Knees (Stifles, Patellas) – 5 Articles
“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 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
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.
More Than Half of All ACL Reconstructions Could Be Avoided, Five-Year Follow-Up Study Shows
(From RehabDeb: This report is from human medical research, however animal studies are currently being conducted at Colorado State University. When I began animal rehab in 2005, I developed some protocol for people to use to benefit their animals if they did not want surgery for their pet, even though I was working at the time in a surgery specialty hospital. When I began independent practice in 2007, I took years of accumulated research, experience, and knowledge and created some simple functional exercise and drill protocol that has benefited hundreds of my canine patients whose people opted to not pursue surgery. That protocol and some other papers citing surgery text recommendations may be found elsewhere on this site-see the index to the right. In every case where my protocol has been followed (and there are no extenuating circumstances), the pets have stabilized the joint with muscle and scar tissue, and they have functioned very well. This work is all done in the home environment with no dependence on specialized equipment…no need when we are drawing from centuries of known exercise physiology and dynamic principles of body function. Blessings-)
Jan. 30, 2013 — In the summer of 2010, researchers from Lund University in Sweden reported that 60 per cent of all anterior cruciate ligament (ACL) reconstructions could be avoided in favour of rehabilitation. The results made waves around the world, and were met with concerns that the results would not hold up in the long term. Now the researchers have published a follow-up study that confirms the results from 2010 and also show that the risk of osteoarthritis and meniscal surgery is no higher for those treated with physiotherapy alone.
“We have continued with our study and for the first time are able to present a five-year follow-up on the need for and results of ACL surgery as compared with physiotherapy. The findings have been published in the British Medical Journal and are basically unchanged from 2010. This will no doubt surprise many people, as we have not seen any difference in the incidence of osteoarthritis,” says Richard Frobell, one of the researchers behind the study, who is an associate professor at Lund University and a clinician at the orthopaedic department, Helsingborg Hospital.
Richard Frobell explains that the research group’s results from 2010, which were published in the New England Journal of Medicine, caused a stir and questions were raised as to whether it was possible to say that an operation would not be needed in the long term.
Half of the patients who were randomly assigned not to undergo reconstructive surgery have had an operation in the five years since, after experiencing symptoms of instability.
“In this study, there was no increased risk of osteoarthritis or meniscal surgery if the ACL injury was treated with physiotherapy alone compared with if it was treated with surgery. Neither was there any difference in patients’ experiences of function, activity level, quality of life, pain, symptoms or general health,” says Richard Frobell.
“The new report shows that there was no difference in any outcome between those who were operated on straight away, those who were operated on later and those who did not have an operation at all. The message to the medical experts who are treating young, active patients with ACL injuries is that it may be better to start by considering rehabilitation rather than operating straight away.”
In Sweden, over 5 000 people every year suffer an anterior cruciate ligament injury — mainly young people involved in sport. There are different schools of treatment and Sweden stands out with treatment that is in line with the results of the study.
“On an international front, almost all of those with ACL injuries are operated on. In Sweden, just over half are operated on, but in southern Sweden we have been working for many years to use advanced rehabilitation training as the first method of treatment. Our research so far has confirmed that we are right in not choosing to operate on these injuries immediately. Longer-term follow-up is important, however, if we are to look more closely at the development of osteoarthritis in particular,” says Richard Frobell.
The research group, whose study is called KANON, Knee ACL NON-operative versus operative treatment, is now moving on to the next stage. This year, the third part of the study will begin, following up the patients ten years after anterior cruciate ligament injury.
Richard Frobell has also entered into a collaboration with researchers at the School of Economics and Management at Lund University to evaluate the health economics aspects of different treatment methods for ACL injury.
