Disturbing trends in injury diagnosis and management

[jwinch2]

Below are the abstracts from three seperate studies. Unfortunately these three studies highlight the lack of competency of many physicians and therapists when it comes to diagnosing and treating musculoskeletal injuries. This is the reason I get a little crazy on here when people start talking about "my doctor told me to do this" and "my brother is a physical therapist and he said..." and that sort of thing.

The point of this is as follows. When being diagnosed by a PT or MD ask questions. Ask about the literature involved and the criteria used to come up with an assesment. When an intervention strategy is presented (Surgery, rehab, prehab, medication, whatever!), ask about the literature. Why did he/she choose this treatment over another? Why is this or that exercise being performed? Are they aware of any peer-reviewed literature which you could read to get further information? If they cannot or will not answer those questions, it is time to leave!

In short, always know your source of information! Know why treatments are being prescribed and what sort of evidence is behind the treatment strategy! In addition, if the diagnosis of a PT or MD is not based on at least some form of testing, preferably MRI, then it is likely to be an inaccurate wild-*** guess.

Too many tests being performed are subjective in nature and go something like this: "push on my arm, OK that was about a 3 out of 5...". Testing like that is complete hogwash and if that is the basis for an intervention given to you or to assess if you have made improvement, leave quickly and find somewhere else to go!

To be fair, PT's and MD's do tend to score very well at diagnosis when tested using MRI's. In fact, PT's even tend to score about 5% higher in that situation. They just tend to fall short when it relates to prescribing treatments.

Anyway, enough of my ranting, here are the studies I mentioned!




J Bone Joint Surg Am. 1998 Oct;80(10):1421-7.

The adequacy of medical school education in musculoskeletal medicine.

• Freedman KB,
• Bernstein J.

University of Pennsylvania School of Medicine, Philadelphia, USA.

A basic familiarity with musculoskeletal disorders is essential for all medical school graduates. The purpose of the current study was to test a group of recent medical school graduates on basic topics in musculoskeletal medicine in order to assess the adequacy of their preparation in this area. A basic-competency examination in musculoskeletal medicine was developed and validated. The examination was sent to all 157 chairpersons of orthopaedic residency programs in the United States, who were asked to rate each question for importance and to suggest a passing score. To assess the criterion validity, the examination was administered to eight chief residents in orthopaedic surgery. The study population comprised all eighty-five residents who were in their first postgraduate year at our institution; the examination was administered on their first day of residency. One hundred and twenty-four (81 per cent) of the 154 orthopaedic residency-program chairpersons who received the survey responded to it. The chairpersons rated twenty-four of the twenty-five questions as at least important. The mean passing score (and standard deviation) that they recommended for the assessment of basic competency was 73.1 +/- 6.8 per cent. The mean score for the eight orthopaedic chief residents was 98.5 +/- 1.07 per cent, and that for the eighty-five residents in their first postgraduate year was 59.6 +/- 12 per cent. Seventy (82 per cent) of the eighty-five residents failed to demonstrate basic competency on the examination according to the chairpersons' criterion. The residents who had taken an elective course in orthopaedic surgery in medical school scored higher on the examination (mean score, 68.4 per cent) than did those who had taken only a required course in orthopaedic surgery (mean score, 57.9 per cent) and those who had taken no rotation in orthopaedic surgery (mean score, 55.9 per cent) (p = 0.005 and p = 0.001, respectively). In summary, seventy (82 per cent) of eighty-five medical school graduates failed a valid musculoskeletal competency examination. We therefore believe that medical school preparation in musculoskeletal medicine is inadequate.




Br J Sports Med. 2005 Dec;39(12):912-6; discussion 916.

How evidence based is the management of two common sports injuries in a sports injury clinic?

• Murray IR,
• Murray SA,
• MacKenzie K,
• Coleman S.

College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh EH16 4SB, Scotland, UK.


