In this article published at MedPage Today, the doctor is recommending people try physical therapy before submitting to surgery, especially for back surgery and knee surgery. ~ Dr. Broussard
— Physical therapy should be considered early on in the treatment conversation
by Vijay Yanamadala, MD, MBA May 23, 2022
For decades, the U.S. healthcare system has been burdened by the persistent problem of medical overtreatment. Every year, countless Americans with chronic illness are subjected to unnecessary tests and procedures that don’t lead to healthier outcomes. This exposes them to greater risk of complications and spiraling medical expenses. For many of these conditions, physical therapy is a low cost and more effective solution, but it’s too often ignored in favor of “quick fixes” that might actually be more harmful.
Physicians themselves acknowledge the problem: A landmark survey of board-certified doctors found that most (64.7%) believe that at least 15-30% of medical care is unnecessary. The issue is most problematic when it comes to unnecessary surgeries. The consequences can be potentially devastating, including hospital readmissions, debilitating post-surgical pain and injury, and even mortality.
For example, one of the most frequent musculoskeletal complaints and the leading driver of years lived with disability worldwide is low back pain. It is estimated that low back pain affects a staggering 60% to 84% of the population at some point in their life in industrialized countries. Not surprisingly, back pain is also one of the most common reasons patients seek medical consultation. But the condition is reliably difficult to diagnose: In the vast majority of cases, the exact origins of the pain remain unknown to both patient and medical practitioner.
Yet, despite the fact that physical therapy has been shown to be just as effective or better than surgery, patients with back pain frequently receive a recommendation to pursue lumbar spinal fusion as a remedy (along with other options such as laminectomy). Spinal fusion is not an insignificant surgery. It usually lasts several hours and involves joining, or fusing, two or more vertebrae together to eliminate motion between the bones that might be causing pain.
Not only is physical therapy often better, but various clinical trials have shown that most spinal fusions do not lead to improved outcomes for patients over the long term. In many cases, surgery actually leads to worse outcomes than no surgery at all.
In 2005, Fairbank et al published the results of a randomized controlled trial involving 349 participants who were considered candidates for spinal fusion by an experienced surgeon. The objective was to assess the clinical effectiveness of spinal stabilization or fusion compared to intensive rehabilitation for patients with chronic low back pain.
What did the clinicians find? “The statistical difference between treatment groups in one of the two primary outcome measures was marginal,” the authors reported. “No clear evidence emerged that primary spinal fusion surgery was any more beneficial than intensive rehabilitation.”
It’s not just back surgeries. About 750,000 arthroscopic knee surgeries are performed in the U.S. each year at a cost of $3 billion. Yet, multiple studies have shown this surgical intervention is no more effective in the long-term than non-operative treatments for conditions like arthritis, torn cartilage, and knee pain.
One study involving 205 patients who underwent total knee arthroplasty found that the procedure was inappropriate in approximately one-third of the patients (primarily those with mild to moderate pain), leading to unnecessary costs and undue impact on daily life.
Of course, surgery is not the only option for treating back, knee, and other musculoskeletal pain. One of the most reliable and effective interventions — physical therapy — is also, perplexingly, one of the least recommended options by medical practitioners who consult patients complaining of musculoskeletal (MSK) disorders.
Physical therapy-based rehabilitation frequently leads to better outcomes using fewer resources for patients with MSK pain when compared to operative procedures. But physical therapy must be a part of the treatment conversation early on, while surgery should be positioned as a last resort with the patient made well aware of surgery’s risks and complications. This is currently not the case in many patient-provider interactions.
When surgical treatment decisions are made in isolation, without considering physical therapy as a serious alternative, inappropriate and overutilization of surgical interventions tends to be the result. Conversely, when physical therapy is presented as an option, patients are more likely to postpone — and often replace — surgery with non-invasive therapy.
Together with a team of researchers in 2017, I published a study looking at treatment decisions for lumbar degenerative spine disease, which found that a multidisciplinary decision-making approach that included physical therapists along with orthopedic spine surgeons and pain specialists resulted in fewer patients choosing lumbar spinal fusion.
Of the 137 patients who were evaluated during a 10-month period, 100 had been recommended to pursue back surgery. But when non-surgeons were empowered to make decisions in their cases, non-surgical options were deemed appropriate for nearly 66% of these patients. In fact, 22% found relief from pain from additional physical therapy.
In the end, using this multidisciplinary approach, only nine patients underwent lumbar posterolateral fusion, compared to 42 who had been recommended to undergo the procedure by an outside surgeon.
These findings were further supported by another study I published with a team of researchers earlier this year, which found that patients evaluated in a multidisciplinary decision-making setting received more efficient care and were less likely to undergo surgery as a first-line treatment.
What these studies illustrate, and what is increasingly being understood by mainstream medical professionals, is that isolated surgical decision-making often results in suboptimal treatment recommendations, likely leading more people to pursue tests and procedures they do not need — creating needless harm and wasting precious healthcare resources. Instead, the emphasis should be on producing positive patient outcomes.
In so many cases, especially for more mild to moderate conditions, better outcomes for MSK disorders result when both patients and doctors embrace a physical therapy-first approach, and consider surgery as a last resort.
Vijay Yanamadala, MD, MBA, is chief medical officer of SWORD Health.