Too much imaging: the author proposes a change in musculoskeletal diagnostics and care, using back pain as an example.

Pages 46-48

Musculoskeletal pain is arguably one of the broadest topics to consider when discussing pain. This type of pain can affect nerves, muscles, bones, ligaments, and tendons. While musculoskeletal (MSK) pain may be viewed through the eyes of the International Association for the Study of Pain (IASP) task force,1 which attempts to categorize the various types of chronic pain, perhaps it is time to look through a more pragmatic lens, especially given the way many conditions are either ill-defined or overlap.

Most providers would likely argue that MSK pain is just as old as humans themselves. Yet, we often look at pain as a modern problem in need of a timely solution. To exemplify just how current the subject of MSK pain is today, consider the Edwin Smith Surgical Papyrus dating back to 1600 BC.2 Ignoring the recipe for youth, the document’s cases describe spinal and head trauma, back sprain, and neck sprain. The examinations cited from nearly 4,000 years ago are eerily similar to what may be considered the standard assessments of today. The question is, then, does the healthcare community need to invest in a new type of test, or could something else be considered?

Moving the Assessment Model from Practical to Effective

For me personally, the practical model starts with the assumption that clinicians already have a considerable number of tools that help to provide effective pain relief, and there is likely a patient who can benefit from individualized treatment. That said, no single treatment is a panacea, despite that fact that most single approaches are presented as such. The key to a successful outcome for treating pain, in my view, is to start with knowing what treatment may best serve an individual patient at a particular time, essentially a highly patient-centered approach. In this model, the primary goal is to treat the pain to resolution, and if that is not possible, to at least lessen the severity of pain, which then opens the door for more effective management and the prevention of worse pain.

Back pain is an ideal example of this model as it meets all the criteria any good novel would have for its characters. By definition, “back pain” is a generic term that often encompasses a rather long list of symptoms. Several clinicians have even reported the cause of pain as being nonspecific.3 Providers and researchers alike tend to agree that possible causes may involve cortical and subcortical regions, as well as the with the spinal cord, peripheral nerves, and tissues.4 CJ Woolf is credited with categorizing the types of pain as nociceptive, inflammatory, neuropathic, and function (ie, dysfunctional) pain.5 When further distilling the underlying causes of back pain, providers are left with the classic battle of nociceptive, neuropathic, or mixed.6,7

Consider for a moment what happens when a patient presents to an emergency department with the complaint of chest pain. With potentially life-threatening sequelae, there is a concerted effort made to determine the underlying cause. Yet for back pain, there is a lack of urgency. Treatment is attempted at random based on a provider’s clinical background or an institutional guideline. Remember, not every treatment will be effective for every patient. For that matter, what happens in the highly likely event that a patient has overlapping components to his or her pain? Teasing out underlying causes then becomes even more difficult, especially when considering the potential and likelihood of neuroplastic changes occurring.

The Need for Provider Education and a Patient-Centered Focus

To change this model, two components must be addressed. The first is education. Short of multidisciplinary pain programs, multidisciplinary professional meetings provide a venue and vehicle to share information across a broad spectrum of providers. Clinicians can use the information culled at meetings to assess patients from a wider viewpoint. Providers return to their practices with a better sense of all the tools available that may be available for a specific type of pain, how these tools may work in a particular patient, and, more importantly, when they should be used. Such tools, in general, include: pharmacologic approaches; palliative and restorative physical therapy and manipulation; acupuncture, interventional injections; neuromodulation; surgery; and other integrative therapies.

However, how many of us attend specialty-specific meetings where the focus is on the latest and greatest within the specialty itself? In contrast, at a multidisciplinary clinic, we are given the ability to learn the perspective of other specialties. Of course, this obtainment of knowledge requires clinicians to step outside of their discipline and choose sessions that offer a broader potential for learning. Having attended multidisciplinary clinical meetings for more than 20 years, I opine that one of the most overlooked opportunities to learn comes from engaging other attendees directly.

The second component to changing current practice is to treat the patient as an individual. I admit to having the primary goal of identifying a physical underlying pain generator. While that model is necessary for treating the patient, one does have to remember that the perception of pain does have an emotional component. To this end, applying biopsychosocial strategies, such as cognitive behavioral therapy (CBT), may be helpful when utilized across the spectrum of the other treatments. Such approaches are a key principle in the US Department of Veterans Affairs Stepped Pain Care Model, which essentially describes the first step in pain care as “Self-Care.”8

Part of treating the patient as an individual includes patient engagement—taking a medical history and conducting a clinical examination—before determining the best course of treatment. When making a diagnostic or treatment decision, clinicians tend to look for the latest and greatest research in journals and textbooks. Certainly, the diagnostic textbooks by Maigne, Diagnosis and Treatment of Pain of Vertebral Origin,9 and Waldman, Physical Diagnosis of Pain,10 provide helpful guidance to any clinician evaluating for painful conditions relating to the spine, but perhaps we should be looking backward, acknowledging that not much has changed with respect to physically evaluating a patient with back pain.

The real challenge lies in applying the greater, even historical, knowledge to the clinical information we receive directly from our patients. Their feedback can help to better refine potential underlying pathologies responsible for the pain. For me, migrating from a face-to-face clinical practice to that of a telemedicine practice has revealed an interesting observation. The ability to perform a thorough and detailed examination suddenly seemed limited; I now place greater emphasis on the history and interview process. It is amazing how much clinically relevant information can be gleaned when we listen and ask the right questions. It is clear that a key conflict in today’s healthcare model is that of “time,” which is all too often limited when it comes to our patients.

