In a recent study by Hart et al, the authors looked into the risk factors associated with blood transfusion during total hip and knee replacements. They looked at information from the National Surgical Quality Improvement Program, which is a nationally validated, outcome based program that collects data about preoperative risk factors, variables during surgery, thirty-day postoperative complications and mortality rates. This database was used to identify patients undergoing elective primary hip and knee replacements in 2011. A total of 9362 hip replacements and 13,622 knee replacements were identified. For this set of patients the blood transfusion rate for hip replacement was 22.2 percent, and for total knee replacement 18.3 percent. Significant risk factors associated receiving a blood transfusion were similar for both knee and hip replacements and included (in order of importance) age, preoperative hematocrit (red blood cell count), BMI 2. These results were somewhat surprising, for example the authors did not expect lower BMI to be associated with increased transfusion requirement, and they also found that smoking was actually a protective factor against needing a transfusion. The authors hypothesize that with decreased BMI and lower red blood cell count before surgery, with too much loss of blood then a blood transfusion may more likely. They also hypothesize that smoking increases the red blood cell count over time to make up for less ability of the smokers red blood cells to carry oxygen, thus these patient may have more blood cells available to make up for blood loss during a surgery.
There have been a few research studies trying to answer just this question. Pedersen et al looked at hip replacements and found some association with post operative pneumonia and death. Browne et al showed blood transfusions with total hip replacement to have increased mortality, length of stay in the hospital and total hospital charges. A more recent and larger study by Hart et al found that there was no increase in serious complications in the first thirty days after having a blood transfusion during a total knee or total hip replacement.
Studies vary on the prevalence of sciatica annually, however recent reviews of nine large studies found that the injury ranges between two and 34 percent of adults each year.
Hopefully, you will feel better with PT and medical interventions for your sciatica in the first few weeks of PT after the onset of your pain. There is good evidence to support that the higher the level of your fear of movement and pain initially, the better the chance you will benefit from reducing your leg pain with treatment as far out as one year following your injury.
Adhesive capsulitis, also known as frozen shoulder is often associated loss of range of motion in the shoulder with no known cause. In general an MRI is not needed to confirm this diagnosis, however there has been some recent indications that in some cases of frozen shoulder the rotator cuff may be involved. In this case an MRI would be appropriate to confirm or deny the presence of injury to the rotator cuff. In a recent study by Ueda et al research was conducted to determine the prevalence of rotator cuff injuries in patients with stiff shoulders. This study found that patients who had global loss of range of motion, in all directions, for example less than 100 degrees of forward flexion, external rotation of 10 degrees or less and internal rotation reach to the 5th lumbar level or less it is not likely that there is a rotator cuff injury. However, if you have loss of motion in only one direction, or less severe loss in all directions there can be up to a fifty percent chance of having a rotator cuff injury. In this case, according to Ueda et al, it would be appropriate to have imaging, such as an MRI, to look further into this possibility.
There has recently been some discussion of rotator cuff injuries being associated with adhesive capsulitis, or frozen shoulder, with no known cause and this is something to consider. A recent study by Ueda et al has attempted to clarify some of the information that is in the research these days. This study has better defined the range of motion restrictions in frozen shoulder as they relate to possible rotator cuff injuries. They have shown that if there is severe restriction in all motions, for example less than 100 degrees of forward flexion, external rotation of 10 degrees or less and internal rotation reach to the 5th lumbar level or less it is not likely that there is a rotator cuff injury. However, if you have loss of motion in only one direction, or less severe loss in all directions there can be up to a fifty percent chance of having a rotator cuff injury. In this case, according to Ueda et al, it would be appropriate to have imaging, such as an MRI, to look further into this possibility.
I have good news for you. According to a recent study conducted by Moffat et al there is good evidence that there is no down side to having your at home physical therapy provided via the internet and video. They showed no significant difference at four months after hospital discharge between face to face and video therapy after total knee replacements. They also described that the treatments provided were exactly the same. They included individual evaluation, supervised exercises, instruction in exercises to complete on days without a session, advice about pain control, use of walking aids and return to activities. The intensity and difficulty was based on each individual patients progress. This is good news for patients and therapists looking for the benefits of physical therapy following a total knee replacement, but do not have the resources to access at home face to face treatments.
This is a problem for many people in all areas of medicine and with improvements in internet access telemedicine is increasing. There haven’t been too many studies on comparing the quality of these services as far as physical therapy is concerned. However there has been on recent study by Moffat et al, published in July 2015. In this study they were able to have two large sample sizes for two groups, one receiving at home face to face PT following knee replacement and the other receiving at home video based PT. The results of their study are promising that there is very little to no difference between the outcomes for these two groups. This results of this study indicate that if you have the option for tele rehabilitation it can be a good option.
In the past, recovery from a burst fracture in the thoracolumbar region could include any combination of significant bed rest, surgery, and a brace (orthosis). However, recent treatments have been moving away from these due to the increased costs and risks of surgery and bed rest. In a recent study by Bailey et al they demonstrated that there was no difference between treatment of this injury with or without a brace. The treatment for both groups included a lifting restriction of less than five pounds, and a bending restriction not past ninety degrees at the waist. Neither group was instructed in bed rest and restrictions were lifted after eight weeks. The results of this study indicate that neither a brace or significant bed rest is required for safe recovery. It is important however to discuss your injury with your physician because there can be individual circumstances which would call for different course of treatment.
