359- Reliability of Cervical Spine Pain Drawings

Welcome to the Evidence Based Chiropractor where each week we deliver the latest chiropractic research and marketing strategies all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. This week we are back with research. A literal brand new study that just came out. It's all about determining the level of cervical radiculopathy. Agreement between visual inspection of pain drawings and MRI imaging. So this is going to be an interesting one. A lot of interesting take home findings, many of which are clinically relevant. As you examine your patients, as you see what's going on, as you make those decisions, not only to what you're going to do in your practice, but but if you need to make a referral decision out of your practice, we're gonna touch on that and much more on today's episode. Before we get started, I wanna say a few words about the smart chiropractor. The smart chiropractor can power your patient journey to provide you with more new patients, better retention and consistent reactivations without spending any money on paid advertising. You wanna see how we do that for over 300 chiropractors around the world? Head over to thesmarchiropractor.com Hop on a demo, see what we can do with you. And for your practice, TheSmartChiroPractor.com schedule a demo over there. But as I said at the top, we're talking research. This study came out really, really recently in 2022 in pain practice. The title is what I said earlier. I'm gonna drop the link down in the show notes if you wanna check it out, but it's titled Determining the level of cervical radiculopathy. Agreement between visual inspection of pain drawings and and mri. So this is all about the cervical spine. Cervical radiculopathy, as we all know very well, refers to a group of signs and symptoms that are about nerve compression or irritation of a cervical nerve root. Patients with cervical radiculopathy, we've seen it all a million times. They have sensory changes, they might have sensory loss, sensory gain, they have motor abnormalities that could be reduction in strength or reflexes. And many of them also have unilateral neck and arm pain traveling down along those dermatones, which we'll go into later. So how often does this happen? The age adjusted incidence is 83.2 times out of 100,000, so probably a little less frequently than initially considered. And that Tops out at about 203 out of every 100,000 people between the ages of 50 and 54. So between 50 and 54 is the highest incidence. Incidence, highest likelihood, about 203 people out of every 100,000 people. So I actually thought that was a little bit lower than I anticipated. Especially when you think about low back pain and how ubiquitous it is. Cervical radiculopathy, all right, you know, 200 out of 100,000, that's a decent amount, but not nearly as much as I initially thought. Now, about 55% of individuals experience most improvement in symptoms and function within 12 months. And here's the real good news. 83% recover completely within two to three years. Now, here's the catch. Somebody comes in with cervical radiculopathy and you start and they have a hot disc pressing on a nerve, causing pain, numbness, tingling, whatever it might be. And you say, well, 83% of people recover within two years. They're like, how about two days from now, man? Like, I can't wait two to three years. Which is often why people go to advanced interventions far too early, is they just don't want to put up with it. And they can't put up with it because it could really hurt and really cause issues. But the really great part about it is over half of people have a lot of improvement in, again, symptomatology, the pain as well as function within 12 months, and 83% recover completely within two to three years. I think about this and it reminds me of marketing I was listening to on a guy named Alex Hermosi, ran a lot of gyms a while ago, and he talks about one of the value adds is the reduction in time between the conversation and the result. And the more that you can crush down that time between conversation, quote, unquote, sale and result, the more value you have. And to me, I'm like, man, this makes sense. When somebody walks into a doc that's not a chiropractor and they're like, take this pill and you'll feel better today. Let's do an ejection. And you'll find relief in one hour. And why people go that direction and why it's a lot more challenging and a lot more difficult when it takes longer. Now, as we all know as chirofractors, usually within two to three visits, they're gonna be feeling a heck of a lot better, which is awesome. We have that supremely in our favor. But two to three year thing, what I'm saying here is it's awesome news. But it's probably not what you want to bring up on the first visit. You're gonna scare a lot of people off being like, oh, my gosh, I cannot wait that long. I'm worried about tomorrow. Nevermind two to three years down the road. But it's reinforcing to know that. So the attribution of symptoms to specific nerve roots using MRI is challenging. Why? Because of spondylytic changes, discogenic changes in asymptomatic individuals. It just sort of muddles the pie. I brought up this example before. I'll bring it up again. When IU was reviewing about 20 MRIs with patients every single day in the orthopedic group, I would just tell them straight up, hey, when we look at your report, it's gonna look like you have stuff wrong all over the place. It's pretty scary. I understand that. But think about it this way. Everything listed on your MRI report is everything that's not perfect. Not perfect is a. Okay, you are 45 years old. You're 60 years old. Whatever it might be. Not perfects are okay. My job is to sort through those and find the problem. And quite often, they were, of course, presenting with pain, so they'd have something going on to be. Quite often the problem is one or two things, not the 20 things