OBJECTIVES: To examine the diagnosis and management of adults attending a sports injury clinic, to establish to what extent the management of the two most common injuries treated at this clinic is evidence based, and to explore factors that affect management. METHODS: A retrospective examination of 100 random case notes extracted age, sex, sport, type and site of injury, treatment, and outcome. Systematic literature reviews examined the extent and quality of scientific evidence for the management of the two most commonly presenting injuries. A clinical attachment period and practitioner interviews allowed recognition of factors impinging on management decisions. RESULTS: Patellofemoral pain syndrome (PFPS; 10% of all injuries) and Achilles tendinopathy (6% of all injuries) were the most commonly presenting injuries. The mean (SD) number of treatments used for PFPS was 2.8 (0.9). The mean number of treatments used for Achilles tendinopathy was 3.7 (1.0). Clinicians reported that personal experience formed the basis of management plans in 44% of PFPS cases and 59% of Achilles tendinopathy cases, and that primary research evidence only accounted for 24% of management plans in PFPS and 14% in Achilles tendinopathy. Practitioners were unaware of literature supporting over 50% of the treatment modalities they used. However, clinicians were often using evidence based treatments, unaware of the supporting research data. CONCLUSIONS: This study highlights a lack of evidence base, a lack of knowledge of the research evidence, and a lack of management based on the current evidence that is available for these conditions. Practitioners practised evidence based medicine in under 50% of cases.





Clin Orthop Relat Res. 2005 Aug;(437):251-9

More evidence of educational inadequacies in musculoskeletal medicine.

• Schmale GA.

Children's Hospital and Regional Medical Center, University of Washington, Seattle, 98105, USA.


In their study, Freedman and Bernstein suggested that 80% of a group of graduates from many of the best medical schools in the United States were deficient in their knowledge of basic facts and concepts in musculoskeletal medicine. How do these results compare with results from students attending a medical school with a long-standing dedicated program to musculoskeletal education? Does additional clinical experience in musculoskeletal medicine improve understanding of the basic facts and concepts introduced in a second-year course? A modified version of an exam used to assess the competency of incoming interns at the University of Pennsylvania was used to assess the competency of medical students during various stages of their training at the University of Washington. Despite generally improved levels of competency with each year at medical school, less than 50% of fourth-year students showed competency. Students who completed a musculoskeletal clinical elective scored higher and were more competent (78%) than students who did not take an elective. These results suggested that the curricular approach toward teaching musculoskeletal medicine at this medical school was insufficient and that competency increased when learning was reinforced during the clinical years.

[KayJay]

Ouch!!! Nice to notice this today, of all days, after my first visit ever to an Orthopedics clinic.

But it makes me wonder and if your opinion is the same as mine, Jason...
As previously discussed, I went to the doctor about my current problem. An x-ray was requested and everything looked perfectly fine. But the doctor went ahead and scheduled me for physical therapy for them to work on my leg.
WHY????
They don't even know what's wrong with it! Why chance therapy when they could possibly make it worse. I refused to go. (Or was I wrong to think this way?)

[jwinch2]

Ouch!!! Nice to notice this today, of all days, after my first visit ever to an Orthopedics clinic.

But it makes me wonder and if your opinion is the same as mine, Jason...
As previously discussed, I went to the doctor about my current problem. An x-ray was requested and everything looked perfectly fine. But the doctor went ahead and scheduled me for physical therapy for them to work on my leg.
WHY????
They don't even know what's wrong with it! Why chance therapy when they could possibly make it worse. I refused to go. (Or was I wrong to think this way?)

I think you probably did the right thing in the short-term but that is not going to fix the problem. I would try to get an MRI scheduled if you can and get a better idea of what you are dealing with. The amount of information you can get from an x-ray is pretty limited.

Also, I don't want to scare you away from PT's completely, as there are many good ones who go out of their way to dig through the research as it is published or presented. Just be sure to ask good questions about the evidence behind what they are suggesting for treatment and diagnosis. If you are statisfied with the response, then go for it. If not, ask more questions or find someone else.

It is your body and you need to be comfortable with what is going on. In addition, you have the right to expect that the people handling your medical concerns have a good knowledge of the applicable research, as well as the education and experience to apply it.

Good luck and please let me know if I can be of any help. Feel free to PM me or e-mail if you have questions.

Later,

[Eye4NEye]

This thread is of great interest to me. As some of you may know, I suffered a disc injury earlier this year that aggravated an old chronic injury and created a new one that pretty much put me out of MA. My ortho doc took x-rays (which show nothing) and sent me to physical therapy. I spent a few months in PT and things seemed to be getting better. Well, a few weeks ago I started getting shooting pain down my left leg. I've had it in my right leg before and it feels like someone is stabbing me in the butt with a pair of scissors, but this is the first time I have ever experienced it in my left leg.

