Resources to Get Joint Pain Treatment and Fight Treatment Denials
Fat People and Joint Pain Part 3
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In part one we talked about the conceptual issues with blaming fat people’s joint pain on their body size and with recommending weight loss as a solution, in part two we discussed osteoarthritis specifically. Today we’ll talk about options for those dealing with joint pain, including options to help you fight if you’d been denied treatment because of weight bias.
As a baseline idea, people of all sizes deal with all kinds of joint pain. So one way that healthcare providers can start to form an ethical, evidence-based response is to ask “what is recommended for thin people with these same symptoms/diagnoses?”
It may be that strengthening the supporting muscles, correcting movement patterns that lead to imbalances, massage, stretching, physical therapy, medications, surgery, mobility aids or the many other things that are prescribed for knee problems in thin people might help.
Or maybe the pain is something that’s not curable and/or those possible solutions aren’t something that the patient wants to pursue – there is absolutely no shame in that. Regardless of someone’s size or situation, patients should be given all of the options - with all of the risks explained, and their choices should be respected. (And if a lack of research/training/competency dealing with fat bodies is creating the risk, that should never be blamed on the bodies themselves. Healthcare practitioners need to be honest and accept responsibility for healthcare’s shortcomings in supporting fat patients.)
And, of course, lack of access is still a serious issue for many people that needs to be solved systemically. We should all have access to compassionate, competent, evidence-based health care based on our own priorities, and that includes our joints.
In some cases, it may make the most sense to provide mobility aids/assistive devices either permanently or as a way to immediately help with pain and/or mobility if other treatments are recommended for long-term improvement. (So, instead of leaving someone in pain or with limited mobility during long-term physical therapy, a scooter could be provided to give freedom of movement during treatment.)
This can involve difficulty with accessing the mobility aid/assistive device - they are often expensive and difficult to qualify for even if someone has insurance.
It can also involve navigating ableism. Unfortunately we live in a society that is rife with ableism that can impact all aspects of our lives, including choices around joint care. In some cases healthcare providers see the use of mobility aids as a “failure” and prefer that their patients have increased pain and decreased mobility rather than “rely on'“ mobility aids. seeing them as a “last resort.” Sometimes the patient may have internalized ableism that creates resistance to the use of mobility aids and/or assistive devices.
And then there is the very real impact of ableism on everything from access to the world, to relationships, to employment. To use Kimberlé Crenshaw’s framework, when someone is both fat and disabled, they face fatphobia, ableism, and are oppressed at the intersections of these, which can often involve additional blame and shame. This oppression can increase exponentially when the person has other marginalized identities as well.
If you are higher weight and need joint surgery, you may run into an arbitrary BMI or weight limit. (At this point I will point out that if the medical establishment wants to improve fat people’s health, a good first step would be to actually care about our health, rather than refusing to give us good healthcare unless and until we become thin people.)
Sometimes the doctor suggests that the patient attempt weight loss through diet and exercise prior to surgery. This is an issue on several levels - even if diet and exercise might lead to short term weight loss (and even if the patient could manage exercise on a joint that requires replacement!) the most likely long-term outcome, based on the research, is that they would gain the weight back. Besides which, the research doesn’t support under-nourishing a body prior to surgery, but we’ll get to that in a moment.
I’m hearing more and more from people whose doctors have claimed that knee surgery is “too dangerous” at their current size and then have recommended … wait for it … weight loss surgery. You aren’t reading that wrong – doctors are refusing to fix someone’s knee because it’s “too dangerous” and then telling them to have a surgery in which their perfect healthy digestive system will be mutilated to create a disease state, forcing behaviors that mimic an eating disorder.
Suggesting these dangerous surgeries is an extraordinary breach of the promise to do no harm, since they are asking fat patients to risk their lives and quality of life by having a surgery that is a complete crapshoot in terms of outcome in order to get a surgery that could be done at their current size, and despite the fact that two surgeries are riskier than one. Jumping through hoops to receive knee surgery is bad enough, risking your life to receive it should be out of the question.
Even if you believe that fat people face additional risk from the surgery and/or receive less benefit, that doesn’t mean that the procedure should be denied. Less pain and/or more mobility is a valid reason for providing healthcare even for patients who are unlikely to have the absolute best outcome for any of many reasons (which is why so many other professional athletes have received these surgeries, even though it was their plan to continue the professional athlete lifestyle that trashed their joints in the first place.)
Below you’ll find some resources for getting treatment and for fighting weight-based treatment denials, though I do want to point out, as always, that none of this should be necessary.
For options around weight neutral care, you can check out the HAES Health Sheets:
I have a workshop on dealing with fatphobia at the doctors office, you can get the video here (there’s a name your own price option) as well as free cards for what to say at the doctor’s office that you can print out here
Deb Burgard, PhD, FAED, who is an absolutely brilliant therapist and fat liberation advocate has created a list of research to help fat people and our advocates who want to fight joint replacement denials. She has graciously agreed to let me share them, and I’ve added a couple to her original list since she compiled it.
