#when to start

[vaguely-problematic]

how inconvenient it is to have executive dysfunction when you might have to flee a fascist regime

[lhlr]

Does early mobility lead to better clinical outcomes than delayed mobility following arthroscopic rotator cuff repair?

Rehabilitation protocol following arthroscopic rotator cuff repair is a highly debated issue, specifically the timing of post-operative mobility. Surgeons and rehab protocols vary greatly in regard to initiating range of motion after rotator cuff repair, with some starting passive motion within one week after surgery, while others keep the shoulder immobilized for four to six weeks before initiating motion. Advocates of early mobility following rotator cuff repair propose that it leads to increased shoulder range of motion by preventing postoperative stiffness. In contrast, advocates of delayed mobility argue that early mobility does not allow proper tendon healing time and increases risk of retear. In recent years, there has been a surge in meta-analyses comparing the rehabilitation protocols, aiming to discover which protocol leads to superior patient outcomes. 

A meta-analysis by Li et. al. [1] found that early passive motion (EPM) protocols led to significant increases in shoulder flexion and external rotation range of motion at short-term follow up when compared to delayed passive motion (DPM) protocols. At long-term follow up, flexion remained significantly higher in the EPM group, but external rotation measurements were equivalent between groups. There were no significant differences in tendon healing between groups at long-term follow up, but the researchers found that larger sized tears were more susceptible to retear with early mobility. A systematic review by Saltzman et. al. [2] also found a significantly higher retear rate in patients with large-sized tears who followed the early passive motion protocol compared to those that used the delayed motion protocol. Therefore, it is important to consider initial tear size and other factors, such as patient demographics and surgical technique, when determining the best rehab protocol for each patient. An overview of systematic reviews by Mazuquin et. al. [3] concluded that passive motion can begin on post-op day one for patients with small-medium size tears, but passive motion should be delayed four to six weeks for patients with more complex, larger sized tears.

Another important consideration is cost-effectiveness of treatment. It may not be beneficial for some patients to pay for and attend several more weeks of physical therapy in order to gain an additional five to ten degrees of shoulder range of motion. Therefore, it is crucial to discuss and reach a consensus between not only the physical therapist and surgeon, but also the patient. The patient’s goals for treatment should be taken into consideration as well. Overhead athletes and manual laborers may benefit from an early motion protocol to recover range of motion more rapidly, whereas older patients with risk factors for retear may prefer to delay motion to promote tendon-bone healing.

References

Li, S., Sun, H., Luo, X., Wang, K., Wu, G., & Zhou, J. et al. (2018). The clinical effect of rehabilitation following arthroscopic rotator cuff repair. Medicine, 97(2), e9625. https://doi-org.proxy.kumc.edu/10.1097/md.0000000000009625

Saltzman, B., Zuke, W., Go, B., Mascarenhas, R., Verma, N., & Cole, B. et al. (2017). Does early motion lead to a higher failure rate or better outcomes after arthroscopic rotator cuff repair? A systematic review of overlapping meta-analyses. Journal of Shoulder and Elbow Surgery, 26(9), 1681-1691. https://doi-org.proxy.kumc.edu/10.1016/j.jse.2017.04.004   

Mazuquin BF, Wright AC, Russell S, Monga P, Selfe J, Richards J. Effectiveness of early compared with conservative rehabilitation for patients having rotator cuff repair surgery: an overview of systematic reviews. Br J Sports Med. 2018 Jan;52(2):111-121. https://doi-org.proxy.kumc.edu/10.1136/bjsports-2016-095963  

[douglasowen]

Start Writing? If You Wrote Down a Good Idea You Already Have

Start Writing? If You Wrote Down a Good Idea You Already Have

Start Writing Now!

Yes, I said it, start writing now. So here’s the question that prompted this statement.

“I have a brilliant idea of a novel but I do not know when I am ready to write it, when is the right time to start?”

Start writing your novel? Good news, you’ve already started to write your novel. Every novel starts with a good idea, then moves to an out outline, and finally a draft.

Ideas…

View On WordPress

[gom-gashtah]

I'm thinking of making like a short video of both of my trips to Kabul this year combined

[hivforum]

Hello Doctor, I've read the article about the new study conducted by NIH, which says that patients “who initiated treatment when their immune system was still strong were 53% less likely to die or develop a serious illness" I am a little surprised about 53%, as I thought that ALL HIV + patients with no other health issues, who are on treatment will stay healthy and live long lives, pretty much as HIV -, as long as the virus is suppressed regardless of initial CD4 count. What are your thoughts?

I’ve been meaning to blog about the important START study, but haven’t got around to it yet.

All we’ve seen so far is a press release, so we don’t have details about the events and causes of death. Keep in mind that they’re lumping together serious illness and death, and they’re lumping together serious AIDS-related and non-AIDS-related events. So if you assume that even early treatment doesn’t prevent all bad things from happening to you (you can still get run over by a bus, for example), then under the best of circumstances, it’s conceivable that deaths and serious events in the group treated early group might just represent the background rate of “badness” that happens to people in life, regardless of HIV status, whereas the greater number of deaths and serious events in the delayed treatment arm were due to untreated HIV infection.

Of course, it’s unlikely to be that simple. There are some uncommon HIV-related complications that can happen even to people who start treatment early (some lymphomas, for example). And not everyone in a clinical trial takes their medications as prescribed. We’ll have to see the details in the actual presentation (probably at the Vancouver IAS conference in July) before we can understand this completely. 

In the U.S. we’re already treating people regardless of CD4 count, so the START study is unlikely to change practice very much. But this study will certainly influence guidelines in other countries that haven’t jumped on our universal treatment bandwagon yet.

[hivforum]

Have been HIV+ as of April 14 w/ VL-900, and CD4-1234. Recent test was mid Dec2014 VL-3000 CD4-1024. My doc still recommends not to take meds. He tells me that I am doing great for where my health stands and we can have a happy balance to avoid pumping me up with meds to help keep my organs healthy for the long run. Till i am ready to take them or need to. I want to but fear of the long term effects of meds to my body. Thoughts? Thanks again

In Europe and many other parts of the world, most doctors (and certainly most guidelines) would agree with your doctor. Here in the U.S., however, we believe that everyone with HIV should be treated, or at least everyone with a detectable viral load. Having any circulating virus, even at low levels like yours, increases chronic inflammation and immune activation, which could have long-terms health consequences if it persists over time.  In addition, detectable virus allows you to transmit HIV to others. 

When we treat HIV, we don’t “pump people up” with meds that are likely to affect organ systems.  HIV itself is much more likely to damage organs than modern medications are. You’d be likely to be treated with a very safe and well tolerated once a day regimen, possibly using just one pill.

I recommend treatment to everyone except the occasional elite controller, who has a normal CD4 count and an undetectable viral load.  If it were me, I’d be very uncomfortable knowing I had replicating virus in my body. Treatment would help put my mind at rest.

[hivforum]

Why does how low your CD4 ever was matter when it's gone back up to 400? Is previously low cd4 a risk factor for something?

What matters most is your viral load and CD4 count on therapy.  But the baseline CD4 count also matters, though to a much lesser degree. Studies do show that starting treatment with a lower CD4 count may put you at greater risk for some long-term complications, such as cognitive deficits, cardiovascular disease, and loss of bone density. This is one of the many reasons why routine screening and early treatment is so important.