Fortin finger nonsense.

[101N]

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[lobelsteve]

Umm..

 

[drusso]

http://osteopedia.iao.be/uploads/sacroiliac_joint_demo.pdf

 

[Dr. Ice]

So would this argue for sij fusion? Because I've been telling patients this is a horrible idea

 

[bedrock]

The SIJ can develop rotational changes, upslip, down slip, etc after trauma or pregnancy.

I've diagnosed this many times in patients who were failed by less competent doctors who think all pain is just in the head.

I send these patients to a trusted PT (who had additional post grad training) for SIJ manipulation and pelvic floor/core strengthening and 90% of these patients improve dramatically without opioids, shots, or surgery.

 

[freddydpt]

Is this guy the Trump of the SI joint?

 

[101N]

In the absence of inflammatory ds or Serious trauma the SI is more like a long bone than a joint.

 

[freddydpt]

In the absence of inflammatory ds or Serious trauma the SI is more like a long bone than a joint.

I think it's extremely dependent on the person.

 

[bedrock]

In the absence of inflammatory ds or Serious trauma the SI is more like a long bone than a joint.

as i mentioned, many pain physicians suck at treating SIJ pain that isn't inflammatory or DJD in old people. That doesn't mean pain from SIJ dysfunction doesn't exist, it just means those physicians don't understand it. Do your patients a favor and refer to a good PT with strong manipulation skills.

You might not have one in rural oregon, but portland will have a couple PTs with this level of skill.

 

[101N]

The SIJ - like the facets - are an IPM piggy bank. Or in the words of a person on this forum, an annuity.

 

[bedrock]

The SIJ - like the facets - are an IPM piggy bank. Or in the words of a person on this forum, an annuity.

I just stated that there is a huge percentage of SIJ patients who don't need an injection, so no money here other than the initial office visit before I send them to PT.

101N. I know you must be jaded after treating all those mental cases on medicaid, but if you spend time treating normal people, who work full time, have a family, and have real insurance, you will see countless cases of mechanical issues causing pain, not mental ones.

I feel sorry for the real patients that come to your clinic with solvable problems only to be told its all in their head.

 

[clubdeac]

I know who 101N is! You're secret is out John Sarno....we know it's you

 

[Taus]

The SIJ - like the facets - are an IPM piggy bank. Or in the words of a person on this forum, an annuity.

What's w the absolutist approach? A thorough eval guides you on who to use the 10 foot pole approach to needles vs those who can get 1-2 years excellent relief with RFA, work full time or enjoy their retirement, not be on on opioids bc they never were on them first place. Am I always correct on who's who? Of course not. Is it appropriate to tell that latter group to just go do cbt as nothing left to offer? Of course not. I think you need a change of scenery and better patient population. I'd quit if I only treated young w axial lbp on narcs and disability.


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[drusso]

Everyone thinks that the SIJ can't be a real pain generator...until after their first snowboarding lesson.

 

[SSdoc33]

now the SIJ isnt real either?

next yo are gonna tell me that santa claus is a hoax.

btw, if i never did another SIJ injection id be happy. it pays peanuts. but, i do what is in the patient's best medical interest. what a novel concept.

 

[jesspt]

The SIJ can develop rotational changes, upslip, down slip, etc after trauma or pregnancy.

I've diagnosed this many times in patients who were failed by less competent doctors who think all pain is just in the head.

I send these patients to a trusted PT with additional post grad training for SIJ manipulation and pelvic floor/core strengthening and 90% of these patients improve dramatically without opioids, shots, or surgery.

So, do you use something like this for your physical exam?

