Imaging and Shoulder Pain: Why we don't treat MRIs....

How many of us have heard patients tell us they'll be relieved if they could just get an MRI to "tell them what's wrong."? I'll be the first to admit I too jumped on this bandwagon early in my career. I was very eager to see an individuals MRI report to correlate their clinical symptoms. You've heard me quote a wise old PT friend of mine who said "We don't treat MRIs". Well RV, this one goes out to you. ;)

This fascination with "seeing" what's wrong has lost a bit of its luster as I've read some very interesting reports on the lack of agreement between MR and clinical presentations. We've seen this phenomenon in low back and shoulder pain where imaging studies don't necessarily correlate with the patients clinical presentation.

It'd been a while since I've seen a good study on this topic so I figured I'd look up what the American Journal of Roentgenology had to say on the issue. The article takes a whopping 1079 consecutive patients referred for shoulder MRI. The subjects were asked to complete validated shoulder questionnaires regarding pain and disability. These were correlated with the radiologists' MR findings.

What did the authors conclude?

• MRI is highly accurate at detecting the presence of a partial or full-thickness rotator cuff lesion.



• There was no relationship between pain or disability with the size or location of the rotator cuff tear.



• Rotator cuff lesions may be thought of as a natural correlate of aging



• It is not clearly identified why some rotator cuff lesions are symptomatic while others are "silent"



• Factors such as bursitis, capsuloligamentous lesions, or cartilage lesions may confound the findings of MRI as they pertain to the rotator cuff



• There may be "no relationship between rotator cuff tear size and the inflammatory reaction responsible for the pain and disability, like low back pain is unrelated to the size of disc herniations."

What are the author's recommendations?

• "Despite the absence of correlation between the size of the rotator cuff tears and the level of disability,MRI provides important data that may affect the management of rotator cuff lesions and should be performed before rehabilitation or surgery."

Really AJR? Let me make sure I understand. There is little to no correlation between imaging and symptoms, yet folks should go ahead and get the MRI anyway? Even before rehab? That's a hard one to swallow. In his defense of the study's author, the investigation took place in France within a socialized health care system where utilization would doubtless be far different from ours.

Regardless of the author's curious conclusion, the study is an honest representation of how limited the value of MRI can be for common musculoskeletal complaints. It also underscores the importance for physical therapists not to get too caught up in hounding the referring physician for the MRI report.

Treat the patient, not the report!

Krief, O.P. (2006). Shoulder Pain and Disability: Comparison with MR Findings. American Journal of Roentgenology, 186(5), 1234-1239. DOI: 10.2214/AJR.04.1766

Adverse Events of Chiropractic Care: Transparency Now!

So I've been binging on literature lately....One of my first courses at Texas Tech's doctoral program is Advanced Clinical Practice for the Cervicothoracic Junction and Thoracic Outlet. Let me be the first to say I had no idea this part of the body would be quite so involved and interesting at the same time.

Our weekly assignments involve reading research ranging from randomized clinical trials to anatomical reviews. After only one week in this program, I've already picked up some good information I can use in the clinic.

Today's article came from reading some anatomical studies on the vertebral artery. In reading more about the anatomy of this area, my mind wandered to the topic of potential risks for cervical manipulation. The most dramatic adverse events seem to focus on dire occurrances such as stroke. However, we've all seen folks come to our clinics saying they had a range of responses to chiropractic care ranging from pain and stiffness to a worsening of radicular symtoms.

I wondered in particular if the chiropractic profession was any more transparent with reporting adverse events pertaining to cervical manipulation. We've all heard the chiros tell us a manipulation has fewer complications associated with it than taking an NSAID, but we've heard this boy cry wolf before and a little hard data would be nice.

