MRI and ESI

[PMR 4 MSK]

Would you do an ESI without an MRI being done?

If no, how old an MRI will you allow - 1 year, 2 years, 3 years or more?

Similarly, do you require MRI prior to facets or MBB?

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[Tenesma]

having been burned enough times - I require an MRI or thin-slice CT scan as a baseline for anybody who presents with chronic axial/radicular pain...

if they have previous imaging it depends on their age

1) 93 year old w/ neurogenic claudication with 7 year old MRI showing severe stenosis - doubt i need another MRI especially since surgery ain't gonna be considered

2) 45 year old w/ progressive back pain with 7 year old MRI - will get new MRI...

so, I would not consider injections until i can view imaging... actually put my eyes on it, not just read a report

i have had patients referred to me for ESI and/or facet injections and/or discography and it turned out that their imaging revealed 1) prostatic mets to the spine 2) discitis/osteomyelitis 3) psoas abscess 4) lymphoma 5) malignant perineural masses, etc....

 

[dc2md]

Let me give you another scenario:
PCP refers 50yo male patient to you for lumbar facet injections. He/she has been managing the patient's chronic LBP for years with hydrocodone. Increased pain recently (and new knowledge of facet injections) has prompted the referral to you. He comes in and you realize he has what may be S1 radic instead of facet referral down the leg. He has xray of L-spine but not an MRI. So since you'll require an MRI before any injection, he'll have to schedule that and come back with the films (on cd of course). But now that his pain is significantly worsened lately (and especially after your poking and proding with the physical exam), he says his hydrocodone just isn't enough.
What would you do now??
Be a second prescriber of opioids (even though it'll only be enough to last him til next week after the MRI)? Tell him to schedule an appt with his PCP to get more pills? Give him a one-time toradol injection to help with the pain the PE just caused? OR, require that ALL patients referred to you MUST have an MRI prior to the appt?

 

[PMR 4 MSK]

Let me give you another scenario:
PCP refers 50yo male patient to you for lumbar facet injections. He/she has been managing the patient's chronic LBP for years with hydrocodone. Increased pain recently (and new knowledge of facet injections) has prompted the referral to you. He comes in and you realize he has what may be S1 radic instead of facet referral down the leg. He has xray of L-spine but not an MRI. So since you'll require an MRI before any injection, he'll have to schedule that and come back with the films (on cd of course). But now that his pain is significantly worsened lately (and especially after your poking and proding with the physical exam), he says his hydrocodone just isn't enough.
What would you do now??
Be a second prescriber of opioids (even though it'll only be enough to last him til next week after the MRI)? Tell him to schedule an appt with his PCP to get more pills? Give him a one-time toradol injection to help with the pain the PE just caused? OR, require that ALL patients referred to you MUST have an MRI prior to the appt?

Been there, done that - add in tramadol. It might not help but it'll put him off long enough to get the MRI and schedule the LESI. I sometimes tentatively schedule the ESI pending the MRI findings. Just did that today.

 

[SSdoc33]

having been burned enough times - I require an MRI or thin-slice CT scan as a baseline for anybody who presents with chronic axial/radicular pain...

if they have previous imaging it depends on their age

1) 93 year old w/ neurogenic claudication with 7 year old MRI showing severe stenosis - doubt i need another MRI especially since surgery ain't gonna be considered

2) 45 year old w/ progressive back pain with 7 year old MRI - will get new MRI...

so, I would not consider injections until i can view imaging... actually put my eyes on it, not just read a report

i have had patients referred to me for ESI and/or facet injections and/or discography and it turned out that their imaging revealed 1) prostatic mets to the spine 2) discitis/osteomyelitis 3) psoas abscess 4) lymphoma 5) malignant perineural masses, etc....

i agree with tenesma here, but i wish i didnt. i think its a crock of @#@$! and a huge boon to the radiology community to have that many MRIs done. essentially EVERY spine patient we see has an MRI done. that is pretty ridiculous. i honestly feel ashamed that we practice so defensively, rather than judiciously distributing the limited financial resources we have.

in the scerarios you pointed out here, what happens if you do the ESI anyway? 1.) prostatic mets -- you do the injection, pain maybe gets better, but invariably comes back and the mets declare themselves anyway. maybe the diagnosis gets made a month later. 2 and 3.) discitis/osteomyelitis -- injection doesnt help/steroids could worsen the infection or seed another area. one would hope think that they would have signs of an infection and wouldnt get an epidural anyway 4 and 5.) lymphoma -- see #1 above.

id really like to think that we could use our history and exam skills a bit better and rely on the MRIs when there is a harder indication (history of CA and new back pain with fevers for ex.).

uggh, that being said, i do feel more comfortable having the MRI. not necessarily because i fear of doing harm to the patient, but rather of the legal repercussions associated with injecting someone who may have something bad brewing down there.

i really think its silly to get an MRI on a 90 year old with obvious stenosis. that being said, i get the MRI on a 90 year old with obvious stenosis.

 

[mille125]

having been burned enough times - I require an MRI or thin-slice CT scan as a baseline for anybody who presents with chronic axial/radicular pain...

if they have previous imaging it depends on their age

1) 93 year old w/ neurogenic claudication with 7 year old MRI showing severe stenosis - doubt i need another MRI especially since surgery ain't gonna be considered

2) 45 year old w/ progressive back pain with 7 year old MRI - will get new MRI...

so, I would not consider injections until i can view imaging... actually put my eyes on it, not just read a report

i have had patients referred to me for ESI and/or facet injections and/or discography and it turned out that their imaging revealed 1) prostatic mets to the spine 2) discitis/osteomyelitis 3) psoas abscess 4) lymphoma 5) malignant perineural masses, etc....

i have seen all of these described conditions and have the same philosophy as tenesma...just this week i had a patient who was sent for an "ESI" and actually had diskitis presumably from a poorly treated soft tissue infection 2 weeks earlier...

