Astonishingly Simple Change Lowers Back Pain 40% in Obese Patients
A team of researchers—from a study of nearly 7, 000 people—has discovered that obese people have an advantage over those of normal size when it comes to exercise. Matthew Smuck, M.D. is a physiatrist in the Department of Orthopaedics at Stanford University Medical Center. He tells OTW,
“Our study found that if you are obese and increase your activity level by only modest amounts, your risk of low back pain is significantly reduced. In fact, improvements in activity are more helpful at reducing back pain risk for obese people than for those of ‘normal’ weight.
We completed a detailed analysis of people’s everyday activity from a 24-hour activity monitor worn for 7 days, focusing on ‘bouts’ of different levels of activity. A ‘bout’ is the amount of time someone spends within a certain activity intensity range; we looked at how often each person enters into different ranges and the average amount time spent in those ranges. We found that morbidly obese people spend on average 1.3 minutes in the moderate activity range; we determined that if they increase this average by less than one minute their risk of back pain is reduced by almost 40%.
Interestingly, our work received a comment from a chiropractor, who said, ‘Many patients who undergo chiropractic care three times per week for six weeks will be fine.’ We have a large population of people with chronic, nonspecific LBP [lower back pain] who are sedentary…and the answer is not to treat them clinically, but to have them get more active. They shouldn’t be spending their money—or the taxpayers’ money—when they could do just a little more for themselves and reduce their lower back pain. As healthcare providers we want to do something, but sometimes that ‘just’ means lighting a fire under the patient and requiring them to do it for themselves.
Motivating patients is not always easy. Fortunately, our study showed that even small increases in moderate activity, such as walking or gardening, and reductions in sedentary time can produce big changes in the risk of back pain for overweight and obese patients.”
More Fractures at Higher Bone Density in Diabetics
A new study from Mayo Clinic endocrinologist Sundeep Khosla, M.D., probed deeper in the bones of diabetic patients than ever before and discovered that these patients have more fracture risk at higher bone densities. Orthopedic surgeons need to watch diabetic patients more closely, says a new Mayo Clinic study. Dr. Khosla is an endocrinologist at that institution. He tells OTW,
“There is growing evidence that patients with diabetes have an increased risk of fracture and based on clinical studies it appears that patients with type 2 diabetes fracture at a higher bone density than those without diabetes. This suggests that diabetics’ bone is somehow abnormal or that the quality of bone is abnormal. Previous studies have shown that there may be changes in the porosity of bone; our study used a new technology called microindentation to test the idea that the material properties of bone are abnormal in diabetic patients. We found that those with longstanding diabetes did have worse bone material properties as assessed by this technology. The process involved numbing the skin and using a handheld instrument to induce a microcrack in the bone. The depth of the crack was related to bone strength, so the deeper the crack the weaker the bone. In diabetics the probe went in significantly deeper than in non-diabetics.
Also, we looked at average diabetes control in these patients and it turned out that those who had the worst diabetes control over the previous ten years also had the worst bone material strength. So the message to orthopedic surgeons is that just like other complications of diabetes (eyes, feet), bone needs to be considered as another target. These patients should have their bone density evaluated by a DEXA scan…and orthopedic surgeons may want to treat patients with diabetes more aggressively because they fracture at a higher bone density.
We look forward to our next study, which will look at diabetics with fractures versus those without fractures to see if those who fracture have worse bone material strength.”
Alarming Rise in MRSA in Pediatric Musculoskeletal Cases
A new retrospective case review from the Children’s Hospital of Philadelphia (CHOP) indicates that the proportion of pediatric musculoskeletal infections involving methicillin-resistant Staphylococcus aureus (MRSA) compared to methicillin-sensitive S. aureus (MSSA) has increased dramatically over the past decade. This work, which focused on cases at CHOP, was co-authored by Eric Sarkissian, a fourth-year medical student at Drexel University in Philadelphia. Sarkissian told OTW,
“While other studies have shown a rise in MRSA specifically pertaining to the musculoskeletal system—and that these infections are more severe—we wanted to look at what was going on at CHOP because there is reason to believe that MRSA in one area doesn’t behave the same as in another area.
We found that the proportion of musculoskeletal cases involving MRSA increased from 12% in 2001-2002 to about 35% in 2009-2010. In addition, we found that MRSA infections were associated with a significantly more complicated hospital stay. The average duration of hospitalization was longer for the MRSA patients (13 vs. 8 days), and more MRSA patients required multiple surgical procedures (38% vs. 15%).
In addition, mean presenting C-reactive protein levels were higher in the MRSA vs. MSSA patients (14.7 mg/L vs. 9.8 mg/L), as were infection-related complications, including deep vein thrombosis, septic emboli, septic shock, recurrent infection, and/or avascular necrosis (24% vs. 6%).
Orthopedic surgeons need to be aware of the serious complications that MRSA musculoskeletal infections can cause in pediatric patients. It is important to use broad spectrum antibiotics early on and to be willing to go to the OR for multiple wash outs.
We may undertake another study to identify predictors of these infections when pediatric patients present. This would be based on their initial lab markers such as elevated temperature, white blood cell count above XYZ amount, etc.”
Young Patients and Reverse TSA: Same Outcomes, Worse Satisfaction
The young are restless…A new study, led by Stephanie Muh, M.D., has found that young people aren’t always happy campers when it comes to reverse total shoulder arthroplasty (TSA). Dr. Muh, an orthopedic surgeon with Henry Ford Hospital in Detroit, tells OTW,
“This was a multicenter study involving patients from the Cleveland Shoulder Institute (Reuben Gobezie, M.D.), the Fondren Group (Bradley Edwards, M.D.) and OrthoNeuro in Akron (Robert Nowinski, D.O., F.A.O.A.O.). It is the first study to describe the short term outcomes and satisfaction of young people with reverse TSA. This procedure was originally meant for the elderly with massive irreparable rotator cuff tears, but has become more popular and we are pushing the indications and putting them in younger patients without knowing the clinical outcomes.
The most surprising finding was that the objective outcomes were the same as what we would expect in the elderly (they achieved the same improvement in range of motion and decrease in pain). Subjectively, however, they were less satisfied. This is likely due to their expectations, i.e., the younger population wants zero limitations on their activities. This reinforces the importance of fully educating the patient before proceeding with this surgery.
Another interesting finding was that these young people often had multiple surgeries; some had lots of rotator cuff procedures that failed while others had post trauma surgeries. And, while not clinically significant, we did find that the more surgeries the young patients had, the worse the outcomes and satisfaction. Orthopedic surgeons should impress this on their patients as well and proceed with caution.
The next step is to report on midterm outcomes. We don’t know what happens to these young patients after ten years…and we’re not sure what the next step will be when their surgeries fail.”
