OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Chad Krueger, MD, in response to an Annals of Internal Medicine study investigating the effectiveness of tai chi for treating knee osteoarthritis (OA).
We have put men on the moon, but we still have no cure for the osteoarthritis that affects millions of Americans. We try a variety of injections and other conservative measures to help slow the progression of the disease, but at some point arthritis wins. Undaunted, we search for new modalities of easing the disability the disease brings to our patients in hopes of offering an effective treatment.
That is why I read with interest the recent study “Comparative Effectiveness of Tai Chi Versus Physical Therapy for Knee Osteoarthritis” in the Annals of Internal Medicine. I have many patients with debilitating knee arthritis who are not quite ready to embark on a joint replacement until they feel they have exhausted all other options. I have never referred a patient to tai chi, so would this provide another avenue for those patients to explore?
In this trial, 200 patients were randomized to either 24 total tai chi classes or standard physical therapy sessions (12 sessions at the PT office followed by six weeks of monitored home exercise). The primary outcome measure was the WOMAC score. After following the patients for a year, the researchers found that both groups had substantial improvements in their WOMAC scores, along with improvements in four secondary outcome measures: physical function, quality of life, depression, and medication usage. The one notable between-group difference was that the tai chi group had significantly greater improvements in depression and quality of life.
It’s clear that increasing physical activity, within reasonable bounds, helps patients with knee arthritis in many ways. Whether that extra activity comes from a tai chi class or a structured physical therapy program may not matter. However, it is possible that the tai chi classes (and other group-based physical activity programs) have social benefits that standard physical therapy does not—and that the patients in the tai chi classes may have benefited substantially from that social connection. Many studies, including those of the Lower Extremity Assessment Project (LEAP) cohort, have shown the power that social and psychological factors can have on a patient’s outcome. It’s not surprising that similarly positive social effects would be found in patients with knee osteoarthritis.
Still, not everyone with knee osteoarthritis will want or be able to attend a group class, so such a treatment option is not universally applicable. However, these findings should provoke orthopaedic surgeons and payers to consider seriously the social and emotional aspects of OA treatments. Tai chi is certainly not a “moonshot” solution to knee osteoarthritis, but then again, what is?
Chad Krueger, MD is a military orthopaedic surgeon at Womack Army Medical Center in Fort Bragg, NC.
During the last two decades, we have made tremendous progress in orthopaedic surgery in terms of limiting the negative impact of surgical dissection on patient functional outcomes. The expanding use of the arthroscope has been at the forefront of these advances. Limiting the breadth, depth, and imprecision of surgical dissection has obvious benefits that have been well documented in hundreds of musculoskeletal procedures.
In the August 3, 2016 issue of The Journal, Kim et al. demonstrate arthroscopic repair of elbow instability following elbow dislocations with injury to the lateral ulnar collateral ligament. Despite the notable success reported by the authors in 13 patients, arthroscopic elbow ligament repair is obviously a technique that requires careful preparation, and patients should be advised to work with a surgeon who is experienced in this specific application of arthroscopy.
This study does not address the question of whether or not surgery is indicated for an individual patient with post-dislocation elbow instability. Comparing outcomes among surgically managed and non-surgically managed patients would be the mode of addressing that important question. Nevertheless, we should continue efforts to advance “limited surgical damage” approaches by applying appropriate clinical research designs to clarify the reward /risk tradeoffs related to patient outcomes.
Marc Swiontkowski, MD
Developmental cervical stenosis is usually asymptomatic in adults until an acute injury or degenerative soft-tissue abnormalities cause nerve compression and associated symptoms. Thus, it would help orthopaedists and their patients to have a robust radiographic tool to assess for developmental cervical stenosis in its presymptomatic stages.
Horne et al. seem to have developed such a tool, as they describe in the July 20, 2016 issue of The Journal of Bone & Joint Surgery. Using a canal diameter of <12 mm, as measured by computed tomography (CT), as the definition of developmental cervical stenosis, the authors made detailed measurements of lateral cervical radiographs from 150 adult patients. They then calculated several ratios from those measurements and compared the ratios to the “true” CT-determined canal diameter. After analyzing the predictive value of the ratios, they determined that:
- At C5, a ratio of lateral mass-to-posterior vertebral body distance (LM) to spinolaminar line-to-vertebral body (canal) diameter (CD) ≥0.735 indicated cervical stenosis at any level from C3 through C6, with a sensitivity of 76% and a false-positive rate of 20%.
- This LM/CD ratio minimizes the confounding effects of patient size, sex, and ethnicity, which have hampered the statistical strength of earlier predictive measurements, such as the Torg-Pavlov ratio.
The authors conclude that the LM/CD ratio “may help practitioners to assess the risk of underlying cervical stenosis and the need for additional imaging or referral to a surgical specialist,” but they are quick to add that “this ratio should not be used in isolation for clinical operative decision-making or for withdrawing athletes from sports participation.”