We are proud sponsors of Theatre Collingwood and their upcoming production “One Moment”. We will be there to enjoy the show and meet the casts on July 28, 2015. We hope to see you there!
We are proud sponsors of Theatre Collingwood and their upcoming production “One Moment”. We will be there to enjoy the show and meet the casts on July 28, 2015. We hope to see you there!
Spinal stenosis: physical therapy before surgery
Is surgery more effective than physical therapy in patients referred for surgery for spinal stenosis?
Assigning patients to 6 weeks of physical therapy is as effective as initially sending them for decompression surgery, with fewer complications, even in patients who have a strong preference for surgery. A trial of 6 weeks of physical therapy makes sense for many patients with confirmed spinal stenosis before getting out the scalpel. (LOE = 1b-)
Randomized controlled trial (single-blinded)
The investigators enrolled 169 patients (average age: 66-69 years) with image-confirmed lumbar stenosis who consented to surgery. This approach to enrollment eliminated many patients, presumably those with milder symptoms. The patients were randomly assigned (allocation concealed) to surgery or physical therapy. The decompression surgery was the typical procedure used in research and practice. Physical therapy, administered twice weekly for 6 weeks, consisted of lumbar flexion exercises and conditioning to identify the issues of strength and flexibility identified at enrollment. Analysis was by intention to treat, meaning that patients assigned to physical therapy were analyzed as being in that group even if they eventually received surgery, which 57% of them did over the 2 years of follow-up (most of them within the first 10 weeks of the study). Approximately 20% in each group sought additional physical therapy. Two years after identification, general quality of life (as measured by the Short Form-36 Health Survey, a typical measure of quality of life) improved equally in both groups, to an average score of 48-50 from a baseline of 26-28 of a possible 100. Analyzing by actual treatment rather than by intention to treat yielded similar results though the study may not have had enough power to find a difference if one existed. Pain, disability, and neurogenic symptoms improved similarly in both groups. Complications were common in the back surgery group, including the need for re-operation. Many patients were not returned to “normal” but continued to visit either a back surgeon or primary care physician for back pain 2 years after the intervention.
Many individuals have experienced injuries to muscles and tendons and have attended therapy to assist in their recovery. Even famous athletes, including Tiger Woods and tennis star Rafael Nadal, have suffered with chronic tendon injuries. These types of conditions have typically been treated with medications, physical therapy, chiropractic care, therapeutic exercise or even surgery. Unfortunately, tendons have a poor blood supply – this is the reason why some tendon injuries take so long to heal.
Over the past several years, a treatment known as Platelet-Rich Plasma injection (PRP injection) has become increasingly common in sports medicine clinics. Platelets are found in our blood – while they are best known for their importance in clotting blood, platelets also contain proteins which are crucial in the healing of injuries.
PRP injections involve:
According to the research studies currently reported, PRP is most effective in the treatment of chronic tendon injuries, especially tennis elbow, a very common injury of the tendons on the outside of the elbow. PRP is also commonly used to treat golfer’s elbow, knee tendon injuries, Achilles tendon pain and plantar fascia injuries.
Depending on the area injected and the severity and chronicity of the problem one or two subsequent injections may be necessary. Following successful PRP treatments, a good program of physical rehabilitation is required to fully rehabilitate the body back to full functional capacity.
If you have any questions please contact Dr. Olivia Cheng, Orthopaedic Surgeon, at the Orthopaedic Sport Institute for timely consultation. Diagnostic ultrasound is utilized for PRP injections to ensure that PRP is delivered directly to the diseased tissue.
For further information on managing your injury, please contact the Orthopaedic Sport Institute at (705) 467-0701 or email@example.com and ask for a consultation with one of our friendly healthcare professionals.
Darryl Novotny, BScPT
We would like to welcome Sarah Hornby to the Orthopaedic Sport Institute.
Sarah has extensive training in physical rehabilitation with a focus on sports injuries and post surgical recovery. She is a Registered physiotherapist and a registered massage therapist. She also carries a certificate in Acupuncture.