Sure enough, a trial spawned out of the UCLA Neck Pain study attempts to help us learn more. In a randomized clinical trial, a total of 336 patients with neck pain were randomized into three groups of chiropractic care:

• Manipulation with or without heat
• Manipulation with or without electrical stimulation
• Mobilization with or without heat or electrical stimulation

The adverse event in this trial was "discomfort or unpleasant reactions from chiropractic care" assessed at 2 weeks from the baseline assessment. Of the 280 patients who responded, 85 patients (~30%) reported having one or more adverse symptoms as a result of chiropractic care. A total of 212 adverse reactions were reported from the 85 patients who had complications. Of the 212 adverse reactions there were:

• 70 episodes of moderate to severe neck pain or stiffness
• 44 episodes of moderate to severe headaches
• 28 episodes of tiredness or fatigue

Other less common adverse events included dizziness, nausea, depression, tinnitus, arm or leg weakness, blurred vision, confusion or disorientation. Nearly 20 percent of the respondents reported the adverse events had a significant impact on their tolerance for ADL. There is plenty of good data within the results and discussion section to read over so I would encourage you to take a look through it.

The authors, one of whom is a chiropractor, concluded the following:

• Adverse events from chiropractic manipulation are common
• Adverse events are more likely to follow manipulation vs. mobilization
• Chiropractors should consider mobilization over manipulation in the treatment of neck pain, particularly for those with severe pain.

I have bad news for the chiropractic profession... If you take the judicious application of manipulation based on a medical vs holistic model, you get what many well-trained manual physical therapists provide on a daily basis. This study does not bode well for a chiropractic profession that is very slow to let go of its roots in subluxation.

I don't take this study as an indictment of the chiropractic profession, as there are some very skilled manual practitioners out there. However, they dug their own hole in the form of subluxation-based care and are going to have to work hard to dig themselves out. It will be interesting to see if they can do it before the clock runs out on their profession....and believe me it is ticking. Chiropractic tuitions have never been higher and their revenues have never been lower...tick tock...tick tock....!

Hurwitz, E., Morgenstern, H., Vassilaki, M., Chiang, . (2005). Frequency and Clinical Predictors of Adverse Reactions to Chiropractic Care in the UCLA Neck Pain Study. Spine, 30(13), 1477-1484.

Tough Love: Eccentric exercise for lateral elbow pain

Some issues in physical therapy just seem counterintuitive upon first glance. An emerging treatment method used in the management of tendonopathy is eccentric training. While eccentric training has obviously been around for years, researchers are beginning to see its utility in managing chronic tendon disease.

Adding mechanical stress to a tissue that is already mechanically stressed didn't match my intuition early in my career. Fortunately for many of my patients, I still had a lot to learn. We are now learning that many cases of chronic tendonopathy bear little resemblance to the inflammatory process of tendonitis. In fact, some histochemical studies of chronic tendonopathies have revealed no evidence of inflammatory tissue.

With a more sophisticated understanding of the pathophysiology of tendon disease, researchers have begun to explore treatment options that fall out of the typical inflammation-based treatment paradigms. Another (perhaps even more significant) driving force behind these investigations is that our current methods are meeting with mixed results. An emerging treatment option is the use of eccentric training in the management of chronic tendon disease.

Today's article published in the British Journal of Sports Medicine provides a framework for using exercise to manage lateral elbow pain (LEP). While not a clinical trial, the article provides a solid framework for utilizing supervised eccentric training coupled with static stretching to treat recalcitrant LEP. The authors acknowledge that more work needs to be done in this are to determine the optimal mechanical load for the lateral elbow that would elicit positive adaptations without exceeding the tissue tolerance of the musculotendinous complex.

Although I wasn't bowled over by the caliber of this report, I think it does indicate that we are moving into a more sophisticated and precise way of handing tendonopathy. The use of eccentric training reflects a deeper understanding of the pathophysiology of chronic tendon disorders. Upon first glance, it certainly doesn't fit the paradigm of a how we traditionally handled these types of problems. Good thing we are giving these issues a second glance.

Stasinopoulos, D. (2005). An exercise programme for the management of lateral elbow tendinopathy. British Journal of Sports Medicine, 39(12), 944-947. DOI: 10.1136/bjsm.2005.019836