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‘Pain is not the only problem’: Advanced Imaging, Part 2

Diagnostic Competence is the physician’s diligence to the highest standard of professionalism; a duty to completeness and excellence in medicine with cross-culture respect.

Waite, et al. 2016, recommends four non-technological solutions to reduce interpreter error: (1) optimize their experience by offering ergonomic features, enhanced lighting, breaks/ naps, and social interaction, (2) reducing uninformative interruptions that occur during error-prone scenarios, (3) double reading benefits to accuracy and completeness, and methods to reconcile discrepancies between readers, (4) non-punitive approaches to performance improvement; self-disclosure of mistakes.

There are many important organic LBP findings that can be seen on advanced imaging. These findings may seem novel, however, I would argue strongly for their interpretation and representation in a LBP report: (1) Fatty replacement represents an infiltration of fat ‘marbling’ within the muscle belly. Fatty replacement is an excellent indicator of a muscle-use change, stronger to weaker, for example in the lumbar spinal erectors, (2) thickening of non-contractile tissues indicates an increasing reliance on ‘hard tissues’ to provide structural tension and trussing in the absence of spinal stability or muscle belly diameter, (3) flattening of muscle (~ density) indicates muscle bellies at high tension, not to be confused with (4) diametric reduction of muscles indicating weakness; underdeveloped muscle bellies even in adult patient/athletes (notable to the psoas and abdominal walls.) LBP studies should include the surrounding CORE musculature… to include the transversus, respiratory diaphragm, and pelvic floor.

Classical advanced imaging interpretation includes the usual organic LBP suspects; however, in this list I have omitted disc herniation classifications and spinal cord impingement due to lack of evidence. Instead, the list includes primarily contributors to root imbrication, instability, alignment, and inflammation: (1) thickening of the corpora-transverse ligament possibly contributing to nerve root imbrication, (2) densification of the spinal and lumbo-sacral ligaments, (3) measurements of the spinal curvatures and vertebral alignment, that are a result of and contribute to, spinal instability, (4) high signal or sail signs (etc.) indicating inflammation and swelling, (5) IVF encroachment factors (fat, bone, nerve inflammation, tumor), (6) cord pathology including tethered cord, Chiari malformation, and CES.

“Help patients understand the current evidence about the limited value of immediate imaging in cases involving nonspecific low back pain.” (Anderson, 2008)

Case study: a 22 yo RH female collegiate soccer player (wing-back defender) is complaining of non-specific low back pain when she traps the ball with her left foot, and right shin pain related to a traumatic injury since a game 3 days ago. What questions would you ask? What do you know about the demands of her position as a defender, and how it might contribute to the diagnosis?

A wing-back defender “…is one of the most physically demanding, … more often adventurous, and expected to provide width, and need to be of exceptional stamina, be able to defend against opponents’ attacks down the flanks.” (Wikipedia, wing-back defender, 60 citations, April 30th, 2019.) Consider the demand of aggressive lateral leg-work and likelihood of blunt force contact, the sudden decision making, and automatics required to steer her body athletically through the game… beginning to end. Play time goes until a foul is called or a goal is made. She is an inspired young athlete willing to deal with the demands of the sport; she didn’t choose archery. Is she pushing through pain? Does her coach allow her to push through pain? What kind of in-house therapies does she get? Are they working? What is her training & recovery experience? What is her nutrition like? Is she injured often? Is it the same injury? Is she left or right footed? Is she watching videos of her practice and game-time? None of the aforementioned points can be seen or answered using advanced imaging. It is gross negligence and unprofessional medicine to simply aim the patient toward imaging without genuinely learning about the patient and their values, and learning about their specific impeded sport or skill. What is your diagnosis?

The purpose of this imaginary case study is to exemplify the prevailing LBP patient/athlete in the clinical setting; non-specific LBP with other presenting symptoms (related or not) and an inability to perform certain skills or duties with/without pain, and with or other pain-free performance limitations (no complaint.) Therefore, a robust conversation with the patient/athlete is in order. In my office, we use soccer balls, volleyballs, tennis racquets, golf clubs, baseballs, and softballs to get a better sense of the patients functional and symptomatic mechanics. We review videos together of their performance (screen-shared on a 75” TV), or YouTube videos that I have made. Or, I meet them at a tennis court, at the track, or on a field.

Detailed attention to patient specificity has been lost in the field of medicine. It has been diluted down to a sweep of the pen, or an imaging order. Old habits are just that… ‘old’ and ‘habits.’ Maybe we need to take another look at the science, and ourselves. Isn’t it easy to agree that ‘pain is not the only problem?’

LBP Blog General information

Series Description

These articles intend to (1) re-evaluate the prevailing clinical practices thought to manage low back ‘pain’, (2) submit and debate novel low back ‘pain’ contributors and mechanisms, (3) meet patient expectations & satisfaction and clinically meaningful results, (4) recommend a conservative non-surgical course of care to over-ride ‘pain’ instantly, and (5) restore ADLs and patient confidence on the first visit at low cost. This article has a companion podcast.

Dr. Dean Bio

Forester Dean is a chiropractic and physiotherapy sports medicine doctor practicing in Los Angeles, California. Dr. Dean is a lifetime athlete, and currently teaches tennis, track, boxing, yoga. The Core X System™ Campus flagship location was opened by Dr. Dean in 2020.

© Copyright 2021 SpineSync, Forester Dean, DC
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