Images like MRIs, CTs and X-rays are used to make sure you have nothing wrong or sometimes done as practitioners are not sure what is causing patient’s presentation.
They are helpful to find serious conditions such as fractures, cancer and spinal cord injuries.
However, there are research papers showing that even asymptomatic patients have degenerations and abnormalities on images [1 ,2]. Despite this fact, imaging rates had increased between 2000-2016 in adults [3].
Anatomical model
Perception of pain had been thought that it was from damages in the tissue or anatomical abnormalities until biopsychosocial model emerged [4]. I have come across not only allied health practitioners but also patients who understand this concept. However, some people still believe that abnormalities on images are the definite causes and need to be fixed if possible.
Abnormalities on images
Two famous papers by same authors show that both symptomatic and asymptomatic low back pain patients had disc degenerations. However, it seems that symptomatic patient tend to have disc degenerations in comparison to asymptomatic group [1 , 5]. These studies illustrate that disc degenerations regardless of symptoms are prevalent over age 50.
Associations between cervical abnormalities on images and clinical symptoms
20 years longitudinal study shows that disc degeneration was seen in 95.3% of participants over 20 years while the rate of clinical symptoms development (stiff shoulder, HA, neck pain, tinnitus and numbness in upper limb) was 66.9% [6]. There was a significant association between the occurrence of symptoms (upper limb pain) and foraminal stenosis. The degeneration rates of foraminal stenosis and disc space narrowing were quite low, yet increased with age especially after age 60. Thus, degeneration change in images are normal age-related changes and does not relate to clinical symptoms [6].
Shoulder impingement?
Shoulder impingement or subacromial impingement is one of the most prevalent diagnoses of shoulder pain. However, the term impingement has been avoided as it seems it is not related to pain and it can mislead patients to have an unnecessary surgery [7].
A recent systematic review demonstrated that there was no association between subacromial space and patient’s symptoms. Also, it showed that there was no relationship between increase in subacromial space and improvement in pain or dysfunction, which means that having a surgery like decompression or bursectomy does not guarantee the reduction of pain [8].
Knee OA and images
Knee OA seems age, BMI and female sex related [9] yet some research says that even asymptomatic patients have knee OA changes on images [10]. The study shows that asymptomatic people with age over 40 have 19-43% of knee OA changes (cartilage defect, meniscal tears and osteophytes) on MRI [10].
I remember when I was doing a placement with a physio, a patient in his 30s with anterior knee pain came in with a X-ray report saying he has the knee OA. We thought he was too young to have that yet it can be seen in young patients though it is uncommon [11].
Diagnostic error and unnecessary treatment
A study investigated the accuracy of MRI findings between clinicians. A lady took 10 MRI images over 3 weeks from different facilities, 2 reference images just before after study examinations (MRI) and got results from different clinicians.
The definition of diagnostic errors (error in interpretation) in this study were either no positive findings mentioned in the report of study examination despite positive findings being present in the reference findings or there was no mention in the report of reference findings. The interpretive error rates for all other pathologies such as anterior spondylolisthesis, disc herniation, nerve root compression, neural foraminal stenosis, vertebral fracture, central canal stenosis, facet degeneration and lateral recess stenosis are 30-47.5% and 10% was the lowest miss rate [12].
Intriguing study investigated if the 24 experts in radiology and 25 people with no medical background can detect a small gorilla image in the CT image for lung cancer screening. Firstly, detection rate of nodule for lung cancer was 55% in expert group and 20 of them failed to report a gorilla although eye-tracking showed 12 out of 20 looked at the gorilla. None of the no experience group found a gorilla in the images [13].
Thus, showing some abnormalities may be missed or made up and most importantly, they do not mean that is the cause of pain.
How should we use images?
As I have previously written the post about the importance of subjective history, images should be followed by thorough history taking and clinical assessments. There is a rule to reduce unnecessary imaging called the Ottawa Ankle Rules [14] is widely used for ankle sprain and possible fracture and ligament injuries.
Some patients want to take images to make sure everything is ok. Before taking images, clinicians should consider the fact that age related change may be present in the image.
Therefore, clinicians and practitioners should use cumulative knowledge, thorough history taking, physical assessment and consider patient’s characters and psychological factors whether medical imaging should be taken and patient can benefit from it especially when it comes to chronic musculoskeletal conditions [14].
