Does advanced imaging guide therapy

[clubdeac]

I’m a PMR/spine specialist and was curious if MRIs help you all when treating chronic neck and/ or low back pain? If so can you give specific examples of how it would guide your treatment plan in both the neck and low back.

Appreciate all that you do

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[Smash Atoms]

Randomly hopped on here late.

By and large - no.
There’s a long answer on this, get back soonish.

 

[SuckyGolfer]

I’m a PMR/spine specialist and was curious if MRIs help you all when treating chronic neck and/ or low back pain? If so can you give specific examples of how it would guide your treatment plan in both the neck and low back.

Appreciate all that you do

Hola,

I'm a PT in the acute setting with 15 years experience. In the setting I work in, imaging does influence care in terms of precautions or as a means to rule things out. Examples is a compression fracture where we teach no BLT and ruling out fractures. In the OP setting, it's been about 10 years since I've done it, but generally imaging would not help much. We're used to not having the reports and therefore doing evaluations and treatments without the results or tests. You can look up clinical practice guidelines on orthopt.org for chronic neck or LBP and notice not much of any reliance on imaging. I think there's actually discouragement of talking to a patient regarding specific findings on imaging (that do not create a precaution) so as not to scare them into being fearful or avoidant of moving/exercising, etc.

 

[clubdeac]

That was my general thought but wanted to double check with the experts

 

[Smash Atoms]

Alllright!

Back again.

A little more color (I am an outpatient ortho PT with some growing alphabet soup), but essentially in absence of an acute injury warranting further workup (possible surgical intervention, fracture, etc) imaging really isnt very helpful for anything we do. There is a growing body of evidence that what we see on imaging has little to no correlation to pain in sub acute and chronic populations and actually creates barriers to improvement as patients tend to perseverate on what was seen on imaging, or what some other provider (usually their physician or PA) has told them about their imaging.

OA, atraumatic meniscal tears, atraumatic RTC tears, non specific/mechanical LBP or neck pain, etc... I can't think of any of these where imaging helped to guide a decision or provided anything other than a problem. I actually urge patients against imaging in a lot of instances unless I think there is need to get ortho, neuro, or another provider involved.
Then we get into the whole tire fire that is steroids and NSAIDS... :/

But yes, in an acute/traumatic injury imaging can be helpful depending on situation and severity/mechanism of injury.

 

[clubdeac]

Alllright!

Back again.

A little more color (I am an outpatient ortho PT with some growing alphabet soup), but essentially in absence of an acute injury warranting further workup (possible surgical intervention, fracture, etc) imaging really isnt very helpful for anything we do. There is a growing body of evidence that what we see on imaging has little to no correlation to pain in sub acute and chronic populations and actually creates barriers to improvement as patients tend to perseverate on what was seen on imaging, or what some other provider (usually their physician or PA) has told them about their imaging.

OA, atraumatic meniscal tears, atraumatic RTC tears, non specific/mechanical LBP or neck pain, etc... I can't think of any of these where imaging helped to guide a decision or provided anything other than a problem. I actually urge patients against imaging in a lot of instances unless I think there is need to get ortho, neuro, or another provider involved.
Then we get into the whole tire fire that is steroids and NSAIDS... :/

But yes, in an acute/traumatic injury imaging can be helpful depending on situation and severity/mechanism of injury.

Good to know. What are your thoughts on imaging on a weight lifter who injured his neck while lifting 2 years ago and has had chronic neck and trap pain since? Normal neuro exam and no myelopathic or radicular symptoms. Guessing imaging still unnecessary. Also what’s the tire fire with steroids and NSAIDs. Are you talking about the potential or theoretical inhibitory effects on healing?

 

[SuckyGolfer]

Maybe imaging indicated? That's a traumatic MOI and perhaps myotome weakness and dermatome symptoms C3/4. The shoulder shrug is innervated by CN 11, C3 and C4 and the UT is so strong that I wonder if it's imperceptibly weak.

 

[Smash Atoms]

Good to know. What are your thoughts on imaging on a weight lifter who injured his neck while lifting 2 years ago and has had chronic neck and trap pain since? Normal neuro exam and no myelopathic or radicular symptoms. Guessing imaging still unnecessary. Also what’s the tire fire with steroids and NSAIDs. Are you talking about the potential or theoretical inhibitory effects on healing?

Unless there is some sort of weakness pointing to a fully ruptured muscle, or some sort of progressive myotomal weakness, then nah... What would it show? Also this is a small snap shot of a much larger picture.
(Assuming imaging is looking for a bulging disc or the like, Nakashima 2015 is worth a glance and is just one of a library on imaging and absent correlates to pain specific to cervical spine, Baretto 2019 for shoulder, etc etc etc)

A few things I would want to consider:
What have other providers told this patient to create kinesiophobia, catastrophizing, and maladaptive pain beliefs? (Darlow 2012, Gardner 2017, etc)
What does sleep look like?
Anxiety?
Depression?
Diet?
Pain beliefs?
Daily activity levels? Aggravating and easing factors? Irritability? Severity?
With trap pain is it R or L and is there any possibility of referral from a systemic/visceral issue?

And if its trap pain, where? I dont know if I have ever seen true trap pain, with neck issues I would generally assume thats our primary culprit causing some referrals.
Also consider healing timelines - a muscle is generally going to heal up pretty quick as they are highly vascular, 2 years in what would I expect imaging to show? Maybe looking for calcific tendonitis?

With the neck itself what will I find looking at lateralization, pain pressure threshold algometry, 2 point discimination, etc... Is there any pain anywhere else? Is this just an issue of central sensitization? Or peripheral neuropathic pain involved? Unlikely nociceptive at this point.
What there failure with conservative treatment (PT)? If so did the PT understand managing chronic pain or did they just load the hell out of peripheral tissues hoping for the best?

NSAIDS - yeah, generally the growing data pool supporting both inhibitory effects on long term outcomes and potential increased risk of transitioning from acute to subacute and chronic.


Steroids.. Oh boy. Thats a long one. Same as above, but more than that its capacity to degrade tendons and ligaments just isnt worth it. I cant rattle the studies off the top of the dome like the ones above, but its pretty clear that we have a total, not relative, risk increase of 9.7% increased likelihood of a TKA with every steroid injection to the knee, increased chances of full thickness traumatic RTC tears with each injection, etc etc etc... 0 effect on non specific or mechanical low back pain (in absence of clear dermatomal pain indicating what is likely a herniated disc they arent well evidenced to do anything more than placebo ((But hey, placebo 100% has an effect))), similar with neck pain. Only sort of evidenced reason to stick them in the shoulder is early stage adhesive capsulitis alongside lidocaine, but thats still dubious.


If its a last resort, its a last resort, but other options should have been exhausted first.

 

[Smash Atoms]

I generally tell patients that with regards to imaging the data doesn't really support that what we saw on imaging as a cause of pain in non acute instances.
That doesn't give me the answer, but I think we need to be asking questions. Pathoanatomic diagnosis are not very helpful, and particularly in chronic pain populations give them something to perseverate on, most frequently because another provider was careless with verbiage in their communications.
"Bone on bone" "Horrific arthritis" (Ie normal age related changes - australia had a huge piece on this last year with knee OA)
"Degenerative Disc Disease" (Ie normal age related changes) - again, data doesnt support that this causes pain. Too many folks with it that are pain free... Just like "bulging disc", and on and on and on and on... A not so fun thought experiment is to imagine you are an advertiser trying to evoke an emotion in someone, then google those words above and see what kinds of images you get and think about the psychology behind it.