By February 20, 2015 7 Comments Read More →

“Over-Imaging” the Lower Back

Not a very imaginative title I know! But hopefully my final post on Imaging for a little while. Apologies if it has become a of focus on this blog recently, but I think it is a critical issue in musculoskeletal medicine.

I have outlined in previous posts that my interpretation of the research (systematic reviews) on this topic would suggest to me that basically:

The majority of imaging findings DO NOT correlate with pain.

Results shown on imaging are, in the vast majority of cases, NOT a reason to prevent a patient from doing well.

This post will once again will focus on lower back pain, but the above two points appear to be the case for both spinal and peripheral joints.

Based on evidence based guidelines, it is quite clear when, and when not, imaging is appropriate in patients with low back pain. Please see here, herehere and here for some evidence based guidelines and summaries. Key points being imaging is not recommended immediately in patients with back pain who do not have:

  • Major risk factors for cancer
  • Risk factors for spinal infection
  • Symptoms/signs of cauda equina
  • Severe neurological deficits (progressive/worsening deficits and/or multiple levels of deficits)

The evidence also broadly suggests that imaging should be deferred for a period of 4 to 6 weeks (depending on what you read) when these presentations above are not present.

Now I realise that clinician judgement comes into the picture, but despite these type of guidelines we still see the following research findings emerging:

Mafi et al (2013) analysed the treatment of back pain from January 1, 1999, through December 26, 2010 (emphasis in the following added by me):

We identified 23,918 visits for spine problems, representing an estimated 440 million visits. Approximately 58% of patients were female. Mean age increased from 49 to 53 years (P< .001) during the study period. Nonsteroidal anti-inflammatory drug or acetaminophen use per visit decreased from 36.9% in 1999-2000 to 24.5% in 2009-2010 (unadjusted P< .001). In contrast, narcotic use increased from 19.3% to 29.1% (P< .001). Although physical therapy referrals remained unchanged at approximately 20%, physician referrals increased from 6.8% to 14.0% (P< .001). The number of radiographs remained stable at approximately 17%, whereas the number of computed tomograms or magnetic resonance images increased from 7.2% to 11.3% during the study period (P< .001). These trends were similar after stratifying by short-term vs long-term presentations, visits to PCPs vs non-PCPs, and adjustment for age, sex, race/ethnicity, PCP status, symptom duration, region, and metropolitan location.

Despite numerous published clinical guidelines, management of back pain has relied increasingly on guideline discordant care. Improvements in the management of spine-related disease represent an area of potential cost savings for the health care system with the potential for improving the quality of care.

Perez and Jarvik (2012) also weigh into this topic:

Expensive advanced imaging, such as magnetic resonance (MR) imaging, contributes to the unsustainable growth of health care costs in the United States. Evidence-based imaging decreases costs and improves outcomes by guiding appropriate utilization of imaging. Low back pain is an important case illustration. Despite strong evidence that early advanced imaging with MR imaging for uncomplicated low back pain leads to increased costs without significant clinical benefit, MR imaging utilization for acute low back pain has increased. Barriers to evidence-based imaging can be traced to patient and physician-related factors. Radiologists have a critical role in addressing some of these barriers.

So overall, imaging rates, amongst other things, continue to increase. My clinical experience, and I am interested in hearing yours, would support this for both spinal and peripheral joint presentations.

Apart from increasing and unnecessary economic costs associated with increasing imaging rates we also see another critical issue emerging: Webster et al (2013):

Early MRI without indication has a strong iatrogenic effect in acute LBP, regardless of radiculopathy status. Providers and patients should be made aware that when early MRI is not indicated, it provides no benefits, and worse outcomes are likely.

For those unsure (me included) Iatrogenic means “relating to illness caused by medical examination or treatment”.

I have discussed this type of issue previously using examples of patients, who I am sure we all have seen, who believe that they should never bend their back again because they have a disc bulge, or that their back will most likely continue to always be painful because of the disc bulge. The imaging results and, quite probably, the lack of correct information provided to the patient regarding the imaging findings causes or strongly relates to their illness (ongoing pain). In essence the patient has beliefs relating to the structure of their back that are incorrect and contribute to perpetuation of their pain/functional impairment.

My Thoughts:

There is nothing wrong with referring patients for imaging if it is indicated. There are appropriate times to do so, but even then it is critical to educate them regarding what the results mean. I think this lack of education is probably one of the critical reasons why imaging has a strong iatrogenic effect.

But why are imaging rates increasing? I would love to hear your thoughts. Is it because the practitioner:

  • Simply lacks knowledge on, or the drive to stay up-to-date with, clinical guidelines.
  • Has an ego that gets in the way (the “I know best” practitioner).
  • Has vested interests, or is swayed by people with vested interests. I am sure there are some people out there who don’t want imaging referrals/rates to reduce!

