Should More Physical Therapy be Authorized When Patients See Little Progress?
I can’t believe what I saw and heard from a woman who came to purchase a couple items from me on craigslist. She mentioned that she’d had knee surgery for a torn meniscus 10 weeks before. I asked her how she was progressing and was shocked with what I heard her say…
She continues to be in pain after going to physical therapy on a regular basis since the surgery. She also had just been given authorization for another 10 sessions of physical therapy. When I asked her to describe how she was progressing there was a sense of discouragement, as she still needed to medicate with NSAIDs, which were affecting her stomach adversely.
When she described what she was doing at physical therapy it sounded as if the majority of her therapy was designed to try to strengthen her knee. I asked her if I could simply have a look at her knee. I compared it to the other side and palpated for the temperature of her knee – it was several degrees warmer and visually it was swollen, with a reddish color. She was unable to fully extend her knee and it had a springy feel when I attempted to. She obviously then had a residual synovitis which was inhibiting her motor control and rendering attempts to strengthen useless.
I explained to her that my experience over a half-century, treating thousands of postoperative knees, would indicate that she was not making great progress to which she totally agreed. Furthermore, the nature of her work, which is being on her feet refinishing furniture, as well as her overweight status clearly was playing a role in further aggravating her knee postoperatively. I shared with her my sense that at this point, two and a half months after surgery, having had physical therapy this entire time, the fact that she wasn’t noticing progress; it was likely that her knee probably had a greater degree of degenerative change than had been anticipated preoperatively. She reluctantly agreed.
Additionally, she shared that her surgeon was now saying the reason she’s not progressing was probably she would’ve been a candidate for at least a partial if not a total knee. What concerned me is that this is an example of the over-utilization of physical therapy on someone who doesn’t seem to be benefiting from them on virtually a month-to-month basis. After 10 weeks of little progress it surprised me that she would be authorized for another 10 sessions of the same type of approach.
I mentioned to her, reiterating that I was not her physical therapist nor was giving her medical advice, that she might want to consider a couple of supplements that might help with the degree of swelling, pain and inflammation (which she pleaded with me to share). So I mentioned both Boswellia and omega-3 fish oil as two very powerful natural anti-inflammatory supplements that I’ve had great experience with and the literature supports their value. I told her that as the weeks would go by if she was not seeing progress that she needed to discuss with her orthopedic surgeon the likelihood that she was not now going to successfully rehab from this attempt at a partial meniscectomy. My feeling is they would then need to discuss the other options so that she could seek to be free of pain and still able to perform her activities both at home as well as at work.
I hope that sharing this story will bring about a greater awareness of making hard decisions in terms of how a patient should progress. With this procedure a person should normally be noticing improvement week by week. Their need for medication for inflammation & pain should also be decreasing as time passes.