According to RateMDs.com, the top two orthopedic surgeons in Canada are women, which is surprising given that this field of medicine is traditionally dominated by men.Dr. Andrea Veljkovic and Dr. Olivia Cheng have higher ratings from surgical patients undergoing orthopedic procedures than any other surgeons in Canada, but the rest of the top ten list looks more familiar, with all eight of the other top spots taken by men.
The Top 10 Orthopedic Surgeons in Canada
Dr. Cheng operates in Collingwood, Ontario, while Dr. Veljkovic works out of Toronto, Ontario. Both have an average 4.9-star rating from patients, despite familiar complaints about inefficiencies in the hospitals in which the surgeons work.
Dr. Cheng focuses on musculoskeletal and sports related issues, having completed her medical training, and training in orthopedic surgery at the University of Toronto. She became a Fellow of The Royal College of Surgeons of Canada in 2009, and has received extra fellowships training in trauma and upper limb reconstruction at St. Michael’s Hospital, Toronto. Dr. Cheng and her husband, chiropractor Dr. Todd Starr, recently pledged $100,000 to the General & Marine Hospital’s New Age of Care campaign.
Dr. Veljkovic is a foot and ankle orthopaedic surgeon interested in alignment restoration in complex foot and ankle deformities, arthroplasty, and advanced arthroscopic reconstruction. She is currently completing an MSc in Epidemiology, when not replacing people’s ankle bones.
Unfortunately, none of the top ten specialises in spinal surgery, so perhaps 2015 will be the year spine surgeons in Canada step up their game and make some changes in this list of top orthopedic surgeons.
Osteoarthritis is the most common type of arthritis, affecting 1 in 10 Canadian adults (www.arthritis.ca). The knee is one of the most common and most symptomatically affected joints, causing knee pain in many people. They often try over-the-counter remedies to help the pain, and to avoid knee surgery. Amongst these treatments are the supplements glucosamine and chondroitin sulfate, which are very popular.
Because glucosamine and chondroitin are building blocks of cartilage, and because osteoarthritis is related to cartilage degradation, many believe that adding these building blocks to the diet of a person suffering from osteoarthritis will help rebuild cartilage and lessen pain. While on the surface this may seem logical, in reality these supplements do not provide effective pain relief. Here’s why:
Many studies have shown that glucosamine and chondroitin sulfate do not help to relieve pain from arthritic knees. People who take the supplements often report less pain or swelling of their joints. But people get similar results if they take a placebo—a “sugar pill” with no active ingredients. Pain relieving drugs, such as acetaminophen (Tylenol and generic) and ibuprofen (Advil, Motrin IB and generic), help a lot more.
Glucosamine and chondroitin are not harmful by themselves, but they can interact with other medicines. For example, the supplements can increase the effect of warfarin (Coumadin and generics) on blood clotting. This increases the risk of bruising and serious bleeding. Problems with warfarin frequently lead to emergency room visits.
To make matters worse, often the labels on the bottles are misleading. In 2013, Consumer Reports tested 16 joint pain supplements and found that seven had less chondroitin than the label listed.
There are more effective ways to relieve arthritic knee pain:
If these don’t help, you can talk to your doctor about treatments such as injections or surgery.
Lose excess weight. Losing a pound of excess weight can take about four pounds of pressure off your knees when walking.
Physical activity. To build support of the knees, do strength training, especially of the quad muscles on the front of the thigh. Aerobic exercise builds strength and can reduce pain. Stretching can help prevent stiffness. Ask a local YMCA or gym about exercise programs for people with arthritis.
Mechanical aids. A cane, crutch, or walker can take a load off painful knees.
Heat and cold. A heating pad can ease ongoing stiffness and soreness in joints. For acute pain and swelling, switch to ice packs.
Massage. Deep-tissue massage got high marks in a 2010 survey of Consumer Reports online readers. Half of them said that it “helped a lot” with their osteoarthritis.
Use drugs carefully.
Since ultrasound is not effective at diagnosing unsuspected deep vein thrombosis (DVT) and appropriate alternative screening tests do not exist, if there is no change in the patient’s clinical status, routine post-operative screening for DVT after hip or knee arthroplasty does not change outcomes or clinical management.
