BBC Health carries an article about a review of six trials
covering 1800 patients which concluded that MRI scanning does not help
in the management of normal low back pain and should be reserved for
specific conditions such as nerve root lesions, infections and tumours.
The outcome of low back pain is not improved by the use of scans and
there were no differences between the two groups, one group with typical
management and the other having an MRI scan at some stage. This was the
same for the early outcomes and for up to a year after the onset of
acute low back pain.
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.
Explanations to patients are fraught with difficulties and many fall into what I call concepts without explanation, where the explanation is given to the patient with little or no care or checking as to what they take away from it. If we give them a concept to think about we have a responsibility to help them understand and fit it in to their attitudes and beliefs about their back pain in a realistic way. If we get this wrong by being careless with our communication this can have important and negative consequences.
When we refer a patient for an MRI scan we should give careful counselling as to the limits of the imaging or we will store up disappointment for later. The scan should be small part of the overall strategy for managing the pain and a surgical opinion should be available for explanation, interpretation and a decision on operative management. Patient expectations need to be carefully managed as to what the scan might show and how the findings might be handled or when the negative results come in there will be frustration and disappointment.
Low back pain management is complicated and need time and good communication skills in the health professionals managing these types of condition and many other pain conditions. MRI scanning can be very useful in identifying disc prolapses, degenerate discs and infection or tumour. For mechanical low back pain it has a very limited role.
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.
Explanations to patients are fraught with difficulties and many fall into what I call concepts without explanation, where the explanation is given to the patient with little or no care or checking as to what they take away from it. If we give them a concept to think about we have a responsibility to help them understand and fit it in to their attitudes and beliefs about their back pain in a realistic way. If we get this wrong by being careless with our communication this can have important and negative consequences.
When we refer a patient for an MRI scan we should give careful counselling as to the limits of the imaging or we will store up disappointment for later. The scan should be small part of the overall strategy for managing the pain and a surgical opinion should be available for explanation, interpretation and a decision on operative management. Patient expectations need to be carefully managed as to what the scan might show and how the findings might be handled or when the negative results come in there will be frustration and disappointment.
Low back pain management is complicated and need time and good communication skills in the health professionals managing these types of condition and many other pain conditions. MRI scanning can be very useful in identifying disc prolapses, degenerate discs and infection or tumour. For mechanical low back pain it has a very limited role.
Jonathan Blood Smyth is a Superintendent of Physiotherapy
at an NHS hospital in the South-West of the UK. He specialises in
orthopedic conditions and looking after joint replacements as well as
managing chronic pain. Visit the website he edits if you are looking for
physiotherapists in Leeds.
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