Medical Briefs: Shoulder Surgery, Platelet-Rich Plasma Therapy, Imaging for Low Back Pain & Headaches, & Rehab for Knee Pain

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By: Dr. Jill Murphy, DPT, LAT, CSCS

Shoulder Surgery

Many middle-aged patients have shoulder pain that comes on for no particular reason, sometimes due to early sports participation such as swimming, baseball, and softball. For patients who do not have a large rotator cuff repair on imaging, orthopedic surgeons typically recommend a procedure called subacromial decompression to “clean out” the shoulder joint once conservative therapy has failed (icing, resting, physical therapy, and injections). A recent study published in the British Medical Journal comparing patients who underwent this surgery compared to a group of patients who underwent a placebo diagnostic-only surgery, both displayed the same levels of pain and shoulder function at 24 months. What does this mean for you? If you have shoulder pain at rest and with activity, quality physical therapy with a manual physical therapist for an extended period of time is likely to improve symptoms just as well as surgery- so be patient and skip the surgery if you can!

Platelet-Rich Plasma Therapy

For those of you curious about the latest technology applied to orthopedics and sports medicine- leukocyte-rich platelet-rich plasma (LR-PRP) therapy is it! In a meta-analysis published in The American Journal of Sports Medicine, researchers concluded that nearly all PRP treatments for tendon issues in particular showed some positive effects that exceeded control treatments such as saline, anesthetic, and corticosteroid injections and dry needling, although dry needling produced the most positive results among the control treatments. At this time, we still do not know which tendons of the body benefit most from this treatment, and the most appropriate timing and number of LR-PRP injections is also still unknown. The results of this study were based on patients’ pain and function ratings at 12 weeks, 6 months, and 12 months following treatment.

Imaging for Low Back Pain & Headaches

If you have low back pain or headaches, patient beware. The Journal of the American Medical Association recently published a study that found that doctors who own their own MRI machines order significantly more MRIs for the lumbar spine and brain for patients with low back pain and headaches, respectively, compared to doctors who do not. The study analyzed 4 years of insurance claims data and found that primary care physicians were 1.81 times more likely to order low value (clinically unnecessary) imaging if they had done so for previously patients, while chiropractors and specialists such as neurosurgeons or pain management were 3x as likely to do so. All clinician types (primary med, chiropractors, and specialists) were more likely to order imaging for low back pain if they owned the equipment, with chiropractors at nearly 8x the odds, followed by physician specialists at 5x the odds, and then primary care physicians with 2x the odds. For headaches, clinicians who owned the imaging equipment were nearly 2x more likely to order the unnecessary imaging for their patients. Ordering images that are not medically necessary, especially early in care for low back pain and headaches, adds to overall medical costs, leads to unnecessary invasive treatments, and does not tend to improve outcomes for patients. The takeaway for patients? Put a pause on any recommended imaging and focus on conservative care first, such as high-quality, manual physical therapy. Should symptoms worsen or not improve over time (which can happen in ~5% of patients), then imaging may be a good next logical step in treatment.

Rehab for Knee Pain

Bothered by that achy knee? It’s best to get some physical therapy early on to prevent the need for opioid medications, injections, and knee surgery according to a study published in the Physical Therapy journal. In this study of over 50,000 Medicare beneficiaries, patients who received physical therapy within 2 weeks after diagnosis were 33% less likely to require narcotic pain medicine, 50% less likely to need a corticosteroid injection, and 42% less likely to move onto an invasive surgery such as a knee scope.

References

Paavola M, Malmivaara A, Taimela S, et al. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomized, placebo surgery controlled clinical trial. British Medical Journal 2018;362:k2860.

Fitzpatrick J, Bulsara M, Zheng MH. The effectiveness of platelet-rich plasma in the treatment of tendinopathy: a meta-analysis or randomized controlled clinical trials. American Journal of Sports Med 2017;45(1):226-233.

Hong AS, Ross-Denan D, Zhang F, et al. Clinician-level predictors for ordering low-value imaging. Journal of the American Medical Association Internal Med 2017;177(11):1577-1585.

Stevans JM, Fitzgerald GK, Piva SR, Schneider, M. Association of early outpatient rehabilitation with health service utilization in managing Medicare beneficiaries with nontraumatic knee pain: retrospective cohort study. Physical Therapy, 2017;297(6):615-24.