The use of needle lavage in patients with symptomatic osteoarthritis of the knee does not lead to measurable improvements in pain, function, 50-foot walking time, stiffness, tenderness or swelling.
Both glucosamine and chondroitin sulfate do not provide relief for patients with symptomatic osteoarthritis of the knee.
In patients with symptomatic osteoarthritis of the knee, the use of lateral wedge or neutral insoles does not improve pain or functional outcomes. Comparisons between lateral and neutral heel wedges were investigated, as were comparisons between lateral wedged insoles and lateral wedged insoles with subtalar strapping. The systematic review concludes that there is only limited evidence for the effectiveness of lateral heel wedges and related orthoses. In addition, the possibility exists that those who do not use them may experience fewer symptoms from osteoarthritis of the knee.
Routine post-operative splinting of the wrist after the carpal tunnel release procedure showed no benefit in grip or lateral pinch strength or bowstringing. In addition, the research showed no effect in complication rates, subjective outcomes or patient satisfaction. Clinicians may wish to provide protection for the wrist in a working environment or for temporary protection. However, objective criteria for their appropriate use do not exist. Clinicians should be aware of the detrimental effects including adhesion formation, stiffness and prevention of nerve and tendon movement.
The Canadian Orthopaedic Association (COA) established its Choosing Wisely Canada Top 5 recommendations by asking its National Standards Committee to review the evidence base associated with the five treatments and procedures chosen by the American Academy of Orthopaedic Surgeons for the Choosing Wisely® campaign in the United States. Satisfied that the list was relevant to the Canadian clinical context, the Committee recommended its adoption to the COA’s Executive Committee, and the motion was then unanimously approved by the Board of Directors. Therefore, all five items were adopted with permission from the Five Things Physicians and Patients Should Question. © 2013 American Academy of Orthopaedic Surgeons
Chris Waddell has been an élite athlete for more than two decades. He has won twelve medals in downhill skiing, including five golds, in four Paralympic Games events; he was a world-record-holding wheelchair track sprinter; and, in 2009, he became the first paraplegic to climb Mt. Kilimanjaro, using his arms to power a customized four-wheeled cycle. Even at forty-five, Waddell, who was paralyzed in a college skiing accident, has a muscular, sharply defined upper body, the product of thousands of hours of training.
But all this exercise has taken a toll. Several years ago, Waddell’s shoulders began to ache constantly. Last year, he tore a rotator cuff while weightlifting, and began having trouble lifting himself into and out of his wheelchair. “I had no control,” he said. “When I was getting off a couch, I had to marshal all of my strength.”
Waddell, who lives in Park City, Utah, went through a range of treatments. “I tried a lot of rehab, I did a lot of exercises, I had a cortisone injection,” he said. “I wasn’t making any progress.” Several orthopedists told him he would have to accept being in pain for the rest of his life.
Rotator-cuff surgery seemed like Waddell’s last option. It would mean losing the use of his arms, and his ability to move on his own, for several months. And he worried that, if surgery failed, he would have to give up any strenuous physical activity. “Being able to ask a lot of my body makes me feel good,” he said. “It’s a lot of who I am.”
As Waddell considered his options, a friend suggested looking into a treatment known as platelet-rich plasma, in which doctors inject a modified version of the patient’s own blood into injured tissue. Eager to avoid surgery, Waddell flew to Washington, D.C., to see Victor Ibrahim, a sports-medicine doctor who specializes in P.R.P. Ibrahim found that Waddell had a torn rotator cuff in one shoulder and a torn biceps tendon in the other. Using ultrasound to locate the precise locations of the injuries, Ibrahim injected the tendon and rotator cuff with P.R.P. Over the course of a month, he repeated the procedure twice more.
In the weeks afterward, Waddell saw his strength improve and his pain decrease; he says he is now “close to one hundred per cent,” and is no longer thinking about surgery. “I was shocked that I kept getting better,” he said. “It had been so bad for so long.”
