By Larry Hand
Research indicates that primary care physicians are underprescribing exercise as a treatment for knee osteoarthritis, and experts suggest the same can be said about bracing.
“I think primary care physicians probably don’t know much about braces. Being primarily internists, primary care physicians may turn to what they know best, and that’s pharmacological therapy, because that’s what they’re accustomed to doing,” said Nicholas Giori, MD, PhD, an orthopedic surgeon at Stanford University School of Medicine in Palo Alto, CA.
In a 2010 British study published in BMC Family Practice, researchers analyzed 20 articles on general practitioners’ attitudes, beliefs, or behaviors toward prescribing exercise as a treatment for chronic knee pain. They concluded that though attitudes varied widely, practitioners appeared to be underusing exercise as a treatment, and in reviews of actual practice, the range of those advising exercise was 5% to 52%.
The study and the issue underutilization of nondrug treatments for chronic knee pain was discussed at this year’s World Congress on Osteoarthritis by senior author Nadine Foster, PhD, professor of musculoskeletal health in primary care, Keele University, Staffordshire, UK.
“I cannot comment on whether bracing is underused, as it is not something we have not specifically looked at,” Foster said.
Similar studies have not been done on utilization of OA bracing. However, a number of experts say anecdotally that primary care practice patterns for bracing mirror those for exercise.
“Is bracing being used to its fullest extent? In the family practice office, absolutely not. At the orthopedic office, if the arthritis diagnosis is specific to one that braces can help, absolutely yes. It’s a complicated question,” said Andrew Pruitt, ATC, EdD, a sports medicine expert at the Sports Medicine Physician Clinics at Boulder Community Hospital, CO. “Most primary care doctors are going to send an osteoarthritic patient home with prescriptions for an anti-inflammatory and maybe a prescription for physical therapy—maybe—and not a prescription for orthotics. I don’t understand it.”
“Advances in technology and design have allowed braces to be used more effectively and more universally than ever, yet bracing is likely underused [in the primary care setting], and I fear that, often, the inappropriate brace is chosen,” said Mark Galland, MD, an orthopedic surgeon with Orthopedic Specialists of Raleigh, NC, and team physician for the Carolina Mudcats.
Part of the problem may have to do with patient expectations, said Terry Malone, PT, EdD, ATC, professor of physical therapy at the University of Kentucky College of Health Sciences in Lexington.
“In the United States, the attitude is ‘fix me now, we don’t want the six-week answer, what can you give me to take away the pain?’ Thus, doctors are often faced with the patient demanding an immediate outcome,” Malone said.
Experts agree that education is what is needed to improve on the perceived practice, as is research to confirm what is taking place.
“Most people would agree that there’s a deficiency in musculoskeletal education for people going into primary care. There’s a lack of understanding of treatment options for OA among primary care physicians,” Giori said.
Bracing technology can also be intimidating to untrained practitioners, Galland said.
“In the 21st century, bracing is very technical and special training is required to make the best choices,” he said. “If a patient has a musculoskeletal issue, it seems intuitive that he or she is most efficiently handled by a musculoskeletal specialist. This could be a primary care physician who may have an interest or training in treatment and bracing of musculoskeletal issues.”
Education could range from continuing medical education courses to new courses in the medical school curriculum.
“We could have well-designed studies completed [that illustrate how bracing is underprescribed] and then published in the family medicine literature,” said Malone.
Giori suggested basing clinical studies on the recommendations of the American College of Rheumatology and the UK’s National Collaborating Centre for Chronic Conditions.
Sponsored by an educational grant from Townsend Design