The following case study follows the interactions between a doctor of chiropractic and a medical doctor, both dealing with the same pre-existing condition in the same patient.
It is based on a patient in the practice of Jeffrey Bentz, DC, whose knee pain treatments eventually involved an MD. The case study involves a persistent history of left knee pain following knee replacement surgery in 2004 and the varieties of treatments, many insurance company mandated, that followed. Our extended 2014 write-up of the chiropractic dimensions and innovative treatments can be found in the links under footnotes 1 and 2.
The rise of post-op knee replacement pain
Chiropractors will see more and more post-operative knee replacement patients with differing types of pain, the most common being low-level chronic achiness (the ‘I can tell it is going to rain’-type pain) or flare-ups (‘I just tried some exercise walking around my block and my knee really hurt next day.’) 
The standard sequence in reaction to post-operative includes a wide range of home remedies, medications, over-the-counter compounds, professional treatments including orthopedic specialists, PCPs, pain managers, DCs, MD’s physical therapists, massage therapists and acupuncturists. Note that many of these options create billable events and unavoidably involve health insurance providers, Medicare and Medicaid. We are particularly interested in the economic and treatment implications where chiropractic transitions to MD-delivered treatment.
Full knee implant case
The patient in this case study had a very successful full knee implant in 2004. By 2011 that knee was generating flare-up pain. Revisits to the orthopedic surgeon’s practice generated what seems to be a semi-standardized sequence of conventional wisdom about pain management: go to PT, consult specialists about exercise, diet, using certain NSAIDs (or not, depending on kidney, diabetes, etc). After that, maybe you get access to a pain management practice, or you’ve found a DC who can apply the techniques described in the 2014 articles in footnote 2. All of these procedures are billable.
After trying many of the treatments listed above, including extensive use of customized chiropractic manipulations, the patient tried a pain management MD. That resulted in treatment using RFN (Radio Frequency Neurolysis) to temporarily sever the pain transmitting nerves. Three genicular nerves around the knee are targeted. Genicular nerves are pain-transmitting nerves; the strategy is to break the nerve so that the pain signals never get to the brain.
During the intake process for the RFN procedure the MD’s staff was interested in the chiropractic knee pain treatments used in the preceding 10 years. The patient and his chiropractor knew about chiropractic manipulations but not RFN; the MD knew about gabapentin and RFN but not the Maitland scale or the use of PNF (Proprioceptive Neuromuscular Facilitation) stretching, etc.
RFN and regenerating nerves
An economic implication of this is the regeneration of the severed portions of the three genicular nerves. After 6-12 months approximately the nerves will re-attach themselves and resume sending pain signals to the brain that the knee hurts.
Before that pain again becomes the province of the pain management MD (RFN is a repeatable procedure) it is very likely that the patient will resume knee pain treatment with the chiropractor who was so helpful before the RFN and is ready to help again when the regenerated pains start. After some time the RFN MD will re-enter the treatment protocols and the cycle will resume. RFN is relatively new and we could not find projections about the limit on how many times it might be done.
DCs and MDs working together
A communications implication of this case study: the DC and MD offices were three miles apart in the same zip code but within different organizations.
The two doctors knew many colleagues in common. The chiropractor’s retired dad was a well-respected MD in the area but the awareness gap between the DC and the MD communities lessened the chance for a meaningful transition from DC to MD.
We are arguing here that knowledge by the DC and MD of each other’s capabilities will increase the likelihood of patient appreciation and loyalty to each, with continuity of care enhanced.
JEFFREY W. BENTZ, DC, is a Palmer-trained, board-certified doctor of chiropractic who writes about patients whose treatments lead to broader educational applications for his professional colleagues. He practices at Genesis Chiropractic in Pittsburgh and can be contacted at 412-847-0066, email@example.com, or www.genesischiros.org.
V. ROBERT AGOSTINO, Ed.D, retired from the School of Education at Duquesne University in 2008. He partnered with Bentz to write about knee implants and pain mitigation in 2014.
- https://www.dynamicchiropractic.com/mpacms/dc/issue.php?id=1161 (part 1)
- https://www.dynamicchiropractic.com/mpacms/dc/issue.php?id=1163 (part 2)
- The Update.com website stated that: Approximately 700,000 knee replacement procedures are performed annually in the US. This number is projected to increase to 3.48 million procedures per year by 2030. https://www.uptodate.com/contents/total-knee-replacement-arthroplasty-beyond-the-basics
- Mayo Clinic on RFN: https://www.mayoclinic.org/tests-procedures/radiofrequency…/about/pac-20394931
- Web MD on RFN: https://www.webmd.com/pain-management/knee-pain/default.html
- Advanced Pain Care, Medford, Oregon Radiofrequency Neurotomy; apcpain.net/radiofrequency-neurotomy/