People who get prompt physical therapy for pain in the knee, shoulder or lower back may have less need for opioid painkillers, new research suggests.
The study, of nearly 89,000 U.S. patients, found that people given physical therapy for their pain were 7 percent to 16 percent less likely to fill a prescription for an opioid.
The researchers said the findings suggest that early physical therapy is one way to reduce Americans’ use of the risky, potentially addictive painkillers.
“For people dealing with these types of musculoskeletal pain, it may really be worth considering physical therapy — and suggesting that your health care provider give you a referral,” said lead researcher Dr. Eric Sun. He is an assistant professor of anesthesiology, perioperative and pain medicine at Stanford University.
Dr. Houman Danesh, a pain management specialist who was not involved in the study, agreed.
“This study shows how important physical therapy can be,” said Danesh, who directs the division of integrative pain management at Mount Sinai Hospital, in New York City.
Physical therapy does require a much bigger investment than taking pain medication — and, he said, patients may have to travel to find a therapist who is the best fit for them.
“Physical therapy is highly variable,” Danesh said. “Not all physical therapists are equal — just like not all doctors are.”
But the effort can be worth it, according to Danesh, because unlike painkillers, physical therapy can help people get at the root of their pain — such as imbalances in muscle strength.
“You can take an opioid for a month, but if you don’t get at the underlying issue [for the pain], you’ll go back to where you started,” he explained.
The findings, published online Dec. 14 in JAMA Network Open, come amid a growing national opioid epidemic. While many people who abuse opioids are hooked on illegal versions — like heroin and illicitly manufactured fentanyl — prescription opioid abuse remains a major concern.
Medical guidelines, from groups like the American College of Physicians, now urge doctors to first offer non-drug options for muscle and joint pain. Opioids, such as Vicodin and OxyContin, should be reserved as a last resort.
The new findings support those guidelines, according to Sun’s team.
The results are based on insurance records from nearly 89,000 Americans who were diagnosed with pain affecting the lower back, knee, shoulder or neck.
All of the patients had a second doctor visit within a month of the diagnosis, and an opioid prescription within 90 days. So the group included only people with significant pain, the researchers said.
Overall, 29 percent of the patients started physical therapy within 90 days of being diagnosed. Compared with those who did not have physical therapy, the therapy patients were 7 percent to 16 percent less likely to fill an opioid prescription — depending on the type of pain they had.
And when physical therapy patients did use opioids, they tended to use a little less — about 10 percent less, on average, the researchers found.
The findings do not prove that physical therapy directly prevented some opioid use.
Sun explained that, “since physical therapy is more work than simply taking an opioid, patients who are willing to try physical therapy may be patients who are more motivated in general to reduce opioid use.”
But his team did account for some other factors — such as a patient’s age and any chronic medical conditions. And physical therapy was still linked to less opioid use.
While this study focused on physical therapy, Danesh said, there are other opioid alternatives with evidence to support them.
Depending on the cause of the pain, he said, people may find relief from acupuncture; exercises to strengthen particular muscle groups; injections of anti-inflammatory steroids or other medications; platelet-rich plasma — where a patient’s own platelets (a type of blood cell) are injected into an injured tendon or cartilage; and nerve ablation, where precisely controlled heat is used to temporarily disable nerves causing the pain.
It’s also possible that some simple lifestyle adjustments will help, Danesh pointed out. An old worn-out mattress could be part of your back pain woes, for instance. Ill-fitting, non-supportive or worn shoes could be feeding your knee pain.
What’s important, Danesh said, is to get at the underlying issues.
“We have to match patients with the right treatment for them,” he said.
The U.S. National Center for Complementary and Integrative Health has more on managing pain.
SOURCES: Eric Sun, M.D., Ph.D., assistant professor, anesthesiology, perioperative and pain medicine, Stanford University School of Medicine, Stanford, Calif.; Houman Danesh, M.D., assistant professor, anesthesiology, perioperative and pain medicine, and director, division of integrative pain management, Mount Sinai Hospital, New York City; Dec. 14, 2018, JAMA Network Open, online
TUESDAY, Nov. 27, 2018 (HealthDay News) –What if a simple zap to the spine could relieve the debilitating lower back and leg pain brought on by a herniated disk?
Such is the promise of “pulse radiofrequency” therapy (pRF), which sends inflammation-reducing pulses of energy to nerve roots in the spine, a new study claims.
The therapy is not new, having first received U.S. Food and Drug Administration approval in the 1980s.
But recent advances in CT scan technology now enable clinicians to deploy those energy pulses with much more accuracy, experts said. And the new research suggests the treatment could prove a boon to back pain patients for whom standard therapies have failed to do the trick.
“I was amazed with the results of pRF,” said study author Dr. Alessandro Napoli. “Especially having read, as a radiologist, numerous lumbar MRI scans of patients with recurrent hernia after surgery.”
