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Is Physical Therapy Overrated?

Not all treatments are necessary and every method does not provide the same bang for the buck.

by
Theodore Dalrymple

Bio

March 30, 2013 - 7:00 am

Twenty-seven years ago I found what seemed to be the only functioning storm-drain in Tanzania, in East Africa, and fell down it, severely injuring a knee in the process. The journey to the mission hospital in the back of a pick-up truck over sixty miles of rutted laterite road was one of the more agonising experiences of my life.

I had an arthroscopy when I returned home several weeks later — I could not even hobble until then — and the orthopaedic surgeon told me that unless I did physical therapy every day for a very long time it was inevitable that I should be crippled by arthritis within twenty years.

It was equally inevitable that I would not do physical therapy every day for a long time; and here I am, twenty-seven years later, without so much as a twinge from my knee. My faith in the predictive powers of orthopaedic surgeons has been somewhat dented.

That was why I read with interest a paper in a recent edition of the New England Journal of Medicine comparing physical therapy with surgery for meniscal tears in the knees of people with osteoarthritis. To cut a long story short, there was no difference in outcome, an important finding, since 465,000 people undergo operations for precisely this situation every year in the United States alone.

Actually, the uselessness of operation had been established before — the uselessness from the patients’ point of view, that is. Two previous trials had compared real with sham operations, and with no operations at all, and found no difference in the outcome two years later. One might suppose that, in the light of these findings, the 465,000 operations still performed annually constituted something of a scandal.

The clinical trial reported in the NEJM is, like all such trials, not definitive. The follow-up period was only 6 months, relatively few patients were recruited to it, and some patients initially allocated to physical therapy had an operation nonetheless for reasons that are not entirely clear. Moreover, the trial is only that of operation versus physical therapy; strictly speaking, there should also be a comparison with patients who had no treatment at all.

There is an important matter that the paper does not consider or overlooks: and that is the economic aspect of unnecessary operations.

Let us, for the sake of argument, grant that unnecessary operations are more expensive than intensive physical therapy. (After operation, patients have some physical therapy anyway.) Do these operations increase or decrease the Gross Domestic Product? The GDP is defined as “the market value of all officially recognized final goods and services produced within a country in a given period of time.” (I quote from Wikipedia.)

At first sight they do. As everyone knows, operations are not cheap. Without them, the GDP would fall. So would the incomes of those who perform them – orthopaedic surgeons, for example, and all their hangers-on such as operating room nurses. Presumably their incomes have a multiplier effect, for example on the legal profession.

On the other hand, there are the opportunity costs of employing money in this rather futile, indeed counterproductive, manner. But would the money in fact be better employed elsewhere? Would not something just as unproductive be done with it? These, surely, are unanswerable questions, being so entirely hypothetical.

And so what this paper titled “Surgery versus Physical Therapy for Meniscal Tear and Osteoarthitis” (which, incidentally, has 29 authors) really establishes is that the GDP is a more or less useless measure of economic output, to say nothing of human welfare. Of course, further research is needed: that should increase GDP a little. Or should it?

****

images courtesy shutterstock / decade3d /Maryna Pleshkun

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Theodore Dalrymple, a physician, is a contributing editor of City Journal and the Dietrich Weismann Fellow at the Manhattan Institute. His new book is Second Opinion: A Doctor's Notes from the Inner City.

Comments are closed.

Top Rated Comments   
PT, like all other treatments, can be over done and over prescribed but in my case it has worked wonders. The best result was that I learned specific exercises to do at home and all without pain killers and other drugs. I was also able to avoid an operation. Thumbs up for my local PT people.
1 year ago
1 year ago Link To Comment
All Comments   (11)
All Comments   (11)
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I had a painful bucket-handle meniscus tear. The thing had a particular "popping" sound/ sensation w/ corresponding P-A-I-N followed by falling down and taking a moment or two to appreciate the floor.

A "placebo" operation would NOT have made it past my notice. No way.