I went to see my doc again this morning (which is why it's so ironic to see this post today) and he again told me it was a disc issue and that there wasn't really any surgery or therapy that would help me and that I should do a different set of exercises and come back in a month. He also told me that I would more than likely have to stop martial arts indefinitely. I felt like I was hit in the chest with a hammer. From my reaction you would have thought that I was diagnosed with terminal cancer. After talking with some good friends who have brought me out of my depression this morning I've decided to seek a second opinion and to force an MRI.

I'm just tired of being prescribed exercises and being told to come back in a month with no significant change in my condition. What bothers me most about this whole process is that not once has anyone ever given me an MRI!!! Right now they are just shooting in the dark at what the underlying condition may be and their stupid exercises could actually be causing more harm than good.

I just want my life back damn it! I'm sick of being in pain all the time and I'm sick of feeling helpless. I want to be 205 again and in fighting shape and I want to be able to pick my kids up (one day when we have them) and not suffer severe pain. I'm not even 30 years old and for the last 8 years I've been battling this bs!

I'm grateful for this thread. Thanks, Jason.

[jwinch2]

Jason,

You have every right to feel the way that you do. It is difficult sometimes but remember that YOU are the client, not the other way around. Get recommendations and referrals from your friends. Find out who the local sports teams or universities send their athletes to and try to see them. Check to see if they publish or have published on medline and do your homework.

I really hope you get some resolution. Your situation is classic when it comes to examples that piss me off about the medical community.

Good luck and please let me know if I can help in any way!

Jason

[Eye4NEye]

Thanks, Jason. I've learned a lot from the things you have posted and a lot from the Dr. McGill book that you suggested. It's really made me see how ridiculous this whole situation is. I've been prescribed more exercises than you will find in most exercise manuals and it's just not solving anything.

I'll follow your suggestions and see if I can't find someone with a better model of diagnosis (one based on evidence.)

Thanks for the help!

[KayJay]

I think you probably did the right thing in the short-term but that is not going to fix the problem. I would try to get an MRI scheduled if you can and get a better idea of what you are dealing with. The amount of information you can get from an x-ray is pretty limited.

Also, I don't want to scare you away from PT's completely, as there are many good ones who go out of their way to dig through the research as it is published or presented. Just be sure to ask good questions about the evidence behind what they are suggesting for treatment and diagnosis. If you are statisfied with the response, then go for it. If not, ask more questions or find someone else.

It is your body and you need to be comfortable with what is going on. In addition, you have the right to expect that the people handling your medical concerns have a good knowledge of the applicable research, as well as the education and experience to apply it.

Good luck and please let me know if I can be of any help. Feel free to PM me or e-mail if you have questions.

Later,

Yes, you're right, it didn't fix the problem. But after a short stint of taking a break everything seemed fine and I returned to what I was doing until this time. I have a good doctor now that cares about what I want and helps come up with ways to work with and around it rather than just telling me to stop everything. He's also the one who finally scheduled me for an MRI to get me where I'm at.
And speaking of research - between what you've told me and what I've read on the internet, my surgeon said pretty much said the same thing. He also said it was good to do the research too.
I have only had physical therapy once in my life and that was recovering from a sprained ankle. I quit and went on my own after two visits. Theirs seemed to prolong the "agony" and although it took a bit of time, I did recover fully and believe my ankle to be as strong as ever.
I do intend on doing PT (physical therapy, not the other ) at the base for however long it takes (for my knee) and will keep your words in mind (along with others who have helped my decision making).

[KayJay]

Thanks, Jason. I've learned a lot from the things you have posted and a lot from the Dr. McGill book that you suggested. It's really made me see how ridiculous this whole situation is. I've been prescribed more exercises than you will find in most exercise manuals and it's just not solving anything.

I'll follow your suggestions and see if I can't find someone with a better model of diagnosis (one based on evidence.)

Thanks for the help!

Kind of been there and understand what you're going through. Very frustrating to say the least. Good luck on finding a decent therapist.

[Eye4NEye]

Thanks, Kara. Good luck with your knee!

[wildwills]

Jason,
Find out who the local sports teams or universities send their athletes to and try to see them. Check to see if they publish or have published on medline and do your homework.

Jason,

It's not any better in the Air Force. Back in 2000 I tore my left hamstring in two places playing racquetball. Right behind (and slightly above the knee) and up towards the buttocks. The AF's solution was utlra-sound therapy...which didn't do squat. I got further along doing my own strecthes and weight training. Then I did another partial tear while at Squadron Officer School in 2002 on a 5 mile run. Again, McGuire AFB had me on the utlra-sound therapy even at my objection to this.