 

[mille125]

Let me give you another scenario:
PCP refers 50yo male patient to you for lumbar facet injections. He/she has been managing the patient's chronic LBP for years with hydrocodone. Increased pain recently (and new knowledge of facet injections) has prompted the referral to you. He comes in and you realize he has what may be S1 radic instead of facet referral down the leg. He has xray of L-spine but not an MRI. So since you'll require an MRI before any injection, he'll have to schedule that and come back with the films (on cd of course). But now that his pain is significantly worsened lately (and especially after your poking and proding with the physical exam), he says his hydrocodone just isn't enough.
What would you do now??
Be a second prescriber of opioids (even though it'll only be enough to last him til next week after the MRI)? Tell him to schedule an appt with his PCP to get more pills? Give him a one-time toradol injection to help with the pain the PE just caused? OR, require that ALL patients referred to you MUST have an MRI prior to the appt?

This is a very common scenario in our field. My answer is to order the MRI and defer other treatment until after the exam is complete. This patient had been stable on hydrocodone for years and now has worsening pain with a radiculopathy. This does warrant an MRI specifically to rule out some of the things that Tenesma listed. A reasonable patient would understand that in order to be treated appropriately and effectively a diagnosis must be made. A reasonable patient would get the study without delay. An unreasonable patient or a drug seeker/malinger would demand drug without a diagnosis. What would happen if this patient went to an ortho with a suspected rotator cuff tear? or an ACL tear of the knee? The ortho would order films before rendering treatment. These are also painful conditions (many times more painful than chronic back pain). Why should we be any different? In my opinion a diagnosis must be made prior to administering potentially dangerous drugs. What does everyone else think?

 

[Tenesma]

it is VERY RARE for patients to come to me with acute back pain --- i agree that we over image acute back pain...

in fact I don't get any imaging for acute pain if there is no evidence of neurologic deficit until 2 months go by - if at 2 months symptoms same or worse, and not responding to conservative care, then i'll get an MRI

sometimes these acute patients WANT an MRI - i then explain to them that the literature doesn't support it, and that while I don't mind facilitating more imaging that they will likely end up with the bill as i don't believe it is medically necessary - once they realize the costs they will frequently agree to defer further imaging

the only exception i make is for Lawyers --- all lawyers get as MUCH imaging as i can think of... hopefully the radiation will slow them down a bit

 

[Tenesma]

dc2md - if you suspect it is a radiculopathy pain then why would more hydrocodone help? i would just recommend neurontin or lyrica and have them return w/ imaging studies.

 

[lobelsteve]

Call referring MD, explain more likely radicular pain and would like to perform S-1 TFESI and order an MRI. Now you can do a safe procedure to help relieve pain while the workup ensues.

I do not do CESI without imaging owing to the relative lack of space in the normal spine and the complete potential lack of space in a compromised spine.
EG: Severe canal stenosis with additional volume at the same location would be ill advised- or at least would increase the pain and possibly cause transient myelopathic symptoms- but I do not know if this would occur and I do not need to find out for myself. The anatomy and physiology dictate it could occur, and I feel that by just turning the head we could reduce pressure by having fluid come out the foramen. Still, no thanks- not a cowboy.

 

[dc2md]

dc2md - if you suspect it is a radiculopathy pain then why would more hydrocodone help? i would just recommend neurontin or lyrica and have them return w/ imaging studies.

sure. either of them. my questioning wasn't really into what script is best for suspected radic pain. it was about are you basically sending a patient out of your office in more pain than when they came in and without any procedure (d/t lack of films) or new meds (temporary). besides, i wouldn't give someone i just aggrevated (physically) lyrica or neurontin that normally takes time to adjust to a therapeutic dose (300 tid just doesn't cut it most of the time with neurontin, but it's a good starting dose).

i guess another way of asking it is, are you mostly getting referrals from PCPs to manage the patient's pain entirely (including meds)? or are you getting most of your referrals for intervention procedures only?? (stick em and flick em back to PCP)

 

[dc2md]

I feel that by just turning the head we could reduce pressure by having fluid come out the foramen.

Wish we could radiotag (label) some steroid, shoot it epidural, then see where it is 10 minutes (30min; 1-hr) later. Does it stay focal at all, or does it all diffuse to all surrounding structures? How much gets taken up by vasculature and goes systemic?

 

[Tenesma]

dc2md....

oh boy --- where do i start?...

a patient who leaves my office in more pain because of an examination I did, 99% is full of crap (0.5% they have some weird hyperesthesia and 0.5% they have an abscess that you aren't aware of)...

there is NO requirement to treat pharmacologically an increase of pain due to manipulation.... as a chiropractor you should know that by now


if they complain, i recommend heat/ice, rest, massage, hot shower, NSAID/Tylenol --- but DON't get sucked into this sense that every patient who comes to your office in pain needs to leave your office with a script in their hand.... while it may make you feel psychologically better that you did at LEAST something physician-like - it isn't always the answer nor is it always the appropriate answer...

chronic pain is a chronic condition - there are no emergencies and there are flare-ups...

don't get manipulated.

the next thing, you will do an ESI, and the patient calls your office because their injection site is sore and now they need more vicodin --- gimme a break...

as to the latter question re: "Stick and Flick" --- referrals are for evaluation of a specific pain condition or for pharmacologic evaluation.... the PCPs know i don't prescribe opioids, but that i am there as a support system to 1) educate the patient 2) collaborate on diagnostic/therapeutic modalities 3) aid the PCP on pharmacologic changes/escalations/weans....

