MRI and ESI

[PMR 4 MSK]

Advertisement - Members don't see this ad

Maybe you guys can start a different thread on chiro vs MD.

This one's been hijacked.

 

[dc2md]

Maybe you guys can start a different thread on chiro vs MD.

This one's been hijacked.

yeah sorry pmr 4 msk. :-(

back to the original question. i'd be comfortable with an MRI 2-3 years old unless the pain has changed a lot recently and the old one was pretty benign (just some bulges and hypertrophic changes). i don't really worry about it though with facets/MBB (lumbar).

 

[lobelsteve]

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.

I don't do trigger points, they do not work (well maybe a few hours of relief). And I tell my patients so. And I tell them if anyone wants to inject steroids or Sarapin, or anything else into the "trigger point", that they are an idiot, misinformed, or both.

 

[analgesic]

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

what the? did i read the wrong books?

Tenesma,

The Sciatic originates from roots L4-S3 and is purely motor to the posterior thigh. The posterior femoral cutaneous originates originates from S1-3 and is responsible for cutaneous information to the posterior thigh.

This is not to say that the sciatic does not carry sensory information. It does but not to the posterior aspect of the thigh where alot of individuals complain of radicular sensation. Any sensory information relayed via the sciatic will have to be relayed below the knee in either the tibial or peroneal divisions of the nerve. I hope I didn't confuse you with the way I worded my previous post.😕

 

[paindefender]

Maybe you guys can start a different thread on chiro vs MD.

This one's been hijacked.

Let it be the first thread in the chiro forum. Analgesic and dc2md can be moderators.

 

[analgesic]

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?

PTnotMD,

You don't have to alter the perception of pain to treat the dysfunction unless it interferes with your ability to perform rehab. However, as a scientist you should have some kind or rationale as to why a individual under your care may be experiencing less pain than the previous day after one to two sessions. Remember skeletal muscle replication takes at least 7-14 days and alot of patients are already beginning to experience less pain before their muscle protein is fully replicated.

As a pain specialist I find this extremely interesting and can not explain such a phenomenon based on the fact that physical therapy has restored their function. Steve on the other hand is not a PT, Phd but a PMR trained pain specialist who commonly refers to PT's because there is more "science" to support it. I can't say for certain that he is like a lot of other physiatrists who just write evaluate and treat but I will say that he should be able to explain this if you can't for he is liable for the treatments and exercises you perform regarding his specialty. As a pain specialist what does he care if they went from a 4/5 to a 5/5 with increased ROM but have the exact same type and degree of pain which renders no change in their overall quality of life despite this enchanced degree of function?

The question was never directed toward you but to him. I am quite surprised that neither one of you can enlighten us.

 

[lobelsteve]

PTnotMD,

You don't have to alter the perception of pain to treat the dysfunction unless it interferes with your ability to perform rehab. However, as a scientist you should have some kind or rationale as to why a individual under your care may be experiencing less pain than the previous day after one to two sessions. Remember skeletal muscle replication takes at least 7-14 days and alot of patients are already beginning to experience less pain before their muscle protein is fully replicated.

As a pain specialist I find this extremely interesting and can not explain such a phenomenon based on the fact that physical therapy has restored their function. Steve on the other hand is not a PT, Phd but a PMR trained pain specialist who commonly refers to PT's because there is more "science" to support it. I can't say for certain that he is like a lot of other physiatrists who just write evaluate and treat but I will say that he should be able to explain this if you can't for he is liable for the treatments and exercises you perform regarding his specialty. As a pain specialist what does he care if they went from a 4/5 to a 5/5 with increased ROM but have the exact same type and degree of pain which renders no change in their overall quality of life despite this enchanced degree of function?

The question was never directed toward you but to him. I am quite surprised that neither one of you can enlighten us.

