Triathlete Imaging- Supporting active care.

To view the original, well referenced blog post look here, from Toronto physiotherapist Laura McIntyre.

So is active care and exercise important?  (Yes, this is rhetorical.)

  • Compared to the top image… which do you like the looks of better?
  • Image 2: Sedentarism?
  • Image 3: Active lifestyle?

You will see the active triathlete with significantly more muscle mass, less fatty (adipose) tissue, and denser bones.  More muscle, less fat, & stronger bones. Sound like something you might want to be part of?

I once heard Craig Liebenson, DC say that we need patients to ‘fear inactivity, more than they fear activity’.  To add context this includes having someone knowledgeable helping them choose appropriate movements, exercises, and activity.

With this being said, there is another side.  Elite athletes and extreme performance are not exactly the best examples of healthy living.  While there are clear benefits to remaining active, at the extremes there is some negative consequence as well.  These feats of athleticism place a toll on the body as well.  This was very clear to me after completing my first marathon. I was convinced by personal experience that there is another extreme.  Another example is the shortened average lifespan of the NFL player.

To summarize:

  • What happens as you age is partially (& significantly) your choice? (see images).
  • There’s a middle road between the couch and ultra-marathons.  Maybe the focus should be on long term athletic participation.

What do you know about FAI?

I found myself talking about this with patients and other providers a lot lately…. thought someone else may be interested.

Sometimes you must admit when you’re not the expert… this is it for me.  Still working at mastering this.  So here’s what a few others have to say.FAI Hip

As several of my patients had hockey related hip pain I asked a Canadian… here’s what Jeff Cubos, DC sent me:

From Kevin Neeld:

From Eric Cressey:

From Craig Liebenson, DC:

And below, 52 seconds to remind you that conservative measures should be attempted prior to performing surgery due to imaging findings of impingement.  (Please seek care and advise from a qualified health care professional to be sure you’re a candidate for conservative care and something more pressing is not going on.)  For appropriate conservative care, see above links.

Imaging Adolescents

“No Imaging Needed For Most Low Back Pain”

From the American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition and research of Denis Drummond, MD the following facts on back pain and imaging of adolescents:

  • mechanical low back pain is common in the pediatric population
  • recent studies have shown that undiagnosable mechanical low back pain accounts for up to 78% of cases in adolescents (we can’t always identify the exact cause, this is true in adults in 85% of cases per Deyo & Weinstein in 2001 in the New England Journal of Medicine) 
  • a child absorbs more radiation and their metabolism is much greater than an adult’s (radiation is likely more harmful to young)
  • attempt conservative management first. After 6 weeks a 50+% improvement should be seen, if so continue with conservative care.  If not, imaging and further investigation is warranted.

Most of these recommendations are not dissimilar from adult clinical guidelines and best practices.  While back pain in children is concerning, we must remember it is not uncommon and is often treated successfully with conservative care allowing us to avoid radiation.  The other aspect is the limited value of imaging as noted in “Is Your Telephone Ringing“.  This is not to say that at times imaging isn’t necessary and appropriate.  Imaging should be used in cases of significant trauma or abnormal presentations to evaluate for conditions such as: fracture, dislocation, infection, tumor, cauda equina syndrome, or with stress views to assess joint instability.

Appropriate and judicious use of imaging controls costs and avoids risks of unnecessary testing, treatment, and radiation.

Is your telephone ringing???

It is common for patients to call or enter the office for their first appointment proclaiming that they have a degenerating disc.  It is also fairly common for people to tell me they can’t do certain things because they have degenerating discs.  The blunt truth is who cares. (at least in most cases)

The best analogy I’ve heard (and unfortunately I forget where I heard it first, so I cannot give appropriate credit) is that having an MRI is like having a picture of a telephone.  By looking at the picture you can tell me the color, size, shape, relative age, apparent damage, and type of telephone.  Is it a cell phone, cordless phone, or rotary phone?  However, you cannot tell me the most important thing… is it ringing?  Pictures of spines (MRIs, x-rays, CT scans) do not show pain, just as pictures of phones do not show ringing.

We have a society where we want answers and we want them quickly. We expect science and our health care providers to give these answers to us.  With regards to back pain this often comes in the form of an MRI (which is too frequently requested by patients and often ordered too early in care by doctors).  This is not to say that MRIs aren’t necessary or valuable tools in some cases, but it is to say that they are over utilized and that we hold them to a higher standard than they deserve.  They are simply one more piece of a the clinical picture.  This is evidenced clearly by a study performed by Bigos, and an associated chart from Management of Pain.  The chart below shows prevalence of disc findings in normal, asymptomatic subjects.

Disc findings in normal subjects

Note: The frequency of degenerative change seen on x-ray is comparable to the patients age.

Immediate imaging for low back pain is necessary in cases of severe trauma, progressive neurologic symptoms, suspicion of cancer, instability, and cauda equina syndrome.  Beyond that it should often be done after a failed course of conservative management.  When it is ordered early in care it often creates psychosocial factors (yellow flags) which complicate care.  There is almost always something ‘wrong’ on the MRI and this can facilitate fear/pain avoidance behaviors in patients, it can also lead to unnecessary (and costly) medical procedures if the imaging findings are treated rather than the patient.  MRI findings must be carefully considered and compared to the patient’s condition, and examination findings.  Functional assessment should also be performed and addressed in most cases of back pain, sciatica, radicular symptoms prior to considering aggressive intervention, when possible.

For further reading, a well referenced, article on this topic from Craig Liebenson, DC entitled The Emperor Has New Clothes.