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Many Shades of Grey
December 29, 2013 by Dr Matthew D. Long
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December 29, 2013 by Dr Matthew D. Long
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Many Shades of Grey
December 29, 2013 by Dr Matthew D. Long
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While there remains ongoing debate about the role of chiropractors in the health care system, the public typically looks to us for help with some form of musculoskeletal pain. Indeed, most contemporary surveys show that the treatment of pain ranks at the top of the list of reasons why a patient will consult a chiropractor (1,2,3). Although we could effectively argue about the importance of functional deficits as a precursor to musculoskeletal damage, the fact remains that our patients expect us to be competent in diagnosing the origin or their pain. The trouble is, this isn’t always straightforward…
Over past decades science has worked hard to establish a body of knowledge capable of giving us diagnostic certainty. During our undergraduate training we typically learn the characteristic patterns of musculoskeletal disease. How does a particular condition present? What will a patient usually complain of? How will the examination unfold? The question is, how reliable are these characterisations and can they really give us better outcomes? If we wish to be mature and honest clinicians then the first step is to realise the limitations of our knowledge and our tools - whether they are traditional orthopaedic tests or the assessment procedures put forward by chiropractic technique systems.
An example of our need to remain cautious can be seen in the validity of dermatomal maps. Traditional dermatome theory suggests that individual nerve roots will reliably innervate discrete territories of skin, with perhaps small variations amongst individuals. But contemporary research suggests that they differ more widely than previously thought. Indeed, a paper by Murphy et al (4) investigated the reliability of such maps in the lower limb and suggests that;
Over past decades science has worked hard to establish a body of knowledge capable of giving us diagnostic certainty. During our undergraduate training we typically learn the characteristic patterns of musculoskeletal disease. How does a particular condition present? What will a patient usually complain of? How will the examination unfold? The question is, how reliable are these characterisations and can they really give us better outcomes? If we wish to be mature and honest clinicians then the first step is to realise the limitations of our knowledge and our tools - whether they are traditional orthopaedic tests or the assessment procedures put forward by chiropractic technique systems.
An example of our need to remain cautious can be seen in the validity of dermatomal maps. Traditional dermatome theory suggests that individual nerve roots will reliably innervate discrete territories of skin, with perhaps small variations amongst individuals. But contemporary research suggests that they differ more widely than previously thought. Indeed, a paper by Murphy et al (4) investigated the reliability of such maps in the lower limb and suggests that;
“In most cases nerve root pain should not be expected to follow along a specific dermatome, and a dermatomal distribution of pain is not a useful historical factor in the diagnosis of radicular pain. The possible exception to this is the S1 nerve root, in which the pain does commonly follow the S1 dermatome.”
Such overlap may well create confusion when faced with a patient exhibiting multilevel spinal degeneration and nerve root compromise. Which root is the cause of the patient’s pain? This might not seem too problematic for a chiropractor, who has the opportunity to try more than one approach to treatment - but to a surgeon the need for specificity is critical.
And what about a patient who has more than one potential pain condition - such as the individual with spinal stenosis and hip joint osteoarthritis? Could a hip disorder truly mimic the pain of radiculopathy? According to a paper by Saito and colleagues (5), this is exactly what can happen. In their study the authors identified patients with severe pain in the lateral aspect of their lower leg, yet little-to-none in their back, buttock or thigh. While plain X-rays of the hip did identify osteoarthritis, advanced imaging of the spine confirmed significant central canal stenosis (see Fig 1.) and compression of the L5 nerve root. But the investigators went even further - using lidocaine to anaesthetise the L5 root and confirm it as the origin of the patient’s symptoms. Finally, they also infiltrated the hip joint on the symptomatic side with lidocaine to rule out the possibility that the hip was actually the culprit - in no case did this injection reduce the lower leg pain.
You would be forgiven for thinking that this battery of tests and procedures should be sufficient to confirm the L5 nerve root compression as the origin of the patients’ lower leg pain. But after successful decompression and posterior fusion surgery they were still left with their original symptoms, and12 months later it remained. Finally, the authors decided to perform a total hip replacement on the affected side, which was successful in removing the patients’ symptoms in all cases.