And as a patient himself, Napoli added that “from personal experience I can tell you that the treatment is not painful, and the results are appreciated within days after a single treatment lasting 10 minutes.”
Napoli is a professor of interventional radiology at Sapienza University of Rome in Italy.
He and his colleagues plan to report their findings Tuesday at the Radiological Society of North America annual meeting, in Chicago. Such research is considered preliminary until published in a peer-reviewed journal.
Lower disk herniation results when the insulating disks that sit between spinal vertebrae tear open, allowing jelly-like material to protrude and exert pressure on surrounding nerve roots. Beyond lower back pain, the condition often triggers sciatica, a pain that radiates down a patient’s leg.
Standard therapies include over-the-counter pain meds, corticosteroid spinal injections, and/or invasive spine surgery that sometimes involves disk removal and vertebrae fusion.
The problem, said Napoli, is that such options entail risks without assured relief.
“Steroid injections are effective only in portion of the patients, and generally require more sessions,” he noted. And though surgery safety has “largely improved,” Napoli pointed to the risk for bleeding and infection, the need for a minimum two- to three-day hospital stay, the high cost, and the fact that some patients ultimately realize little benefit.
By contrast, pRF is scalpel-free, delivering radio signals directly to affected nerves via a CT scan-guided electrode. The process, said Napoli, requires no hospital stay, is noninvasive, far cheaper and less risky.
“The rationale for using pRF on disk herniation is that we eliminate the inflammation process of the compromised nerve root,” he explained. “Without inflammation the pain fades, and the body starts a self-healing process that allows for complete resolution of the disk herniation in a large proportion of patients.”
For the study, the Italian investigators compared 128 lumbar herniation patients who underwent a single 10-minute round of CT-guided pRF with 120 patients who received one to three rounds of steroid injections.
All the patients had already undergone standard interventions, with poor results.
By the one-year mark following either treatment, a full “perceived” recovery was reported by 95 percent of the pRF patients, compared with just 61 percent of the steroid injection patients.
Dr. Daniel Park, director of minimally invasive orthopedic spine surgery at William Beaumont Hospital in Royal Oak, Mich., offered some caution on the findings.
He noted that because “the majority of people with back pain improve with time and exercise alone,” it remains an open question as to whether the pRF procedure really cured the condition.
Still, Park noted that diagnostic uncertainty can undermine the ability of surgery to get at the true source of a patient’s pain, given that “the problem with low back pain is that there are many causes of it, and physicians have trouble identifying the cause of pain.”
Nevertheless, he remains unsure if pRF is truly ready for prime time.
“Best case, I think [pRF] could be an option for people if they [have already] failed therapy and medication,” said Park. “It may be a similar option for people if they do not or cannot have steroid injections, but they need more treatment. I think this is experimental, and should not be first-line.”
The American Academy of Orthopaedic Surgeons offers more information on herniated disks.
SOURCES: Alessandro Napoli, M.D., Ph.D., interventional radiologist and professor, interventional radiology, department of radiological, oncological and pathological science, Sapienza University of Rome, Italy; Daniel Park, M.D., orthopedic spine surgeon, associate professor, orthopedic spine surgery, and director, Minimally Invasive Orthopedic Spine Surgery, William Beaumont Hospital, Royal Oak, Mich.; Nov. 27, 2018, Radiological Society of North America annual meeting, Chicago
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If you’re experiencing knee pain, you may have a meniscal tear. Our orthopedic experts explain what causes this injury and what you can expect during your recovery.
The meniscus is a key cartilaginous structure in the knee joint. Pain and swelling in the medial, or inside, part of the knee can unfortunately be a sign of tearing, but your treatment options will look different depending on the type of tear, the cause, and the severity. Our guide explains meniscal injuries, and what you can expect when you visit your doctor.
WHAT IS THE MENISCUS?
The meniscus is the C-shaped, rubbery cartilage in the knee that acts as a shock absorber and stabilizer for the joint, distributing the body’s weight and providing a cushion between the femur and tibia bones. The medial meniscus is located on the inner knee, while the lateral meniscus is on the outside. Medial tears are more common, but the symptoms are the same for both injuries.
Meniscal injuries can be classified according to the “zone” of the meniscus that is affected. This allows the physician to determine the amount of blood flow available to aid in the healing process. The red zone is the outer third, which has blood vessels and is more easily repaired by the body. The red-white zone has fewer blood vessels and is less quick to heal. The inner third, the white zone, has poor blood flow and is therefore more difficult to repair.
Meniscal tears also come in a variety of shapes, which may influence the course of treatment. Common shapes include bucket-handle, flap, and radial tears, or complex combinations of the three. A tears is considered “complete” if a piece of tissue has become separated from the meniscus. Degenerative tears, which are generally caused by arthritis, are more typical of older patients. Traumatic tears are common among athletes, who often twist and turn the meniscus.
