treatments in outpatient MSK

[pmr2010]

Hi all,

I'm a pgy2 just starting off in outpatient MSK. While the nature of work, hours, and patient interaction are great, I have concerns upon discovering what seems to me to be a rather narrow range treatments for most MSK conditions. Its seems that for any given complain, say chronic shoulder pain or LBP, we do a w/u of exam and imaging if needed. Assuming its soft tissue, joint, ligament, we start with PRICE (usu has been tried), anti-inflammatory PO and cream, physical therapy (for which its typically ROM or stabilization exercises), orthotics, changing their posture/biomechanics, maybe steroid injection if indicated. Then various physiatrists may choose to proceed with more controversial tx if they fail include spinal manipulation, acupuncture, etc. Personally I love acupuncture but I realize the jury is still out there even though last cochrane review was moderately favorable.

So while diagnostically there is a lot of anatomy, exam expertise to learn, imaging including MSK u/s to learn about, it seems a bit repetitious in terms of formulating a treatment plan. But I'm new and naive, can any upper levels or better yet sports trained physiatrist comment on this? Hopefully there will be new technologies/drugs emerging to help us better tx recalcitrant MSK issues.

Of course, I did not go into PM&R solely for outpatient MSK, but it was an aspect I thought I would be more excited about.

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[bedrock]

PMR2010,

I speculate (and correct me if this isn't your situation), but in most PM&R outpatient clinics, a few common chronic conditions comprise >95% of the practice, including knee OA, rotator cuff injuries, & DJD of the spine.

From both a treatment and diagnosis standpoint, you might find the work more interesting if you get time to work in a true sports med clinic where you can see acute and sub-acute injuries presenting in more interesting ways. Different joints, ligaments, tendons are affected and the biomechanics of sports injury tend to be more complex and interesting to remedy than medial compartment knee OA.

In these settings, the sports physician often plays a greater role analyzing the biomechanical issues, recommending specific exercises, specific braces, specific orthotics, etc, than with the common chronic conditions where often a general script is written without much thought.

New emerging technologies you may or may not have been aware of include MSK ultrasound, prolotherapy, PRP therapy, intradiscal injections, among others.

Good luck-

 

[caedmon]

There are some out there looking at novel treatments for chronic tendinopathies. Studies overseas and early studies in the states have shown good treatment outcomes with topical nitrates, sclerosing of neovessels with injectible agents such as polidocanol, injections of autologous blood or platelet rich plasma, and ultrasound guided needling and enthesophyte manipulation.
As mentioned previously, muskuloskeletal ultrasound is an exciting arena that physiatrists should embrace and is used in guidance for many of the above treatments.

 

[pmr2010]

Actually, thanks guys for the input. I have heard of therapies like PRP and prolo before. Obviously at this point, one can consider them experimental. As I understand it, MSK u/s is increasingly being used in the US and I'm very excited about this dx tool. Bedrock, you're right in that I don't work in a true sports med clinic although we do see 25% pt are sports injuries.

I think once some of these experimental therapies are established, this field can really lift off. As it is right now, if you wanted to be conservative/parsimonious with practicing only evidence based medicine, you would be frustrated in lots of cases because we don't have enough tx for back strain, neck strain, etc. We definitely have to push the envelope until more research comes out. (I have a feeling that something like acupuncture is one day going to become very mainstream).

 

[SSdoc33]

"So while diagnostically there is a lot of anatomy, exam expertise to learn, imaging including MSK u/s to learn about, it seems a bit repetitious in terms of formulating a treatment plan. But I'm new and naive, can any upper levels or better yet sports trained physiatrist comment on this? Hopefully there will be new technologies/drugs emerging to help us better tx recalcitrant MSK issues."


what? wait a minute. what?

I am by no means an expert, but the breadth of diagnoses and treatment options in PM&R constantly overwhelms me. You have everything in your arsenal except surgery. Anything that you can think of!! And you have basically every single musculoskeletal ailment to understand and know how to treat. Bread and butter? what? what???!?!?!?!?!?!?!?!?

