Controversy: Imaging, is it helping your patient or wallet?

Controversy: Imaging, is it helping your patient or wallet?

When diagnosing the culprit of lower back pain, many clinicians rely on diagnostic imaging (i.e.: x-ray, MRI, CT). Lumbar pain is reassuringly benign, 85-90% of the time. Lumbar pain involving nerve compression comprises 10% of lumbar pain patients. Sinister or serious disease make up the remaining 2% of lumbar pain patients. The great news is that these ‘sinister’ conditions are ruled out by a proper history and exam. However, many clinicians still seem to be ordering imaging during the initial exam. The question often raised is

“structural pathology is often evident in images, so why wouldn’t we (the clinician) want to identify such abnormalities?”

While structural pathologies do have there place in medicine, they usually have little to do with lower back pain. In fact, most lumbar pain patients do not have a structural pathology that can be precisely identified as being a cause of their symptoms. McGuirk et-al found that 1.4% of lumbar pain patients had serious causes as a result of their lumbar pain, but they were suspected from the initial exam and history.

What about disc herniation?

Because the false positive rates are so high, in identifying a herniated disc, it makes imaging inappropriate as a screening procedure. Moreover, it can lead to labelling thus allowing the patient to assume a sick role or cause the doctor to prescribe unnecessary treatment. In a study performed by Bonenstein et-al, 67 asymptomatic individuals received MRI’s. The results were staggering, in that, 31% of them showed abnormality of the disc or spinal canal. Moreover, additional studies showed that these abnormalities didn’t predict a greater chance of future problems. Multiple studies have also shown that common “positive” findings are present in 28% to 50% of people with no pain at all! Disc herniations have a tendency to resolve in a natural process without surgery. But, what about the herniations that require surgery? The Danish guidelines show the following as being surgical indicators for herniated discs. 1: No improvement after 4-6 weeks 2: Progressive weakness in the leg 3: Leg symptom remains severe despite treatment and medication 4: There is a positive correlation between clinical findings and imaging reports. What about spinal degeneration (decay)? Again this is a term that instils fear into a patient. Disc degeneration is demonstrated with equal properties between those with and without pain. The prevalence of disc degeneration in people without pain and in their middle ages ranges from 46% to 93%! Therefore there is little correlation between radiological signs of degeneration and clinical symptoms.

When is imaging appropriate?

Most acute lumbar pain patients resolve quickly and with little intervention. In fact, It has been shown time and time again that reassurance, simple pain relief and staying active, is the best strategy for managing active lumbar pain. If there are red flags (sinister conditions) present, they should be picked up during the initial history and exam. Red flags of the serious disease are as follows: Mri of the back 1: Age younger than 20, older than 50 2: Trauma 3: History of cancer 4: Night pain (unremitting) 5: Fevers 6: Weight loss (unexplained)\ 7: IV drug use 8: Cortico steroid use 9: Recent infection 10: Cavda Eqvina 11: Generalised Systemic Disease (diabetes) 12: Saddle Anesthesia 13: Motor weakness of lower limbs 14: Sphincter Disturbance 15: Failure of 4 weeks conservative care Given these guidelines we are able to form a simple strategy. If there are no red flags, consider: 1: Reassuring the patient no serious disease is present 2: Relieve and reduce pain (simple analgesics, manipulation) 3: Reactivation (stay active, no bed rest) If there are red flags present consider the following: 1: Imaging 2: Lab work 3: Referral Informing your patient that you are able to rule out sinister conditions, even though an exact cause of their pain may not be identified, will register as very reassuring news. Craig Leibenson gives a wonderful analogy for simple back pain:

“liken the pain to a common cold or the pain experienced from gardening for the first time after a long winter”.

Conclusion

In a study by Kendrick, patients who received x-rays were likely to report a longer duration and greater severity of pain. Why reinforce a patient’s belief that they are unwell and cause them to limit their activities and in essence promote a more negative outlook? Yes patient satisfaction may be higher but the patient must be educated on why radiography is unable to improve therapy, decision making, or outcomes. If after 4-6 weeks there is no sign of improved function or red flags are identified from the patients history and exam, then consider (imaging or appropriate refferal). But always remember, a picture of a car doesn’t mean its running.

References. Leibenson C, Rehabilitiation of the spine. 2nd edition: 2007 Bonenstein DG, et-al. The value of MRI of the lumbar spine to predict lumbar pain in asymptomatic subjects. J Bone and Joint Surg 2001:83-A:1306-1311. Boden SD, abnormal MRI of the lumbar spine in people without back pain. N engl J med 1994;2:69. Kendrick D, Radiography of the lumber spine in primary care patients with lower back pain: Randomised controlled trial.  BMJ 2001; 322: 400-405. Jaruik JG, the longitudinal assessment of imaging and disability of the back study.  Spine 2001; 26:1158-1166.