Back Pain: Choosing the Right Tools from the Beginning

To compensate for the perceived limitations in time, some clinicians overly rely on imaging studies, using their results to treat patients and hoping for positive clinical outcomes. With regard to back pain, in particular, deficiencies in this assessment model may be best cited by Manchikanti, et al, in the updated evidence-based guidelines for interventional techniques for spinal pain.11 Not only does the guideline credit the difficulty in reaching a definitive diagnosis in primary and tertiary care settings, but it also points to extensive references which cite that determining precise cases of pain may be as low as 15% by history, physical examination, imaging, and electrodiagnostic studies. The same guideline also notes that diagnosis can become a reality in 85% of the patients as a result of diagnostic interventional techniques. The question we should ask, therefore, is at what cost and at what risk to the patient should we continue to use this model?

A review of the studies cited in Manchikanti’s guideline further demonstrate that large numbers of patients have not received clinical benefit from most every diagnostic or therapeutic injection. Part of these findings may be due to poor patient selection for the procedure(s) to begin with, which brings me back to the need for enhanced clinical assessment.

In my practice, interventional treatments play an important role, as do manual therapies, biopsychosocial techniques, and patient education. The goal is to rely more on the therapeutic values of specific interventional treatments rather than its diagnostic potential alone. This switch in approach may be accomplished, in large part, by enhancing the initial examination to obtain more clinically relevant information—that is, by investing more time. A narrative review by Bardin, et al, establishes a route for relying more heavily on differential diagnosis and matching pathways of care,12 again supporting the theme of using the most appropriate tool(s) for the individual patient’s specific pain.

The Problem with Imaging as a Diagnosis

One lauded technology advance that may actually be contributing to failed patient outcomes and the persistence of chronic pain is imaging. I recently had the opportunity to engage several dozen patients in a non-medical consumer setting. Most suffered from some sort of MSK pain, especially back pain. When asked for more detail, “My MRI results” was the most cited response as the “reason” for their pain. This answer should be alarming as pathologies attributed to musculoskeletal findings seen on imaging studies may not always be clinically relevant.

Take, for instance, a report by Jensen and his team from over 20 years ago which found that 52% of a group of asymptomatic subjects had at least a single disc pathology on an MRI of the back.13 A similar study led by Jarvik in 2001 found that, of 148 asymptomatic subjects, 69 (46%) had never experienced low back pain. Yet, 123 subjects (83%) had moderate to severe desiccation of one or more discs; 95 (64%) had one or more bulging discs; 83 (56%) had loss of disc height; 48 (32%) had at least one disc protrusion; and 9 (6%) had one or more disc extrusions.14 Again, all patients were asymptomatic.

Armed with an interesting application of the Jarvik data, when including the epidemiological information with the MRI reports, McCullough’s group cited a slightly lowered incidence of opioid prescriptions, physical therapy, and repeat injections.15 Clearly, utilization may have been affected; there was, however, no information concerning outcomes.

Looking at patients with symptoms of pain, Yu and his group retrospectively studied 3,107 lumbar spine MRIs taken at two emergency departments over the course of a month in China for patients presenting with acute low back pain. Only 41.3% of the MRIs were said to have identified some finding of potential significance, although not necessarily clinically correlated, and 32.7% were completely normal.16

It is worth noting that these same considerations apply not just to back pain, but also to most any other MSK pain condition. Matsumoto and his team evaluated a group of 497 asymptomatic individuals with cervical MRIs and found the frequency of degenerative findings increased with age, starting with 12 to 15% for those in their 20s, and going up to 86 to 89% for those over age 60. Even worse, 7.6% of the subjects over age 50 demonstrated severe cord compression where surgical interventions were most always considered.17 Should these patients undergo decompressive surgery even though they are asymptomatic?

There seems to be a small, seemingly silent number of physicians who acknowledge the potential financial burden placed on patients and the healthcare system when over-reliance on imaging is used without adequate clinical correlation.18,19 Another question worth pondering: How often do patients undergo an epidural or take an oral steroid to address a suspected disk pathology and then obtain clinical benefit from the treatment? Since we know the disk pathology would likely still be present on imaging, is it possible a situation was created in which the pathology seen on imaging studies would now be asymptomatic?

Conclusion

When giving thought to the preponderance of studies that question the results of imaging studies, perhaps it is time to focus on how imaging may play a significant role in identifying pathologies that may be contributing to MSK pain as well as what treatment may be best served. The problem is that, in the absence of a sufficient clinically relevant physical examination, and a focus on imaging studies alone, there may be the potential for doing greater harm than good. In a workers’ compensation setting, for instance, it was found that early use of MRI was associated with an increased likelihood of disability and its duration.20 One needs to ask: Are these scans and interpretations contributing to the perception of pain and ongoing impairment?

Rather than spending time and expense on imaging and sometimes unnecessary surgical interventions, time may be better spent on obtaining an adequate patient history and problem-focused examination. When asking a patient about his or her pain, do not accept “My MRI showed XYZ.” Instead, ask for details about their pain and how it affects them, not the name it was given. While providers may have to tweak their standard assessment practice one patient at a time, this approach may very well provide a path for improving clinical outcomes while also decreasing the cost of care.

Last updated on: May 3, 2019

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