 

[pmr2010]

I think you misunderstand what I'm saying. I'm saying diagnostically there is a lot to learn. Therapeutically, "everythign in our arsenal except surgery" usu boils down to a few broad categories for non-interventional physiatrist:

PT/OT referral
pain meds, pain patches
trigger point inj, peripheral inject in joints
splints, bracing
manipulation (which relatively few % of physiatrists perform)

what i'm saying is that newer/ less evidence based treatments are coming, but not everyone is using prolotherapy, acupuncture. Also there are no blockbuster drugs that affect OA the way TNF inhibitors affect RA. I've since spoken with a few PM&R docs, and some agree wth my opinion.

 

[Louisville04]

boils down to a few broad categories for non-interventional physiatrist:

PT/OT referral
pain meds, pain patches
trigger point inj, peripheral inject in joints
splints, bracing
manipulation (which relatively few % of physiatrists perform)

I think that is a fair assumption. However, I think most specialities and primary care physicians have a similar limited arsenal.

Most ortho docs don't much more than x rays, injections, PT, NSAIDs in a clinic setting
Dermatology seems to prescribe steroids for most of their patients
Primary care physician usually only try different meds for HTN (I guess diet, exercise too)
Neurology will mostly try different meds, EEG, an EMG (which pm&r docs do as well) as an outpatient

Disclaimer: This is what I remember rotating through as a med student and resident

 

[ampaphb]

I think you misunderstand what I'm saying. I'm saying diagnostically there is a lot to learn. Therapeutically, "everythign in our arsenal except surgery" usu boils down to a few broad categories for non-interventional physiatrist:

PT/OT referral
pain meds, pain patches
trigger point inj, peripheral inject in joints
splints, bracing
manipulation (which relatively few % of physiatrists perform)

what i'm saying is that newer/ less evidence based treatments are coming, but not everyone is using prolotherapy, acupuncture. Also there are no blockbuster drugs that affect OA the way TNF inhibitors affect RA. I've since spoken with a few PM&R docs, and some agree wth my opinion.

Not everyone is using prolo and acupuncture not because there is no evidence, but because there IS evidence that both of these modalities are no better than placebo/sham

 

[clarence]

can anyone tell me what PRP therapy is?

 

[ampaphb]

can anyone tell me what PRP therapy is?

Platelet Rich Plasma

Am J Sports Med. 2006 Nov;34(11):1774-8.
Treatment of chronic elbow tendinosis with buffered platelet-rich plasma.

Mishra A, Pavelko T.
Department of Orthopedic Surgery, Menlo Medical Clinic, Stanford University Medical Center, 1300 Crane Street, Menlo Park, CA 94025, USA. [email protected]

BACKGROUND: Elbow epicondylar tendinosis is a common problem that usually resolves with nonoperative treatments. When these measures fail, however, patients are interested in an alternative to surgical intervention.

HYPOTHESIS: Treatment of chronic severe elbow tendinosis with buffered platelet-rich plasma will reduce pain and increase function in patients considering surgery for their problem.

STUDY DESIGN: Cohort study; Level of evidence, 2.

METHODS: One hundred forty patients with elbow epicondylar pain were evaluated in this study. All these patients were initially given a standardized physical therapy protocol and a variety of other nonoperative treatments. Twenty of these patients had significant persistent pain for a mean of 15 months (mean, 82 of 100; range, 60-100 of 100 on a visual analog pain scale), despite these interventions. All patients were considering surgery. This cohort of patients who had failed nonoperative treatment was then given either a single percutaneous injection of platelet-rich plasma (active group, n = 15) or bupivacaine (control group, n = 5).