 

[dc2md]

Tenesma,
Thanks for the wise words from your experience. True, even though we do cause them pain from our exam, if their "9/10" pain is even close to that, our exacerbation is a drop in the bucket. ice pack/IFC/ultrasound/TENS/OTC nsaids are much better options.

"don't get manipulated" - great line for a former DC. :-D

 

[Ligament]

Agreed 1000% percent!

My favorite complaint is the "Dr. Ligament THREW ME DOWN TO THE FLOOR when he was examining me" translated: I did facet loading maneuvers, flared up back pain, patient did not fall at all.


I do a very good physical exam, very in depth. I stretch muscles and joints that have not been moved in decades. If they complain, I tell them it was free physical therapy and it was good for them.

dc2md....

oh boy --- where do i start?...

a patient who leaves my office in more pain because of an examination I did, 99% is full of crap (0.5% they have some weird hyperesthesia and 0.5% they have an abscess that you aren't aware of)...

there is NO requirement to treat pharmacologically an increase of pain due to manipulation.... as a chiropractor you should know that by now


if they complain, i recommend heat/ice, rest, massage, hot shower, NSAID/Tylenol --- but DON't get sucked into this sense that every patient who comes to your office in pain needs to leave your office with a script in their hand.... while it may make you feel psychologically better that you did at LEAST something physician-like - it isn't always the answer nor is it always the appropriate answer...

chronic pain is a chronic condition - there are no emergencies and there are flare-ups...

don't get manipulated.

the next thing, you will do an ESI, and the patient calls your office because their injection site is sore and now they need more vicodin --- gimme a break...

as to the latter question re: "Stick and Flick" --- referrals are for evaluation of a specific pain condition or for pharmacologic evaluation.... the PCPs know i don't prescribe opioids, but that i am there as a support system to 1) educate the patient 2) collaborate on diagnostic/therapeutic modalities 3) aid the PCP on pharmacologic changes/escalations/weans....

 

[dc2md]

...I tell them it was free physical therapy and it was good for them.

LOL. love it!!!

 

[Ligament]

LOL. love it!!!

It really is free PT!!

 

[Mister Mxyzptlk]

If someone complains about increased pain after an exam just say "Well of course. I'm a pain doctor. I cause pain. Did you think you were here for something else?"

As for whether or not to get an MRI - our anesthesia brethren routinely enter the spinal canal by both epidural and intrathecal routes without benefit of preop MRI with excellent safety records.

If I suspect mechanical pain I do not get an MRI. I get them if I suspect an intra-spinal etiology for the pain or someone has asked me to enter the canal with a needle.

For suspected mechanical pain I do MBBs and/or SI injections and if there is still axial pain then an MRI would be reasonable to r/o other things such as annular tear, diskitis, etc.

Middle and anterior column pain processes are usually different enough in their clinical presentation that you can distinguish them from joint pain and order tests such as MRI with good reason.

 

[analgesic]

Tenesma,
Thanks for the wise words from your experience. True, even though we do cause them pain from our exam, if their "9/10" pain is even close to that, our exacerbation is a drop in the bucket. ice pack/IFC/ultrasound/TENS/OTC nsaids are much better options.

"don't get manipulated" - great line for a former DC. :-D

DC2MD,

I am surprised that you think this such a great line. Manual medicine is by far one of the most potent analgesics you can offer patients in pain. A mechanical problem mandates a mechanical solution. Perhaps a genuine individual in pain is experiencing a segmental loss of biomechanical functionality secondary to aberrant frequencies of firing of large diameter fibers which allow nociceptive escape/ disinhibition of the pain pool. One of the best ways to restore this misfortune is to appropriately assess and specifically correct the biomechanics related to that level through manual medicine. If you just want to send them to PT, don't just write evaluate and treat. You should have the knowledge to prescribe specific strengthening and stretching exercises for the soft tissues involved that have allowed the pathology to manifest. The problem surfaces by carefully selecting which patients are genuine and which patients may be FOS/letiginous. Don't be ashamed, take pride in being a chiropractor but be knowledgable enough to differentiate yourself from others who did not take the time to understand how we evoke change through mechanical means.

S1 radicular vs. Facet mediated pain is quite easily differentiated. Remember pain does not radiate down the leg to be perceived in the toe. Pain is a parietal based cortical perception. A great question every pain specialist should ask is why is my patient is experiencing the perception of pain radiating down the leg. The answer lies in the dorsal lateral tract of lissauer and in segmental proximal-distal ascending distributions of the nociceptive pool of neurons as they are brought to threshold. We can discuss this further if others care to question it.

Hany Helmi MD, DC
Case Western University
PMR department PGY4

 

[dc2md]

hany,
i thought the "don't get manipulated" line was so funny b/c tenesma was talking about getting manipulated by the pain patient...them manipulating me into prescribing meds for the discomfort i caused them during the exam. he/she wasn't saying don't get spinal manipulations. i love adjustments (getting and giving). unfortunately, no attending at my program is very comfortable with me doing them on patients.

and as far as being ashamed, i gotta admit to being more tight-lipped about it down here in south. i don't know which chiro school you went to, but we all know the programs in the south (Life especially) and Palmer and a few others really teach about spinal manipulation helping with cancer and heart disease and gallstones. complete quackery to me. and since most of the chiros down here were trained down here, the physician preception of chiropractic is one of more skepticism than when i was in illinois.

