National Strength and Conditioning Association


Filed under: OCD, Pain, Q&A Tagged: Adequan, canine, limping, OCD, Omega 3's, pain, Pano, recovery, rehabilitation, rehabilitation after dog surgery, Rimadyl, shoulder leision, surgery

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. 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. 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. 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 byAmerican 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

Note: If no author is given, the source is cited instead.

Here is a second report of the same issue:


Medscape Medical News from the:

American Academy of Orthopaedic Surgeons (AAOS) 2013 Annual Meeting

This coverage is not sanctioned by, nor a part of, the American Academy of Orthopaedic Surgeons.

Medscape Medical News > Conference News
Physical Therapy as Effective as Surgery for Meniscal Tear

Medscape Medical News from the: American Academy of Orthopaedic Surgeons (AAOS) 2013 Annual Meeting Physical Therapy as Effective as Surgery for Meniscal Tear Kathleen Louden Mar 20, 2013 CHICAGO, Illinois — Patients with knee osteoarthritis and a meniscal tear who received physical therapy without surgery had good functional improvement 6 months later, and outcomes did not differ significantly from patients who underwent arthroscopic partial meniscectomy, a new clinical trial shows. In the Meniscal Tear in Osteoarthritis Research (METEOR) trial, both groups of patients improved substantially in function and pain. This finding, presented here at the American Academy of Orthopaedic Surgeons 2013 Annual Meeting and published online simultaneously in the New England Journal of Medicine, provides “considerable reassurance regarding an initial nonoperative strategy,” the investigators report. Patients with a meniscal tear and osteoarthritis pose a treatment challenge because it is not clear which condition is causing their symptoms,” principal investigator Jeffrey Katz, MD, from Brigham and Women’s Hospital in Boston, Massachusetts, told Medscape Medical News. “These data suggest that there are 2 reasonable pathways for patients with knee arthritis and meniscal tear,” Dr. Katz explained. “We hope physicians will use these data to help patients understand their choices.” In an accompanying editorial, clinical epidemiologist Rachelle Buchbinder, PhD, from the Monash University School of Public Health and Preventive Medicine in Victoria, Australia, said that “these results should change practice. Currently, millions of people are being exposed to potential risks associated with a [surgical] treatment that may or may not offer specific benefit, and the costs are substantial.” These results should change practice. The METEOR trial enrolled 351 patients from 7 medical centers in the United States. Eligible patients were older than 45 years, had osteoarthritic cartilage change documented with magnetic resonance imaging, and had at least 1 symptom of meniscal tear, such as knee clicking or giving way, that lasted at least 1 month despite drug treatment, physical therapy, or limited activity. In this intent-to-treat analysis, investigators randomly assigned 174 patients to arthroscopic partial meniscectomy plus postoperative physical therapy and 177 to physical therapy alone. The physical therapy in both regimens was a standardized 3-stage program that allowed patients to advance to the next intensity level at their own pace, Dr. Katz explained. The program involved 1 or 2 sessions a week for about 6 weeks and home exercises. The average number of physical therapy visits was 7 in the surgery group and 8 in the nonsurgery group. Investigators evaluated patients 6 and 12 months after randomization. The primary outcome was the between-group difference in change in physical function score from baseline to 6 months, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). At baseline, demographic characteristics and WOMAC physical function scores were similar in the 2 groups. At 6 months, improvement in the WOMAC function score was comparable in the 2 groups. The mean between-group difference of 2.4 points was not statistically significant after analysis of covariance. There was also no significant difference between groups in pain improvement or frequency of adverse events. METEOR: Mean Improvement in Osteoarthritis Index at 6 Months Treatment Group Mean Improvement (Points) 95% Confidence Interval Surgery plus physical therapy 20.9 17.9–23.9 Physical therapy 18.5 15.6–21.5 There was 1 death in each group, and 8 patients in the nonsurgery group and 13 in the surgery group withdrew in the first 6 months of the study. Patients in the nonsurgery group were allowed to cross over to the surgical group at any time. Within 6 months, 30% of patients did so. “They were not doing very well,” Dr. Katz said. His team is still analyzing the reasons these patients did not benefit from intensive physical therapy. The 12-month results were similar to the 6-month results. In addition, by 12 months, outcomes for the crossover patients and for those in the original surgery group were similar. Meeting delegate John Mays, MD, an orthopaedic surgeon practicing in Bossier City, Louisiana, who was asked by Medscape Medical News to comment on the findings, said most patients don’t choose physical therapy. “In the real world, most people want a quick fix” and choose surgery, he noted. Dr. Mays said he would have liked to have seen a group of patients who underwent surgery but did not receive postoperative physical therapy. He explained that his patients with osteoarthritis and meniscal tear rarely get physical therapy after arthroscopic meniscectomy; they most often do home-based exercises. He added that “most insurance plans have limits on the number of physical therapy sessions they allow.” This study is funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Katz, Dr. Buchbinder, and Dr. Mays have disclosed no relevant financial relationships. N Engl J Med. Published online March 19, 2013. Abstract, Editorial American Academy of Orthopaedic Surgeons (AAOS) 2013 Annual Meeting: Abstract SE67. Presented March 19, 2013.


Filed under: Arthritis, Exercise Heals, Knees (Stifles), Knees (Stifles, Patellas), Surgery Tagged: arthritis knee, does my dog need surgery?, dog knee surgery, knee surgery, meniscal surgery for my dog, meniscal tear, meniscus, surgery, torn knee ligament

Water Treadmill

Not necessary in over 90% of cases, in my estimation and experience. The majority of cases may be recovered well with very good pain meds and solid, gravity-and-land-based exercise programs that are progressive. These programs should be written by a strength and conditioning professional.

Filed under: Water Treadmill