Journal References:
R. B. Frobell, H. P. Roos, E. M. Roos, F. W. Roemer, J. Ranstam, L. S. Lohmander. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ, 2013; 346 (jan24 1): f232 DOI:10.1136/bmj.f232
Richard B. Frobell, Ewa M. Roos, Harald P. Roos, Jonas Ranstam, L. Stefan Lohmander. A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament Tears.New England Journal of Medicine, 2010; 363 (4): 331 DOI:10.1056/NEJMoa0907797
From ScienceDaily
Stifle (Knee) Ligament Ruptures (Torn ACL, CCL) Information Overview
(This post contains information about ligaments and cites surgery recommendations and some rehab possibilities. The homework protocol I have written for use after surgery and/or instead of surgery and which has been used successfully for years is now available in book form, and here are the links: http://www.amazon.com/dp/B00F7VMJYW and http://www.amazon.com/dp/B00EY3D03S)
Ligaments are dense connective tissue structures consisting of fibroblasts, water, collagen, proteoglycans, fibronectin, and elastin that connect two or more bones (1, 2). Currently, a great deal of information remains unanswered regarding timing of ligamentous healing, especially with respect to postoperative mobilization techniques (graft, suture, TPLO, etc…). This is because ligaments heal differently depending on the location. For example, the healing potential of the medial collateral ligament of the stifle is very good, but the cranial cruciate ligament, which has received the most investigation, demonstrates virtually no healing response following injury (2). Within hours of injury, the defect is filled with an organized hematoma and the surrounding tissue becomes edematous from perivascular leakage of fluid. Monocytes and macrophages are found in the wound by 24 hours and respond by cleaning up the site and transitioning to the next phase.
This acute injury phase lasts approximately 48-72 hours (2). In other words, the knee will swell, sometimes only a little, inside the joint, thus making the bony parts thicker or wider, expanded due to fluid accumulation. Other times there is swelling in the soft tissue as well. It is during this acute phase that the use of ice is recommended, 1-6 times per day, for 20 minutes each application, on average, depending on fur density and type of ice used. I have a separate paper with icing recommendations on this site, under “Homework”. The method of delivery most recommended yet one of the least effective is frozen veggies, so check out the other options noted in the other paper. The use of heat on an acute injury is not recommended and will likely be destructive to the natural healing process. Again, do not use heat on the knee injury at this time. During this time and throughout the healing process the use of low-level laser therapy is also warranted.
More research in recent years has shown that stopping the inflammatory process, a process that is a natural part of healing, is not a good idea much of the time for this type of injury. If the body is allowed to go through the inflammatory process, especially if there are pain medications like Tramadol available, then healing may occur faster. Ice and nsaids, non-steroidal anti-inflammatories, work against inflammation, and nsaids also work against healing. The main idea is to lower the level of pain and to encourage healing, so use the best tools and information you have available.
In many cases, loss of ligamentous support invariably leads to progressive osteoarthritis, such as in cranial cruciate ligament (ACL) ruptures. Please note that the arthritic process began when the first disruptions occurred in the joint, when damage first occurred and then when tearing first began. A ligament usually will tear for some time prior to total rupture. A ligament rupture is not a matter of life and death. Many people come to me relaying that they have felt rushed into or forced toward surgery for this condition in their dog. In contrast, I had one client who is a human medical doctor state, “I wish we could get people off of the surgery idea…we don’t even rush every human athlete into surgery, much less every person in general.”
Slatter’s Textbook of Small Animal Surgery, 2nd Edition states that small dogs often do well without surgical intervention, and that based on particular studies, “it is prudent to wait for at least 6 to 8 weeks before recommending surgery for small dogs. These dogs are older at diagnosis and are often obese with concurrent medical problems. Small dogs that are lame for 6 weeks after diagnosis and show no improvement often have meniscal tears and are operated on for meniscectomy and joint stabilization.” (pg.1832) Your veterinarian or I may help you evaluate whether or not your dog has a meniscal tear.
Additionally, I have successfully used basic and advanced functional rehab protocol I developed based on principles of athletic training to address joint instability and muscle atrophy that occurs along with torn and ruptured knee ligaments in large dogs. Some positive feedback from veterinarians and owners is cited on my websites and in separate blog posts regarding this exercise protocol.