Man Ther. 2005 Aug;10(3):207-18.
Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests.
Laslett M1, Aprill CN, McDonald B, Young SB.
Author information

• 1Department of Health and Society, Linköpings Universitet, Linköping, Sweden. [email protected]

Abstract
Previous research indicates that physical examination cannot diagnose sacroiliac joint (SIJ) pathology. Earlier studies have not reported sensitivities and specificities of composites of provocation tests known to have acceptable inter-examiner reliability. This study examined the diagnostic power of pain provocation SIJ tests singly and in various combinations, in relation to an accepted criterion standard. In a blinded criterion-related validity design, 48 patients were examined by physiotherapists using pain provocation SIJ tests and received an injection of local anaesthetic into the SIJ. The tests were evaluated singly and in various combinations (composites) for diagnostic power. All patients with a positive response to diagnostic injection reported pain with at least one SIJ test. Sensitivity and specificity for three or more of six positive SIJ tests were 94% and 78%, respectively. Receiver operator characteristic curves and areas under the curve were constructed for various composites. The greatest area under the curve for any two of the best four tests was 0.842. In conclusion, composites of provocation SIJ tests are of value in clinical diagnosis of symptomatic SIJ. Three or more out of six tests or any two of four selected tests have the best predictive power in relation to results of intra-articular anaesthetic block injections. When all six provocation tests do not provoke familiar pain, the SIJ can be ruled out as a source of current LBP.

 

[SeniorWrangler]

Is this guy the Trump of the SI joint?

"It's a great joint! The best joint! You won't believe how stable it is, I'm telling you."

 

[SSdoc33]

"It's a great joint! The best joint! You won't believe how stable it is, I'm telling you."

"Failed SIJ keeps trying to cause pain, but doesn't respond to needed cortisone injections. Sad"

 

[drusso]

"Failed SIJ keeps trying to cause pain, but doesn't respond to needed cortisone injections. Sad"

"We will inject the SI joint--it'll be a great injection, the nicest you've seen, pristine arthrogram trust me, I know how to inject SI joints, I've injected them all around the world, and they've been beautiful, never a complaint-- and the patient is going to PAY for it!"

 

[lonelobo]

SIJ Pain is caused by the Corrupt mainstream media

 

[drusso]

It disgusts me, really, Crooked Sacroiliac...lock it up!

 

[knoxdoc]

Everyone thinks that the SIJ can't be a real pain generator...until after their first snowboarding lesson.

Haha - thats awesome DR! Happened to me skiing. I didn't believe it until I put my butt under the fluoro with a skin marker - directly over the SIJ.

 

[drusso]

Haha - thats awesome DR! Happened to me skiing. I didn't believe it until I put my butt under the fluoro with a skin marker - directly over the SIJ.

@knoxdoc, haven't heard from you in a while. Seeing DP this weekend. We'll cook-up a Schmidt-burger with extra Mayo in your honor.

 

[knoxdoc]

@knoxdoc, haven't heard from you in a while. Seeing DP this weekend. We'll cook-up a Schmidt-burger with extra Mayo in your honor.

Sweet, say hello for me. I haven't been in his neck of the woods since my dad sold his place there and moved to Florida. Hope you are doing well.

Remember - everyone deserves a chance! (to crump in the middle of the night on a minimally-equipped rehab floor with nursing superstar Mandy)

 

[ampaphb]

So, do you use something like this for your physical exam?

Man Ther. 2005 Aug;10(3):207-18.
Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests.
Laslett M1, Aprill CN, McDonald B, Young SB.
Author information

• 1Department of Health and Society, Linköpings Universitet, Linköping, Sweden. [email protected]

Abstract
Previous research indicates that physical examination cannot diagnose sacroiliac joint (SIJ) pathology. Earlier studies have not reported sensitivities and specificities of composites of provocation tests known to have acceptable inter-examiner reliability. This study examined the diagnostic power of pain provocation SIJ tests singly and in various combinations, in relation to an accepted criterion standard. In a blinded criterion-related validity design, 48 patients were examined by physiotherapists using pain provocation SIJ tests and received an injection of local anaesthetic into the SIJ. The tests were evaluated singly and in various combinations (composites) for diagnostic power. All patients with a positive response to diagnostic injection reported pain with at least one SIJ test. Sensitivity and specificity for three or more of six positive SIJ tests were 94% and 78%, respectively. Receiver operator characteristic curves and areas under the curve were constructed for various composites. The greatest area under the curve for any two of the best four tests was 0.842. In conclusion, composites of provocation SIJ tests are of value in clinical diagnosis of symptomatic SIJ. Three or more out of six tests or any two of four selected tests have the best predictive power in relation to results of intra-articular anaesthetic block injections. When all six provocation tests do not provoke familiar pain, the SIJ can be ruled out as a source of current LBP.

