To Scan Or Not To Scan

February 17, 2018

Welcome one and all. I hope you are all able to enjoy this blog post and find some element of interest from it. In this post I am going to delve into the contentious area of imaging. Should we, shouldn’t we? When? Why? What type? Fortunately, the answer as to whether we should scan or not scan is a little more complicated than you may suspect. Why fortunately? Well, if it was easy, there would be no satisfaction in the decision!

 

So firstly allow me to introduce you to some of the more common forms of imaging:

  • X-ray - utilises radiation to generate images of inside the body. Most commonly utilised for looking at the health of bones, teeth and chest/lungs

  • Magnetic Resonance Imaging (MRI) - a type of scan that uses magnetic fields and radio waves to produce detailed images of the body, and can be used on almost all body parts

  • Computerised Tomography (CT) Scan - uses X-rays and a computer to create detailed images of various aspects of the body

 

Throughout my career, one of the most common questions I have heard is:

 

“Do you think I need a scan?” (Feel free to replace the word scan with picture, image, X-ray, MRI, CT, photo, or with whatever word resonates for you.)

 

Imaging is seen as a sacred tool that bestows the answers to all of our questions. Is it broken? An X-Ray may tell us. Is it torn? An MRI may tell us. Is there an abnormality? A CT may tell us. However, this is a very crude way of looking at it, and there has long been a debate as to whether images are taken too often/sparsely.

 

When I first started practising I was very much of the mindset that if there is any risk of something more sinister, then seek imaging to add to my clinical reasoning. As an example, if a rugby player came into the clinic with a sudden, debilitating pain in her knee following a twisting/cutting movement whilst playing, I may want to delve into this with further diagnostic tests. If an ACL ligament tear was suspected, I would have advised to seek an MRI in order to ascertain the extent of the injury. Given her sport and requirements to function fully, having this additional information may help to better plan her rehabilitation. However, being a lowly junior physio in the NHS at the time, I was soon advised to use imaging with caution and hesitance. 

 

“How would a scan change your future planning?” I would be asked.

“We cannot scan everyone that comes through the doors.” I would be told (I would hasten to add that this was a mild to severe exaggeration of my practice at the time).

 

At the time I could not really understand their perspective. To me it seemed that I was being advised not to suggest further imaging due to monetary reasons, with senior management eluding to reduced finances within the NHS and highlighting the financial burden that imaging generates. I was a little resistant to this argument and felt that whilst I would suggest further imaging to a number of patients, I did not feel this was disproportionate to the severity of the injury. Anyhoo, several debates later and an unrequested course of pallov training (every time I discussed a more sinister injury I would receive an unprovoked comment such as “not another image?!”), I found myself steering patients away from the need to scan. At the time I found it difficult to justify my reasons for advising against imaging and felt that I was losing trust from patients, inhibiting the rehabilitation process.

 

Fast forward five years and I found myself trying to reason my decisions from the opposite end of the spectrum. Rarely did I now find myself advising imaging and when I did I really had to clinically scrutinise whether it would add any value to the planning of the rehabilitation. It was no longer based on financial disgruntlement, but instead on the accuracy of the scanning and the true value that images add. 

 

With increased exposure to scanning of all varieties it became apparent that images and their reporting was not as objective as we would like to think. Two radiologists could view the same images and report very different things. Some reports may be clinically relevant to the individual’s symptoms, whilst others probably had as much value in adding to the reasons why an individual was experiencing their pain as a Magic 8 ball would. This may be fine and as practitioners who are forced to embrace scientific reasoning throughout their training, it is logical to understand that we must correlate the imaging reports with the clinical presentation before jumping to conclusions. However, the current Western culture tends to instil a lot of faith in the imaging reports and appears to lack understanding of the fragilities of the pictures. Consequently, I have seen images and reports do much more damage than good. 

 

As an example, an individual I met during my time in private practice had long standing lower back pain for many months. Following a few visits to his GP he took it upon himself to independently seek an Xray. The Xray demonstrated signs of osteoarthritis (OA), a very common pathology associated with the ageing process, just as wrinkles on the skin are. With this ‘diagnosis’ of OA, the individual became very anxious about the ‘state’ of his back and catatstrophised that this spelt the end of his function capabilities as he knew it. In his mind, he was destined to have low back pain forever more. The caveat to this story was that, upon assessment, the individual presented with an entirely different pattern of pain than that expected from OA. 

 

My point here is that imaging can sometimes be misleading, and whilst this example highlighted an underlying, age-related change in structure, the results did not explain the reason behind his pain. He became fixated on the results of the scan and it took a great deal of reassurance and education to overcome the fears of what was reported from the images. Even now, this individual is very conscious of OA and attributes any low back sensation with his ‘old back’.

 

With all of this said, as I sit on the Stansted Express back to Bishops Stortford, I am moving full circle with my opinions on imaging. My current working environment is a highly competitive, athletic one with adolescents who need to achieve an aesthetic that adds additional stress (in many forms) to their performance programmes. This population has not adhered to the norms of the variety of environments I have previously worked in. Incidence of bony stress injuries and a vast array of weird and wonderful pathologies has fed into a more cautious approach. Not only because of their age and the implications a growing body will have on the diagnosis, but also for their wellness. I therefore find myself being more cautious and seeking further imaging more frequently than in previous environments. However, I would argue that there is a reasoned and sensible need to do so. 

 

The request for further imaging should therefore be a holistic and individualised decision between the patient and practitioner. An educated discussion around the pros and cons should take place thus allowing for an informed and clinically reasoned decision. It should not only be based on finances or if the client wants it, but the decision should reflect a lengthy discussion as to mechanism of injury, potential risk factors, the requirements of training, and many more contributing factors. There can be great value in, but significant consequences of imaging, and as our great friend Yoda so aptly noted, with great power comes great responsibility. 

 

Signing out 

 

James Boyd

 

 

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