Posts in MRI
Resolution of Lumbar Disk Herniation Without Surgery

Physical Therapy remains the first line treatment for lumbar disk injuries due to its' non invasive nature and clinical effectiveness.  The natural history of disk injuries is not well established but preliminary data covered in prior blog posts demonstrates regression of these injuries over time.  A recent case study in the New England Journal of Medicine (Hong et al. 2016) described the case of a 29 year old female with pain and pins and needles into her leg.  Her MRI is shown above on the left side of the screen.  The patient did not want surgery and was instead treated with an injection and Physical Therapy.  After 5 months a second MRI was taken, shown on the right, showing resolution of the disk injury. 

This case adds evidence to the regression and resolution of disk injuries over time with conservative care.  Patients are advised to seek care from a local Physical Therapist before attempting more invasive and costly procedures.

Mental Health and Its' Impact on Shoulder Function

 "We are what we think. All that we are arises with our thoughts. With our thoughts, we make the world."  - Buddha.

Mental health has a significant impact on recovery from many musculoskeletal diagnoses including low back pain, neck pain, and shoulder pain.  Our thoughts and perceptions about our bodies and their ability to recover from injury and illness strongly influence our course for recovery and healing.  In prior posts we have described the limitations of imaging such as MRI and CT for musculoskeletal diagnoses.  In particular, we can find the same pathology (disc herniation or rotator cuff tears) in people with and without symptoms.  Thus, imaging does not correlate strongly with how patients function and what symptoms they experience due to these imaging findings.  

A recent study in the Journal of Bone and Joint Surgery highlights both the limitations of imaging findings and the importance of mental health on patient function (Wylie et al. 2016).  The authors recruited close to 200 patients with complete rotator cuff tears to determine which clinical and diagnostic factors correlated best with the patients' symptoms of shoulder pain and function.  Interestingly, a patient's mental health had the strongest association with the patient's reporting of pain and shoulder function.  This association was stronger than the correlation between the severity of the shoulder injury on MRI and their reporting of pain and function.  

This study adds evidence to support the assessment of mental health variables in individuals suffering from musculoskeletal pain and may help us understand which patients can or cannot function well given a positive imaging finding.  In our experience, patients with a positive outlook on their recovery have the most optimal outcomes with Physical Therapy.

Physical Therapy or Surgery for Rotator Cuff Tears

Despite having no symptoms, many of us will develop age-related changes in the musculoskeletal structures of our bodies, similar to the aging effects on our skin. These findings are most prevalent on highly sensitive imaging techniques such as MRI and often lead to unnecessary and costly medical procedures. Our shoulders are also prone to development of age related changes including rotor cuff muscle tears which may or may not be symptomatic or interfere with our functional and recreational activities. In particular, rotator cuff tears are age dependent and the prevalence of both symptomatic and asymptomatic tears increases with increased age (Sher et al. 1995). For example, 1 in 3 adults over the age of 60 will have a rotator cuff tear on MRI (Fehringer et al. 2008). A Key question to ask when these changes are found would be, "what treatment, Physical Therapy or surgery, is most effective for my symptoms?"

A recent article asked the question, "Which is the most effective treatment for non traumatic rotator cuff tears?" Kukkonen and colleagues released their findings in this month's Journal of Bone and Joint Surgery (2015). They studied 167 shoulders (full thickness supraspinatus tears) in 160 patients and randomized these patients to one of three groups. 1. Physical Therapy 2. Physical Therapy plus bone spur removal and 3. Physical Therapy, bone spur removal and rotator cuff repair. All of the patients who entered the study had functional range of motion in their shoulders before being randomized. Patients were followed for up to 2 years which provided excellent data on symptoms, function, and patient satisfaction. The authors found no significant differences between groups on patient satisfaction, symptoms, and function at the 2 year follow up.    

rotator cuff tear physical therapy versus surgery
boulder physical therapy shoulder surgery versus physical therapy

Given the long term evidence, individuals with non-traumatic tears should strongly consider a 8-12 week course of Physical Therapy prior to any surgical intervention. Failure of conservative treatments including Physical Therapy, unrelenting night pain, and progressive loss of function warrants surgical consultation. To learn more about the effectiveness of conservative treatments for rotator cuff disease contact your local Physical Therapy experts at Mend.    

Does diagnostic imaging improve outcomes?

Our imaging technologies have made tremendous improvements in their ability to detect abnormalities in our body.  These positive findings may or may not be related to our current symptoms including stiffness, giving way, or pain.  We have seen improvements in the sensitivity of these tests where we are able to detect individuals with the condition of interest such as a lumbar disk injury, but with increased sensitivity comes limitations.  In particular, these tests can often lack specificity leading to false positive results.  In our prior posts on low back pain we have described the large portions of the population who will have a (+) MRI scan for injury or pathology but have no symptoms, but this is often the case in other body parts as well including the neck, shoulder, hip and knee.  Given the high cost of diagnostic imaging, false positive rates and association with higher risks including unnecessary surgery it is important to ask how important these tests impact patient outcomes. 