Tactile Pain Management: iPhone Application

Over the past few years I have really wanted a way to be more analytical and technological with monitoring my patients outcome assessment. I have tried everything from standard forms and progress reports to mailing out weekly spreadsheets which patients fill in and return. All of these are time-consuming. Ironically enough, often patients lose motivation as well and do not always complete or return forms properly. Through this I began to develop an iPhone application that would allow for reminders and a tactile surface to measure their daily outcomes. I am happy to announce that I used my concept for the first time as a prototype today and am very excited about the potential of the application.

This may serve as a vital tool for simple, cost-effective, and reliable outcome assessment and patient monitoring.  According to the data, outcome assessment should be valid, reliable, responsive to clinical change, and practical.  I believe this application contains these components on a fundamental level.  Most importantly it is practical.  It is simple to administer, requires little input (if any) from the practitioner.  Moreover, it allows for yes/no or quantitative type responses for the user.  Therefore, this application is time and cost efficient as well as valid, reliable, and responsive.

please note these screenshots are from the prototype and are being sharpened up at the moment.

The application will allow the patient/client to monitor the following areas on a daily basis:

1. Pain and Soreness
2. Energy Levels
3. Quality of Sleep
4. Motivation
5. Impact on Others
6. Willingness to Change
7. Productivity
8. Custom Field (Add in anything you would like here; i.e. Job Satisfaction)

The custom field also allows the individual to place a baseline on the lowest and highest values.  For instance, if we use Job Satisfaction as an example, the lowest value may be labeled as “I Hate My Job” and the highest being “I Cant Believe I Get Paid to do This!”.  It will give freedom over the labels allowing the patient to connect better with their questionnaire.

The application then stores the info and begins to chart the data over time.  This is important for a few reasons:

1. It allows the patient to “SEE” their progress.  Any healthcare practitioner can appreciate the impact this has in demonstrating pain trends.
2. It allows the patient to recall and reflect on their treatment over large periods of time in a matter of seconds.
3. It allows the patient to understand flare ups and how even though they may be having a flare up, their overall trend is improving
4. It allows the patient to monitor their own progress and give a sense of accountability

The graphical input will allow the user and practitioner to see the patients progress over the course of:

1. One Week
2. 6 Months
3. 12 Months
4. Year to Date (YTD)

Furthermore, the user is able to enter in reminders so that the alarm on the phone goes off or vibrates during the day to prompt them to do one or more of the following:

1. Record their Levels
2. Do their exercises/stretches
3. Custom Field (Add in anything you would like here)

Because it is important for the patient to have great and effective communication with their personal practitioner(s) I have included a function that allows them to email the charts and data (on the spot) to their practitioner(s).  I am really excited about this because it puts the accountability in the patients hands and empowers them to understand their pain and talk about their pain in a direct and easy manner.

It will also allow the patient to upload their outcomes to Facebook as a way of showing off their improvement (or perhaps lack of).

The update pathway includes:

1. Secure data (no patient names for security) upload to a server for pain management research
2. Children’s version for child cancer patients
3. Graphical Comparison (look at perhaps pain vs mood)
4. Advanced Statistical Analysis
5. Various Graphical Forms

This application will also be able to be branded to your clinic through our brand-the-app affiliate program.  This will allow your clinic to place all branding and information on the app (such as splash screen, about, and contacts) for sales to your patients.  You will also retain royalties from the sales of the app on iTunes or other supplying stores.

In summary, I am VERY excited about the potential of this application as there is hardly anything of its kind currently available.  Its simple, easy to use, and any patient that has an iPhone will love it.  Plus, it makes something that was bland and boring, actually fun.  The potential for research using this application is also very exciting.  This form of outcome measurement is essential in enhancing doctor-patient communication and improving goal setting and decision-making abilities.  Consider this when thinking of this application:

1. Establishes quicker more reliable report with the doctor and patient
2. Unmasks Ineffective Treatments believed to be Effective
3. Improves Goal Setting and Goal Achieving (are we making our goals?)
4. Improves Decision Making
5. Reduces the “burden” of typical paperwork and progress reports
6. Highly responsive
7. Helps justify treatment outcomes to 3rd party providers

I expect this to be available in the iTunes store by the second week of October and for a very affordable price (especially when compared to the cost of a patients office visit).  I hope you share my joy in this application.

If you have any questions feel free to contact me via comments below or through my website: www.anthonyclose.com

Self Assessment and Care: Spinal Seminar

Saturday, October 2nd
2:00pm to 5:30pm
Cost: Free/Donation

“80/20 Rule: 20 percent of this seminar you will remember, 80 percent you will forget.  I will try to keep the information simple, compact, and easy to follow.”

This seminar is geared at teaching the following:

1. Relevant Anatomy in a simple, easy to understand manner
2. How we are injured and how we recover (micro, macro-trauma, trigger points)
3. Self Mobility and Functional Assessment
4. Self Treatment and Progressions

1/3 of this seminar will be lecture, the other 2/3 will be hands on coaching.  Expect this to be a very informative seminar that covers everything from assessment to self-treatment to pain management and prevention.

For directions click here