RESULTS: Eight weeks after the treatment, the platelet-rich plasma patients noted 60% improvement in their visual analog pain scores versus 16% improvement in control patients (P =.001). Sixty percent (3 of 5) of the control subjects withdrew or sought other treatments after the 8-week period, preventing further direct analysis. Therefore, only the patients treated with platelet-rich plasma were available for continued evaluation. At 6 months, the patients treated with platelet-rich plasma noted 81% improvement in their visual analog pain scores (P =.0001). At final follow-up (mean, 25.6 months; range, 12-38 months), the platelet-rich plasma patients reported 93% reduction in pain compared with before the treatment (P <.0001).

CONCLUSION: Treatment of patients with chronic elbow tendinosis with buffered platelet-rich plasma reduced pain significantly in this pilot investigation. Further evaluation of this novel treatment is warranted. Finally, platelet-rich plasma should be considered before surgical intervention.

 

[dc2md]

pretty cool, ampaphb. obviously this is only a pilot study and plagued with numerous problems, but this is at least eye-opening and encouraging. i'd love to see a larger study. what do they think the MOA of this PRP is?
i don't believe any of our clinics do this here at LSU...do anyone know if they use this method at any PM&R programs?

 

[SSdoc33]

PMR 2010, i do think understand you, but you are categorizing the treatments so broadly, i think you may be missing the depth of the actual treatments. if someone comes in with a spine problem, and you prescribe "PT/OT eval and treat", then you and whomever your mentor is are COMPLETELY missing the boat. unfortunately, this happens all to often, and physiatrists come off looking like the ugly stepchild. writing a specific therapy prescription and being able to differentiate "good PT" from "bad PT" is integral.

and that example really goes for all of the other treatments you've listed. i think you are selling physiatry a bit short. its our knowledge as specialists to be able to tease out what the PCP or orthopedist might miss and provide BETTER diagnoses and treatment plans that sets us apart.

outpatient MSK can be bland and formulaic if you let it be and dont give yourself the skill and knowledge base to be good at it. ive worked with a bunch of "mentors" that spend an hour doing the H & P, and then write for some naprosyn and generic PT. to be honest they are doing a crappy job, most likely because they dont know any better

 

[pmr2010]

PMR 2010, i do think understand you, but you are categorizing the treatments so broadly, i think you may be missing the depth of the actual treatments. if someone comes in with a spine problem, and you prescribe "PT/OT eval and treat", then you and whomever your mentor is are COMPLETELY missing the boat. unfortunately, this happens all to often, and physiatrists come off looking like the ugly stepchild. writing a specific therapy prescription and being able to differentiate "good PT" from "bad PT" is integral.

and that example really goes for all of the other treatments you've listed. i think you are selling physiatry a bit short. its our knowledge as specialists to be able to tease out what the PCP or orthopedist might miss and provide BETTER diagnoses and treatment plans that sets us apart.

No my mentor writes fairly detailed requests for PT/OT. The distinction between Good PT and bad PT is such as controversial issue. Most MSK injuries don't have clinical trials comparing exercise A to exercise B, therefore we know that exercise/pt is good, but we don't know which ones really work for sure. Therefore, it seems the vast majority of injuries we first stretch it, then strengthen it--'it' being some kind of muscle or tendon strain. As time passes, hopefully we can have research that this exercise works for this condition well, but avoid doing this. Right now I think most the recs are based on experience and anecdotes, which leads to a lot of variability in how PT/OT is implemented. I hope one day the therapy is much more standardized.


Compared to GPs, we definitely do a better job identifying the pathology. But I've worked with sports medicine trained orthopedists in the past, and I don't think our treatment plans for non-surgical care are different or "BETTER" than theirs. If anything, its pretty much the same. I don't feel I'm selling physiatry short, but I want to be realistic about what we are doing for our patient and what we know.

 

[ampaphb]

we know that exercise/pt is good

My understanding is that, truthfully, we don't actually know that, based on EBM criteria.

 

[caedmon]

pretty cool, ampaphb. obviously this is only a pilot study and plagued with numerous problems, but this is at least eye-opening and encouraging. i'd love to see a larger study. what do they think the MOA of this PRP is?
i don't believe any of our clinics do this here at LSU...do anyone know if they use this method at any PM&R programs?

