CF 108: Are MRI’s On The Outs? & The Ease of The Arm Squeeze
Today we’re going to talk about why MRI’s in the early going are out and we’ll talk about how easy and useful the Arm Squeeze Test is for differentiating arm pain from cervical radiculopathy pain.
But first, here’s that sweet sweet bumper music
OK, we are back and you have found the Chiropractic Forward Podcast where we are making evidence-based chiropractic fun, profitable, and accessible while we make you and your patients better all the way around.
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You have collapsed into Episode #108
Now if you missed last week’s episode, we talked about how insurance may be warming up to chiropractic in the coming year and years and we covered research behind chiropractic treatment for sciatica. Make sure you don’t miss that info.
On the personal end of things. I don’t even want to tell you how my life’s been going lately to be honest because it hasn’t been a lot of fun.
We put my Dad in a nursing home this weekend because insurance is done paying for him to continue to stay at a rehabilitation hospital. My stepdad had his appendix out on Christmas day. I have a pre-teen daughter that I’m trying to figure out. I had someone throw a rock through my office’s front door glass just yesterday and steal our cash box. Luckily they only got about $500. Then, later that night I got a nail in my tire picking up food for the family, get it home, hear my tire hissing, get my son to follow me to drop my truck off at the tire store for the next morning, then get back home only to find out that the only sandwich left out of the damn take-home order……yes…it was my freaking sandwich.
So, that’s my life lately and I don’t want to talk about it. I want to talk about research. Lol. So let’s get to it. –
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Let’s start with an orthopedic test that came up on a post on the Forward Thinking Chiropractic group. I had actually learned about the Arm Squeeze Test from the DACO/DIANM program and through Tim Bertelsman and Brandon Steele with ChiroUp but for whatever reason, have been inconsistent in using the test. I forget about it is what I’m saying to you right here right now. But no more I say!
This paper we’re using today is called “Arm Squeeze Test: a new clinical test to distinguish neck from shoulder pain” by Gumina, et. al. and published in European Spine Journal in 2013(Gumina S 2013).
Now, look, what if you could find the fastest, easiest way to distinguish pain in the arm either coming from the shoulder or arm or whether it’s coming from the neck? What if it was so easy that you could just reach out and grab someone’s arm? Like…..really….that easy. The ease of the arm squeeze. That just rolls off of the tongue. Don’t you agree? The Ease Of The Arm Squeeze. Lol
Well, it is that easy so listen up friends, family,……loved ones.
Why They Did It
They wanted to evaluate the diagnostic values of the Arm Squeeze Test where the clinician basically grabs the middle third of the arm and gives it a bit of a squeeze.
How They Did It
- There were 1,567 patients included in the study.
- DX of cervical root compression or shoulder disease was clinically formulated and confirmed with imaging
- 350 healthy volunteers were used as the control group
- The test was positive when the score on the VAS scale was 3 points or higher on squeezing the middle third of the upper arm
What They Found
- The test was positive in 295 out of 305 patients with cervical nerve root compression.
- The test had a sensitivity of 96% and a specificity of 91%.
The conclusion states, “The Arm Squeeze Test may be useful to distinguish cervical nerve root compression from shoulder disease in case of doubtful diagnosis. A positive result to this test may lead to cervical etiology of the shoulder pain.”
From reaching out and grabbing someone’s arm. You’re welcome folks. You’re welcome. Making you better every damn day.
Being in an evidence-based practice and being aware of updated guides and recommendations, you know that healthcare is moving away from MRI’s as a knee-jerk reaction. Why would that be, you may ask… Well, because they’ve found it leads to an escalation of care.
When a surgeon sees a bulge or herniation, if he or she isn’t quite up to snuff on research, they may just think they can cut that out and the person will be off and running again. When many times, that little bulge isn’t what is causing the pain.
Did you know that a perfect surgery performed on a person in chronic pain syndrome puts them at a 60% chance of developing new chronic pain at the new site of injury? That’s when everything goes perfectly.
What I’m saying is that you can’t always just cut out pain and MRI’s many times lead doctors to think that they actually can so care gets escalated.
I tell patients to be careful what they’re looking for because they sure as hell just might find it. If you go barking up the surgery tree, you just might get some of that tree on you.
So this article is by Paul Ingraham and is called “MRI and X-Ray Often Worse than Useless for Back Pain” and it was published on PainScience.com on February 16, 2019(Ingraham P 2019).
Not piping hot but hot enough for this!!!
We’ll just hit the highlights here.
One of the first interesting statements is when he says, “Premature MRI is actually often worse than useless.” Look, let’s be honest, healthcare is a profit-driven profession for the most part. It’s not very patient-centered in my experience. Especially when we’re talking about our medical counterparts.
