TREAT THE MAN, NOT THE SCAN
As chartered physiotherapists, we often come across cases where we question whether to send a patient for an MRI or not. Why wouldn’t we, you might say? Sending a person through a machine that can literally have a peek inside the human body to detect any injuries or problems should be a no-brainer, and should be done as soon as possible! If it was that easy, you would see an MRI machine in every GP practice. Unfortunately, some considerations need to be taken before sending a patient through an MRI.
Anatomy vs. Function
One of the main reasons why your physiotherapist might wait a while with referring for an MRI is the fact that an MRI gives you an image of anatomy and not function. Patients come to us with a problem with function or with pain, and this does not always correlate with damage to anatomy. Especially with hip and groin related problems we find that MRI findings poorly corelate to the patients perceived pain and limitation in function. This means that we are running a risk of treating the wrong area if blindly following an MRI image without comparing it to the person in front of us. Early screening may also lead to over diagnosis and over treatment of pathologies that exist in non-symptomatic patients.
Being concerned about the anatomy and not the function can lead to multiple findings of pathology (causes and effects of injury and disease). This is regularly found during MRI scans of the lumbar spine. 30% of 20-year-olds with no reported back pain have disc bulges. If we look at 80-year-olds with no reported back pain, 84% have disc bulging. However, the most common finding we get reported after an MRI scan is ‘Disc Degeneration.’ I have had patients sitting in front of me in my office crying with their MRI report in hand after reading they have disc degeneration. And it does sound scary! But if we go back to our population with no reported back pain we find that 37% of the 20-year-olds, and 84%!! of the 80-year-olds have disc degeneration. In other words, you can say this is quite natural in the ageing process for all of us, and not necessarily something that needs any specific treatment. Without appropriate guidance and “interpretation” this scan will cause unnecessary fear and avoidance of using our backs even though a heap of contemporary research suggests movement is the best medicine for both disc bulges and disc degeneration. Simply put, your back can take a beating, and there is strong evidence that exercise therapy is the most beneficial in both treating and preventing low back pain. In the majority of cases, doing nothing is the worst thing you can do for your back! Added apprehension and fear from a comprehensive list of MRI findings might be counterproductive.
On the other hand, if we get a report back with no significant finding it does not neccesarily mean we have no problems. No MRI finding does not mean no pain or loss of function, but this may discourage the patient from further treatment running the risk of worsening the problem.
Perhaps the greatest weakness of an MRI reading is the vast variability of findings when comparing different radiologist readings and different scans. In the example below, a 63-year-old woman with a history of low back pain was scanned at 10 different accredited MRI centres over a period of 3 weeks. The subsequent readings provided 49 distinct findings, with not one single finding reported in all readings. 32.7% of the findings appeared only once in the 10 separate readings. This might make us wonder about the usefulness of the scans at all when the readings of the very same back can be interpreted in such a wide variety of ways. Will it add to or improve the rehabilitation process?
Strain on the HSE
But sometimes you really need to go through the MRI scanner. Whether there is a suspected space occupying lesion in the spinal canal, a suspected damage to soft tissues like cartilage or tendons, to rule out possible tumours and fractures or if you want to assess the damage prior to a consultation with a surgeon (many consultants require an MRI done prior to the first consultation), the MRI scanner is an exceptionally useful tool, and early diagnostics is important for best practice treatment. As discussed above, in many cases the scans are not needed at all, and unnecessary scans put a huge load on the health care budgets. We know that an excess of 27000 people were waiting for an MRI scan in Ireland in 2014 with over 7000 waiting for over a year. Numbers from subsequent years are not available, possibly due to the sheer size of the waitlists. If we can reduce the number of unnecessary MRI scans, we will be doing everyone a favour, and shortening the waitlist for those who urgently require a scan.
Your first port of call in any case should be a visit to your local GP or Physiotherapist. They have training in interpreting your medical history and clinical findings in order to establish whether you need to have a scan done immediately, or whether it would be more beneficial to wait a while and approach your case from a different angle. Your health care provider is able to talk you through the process and guide you in the right direction.
Chris Smetana, MISCP< Back to All Blog Items