Yes, but according to 101N, Aprill, Bogduk, Derby, Dreyfuss, etc. are all IPM sellouts, and can't be trusted.

 

[ampaphb]

Or in the words of a person on this forum, an annuity.

Since he's making reference to something I said, let me take ownership of the quote. I guess the assumption is, if you cant fix someone, you shouldn't bother attempting to provide them with durable relief for a reasonable period of time. In my experience, cervical and lumbar intra-articular facet joint injections, when they work, provide relief for between 3-6 month. Over time, the duration of this relief degrades, at which time, I move forward with RF.

So yes, I do repeat the simplest, least invasive, effective procedure until I need to move forward with something more aggressive. If that makes me deserving of 101N's scorn and derision, so be it.

 

[Apollyon]

Everyone thinks that the SIJ can't be a real pain generator...until after their first snowboarding lesson.

Late post - 5 days ago, I slipped on the ice in a supermarket parking lot - getting out of my pickup truck, feet down, and they slid right out from under me. Flat on my ass. No "crack", and no numbness, so, just pain. SI joint pain. Sitting and standing aren't bad - but, between one and the other, different story.

But, being a dumb ER doc, I have just been taking ibuprofen. This morning, I turned the corner, and am finally doing better.

 

[DrCommonSense]

I just stated that there is a huge percentage of SIJ patients who don't need an injection, so no money here other than the initial office visit before I send them to PT.

101N. I know you must be jaded after treating all those mental cases on medicaid, but if you spend time treating normal people, who work full time, have a family, and have real insurance, you will see countless cases of mechanical issues causing pain, not mental ones.

I feel sorry for the real patients that come to your clinic with solvable problems only to be told its all in their head.

Its worse than that. 101N seems to believe real anatomic pathology that can be found on imaging studies are all "in the head and fake" whereby we should just send them to a CBT dude to talk it over as their best "fix".

However, he is more than willing to spend literally BILLIONS on the treatment of "fibromyalgia" that has no objective lab/imaging studies that confirm its diagnosis with highly dangerous plus infinitely expensive drugs such as "Lyrica" sold by Pfizer (who amazing pays "consultant fees" to the docs that "study" this "disease").

Funny how that works right?

 

[Ducttape]

I don't ever remember a thread where 101N recommended Lyrica or other expensive medications. he clearly has identified that opioid medications are not appropriate.

 

[nolapsych]

Everyone needs to chill on the 101N bashing. Ball breaking is one thing...the personal attacks speak much more to your own character / bias / insecurities than your perceived flaws of his approach. I really doubt his outcomes are much different than anyone else here


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[lonelobo]

Everyone needs to chill on the 101N bashing. Ball breaking is one thing...the personal attacks speak much more to your own character / bias / insecurities than your perceived flaws of his approach. I really doubt his outcomes are much different than anyone else here


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You apparently don't visit much? This site is for
-Political arguments
-Bashing other specialties
-Telling everyone how we are such great doctors that do it the right way
-Telling others why they are doing it wrong

-and then if that doesn't finish it we get personal

 

[drusso]

Everyone needs to chill on the 101N bashing. Ball breaking is one thing...the personal attacks speak much more to your own character / bias / insecurities than your perceived flaws of his approach. I really doubt his outcomes are much different than anyone else here


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First, you need to distinguish between "free speech" and intellectual pollution. Exaggerating evidence (using level 3 and level 4 studies and meta-analysis to deduce clinical decision-making), mis-attributing causal and associative relationships, and comporting oneself in a feral/unprofressional manner is never to be tolerated.

 

[bedrock]

Everyone needs to chill on the 101N bashing. Ball breaking is one thing...the personal attacks speak much more to your own character / bias / insecurities than your perceived flaws of his approach. I really doubt his outcomes are much different than anyone else here


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what do you know about anything?
according to your sig you are a resident, thus you don't even know what you don't know. Residents should know their place. You can't make presumptions about the quality of various treatments when you don't know anything personally about being a pain attending for many years.

 

[ampaphb]

what do you know about anything?
according to your sig you are a resident, thus you don't even know what you don't know. Residents should know their place. You can't make presumptions about the quality of various treatments when you don't know anything personally about being a pain attending for many years.

