As an orthopedic spine surgeon who performs approximately 500 surgeries a year, my favorite type of patient is the one I never have to see—not even once. The reason for this is that means their musculoskeletal (MSK) issues—any condition or injury affecting joint, bone, tendon or muscle—haven’t progressed to the point where they need to consult with a surgeon.
To put it bluntly, surgery is not always the best answer. Surgery is invasive, expensive and sometimes risky. Often behavior modifications that help with losing weight and increasing mobility, such as exercise, stretching and eating healthily or physical therapy, can successfully address many MSK issues, while at the same time reducing healthcare spending. For example, when physical therapy is the first line of treatment, according to a systematic review in the Physical Therapy & Rehabilitation Journal, it results in lower overall healthcare costs, fewer visits to the doctor and better patient mobility.
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Unfortunately, a lot of people still end up consulting with a surgeon even though it’s clear their conditions are not at the point of requiring an invasive operation. In many of these cases, diet, exercise and physical therapy haven’t been the first-line treatment, even though these are often the most effective and affordable treatments for the majority of MSK injuries.
This isn’t the patient’s fault. It’s a systemic industry problem. When patients are in pain and in desperate need of a solution, they seek out immediate treatment to fix their MSK issues. General practitioners often aren’t experts on MSK and refer patients to orthopedic surgeons to figure out whether an individual needs surgery or not. A referral to an orthopedic surgeon may sound innocuous, but a visit with a specialty doctor is both costly for insurance and patients. Plus, what surgeons do best is perform surgeries.
In addition, in some cases orthopedic surgeries are no more effective than other non-surgical interventions, according to a 2021 review of meta-analyses. The study concluded that “despite a lack of strong evidence, some of these procedures are still recommended by national guidelines in certain situations.” Even with most people avoiding surgery, it makes one wonder how many of the 4.8 million elective orthopedic MSK surgical procedures performed annually, such as knee or hip replacements or spine fusions, are actually needed.
A shift in how the industry thinks about MSK issues needs to happen, from both patients and the physicians, toward a holistic treatment approach prior to any referral to an orthopedic surgeon. A holistic approach can include one or a combination of a physical therapist, nutritionist, behavioral change health coach or a comprehensive digital MSK program.
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Here’s what every person needs to be told before visiting an orthopedic surgeon:
- Surgery is not a quick fix
Before making an appointment with an orthopedic surgeon or other MSK specialist, run through this quick assessment:
- Is weight an issue?
- Is stretching a regular part of the day?
- Could strengthening improve the condition?
- Is surgery being considered because it’s thought to be a quick fix?
Exercise and diet change are extremely difficult to begin, especially when a person is in pain. Behavior change is one of the hardest things to accomplish. With that in mind, it makes perfect sense for a person with chronic MSK pain and stiffness to get to a point where surgery seems like the best and only answer as a quick fix.
While that is a valid and normal feeling under such circumstances, surgery isn’t always the best quick fix or the only answer. With any surgery, there is risk involved. In many back surgeries, the patient will be under general anesthesia, and then a surgeon is going to perform an incision and remove parts of bone, bone spurs or ligaments in the patient’s back.
Even then, there is no guarantee the pain will be gone and mobility restored. Afterward, most patients will be asked to go to physical therapy, eat healthfully and do stretching. Why not skip the surgery and go straight to holistic nonsurgical treatment first?
- Most people need help getting started and staying committed
A sliver of people with MSK problems will benefit from surgery. Many more people can adjust their lifestyle to include exercise, stretching and diet to address an MSK condition. But to succeed over the long term they won’t be able to do it all by themselves. Most of us need help. A new active lifestyle is as much mental as it is physical.
For patients struggling to make a change, I recommend people get a health coach, who can help with motivation while providing support and guidance. A health coach could be a physical therapist or a behavioral change coach who is solely dedicated to helping people follow a health regimen to strengthen their bodies and reduce pain.
Often a health coach can put you in touch, either in person or remotely, with a group of other individuals going through similar MSK issues. Social support is a known contributor to long-term success.
- Virtual MSK programs offer coaching and convenience
With the rapid adoption of digital health in recent years, patients have access to a variety of new and exciting virtual physical therapy and MSK solutions. These could be an app on a phone or access through a laptop and include access to a health coach and exercise videos.
When exploring digital health options, whether as a consumer, a health plan seeking to save costs or an employer to add as a new benefit, consider the following criteria when selecting solution providers:
- Does it have clinically validated programs and individualized recovery pathways for a wide number of MSK needs?
- Is there flexibility in the virtual program to adjust to an individual’s progress? Some solutions are set at a certain number of weeks.
- Is a health coach part of the solution? Much of MSK recovery is behavior change and a health coach can help individuals adhere to programs, a key to ensuring recovery.
- Does the solution require extra hardware or devices? Many individuals find these devices intrusive, which affects access and adherence. Additionally, devices such as sensors can add significant costs to be covered by the health plan or employer.
A big value-add that digital MSK products offer over traditional physical therapy is that programs are done virtually on-demand and communication can be synchronous or asynchronous. Instead of having to schedule an appointment and drive to the physical therapists’ office or gym, sessions can be done in the comfort of one’s home. And during the pandemic, that means staying out of harm’s way.
As an industry, we need to consider alternatives to a surgery-first mentality. It begins with making sure each person suffering from MSK issues has access to all the necessary healthcare professionals and tools that will set him or her up for successful healing. That will save time, money and drive down healthcare costs. Surgeons can focus efforts on those who need it most. Nobody can go wrong adding exercise, stretching and good healthy food into their lives.
Photo: Srisakorn, Getty Images
Alan H. Daniels, MD is a board-certified spine surgeon who specializes in adult spinal deformity and other complex spinal disorders. He serves as Chief of Spine for the Orthopedic Department at Rhode Island Hospital and The Miriam Hospital. He is also Director of Spine Surgery Research, an Associate Professor at The Alpert Medical School of Brown University, and co-director of the Brown Spine Surgery Fellowship. Dr. Daniels is on the clinical advisory board for RecoveryOne.
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