Excessive exercise during periods of acute joint inflammation may be detrimental to articular cartilage, and immobilization may be protective during acute bouts of inflammatory joint disease. (4) Joint inflammation will occur with greater stresses that are placed on the joint in the presence of ligament damage. If surgery is not opted, then for a period of time, depending on the severity of the injury, short, controlled leash walks and restricted activity along with mandatory rest are indicated during the first phase of acute injury. Even if surgery is opted, the recovery time and exercise protocol are virtually the same.
There were no written protocol I found within veterinary medicine addressing specific exercise protocol and return to function when I began practicing functional rehab in veterinary medicine in 2005. I subsequently began writing protocol based on how similar human injuries are managed and treated, from athletes to sedentary individuals.
Given that we have discussed loss of support and inflammation of ligament and joint, it would follow that muscle atrophy would be another complication to address. Muscle atrophy will occur whether or not surgery is performed, and rehab interventions are proven to aid in gaining strength and muscle tone in the affected limb. Muscle atrophy has been occurring during the whole time the pet has been injured because the injury will have produced pain and instability, even if mild at first, and that will have encouraged disuse and, therefore, atrophy.
The degree of quadriceps muscle atrophy present before surgery for CCL rupture seems to correlate significantly with the degree of cartilage fibrillation, indicating a relationship with the severity of the condition. In studies, muscle mass improved 7 and 13 months after surgery, but significant residual muscle atrophy remained in many dogs even after 1 year. I usually see muscle atrophy reversed in much less time when owners have followed recommended protocol.
A specific exercise program with changes in protocol as time goes on will indeed build muscle and will usually cause hypertroph better than surgical repair alone or pain medication alone, based on observations. Research citations to validate this foundational truth may be found elsewhere in this blog or in a bazillion places online. Try http://www.nsca-lift.org for foundations in strength training if you have further interest in this specialty.
Outside the scope of this writing is the argument as to whether a natural course of events follows evolution or deterioration without intervention; either way it is the primary purpose of rehabilitation interventions to improve upon what natural abilities would theoretically otherwise be realized. Whether or not an animal will do well on its own without intervention is inconsequential when the overwhelming benefits of rehabilitation intervention are considered. In light of this, rehabilitation treatment is indicated whether or not ligament repair surgery is performed.
For non-surgical patients, rehab treatment may consist of conservative exercise that increases in difficulty as healing progresses and of therapies such as massage, low-level laser, ice, ultrasound, nutraceuticals, and weight control plans. I find assisted, forced specific range of motion exercises to be unnecessary in a companion animal that is functional, one that is able to move their limbs on their own.
For non-surgical patients, building muscle and supporting tissue will be important as well as maintaining protective interventions for affected joints, i.e., the use of therapies mentioned and maintaining dosing supplements and/or pharmaceuticals proven to aid. Nutrition supplement support, or nutraceuticals, proven to aid include glucosamine/chondroitin/MSM (all work better together) and fish oil. There are others. It is also outside the scope of this writing to argue or discuss the benefits of the nutraceuticals mentioned.
A qualified rehabilitation practitioner in collaboration with the treating veterinarian should be able to design a basic appropriate plan of action to meet your and your pet’s needs. It is within the scope of this paper to briefly and generally give information regarding ligament damage and specifically cruciate ligament damage. The conclusion is that if this information generates more questions, then answers should be sought from a qualified animal health care professional. Additionally, please see my separate post regarding homework recommendations for torn knee ligaments. Thank you!