Chill, Bedrock. All of us were once residents and fellows. We all felt we could contribute. It has taken me years to realize how little I knew back then

 

[lobelsteve]

Chill, Bedrock. All of us were once residents and fellows. We all felt we could contribute. It has taken me years to realize how little I knew back then

And it's amazing how easily the rest of us see how little you do know now. Just kidding

 

[bedrock]

Chill, Bedrock. All of us were once residents and fellows. We all felt we could contribute. It has taken me years to realize how little I knew back then

yes we all were residents, and when I was a resident there was respect for the attendings, and would you choose your words when speaking to the attending and never just flippantly tell an attending that all treatments are probably just the same, when the resident clearly doesn't know the treatment literature as well as the attending nor have the experience of seeing thousands of patient and observing the field and treatments evolve over time.

 

[ampaphb]

yes we all were residents, and when I was a resident there was respect for the attendings, and would you choose your words when speaking to the attending and never just flippantly tell an attending that all treatments are probably just the same, when the resident clearly doesn't know the treatment literature as well as the attending nor have the experience of seeing thousands of patient and observing the field and treatments evolve over time.

Then you were a shockingly timid resident. My colleagues and I asked a ton of questions to try and understand why folks did what they did. The resident in question is making a ton of assumptions when he says that 101N's outcomes are similar to everyone else's, but that is obviously said out of ignorance, not out of arrogance. Consider the source, and don't waste your energy.

“Never engage in a battle of wits with an unarmed man.” -Churchill

 

[bedrock]

Then you were a shockingly timid resident. My colleagues and I asked a ton of questions to try and understand why folks did what they did. The resident in question is making a ton of assumptions when he says that 101N's outcomes are similar to everyone else's, but that is obviously said out of ignorance, not out of arrogance. Consider the source, and don't waste your energy.

You made a rather big assumption yourself about me right there.

Asking an attending lots of questions to learn medicine is a far cry from making presumptuous grand statements about topics that the resident clearly doesn't understand fully. That was looked down upon in every academic center I worked at and was the mark of ego over knowledge. It was forgiven once or twice, but if it was a recurring habit, then the med student/resident didn't receive favorable evaluations. Hopefully this resident realizes his mistake here.

I'm done wasting my energy. I'm not sure why you keep bringing this back up.

 

[Ducttape]

I personally think it is a bit disturbing how some are critiquing this individual (who happens to be a resident) who is making a primary claim that some on this board are not being civil in their discourse.

he doesn't need to be an attending to recognize that some comments on this board are borderline inappropriate and do not have to do with the art and science of medicine. he has to be, well observant...

 

[lonelobo]

 

[101N]

Curr Pain Headache Rep. 2016 Oct;20(10):58. doi: 10.1007/s11916-016-0588-2.
Utilization of Facet Joint and Sacroiliac Joint Interventions in Medicare Population from 2000 to 2014: Explosive Growth Continues!
Manchikanti L1,2, Hirsch JA3, Pampati V4, Boswell MV5.
Author information

Abstract
Increasing utilization of interventional techniques in managing chronic spinal pain, specifically facet joint interventions and sacroiliac joint injections, is a major concern of healthcare policy makers. We analyzed the patterns of utilization of facet and sacroiliac joint interventions in managing chronic spinal pain. The results showed significant increase of facet joint interventions and sacroiliac joint injections from 2000 to 2014 in Medicare FFS service beneficiaries. Overall, the Medicare population increased 35 %, whereas facet joint and sacroiliac joint interventions increased 313.3 % per 100,000 Medicare population with an annual increase of 10.7 %. While the increases were uniform from 2000 to 2014, there were some decreases noted for facet joint interventions in 2007, 2010, and 2013, whereas for sacroiliac joint injections, the decreases were noted in 2007 and 2013. The increases were for cervical and thoracic facet neurolysis at 911.5 % compared to lumbosacral facet neurolysis of 567.8 %, 362.9 % of cervical and thoracic facet joint blocks, 316.9 % of sacroiliac joints injections, and finally 227.3 % of lumbosacral facet joint blocks.