I had to do the utlra-sound therapy or risk possible medical separation, but I asked a cousin of mine, an ex Army Ranger and Sapper what the Army did for him when he injured his hamstring. He suggested any type of aqua-aerobics over ultra-sound therapy. I gave it a shot and got more profound results, although my hamstring was still getting stiff and I didn't nearly have the flexibility in it.

I came Wright Patterson AFB in 2005 and was having problems with soreness and spasms in my hamstring after Kenpo. Here the AF redeemed itself with an MRI and prescribed strecthes, aqua exercises/ and accu-pressure massage/sport massage. The massage hurt like hell, but felt better about an hour after. I have scar tissue on my hamstring, which the massage helps "loosen/break-up". So periodically I hit the masseuse, along with my own strectches and that seems to really help.

[Abbax8]

When recognized experts in a field can come to two different conclusions following an exam of the same patient, you know you need to take charge of YOUR health. The problem is the same experts will berate you if you dare to question them.

The other problem is time and money. In most the United States today you do not have doctor's offices you have RATHER medical business establishments. Even if the individual doctor is dedicated to their patient, they will not be allowed to spend the time with the patient to reach a proper diagnosis. Then medical corporations want each doc to see 100 or patients per day, that's how the money is made. The other money problem is a lack of it for those patients whose insurance will not cover all the diagnostic tests a doctor could perform. The other time problem is doctors seeing 100 or patients a day can't keep up with all the latest literature.

In the end, the patient must take control of their health. If a treatment regimen is not helping within a reasonable time, or is making the situation worse, run, don't walk out of there. This goes for ALL health practitioners, western, eastern and alternative.

Peace

Dennis

[Mandeigh Wells]

INteresting topic!

when I was in my teens I had really bad pain in my knee. It was exrayed and nothing showed up, I was given various pain killers and they didn't do anything. Some times I would be in tears with the pain...like a nagging toothache.......

so the doctor decided it was 'rough bones' and they would remove my knee cap. Anyway I didn't fancy that so I stopped going to the doctor.

A couple of years later after a fall from a horse I went to an osteopath......after telling me the my pelvis was rotated and doing a rather big painfull movement to 'fix it' and my mum heard the crack and the scream in the waiting room.....my knee pain miraculously dissapeared!

[CosimoTe]

Below are the abstracts from three seperate studies. Unfortunately these three studies highlight the lack of competency of many physicians and therapists when it comes to diagnosing and treating musculoskeletal injuries. This is the reason I get a little crazy on here when people start talking about "my doctor told me to do this" and "my brother is a physical therapist and he said..." and that sort of thing.

The point of this is as follows. When being diagnosed by a PT or MD ask questions. Ask about the literature involved and the criteria used to come up with an assesment. When an intervention strategy is presented (Surgery, rehab, prehab, medication, whatever!), ask about the literature. Why did he/she choose this treatment over another? Why is this or that exercise being performed? Are they aware of any peer-reviewed literature which you could read to get further information? If they cannot or will not answer those questions, it is time to leave!

In short, always know your source of information! Know why treatments are being prescribed and what sort of evidence is behind the treatment strategy! In addition, if the diagnosis of a PT or MD is not based on at least some form of testing, preferably MRI, then it is likely to be an inaccurate wild-*** guess.

Too many tests being performed are subjective in nature and go something like this: "push on my arm, OK that was about a 3 out of 5...". Testing like that is complete hogwash and if that is the basis for an intervention given to you or to assess if you have made improvement, leave quickly and find somewhere else to go!

To be fair, PT's and MD's do tend to score very well at diagnosis when tested using MRI's. In fact, PT's even tend to score about 5% higher in that situation. They just tend to fall short when it relates to prescribing treatments.

Anyway, enough of my ranting, here are the studies I mentioned!




J Bone Joint Surg Am. 1998 Oct;80(10):1421-7.

The adequacy of medical school education in musculoskeletal medicine.

• Freedman KB,
• Bernstein J.

University of Pennsylvania School of Medicine, Philadelphia, USA.

