As many of you most likely already know, ordering imaging is over-utilized for low back pain (LBP). I am specifically talking about magnetic resonance imaging (MRI) as this is usually what the layperson perceives as appropriate steps in their care to “find” the problem.
I am not going to get into the economics or false-positives of MRI for LBP as it could explode into an even large post (read a prior post here). You can find more on this in multiple articles on the web and in journals.
I really want to twist this concept and talk about how we, as physical therapists, can be of even more help to the management of LBP. The purpose of this post is to educate the physical therapy community about what really matters in the guidance of our LBP patients….the outcomes and how MRI can be negative to the end product.
Our patients usually want more imaging to help understand their pain and can be very pushy and even expect this of the ordering practitioners. I feel we have an advantage as most PTs do not have this ability (unless you work in military setting). It allows us to be able to perform a comprehensive clinical exam and educate the patients without having the weight of this intervention with limited benefit on our shoulders.
Other than in reserved cases (CA, progressive neurological deficit, cauda equina syndrome, infection, etc.), there is limited clinical significant of most imaging abnormalities seen on MRI. Advanced imaging is very important and can affect clinical decision making in the former but for the majority of LBP, the results of magnetic resonance does not change the management of the patient. This is really what matters, right?
Now on to the negative effects:
1. Psychological. Most of the time (~85%), we do not have a clear diagnosis with a clinical exam. MRI can provide the patient with one, or several, but is this better? There is definitely a negative aspect to “knowing” you have bulging discs and degeneration, even if this is seen in asymptomatics. Getting the false positive data through a thick skull is just about the most difficult thing I do daily. Clinically irrelevant imaging can impede the prognosis greatly. It can create fear avoidance beliefs and make the patient worry too much. I see this personally everyday and could use help. Any ideas of how to address this?
2. Increased surgery rates. Patients want to avoid surgery. They tell you this all the time. But, what they don’t know is that having advanced imaging (unless the practitioner suspects a non-mechanical cause) is usually the first step to being wheeled into the operating room. There is a strong correlation between advanced imaging and surgery with research demonstrating two to eight-fold likelihood of going under the knife. Rate of spine MRI increased sharply at same rate of lumbar surgery. These are simply the steps taken that follows clinical guidelines and patient needs to know this.
3. Costs. I really do not want to get into this topic here but I want you to understand that advanced imaging has a huge economic impact. Not only due to the simple cost of MRI (~$2000) but financial incentives by ordering practitioners and greater availability of scanners now. Then, we get the blunt of the financial limitations through co-pays as are are trying to help the patients. You can imagine the souring costs without improved clinical outcomes.
This list is not all-inclusive but gives you an idea of my point.
What I really want to close with is with one study (a meta-analysis at that) from Chou et al in Lancet 2009. This is what the authors concluded:
“1804 patients with primarily acute or subacute low back pain and no clinical or historical features that suggested a specific underlying condition, found no differences between routine lumbar imaging (radiography, MRI, or CT) and usual care without routine imaging in terms of pain, function, quality of life, or overall patient-rated improvement.”
This basically sums it up. Does the “diagnosis” matter, or are we really treating to improve “pain, function, quality of life and overall patient-rated improvement”?
How can physical therapists help? Spend 5 minutes on educating your patients this week about these findings. Also, our face-to-face contact, no burden on ordering advanced imaging, comprehensive clinical examination skills, and touch through manual therapy intervention gives us the advantage to providing the best and most appropriate care.
What are your thoughts? I would love to hear you feedback and get ideas of how you address this to patients in your community.
Chou et al. Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Ann Intern Med. 2011;154:181-189.
Deyle GD. The Role of MRI in musculoskeletal practice: a clinical perspective. JMMT. 2011.
Chou R, Fu R, CArrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009; 373:463-72.