Diagnostic imaging pros & cons – be careful what you ask for

There are many reasons to request a diagnostic image such as a radiograph (X-ray), MRI, sonogram (ultrasound), and CT scan. They are to diagnosis a pathology/trauma; determine treatment options; screen for contraindications; biomechanical analysis; provide reassurance; medical legal reasons; and financial gain for the healthcare provider.

Requests for diagnostic imaging must come from a licensed healthcare provider. However, patients often request that their healthcare provider order a diagnostic image study.

As a Doctor of Physical Therapy ordering a diagnostic image is not consider within my scope of practice. I can and often request or refer a patient to a healthcare professional who can order or request a diagnostic image. I am frequently handling questions that my patients have about their diagnostic images. I observe the benefits and problems resulting from diagnostic images.

Example of a benefit of the diagnostic image providing reassurance

Requesting a diagnostic imaging study can provide comfort and reassurance for the patient.

My experience has been that some patients get better at having a diagnostic imagine performed.

The conversation goes something like this.

Healthcare provider, “How are you doing?”

Patient “much better”.

Healthcare provider “What do you think explains the improvement?”

Patient, “I got an X-ray.”

Obviously, a diagnostic X-ray is not a treatment. A diagnostic image provides the patient some validation and reassurance of their problem. Patients with chronic pain often feel a need to legitimize their pain. Patients value the physical evidence of pathology that imaging can provide. The results can be used to convince their doctor, family, friends, and colleagues that they are in pain. The healthcare provider and patient agree on the evidence facilitate a trusting relationship which is critical to successful outcomes.

Examples of unintended consequences of diagnostic imaging

There are risks and/or unintended consequences to requesting diagnostic images some obvious some not so obvious.

Finding something on the diagnostic imaging that is not related to the pain or problem is incidental. Some incidental findings on diagnostic images can be explained by having too many birthdays. Like changes that occur in skin with age. These changes don’t look great, but they don’t hurt, and don’t slow us down.

Incidental findings can mislead or distract from the original problem.

Josephine Jacobs and colleagues reviewed medical records of patient's back pain in the Veterans Affairs clinics. They found early MRI is associated with more back surgery compared to without early MRI. There is greater use of opioid medication with early MRI compared to without early MRI.

Imran Saijid and colleagues express concern that MRI findings can negatively affect the patient perceptions, with lower confidence in conservative management, fear that exercise may worsen the condition, loss of control, over-reliance on surgery as well as poorer functional outcomes.

Incidental findings can generate anxiety about an innocent pathology. It is important to work closely with the healthcare professional to maintain focus.

Interpreting the results of diagnostic images

Often the results and interpretation by the radiologist of diagnostic imaging are available to the patient as soon as or even before they are available to the health care professional.

If you have access to the diagnostic image report and the interpretation by the radiologist, it is likely to have clear definitions. However, be careful to not let this lead to negative expectations and increased anxiety. The exacting medical terminology can be confusing and scary.

The denotation or definition of a word is what it explicitly means. While the connotation of a word is what it implies or is associated with. The connotation is the emotional & cultural baggage that goes with the word. A connotation can have positive or negative inferences.

S Rajasekaran and colleagues compared a group of back pain patients receiving a factual explanation of an MRI report to a group of back pain patients receiving assurances that the MRI shows normal changes. Both groups were comparable at initial by the level of pain. After 6 weeks of treatment, the group that received the factual report had a more negative perception of their condition, increased catastrophizing, less pain improvement, and poorer functional status.

Without appropriate context, diagnostic image reports have scary connotations and can muddy the waters. For some patients, the results can generate more anxiety rather than reassurance.

Be careful to avoid being a victim of modern imaging technology. Ask questions.

Work with the healthcare professional to better understand the results of diagnostic imaging. Ask can this be a normal or okay finding? Can there be other explanations as to the source of the pain? What are my options? It is okay to ask another radiologist or healthcare professional for a second opinion on the interpretation of the results of diagnostic images.

Alternative &/or augmentation of diagnostic imaging.

A thorough history and physical exam are more helpful than a diagnostic image. The diagnostic image is the least important part of the diagnostic process. My mantra is I don’t treat X-rays and treat the patient. A diagnostic image is not a measure of pain.

Musculoskeletal pain syndromes often involve the movement system. The movement system is a collection of systems (cardiovascular, pulmonary, endocrine, integumentary, nervous, and musculoskeletal) that interact to move the body or its component parts.  Visual observation of movement and analysis of movement is necessary to solve movement system problems. Standard diagnostic imaging occurs without movement.  It is static. Two-dimensional slow-motion analysis can provide valuable information. Two-dimensional slow-motion analysis can:

• Improve the accuracy and reliability of standard clinical examination of movement.
• Provide information of what direction of movements elicits pain.
• Provide information on how altering the movement can diminish or alleviate the pain.
• Fulfill the role of providing validation and reassurance that the clinician and patient are seeking.
• Increase the level of engagement and communication between the clinician and the patient.
• Be less invasive and less expensive than standard static diagnostic imaging.

“It ain’t what you do not know that gets you into trouble.

It’s what you know for sure that just isn’t so” – Mark Twain

Damien Howell Physical Therapy – 804-647-9499 – Fax: 866-879-8591 At-Home, At Office, At Fitness Facility – I come to you, I do home visits Damien@damienhowellpt.com