A basic familiarity with musculoskeletal disorders is essential for all medical school graduates. The purpose of the current study was to test a group of recent medical school graduates on basic topics in musculoskeletal medicine in order to assess the adequacy of their preparation in this area. A basic-competency examination in musculoskeletal medicine was developed and validated. The examination was sent to all 157 chairpersons of orthopaedic residency programs in the United States, who were asked to rate each question for importance and to suggest a passing score. To assess the criterion validity, the examination was administered to eight chief residents in orthopaedic surgery. The study population comprised all eighty-five residents who were in their first postgraduate year at our institution; the examination was administered on their first day of residency. One hundred and twenty-four (81 per cent) of the 154 orthopaedic residency-program chairpersons who received the survey responded to it. The chairpersons rated twenty-four of the twenty-five questions as at least important. The mean passing score (and standard deviation) that they recommended for the assessment of basic competency was 73.1 +/- 6.8 per cent. The mean score for the eight orthopaedic chief residents was 98.5 +/- 1.07 per cent, and that for the eighty-five residents in their first postgraduate year was 59.6 +/- 12 per cent. Seventy (82 per cent) of the eighty-five residents failed to demonstrate basic competency on the examination according to the chairpersons' criterion. The residents who had taken an elective course in orthopaedic surgery in medical school scored higher on the examination (mean score, 68.4 per cent) than did those who had taken only a required course in orthopaedic surgery (mean score, 57.9 per cent) and those who had taken no rotation in orthopaedic surgery (mean score, 55.9 per cent) (p = 0.005 and p = 0.001, respectively). In summary, seventy (82 per cent) of eighty-five medical school graduates failed a valid musculoskeletal competency examination. We therefore believe that medical school preparation in musculoskeletal medicine is inadequate.




Br J Sports Med. 2005 Dec;39(12):912-6; discussion 916.

How evidence based is the management of two common sports injuries in a sports injury clinic?

• Murray IR,
• Murray SA,
• MacKenzie K,
• Coleman S.

College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh EH16 4SB, Scotland, UK.


OBJECTIVES: To examine the diagnosis and management of adults attending a sports injury clinic, to establish to what extent the management of the two most common injuries treated at this clinic is evidence based, and to explore factors that affect management. METHODS: A retrospective examination of 100 random case notes extracted age, sex, sport, type and site of injury, treatment, and outcome. Systematic literature reviews examined the extent and quality of scientific evidence for the management of the two most commonly presenting injuries. A clinical attachment period and practitioner interviews allowed recognition of factors impinging on management decisions. RESULTS: Patellofemoral pain syndrome (PFPS; 10% of all injuries) and Achilles tendinopathy (6% of all injuries) were the most commonly presenting injuries. The mean (SD) number of treatments used for PFPS was 2.8 (0.9). The mean number of treatments used for Achilles tendinopathy was 3.7 (1.0). Clinicians reported that personal experience formed the basis of management plans in 44% of PFPS cases and 59% of Achilles tendinopathy cases, and that primary research evidence only accounted for 24% of management plans in PFPS and 14% in Achilles tendinopathy. Practitioners were unaware of literature supporting over 50% of the treatment modalities they used. However, clinicians were often using evidence based treatments, unaware of the supporting research data. CONCLUSIONS: This study highlights a lack of evidence base, a lack of knowledge of the research evidence, and a lack of management based on the current evidence that is available for these conditions. Practitioners practised evidence based medicine in under 50% of cases.





Clin Orthop Relat Res. 2005 Aug;(437):251-9

More evidence of educational inadequacies in musculoskeletal medicine.

• Schmale GA.

Children's Hospital and Regional Medical Center, University of Washington, Seattle, 98105, USA.


In their study, Freedman and Bernstein suggested that 80% of a group of graduates from many of the best medical schools in the United States were deficient in their knowledge of basic facts and concepts in musculoskeletal medicine. How do these results compare with results from students attending a medical school with a long-standing dedicated program to musculoskeletal education? Does additional clinical experience in musculoskeletal medicine improve understanding of the basic facts and concepts introduced in a second-year course? A modified version of an exam used to assess the competency of incoming interns at the University of Pennsylvania was used to assess the competency of medical students during various stages of their training at the University of Washington. Despite generally improved levels of competency with each year at medical school, less than 50% of fourth-year students showed competency. Students who completed a musculoskeletal clinical elective scored higher and were more competent (78%) than students who did not take an elective. These results suggested that the curricular approach toward teaching musculoskeletal medicine at this medical school was insufficient and that competency increased when learning was reinforced during the clinical years.