 

[dc2md]

S1 radicular vs. Facet mediated pain is quite easily differentiated. Remember pain does not radiate down the leg to be perceived in the toe. Pain is a parietal based cortical perception. A great question every pain specialist should ask is why is my patient is experiencing the perception of pain radiating down the leg. The answer lies in the dorsal lateral tract of lissauer and in segmental proximal-distal ascending distributions of the nociceptive pool of neurons as they are brought to threshold. We can discuss this further if others care to question it.

but the 1st order pain fibers just travel in Lissauer's tract up and down a couple levels before synapsing and going up the contralateral spinothalamic tract. right? what's the big significance of this then?? don't we (pain specialists) just want to find the source of the pain (facet; chemical nerve root irritation; annular tears; etc.) and treat it.

 

[lobelsteve]

but the 1st order pain fibers just travel in Lissauer's tract up and down a couple levels before synapsing and going up the contralateral spinothalamic tract. right? what's the big significance of this then?? don't we (pain specialists) just want to find the source of the pain (facet; chemical nerve root irritation; annular tears; etc.) and treat it.

He's still thinking like DC, trying to explain is science terms what does not exist.

www.quackcast.com

DC's are like ash oles.....

At least you guys had the sense to move on.

 

[dc2md]

He's still thinking like DC, trying to explain is science terms what does not exist.

www.quackcast.com

DC's are like ash oles.....

At least you guys had the sense to move on.

WOW!! steve, way to lump all practisioners of one profession all together with that "ash oles" statement. oh course, u are from georgia which has the most extreme polar end of chiropractic teaching...chiropractic will help asthma, gout, vaginal candidiasis, etc. i agree that that is BS!! but do you know how many millions of people each year get incredible relief from their chiropractor?? me either, but it's a whole big bunch.

do i really give a **** if 80% of the pain relief is psychologic/placebo? NOPE!! i had a patient that was on various prescription pain meds for years and then was convinced to start taking fish oil pill by a friend of his. his pain is finally managed since taking the fish oil daily. and i don't care a bit if there's any science behind that (yes of course there's an anti-inflammatory effect but he was on prescription NSAIDs already). if my patients get LBP relief from rubbing icy hot on their testicles, i support it (as long as it's not harmful). btw, i don't recommend icy hot on balls to my patients (as bad kids we convinced another kid to do that his "boys" turned purple and extremely painful and he had to show his nurse mother his purple boys...not fun i'm sure).

and let me just add one more thing to this conversation. i briefly looked at the "quack" website link you posted and they listed a "links" page with one regarding a Spine article about VBA strokes and chiropractic care (http://www.ncbi.nlm.nih.gov/pubmed/18204390). Here's the conclusion from that article:

"CONCLUSION: VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care."

my only concern is with what i call "fundamentalist chiropractors". the ones i mentioned above that think all a patient needs is chiropractic adjustments and they'll be cured of everything. so the patient then with dizziness, headache, and ataxia isn't gonna get the proper emergency stroke workup needed. they're gonna get a cervical adjustment that isn't gonna harm the patient directly, except for the delay in diagnosis of the real problem. so for me, the problem is with the lack of medical knowledge of most (not all) chiropractors. that's one reason i decided to become an MD instead.

so steve, i think we agree on a lot, but i'm just not ignorant enough to lump all DCs together. also, i know PLENTY of MDs that are quacks. let's start with the ortho surgeons who want to do laminectomies on every patient with back pain not relieved with ibuprofen and flexeril.

 

[lobelsteve]

WOW!! steve, way to lump all practisioners of one profession all together with that "ash oles" statement. oh course, u are from georgia which has the most extreme polar end of chiropractic teaching...chiropractic will help asthma, gout, vaginal candidiasis, etc. i agree that that is BS!! but do you know how many millions of people each year get incredible relief from their chiropractor?? me either, but it's a whole big bunch.

do i really give a **** if 80% of the pain relief is psychologic/placebo? NOPE!! i had a patient that was on various prescription pain meds for years and then was convinced to start taking fish oil pill by a friend of his. his pain is finally managed since taking the fish oil daily. and i don't care a bit if there's any science behind that (yes of course there's an anti-inflammatory effect but he was on prescription NSAIDs already). if my patients get LBP relief from rubbing icy hot on their testicles, i support it (as long as it's not harmful). btw, i don't recommend icy hot on balls to my patients (as bad kids we convinced another kid to do that his "boys" turned purple and extremely painful and he had to show his nurse mother his purple boys...not fun i'm sure).

and let me just add one more thing to this conversation. i briefly looked at the "quack" website link you posted and they listed a "links" page with one regarding a Spine article about VBA strokes and chiropractic care (http://www.ncbi.nlm.nih.gov/pubmed/18204390). Here's the conclusion from that article:

"CONCLUSION: VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care."

my only concern is with what i call "fundamentalist chiropractors". the ones i mentioned above that think all a patient needs is chiropractic adjustments and they'll be cured of everything. so the patient then with dizziness, headache, and ataxia isn't gonna get the proper emergency stroke workup needed. they're gonna get a cervical adjustment that isn't gonna harm the patient directly, except for the delay in diagnosis of the real problem. so for me, the problem is with the lack of medical knowledge of most (not all) chiropractors. that's one reason i decided to become an MD instead.

so steve, i think we agree on a lot, but i'm just not ignorant enough to lump all DCs together. also, i know PLENTY of MDs that are quacks. let's start with the ortho surgeons who want to do laminectomies on every patient with back pain not relieved with ibuprofen and flexeril.