The outcome didn’t surprise Ibrahim, who estimates that he has treated around five thousand people with P.R.P. over the past five years. He says that the treatment can repair tendons, ligaments, cartilage, and nerves, and can even regrow tissue that has been frayed or damaged. This, he suspects, is what happened with Waddell’s rotator cuff. “For a lot of conditions, it’s almost a wonder drug,” Ibrahim told me. “We’ve figured out a way to help the body regenerate itself.”
P.R.P. sounds implausible. But credible scientists and clinicians, many from major institutions, say that it can heal a range of orthopedic injuries, which are often difficult to treat. Dozens of studies, some in cells, some in animals, and some in humans, have found that the procedure can repair chronic tendon injuries, heal damaged muscles and ligaments, and reduce arthritis pain.
Interest in P.R.P. is growing in part because traditional treatments for joint problems, such as arthritis, torn ligaments, and damaged tendons, are only marginally effective. Surgery sometimes succeeds, but it often doesn’t help and can cause further damage; cortisone shots can temporarily reduce pain, but they don’t address the underlying problem; physical therapy can be effective, but it often doesn’t work. Many people are left to limp along with ice and ibuprofen.
“Patients have been dissatisfied with what we have to offer them,” said Allan Mishra, an orthopedic surgeon at Stanford University Medical Center, who has been researching the technique and has used it on his patients for more than a decade. He thinks it will revolutionize orthopedic treatment. “Fifty years ago, getting a new knee was unimaginable,” he said. “Now it’s commonplace. This will have the same trajectory.”
The process of making P.R.P. is relatively simple. A doctor draws between half an ounce and an ounce of the patient’s blood and spins it in a centrifuge to separate the platelets, the disc-shaped cells best known for their crucial role in clotting, from most of the red and white blood cells. The spinning concentrates the platelets in the plasma, the liquid part of blood. When the process is finished, the number of platelets in the plasma increases by a factor of between two and twenty, depending on the spinning method. The substance is then injected into the site of the injury, whether it’s a ligament, a tendon, or an arthritic joint.
The treatment was first used about thirty years ago by dental surgeons, to repair jaws and other facial bones that often don’t heal well. Researchers knew that these areas have fewer blood vessels than many other parts of the body, and wondered if the healing problem was related to a lack of blood. They found that P.R.P. could improve results in these situations, as well as for wounds that were slow to heal. The side effects were generally minimal—soreness, stiffness, and swelling from the injection—so doctors were willing to try it. In the mid-nineties, veterinarians began using it to treat tendon, ligament, and cartilage injuries in horses; like bone, these tissues tend to have a relatively limited blood supply. About a decade ago, P.R.P. moved back to human orthopedics and sports medicine. Practitioners estimate that P.R.P. is now used by a few hundred doctors around the country, mostly orthopedists and sports-medicine specialists. There are no statistics on how many people have been treated, but Ibrahim and others who use P.R.P. put the number in the tens of thousands, including hundreds of élite athletes like Waddell.
At the same time, P.R.P. remains controversial. One of the leading skeptics is Stephen Weber, an orthopedic surgeon in Sacramento. Six years ago, he became interested in P.R.P. and set up a study to see if it could help patients recover from shoulder surgery more quickly. He operated on the rotator cuffs of sixty people, half of whom received a P.R.P. injection afterward. His study, which was published last year, found that P.R.P. made no difference in patients’ recovery speeds. “We need to be very cautious,” he said. “Just because a Los Angeles Laker gets it doesn’t mean that it works.”
Even some pro-P.R.P. doctors worry that marketing and hype have overtaken science. Vijay Vad, a sports-medicine specialist at the Hospital for Special Surgery, in Manhattan, uses P.R.P. in his practice and says the treatment can work especially well for tendon injuries. But he thinks some doctors are using it indiscriminately. “It has merit,” he said. “But people have gone way overboard. Some of it is a moneymaking gimmick. Medicine needs to be careful.”
As sometimes happens in medicine, doctors are offering a treatment before science has figured out how best to administer it. “We did it backwards,” said Lisa Fortier, a veterinary surgeon at Cornell and a leading researcher. “We got to clinical practice before we figured out the best methods.”