you see on the report. Most of that is a normal part of the aging process. So don't be stressed out or scared. Oh, okay. Thank you, doc. So that's an important component there. So a pain drawing is also commonly completed by patients, so that you can really understand. Right. Probably most of us use, whether in our ehr, digitally on our iPads, or whether the patient's drawing it, we really use visual inspection of a pain drawing to get a good idea. And I'm gonna say, especially as chiropractors, quite often patients don't have MRI images. So we're kind of like, okay, let's take a look at what's going on with the pain drawing. Let's go through our exam, of course. But let's take a look at what's going on with the pain drawing to get a good idea of where we think the challenge might be. So in this study, every single patient, 98 patients, every single one of them was actually scheduled already for an anterior surgical decompression or posterior foraminotomy. Laminotomy. Anything anterior, typically, is gonna be a fusion. Posterior is going to be your foraminotomy and laminotomy. So they were literally scheduled, nearly 100 people. They're scheduled for surgery when this was going on. So this is a high stakes study, so to speak. Participants were considered for this study if they were aged between 18 and 70. They had cervical disc disease and cervical radiculopathy diagnosed on an mri. So all these patients had an MRI because they were scheduled for surgery already. So of course that had been reviewed. Participants had to have a minimum two month history of persistent pain. Let's set some baselines. Pain intensity was measured. They did a lot of I guess questionnaires workup in this and I want to touch on three of them right now. One of them is they use a VAS. So 0 was no pain, 100 was worst imaginable pain. And patients were asked to complete the VAs for neck pain, arm pain and headache intensities over the last month. Secondarily they did a ndi, a neck Disability Index. Prob use this in your practice or if you're a student, use it in student clinic. Was used to assess pain related disability, specifically related to neck pain. The NDI consists of 10 items grading neck pain disability from 0 to 50 and then it's expressed as a percentage. And finally they used a psychological test, a depression test, the Zung Self Rating Depression Scale which assesses affective, psychological and somatic symptoms associated with depression. Scores range between 20 and 80 and are classified as normal, mild depression, moderate to marked or major depression or extreme depression. So which I think it's really impactful that they measured that specifically related to neck pain. As we've seen in previous studies, there's a lot of correlation between psychological factors and depression and what people are experiencing in neck pain. And I think it also plays a huge role in the recovery process as well. It's not only the experience of pain, it's the opportunity to break through and find results. A lot of that is mental and it's not that mental. Somebody that's not in the healthcare field, they hear that and they think that translates to you're making it up. And this is one of the challenges. I think one of the big opportunities for us as healthcare providers, as chiropractors, as trusted healthcare providers for many of our, almost all of our patients is being able to help them understand that those are two different things. Just because something has a psychological effect effect or it's influenced by how you're thinking and how you're feeling, it doesn't mean that you're making it up. It actually means that the problem could seem a lot worse than it really is. And that's good news because it shows us that as we take care of that structural issue, as you start to see improvement, then you're going to be able to really rapidly improve because you'll start feeling better, you'll start understanding that there's light at the end of the tunnel. And that can really accelerate the healing process. Because a lot of what many patients are dealing with is catastrophizing, what's going on, a lot of fear, avoidance behavior, rightfully so. And you stack on. And they could have sensitization and really physiological type things, but then you stack on, you know, depression, you stack on all of these other items, man. Chronic pain and even acute pain, it is difficult to deal with. And we see it all day, every day. And sometimes we can become desensitized to it, I think. But it is a super, super real thing for people in guiding their, not that we're psychologists or psychiatrists, but just guiding their optimistic approach to what they can control, how they can improve. Tying back to that 83% of people are going to recover without having advanced intervention. That's a great thing. And less than 5% really probably ever go through surgical intervention. These are great things. So you don't need to be super concerned about that. Even though this is two days old, it hurts like craz, you know that there's an MRI maybe, maybe it's been more than two days old. If they've had an MRI taken, but they see the mri. I got a disc herniation. Gosh, I need surgery. I knew it. Oh man. And then all the fear with that. Hold your horses. Even if you have a disc herniation on an image, it does not mean by any stretch of the imagination they need to jump towards having surgical intervention. So back to this study. The body charts were used for the pain drawings and they had like two androgynous body, you know, templates, you know, with ventral and dorsal sides of the body. Participants were asked to shade with a pencil on these templates every area that they felt pain independent of the pain severity. So it wasn't about where the pain is the worst, it's where they were experiencing pain. And this is the same type drawings that we probably have our patients do all day, every day. So what happened? Well, overall, the clinicians