The basis for chiropractic care is not science. As an MD, we are scientists first.

As far as the spine article, the conclusion does not follow the premise or the data in the article. If you look for an exceedingly rare condition (VBA stroke) in the general population, it is just that, exceedingly rare. It also happens in the elederly much more commonly. If you stratify the Spine article and look at all the patients age 45 or younger, you will find a 3 to 9 fold increased risk of VBA as compared to those not undergoing chiropractic care. The diagnosis of VBA was made by running down the ICD9 codes at hospital discharge- hardly the way to determine who had a VBA stroke.

U have met a few DC's that believed what they did was helpful. The vast majority have been snake oil salesmen and many are just downright criminals.

I've never met a Radiologist who could read plain films as well as a DC. They are able to see the tiniest "subluxations" when the best musculoskeletal Radiologists see "Normal study". I have also seen a DC sit on a spinal met for 3 years while adjusting the subluxation. It was a little late when the patient made it to a real doctor. The X-ray on his intitla eval showed a met.

I've also had unusually bad luck in my personal interactions with DC's. Cannot speak to that further at this time.

I also agree many MD/DO's are as bad. I review cases for the medical board, private isnuranc, and the dept of labor.
I have seen an Ortho Spine Surgeon perform an ACDF on a Fibro patient with neck pain NOT radiating into both arms, a normal EMG, an MRI showing DDD and moderate formainal stenosis. Her exam was completely normal. His plan stated that she has exam finding s of a C6 radiculopathy and low and behold- she gets worse after surgery. The same lady had a "Pain" doctor give her 3 bling ESI's in the office for the same non-radiating pain. His HPI over 5 progress noted was identical. Each one said she has not yet had PT or a TENS unit. These guys should have to pay back her insurance.

 

[dc2md]

The basis for chiropractic care is not science.

Agree

As far as the spine article, the conclusion does not follow the premise or the data in the article. If you look for an exceedingly rare condition (VBA stroke) in the general population, it is just that, exceedingly rare. It also happens in the elederly much more commonly. If you stratify the Spine article and look at all the patients age 45 or younger, you will find a 3 to 9 fold increased risk of VBA as compared to those not undergoing chiropractic care. The diagnosis of VBA was made by running down the ICD9 codes at hospital discharge- hardly the way to determine who had a VBA stroke.

Steve, you can't say in one sentence that there's a 3-9 fold increased risk of VBA storke after chiropractic visit, and then say the diagnosis of VBA stroke diagnosis is suspect at best in another. But yes, i'm trying to access the full article but can't get my institutional password to work. BUT, the authors (even though most chiros themselves) have a point. Patients go to chiropractors (and typically pay out-of-pocket) for a reason...PAIN. And it's not a stretch to presume the reason they went was for headache or neck pain. But actually (and it may say in the full text) the abstract doesn't even say whether they even got neck manipulation from the chiropractor they just saw. For all we know, they may of just gotten a lumbar adjustment...and don't even try to tell me that has anything to do with VBA tears. In addition, these diagnosed VBA strokes could've been basilar aneurysms (which of course aren't affected by neck manip).

Unless I see otherwise from the full text later, this study has way to many flaws to draw any conclusion.

But I did listen to the podcast that went along with this article and the dude is a great speaker. Even though I don't agree with his analysis, I liked listening. Kind of like Obama. Even his critics have to admit he's a damn good speaker. Oh, and this infectious disease doc who does the podcasts likes to keep referring to chiropractic adjustments as modified hangings...which is BS just from a mechanism standpoint (upper cervical extension vs. flexion with rotation/lateral flexion). I personally rotate my C-spine more backing out of my parking spot than I rotated the C-spine of my patients when I adjusted them...just a thought.

snake oil salesmen and many are just downright criminals

Also agree!! And we know plenty of money-hungry "criminal" pain docs out there too. Amp just mentioned some in the new orleans area that love doing bilateral, 3-level TF ESIs...talk about criminal. They just don't have to be as snake oil salesman-like b/c for the most part the insurance companies are putting up the cash, not the patient.

 

[Tenesma]

i am lucky because I have very good chiropractors around me in my community... they are good at what they do (ie: patients feel better) and they understand their limits.

We all have stories about missed diagnoses - but I also have my radiologists (board-certified) miss findings. Just as I am sure that I have missed a few big findings myself...

we use the word science as if we are all knowing... in fact, when the H. Pylori theory came out we ("scientific community") thought it was crap...

i agree w/ dc2md that what our focus should be on is pain relief - sometimes we are lucky and also come up with a reasonable diagnosis. I have patients who read Sarno's books (crap in my opinion) and came back with a complete cure of their EMG-proven radiculopathy... I have patients who take Evening Primrose Oil and are cured of their painful diabetic neuropathy... there is too much out there that I just don't understand other than the brain is super-powerful...

and if the brain interprets spinal manipulation as a pain relieving approach, than super...

 

[analgesic]

He's still thinking like DC, trying to explain is science terms what does not exist.

www.quackcast.com

DC's are like ash oles.....

At least you guys had the sense to move on.