A recent review of the available literature of routine imaging on musculoskeletal disorders was published in the European Journal of Internal Medicine (Karel et al. 2015).  The authors examined 11 studies on patients with low back and knee pain and found moderate evidence of no benefit of diagnostic imaging on all outcomes compared to individuals who did not receive an image.  The authors concluded "these results strengthen the available evidence that routine referral for diagnostic imaging by general practitioners for patients with knee and low back pain yields little to no benefit".  Wise health care consumers should empower themselves with this information and avoid imaging when faced with acute episodes of low back or knee pain.  Patient should instead find a knowledgeable, caring local Physical Therapist to assess their symptoms and determine an appropriate treatment plan. 

boulder physical therapy louisville physical therapy
Return to Sport and Back Surgery

We have previously written on low back pain and the dramatic rise in surgeries with this patient population, despite evidence of superior outcomes over conservative treatment and Physical Therapy.  Prior research has documented the dramatic rise in the number of lumbar MRI imaging for the low back and a corresponding increase in the number of lumbar surgeries (figure 1 below).  One of the main predictors of spinal surgery over age or degree of injury in the spine remains how many MRI machines are in your area.  These images are highly sensitive and find even the smallest pathology, but often lack the specificity (high false positives) to correctly diagnosis every patient without an appropriate clinical examination.  The high false positives, finding pathology in asymptomatic people, is noted on the 2nd figure below in a study of 3,000 people.  As we age there is a higher probability of finding pathology making a negative image less likely past age 30.   Interestingly, many of these severe injuries on our spine heal and improve if given time (3rd figure). 

louisville physical therapy, low back pain
boulder physical therapy, low back pain, MRI results
low back pain, MRI, healing, louisville physical therapy

Tiger Woods has experienced a difficult recent history of injury with missed tournaments due to injuries including back pain.  He recently underwent a discectomy to remove disc material from his spine, but has yet to return to prior levels of play.  His upcoming return highlights a key question, what is the likelihood an athlete return to the same level of play following a lumbar surgery.  A recent review article in the British Journal of Sports Medicine reviewed the recent literature to answer this question (Reiman et al. 2015).  The authors reviewed 14 articles on the return to sport rate after either conservative (including physical therapy) or surgical treatment for lumbar disc herniations.   The authors reported no difference in the return to sport rate between surgical and conservative treatments.  Only 59% of the athletes undergoing surgery return to the same level of play after this procedure.   

This study highlights the limitations of focusing on only pathology/MRI scan in the treatments of patients with low back pain and injury.  Given the equivalent outcomes between Physical Therapy and surgery patients should consider conservative treatments prior to surgical interventions for disc injury.  

How Important is Imaging for Tendon Pain and Injury?

Our prior posts on tendon injuries have described the structural changes that take place with chronic symptomatic tendinopathies.  The disorganization of tendon fibers and the body's attempts to heal the injured tendon are best viewed on ultrasound or MRI imaging.  MRI is a very sensitive tool, but lacks specificity meaning a positive finding may or may not be contributing to a patient's presentation and symptoms.  Further, we often see positive findings in asymptomatic individuals.  Rio et al. described the presence of positive findings (tendinosis) in asymptomatic and active individuals and also the lack of impact of some findings on a patient's presentation (Sports Med. 2014).  The MRI and ultrasound images document both normal and abnormal imaging findings.  Images courtesy of Docking et al. JOSPT. 2015.

achilles tendon, ultrasound, boulder physical therapy
abnormal achilles tendon, MRI, boulder physical therapy

In the pictures above, we can observe healthy tendon alignment primarily in parallel to resist and absorb tensile forces across the ankle joint, as well as, a high water and protein content reducing friction through the tendon.  Conversely, a tendon with features of tendinosis demonstrates a disorganized tendon structure where tendon cells (tenocytes) are in higher numbers and have a more rounded appearance.  This appearance makes the tendon less resisted to traditional tensile forces since the tendon is not arranged in a parallel alignment.  Finally, there is an ingrowth of nerve fibers and blood vessels which likely contribute to the increased pain and symptoms noted in the achilles as well as in other structures within the body (central sensitization).  If a tendinosis progresses in nature, partial tears in the tendon can also be noted on MRI.  The accuracy of these changes on MRI explaining a patient's symptoms is described as diagnostic utility.  

MRI and ultrasounds greatest limitation on accuracy may be the lack of agreed upon gold standard in the literature.  In a review of the literature Docking et al. reports the specificity for diagnosis with MRI (.68-.70) and ultrasound (.63-.83) for tendinopathies.  Up to 59% of asymptomatic individuals will document some change within the tendon on imaging.  These numbers show a degree of false positives making the clinical examination an essential part of any clinical diagnosis.   This is consistent with the majority of musculoskeletal problems.  If we rely solely on the MRI findings we run the risk of being incorrect in both our diagnosis and treatment.  This will lead to higher healthcare costs and a longer duration of care for the patient.

In short, imaging can be a helpful component of our clinical diagnosis but only if we can use our subjective and objective examination to distinguish between asymptomatic tendinosis or symptomatic tendinopathy.  In addition, an image rarely is helpful in determining how to use manual therapy and exercise to appropriately treat the patient.