References
[1] Brinjikji, W., Luetmer, P., Comstock, B., Bresnahan, B., Chen, L., Deyo, R., Halabi, S., Turner, J., Avins, A., James, K., Wald, J., Kallmes, D., & Jarvik, J. (2014). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology, 36(4), 811–816. https://doi.org/10.3174/ajnr.a4173
[2] Daimon, K., Fujiwara, H., Nishiwaki, Y., Okada, E., Nojiri, K., Watanabe, M., Katoh, H., Shimizu, K., Ishihama, H., Fujita, N., Tsuji, T., Nakamura, M., Matsumoto, M., & Watanabe, K. (2018). A 20-Year Prospective Longitudinal Study of Degeneration of the Cervical Spine in a Volunteer Cohort Assessed Using MRI. Journal of Bone and Joint Surgery, 100(10), 843–849. https://doi.org/10.2106/jbjs.17.01347
[3] Smith-Bindman, R., Kwan, M. L., Marlow, E. C., Theis, M. K., Bolch, W., Cheng, S. Y., Bowles, E. J. A., Duncan, J. R., Greenlee, R. T., Kushi, L. H., Pole, J. D., Rahm, A. K., Stout, N. K., Weinmann, S., & Miglioretti, D. L. (2019). Trends in Use of Medical Imaging in US Health Care Systems and in Ontario, Canada, 2000–2016. JAMA, 322(9), 843. https://doi.org/10.1001/jama.2019.11456
[4] Meints, S., & Edwards, R. (2018). Evaluating psychosocial contributions to chronic pain outcomes. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 87, 168–182. https://doi.org/10.1016/j.pnpbp.2018.01.017
[5] Brinjikji, W., Diehn, F., Jarvik, J., Carr, C., Kallmes, D., Murad, M., & Luetmer, P. (2015). MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis. American Journal of Neuroradiology, 36(12), 2394–2399. https://doi.org/10.3174/ajnr.a4498
[6] Daimon, K., Fujiwara, H., Nishiwaki, Y., Okada, E., Nojiri, K., Watanabe, M., Katoh, H., Shimizu, K., Ishihama, H., Fujita, N., Tsuji, T., Nakamura, M., Matsumoto, M., & Watanabe, K. (2018). A 20-Year Prospective Longitudinal Study of Degeneration of the Cervical Spine in a Volunteer Cohort Assessed Using MRI. Journal of Bone and Joint Surgery, 100(10), 843–849. https://doi.org/10.2106/jbjs.17.01347
[7] Cools, A. M., & Michener, L. A. (2016). Shoulder pain: can one label satisfy everyone and everything? British Journal of Sports Medicine, 51(5), 416–417. https://doi.org/10.1136/bjsports-2016-096772
[8] Park, S. W., Chen, Y. T., Thompson, L., Kjoenoe, A., Juul-Kristensen, B., Cavalheri, V., & McKenna, L. (2020). No relationship between the acromiohumeral distance and pain in adults with subacromial pain syndrome: a systematic review and meta-analysis. Scientific Reports, 10(1). https://doi.org/10.1038/s41598-020-76704-z
[9] Muraki, S., Oka, H., Akune, T., Mabuchi, A., En-yo, Y., Yoshida, M., Saika, A., Suzuki, T., Yoshida, H., Ishibashi, H., Yamamoto, S., Nakamura, K., Kawaguchi, H., & Yoshimura, N. (2009). Prevalence of radiographic knee osteoarthritis and its association with knee pain in the elderly of Japanese population-based cohorts: The ROAD study. Osteoarthritis and Cartilage, 17(9), 1137–1143. https://doi.org/10.1016/j.joca.2009.04.005
[10] Culvenor, A. G., Øiestad, B. E., Hart, H. F., Stefanik, J. J., Guermazi, A., & Crossley, K. M. (2018). Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. British Journal of Sports Medicine, 53(20), 1268–1278. https://doi.org/10.1136/bjsports-2018-099257
[11] Ackerman, I. N., Kemp, J. L., Crossley, K. M., Culvenor, A. G., & Hinman, R. S. (2017). Hip and Knee Osteoarthritis Affects Younger People, Too. Journal of Orthopaedic & Sports Physical Therapy, 47(2), 67–79. https://doi.org/10.2519/jospt.2017.7286
[12] Herzog, R., Elgort, D. R., Flanders, A. E., & Moley, P. J. (2017). Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. The Spine Journal, 17(4), 554–561. https://doi.org/10.1016/j.spinee.2016.11.009
[13] Drew, T., Võ, M. L. H., & Wolfe, J. M. (2013). The Invisible Gorilla Strikes Again. Psychological Science, 24(9), 1848–1853. https://doi.org/10.1177/0956797613479386
[14] Dean Deyle, G. (2011). The role of MRI in musculoskeletal practice: a clinical perspective. Journal of Manual & Manipulative Therapy, 19(3), 152–161. https://doi.org/10.1179/2042618611y.0000000009