Steve,

There is nothing wrong with thinking like a DC as long as you have the EBM to validate your clinical management. The science is there but you have to see it from a neurologic perspective. Your exposure in the heart of the bible belt is quite unfortunate for the few DC's out there that pride themselves on practicing efficaciously. The science of chiropractic is deep routed in utilizing joint mechanoreceptor activation to evoke change centrally which can be applied with respect to pain gate theory (Melzack and Wall). If you don't believe this is plausible then don't send your patients to PT either. As a PMR trained pain specialist I am sure that you have no problems sending your patients to PT. A good question I would love for you to answer is how does physical therapy alter the perception of pain?

Hany Helmi MD, DC
Case Western Reserve University
PMR department PGY4

 

[lobelsteve]

Steve,

There is nothing wrong with thinking like a DC as long as you have the EBM to validate your clinical management. The science is there but you have to see it from a neurologic perspective. Your exposure in the heart of the bible belt is quite unfortunate for the few DC's out there that pride themselves on practicing efficaciously. The science of chiropractic is deep routed in utilizing joint mechanoreceptor activation to evoke change centrally which can be applied with respect to pain gate theory (Melzack and Wall). If you don't believe this is plausible then don't send your patients to PT either. As a PMR trained pain specialist I am sure that you have no problems sending your patients to PT. A good question I would love for you to answer is how does physical therapy alter the perception of pain?

Hany Helmi MD, DC
Case Western Reserve University
PMR department PGY4

The premise that spinal manipulation can ameliorate disease is not based in science. THe concept behind PT is. Everything I do has 500 years of biology, physiology, biochemistry, anatomy, and associated scientific fields to support it. But this argument was made before in front of a larger audience.


http://www.ncahf.org/news/saf2.html

I'm open to hearing all arguments and appreciate efforts to relieve pain by any means possible. If a DC wants to treat pain and has the support of a physician who is looking after their spine as well- I see no problem. I cannot send patients to a DC on the basis that it is not scientifically grounded.

 

[analgesic]

The premise that spinal manipulation can ameliorate disease is not based in science. THe concept behind PT is. Everything I do has 500 years of biology, physiology, biochemistry, anatomy, and associated scientific fields to support it. But this argument was made before in front of a larger audience.


http://www.ncahf.org/news/saf2.html

I'm open to hearing all arguments and appreciate efforts to relieve pain by any means possible. If a DC wants to treat pain and has the support of a physician who is looking after their spine as well- I see no problem. I cannot send patients to a DC on the basis that it is not scientifically grounded.

Steve,

I would agree that Chiropractic does not have much of a foundation upon treating anything outside the musculoskeletal or nervous system when it comes to "ameliorating disease". I would appreciate it if you could answer the original question I asked. What is the "concept" regarding the mechanism in which PT's alter the perception of pain?

 

[Mister Mxyzptlk]

I don't know if I would brag about the last 500 years of medical "science". There isn't much to be proud of until maybe the past 125 years when science actually started to creep in. They were still doing bloodletting in the early 1900s.

In the 1930s Dr. Morris Fishbein, then president of the AMA, wrote a book on quackery. I don't have the book in front of me for the actual quote, but in the chapter on chiro he wrote that there is no such thing as pinched nerves and cited cadaver studies that showed no encroachment of spinal nerves. Oops.

I have a different view of chiro, probably because most of the DCs in my area trained at Texas Chiropractic College, which focuses on musculoskeletal treatment and doesn't try to teach treating asthma and ulcers with manipulation. Their grads are well-trained in MSK disorders. I have been pleased with their results in general.

I have had manipulation done twice - once lumbar, once thoracic. Since I was being treated for free it only took one adjustment. In case you were wondering craniosacral massage didn't do me any good at all. Neither did two separate attempts at acupuncture or a magnetic mattress. I'm not above trying things out within bounds of reason and provided it's free.

 

[lobelsteve]

Steve,

I would agree that Chiropractic does not have much of a foundation upon treating anything outside the musculoskeletal or nervous system when it comes to "ameliorating disease". I would appreciate it if you could answer the original question I asked. What is the "concept" regarding the mechanism in which PT's alter the perception of pain?

Discussing with the PT, PhD in my office later today. It would be premature for me to state putative mechanisms or scientific basis of a specific field when I have an expert in my office.

 

[Tenesma]

quackery ---

1) medicine was performing frontal lobectomies in the 50s for depression

2) we were telling people with gastric and duodenal ulcers that it was due to stress/type A personality when in fact it was due to H. Pylori - late 80s

3) the treatment for SI pain was fusion - mid 70s

500 years of medicine is the funniest thing i have heard in a long time - i have a book in my collection from 1648 - only 360 years ago, and that book encouraged the analysis of stool and urine to evaluate for pulmonary diseases, cardiovascular issues and sexual depravities... i really, reall hope you don't base your decisions on that book, because you'd have to be tasting a lot of urine/stool to help diagnose some of your patients

 

[SSdoc33]

quackery ---

1) medicine was performing frontal lobectomies in the 50s for depression

2) we were telling people with gastric and duodenal ulcers that it was due to stress/type A personality when in fact it was due to H. Pylori - late 80s

3) the treatment for SI pain was fusion - mid 70s

500 years of medicine is the funniest thing i have heard in a long time - i have a book in my collection from 1648 - only 360 years ago, and that book encouraged the analysis of stool and urine to evaluate for pulmonary diseases, cardiovascular issues and sexual depravities... i really, reall hope you don't base your decisions on that book, because you'd have to be tasting a lot of urine/stool to help diagnose some of your patients

rheumatologists giving gold for everything well into the 90's

 