References: 1. Fowler D: Principles of wound healing. In Harari J, editor: Surgical complications and wound healing in the small animal practice, Philadelphia, 1993, WB Saunders. 2. Frank C et al: Normal ligament: structure, function, and composition. In Woo S, Buckwalter J, editors: Injury and repair of the musculoskeletal soft tissues, Park Ridge, Illinois, 1991, American Academy of Orthopedic Surgeons Symposium. 3. Moore KW, Read RA: Rupture of the cranial cruciate ligament in dogs. II. Diagnosis and management, Compendium of Continuing Education Pract Vet 18:381391, 405, 1996 4. Agudelo CA, Schumacher HR, Phelps P: Effect of exercise on urate crystal-induced inflammation in canine joints, Arthritis Rheum 15:609-616, 1972
Copyright 2007, Deborah Carroll
Quality of Life of Obese Dogs Improves When They Lose Weight
This is actually recent research that was done in the UK, where they estimate 1/3 of the dog population is obese. Study conducted by Waltham/Royal Canin. I wouldn’t think we needed research to prompt us on this, however human nature proves we do! For those of you who need research to tell you that your dog will have a longer, happier life (same goes for humans…) if they drop the extra fat, here it is! Wheeeeeee!
The results showed that the quality of life improved in the dogs that had successfully lost weight, in particular vitality scores increased and the score for emotional disturbance and pain decreased. Moreover, the more body fat that the dog lost, the greater the improvement in vitality.
…and, interestingly, the study notes this: “The research also found that dogs that failed to complete their weight loss programme had worse quality of life at the outset than those successfully losing weight, most notably worse vitality and greater emotional disturbance.” …sort of as if the dogs failed the program and not that the owners were part and parcel. lol…the dogs didn’t fail to complete the program. And their finding here denotes the close connection and issues to be explored within the human/animal psychology bond; it works both ways-to the positive and to negative effect. The failed dogs notably had ‘worse quality of life at the outset” than the ones who ended up succeeding, and most compromised were their vitality and emotional status. We definitely pass our moods, demeanor, and worry onto our animals. Breathe peacefully with your pets
The “HOW TO” is up to me to help you accomplish, usually in conjunction with your vet.
I have over 30 years experience in program design and nutrition, so I am well qualified to help with lifestyle changes and subtle or great control measures. People are usually able to follow my plans because I work with them to determine how they operate best, whether with large changes or baby steps or in-between. Blessings-Feb. 21, 2012 — Researchers at the University of Liverpool have found that overweight dogs that lose weight have an improved quality of life compared to those that don’t.
A study of 50 overweight dogs, comprising a mix of breeds and genders was undertaken by scientists at the University in collaboration with the University of Glasgow, Royal Canin and the WALTHAM Centre for Pet Nutrition.
Owners completed a questionnaire to determine the health-related quality of life of their dog prior to weight loss. A follow-up questionnaire was completed by the owners of 30 dogs that successfully completed the weight loss programme, enabling changes in quality of life to be assessed. A range of life quality factors were scored, including vitality, emotional disturbance and pain. The quality of life of dogs which succeeded with their weight loss programme was also compared with those dogs that failed to lose weight successfully.
The results showed that the quality of life improved in the dogs that had successfully lost weight, in particular vitality scores increased and the score for emotional disturbance and pain decreased. Moreover, the more body fat that the dog lost, the greater the improvement in vitality.
The research also found that dogs that failed to complete their weight loss programme had worse quality of life at the outset than those successfully losing weight, most notably worse vitality and greater emotional disturbance.
Dr Alex German, Director of the Royal Canin Weight Management Clinic at the University, said: “Obesity is a risk for many dogs, affecting not only their health but also their quality of life. This research indicates that weight loss can play an important role in keeping your dog both healthy and happy.”
Dr Penelope Morris, from the WALTHAM Centre for Pet Nutrition, added: “Strategies for combating obesity and keeping dogs fit and healthy include portion control, increased exercise and diets specifically formulated for overweight pets.”
Established in 2004, the Royal Canin Weight Management Clinic at the University’s Small Animal Hospital UK’s is the world’s first animal weight management referral clinic and was set up to help tackle and prevent weight problems in animals such as dogs and cats.
Veterinary surgeons from any general practice in the UK can refer overweight animals to the clinic. The patients receive a thorough medical examination, and are then given a specific dietary plan and exercise regime to follow over several weeks.
Taken from ScienceDaily
Filed under: RESEARCH CITATIONS (NOT EXHAUSTIVE :))