And what about a patient who has more than one potential pain condition - such as the individual with spinal stenosis and hip joint osteoarthritis? Could a hip disorder truly mimic the pain of radiculopathy? According to a paper by Saito and colleagues (5), this is exactly what can happen. In their study the authors identified patients with severe pain in the lateral aspect of their lower leg, yet little-to-none in their back, buttock or thigh. While plain X-rays of the hip did identify osteoarthritis, advanced imaging of the spine confirmed significant central canal stenosis (see Fig 1.) and compression of the L5 nerve root. But the investigators went even further - using lidocaine to anaesthetise the L5 root and confirm it as the origin of the patient’s symptoms. Finally, they also infiltrated the hip joint on the symptomatic side with lidocaine to rule out the possibility that the hip was actually the culprit - in no case did this injection reduce the lower leg pain.
You would be forgiven for thinking that this battery of tests and procedures should be sufficient to confirm the L5 nerve root compression as the origin of the patients’ lower leg pain. But after successful decompression and posterior fusion surgery they were still left with their original symptoms, and12 months later it remained. Finally, the authors decided to perform a total hip replacement on the affected side, which was successful in removing the patients’ symptoms in all cases.
Figure 1. Seventy-nine-year-old woman showing severe pain at the lateral aspect of her left lower leg but slight pain around her hip joint or buttock pain. Plain radiographs showing degeneration of the lumbar spine and osteoarthritis at both sides of the hip joints (A). Magnetic resonance image (B) and myelogram (C) showing central spinal canal stenosis at L4–L5. Decompression and postero- lateral fusion surgery was performed at the L4–L5 level, but this was not effective for leg pain (D). Ultimately, total hip replacement was performed, and the patient became free of leg pain (E).
From SPINE 37(25), 2089–2093. ©2012, Lippincott Williams & Wilkins
So in Saito et al’s study they found patients who exhibited L5 nerve root compression, L5 dermatomal pain, did respond to L5 anaesthetic block, didn’t respond to anaesthetic block of their hip - yet who ultimately found their pain arose from their hip joint.
How could this be?
The authors theorised that this all comes down to neurology. The hip joint capsule is innervated by spinal levels L2-S1, with the posterior portion of the capsule specifically supplied by the articular branch of the sciatic nerve (L4, L5, S1). Given that the subjects’ pain disappeared with an L5 nerve root block, it seems that hip joint pain is carried by the L5 root level. In a situation in which the patient also shows clear-cut L5 nerve root compression we would be forgiven for thinking that the pain must arise from the spine - particularly if the patient did not exhibit other characteristic signs of hip joint involvement and a local hip anaesthetic was useless. But Saito suggests that this may simply reflect the incomplete nature of hip joint anaesthetic techniques and the fact that central pain mechanisms were probably more involved in this patient population.
Other authors have also confirmed this tendency for the hip joint to radiate pain far from its source. Khan and colleagues (6) found that degenerated hip joints would refer to the leg in the following fashion; anterior thigh (59%), posterior thigh (43%), anterior knee (69%), shin (47%), and calf (29%).
So what are the implications for chiropractors?
How could this be?
The authors theorised that this all comes down to neurology. The hip joint capsule is innervated by spinal levels L2-S1, with the posterior portion of the capsule specifically supplied by the articular branch of the sciatic nerve (L4, L5, S1). Given that the subjects’ pain disappeared with an L5 nerve root block, it seems that hip joint pain is carried by the L5 root level. In a situation in which the patient also shows clear-cut L5 nerve root compression we would be forgiven for thinking that the pain must arise from the spine - particularly if the patient did not exhibit other characteristic signs of hip joint involvement and a local hip anaesthetic was useless. But Saito suggests that this may simply reflect the incomplete nature of hip joint anaesthetic techniques and the fact that central pain mechanisms were probably more involved in this patient population.
Other authors have also confirmed this tendency for the hip joint to radiate pain far from its source. Khan and colleagues (6) found that degenerated hip joints would refer to the leg in the following fashion; anterior thigh (59%), posterior thigh (43%), anterior knee (69%), shin (47%), and calf (29%).
So what are the implications for chiropractors?
1. We need to understand the limits of our science. There is inherent uncertainty in all aspects of patient evaluation, whether it is using standard orthopaedic and neurological testing or other chiropractic ‘technique systems’. While there may not exactly be 50 shades of grey, our world is certainly not black and white. A responsible clinician recognises these limits and keeps their mind open to possibility. Indeed, the more we know the more we can take comfort from the fact that the only certainty is our uncertainty. Embrace it, and maintain a sense of skepticism with all clinical scenarios - constantly asking yourself “What else could this be?”
