Wednesday, October 31, 2018

Knee Surgery, head injuries, cortisone injections, NSAIDS and Harry Potter: Updates from the American Academy of PMR Annual Assembly 2018

Just back from my specialty’s annual conference, I’d like to share my favorite topic headlines from the sessions I attended in the 2 days I was there.  While most of this information reconfirms what I already know, hearing that cortisone injections may protect cartilage in small and limited doses was wonderful to hear.  Read on for a brief summary:

1) Surgery for meniscus tears are a last resort.  There is rarely need to have arthroscopic knee surgery to “repair” or remove a damaged meniscus.  Over the age of 35, this surgery is contraindicated due to a 20-40% failure rate, the degenerative nature of the meniscus, and the fact that after meniscus surgery, only 50% of patients get symptom relief.  In the US, the rate of meniscus surgeries far surpasses those of other countries.  Treatment standards include icing, exercises without pain, physical therapy treatments, and cautious activity for 8-12 weeks.  For meniscus tears that remain symptomatic, conservative treatment may include Platelet Rich Plasma (PRP) and Stem Cell Therapy.
 
2) Head Injuries in kids and adults can happen without a concussion.  Repetitive microtrauma cumulatively leads to concussion symptoms.  More specifically, sports medicine’s attention is on heading the ball in soccer as a cause of brain injury.  Symptoms include poor focus, slower cognitive functions and impaired memory and executive function.  As an injured brain ages, it will be more prone to dementia and chronic traumatic encephalitis.  Women and smaller athletes are more at risk.  US soccer rules since 2016 are that children under age 10 should not head the ball ever, and between the ages of 10-12 only limited to games and 30 minutes practice a week.  The age group leagues organizers, referees, parents and coaches are the ultimate enforcers.  They need to be educated!!

3) Non-Steroidal Anti-inflammatory medications (NSAIDS), most commonly ibuprofen, naproxen and diclofenac, should not be taken at high doses or continuously.   Because they cause easier bleeding, both the muscles and stomach are at risk. Athletes and others who take repeated NSAIDS can develop large collections of blood in muscle or under the skin (hematomas) with even mild contact injury. Life threatening kidney damage is a rare but real occurrence with the risk increasing the longer they are taken; the high blood pressure that can be secondary to these medications makes kidneys even more susceptible. In athletes, dehydration makes kidney damage worse.  While NSAIDS are very effective for pain and inflammation relief, limiting their use to the shortest time possible, or just taking them as needed, is prudent. 

4) Corticosteroid (“steroid”) injections in small doses in humans are actually not as bad to the cartilage as previously thought. Some steroids are actually protective to the cartilage in small amounts, about 1/4 the usual dose.   Steroid injections are very effective for pain and inflammation relief, and can provide a window of irritating symptom reduction that allows for more effective physical therapy, faster return to strengthening, and more balanced use of muscles around the joint that can contribute to long term healing. 

5) Physiatrists are Harry Potter geeks!!!!  There was a private event at Hogsmeade in Islands of Adventure, Universal, and you should have seen us run through the park.  Perhaps because the series is about never giving up, always seeking better, and continuing the fight; just like the  tenacity required of PM&R patients and doctors work together for injury recovery . 
“Understanding is the first step to acceptance, and only with acceptance can there be recovery.” –The Goblet of Fire