Better summed up here: Manipulation is the skilled passive movement of a joint and may be used by a physical therapist, osteopath, or chiropractor. The differences occur between the disciplines in the selection of other treatment that can be offered, the specific techniques used, the theory behind what manipulation accomplishes, and when manipulation is contraindicated. A physical therapist will evaluate to determine how the body moves. Limitation of movement secondary to pain and/or stiffness vs. hypermobility is assessed. A variety of techniques including modalities such as heat and ice, exercise-(isometric, isotonic, isokinetic, open chain, closed chain, core-stabilization, plyometrics, or stretching), and mobilization/manipulation may be selected in a treatment. The strategy is to mobilize tissues that are tight or restricted and stabilize, deferring manipulation, those that have too much segmental mobility. Thereafter it is education of the patient to maintain the new found results and minimize recurrence of symptoms. Again physical therapy treatments are goal directed and the goals are established to be met within a time frame. The goals are determined in a consultation between the therapist and the patient. Physical therapists work closely with neurologists, orthopedists, or any other physician if there is suspicion of pathology or dysfunction that is not musculo-skeletal related or when symptoms do not respond to treatment.

To put it less delicately, PT's treat symptoms through manipulation, modalities, and education. They do so under my orders and supervision. Chirporactors act outisde of the systems based practice. The last honest, realistic, and ethical DC I've met was when was I was playing HS football and he was also an ATC.

Look Anal, you spout a lot of fast-talking gobblety gook nonsense in your posts and it sound slike you are typing like a DC- so pull your head out of your ass and start thinking like a doctor- a real doctor. I won't be able to see your responses because I hit the ignore button. I think you are misguided in your approach to the point where you impress me as somebody who could be dangerous in a clinical setting. You just don't get it.

 

[dc2md]

i got $50 on steve. haven't met him yet, but i see him as a scrappy dude. who wants some action?? just kidding guys. steve you gotta understand though that people get really defensive when their beliefs are attacked. this is kind of like listening to a far left and far right debate, or a fundamentalist christian and an atheist go head-to-head. neither one is EVER gonna change the others mind because they're both 100% set in their ways/beliefs...it's futile.

but just one more time, SOME chiropractors act outside the systems based practice...not all.

so are we gonna get to see a caged match or open pit?? ;-)

 

[Tenesma]

maybe my definition of sciatic is different from yours ---

sciatic nerve to me is in fact the union of the peroneal and the tibial nerve...

 

[analgesic]

maybe my definition of sciatic is different from yours ---

sciatic nerve to me is in fact the union of the peroneal and the tibial nerve...

Agreed,

But what nerves supply what regions and how do you explain the radicular sensation down the posterior thigh as being related to the sciatic nerve?

 

[analgesic]

Better summed up here: Manipulation is the skilled passive movement of a joint and may be used by a physical therapist, osteopath, or chiropractor. The differences occur between the disciplines in the selection of other treatment that can be offered, the specific techniques used, the theory behind what manipulation accomplishes, and when manipulation is contraindicated. A physical therapist will evaluate to determine how the body moves. Limitation of movement secondary to pain and/or stiffness vs. hypermobility is assessed. A variety of techniques including modalities such as heat and ice, exercise-(isometric, isotonic, isokinetic, open chain, closed chain, core-stabilization, plyometrics, or stretching), and mobilization/manipulation may be selected in a treatment. The strategy is to mobilize tissues that are tight or restricted and stabilize, deferring manipulation, those that have too much segmental mobility. Thereafter it is education of the patient to maintain the new found results and minimize recurrence of symptoms. Again physical therapy treatments are goal directed and the goals are established to be met within a time frame. The goals are determined in a consultation between the therapist and the patient. Physical therapists work closely with neurologists, orthopedists, or any other physician if there is suspicion of pathology or dysfunction that is not musculo-skeletal related or when symptoms do not respond to treatment.

To put it less delicately, PT's treat symptoms through manipulation, modalities, and education. They do so under my orders and supervision. Chirporactors act outisde of the systems based practice. The last honest, realistic, and ethical DC I've met was when was I was playing HS football and he was also an ATC.

Look Anal, you spout a lot of fast-talking gobblety gook nonsense in your posts and it sound slike you are typing like a DC- so pull your head out of your ass and start thinking like a doctor- a real doctor. I won't be able to see your responses because I hit the ignore button. I think you are misguided in your approach to the point where you impress me as somebody who could be dangerous in a clinical setting. You just don't get it.

