Sunday, October 18, 2020

Do Patients Present With A Standard Textbook Pattern of Referred Pain While Having A Pinched Nerve?

Dermatomes- look at C4,5 compare below

One of the useful things I learnt while I was still in physiotherapy school, that I am still using daily, are dermatomes. A dermatome is the area of skin that sends signals to the brain through our spinal nerves. These signals help us sense temperature, pressure and pain. 

When a patient comes in to our clinic with radiculopathy, which means a range of symptoms caused by the irritation of a nerve root, we can gauge what levels of the spine are affected, knowing the dermatomes chart. 

These symptoms can include pain, numbness, tingling sensations, sensory changes, loss of strength and even a change in reflexes. These can occur in the cervical (neck), thoracic (upper back) and lumbar (low back) regions. It is often known as a 'pinched nerve'.

C4,5 check with earlier picture
For example, if a patient comes in complaining of pain in the shoulder it may mean that C4,5 may be implicated. This is especially so if treating the shoulder does not make the patient better.

So I was very interested when I read about the following study, where the researchers studied how often patients who had cervical radiculopathy presented with the standard textbook versus non standard patterns.

Only patients with single level cervical radiculopathy operated by six surgeons were included in this study. Their symptoms of radiculopathy were compared to a standard textbook pattern. 

239 patients' records met the inclusion criteria. Their age, weight, BMI, gender and symptom duration were not different between patients with a standard radicular pattern versus those with a non standard pattern.

Picture of referral pattern from article

Overall, 54% (129 patients) fit the standard textbook pattern while 46% (110 patients) differed from the standard pattern. C5-6 and C6-7 were the two most common levels operated on for radicular pain. Non standard patterns of presentation were found in 50.9% (C5-6) and 44.7% (C6-7) of the cases.

Same sided neck pain (81% of patients) was the most common presenting symptom. Shoulder pain was reported in 142 patients (59.4%). 19.2% of the subjects (46 out of 239) had pain/ symptoms at the neck level with no referred pain down the arm. 

When a non standard pattern was encountered, it differed by 1.68 dermatomal levels, either higher or lower.

The authors concluded that observed patterns of cervical radiculopathy in their study only followed the standard textbook pattern in 54% of patients studied. Non standard referral patterns were more common than thought. 

Now, that's a good reminder to doctors, surgeons and physiotherapists (note to self). Patients suspected of referred pain from the neck and back may not always have symptoms that fit the standard textbook pattern.

We need to do our due diligence to ensure each patient get treated appropriately.


Reference 

McAnany SJ, Rhee JM et al (2019). Observed Patterns Of Cervical Radiculopathy: How Often Do They Differ From A standard, "Netter diagram" distribution? Spine. 19(7): 1137-1142. DOI: 10.1016/j.spinee.2018.08.002.

Sunday, October 11, 2020

Are Shoulder Stabilization Exercises Useful?


Your physiotherapist or trainer may have taught you the following exercise(s) to help with shoulder pain. You may have been asked to bring your elbows back while squeezing your shoulder blades together behind you. You were told that you should feel the muscles between your shoulder blades activate and your chest stretching or opening up. This is also to help position your scapula(e) for an improved posture.

R shoulder

I must confess that I, too, have been guilty of teaching this in the past. Fortunately, that's a long time ago! I used to to instruct patients to do scapula (or shoulder blade) stabilization exercises when they come in to our clinic complaining of shoulder impingement. This is also known as subacromial pain syndrome. Sub acromial means all structures below the acromion that can cause problems. Please see picture above and below.




What are some common scapular stabilization exercises? Anything that emphasizes retraction (drawing back)  and depression (bringing lower) of the scapular. Like what I described in the first paragraph of the article.

Well, not all cases of subacromial pain patients will benefit from doing the above exercise. Not according to a recently published randomized controlled study (Hotta et al, 2020).

The objective of that study was to determine if adding scapular stabilization exercises especially retraction and depression of the scapular will help patients with subacromial pain. 60 subjects were randomly divided into two groups. One group did strengthening exercises for muscles around the scapular while the other did the strengthening as well as stabilization exercises for 8 weeks (3x daily).

Results at the end of their study after 8 weeks and even 8 weeks after showed no differences between the 2 groups. The researchers concluded that adding scapular stabilization exercises that emphasized scapular retraction and depression to a general strengthening exercise for muscles around the scapular did not add any benefits to pain, muscle strength or range of motion.

Now after 21 years of treating patients with shoulder pain, my approach has changed dramatically. I now look at a person's shoulder together with the ribcage, neck, spine, hips, feet. I look at how a patient's body is sitting in space and how it moves through space. All while assessing the balance of the structures around their joints. I see which structures need to be worked on by me and which the patient would need to tone and strengthen on their own with specific instructions.  


Reference 

Hotta GH, De Asiss Couto AG et al (2020). Effects Of Adding Scapular Stabilization Exercises To A Periscapular Strengthening Exercise Program In Patients With Subacromial Pain Syndrome: A Randomized Controlled Trial. Muscu Sci Pract 49: 102171. DOI: 10.1016/j.msksp.2020.102171.

Sunday, October 4, 2020

What Happens When Patients Are Sent Too Early For An MRI

Picture by Naiserie from Flickr

My patient came in to our clinic yesterday complaining of some mild low back pain. He had been referred by his family doctor to have an MRI done as the doctor was not sure what was the cause of the back pain.

I was surprised, after examining him, that he was referred for an MRI so soon. His back pain did not seem sinister. At the end of yesterday's session, his back was completely pain free.

I shared with him a really interesting article I had just come across. The researchers studied data of patients seeking treatment for non-specific low back pain without a red flag (warning or danger) condition and no low back pain in the previous six months.

More patients had back surgery if they were referred for an MRI within the first six weeks of an initial visit to the doctor (1.48 % versus 0.12 % in cases without an early MRI). 

The patients also complained of a higher pain score when they had an early MRI. In fact, overall outcomes were worse, including greater use and potential harm for prescription medication (35.1 % versus 28.6 %). There were also higher costs for other medical care ($8,802 versus $5,560).

This association was also true when patients had to pay for their treatment (compared with not having to pay at all).

Perhaps this information will help bring down costs for Singapore's Integrated Shield Plans since there was such an outcry when it was announced that premiums were going higher despite increasing coverage.


Reference

Jacobs JC, Jarvik JG et al (2020). Observational Study Of The Downstream Consequences Of Inappropriate MRI Of The Lumbar Spine. J Gen Int Med. DOI: 10.1007/s11606-020-06181-7.