MRI for back pain –> Lumbar MR Imaging and Reporting Epidemiology: Do Epidemiologic Data in Reports Affect Clinical Management? This is the question posed by the authors of this recent study, seeking to determine whether adding details about changes seen on an MRI scan in those without symptoms had any impact. The conclusion was: ‘Patients were less likely to receive narcotics prescriptions from primary care providers when epidemiologic information was included in their lumbar spine MR imaging reports’.
Why may this be?
We can start by saying that jumping down the route of an MRI scan for back pain is not a given, but rather it requires wise thought. The American College of Physicians published a paper in 2011 stating: ‘Diagnostic imaging is indicated for patients with low back pain only if they have severe progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition. In other patients, evidence indicates that routine imaging is not associated with clinically meaningful benefits but can lead to harms. Addressing inefficiencies in diagnostic testing could minimize potential harms to patients and have a large effect on use of resources by reducing both direct and downstream costs. In this area, more testing does not equate to better care. Implementing a selective approach to low back imaging, as suggested by the American College of Physicians and American Pain Society guideline on low back pain, would provide better care to patients, improve outcomes, and reduce costs’.
One immediate issue is that an MRI scan can show structural changes that could be assumed to be the cause of the back pain. On making that assumption, both the clinician and the patient can be pulled down a route of thinking to somehow alter the structure, or remove the tissue will henceforth change the pain. Of course there are many cases of intervention, including surgery, that lead to pain relief. Is it simply because the structure has been removed? The same is true of joint replacement when relief is frequently obtained. However, there are many cases when this does not happen, with pain and other symptoms persisting. We know that this is because pain is not an accurate indicator of tissue damage — see Lorimer Moseley talking about this here. Phantom limb pain is the ultimate example of pain without body.
Including information about common scan findings in people without back pain appears to be a potent message that affects the patient journey. In essence that is what we are seeking to change, the trajectory of the condition and the patient experience, for the better. Cultivating the conditions for the body’s physiology to adapt and develop in such a way as to emerge with healthy function.
What are we doing with this message? Normalising. The key point is the fact that we can have certain changes in the body, in the spine, that do not cause problems. Clearly, the person sitting in the clinic does have a pain problem that needs to be solved, but not necessarily via an MRI scan. If a scan has been taken and shows no serious pathology, this is great news. Having said that, many people describe uncertainty and anxiousness at the lack of a structural explanation for their pain. This is entirely understandable as they have not had their pain explained to them at that time, hence there is no meaning. No meaning creates further worry and this most certainly affects pain.
So, the first point of action once all the information has been scrutinised, is to create a perspective based upon what we know about the body and pain. Describing the pain mechanisms, the underpinning biology that involves many body systems, and the influences upon pain such as fatigue, previous experience, self-analysis of the situation, stress, anxiety, movement and other factors that are all biological. Everything is biological — this is a key data point. A movement, a thought, an emotion; they are all underpinned by brain activity that often creates and colours sensations in the body. We can use the different yet inter-related dimensions of pain (physical – cognitive – emotional) to construct bespoke programmes to tackle both the sources of pain and the influencing factors.
The second point of action is to plan an individual programme that encompasses specific training to re-programme the way in which the body has been working. This sits alongside techniques to develop confidence and awareness of the body, both vital for normal functioning. The patient’s role in this training cannot be over-emphasised, hence why motivational factors, and barriers, must be considered and addressed.
The third point is the monitoring and progression of the training and treatment, sculpting the change in pain and function that is entirely possible once the right conditions have been set for both understanding and action.
The questions regarding MRI and other investigations will continue to be asked and rightly so. We must continually challenge our own thinking about the best route forward for each individual patient. Understandably, patients will continue to expect and hope for the fullest assessment including MRI, the gold standard, and from this we must use the information wisely and objectively, explaining the findings and creating a perspective that makes sense and propels the best possible treatment.