Not many studies out there right now. Some at our institution are gearing up for treatment trials soon, looking at lateral epicondylosis.

J Orthop Res. 2007 Feb;25(2):230-40.

Platelet rich plasma (PRP) enhances anabolic gene expression patterns in flexor digitorum superficialis tendons.Schnabel LV, Mohammed HO, Miller BJ, McDermott WG, Jacobson MS, Santangelo KS, Fortier LA.
Department of Clinical Sciences, VMC C3-181, Cornell University, Ithaca, New York 14853, USA.

Platelet rich plasma (PRP) has recently been investigated for use in tissue regeneration studies that seek to utilize the numerous growth factors released from platelet alpha-granules.

This study examined gene expression patterns, DNA, and collagen content of equine flexor digitorum superficialis tendon (SDFT) explants cultured in media consisting of PRP and other blood products.

Methods:
Blood and bone marrow aspirate (BMA) were collected from horses and processed to obtain plasma, PRP, and platelet poor plasma (PPP). IGF-I, TGF-beta1, and PDGF-BB were quantified in all blood products using ELISA. Tendons were cultured in explant fashion with blood, plasma, PRP, PPP, or BMA at concentrations of 100%, 50%, or 10% in serum-free DMEM with amino acids. Quantitative RT-PCR for expression of collagen type I (COL1A1), collagen type III (COL3A1), cartilage oligomeric matrix protein (COMP), decorin, matrix metalloproteinase-3 (MMP-3), and matrix metalloproteinase-13 (MMP-13) was performed as were DNA and total soluble collagen assays.

Results:
TGF-beta1 and PDGF-BB concentrations were higher in PRP compared to all other blood products tested. Tendons cultured in 100% PRP showed enhanced gene expression of the matrix molecules COL1A1, COL3A1, and COMP with no concomitant increase in the catabolic molecules MMP-3 and MMP-13.

Conclusions:
These findings support in vivo investigation of PRP as an autogenous, patient-side treatment for tendonitis.

 

[DigableCat]

Unfortunately, it was my experience in residency that, unless you or your attending carried some weight, in the academic setting physical/occupational therapist tend to do what they want to do. I've seen some get downright pissy that residents would have the audacity to write such specific physical therapy requests and modalities, instead of writing "Eval and Rx". Like they were trying to "tell them what to do". And then there are some physical therapists, who think its cute to ask during a departmental meeting when they are finding out that PM&R physicians are going to become a more involved part of the Rehabilitation Department at the hospital and from now on all physical/occupational therapy requests have to go through them:

"A what? A physiatrist? What's that? What do they do??"

True story

If you have a good relationship with your therapists however, it great for everyone involved. You, the therapist, and most importantly, the patient. It's all about teamwork.

 

[SSdoc33]

PMR2010, you might want to think about writing your next response in a green font, because your naivete is pretty obvious.

you can make your "lack of evidence" case for almost everything in PM&R. still, you have to believe that there are better ways of doing things than others. going to PT, getting some ultrasound, heat, and ice, then going home is not "good PT". that situation is ubiquitous. so is sending a patient with SIJ dysfunction to a group of therapists who deal with stroke rehab all day long (like in a community hospital setting).

being an average outpatient MSK physiatrist is kind of like getting Bs in college. it can be done pretty easily, and no one is going to complain about it. but, you could decide to get As and really know what you are doing and be good at it. the choice is yours, i guess.

 

[pmr2010]

PMR2010, you might want to think about writing your next response in a green font, because your naivete is pretty obvious.

you can make your "lack of evidence" case for almost everything in PM&R. still, you have to believe that there are better ways of doing things than others. going to PT, getting some ultrasound, heat, and ice, then going home is not "good PT". that situation is ubiquitous. so is sending a patient with SIJ dysfunction to a group of therapists who deal with stroke rehab all day long (like in a community hospital setting).

being an average outpatient MSK physiatrist is kind of like getting Bs in college. it can be done pretty easily, and no one is going to complain about it. but, you could decide to get As and really know what you are doing and be good at it. the choice is yours, i guess.