Before I share these, I want to be clear that none of this is to suggest that if you are refused joint replacement surgery you are under any obligation to try to change your doctor’s mind. That’s certainly an option (and for those who live in areas with limited practitioners and the inability to travel to see another doctor it may be the only option that works for them.) Many people have found that their best option was simply to find a more talented and compassionate surgeon who isn’t interested in simply cherry-picking what they perceive to be the easiest surgeries. It’s important to remember that, while this becomes our problem, it’s not our fault and we should never have had to deal with this in the first place.
Trigger Warning: These studies are not written from a Health at Every Size paradigm. They use terms like “ob*sity” and “overweight” that stigmatize fat bodies and may contain other triggering wording and weight stigma. The material in quotations under each study link was written by Deb, except where noted:
Resources for joint replacement surgery denial
The risk of surgical site infection and re-admission in obese patients undergoing total joint replacement who lose weight before surgery and keep it off post-operatively
Inacio et al.
https://online.boneandjoint.org.uk/doi/full/10.1302/0301-620X.96B5.33136
This is actually a study of Kaiser members that shows worse outcomes with intentional weight loss before surgery
Does bariatric surgery prior to total hip or knee replacement reduce post-operative complications and improve clinical outcomes for obese patients? Systematic review and metaanalysis
Smith et al.
Click to access Bariatric_surgery_paper_ACCEPTED_10.05.2016.pdf
This review shows weight loss surgery does not improve surgical complication rates:
Functional Gain and Pain Relief After Total Joint Replacement According to Ob*sity Status
Li et al.
Study: https://journals.lww.com/jbjsjournal/Abstract/2017/07190/Functional_Gain_and_Pain_Relief_After_Total_Joint.4.aspx
Article:
https://www.sciencedaily.com/releases/2017/07/170719084707.htm?fbclid=IwAR3b9XS0fzqrY4GYXw8wbW3fYHsTlnIDby0h_9ftiZlgSg7KtOpziiPY8aU
“In our population, BMI did not have statistically significant effects on patient outcome scores following hip arthroscopy. All patient cohorts showed postoperative improvements, and differences between BMI cohorts were not statistically significant at any postoperative time point.”
Risk Reduction Compared with Access to Care: Quantifying the Trade-Off of Enforcing a Body Mass Index Eligibility Criterion for Joint Replacement
Giori et al.
Notes: Difference between flip of coin and screening for BMI>+40 was 6.74-5.05 = 1.69% = less than 2 percentage points. Positive predictive value is the number out of 100 who actually have the problem of the people who are identified by the screening – ie, there are 5 people identified by flipping a coin and 2 more identified by using BMI of 40 or more.
Obesity does not increase blood loss or incidence of immediate postoperative complications during simultaneous total knee arthroplasty: A multicenter study
Cao et al.
https://pubmed.ncbi.nlm.nih.gov/32057638/ (added by me)
“Obesity does not increase blood loss or incidence of immediate postoperative complications during simultaneous total knee arthroplasty: A multicenter study”
A critical review of weight loss recommendations before total knee arthroplasty
Godziuk et al.
https://pubmed.ncbi.nlm.nih.gov/33278590/ (added by me)
“The literature does not show a clear relationship between weight loss and reduction in TKA complications”
Impact of body mass index on hemoglobin level and blood transfusion in total knee arthroplasty: A retrospective case control study
Bashaireh et al.
https://pmc.ncbi.nlm.nih.gov/articles/PMC7264985/
Ob*sity (BMI > 30 kg/m2) did not increase the risk of needing a blood transfusion after total knee arthroplasty. A judicious transfusion strategy involving the pre-operative Hb optimization should be adopted in TKA to decrease transfusion rate, benefit patient outcomes, and increase healthcare system efficiency. This study shows that high BMI is not a risk factor for postoperative blood transfusion.
Higher body mass index is associated with larger postoperative improvement in patient-reported outcomes following total knee arthroplasty
K Giesinger
https://pubmed.ncbi.nlm.nih.gov/34303341/
Post-operative improvement in joint-specific outcomes was larger in obese patients compared to normal weight patients. These findings suggest that obese patients may have the greatest benefits from TKA with regard to function and pain relief one year post-op.
The influence of obesity on functional outcome and quality of life after total knee arthroplasty: a ten-year follow-up study
S Xu
https://pubmed.ncbi.nlm.nih.gov/29701098/
87.9% of ob*se patients had a high satisfaction rate and 100% of ob*se patients said their expectations were fulfilled
The #1 Medical Complication of Binge Eating Disorder: Poor General Medical and Surgical Care Arising from Weight Stigma
Gaudiani
This doctor talks about weight stigma and withholding care
Well Rounded Mama
https://wellroundedmama.blogspot.com
search for “joint”
Well Rounded Mama has Part 1 and Part 2 blog posts on total joint replacement
I also have an in-depth piece about the steps for fighting a BMI-based surgery denial here.
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More research and resources:
https://haeshealthsheets.com/resources/
*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.
Thank you so much for all the work you do! You know you're getting older when you visit the doctor and notice how young they are. Thank heaven though! I had a very young PA's assistant today (assistant needs an assistant? I guess so!) and when I said "That bp cuff won't fit my upper arm is 56 cm and they usually only go to 44." She asked what my bp usually is, I told her, she noted it and we all moved on. It was a non-event. YAY!