In the post-slice-und-dice follow-up visits with herr doktor, he noticed that the leg with the problem had atrophied... I had been favouring it for years. He recommended what might be called do-it-yourself-PT: put weights on the ankle of the atrophied leg, do lifts up forward, do lifts to the rear, so many reps, so many times a day... had it licked in two weeks.

What is it with stuff like this on PJM when Ayatollah Amabo's DOJ is coming after home schoolers and your friendly local police officers? An all the really godawful stuff with AyatollahCare: death panels, placebos for everything...

Stay dark my friends!
1 year ago
1 year ago Link To Comment
I'm an MD who suffered a medial meniscus tear...........physical therapy is really nothing more than flexion, extension and muscle strengthening. It does nothing to correct the subsequent joint instability that will develop.

The layman should understand that much that is published in the medical literature is flawed.
1 year ago
1 year ago Link To Comment
I think it's also an example of how medical science marches forward with recommendations that become settled "truth" long before the science is settled. Or even after it's settled because a shiny object comes along.

I had a skiing injury back in 1979 and tore...something which resulted in everything from the knee down hanging limply and twisting grotesquely. There were no broken bones and they slapped a straight cast on it. Several weeks later it was removed and I was given some exercises to do at home. I have some occasional tendinitis, but otherwise have no problems with it. Somewhere along the way, someone decided that arthroscopic repair was the default treatment. Does it have a quicker recovery time? Is it more cost effective? A better outcome? Why is it the go-to treatment? It's worth considering other options and asking a few more questions before jumping into surgery and...."contributing" your fair share to the economy via surgery and PT.

Incidentally, they do the same thing with dogs. If your dog tears his ACL or meniscus most vets will tell you that without surgery he will be crippled the rest of his life. Our lab/chow mix had a pretty severe injury and was unable to put any weight on his back leg. The vet recommended immediate surgery. I found a Yahoo group that explained how to manage it conservatively: no running, jumping, or stairs; crating him to keep him from running; joint supplements. It took about six months, but his leg is completely healed. He's almost 15 now and has no problems with it. Our new (more conservative) vet said he's seen lots of cases of this happening.
1 year ago
1 year ago Link To Comment
This is just another variation of the 'broken windows' fallacy put to bed by Frederic Bastiat many years ago. All the more reason to eliminate medical licensing.
1 year ago
1 year ago Link To Comment
Yes indeed. More study is definitely indicated. And more trials. Read any medical journal article, and you will encounter this conclusion over and over again. Of course the authors, occupiers of the hallowed halls of academic medicine, who promote additional trials make their living studying and writing about it, so of course, they want the goose to keep laying those golden eggs; grant money. It's an industry which certainly contributes to the GDP. Which brings up continuing medical education, another cash cow for the medical academe.
1 year ago
1 year ago Link To Comment
I had this problem. It happened suddenly and it felt like the tip of a knife was under my kneecap stabbing me. It was a large tear. My knee and all around it swelled up so much I couldn't bend my leg. Even though my knee looked worse after surgery, with bruising and swelling it immediately felt better. The knife was gone. I had two kids under the age of 3 at the time. It was terrible, because they were running around doing who knows what, while I was supposed to be sitting with my leg up strapped to an ice machine. It was also my driving leg. It was awful. Physical therapy without surgery would have been like torture, and I doubt it would have done anything to get rid of problem.
1 year ago
1 year ago Link To Comment
Yeah I'm not sure what the story is about. I thought at first it was about PT after surgery. Turns out it's about PT instead of surgery, with a sarcastic economic coda. Or something.
1 year ago
1 year ago Link To Comment
I hurt my shoulder. The pain was chronic and did not improve over several months. I started doing wall push ups. The pain went away after a very short time.

So I guess with the right injury, PT can be the right treatment.
1 year ago
1 year ago Link To Comment
PT, like all other treatments, can be over done and over prescribed but in my case it has worked wonders. The best result was that I learned specific exercises to do at home and all without pain killers and other drugs. I was also able to avoid an operation. Thumbs up for my local PT people.
1 year ago
1 year ago Link To Comment
One of the most common moves of a physical therapist is to reach behind your back and manipulate your wallet.
1 year ago
1 year ago Link To Comment
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