Maybe I hit a nerve that you have to hurl insults?

What I'm saying is that specific exercises have not been shown to be superior to others in trials for a large number of MSK conditions. I'm not talking about the clearly inept PT where you don't get any active therapy and they just ice your back and send you home. Nobody wants this. Your examples are terrible and anyone with common sense would not send a patient to the a PT without expertise in that particular field.

Take your typical low back pain (non-neurologic, normal imaging). How do you know a regimen of back exercise A 3x/wk with stretching, ultrasound/heat is superior than back exercise B 2x/wk with lumbar manipulation and yoga? You don't have any basis for saying you earn an "A" and I earn a "B" grade with my script. Until you have evidence, its impossible to say you are the expert and I should write in green.

And please no need to generalize the entirety of PM&R as lacking EBM. The more traditional pt population of stroke, TBI, and SCI have more studies (although research is still greatly in need here too).

 

[ampaphb]

Maybe I hit a nerve that you have to hurl insults?

What I'm saying is that specific exercises have not been shown to be superior to others in trials for a large number of MSK conditions. I'm not talking about the clearly inept PT where you don't get any active therapy and they just ice your back and send you home. Nobody wants this. Your examples are terrible and anyone with common sense would not send a patient to the a PT without expertise in that particular field.

Take your typical low back pain (non-neurologic, normal imaging). How do you know a regimen of back exercise A 3x/wk with stretching, ultrasound/heat is superior than back exercise B 2x/wk with lumbar manipulation and yoga? You don't have any basis for saying you earn an "A" and I earn a "B" grade with my script. Until you have evidence, its impossible to say you are the expert and I should write in green.

And please no need to generalize the entirety of PM&R as lacking EBM. The more traditional pt population of stroke, TBI, and SCI have more studies (although research is still greatly in need here too).

Remember when you were eighteen, a senior in high school, and thought you knew everything there was to know? THAT is what you sound like - no insult intended, just that your overly broad generalizations (like there are studies for the "more traditional population", when, in fact there is virtually no Class one EBM for almost any aspect of PM&R OTHER than MSK) belie how uninformed you actually are.

 

[pmr2010]

Remember when you were eighteen, a senior in high school, and thought you knew everything there was to know? THAT is what you sound like - no insult intended, just that your overly broad generalizations (like there are studies for the "more traditional population", when, in fact there is virtually no Class one EBM for almost any aspect of PM&R OTHER than MSK) belie how uninformed you actually are.

So you're saying musculoskeletal medicine has more evidence behind its "PT/OT eval, stretch, and treat" technique than we have for DVT prophylaxis in stroke, and secondary prevention with aggrenox. Sorry its not true. Earlier, weren't you saying that we don't have evidence for exercise or PT. What treatments in MSK are class one? Hopefully not trigger point injections or acupuncture.

 

[SSdoc33]

ugggghhhh..... you are totally missing the point. your original assertion, that outpatient MSK has limited treatment options, obviously flared up some disagreement. fine, whatever. i disagree and im sure im not alone. if you feel more comfortable with inpatient medicine and that there is more evidence
backing it up, thats your opinion. again, i happen to disagree. there are plenty of inpatient jobs out there that need to be filled, and im glad that some people want to do them.


and by the way, your 2 examples are from internal medicine and neuro literature, not "traditional" PM&R as you put it.

 

[axm397]

Take your typical low back pain (non-neurologic, normal imaging). How do you know a regimen of back exercise A 3x/wk with stretching, ultrasound/heat is superior than back exercise B 2x/wk with lumbar manipulation and yoga?

It seems like there are two different discussions going on. The original question asked about the narrow treatment options available in MSK PM&R. Then, another discussion about EBM in PM&R started. I suppose they are related but I wanted to try to address the first issue.

