Magnetic resonance imaging is an astonishingly successful technology which gives us great insights into the internal structure of the body, allowing accurate diagnosis and planning of treatment with a high degree of certainty. However, as recently flagged up in a BBC Health news article, MRI scanning can be positively harmful in the management of low back pain and should only be used if there is a suspicion of a serious underlying condition. Two groups were compared, one of which was scanned and one not, with results not differing over the short or longer term.
Patient expectations are a very strong driver of imaging for low back pain, either x-rays or magnetic resonance imaging, and many patients ask their doctors and surgeons for this, thinking it will indicate what is wrong with their backs. Scanning is something you can do but studies indicate that MRI rarely shows up an important finding in a person's back which was not already suspected. Communicating with the patients about the treatment plan and answering their questions is harder.
The numbers of magnetic resonance imaging scans has been steadily increasing, perhaps because it is a relatively easy thing to request rather than taking the time to answer awkward questions and correct the misconceptions of the patient. We explain the findings and their meaning poorly in many ways and the scan findings throw up many questions which are difficult to answer. Patient expectations should be addressed.
The history and examination of the patient should point clearly towards whether the problem is mechanical low back pain or whether there is a worrying element to the presentation. Scanning should only be requested if there is a significant positive reason for doing so, rather than just a lack of imagination or an inability to manage the patient's condition.
Patient education is a vital part of the management of back pain, explaining the reasons for pain, the reasons for not ordering a scan and the treatment path to follow, with a trial of manual therapy, acupuncture and a structured programme of exercise. A pain management programme may be necessary to address all the aspects of having long term and chronically disabling pain.
Reassurance is not an effective way of dealing with patients' health anxiety and MRI scanning has been shown to be ineffective in accomplishing this goal. Abnormal findings are found in the spines of people without pain symptoms so it is difficult to decide which changes are relevant to the presenting symptoms and which are just incidental. It is vital to avoid creating unhelpful attitudes and images in the patients' minds about what is occurring inside the spine. Sufficient time and communication skills are necessary to achieve a good understanding.
It's too easy to be offhand in communicating with the patient when we are explaining the scan, what it means for the spine and for the treatment choices. We should not give patients concepts without explanation in the sense that we tell them things they interpret and make part of their world view without a careful explanation and answering of any questions they might have about the new information. An incorrect explanation can create damaging images and beliefs which limit what a patient will do to help the self management of their pain.
The reasons, limits and outcome of the MRI scan should be carefully considered with the patient before the scan is ordered or there will be difficulties afterwards. There should be an overall plan formed by the history and examination, into which an MRI scan might fit if the signs justify it. A surgical opinion should be accessible to discuss the findings, answer the questions and make a decision as to the outcome. The scan findings need to be managed appropriately to avoid disappointing and frustrating the patient in their struggle to understand.
Careful explanation must be given if we agree to scan a patient otherwise the answers we give will bring their own problems. Once we agree to scan someone there must be a plan for what we are going to do next. There should be an opinion we can access without delay as an MRI scan on its own has little relevance, it needs to be interpreted, explained and acted upon. Much of the frustration comes from the patient's expectation about what can be shown on the scan and when, as is overwhelmingly the case, little of diagnostic value emerges, there is a feeling of what's next? - 14130
Patient expectations are a very strong driver of imaging for low back pain, either x-rays or magnetic resonance imaging, and many patients ask their doctors and surgeons for this, thinking it will indicate what is wrong with their backs. Scanning is something you can do but studies indicate that MRI rarely shows up an important finding in a person's back which was not already suspected. Communicating with the patients about the treatment plan and answering their questions is harder.
The numbers of magnetic resonance imaging scans has been steadily increasing, perhaps because it is a relatively easy thing to request rather than taking the time to answer awkward questions and correct the misconceptions of the patient. We explain the findings and their meaning poorly in many ways and the scan findings throw up many questions which are difficult to answer. Patient expectations should be addressed.
The history and examination of the patient should point clearly towards whether the problem is mechanical low back pain or whether there is a worrying element to the presentation. Scanning should only be requested if there is a significant positive reason for doing so, rather than just a lack of imagination or an inability to manage the patient's condition.
Patient education is a vital part of the management of back pain, explaining the reasons for pain, the reasons for not ordering a scan and the treatment path to follow, with a trial of manual therapy, acupuncture and a structured programme of exercise. A pain management programme may be necessary to address all the aspects of having long term and chronically disabling pain.
Reassurance is not an effective way of dealing with patients' health anxiety and MRI scanning has been shown to be ineffective in accomplishing this goal. Abnormal findings are found in the spines of people without pain symptoms so it is difficult to decide which changes are relevant to the presenting symptoms and which are just incidental. It is vital to avoid creating unhelpful attitudes and images in the patients' minds about what is occurring inside the spine. Sufficient time and communication skills are necessary to achieve a good understanding.
It's too easy to be offhand in communicating with the patient when we are explaining the scan, what it means for the spine and for the treatment choices. We should not give patients concepts without explanation in the sense that we tell them things they interpret and make part of their world view without a careful explanation and answering of any questions they might have about the new information. An incorrect explanation can create damaging images and beliefs which limit what a patient will do to help the self management of their pain.
The reasons, limits and outcome of the MRI scan should be carefully considered with the patient before the scan is ordered or there will be difficulties afterwards. There should be an overall plan formed by the history and examination, into which an MRI scan might fit if the signs justify it. A surgical opinion should be accessible to discuss the findings, answer the questions and make a decision as to the outcome. The scan findings need to be managed appropriately to avoid disappointing and frustrating the patient in their struggle to understand.
Careful explanation must be given if we agree to scan a patient otherwise the answers we give will bring their own problems. Once we agree to scan someone there must be a plan for what we are going to do next. There should be an opinion we can access without delay as an MRI scan on its own has little relevance, it needs to be interpreted, explained and acted upon. Much of the frustration comes from the patient's expectation about what can be shown on the scan and when, as is overwhelmingly the case, little of diagnostic value emerges, there is a feeling of what's next? - 14130
About the Author:
Jonathan Blood Smyth is Superintendent of a large team of Physiotherapists at an NHS hospital in Devon. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in Edinburgh or elsewhere in the UK.
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