Laurie's Blogs.

Fair warning… This blog is a wee bit of a rant.  This week at the clinic we experienced a couple of incidents where our assessment and recommendations were at odds with these clients' veterinarians.  And the reason for this boils down to a difference in assessment approach and placement of importance of findings.

Case one is a lovely 12 year old female Labrador Retriever.  She suffered a fibrocartilaginous embolism that has affected both back legs and has recently been compromised with a full (unilateral) cruciate tear as well.  So the dog is self-ambulatory, the owner uses a towel to help assist walking, she is coming for UWT, she's improving, and the current discussion we are having with the client is around potentially casting for a brace to stabilize the cruciate.  We think the dog is looking pretty good and could function a bit better with a brace as she is recuperating from her FCE and CCL tear.

But… she went to her vet to have him evaluate the dog's new stifle injury as well.  The vet did x-rays of the hips (yes, hips), and noted some spondylosis and some very narrow disc spaces in the lumbar spine.  He told her that based on these x-rays, this dog must be in tremendous pain and recommended that the owner consider euthanasia!  Needless to say, the owner was very distressed.  On returning to us, we all watched this dog walk and collectively commented that she's doing great and improving with every visit.  My associate evaluated her back and found no back pain!  So we continue to recommend bracing and therapy and provide encouragement to the owner.  

The second case, is a 4 year old little Pit Bull.  She had a sudden onset rear leg lameness and when she went to her veterinarian, they took x-rays and found that her one hip is quite dysplastic.  Her vet recommended a femoral head and neck excision.  She wanted to come for a rehab evaluation, where it was found that she had an iliopsoas strain - which we've been treating.  And in the waiting room on Saturday, I can tell you that she was a wiggling blur of Pit Bull that exhibited no signs of lameness.

So how does this happen?  I think it's quite simply a difference in evaluation techniques, interpretation of findings, and what you learn to care about.  I would have to say that relying solely on medical imaging to make your diagnosis can make one a Victim of Medical Imaging Technology (VOMIT for short - credit for the term goes to Bahram Jam of www.aptei.com).  Without a thorough physical evaluation to determine if there is pain at the site that the imaging points to, then the diagnosis (and subsequent recommendations) based on the imagine is useless or at it's worst a disservice to the patient.  This doesn't just happen in veterinary medicine, we see it as well in human healthcare.  And that's where a full physical evaluation comes into play - as physiotherapists are taught, and teach, and where an assessment of function is taken into account… (hence the term pathofunctional diagnosis - as what physiotherapists provide).

My message in all of this is to say that we (the rehab practitioners) need to lead the charge in this area.  I would love to see rehab and physio become known for providing the most comprehensive physical evaluation of an animal… not just the 'toys' we use to treat with!  Want to learn more about the perils of over-reliance on medical imaging and the traditional pathoanatomical approach to medicine (in humans) , check out this weblink:  

http://www.aptei.com/articles/pdf/IRSAT_1.pdf

and here's an abstract of a lecture at the most recent Canadian Physiotherapy Association's Congress last month…. Happy reading!  Cheers!  Laurie

D002 – Diagnostic Imaging and Low Back Pain: Just Say No 

Authors/Auteurs: Cook C. 

Walsh University, Division of Physical Therapy, North Canton, Ohio, US 

Correspondence: ashley.smith2@uqconnect.edu.au 

Objectives/Objectifs: Upon completion of this session, participants will be able to: 

1. Recognize and identify the limitations of use of imaging for diagnosis of LBP 

2. Compare and contrast imaging methods with clinical methods 

3. Discuss how use of images and the identification of a "label" have affected prognoses of patients 

4. Compare and contrast the recommendations of imaging for LBP guidelines. 

Background/Contexte: Despite the fact that early use of diagnostic imaging for routine conditions of low back pain (specifically, acute low back pain) is not recommend in any of the 39 guidelines for low back pain, diagnostic imaging is still frequently used; even methods such as radiographic imaging.1 Evidence has suggested that use of early imaging may actually be detrimental to recovery from low back pain. 

Relevance/Pertinence: Physiotherapists, worldwide, have increased their presence as first line providers of musculoskeletal conditions. In some countries as well as in military based health environments, physiotherapists can order imaging. Ordering appropriate imaging is a specific skill set that any first line provider should know. The ability to discuss why imaging is not needed and “why” is also an imperative skill and a purpose of this presentation. 

Target Population/Population cible: Physiotherapist and allied health care professionals. All experience levels. 

Supporting Evidence/Résumé des faits: Diagnostic imaging is indicated for patients with low back pain only if they have severe progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition. In other patients, evidence indicates that routine imaging is not associated with clinically meaningful benefits and can actually lead to harmful results. Addressing inefficiencies in diagnostic testing could minimize potential harms to patients and have a large effect on use of resources by reducing both direct and downstream costs.2