How P.R.P. works remains an open question. “To be honest, we barely understand the biology of this,” Mishra said. Platelets contain more than a thousand different proteins and hormones that stimulate cell growth and repair, such as vascular endothelial growth factor and the insulin-like growth factor-1. On their own, many of these chemicals are known for their ability to heal injury and relieve pain. Together, they may have a synergistic effect, which could explain the treatment’s power.
Given this uncertainty, it’s not surprising that there is a good deal of controversy over the best way to make P.R.P. About twenty companies make the centrifuges, and each brand produces a different blend. “P.R.P. is not P.R.P. is not P.R.P.,” said Martha Murray, an assistant professor of orthopedic surgery at Harvard Medical School who has been studying the how the treatment works in ligament injuries. Probably the most heated debate is over white blood cells. Depending on how it is processed, P.R.P. can contain hundreds of white cells or almost none. These cells are part of the immune system; to discourage infection and remove damaged tissue, they cause inflammation at the site of an injury.
Some doctors and researchers, including Fortier and Ibrahim, argue that P.R.P. should contain few white cells, because the inflammation impedes healing. But another faction argues that white cells are crucial for repair. Some doctors even tell their patients to stop taking anti-inflammatory medicines, such as aspirin or ibuprofen, a few days before treatment, to ensure that nothing inhibits the post-injection tenderness and swelling.
Both sides may be right, according to Mishra and other researchers. For chronic tendon injuries, which involve scarring and degeneration but no inflamed tissue, a mixture that triggers inflammation may spark healing; for arthritis, in which damaged cartilage is already inflamed, a version with few white cells could be more effective. “We’re still trying to figure out what the best recipe is for each condition,” said Fortier.
For the past five years, she has collaborated on research with several prominent human orthopedists, including Brian Cole, an orthopedic surgeon at Rush University Medical Center, in Chicago, and a team doctor for the Chicago Bulls and the Chicago White Sox. Together they are examining several issues, including whether P.R.P. can do more if it stays in contact with the injury for longer. To increase its stickiness, they and other research groups are experimenting with fat, collagen, and fibrin, a protein that helps clot blood.
In part because of the many uncertainties surrounding P.R.P., insurance companies rarely cover the treatment, which can be expensive; a single injection costs between five hundred and two thousand dollars, depending on the doctor and the amount of blood needed. Most patients get two or three injections. The University of Pittsburgh orthopedic surgeon James Bradley, who does research on P.R.P. and uses it in his practice, understands insurers’ hesitation. “They’re not going to pay for it until we have really concrete evidence,” he said.
That evidence may not arrive soon. Many positive P.R.P. studies have been published in recent years, but none were large human trials with thousands of subjects—the sort of research that typically persuades insurance companies to change reimbursement policies—because studies such as these can cost millions of dollars, and are almost always paid for by a major drug company that wants F.D.A. approval of a patented drug. P.R.P. is not patented, and is already on the market—the F.D.A. allows the procedure, and approves the centrifuges based on whether they modify blood safely and in accordance with manufacturers’ claims. As a result, the makers of P.R.P. machines have little incentive to conduct large trials.
Despite these issues, P.R.P. continues to spread. “We do not have a perfect grasp of how to use this yet,” Mishra said. “We have a lot of work to do. But it’s beyond the promising stage. We know there is tremendous value in this.” The bottom line, he says, is that even as doctors and scientists refine it, P.R.P. is helping a lot of people.
Last month, Waddell completed a month-long, fifteen-hundred-mile cycling trip from Seattle to San Diego, raising awareness about his educational foundation along the way. Using his arms to power a custom-fitted three-wheeled bike, he rode about sixty miles a day. He says he couldn’t have done it without P.R.P. “For me, it’s been a total godsend,” he said. “I didn’t want to sit on the couch for the rest of my life.”
David Kohn writes about medicine and science. He lives in Baltimore.
An interesting article on Frostbite from Stop Sport Injuries fall issue. http://stopsportsinjuries.org
What is Frostbite and How Do I Prevent It?
by Christopher Tucker, MDAthletes participating in outdoor winter sports, such as alpine and cross-country skiing, snowboarding, and mountaineering, are at increased risk for developing frostbite. Frostbite is a condition in which prolonged exposure to cold temperatures cause an injury resulting in tissue damage— starting superficially with the skin and potentially spreading deeper to blood vessels, muscles, tendons, and even bone.
