Orthopedists too Conservative With Load Bearing? (Orthopedics This Week)
You put a lot of work into that surgery. Why not play it safe and restrict load bearing? Because, says Erik Kubiak, M.D. and collaborators, the patient may likely undergo unnecessary functional decline and prolonged periods of lost productivity…and because medicine should be based on science. Dr. Kubiak, an associate professor at the University of Utah Medical Center, tells OTW, “My colleagues and I have just published a review article in the Journal of the American Academy of Orthopaedic Surgeons indicating that weight-bearing protocols are often applied arbitrarily based on little objective data. Certain studies suggest that patients with normal protective sensation—those who autoregulate—can safely bear weight sooner than most protocols permit. Then there are the randomized, controlled trials of ankle fractures that have shown no difference in outcomes between immediate and delayed (≥6 weeks) weight bearing. Yet patients with periarticular fractures may not fare as well with early weight bearing.”
“My colleagues and I began considering this issue of autoregulation. Pediatric patients do what they want; older people do what they want. We were struck by the question, ‘What is it about those patients in the middle. What makes humans irrational between 20 and 50 years old?’ When you begin discussing restricting weight bearing you move into the realm of opinion; for example, you might hear, ‘They should wait because I don’t want them to hurt themselves or worse yet develop wound or fracture healing complications.’ We realized that there was no concrete evidence to support one way or another. The best evidence we have says that people will autoregulate based on pain—if they have a working neural pain protective mechanism/pain response. What we see in practice is that most patients are being overprotected.”
“I just had cervical spine fusion three weeks ago and my surgeon instructed me not to do any exercise of any kind. But there is nothing in the literature to support his directive! I’m fortunate to have a secure job, but for many people this kind of instruction can result in a prolonged periods of non productivity, anxiety, and depression.”
“We have obtained a grant from the Department of Defense to complete the development of a blinded activity monitoring system to better define the optimal healing parameters for lower extremity fractures. The ultimate aim would be to construct a patient based activity monitoring system which would facilitate an optimal rehabilitation program based on objective data with real time feedback to the patient and the treating physician.”