2. Understand contemporary theories of pain, such as central sensitisation or distorted body schema. Too often a clinician might rule out a possible pain source as it doesn’t fit their narrow understanding of how pain is supposed to work (e.g. nerve compression or inflammation). But pain science is progressing in leaps and bounds, and new ideas of pain expression continue to amaze us and allow us to explain seemingly bizarre clinical situations.
In the end, the pace of scientific discovery is so great that we must all adopt the approach advocated by Robert Leach some years ago in his book “The Chiropractic Theories”, that of the scientist-practitioner. Leach suggests that each of us need to embrace the thinking and methodology of a research scientist in our own practices, both to improve individual patient outcomes and to grow the body of knowledge that we all rely upon to move our profession forward. That is, we approach each patient as an unknown quantity and form our initial hypothesis, then test that hypothesis through a trial of treatment and re-evaluate. In other words, we need to keep our brains’ switched on.
Something to think about…
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
Something to think about…
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
References:
1. Lawrence, D. J., & Meeker, W. C. (2007). Chiropractic and CAM utilization: a descriptive review. Chiropractic & Osteopathy, 15, 2. doi:10.1186/1746-1340-15-2
2. Murthy, V., Sibbritt, D., Adams, J., Broom, A., Kirby, E., & Refshauge, K. M. (2013). Consultations with complementary and alternative medicine practitioners amongst wider care options for back pain: a study of a nationally representative sample of 1,310 Australian women aged 60–65 years. Clinical Rheumatology. doi:10.1007/s10067-013-2357-5
3. Hurwitz, E. L. (2012). Epidemiology: Spinal manipulation utilization. Journal of Electromyography and Kinesiology, 22(5), 648–654. doi:10.1016/j.jelekin.2012.01.006
4. Murphy, D. R., Hurwitz, E. L., Gerrard, J. K., & Clary, R. (2009). Pain patterns and descriptions in patients with radicular pain: Does the pain necessarily follow a specific dermatome? Chiropractic & Osteopathy, 17, 9. doi:10.1186/1746-1340-17-9
5. Saito, J., Ohtori, S., Kishida, S., Nakamura, J., Takeshita, M., Shigemura, T., et al. (2012). Difficulty of Diagnosing the Origin of Lower Leg Pain in Patients With Both Lumbar Spinal Stenosis and Hip Joint Osteoarthritis. Spine, 37(25), 2089–2093. doi:10.1097/BRS.0b013e31825d213d
6. Khan AM, McLoughlin E, Giannakas K, et al. Hip osteoarthritis: where is the pain? Ann R Coll Surg Engl 2004;86:119–21.
7. Leach, Robert. (2003) The Chiropractic Theories - A Textbook of Scientific Research. Lippincott Williams & Wilkins; Fourth edition (November 13, 2003)
1. Lawrence, D. J., & Meeker, W. C. (2007). Chiropractic and CAM utilization: a descriptive review. Chiropractic & Osteopathy, 15, 2. doi:10.1186/1746-1340-15-2
2. Murthy, V., Sibbritt, D., Adams, J., Broom, A., Kirby, E., & Refshauge, K. M. (2013). Consultations with complementary and alternative medicine practitioners amongst wider care options for back pain: a study of a nationally representative sample of 1,310 Australian women aged 60–65 years. Clinical Rheumatology. doi:10.1007/s10067-013-2357-5
3. Hurwitz, E. L. (2012). Epidemiology: Spinal manipulation utilization. Journal of Electromyography and Kinesiology, 22(5), 648–654. doi:10.1016/j.jelekin.2012.01.006
4. Murphy, D. R., Hurwitz, E. L., Gerrard, J. K., & Clary, R. (2009). Pain patterns and descriptions in patients with radicular pain: Does the pain necessarily follow a specific dermatome? Chiropractic & Osteopathy, 17, 9. doi:10.1186/1746-1340-17-9
5. Saito, J., Ohtori, S., Kishida, S., Nakamura, J., Takeshita, M., Shigemura, T., et al. (2012). Difficulty of Diagnosing the Origin of Lower Leg Pain in Patients With Both Lumbar Spinal Stenosis and Hip Joint Osteoarthritis. Spine, 37(25), 2089–2093. doi:10.1097/BRS.0b013e31825d213d
6. Khan AM, McLoughlin E, Giannakas K, et al. Hip osteoarthritis: where is the pain? Ann R Coll Surg Engl 2004;86:119–21.
7. Leach, Robert. (2003) The Chiropractic Theories - A Textbook of Scientific Research. Lippincott Williams & Wilkins; Fourth edition (November 13, 2003)