 

[drusso]

Curr Pain Headache Rep. 2016 Oct;20(10):58. doi: 10.1007/s11916-016-0588-2.
Utilization of Facet Joint and Sacroiliac Joint Interventions in Medicare Population from 2000 to 2014: Explosive Growth Continues!
Manchikanti L1,2, Hirsch JA3, Pampati V4, Boswell MV5.
Author information

Abstract
Increasing utilization of interventional techniques in managing chronic spinal pain, specifically facet joint interventions and sacroiliac joint injections, is a major concern of healthcare policy makers. We analyzed the patterns of utilization of facet and sacroiliac joint interventions in managing chronic spinal pain. The results showed significant increase of facet joint interventions and sacroiliac joint injections from 2000 to 2014 in Medicare FFS service beneficiaries. Overall, the Medicare population increased 35 %, whereas facet joint and sacroiliac joint interventions increased 313.3 % per 100,000 Medicare population with an annual increase of 10.7 %. While the increases were uniform from 2000 to 2014, there were some decreases noted for facet joint interventions in 2007, 2010, and 2013, whereas for sacroiliac joint injections, the decreases were noted in 2007 and 2013. The increases were for cervical and thoracic facet neurolysis at 911.5 % compared to lumbosacral facet neurolysis of 567.8 %, 362.9 % of cervical and thoracic facet joint blocks, 316.9 % of sacroiliac joints injections, and finally 227.3 % of lumbosacral facet joint blocks.

"Beyond the particulars described above, various researchers
have indicated that there has in fact not been an
increase in chronic pain [22, 23]. While the IOM indicated
that the prevalence of chronic persistent pain to be affecting
one third of the US population, other data has focused on the
approximately 30 million individuals with significant disability.
Freburger et al. [23] also have shown increases in the low
back pain in North Carolina from 3.9 to 10.2 % in 1992 and
2006 showing an overall increase of 162 %. These assumptions
are important as perception feeds into the reality of increases
in the utilization of various management strategies
designed to treat chronic pain [50–61]. Thus, proponents argue
that the prevalence of chronic pain is increasing along
with the evidence for diagnostic and therapeutic strategies.
Utilizing appropriate quality assessment measures in systematic
reviews, there has been significant evidence of the value
and validity of diagnostic and therapeutic facet joint interventions,
even though the evidence is only moderate for diagnostic
sacroiliac joint interventions and limited for therapeutic
sacroiliac joint interventions [7••, 8, 10, 13–16, 50–619•,
11•, 12•, ]. Thus, facet and sacroiliac joint interventions performed
in contemporary interventional pain management
settings with proper indications and medical necessity may
be the key to obtaining appropriate utilization. The discordant
evidence illustrated may be dependent on interpretation of the
placebo, long-term/short-term, and statistical analysis utilized
by different groups due to lack of standardization and variable
interpretation of methodologists and clinicians [7••, 8, 10, 13,
14, 62–72, 74–78, 809•, 11•, 12•, 73••, 79•, ].
Multiple limitations of assessment include lack of inclusion
of Medicare Advantage participants constituting approximately
20 to 30 % of Medicare patients, potential coding errors,
and lack of appropriate and identifiable coding patterns for
sacroiliac joint interventions other than sacroiliac joint injections.
However, the major advantage of this assessment is that
we have included all patients in the FFS Medicare which
included both the elderly population as well as the disabled
population. This inclusion often is crucial as the disabled population
tends to be higher utilizers [81].
In summary, the growth of facet and sacroiliac joint interventions
continues. Thus, appropriate evidence synthesis and
application of principles demonstrating medical necessity are
crucial in managing the growth patterns into the future"

 

[nolapsych]

I personally think it is a bit disturbing how some are critiquing this individual (who happens to be a resident) who is making a primary claim that some on this board are not being civil in their discourse.

he doesn't need to be an attending to recognize that some comments on this board are borderline inappropriate and do not have to do with the art and science of medicine. he has to be, well observant...

Proves my point...I'm not a resident anymore, I'm an attending. Again, all personal attacks are projections of your own issues. Fire away


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[ampaphb]

I believe that's the most pompous version of "I'm rubber, you're glue..." I've ever seen