Jason,
I have some issues with your post.
The literature provided cites the lack of diagnosic and immaging diagnostic skills shown by medical students. Medical students have no real skill or experience to provide any diagnosis based soley on an MRI report. This literature does not translate into everyday practice as working knowledge of medicine comes during intenship and residency.

Citing the second literature piece presumes an equivalent trend in the US compared to Scotland's medical care standard. ( I think Mandeigh's knee cap will testify to that.)

Yes, an MRI is a good peice of evidence based medicine, however, you do not treat MRI's, Xrays, and labs. The patient is the sole source of information,all else is supportive documentation. Your reference to hogwash, discounts the most important facet of diagnosing musculoskeletal injuries. That being the response of the patient when specific anatomic locations are evaluated.

Third, you may be surrounded by PT's( presumably Physical therapists ) that are better diagnosticians then physicians, this would not be my experience. I have seen more cases of PT being off base totally and causing serious harm than I have of them being "5% higher" (than what? medical students or practicing physicians)

The take home point here is get your medical advice from the most qualified and knowledgable physican (specialist) available. That doctor needs to put you first. Work with him/her, ask questions, stay involved. MRI's are good, but they are no panacea.
Regards

[lightninrod]

INteresting topic!

when I was in my teens I had really bad pain in my knee. It was exrayed and nothing showed up, I was given various pain killers and they didn't do anything. Some times I would be in tears with the pain...like a nagging toothache.......

so the doctor decided it was 'rough bones' and they would remove my knee cap. Anyway I didn't fancy that so I stopped going to the doctor.

A couple of years later after a fall from a horse I went to an osteopath......after telling me the my pelvis was rotated and doing a rather big painfull movement to 'fix it' and my mum heard the crack and the scream in the waiting room.....my knee pain miraculously dissapeared!

That's interesting, Mandy. I have a pain in my lower back, that also manifests itself as leg pain, knee pain, etc. It is rooted in an injury I caused for myself by rotating my spine as I lifted a very heavy weight at work. Every once in a while, while I'm at work, and I stand up from bending over a car, I feel a kink in the lowest vertebrae of my back. By purposefully erecting my posture and leaning back in such a way as to concentrate the movement into that particular joint, I get a very loud "pop", after which it feels almost as though my leg is waking up from having been "asleep" and my pain is gone for a while. It's a very pleasant feeling and I wish I could stay that way. Have you had any recurrance, or has your "cure" been somewhat permanent?

[Abbax8]

That's interesting, Mandy. I have a pain in my lower back, that also manifests itself as leg pain, knee pain, etc. It is rooted in an injury I caused for myself by rotating my spine as I lifted a very heavy weight at work. Every once in a while, while I'm at work, and I stand up from bending over a car, I feel a kink in the lowest vertebrae of my back. By purposefully erecting my posture and leaning back in such a way as to concentrate the movement into that particular joint, I get a very loud "pop", after which it feels almost as though my leg is waking up from having been "asleep" and my pain is gone for a while. It's a very pleasant feeling and I wish I could stay that way. Have you had any recurrance, or has your "cure" been somewhat permanent?

Go see an Osteopath or a chiropractor. It sounds like your sacrum is out of place and possibly other vertabrae as well. The pain/sensation in your leg sounds like sciatica. See a doc, it is treatable.

Peace

Dennis

[jwinch2]

Jason,
I have some issues with your post.
The literature provided cites the lack of diagnosic and immaging diagnostic skills shown by medical students. Medical students have no real skill or experience to provide any diagnosis based soley on an MRI report. This literature does not translate into everyday practice as working knowledge of medicine comes during intenship and residency.

Citing the second literature piece presumes an equivalent trend in the US compared to Scotland's medical care standard. ( I think Mandeigh's knee cap will testify to that.)

Yes, an MRI is a good peice of evidence based medicine, however, you do not treat MRI's, Xrays, and labs. The patient is the sole source of information,all else is supportive documentation. Your reference to hogwash, discounts the most important facet of diagnosing musculoskeletal injuries. That being the response of the patient when specific anatomic locations are evaluated.

