Don’t Get a Back Scan Until You Read This!
Why Should I Get A Scan?
Have you been told this?
“We’ll get a scan so that we know exactly what is going on.”
This is a common phrase we hear as clinicians, as patient’s and practitioners’ alike search for a diagnosis or “label” to their condition, ultimately as a way of helping to guide appropriate management.
Sometimes MRI Scans Don't Give Us The Full Picture
There is still a commonly held belief by both patients and many clinicians that an MRI or Ultrasound image of a herniated disc, or degenerative joint or a torn tendon can explain why things hurt or are not functioning properly. In a lot of cases it isn’t as simple as this, and the planning of interventions and treatments using medical images alone needs to be questioned and challenged a lot more (Meakins, The Sports Physio blog).
In the case of low back pain, Richard Deyo, Professor of Family Medicine and Internal Medicine at Oregon Health and Science University,(interview with Dr Norman Swan, ABC Radio National, April 2013) cites several studies "that show that normal people, people who have never had any back pain or sciatica, often have herniated discs. They also often have degenerated and bulging discs and things that looked just awful but that don't cause them any problem at all."
In the case of a traumatic fall or accident, a scan may be necessary to rule out a broken bone that will require specific management(eg surgery, immobilisation in plaster/brace/splint).
Where there is no incident or trauma, or if enough time for healing a structure has occurred but pain is persisting, the use of scans and attributing particular findings on imaging as the specific cause of a patient’s pain may be less accurate and reliable.
What Does The Research Suggest?
There appears to be very little correlation with scan findings and a patient's reported symptoms. This has been highlighted in many studies, across many different anatomical regions.
One study (Guermazi et al) found that many common pathologies seen in knee scans - such as meniscal lesions, synovitis and articular cartilage damage are found equally, if not more in people without pain as those with pain.
Another study ( Brinjiki et al) showed a high rate of ‘pathology’ in lower back MRIs in over 3000 subjects without any pain or dysfunction – and this was in people ranging from 20 to 80 years old.
Yet another study (Nakashima et al) of over 1200 subjects, found that many pathologies were reported on neck MRI in people without pain or dysfunction.
In the shoulder, many studies have painted a very similar picture. One study (Grisih et al) found that a remarkable 96% of subjects who reported no pain or issues had at least one identifiable ‘pathology’ on their ultrasound scan. Another study (Teunis et al) also showed an increasing prevalence with age of rotator cuff tears that actually don’t result in pain or dysfunction. They showed that up to 65% of subjects with a rotator cuff lesion on imaging were found to be asymptomatic.
We can see from all of these studies that it is becoming increasingly evident that we simply cannot rely on medical imaging alone to accurately determine the reasons for a patient’s pain and dysfunction.
So what is the answer...?
Are Scans Useful at All?
While it is important to note that medical imaging clearly does have a role to play in aiding diagnosis and management of certain types of problems, it is equally as important to make sure we are using scan in the most sensible and appropriate way. Essentially, it is not prudent to use a scan alone to guide a patient’s diagnosis and management. It is more useful scans be used in combination with a thorough clinical assessment, to ensure consistency between the findings.
The Role of Clinical Examinations
In the majority of cases, a thorough, objective, clinical examination is going to provide much more reliable information to help ensure appropriate management of a patient’s presentation. In many of these cases, this can then negate the need to undertake a scan at all, saving both the patient and the health care system significant time and money, without compromising the outcome for the patient. At times a scan may be ordered purely with the rationale of reassuring the patient about their condition. This can in fact be counter-productive to patient outcomes, with evidence suggesting that patients undergoing scans that aren’t clinically indicated, often to help reassure the patient about their condition, actually “can cause more fear, angst and harm.” (Meakins, 2017; Deyo, 2103).
In many patients that we see at NWPG, the primary contributing factor to their condition is often a different structure to a reported pathology that has been identified on imaging – findings that appear consistent with the research outlined above, as well as current neuroscience research on pain. That is to say, the primary cause of their problem is not where they feel their pain. This further validates why we use the approach we do – the Ridgway Method - which utilises a thorough, whole body assessment for each patient to help solve the underlying cause of their pain and dysfunction.
Meakins, A; https://thesports.physio/2017/01/10/a-picture-is-not-always-worth-a-thousand-words/. The Sports Physio blog. Jan 2017.
Guermazi A et al; Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ. 2012 Aug 29;345:e5339. doi: 10.1136/bmj.e5339.
Brinjikji W et al; Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27.
Nakashima H et al; Abnormal findings on magnetic resonance imaging of the cervical spines in 1211 asymptomatic subjects. Spine (Phila Pa 1976). 2015 Mar 15;40(6):392-8. doi: 10.1097/BRS.0000000000000775.
Girish G et al; Ultrasound of the shoulder: asymptomatic findings in men. AJR Am J Roentgenol. 2011 Oct;197(4):W713-9. doi: 10.2214/AJR.11.6971
Teunis T et al; A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. J Shoulder Elbow Surg. 2014 Dec;23(12):1913-21.
Richard A Deyo. Real Help and Red Herrings in Spinal imaging. (Editorial) New England Journal of Medicine 2013;368;11:1056-1058