[lobelsteve]

quackery ---

1) medicine was performing frontal lobectomies in the 50s for depression

2) we were telling people with gastric and duodenal ulcers that it was due to stress/type A personality when in fact it was due to H. Pylori - late 80s

3) the treatment for SI pain was fusion - mid 70s

500 years of medicine is the funniest thing i have heard in a long time - i have a book in my collection from 1648 - only 360 years ago, and that book encouraged the analysis of stool and urine to evaluate for pulmonary diseases, cardiovascular issues and sexual depravities... i really, reall hope you don't base your decisions on that book, because you'd have to be tasting a lot of urine/stool to help diagnose some of your patients

The big difference is we've learned from those mistakes and do not do any of that anymore. Your patients are not going for a cupping, a leeching, bloodletting, exorcism, etc. When the knowledge that came with anatomy and physiology made these things ridiculous, then mainstream medicine said no. When we try and apply these principles to alternative medicine and chiro care, they just do not hold science. If it hurts you'll do anything- like get a Vax-d for $5k at the chiros, chant mantra's, smoke pot, try acupuncture. Ifyou do this because your doctor (presumably one who knows his head from a hole in the ground (granted they're rare)) says I can't figure it out and it will do no harm- then I'm fine with that. But replacing actual care with fantasy for placebo like outcomes or worse is not ground on which I would care to tread, and more importantly would not let my mom, family, friends, or patients tread.

 

[paindefender]

The big difference is we've learned from those mistakes and do not do any of that anymore. Your patients are not going for a cupping, a leeching, bloodletting, exorcism, etc. When the knowledge that came with anatomy and physiology made these things ridiculous, then mainstream medicine said no. When we try and apply these principles to alternative medicine and chiro care, they just do not hold science. If it hurts you'll do anything- like get a Vax-d for $5k at the chiros, chant mantra's, smoke pot, try acupuncture. Ifyou do this because your doctor (presumably one who knows his head from a hole in the ground (granted they're rare)) says I can't figure it out and it will do no harm- then I'm fine with that. But replacing actual care with fantasy for placebo like outcomes or worse is not ground on which I would care to tread, and more importantly would not let my mom, family, friends, or patients tread.

I suggest opening a chiro forum for DC2md and analgesic so they can indulge themselves with chiro mumbo jumbo.

 

[dc2md]

500 years of medicine is the funniest thing i have heard in a long time - i have a book in my collection from 1648 - only 360 years ago, and that book encouraged the analysis of stool and urine to evaluate for pulmonary diseases, cardiovascular issues and sexual depravities... i really, reall hope you don't base your decisions on that book, because you'd have to be tasting a lot of urine/stool to help diagnose some of your patients

i was stumped today on a patient with LBP and radiation to the posterior calf. unusual S1 radic? facet with referral? SI with referred pain? hmmmm? THEN, i tasted his sample for the UDS...ended up being prostatic bone mets to the lower lumbar spine. did an MRI with contrast and confirmed it. so don't knock the urine and stool analysis tools.

 

[analgesic]

I suggest opening a chiro forum for DC2md and analgesic so they can indulge themselves with chiro mumbo jumbo.

Pain defender,
The discussion was not meant to be focused on chiropracitic but rather in the mechanisms of pain that cross disciplines. My apologies to you and others if my post has drawn too much attention.

 

[PMR 4 MSK]

Pain defender,
The discussion was not meant to be focused on chiropracitic but rather in the mechanisms of pain that cross disciplines. My apologies to you and others if my post has drawn too much attention.

Don't apologize to pain defender, it'll only encourage him to write more...

 

[analgesic]

but the 1st order pain fibers just travel in Lissauer's tract up and down a couple levels before synapsing and going up the contralateral spinothalamic tract. right? what's the big significance of this then?? don't we (pain specialists) just want to find the source of the pain (facet; chemical nerve root irritation; annular tears; etc.) and treat it.

You are right but the 1st order pain neurons travel in this tract and then synapse above and below bringing 2nd order proximal and distal pools of neurons to threshold. These neurons then synapse with the 3rd order neurons in the VPL of the thalamus which ascend to the cortex where the pain is perceived. Now the question is who beats it to the cortex and how will it be perceived in the parietal lobe. For instance L5 based nociceptive information will fire above and below L5 bringing adjacent pools to threshold. So L4-S1 nociceptive afferents are now be perceived cortically (follow the proximal to distal distribution in the race to the cortex) as pain radiating down the posterior thigh into the foot (Sciatica). Correct me if I am wrong but to my knowledge nociception is an ascending stimulus, the Sciatic is purely motor to the posterior aspect of the thigh, and pain is perceived parietally. Food for thought.

 

[dc2md]

The big difference is we've learned from those mistakes and do not do any of that anymore. Your patients are not going for a cupping, a leeching, bloodletting, exorcism, etc. When the knowledge that came with anatomy and physiology made these things ridiculous, then mainstream medicine said no. When we try and apply these principles to alternative medicine and chiro care, they just do not hold science. If it hurts you'll do anything- like get a Vax-d for $5k at the chiros, chant mantra's, smoke pot, try acupuncture. Ifyou do this because your doctor (presumably one who knows his head from a hole in the ground (granted they're rare)) says I can't figure it out and it will do no harm- then I'm fine with that. But replacing actual care with fantasy for placebo like outcomes or worse is not ground on which I would care to tread, and more importantly would not let my mom, family, friends, or patients tread.

who says people from the south (like georgia) aren't open-minded and willing to learn about something before commenting and making blanket statements regarding a whole race, oops, i mean profession. no me!! i would never say that. and i love that today, we don't practice medicine that isn't 100% proven. well, at the literature behind interventional spine injections is concrete.