Third, you may be surrounded by PT's( presumably Physical therapists ) that are better diagnosticians then physicians, this would not be my experience. I have seen more cases of PT being off base totally and causing serious harm than I have of them being "5% higher" (than what? medical students or practicing physicians)

The take home point here is get your medical advice from the most qualified and knowledgable physican (specialist) available. That doctor needs to put you first. Work with him/her, ask questions, stay involved. MRI's are good, but they are no panacea.
Regards

Your assertion about the patients response to anatomical evaluation and the patients being the sole source of information and being the most important part of diagnosis is inaccurate in the extreme. Patients are notorious for remembering things incorrectly, having pain that seems to 'float' on a session by session basis, and not complying with instructions. In addition, MRI's are not evidence based medicine. They are a diagnosic tool which is objective rather than subjective. THEN and only then does the use of evidence come into play, when using an intervention. The point of getting away from subjective methods in diagnosis of musculoskeletal injuries is that they are inaccurate and always have been. The use of techniques such as MRI and CT scan have a much, much higher rate of accurate analysis then subjective analysis based on the feedback of patients regardless of the experience of the person evaluating the injury. Secondly, in this day and age, any practitioner who recommends a surgical intervention without using an MRI to confirm findings from initial diagnosis and X-ray is asking for a malpractice suit. The same physician who instead of asking for an MRI, sends the patient off to PT for 6 months only to find later through use of imaging that the patient has a problem requireing surgial intervention is going to lose patients.

Furthermore, if you take the time to actually read the studies next time in full text before attempting to take someone to task that will help you out big time. The subjects in the Freidman 1998 paper are students who had already completed their coursework and rotations in orthopedics. For those who are not specializing in Orthopedic surgury, this it is the only one they will get, ever. In addition, the study was designed with the involvment of the heads of orthopedics selected from the top tier medical programs in the United States. The questions used to evaluate the students, and later practicing physicians, were those that should have been known by any student who had completed their coursework and rotations in the tested area. The criteria uses was that of those medical professors who regularly evaluated students and taught orthopedic courses in medical schools around the country.

Several follow on studies have been done with practicing physicians a few years out of medical school with very similar results among non orthopedic pracitioners. I posted the 1998 study because it was the original and the rest simply validated their results and used the same methods.

As for the PT's, they do tend to score better at diagnosis then most physicians even orthos (which is where your 5% comes in), and certainly non-orthopedic practitioners (the differences here can be as much as 25 - 30%). In the majority of cases, general practitioners are the first ones people see for evaluation they do not go straight to orthos and do not go straight to PT's.

As for PTs who cause problems, I agree, it certainly does happen. Which is the point of the second study I posted. The results of the Murray 2005 paper have been recently validated in the US and the results presented at conference. The paper, I assume is going through the review process right now, which is pretty typical for how research works. Again, I would still cite the original as they are the ones to document it first. PT's are usually very good at diagnosis providing they have access to imaging. It is the design and implentation of treatments where they begin to have problems.

PT's historically have not done much research with the exception of case studies. There have been little in the way of controlled trials used to evaluate the efficacy of interventions until recently. This is probably the main reason they have been unable to get direct access to patients for screening and treatments purposes from insurance companies. It is pretty hard to get people to pay for you to treat patients when you can't prove your interventions work. Insurance companies are kind of funny that way.

As for differences in health care from PT's in Scotland versus the US, of course there are some differneces. However, the vast majority of their practice is conducted in a very similar manner. Students train overseas and come back to practice in their home countries. Those faculty who research are going to the same conferences and reading the same journals. This is especially true of countries that speak the same language. There are many more commonalities in the practice of PT's between the US and Europe than there are differences.

[jwinch2]

Go see an Osteopath or a chiropractor.

Peace

Dennis

I am a huge fan of D.O.'s. Especially those who have gone on to advanced practice. The majority of them are general pracitioners as that is something of the history of DO's in general so they can be hard to find.

I have had some success with chiropracters and am a fan of manipulation through personal experience as well as reading some of the literature. However, you have to be very careful with Chiro's as many are more than a little bit 'round the bend'.

DO's can do the same manipulation as a chiro, as well as approach the problem from other angles as well.

[Abbax8]

[QUOTE=jwinch

DO's can do the same manipulation as a chiro, as well as approach the problem from other angles as well.[/QUOTE]

Actually no two chiropractors or osteopaths adjust the same. Some use totally different methods of adjustment and then there are the ones who rely on brute strength versus technique. Each patient must decide for themself if their doctor is right for them.

Peace

Dennis

[Mandeigh Wells]

Have you had any recurrance, or has your "cure" been somewhat permanent?

pretty much permanent...I do get achy knees at time if I have done alot of walking....actually its more my shins than my knees.

I have nothing like the pain I had before my back was 'clicked'....it was that throbbing ache like toothache........I could get no relief from it at all.