SYMPTOMS AND CAUSES OF MENISCAL TEARS
The first sign of a meniscal tear may be a “pop” in the joint, and you may continue to feel a popping or clicking sensation with movement. Although you may be able to walk on the knee at first, subsequent pain and swelling can worsen in the days that follow, especially if you continue to use the leg. For a severe tear, the knee may click, lose its full range of motion, or even give way. If a part of the meniscus comes loose, the knee can slip or even lock.
Athletes and young people are especially prone to this injury due to sports trauma or hyper-flexing the joint. A forced twist, especially when the foot is planted, may cause the meniscus to tear. Older people may experience meniscal pain due to arthritis or ordinary degenerative wear to the cartilage. In these cases the pain occurs due to gradual tearing over time, and may present with no trauma to the knee.
KNEE PAIN TREATMENT AND RECOVERY
The first course of action is to follow the rules of “RICE”: rest the knee, ice the area in 20-minute sessions, compress the area, and elevate the leg to reduce swelling. In some cases, the knee may heal with this conservative treatment, but we recommend consulting an orthopedic specialist to examine the joint and monitor your recovery. Your doctor may perform a McMurray test, which includes bending, straightening, and rotating the knee in order to determine if an MRI is necessary. Orthopedic specialists usually will not recommend surgery for older patients, but physical therapy may help you find relief within five weeks.
For younger patients, arthroscopic surgery may actually be a preferred option, as this will help preserve the cartilage and prevent early onset arthritis in the joint. This type of surgery requires only two pinhole incisions. In most cases, when the tear is in the white zone, the fragment is trimmed and the remainder smoothed. Tears in the red zone are usually repaired to retain the full benefits of a complete meniscus. Surgery is often completed in 30 minutes, followed by several days of walking with the assistance of a crutch, or possibly a brace. After a few days you can expect to return to most normal activities. Full recovery, and a return to strenuous activity, can be expected after a few weeks of physical therapy.
Non-invasive treatments should be your first line of defense against neck pain.
Workouts, sports, and even sitting at a desk all day can put strain on the neck, leading to pain and discomfort. While some conditions may require orthopedic surgery, non-invasive treatments often lead to better long-term outcomes, and should generally be the first line of defense against neck pain.
A qualified physical therapist can help you create an appropriate plan for chronic neck pain, which is defined as pain that lasts for more than a few weeks. With a physical therapy plan tailored to your needs, you can safely gain strength and flexibility, as well as lower your chance of developing a future neck injury.
If you’re suffering from neck pain and looking to find relief, your physical therapist might suggest some of the following exercises.
1. SHOULDER AND HEAD ROLLS
These stretches are a good warm-up to start with before attempting other exercises. For a shoulder roll, keep your arms relaxed at your sides, and with your head upright, simply lift and roll your shoulders. Relax briefly between each roll. Do ten rolls forward, and ten back.
Before you try a head roll, stretch the neck. Make sure your shoulder blades are relaxed, and that your head is not tilted forward but sits directly over your neck. Start by dipping your chin slowly toward your chest, and hold for several breaths (if you are unable to dip your chin, or if it causes an increase in pain, stop and contact your doctor). Next, lift your head and lower your left ear toward your left shoulder, and hold. Repeat this movement on the right side, then do a similar stretch with your head tilted back.
After stretching your neck, you can roll your head slowly in sections, from tucked in front or tilted back toward each side, five times each. Avoid doing a full head roll, which can actually strain the neck.
2. SEATED NECK STRETCH
Deceptively simple, this exercise can even be performed at your desk. For a seated stretch, sit upright in your chair with your feet flat on the ground. Extend your right arm along your right side and place your left hand on the top of your head. Tilt your head to the left, applying pressure with your hand to gently intensify the stretch. Hold for 30 seconds, then repeat for the right side. You will feel this stretch in the levator scapula muscles in the sides of the neck.
3. WALL PUSH-UP
This exercise can help strengthen your shoulders and support your neck muscles, without causing as much stress as typical push-ups. Stand facing a wall, with two to three feet of space in front of you and your feet shoulder-width apart. Place your hands against the wall, just below shoulder level. Start with straight arms, and bend your elbows slowly to bring your body closer to the wall. Repeat this 10 times for one or two sets.
4. AQUATIC EXERCISES
While high-impact sports can be hard on the neck, low-impact sports like swimming, walking, or recumbent biking may help you avoid strain. If you have neck pain, many physical therapists recommend that you hit the pool for your aerobic exercises in order to increase blood flow to the neck.