responses correctly corresponded with MRI results on 35% of the time it correlated. There was little agreement with MRI verified C4 and C5 levels by any clinician. The average agreement for CC6 was 34%. For C7 was topping out at a whopping 48%. So pain drawings unbelievably nonspecific and just inter clinician or intra clinician variability, super high. This study revealed a very poor overall agreement between clinical interpretation of the level affected based on the patient's pain drawing and the affected cervical level as identified in mri. Now, important thing to keep in mind, this is about pain and sensory. It is not about whether or not a nerve root, if it has a motor dysfunction, a motor dysfunction, totally different thing. This is pain. I want to be super clear on that. This is pain. And what does that tell us? The dermatome patterns are all over the place. So the C4 and C5 spinal segments comprising of 11 patients showed little to no agreement. A range was 0% to 14%. And we see a lot of issues at C4, C5. So, you know, take, take the pain drawing. Maybe with, I wouldn't say a grain of salt, but not much more. A previous study also concluded that pain attributed to the cervical spine nerve roots was Non dermatomal nearly 70% of the time. So are pain drawings valuable? Maybe. And I know we've all experienced this. I would see a patient and we'd give them the pain drawing and they just would mark their whole arm and neck. And quite frankly, I'd have a hate to admit this, but kind of an eye roll, oh boy, one of these, it hurts every. It probably did. And I'd be looking at an MRI saying, Gosh, they know they have a C5 issue and they're saying they got pain all over the place. Well, 70% of the time pain with a nerve root is non dermatomal in distribution. So what is the efficacy of those pain drawings? Probably pretty low. Participants in this study were scheduled to have surgery. The the psychological profile of the patients showed that 65 of the 98 participants felt their pain as always and 40 of them thought their life was miserable because of the pain. So important from a psychological perspective. As we touched on earlier. Overall, their findings refer to pivotal importance of multi component evaluation of patients with cervical olejiculopathy. What was the conclusion? It was quote, pain presentations of patients with single level cervical radiculopathies proved to be very different to classical dermatomal distributions of pain. There was poor overall agreement between the clinician's interpretation of the cervical level affected based on the pain drawings and that identified on the mri. So big take home message here. Those pain drawings that you're relying on, you might want to not rely on them 100%. MRI can have high variability and there's a lot of noise. So to speak because of asymptomatic findings. However, you're going to see really what's going on where pain distribution can be all over the place. A majority of the time it's non dermatomal in distribution and a majority of that time it does not even follow the dermatomes as would be expected. So all I think important information that we can highlight, think about and utilize as we speak with our patients, understand what's going on with those people struggling with and suffering from cervical radiculopathy. So great new study, really, really impactful, really, really important. We're gonna drop those links down in the show notes. As I said earlier, before we wrap up, I wanna ensure that you take advantage of some that helps this podcast. I want you to help them and help yourself. Head over to Power Step and pick yourself up a free pair of custom orthotics. Yes, I said free. They'll hook you up. Pro.powerstep.com sample pro.powerstep.com sample we'll drop that link in the show notes, use the code ebc Evidence Based Chiropractor ebc and they will hook you up with a free pair of orthotics. These are what I use myself. They're what my father uses. Designed by a podiatrist over 30 years ago. They're the real deal. Check them out. Get a free sample pair. See if it's something that you can use yourself or even better, that you can help many of your patients with that are struggling. Additionally, if you're looking to build your team as we drive into this fourth quarter of the year, are you looking to hire a new chiropractic assistant or a new associate doctor in your practice? If so, don't go it alone. Head over to Chiro Matchmakers and schedule a complimentary call with one of our DC placement specialists. We've done this hundreds of times. We use assessments. Not gut feeling, sourcing, vetting, assessing, interviewing. There's no wonder that so many relationships turn out poorly. And that is because chiropractors are not professional recruiters. And there's contract and comp plan issues. You name it. We've all probably either experienced it from one side being the associate or the other side being the owner. You don't need to go that way if you're an associate. We have over 100 jobs available right now where we go through that entire process. Comp plans are great. 85k base and above. Head over to Cairo Matchmakers if you're looking to hire a CA or a DC do not go alone. You're going to waste a ton of time, effort, energy and money. Head over, have a conversation, complimentary conversation. See if we can help you. Chiromatchmakers.com I hope you have a fantastic week in practice and let me pause on that. If you've listened to this and you continue to listen to this podcast, each and every week I meet more and more people that have. Thank you so much. It really means a ton to me. We've been producing this podcast I think for almost five or six years. We're closing in not too distant Future here on 400 episodes. So thank you so much for taking time out of your day. Thank you for the emails that I receive. And if you have not left a rating or review, scroll on down. 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