Steve,

Do you kiss your MOM with that mouth? That was pretty rude but I can tell that you are probably just frustrated due to the fact that you have to rely on others to answer your questions for you. You make way too many strong statements with no concrete explanations in what you call science. I agree that there are alot of quack chiropractors but you talk way too much out of your wawa. Granted, you have probably been exposed to most of the profession that drove me to medical school. Stop talking about chiropractic and start thinking about manual medicine. Whether it is a DO, PT, or DC. While you think you understand pain, don't allow yourself to be so narrow minded that you fail to explore other avenues that may potentially enhance your clinical outcomes. That is a disservice to your patient.

I will answer the question for you. The same joint fibers PT's activate to evoke change centrally (ie Abeta, Aalpha large diameter afferents) are the exact same ones we do when we practice manual medicine. Now go study Melzack and Wall's pain gate theory and see if you can answer the question in terms of mechanism. Stop defining PT and start asking yourself how they alter pain perception and you just might gain some insight as to why practitioners like DC2MD and I feel it is so essential to be able to assess what a lack of ROM/aberrant biomechanics means neurologically with respect to the central integrated state of the pain pool.

Individuals that have to resort to profanity lack the ability to express themselves intelligently. 😡

 

[dc2md]

Agreed,

But what nerves supply what regions and how do you explain the radicular sensation down the posterior thigh as being related to the sciatic nerve?

isn't radicular pain more related to the nerve roots/DRG/mixed spinal nerve that's being impinged upon (or inflammed; or irritated)?? the sciatic nerve would only come into play if we're talking about piriformis syndrome. BUT, since wikipedia (which never lies) says that the posterior femoral cutaneous nerve has fibers from the S1-3 roots, it's likely nerve root compression isn't the reason for perceived radicular pain down the back of the thigh with S1 radic. maybe it's just the way the neurons arrange in the homunculus. 😕

 

[analgesic]

isn't radicular pain more related to the nerve roots/DRG/mixed spinal nerve that's being impinged upon (or inflammed; or irritated)?? the sciatic nerve would only come into play if we're talking about piriformis syndrome. BUT, since wikipedia (which never lies) says that the posterior femoral cutaneous nerve has fibers from the S1-3 roots, it's likely nerve root compression isn't the reason for perceived radicular pain down the back of the thigh with S1 radic. maybe it's just the way the neurons arrange in the homunculus. 😕

Your asking all the right questions but you should probably ask steve to ask his PT.

It is important to differentiate what some clinicians call Sciatica-waste basket diagnosis (radicular leg pain originating from the low back) vs. Sciatic neurits (Unlike the sciatica from a herniated disk, there is often little or no back pain while buttock pain predominates.) The pain is worse when sitting, relieved by standing or walking, and often has a spotty distribution that can involve the ankle, mid-foot, or toes depending on the distribution of nerve fiber involvement.

Piriformis syndrome is usually secondary to aberrant joint mechanics regarding the femoral acetabular joint in relation to the SI joint. Such an imbalance in the pelvis places considerable strain on the piriformis to maintain normal resting tone regarding it's primary function of shunt stabilization to counterbalance the internal rotation/flexion of the iliopsoas and rectus femoris. Like any weak muscle, this predisposes the muscle to work harder. Unfortunately, in the abscence of adequate mitochondrial stores this causes the piriformis to undergo anearobic mechanisms resulting in the production of lactic acid. As I am sure you are aware, lactic acid is a noxious chemical irritant which sensitizes type c nociceptive afferents which if fired into the DRS @ the L5/S1 level can create a sciatic referred pain perception so called "pseudo sciatica". Once again, it is the posterior femoral cutaneous not the sciatic that relays cutaneous information regarding the posterior aspect of the thigh. Furthermore, antalgic posture during ambulation adds insult to injury. Disuse of the pyriformis secondary to pain/weakness can lead to breakdown of the sarcoplasmic reticulum in skeletal muscle which causes release of calcium that can produce painful spasm in the piriformis upon deep palpation or Orthopedic testing. I am sure if you asked Steve's PT he could give just as good of an explanation. Just don't ask Steve.😱

 

[Tenesma]

1) there is a difference between sensory afferent and referred/radicular patterns of pain.

2) a-beta/a-schmeta.... nobody knows why manipulation REALLY works --- in my opinion it works because it releases endogenous endorphins... but don't act like any of you know because NOBODY knows...

 

[lobelsteve]

1) there is a difference between sensory afferent and referred/radicular patterns of pain.