 

[Tenesma]

lobel -- before you bash other healthcare fields that are based on no science, why don't you review the science that we have been using to practice pain...

my favorite pain practice is the concept that performing a nerve block breaks the "cycle of pain"... whoever came up with that was a revenue genius but not a scientist...

 

[dc2md]

...the Sciatic is purely motor to the posterior aspect of the thigh, and pain is perceived parietally. Food for thought.

wait, what? the sciatic nerve isn't purely motor at all. right? but yeah, i take it as those ascending and descending 1st order neurons in the tract of Lissauer either know where to go to join up with the true L5 neuron (maybe they hook back up in the VPL??), OR, that's the reason for the vague dermatomal distribution of pain. i rarely see a patient with 100% textbook/classic dermatomal pain. it's usually like mostly L5 but with some lateral foot involvement that makes me think L4, or some plantar foot pain that makes me think S1 too. happened today actually in the fluoro suite. luckily the guy also had a 2/5 EHL weakness and 4/5 ankle dorsiflexor strength (5/5 for both on the other side). but then he had plantar foot pain too, and since MMTing of the gastrocs are so hard to find weakness, i ended up giving an S1 and L5 TF ESI on the left with good visual spread of the L5 up to the L4 foramen.

 

[Aether2000]

DC, you are far more daring than I would be and have clinical skills that exceed that of virtually everyone on this forum.

"THEN, i tasted his sample for the UDS"

I have never tasted any of my patients urine specimens, and wouldn't know what bone mets taste like. I guess chiro school can teach us things that traditional medicine cannot.

 

[dc2md]

DC, you are far more daring than I would be and have clinical skills that exceed that of virtually everyone on this forum.

"THEN, i tasted his sample for the UDS"

I have never tasted any of my patients urine specimens, and wouldn't know what bone mets taste like. I guess chiro school can teach us things that traditional medicine cannot.

hahaha. surely you know i'm joking. no tasting urine or stools specimens for me.

 

[lobelsteve]

lobel -- before you bash other healthcare fields that are based on no science, why don't you review the science that we have been using to practice pain...

my favorite pain practice is the concept that performing a nerve block breaks the "cycle of pain"... whoever came up with that was a revenue genius but not a scientist...

Putting a potent anti-inflammatory (Celestone) on an impinged nerve root to relieve radicular pain seems like a well grounded, reasonable, and clearly explainable TEMPORARY solution for a 90% TEMPORARY problem. I can fully explain the pathology, symptoms, physiology, anatomy, and usual response to a fluoroscopically guided contrast enhanced transforaminal steroid injection.

I cannot explain how a "subluxation", both palpable and visible only to the "trained" DC can improve their asthma. Neither can Rubin/Farber/Netter/Guyton/Burn it and Leave It.

Granted: Pain is a completely subjective entity and I applaud any attempt to ameliorate it. As long as it is reasonable and is grounded in basic science.

 

[SSdoc33]

DC, you are far more daring than I would be and have clinical skills that exceed that of virtually everyone on this forum.

"THEN, i tasted his sample for the UDS"

I have never tasted any of my patients urine specimens, and wouldn't know what bone mets taste like. I guess chiro school can teach us things that traditional medicine cannot.

hey, "piss prophets" used to be able to diagnose diaseases like diabetes by tasting urine. it would taste sweet. then again, that was the 16th century.......

 

[Aether2000]

Hmmmm...interesting...I wonder if one must be CLIA certified to be able to taste urine in an office setting....
We need to query our pathology friends on that one...

 

[PTnotMD]

Analgesic,

Why would I alter the perception of pain?

I have always operated under the following premise (from the Univeristy of St. Augustine's philospohy of dysfunction):

That PTs treat dysfunctions, not diseases.
That dysfunction is manifested as increases or decreases in normal movement.
That since dysfunctions cause pain, the goal of the PT is to correct the dysfunction, not the pain (unless pain interferes with the treatment of the dysfucntion).

Also, from the APTA website:
APTA Mission Statement

The mission of the American Physical Therapy Association (APTA), the principal membership organization representing and promoting the profession of physical therapy, is to further the profession's role in the prevention, diagnosis, and treatment of movement dysfunctions and the enhancement of the physical health and functional abilities of members of the public.

No where is pain mentioned in the mission statement, nor has it been for decades.

This is a failing that many in the medical profession seem to further. PT is about function, not pain. If all function is normalized, then pain will improve.

Now, as far as the mechanisms that PTs use to help ameliorate pain, which are you interested in? Is this worthy of a different thread?

 

[Tenesma]

analgesic: sciatic is purely motor to the posterior thigh... (?)

what the? did i read the wrong books?

 

[dc2md]

I cannot explain how a "subluxation", both palpable and visible only to the "trained" DC can improve their asthma. Neither can Rubin/Farber/Netter/Guyton/Burn it and Leave It.

hahaha. steve, why do you keep arguing against a part of chiropractic that NO ONE on this forum is trying to argue for?? stop and reread the thread if you need to. we're not the fundamental chiros you're used to dealing with in Georgia.
while you're at it, show me the PROOF behind the trigger point injections we do all the time. my patients get relief though so i'll keep doing it despite lack of great randomized, controlled, double-blinded studies.