What Does Frostbite Feel Like?
Many people who are developing frostbite experience early symptoms such as numbness or a tingling sensation in the skin, such as the “pins and needles” that you can feel after a hand or foot falls asleep. The affected body part may also be extremely painful, feel itchy, or have a burning sensation. The skin can initially
appear white or grey with a surrounding area of redness, and as frostbite progresses, blisters may form and
the skin will feel hard, waxy, or numb.
Who is at Risk?
While anyone can potentially develop frostbite, both the very young and the elderly are at particularly high risk and should take special precautions to prevent over-exposure in cold environments. In addition, athletes with medical conditions such as diabetes or heart conditions can be at increased risk due to decreased blood flow to the skin.
How Cold is Too Cold?
Generally, the risk of frostbite is low when the outside temperature is above 14°F (-10°C), but that risk can go up significantly with prolonged exposure, increased elevation (>17,000 feet), and increased wind speed.1
How Do You Treat Frostbite?
Preventing injury begins with protection from the elements, which requires getting out of the cold as soon as possible and replacing all wet clothing with dry, warm, insulated layers. Immobilizing the extremity to prevent
damage to the cold, stiff skin and muscles can prevent further injury. Once inside, rewarming the affected extremity should be done rapidly by immersion in a warm water bath at 104°–107.6°F (40°–42°C) for 15 to 30 minutes until thawing is complete.1,2 If warm water is not available, body heat can be used to rewarm the hands or feet, such as tucking them in your armpits. When successful, the skin becomes soft and pinkish again. Avoid rubbing or massaging the skin to avoid damaging the skin or rupturing blisters.
An Ounce of Prevention
While outdoor winter sports provide an excellent opportunity for physical exercise and competition, they can be dangerous if athletes are not properly prepared. Useful tips to help prevent frostbite include:
Check weather forecasts to prepare for inclement weather or avoid extreme weather.
Wear adequate clothing to protect from the cold and wind—dressing in loose-fitting layers, including fabric that wicks away body moisture and sweat is best.
Cover exposed skin with gloves or mittens, a hat, scarf, and face mask, if needed.
Minimize alcohol consumption and tobacco use.
Stay active! Physical activity maintains core body temperature as well as increases blood flow to the hands and feet.
1. Golant A, Nord RM, Paksima N, Posner MA. Cold exposure injuries to the extremities. J Am Acad Orthop Surg. 2008;16:704-15.
2. McIntosh SE, Hamonko M, Freer L, Grissom CK, et al. Wilderness medical society practice guidelines for the prevention and treatment of frostbite. Wilderness Environ Med. 2011;22:156-66.
Darryl Novotny BScPT, Registered Physiotherapist at Orthopaedic Sport Institute has written an article for Georgian Life December issue about custom knee bracing.
As winter looms and the ski hills are blanketed in snow, many people are reminded that their knee pain may limit, or even stop, their participation in snow-related sports.
Many individuals have been diagnosed with osteoarthritis (OA) of the knee – this is characterized by a loss of the protective cartilage at the end of each bone in your joint, usually more on one side of the knee than the other. OA generally occurs due to gradual wear and tear of a joint over decades of physical activity, but can also be caused by an injury.
For those situations in which surgery is not yet an option, conservative treatments of OA-related conditions can include:
While these interventions are sometimes successful, patients do not always experience 100% relief and, as a result, regular physical activity becomes increasingly limited and painful. The development of Custom OA Knee Unloader braces have led to another non-invasive, drug-free solution for people suffering from knee OA. These lightweight braces are designed to reduce pressure on the side of the knee that has worn down. Once fitted, these braces are easy to don and, due to their low-profile build, can easily fit underneath your outdoor skiwear.
For further information on treatment options, please contact the Orthopaedic Sport Institute at (705) 467-0701 or firstname.lastname@example.org and ask for a consultation with one of our friendly healthcare professionals. Let us help get you back onto the ski hill!