2) a-beta/a-schmeta.... nobody knows why manipulation REALLY works --- in my opinion it works because it releases endogenous endorphins... but don't act like any of you know because NOBODY knows...

C'mon Anal knows. He lives in Rexed 1,2,5. Adhominim.

Maybe close the thread and Anal can email me privately to educate me on the science of PT/Chiro/Homeopathy. I have been conquered.

Back to the original topic:

MRI useful only for radicular pains that are new and different from time last MRI taken (2yrs). Good for axial pain with suspicion of malignancy, fracture, and infection. MRI bad for axial pain without red flags- it will give lots of findings of unknown or no clinical significance. THis applies for L-spine.
For C-spine, I still need imaging before poking into the epidural space. No imaging is needed for facets- my fluoro does that for me.

 

[analgesic]

1) there is a difference between sensory afferent and referred/radicular patterns of pain.

2) a-beta/a-schmeta.... nobody knows why manipulation REALLY works --- in my opinion it works because it releases endogenous endorphins... but don't act like any of you know because NOBODY knows...

1)I agree whole heartedly there is quite a difference bt dysafferentation and referred/radicular pain.

2)The best evidence we have that makes sense mechanistically would support the pain gate theory. The whole subluxation model just doesn't jive with me at all.

3)Finally I agree with Steve that I have spent way too much time in Rexed laminae I, II, V for there lies the neuroscience basis for alot of cord based pain syndromes.

It is definately time to move on to another topic. 😀

 

[dc2md]

It is definitely time to move on to another topic. 😀

YES. let's start talking about something less controversial...like politics or religion. so what's with this Jesus fella anyway?? just kidding.

 

[Mister Mxyzptlk]

I won't be able to see your responses because I hit the ignore button.

There's an ignore button? Dammit, NOW you tell me. Excuse me - time to go press some ignore buttons.

 

[Tenesma]

lobel

i have changed my mind about imaging for c-facet joints...

i have had 2 patients that presented with cervical axial pain after acceleration/decel. injuries... decided to diagnostic MBBs... neck pain got worse... got MRI... both MRIs showed TON of fluid in and next to the joints and the radiologists thought it was an abscess (in light of my having done those procedures).... both of these patients went around town bad-mouthing me to their PCPs AND to the Spine surgeons they ended up seeing...

it turned out that both had previous neck MRIs (that the patients conveniently forgot about when they saw me) in the last 2 years... i found this out when trying to calm the fears of their PCPs, and the PCPs told me that these were new findings compared to their old MRIs.

I got access to their old MRIs, and what do you know, their old MRIs showed fluid in those exact same joints (prior to me doing the procedure) - but the reading radiologists (who usually don't comment about joint fluid) did not dictate any comments about the joints...

that saved my ass... and helped with my burgeoning alopecia...

so to prevent the rigamarole of worrying about post-procedure trauma/infections to those joints, i establish a baseline with a cervical MRI in anybody who has axial pain that has lasted >6 months with poor response to conservative modalities...

this policy has helped me catch a few zebras - primarily neoplasms and two spontaneous retro-pharyngeal abscesses..

 

[mille125]

lobel

i have changed my mind about imaging for c-facet joints...

i have had 2 patients that presented with cervical axial pain after acceleration/decel. injuries... decided to diagnostic MBBs... neck pain got worse... got MRI... both MRIs showed TON of fluid in and next to the joints and the radiologists thought it was an abscess (in light of my having done those procedures).... both of these patients went around town bad-mouthing me to their PCPs AND to the Spine surgeons they ended up seeing...

it turned out that both had previous neck MRIs (that the patients conveniently forgot about when they saw me) in the last 2 years... i found this out when trying to calm the fears of their PCPs, and the PCPs told me that these were new findings compared to their old MRIs.

I got access to their old MRIs, and what do you know, their old MRIs showed fluid in those exact same joints (prior to me doing the procedure) - but the reading radiologists (who usually don't comment about joint fluid) did not dictate any comments about the joints...

that saved my ass... and helped with my burgeoning alopecia...

so to prevent the rigamarole of worrying about post-procedure trauma/infections to those joints, i establish a baseline with a cervical MRI in anybody who has axial pain that has lasted >6 months with poor response to conservative modalities...
this policy has helped me catch a few zebras - primarily neoplasms and two spontaneous retro-pharyngeal abscesses..

bravo