I still have very limited knowledge of MSK medicine and feel overwhelmed by everything I need to know in order to properly care for patients with MSK issues. pmr2010, you are concentrating solely on the treatment plan - but you are missing most of the "art" of MSK medicine by only looking at the end product. There's a HUGE differential diagnosis to back pain. What exactly is a "typical low back pain"?

Is the pain acute or chronic? If it's chronic, there's a whole different paradigm you have to go down - (multidisciplinary chronic pain program? psych? 2ndary gain issues? etc.) If it's relatively acute, what is the pain generator? Is it disc? facet? muscle? is there a radic? SI joint? hip? referred pain? skin? scoliosis? Where is it coming from? foot/ankle, knee, hip, and even shoulder pathology can contribute to back pain. All those joints have their own physical exam techniques and provocative maneuvers. Do they need orthotics or additional imaging? Is there a tight muscle? what about the range of motion? is there "extension based" or "flexion based" pain? dural glide maneuvers? Have they tried PT/OT before? If so, what did that therapist do with the patient? What about function/QOL stuff? Do they need an OT to go to their workplace and look at ergonomic stuff? Do they need work restrictions? work hardening program? Do they need interventional techniques? if so, which one?

When you do order therapy, what do you want the PT/OT to work on? Where I train, we hold journal clubs with the PT/OTs and we are in constant conversation with them about our patients. What goals do the patients have? Do they want to walk down the aisle with their grand daughter? play a round of golf? Are there co-morbidities? contraindications to therapy? precautions? Any systemic issues like rheum stuff? How about medications? any possible interactions? any sleep or psych issues that need to be addressed?

You talk about passive modalities like heat, ice, and ultrasound - we usually don't focus on those things. the therapists do use them but only as adjunct to giving patients a progressive HOME BASED exercise program. Yoga, chiro or OMT, acupuncture, etc. are good complementary therapies but most of our therapists usually don't provide those services. Our chiros, DOs, and LAcs do. The PTs are always holding conferences about different PT exercises and we learn how to look for weaknesses and imbalances that may be contributing to the patient's pain.

The anatomy I have to know, the physical exam and provocative maneuvers I have to know, the differential diagnoses I have to formulate, the imaging studies I have to "preliminarily read" not to mention MSK U/S, the medical and psychosocial issues I have to consider, and the various treatment modalities I need to be able to provide or refer the patients to - just seem overwhelming at times. I still have a lot to learn and am humbled daily by the knowledge base of my attending physicians.

 

[pmr2010]

ugggghhhh..... you are totally missing the point. your original assertion, that outpatient MSK has limited treatment options, obviously flared up some disagreement. fine, whatever. i disagree and im sure im not alone. if you feel more comfortable with inpatient medicine and that there is more evidence
backing it up, thats your opinion. again, i happen to disagree. there are plenty of inpatient jobs out there that need to be filled, and im glad that some people want to do them.


and by the way, your 2 examples are from internal medicine and neuro literature, not "traditional" PM&R as you put it.

If you use it, and its relevant to inpatietn PM&R care, then call it what you want. Internal medicine, neurology, its a part of PM&R too, even if the original investigators weren't physiatrist.

I'm still waiting on what is class 1 evidence based medicine in outpatient MSK. I've given you good examples of patient care that is evidence based, by the way i have an internal medicine training too.

 

[ampaphb]

If you use it, and its relevant to inpatietn PM&R care, then call it what you want. Internal medicine, neurology, its a part of PM&R too, even if the original investigators weren't physiatrist.

I'm still waiting on what is class 1 evidence based medicine in outpatient MSK. I've given you good examples of patient care that is evidence based, by the way i have an internal medicine training too.

cite me one good stroke, SCI, or TBI primarily rehab-related multicenter RCT. The reason you ahve to reach for an inpatient internal medicine example is 'cause there are none in primary rehab-related disciplines.