Those points are perhaps a bit harsh, but I cannot think of any other reasons that can explain it.

Thanks for reading.

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Branch Councillor on the Western Australian Branch of the Australian Physiotherapy Association.

7 Comments on "“Over-Imaging” the Lower Back"

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  1. Cam says:

    Mark,

    When Physiotherapy is stripped of all it’s unnecessary bullshit, it becomes a very simple proposition. The problem is that this ‘simple proposition’ doesn’t equate with prestige, status and importance. And so these deeper understandings about manual techniques and radiology etc. can be painful to hear. They will feel like a loss. In fact they are a loss – to the ego. Many people resist that very strongly.

    For real estate agents, the European car and tailored suits are important because they disguise the fact that a computer program could replace the whole industry and offer consumers a far less expensive and more efficient service. But in healthcare we have to go beyond that mode of operation. We have to strip the whole thing bare and see what’s real.

    • Mark Gibson says:

      Well said Cam.

      Far too many vested interests and egos in healthcare.

      I think they (the egos) are slowly being weeded out but strong resistance is there. Mainly because those that stand out to lose the most are those that drive the fancy cars and wear the expensive suits because they have built up some status based on the “bullshit” in our profession.

      Not sure if you have seen this great post by Adam Meakins over at his blog, but I think it is a must read in relation to the “bullshit” that goes on in our profession. Had me laughing anyway!! 🙂

      https://thesportsphysio.wordpress.com/2015/02/18/the-10-worst-types-of-therapist/

      Thanks for taking the time to comment.

      Cheers
      Mark

  2. Hi Mark,

    Other reasons why clinicians over-image simple LBP?

    Occasionally:
    * Lack confidence in history to identify red flag pathology.
    * Fear of litigation if something ‘missed’.
    (I have some sympathy for this, perhaps we need to allow clinicians some licence to occasionally follow their ‘hunches’ with RF pathology?)

    More commonly:
    * Treatment ‘failed’ so feels need to offer patient ‘something else’ (clinician takes failure personally, wants to satisfy patient).
    * Clinicians need for a structural diagnosis (uncomfortable with diagnostic ambiguity/uncertainty)
    * Patients demand imaging (their need for a structural diagnosis to validate illness/disability/secondary gain).
    * Imaging as a referral requirement for escalating care to secondary/surgery.

    Less sympathy for this. Much stems from continuing the futile search for a cure….rather than have the challenging discussion where both patient and clinician acknowledge the problem may be chronic, incurable (but benign) and help the patient reach ‘acceptance’ and develop a sensible management plan. Avoidance of uncomfortable discussions.

    • Mark Gibson says:

      Hi Robert,

      Well said. Thanks for your comment. I also have little sympathy for the more common reasons you outlined above, and some empathy in regards to being a young inexperienced clinician (hopefully I am still somewhat young….) and being scared about missing something.

      You also raise a good point about the “hunches” with RF pathology. We only need to look at some of the published case studies that demonstrate RF cases with no obvious RF history and often mechanical symptoms that are just simply not improving. So I think some leeway to scan patients based on lack of improvement and/or hunches is sensible.

      I think some patients actually appreciate the uncomfortable discussions that help them “move on” so to speak, and it is the therapist that finds it uncomfortable. Less so the more you do it!

      Thanks again.

      Cheers
      Mark

  3. Jordana says:

    I have started hvnaig major back pain, mainly in my lower back, but have never been to a doctor for it. Unfortunately in high school I chose to march a tuba in band for three years straight about 20-25 hrs. a week. I am only 4’10 and 105 lbs. Also, I am a waitress and I have to carry 50-60 lb. trays all day full of food. I have tried taking advil, tylenol w/codeine, ibuprofen- everything, even stonger stuff. Nothing has worked, except for my father’s vicodin which he lets me take on occasion. I want to go to the doctor and have him help me with this problem, but I don’t want to come off as a drug-addicted young person begging for pills, but so far vicodin is the only thing that has seemed to do the trick. And I don’t like going to the chiropractor, I just feel uncomfortable with someone touching my back and it cures the pain for a day then it comes back. So I don’t know how to tell the doc that I can’t get physical help with it.I dont really believe in taking pills, but lately vicodin has been wonderful to me. What do doctors usually prescribe or recommend for back pain? What do I do?oh I’m 20 by the way

    • Mark Gibson says:

      Hi Jordana,
      I would suggest seeing someone (in my experience a good physiotherapist) who is going to give you, amongst other things, a more “active” management approach such as an appropriate exercise/rehabilitation program.
      Best wishes.
      Mark

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