Want proof? Is charging $15-$20 for an ibuprofen or Tylenol patient-centered? Hell no it’s not but hospitals do that crap all day every day. Well, MRI centers are the same. $550 cash but $2500 for insurance payors. Lol. I mentioned not long ago on the podcast that I had the opportunity to buy into an imaging facility but two different lawyers told me to stay far far away because I don’t look good in orange.
However, the imaging center acted like it was as legal as could possibly be.
Anyway, back to the actual usage of MRI…..The American College of Physicians recommended in a paper all the way back in 2007 that “Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence).(Chou R 2007)”
For the WHEN part, they recommended: “Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence).”
In this same ACP paper from way back in 2007, they made the recommendation “For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation”
Now we know they updated that recommendation in 2016(Qaseem A 2017) to a strong recommendation for those alternative therapies but I was this many days old when I found out they were talking about spinal manipulative therapy way back in 2007.
Another interesting statement from Mr. Ingraham was this one: “Consider the results of a major 2015 review by Brinjikji et al: signs of degeneration are present in very high percentages of healthy people with no problem at all. “Many imaging-based degenerative features are likely part of normal aging and unassociated with pain.”
Well, we know this. We can even put rough numbers to it. We know that 40-50-year-olds with no pain at all can get an MRI and 60% of them are going to have degenerative changes, disc findings like herniations or disc bulges, and/or facet hypertrophy. It’s just a given.
They’re going to find disc findings in about 30% of freaking 20-year-olds.
So, he says, let’s assume we understand some MRI findings are red herrings. OK, so what’s the harm in getting them then? Well, because findings on MRI’s freak people the hell out and not all practitioners have a firm handle on how to actually communicate with people in a productive way when they give the report.
If the doctor says well there’s this degeneration and we see a narrowing of this hole here where the nerves run that will probably get worse in the next decade so you’re going to really want to be careful and keep an eye on that……well hell….. Take a person already on the verge of chronic pain syndrome, that doctor just pushed them off the cliff. A patient already in chronic pain syndrome just got pushed in deeper. It’s like taking someone that’s having a hard time keeping afloat in the water and tossing them a bag that weighs 20lbs. Not helpful.
He says, “There’s expert consensus on this topic because the evidence is quite clear. Consider the hair-raising 2016 experiment that sent the same woman with back pain and sciatica to ten different MRI facilities, producing such a variety of conflicting diagnoses that it would be laughable if it weren’t so tragic.”
The bottom line: Typically, no imaging outside of red flags. If you think something ominous may be going on, of course you do imaging. Without question. If there are no red flags, how about a two-week treatment trial to see how the patient progresses before sending out for imaging?
That’s patient-centered. That’s evidence-based.
Part of making your life easier is having the right patient education tools in your office. Tools that educate based on solid, researched information. We offer you that. It’s done for you. We are taking pre-orders right now for our brand new, evidence-based office brochures available at chiropracticforward.com. Just click the STORE link at the top right of the home page and you’ll be off and running. Just shoot me an email at [email protected] if something is out of sorts or isn’t working correctly.
If you’re like me, you get tired of answering the same old questions. Well, these brochures make great ways of educating while saving yourself time and breath. They’re also great for putting in take-home folders.
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I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment instead of chemical treatments like pills and shots.
When compared to the traditional medical model, research and clinical experience show us that patient results for headaches, neck pain, back pain, and joint pain just to name just a few.
It’s safe and cost-effective. It can decrease surgeries & disability and we normally do it through conservative, non-surgical means with minimal hassle to the patient.
And, if the patient develops a “preventative” mindset going forward from initial recovery, we can likely keep it that way while raising the general, overall level of health of the patient!
Patients should have the guarantee of having the best treatment offering the least harm. When it comes to non-complicated musculoskeletal complaints….
Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show or tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on iTunes and other podcast services. Y’all know how this works by now so help if you don’t mind taking a few seconds to do so.
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We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.
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About the Author & Host
Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger
- Chou R, Q. A., Snow V, Casey D, (2007). “Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society.” Annals of Internal Medicine 147(7): 478-491.
- Gumina S, C. S., Postacchini F, (2013). “Arm Squeeze Test: a new clinical test to distinguish neck from shoulder pain.” Eur Spine J 22(7): 1558-1563.
- Ingraham P (2019) “MRI and X-Ray Often Worse than Useless for Back Pain Medical guidelines “strongly” discourage the use of MRI and X-ray in diagnosing low back pain, because they produce so many false alarms.” PainScience.com.
- Qaseem A (2017). “Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians.” Ann Intern Med 4(166): 514-530.