While in the water, you can attempt neck flexibility stretches like the “clock” exercise. Repeat the following on both sides:
- Stand in a lunge position, with both arms at shoulder height. While the right foot and hand are forward at a 12 o’clock position, sweep the left hand back to 6 o’clock, following with the head and body. Repeat five times.
- Keep the left hand sweeping to 6 o’clock, while the head moves only to 9 o’clock, for five repetitions.
- For the last set of five, the head remains at 12 o’clock while the arm sweeps to 6 o’clock.
5. PRONE ROWS
This exercise strengthens the muscles that pull the shoulder blades together. You’ll want to lie facedown on a bed or similar surface, angled so that your face is in a corner, and you can dangle your arms off each side. Row upward, bending the elbows and squeezing the shoulder blades together without moving your head. Try about 20 repetitions for one or two sets. You can add light weights to this exercise if it is too easy.
EXERCISES TO AVOID
While adding these exercises to your routine, you should be careful to avoid workouts that may impede your progress. Don’t do sit-ups or crunches, as these can strain your neck vertebrae. In weightlifting, both the military press and lat pulldown put pressure on the vertebrae, and should be avoided.
The five exercises above can get you started on the road to recovery, although for best results, we recommend working with a physical therapist. If these exercises don’t relieve your pain, or cause pain that shoots into your shoulders or arms, contact a doctor as soon as possible. The orthopedic specialists at Comprehensive Orthopaedics can help you develop a personalized treatment plan and get back to the activities you love.
Here’s what you need to know about the painful but treatable condition called adhesive capsulitis, or frozen shoulder.
Frozen shoulder, or adhesive capsulitis, is an inflammation of the shoulder capsule. This band of connective tissue encases the shoulder joint, so as inflammation progresses, patients experience a restricted range of motion along with extreme stiffness.
While the medical community has not yet been able to pinpoint the exact cause of frozen shoulder, there are a number of conditions that can contribute to its development. These include diabetes, thyroid disorders, and past surgeries on the shoulder or chest.
SIGNS AND SYMPTOMS OF FROZEN SHOULDER
Patients suffering from frozen shoulder generally experience moderate to severe pain, inflammation, stiffness, and a limited range of motion in the shoulder.
This condition normally cycles through three progressive stages. These are:
- The “freezing” phase, where the patient experiences increasingly severe shoulder pain lasting from several weeks to nine months.
- The “frozen” phase, where pain in the shoulder decreases but stiffness lingers, lasting from four to nine months.
- The “thawing” phase, where pain continues to lessen and the range of motion in the shoulder slowly improves, lasting from five months to two years.
HOW TO PREVENT FROZEN SHOULDER
Frozen shoulder predominantly affects people in middle age, and it is possible to preemptively avoid this condition — especially if you’ve been diagnosed with any of the risk factors commonly associated with it, like diabetes or a thyroid disorder. The best possible prevention method is to steadily increase shoulder flexibility through stretching, including external rotation, forward flexion, and crossover arm motions.
HOW TO TREAT FROZEN SHOULDER
In many cases, conservative treatments can effectively ease shoulder pain and stiffness. These methods generally include a physical therapy regimen designed to restore shoulder motion and strengthen the surrounding muscles. Most patients will need to undergo a rehabilitation plan for approximately four to five months to ensure a complete recovery.
Sometimes, anti-inflammatories and corticosteroid injections are used to supplement physical therapy. If mobility issues continue, minimally invasive arthroscopic surgery can be utilized to break up and remove scar tissue that has built up in the shoulder, with full recovery occurring in as little as six weeks.
If you think you may be suffering from frozen shoulder, set up an appointment with an orthopedic specialist today. Backed by decades of experience in treating shoulder injuries, CompOrtho Specialists can work with you to develop a personalized recovery plan. Dr. Main and Dr. Gershtenson are top-rated orthopedic surgeons in Southeastern Wisconsin who specializes in the shoulder. Our team of specialists can help you through every step of your treatment, ensuring a quick and complete recovery.
Joint replacement surgery removes damaged parts of a joint and replaces them with man-made parts. The goal is to restore function and reduce pain and inflammation.
The most commonly replaced joints are the hip or knee. Less often, a shoulder, finger joint, ankle or elbow is replaced, the U.S. National Institute of Arthritis and Musculoskeletal and Skin Diseases says.
The agency describes what to expect while preparing for and recovering from joint replacement surgery:
- You doctor probably will prescribe pain-relieving medication, both before and after the procedure.
- A growing number of patients are able to take advantage of out patient surgery centers where you can go home the very same day. If you are elderly or disabled, you may spend some time at an in-patient rehabilitation center before going home.
- Expect to use a walker or crutches for at least a few days.
- Physical therapy should begin soon after surgery, to help strengthen muscles around the new joint and help you regain motion in the joint.
- Pain and discomfort can be relieved with medication. Both should go away within a few weeks or months.