Unnecessary radiology reports
As I was scrolling through the ‘Guide to assessing psychological yellow flags in acute low back pain’ I gazed across a section suggesting “investigations in the first 4-6 weeks do not provide clinical benefit unless there are Red Flags present. There are risks associated with unnecessary radiology (X-rays and CT scans).” Their explanation is that radiological investigations carry the risk of potential harm from radiation-related effects. Good point. But perhaps it’s also worth considering the psychological risks of perceived threat.
Inherently, a radiology report is likely to increase threat, especially without education. Consider how strong the perception of ‘Danger in Me (DIM)’ would be when a health professional sends you to a radiologist who uses his expensive, fancy machine to magically look inside you. For your efforts, you’re provided a complicated report with some pretty scary sounding words on it. Any fear you previously had now seems to be confirmed (or exacerbated) by reliable people, high-tech equipment and medical jargon. It’s not easy to dethreaten such a potent message of damage.
What is ‘normal’?
It’s worth considering what a ‘normal’, asymptomatic radiology report would look like. Brinjikji et al. (2015) have systematically reviewed spinal imaging reports for those not in pain, and the results are pretty interesting. If we deconstruct their findings it seems that if an asymptomatic 60 year old walked through the door with lumbar imaging their prevalence estimate of reporting ‘disc degeneration’ is 88%, ‘disc signal loss’ is 86%, ‘disc bulge’ is 69%, ‘disc protrusion’ is 38% and even ‘spondylolisthesis’ at 23%. Remember, this (hypothetical) person is pain-free.
Credible evidence of danger
If we consider that ‘any credible evidence of danger to body tissue can increase pain’ (Moseley & Butler 2015) then we must consider the risk of unnecessary radiology reports. Hopefully, when patients come to us with reports in hand, our educational skills can help to detangle perceived threat and provide accurate explanation of what it means for them. As Brinjikji et al. (2015) concludes – “Many imaging-based degenerative features are likely part of normal aging and unassociated with pain”.
– Hayley Leake
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Noosa 17 – 19 June Explain Pain and Graded Motor Imagery (Both courses SOLD OUT)
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Great post. I reckon it is still a big problem in reality. It is rare for radiologists to comment that the changes were ‘normal for age’. (Thompson et al 2007) and gp’s are not trained in interpretation and educating. This problem has been identified ever since 1998 (Roland et al). The increase of the use of MR imaging in low back pain has been +300%. It is widely used to reassure, but it lacks power and potentially a potent nocebo! Traeger (2015) did a nice review. Thanks again for this post. Looking forward to some reflection.. Cheers from Amsterdam
Hey Bart – Thanks for the articles, I particularly liked the Traeger et al. (2015) review. Here is an open access of the paper if anyone is looking.
“One option to reassure patients is to provide diagnostic test results. In LBP, routine diagnostic imaging is discouraged because these tests are expensive, may not be reassuring, and do not appear to improve health outcomes. Despite this, physicians order imaging in 25% of LBP consultations, and this figure is increasing.”
“Our data suggest that when practitioners are trained to deliver structured patient education interventions, the reassurance this provides to patients is superior to usual care. A recent survey of Australian general practice activity found that only 20% of primary care physicians report giving advice and education of this type in the treatment of LBP (Traeger et al. 2015).”
A big problem for sure!
I am still reeling from the figures – “if an asymptomatic 60 year old walked through the door with lumbar imaging their prevalence estimate of reporting ‘disc degeneration’ is 88%, ‘disc signal loss’ is 86%, ‘disc bulge’ is 69%, ‘disc protrusion’ is 38% and even ‘spondylolisthesis’ at 23%
No wonder our job is so hard!