According to a recent study by Bailey et al in 2015, treatment of a thoracolumbar burst fracture can include a brace or not with equivalent results. The group utilizing the brace was instructed to wear it at all times, unless in bed, for ten weeks, with a weening out period after eight weeks. In both groups there was a lifting limitation of less than five pounds, and no bending past ninety degrees at the hips for eight weeks. However you should always ask your physician for their specific instructions about use of the brace following your injury, as individual circumstances may indicate a different course of treatment.
A group of large randomized clinical studies investigated long term outcomes comparing anterior cervical discectomy and fusion (ACDF), to cervical disc replacement (CDR). They looked at measures including perceived neck function, general health, neurologic improvement and avoidance of future secondary surgical needs. All reported improvement in all outcomes with both CDR and ACDF, with no significant difference between to two procedures. However there have been studies showing that cervical disc replacement in the long term is more effective at preserving range of motion and decreasing degeneration at adjacent segments. In 2014, a cost effectiveness review that included measuring quality-adjusted life years (QALYs)for a five year follow-up found that CDR resulted in 2.84 QALYs while ACDF generated 2.81 QALYs. The cost-effectiveness ratio using these two measures was $35,976/QALYs for cervical disc replacement and $42,618/QALYs for anterior cervical discectomy and fusion. Ultimately, CDR was found to be less costly and also more effective when compared results in a 5 year follow-up span.
Both procedures are used for treatment of long term neck pain, neurological deficits, and radiculopathy stemming from the degenerative changes of the neck. Anterior cervical discectomy and fusion (ACDF), has been the gold standard for years. It involves a surgical procedure where an incision is made in the front of the neck in order to remove part of a cervical disc which lay between two vertebrae. Once the disc is removed the two vertebrae are fused together. This procedure has a very high clinical success rate for alleviating symptoms but is also associated with some negative long term side-effects including loss of cervical range of motion, increased degenerative changes at segments adjacent to the fusion level and an increased reliance on future need to solid bony fusion. A cervical disc replacement(CDR), procedure is relatively new. It involves the same approach as ACDF with an incision on the front of the neck. The disc is removed, but rather than fusing the two vertebrae, and artificial disc is implanted. This procedure also has a high clinical result in symptomatic relief, but it also helps maintain range of motion and can decrease degeneration at adjacent segments.
On the surface, with results such as shorter hospital stays, less blood loss, and a lower chance of infection, it would seem that minimal access surgery would be more cost effective than an open spinal surgery. However, the instrumentation required for these techniques is often expensive and can outweigh the savings. A review of the literature comparing cost of minimal access surgery to open surgery found that there is no economic difference in the two techniques. However, several studies that suggested cost-saving with minimal access surgery were excluded from the review as they did not meet requirements of detailed methodology or long term follow up on clinical outcomes. There is a need for more detailed studies comparing cost-effectiveness of minimal access surgery to open conventional spine surgery in order to better understand the economic details of these surgical approaches.
Surgical techniques for lumbar spine fusion can be separated into two categories based on amount of tissue disruption. Minimal access surgery is reported to have better short term perioperative results as it utilizes small incisions and minimal muscle disruption. This technique involves use of a tube or sleeve to complete a muscle dilating or muscle splitting approach. Conventional surgery or open spine surgery involves lifting or stripping the musculature along the spine to gain access to the spine. Patients undergoing minimal access cervical or lumbar surgery report less blood loss, lower chance of infection shorter hospital stays and less pain medication and often a faster return to activity.
In a recent report by Dines at al, there is a good description of common tennis injuries and why they occur. Tennis has many different movements associated with playing, but frequently there are explosive bursts of energy and there are repeated motions. Over the course of a few months playing this can involve thousands of repeated strokes. This high repletion and high energy can often lead to overuse injuries and many back injuries fall into this category. Specifically, repetitive rotational forces in combination with flexion or extension (very common in tennis, think serving or reaching way in front to get a ball with your back hand) increases the risk for injury to both the discs and joints of the lumbar spine. Usually injuries of this kind are due to tiny forces adding up over a long time. This probably includes forces while playing tennis and in other life activities. As we age this repetitive trauma adds up and can eventually result in pain. Back injuries of this kind are quite common in tennis players because of these factors. Fortunately there are some preventative measures to take, such as working on core strength, flexibility, and body awareness for all movements.
According to a report by Dines et al, there are several studies which have concluded that the most common injury to the tennis player is an ankle sprain. One of the easiest prevention measures to take, and if you notice at the US Open this summer most professionals have them, is to utilize a supportive ankle brace while playing. This helps to support the ankle and can minimize inversion ankle sprains, which occur easily with abrupt stopping and change of direction movements. Other preventative measures can be taken including improving ankle and hip strength, as well as working on your balance. You can speak to a tennis professional or even a physical therapist in your area to get more specific recommendations.
A review study found supportive evidence on electing for the conservative non-surgical choice followed by rehabilitation focused on getting the person back to prior function gradually. Better outcomes, less infections, less medical cost all weighed in on the side of avoiding the knife.
Getting your leg fully examined by a qualified medical provider is a good start. They are recommended to use the Thompson test or calf-squeeze-test, which been found to be the most effective way to diagnose a full Achilles tendon tear.
Hill and Keating’s study found that regular exercise and spine health education reduce the incidence of low back pain in children (ages eight-11) more than just back care education alone.
According to the conclusions of this randomized and controlled study, the evidence does not support specific therapeutic exercises in reducing the frequency of episodes of low back pain.