This week we are looking at an article review covering a brilliant paper that has recently been published out of Hong Kong. I have been waiting for a paper like this for some time now, that looks systematically at all the literature behind the current approach to pain management education that we are encouraged to provide to our patients about lower back pain and medical imaging. As I read through this article I kept thinking to myself yes, this is the concept I have been taught but I can’t recall which literature supports it.
Now we have an excellent summary to help advance our understanding of pain management further. It is a must-read and very well written and thoroughly research paper about the role of medical imaging for lower back pain. They touch on all the research we all currently know but pull it together in a compelling argument with many great key phrases we can use to educate patients better about the role that imaging will play in their recovery.
Below are the key take away messages that caught my attention.
Lower back pain is a symptom, not a disease.
"For most patients presenting with LBP, the specific nociceptive source cannot be identified, and those affected are classified as having “nonspecific LBP” (Wang, et al., 2018, p.22). Here the authors summarise the key components of the history and physical exam that aid in our distinction between specific and non-specific causes of LBP. Clinical reasoning is a very important component in the assessment and treatment of LBP and therapists need to understand how different conditions are likely to present, what red flags are important to consider and then form a decision about the role of medical imaging and how it assists with the patient’s recovery.
What value is there in a name?
One challenge that clinicians continually face is the incredibly high importance patients place on being able to label or name their problem. Labelling can often lead to negative beliefs around recovery and prognosis and in reality might not change the treatment path followed.
Despite clinical guidelines being available that discourage routine medical imaging, referral for scans continues to be incredibly high. Wang et al (2018, p. 22) state that "to be effective, efforts to reduce imaging overuse should be multifactorial and address clinician behaviours, patient expectations and education and financial incentives”.
Degenerative spinal changes are commonly found in patients with and without LBP. Here is a previous blog explaining how frequently degenerative changes are found on imaging and the discussion about the natural process of aging.
Wang et al (2018) cover the current discussion about the reporting of Modic changes in the spine - so read this section if you are wanting to improve your knowledge about the meaning of Modic changes and the impact they have on pain and recovery.
Current guidelines recommend to refer for imaging if the patient has severe or worsening neurological symptoms or signs of a serious or specific underlying condition (which occurs in <1% of cases).
What will imaging change?
When referring a patient for medical imaging it is important for the clinician to consider and for the patient to understand that (Wang, et al., 2018, p.22):
"The presence of imaging abnormalities does not mean that the abnormalities are responsible for symptoms."
"No evidence suggests that selecting therapies on the basis of the presence of the most common imaging findings improves outcomes compared with a generalised approach."
Most patients present with a benign condition - which means that most presentations of LBP, although may be very painful in the initial stages, are self-limiting and medical imaging will not speed up the recovery process. So the question you need to ask yourself is whether or not routine imaging will change/improve the treatment, prognosis and course of recovery? You also need to consider what harm patients are exposed to during medical imaging.
"In summary, there is strong evidence that routine imaging for LBP by using radiography or CT/MRI is not associated with a clinically meaningful benefit on patient outcomes. Unnecessary imaging exposes patients to preventable harms, which may lead to additional unnecessary interventions. Diagnostic imaging studies should be performed only in selected, higher-risk patients who have severe or progressive neurologic deficits or are suspected of having a serious or specific underlying condition. A thorough history and physical examination are necessary to guide imaging decision.” (Wang et al., 2018, p. 31).
Again, I’d love to recommend that clinicians refresh or expand their knowledge by reading this article. What a treat it was more me and I hope you enjoy it too.
Wáng, Y. X. J., Wu, A. M., Santiago, F. R., & Nogueira-Barbosa, M. H. (2018). Informed appropriate imaging for low back pain management: A narrative review. Journal of orthopaedic translation.