[CosimoTe]

Your assertion about the patients response to anatomical evaluation and the patients being the sole source of information and being the most important part of diagnosis is inaccurate in the extreme. Patients are notorious for remembering things incorrectly, having pain that seems to 'float' on a session by session basis, and not complying with instructions. In addition, MRI's are not evidence based medicine. They are a diagnosic tool which is objective rather than subjective. THEN and only then does the use of evidence come into play, when using an intervention. The point of getting away from subjective methods in diagnosis of musculoskeletal injuries is that they are inaccurate and always have been. The use of techniques such as MRI and CT scan have a much, much higher rate of accurate analysis then subjective analysis based on the feedback of patients regardless of the experience of the person evaluating the injury. Secondly, in this day and age, any practitioner who recommends a surgical intervention without using an MRI to confirm findings from initial diagnosis and X-ray is asking for a malpractice suit. The same physician who instead of asking for an MRI, sends the patient off to PT for 6 months only to find later through use of imaging that the patient has a problem requireing surgial intervention is going to lose patients.

Furthermore, if you take the time to actually read the studies next time in full text before attempting to take someone to task that will help you out big time. The subjects in the Freidman 1998 paper are students who had already completed their coursework and rotations in orthopedics. For those who are not specializing in Orthopedic surgury, this it is the only one they will get, ever. In addition, the study was designed with the involvment of the heads of orthopedics selected from the top tier medical programs in the United States. The questions used to evaluate the students, and later practicing physicians, were those that should have been known by any student who had completed their coursework and rotations in the tested area. The criteria uses was that of those medical professors who regularly evaluated students and taught orthopedic courses in medical schools around the country.

Several follow on studies have been done with practicing physicians a few years out of medical school with very similar results among non orthopedic pracitioners. I posted the 1998 study because it was the original and the rest simply validated their results and used the same methods.

As for the PT's, they do tend to score better at diagnosis then most physicians even orthos (which is where your 5% comes in), and certainly non-orthopedic practitioners (the differences here can be as much as 25 - 30%). In the majority of cases, general practitioners are the first ones people see for evaluation they do not go straight to orthos and do not go straight to PT's.

As for PTs who cause problems, I agree, it certainly does happen. Which is the point of the second study I posted. The results of the Murray 2005 paper have been recently validated in the US and the results presented at conference. The paper, I assume is going through the review process right now, which is pretty typical for how research works. Again, I would still cite the original as they are the ones to document it first. PT's are usually very good at diagnosis providing they have access to imaging. It is the design and implentation of treatments where they begin to have problems.

PT's historically have not done much research with the exception of case studies. There have been little in the way of controlled trials used to evaluate the efficacy of interventions until recently. This is probably the main reason they have been unable to get direct access to patients for screening and treatments purposes from insurance companies. It is pretty hard to get people to pay for you to treat patients when you can't prove your interventions work. Insurance companies are kind of funny that way.

As for differences in health care from PT's in Scotland versus the US, of course there are some differneces. However, the vast majority of their practice is conducted in a very similar manner. Students train overseas and come back to practice in their home countries. Those faculty who research are going to the same conferences and reading the same journals. This is especially true of countries that speak the same language. There are many more commonalities in the practice of PT's between the US and Europe than there are differences.

Jason,

Allow me to substitute "most important" for "sole". With this said the essence of my post is to not discount the importance of the patient encounter, and hail the panacea of MRI. Im sure you know from your vast experience as a physician, that patients once in awhile actually know what they are talking about.
Have you ordered an MRI for lateral epicondylitis? How about carpal tunnel syndrome? Do you treat many patients with iliotibial band friction? How useful would the MRI be in these cases? Do you need an MRI for diagnosis of plantar fasciitis? Obviously there are many other examples, but being verbose is not my strong suit. In each clinical situation, an MRI is not needed, surgery is not the first step. The diagnosis is made clinically, based on what the patient tells the physician, the mechanism of injury, and what the physician finds on exam.
Not every musculoskeletal injury needs an MRI.
Your post discounts the vital role of listening to the patient and examining the patient as a whole. Patients need to be treated, not MRI's. When a patient has a problem, you dont simply refer them for MRI of this or that.You simply cannot put a radiologist and an MRI ( or a physical therapist for that matter) in a radiologist suite and expect a good medicine to pop up.
MRI has its place. It also has false positives and negatives. Using this as your sole treatment compass is a mistake.

Regards