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Ask Dr. Nancy: A Picture May Not Always Be Worth a Thousand Words

Note: This article is over 60 days old, and may contain information that is out of date, or has been superseded by newer information.

Everyone who is part of the CHP network wants patients to have good clinical outcomes. The crucial first step for any medical problem is talking to the patient, and the second step is examining the patient. The easiest way to get off on the wrong track is to skip or short-cut these essentials.

While technology has helped in the diagnostic process, all technology has limitations and needs to be considered in light of the first two steps or, specifically, what the patient is experiencing.

A suggestion often seen on a report of a CT scan, x-ray, or MRI is that the ordering physician correlate (compare to see if it makes sense) the imaging findings with the clinical situation of the patient. The reason this is such a good idea is that oftentimes abnormalities are seen on imaging studies that have nothing to do with the patient’s symptoms, or the imaging study cannot be used to make a definite diagnosis. Let’s look at some examples.

Knee Pain: An article published in the New England Journal of Medicine in September, 2008, showed that when knee MRIs were done in middle-aged and elderly persons, a cartilage tear was found in 63% of people with knee pain, BUT 60% of people in the same age group without knee pain also had a cartilage tear. The take-home message? Just because you have a cartilage tear doesn’t mean it has anything to do with your knee pain. Clinical correlation is the key.

Multiple Sclerosis: A study, published in the British Medical Journal in 2006, compiled the results from 29 previous clinical studies that assessed MRI results along with patient outcomes. Its findings were that, with a first episode of a neurological symptom, MRIs had “limited utility for both ruling in and ruling out multiple sclerosis.” The most important information came from the clinical course of the patient. With regard to multiple sclerosis, a second episode of neurological symptoms occurring at least a month after the first episode is necessary to make the diagnosis.

Low Back Pain: Low back MRIs (noted in the back pain article) are another example of how imaging studies can potentially lead down a path of treatment that may not yield good clinical results: “65 out of 100 adults without any back pain have abnormalities such as arthritis and bulging discs.” These imaging results make early clinical correlation problematic and can lead to inaccurate associations between chronic asymptomatic findings and acute pain.

COPD: The final example is Chronic Obstructive Pulmonary Disease (COPD), also called chronic bronchitis and emphysema. If COPD becomes severe, changes may appear on a chest x-ray, but for mild and moderate cases, the chest x-ray can easily appear normal. The way to diagnosis COPD is, once again, the duration of the patient’s symptoms, such as cough, along with pulmonary function testing (PFT) to measure the function of the lungs, rather than viewing the anatomy of the lungs. So the next time you hear from someone who smokes that they are fine because their chest x-ray is normal, ask them if they have had the appropriate history and testing that diagnoses COPD. As with many medical conditions, earlier diagnosis of COPD leads to more treatment options. Not being able to breathe is a bad outcome.

It’s not that there is anything wrong with images; it’s just that a picture doesn’t tell the patient’s story. Patients have to do that, and the best place to start is with your primary care physician. The last thing that anyone wants is to treat a radiological abnormality but end up with no relief from an underlying medical condition because the image told a different story. Remember, too, that keeping track of your symptoms in a diary—knowing the details of what you are experiencing—is invaluable to getting to the right next step.

Get Your Neck and Back on Track

Note: This article is over 60 days old, and may contain information that is out of date, or has been superseded by newer information.

How many of us can say we’ve never had neck or back pain? Not many. Studies show that more than 80% of people between 20 and 60 will experience at least one episode of back pain in their lifetime. Once it happens, the chance of reoccurrence within three years is 80–90%. This high incidence, along with the cost of treatment, has made spinal pain the most researched medical condition in the past 30 years. Real advances have come from the research: effective, validated methods to assess, treat, and prevent these painful conditions.

Our Program for Members.

In response to these studies, CHP and the Center for Orthopedics and Sports Physical Therapy (COSPT) have developed the Back and Neck Program. This evidence-based program uses the process known as Mechanical Diagnosis and Therapy (MDT) to evaluate spinal pain. Research has shown the initial MDT assessment process is reliable in determining the source of the problem. MDT is a philosophy of active patient involvement and education. Trusted and used by practitioners and patients around the world, this approach continues to be the most researched conservative care method available for back, neck, and extremity problems. The therapy’s success relies on three key steps: (1) assessment, (2) treatment, and (3) preventive strategy. All of the clinicians involved in the Back and Neck Program are credentialed in MDT and well trained to manage most spinal conditions. They will work with your primary care physician to find the best solution for you. The goals are to reduce pain, restore function, and give the patient tools to prevent recurrences.


A Two-Year Record of Success.

The program has had great success, demonstrated by data collected for the past two years. To date 252 CHP members have participated in the study, allowing us to track their outcomes using pain and function scores as a benchmark. In less than four visits, pain scores dropped from an average of 53/100 at initial evaluation to 10.6/100 at discharge. Function scores or physical activity scores improved from 57.5/100 at initial evaluation to 91.2/100 at discharge from the program. Recurrence of the pain occurred in less than 20% of the population, compared to 80–90% in the general population receiving usual care. This is a program that promotes the body’s ability to heal without medication, surgery, or dependence on practitioners.


In a Patient’s Own Words.

Deanna Barath reports of her experience in the Back and Neck Program:

I was in a horrible car accident one year ago and could barely walk, sit, or stand for even short periods of time. The medication I took for the pain in my legs did very little to change my symptoms. I’ve been receiving therapy for about two months—5 to 6 visits—and never thought in such a short time I could feel this great! Asking for something more than drug therapy was the best question I ever asked.


If you feel the Back and Neck Program could benefit you, discuss it with your primary care physician or contact COSPT to learn more (850-656-1837). No authorization is necessary.

Oh, your aching back? A real pain in the neck?

Note: This article is over 60 days old, and may contain information that is out of date, or has been superseded by newer information.

For too many people, the reaction to those common questions is a resounding “Yes!” Low back and neck pain trouble a number of CHP members. Now, a new program is doing something about these aches and pains—with definite success.

The education and intervention program, a collaboration with the Center for Orthopedic & Sports Physical Therapy, was conducted as a pilot study for one year. Approximately 170 patients achieved nearly 80% improvement in their pain after a little more than three visits. Physical ability or function scores improved on average from a capacity score of 59 on entering the program to 91 on completion.

CHP physician Charles Tomlinson, MD, worked on the pilot program with the Center’s Tom Kane, MS, PT (cert. MDT), and Chad Gray, PT (cert. MDT). Physical therapists Kane and Gray are pleased to provide the safe and effective treatment and education. If you feel that you might benefit from this program, please discuss it with your primary care physician or contact the Center. No authorization number is necessary. Contact the Center for Orthopedic & Sports Physical Therapy at 850-656-1837. Office location is 1834-A Jaclif Court, just off Capital Medical Boulevard. CHP members experiencing back and neck pain also can get additional information by calling a CHP Health Coach at 850-383-3400.