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To image or not to image... That is the question...

Updated: May 30, 2021

“My Dr. said my MRI looks great and doesn’t know why I have so much pain.” Or, “your spine looks like that of an 80-year-old”

Does either of these make you feel very good about your prognosis? From my experience, saying things like this and throwing out words you know the average patient does not understand simply encourages a negative cycle of thoughts. The biggest barrier to active recovery is the mental side of it. If you have it in your head that you have no control, you probably won’t put much effort in. It wouldn’t make much sense to spend your time trying to accomplish the impossible right? So why does this continue to happen? Is it a lack of empathy, a lack of awareness, or something else?

Physical Therapy | MRI | New Braunfels, TX

Imaging reports have been used for a long time as the gold standard, especially in a patient’s eyes. This is probably why so many patients look at me sideways when I tell them I do not need their imaging report yet. As a matter of fact, I would prefer that no one had an imaging report prior to their mechanical assessment. The human body is an amazingly complex system that challenges health care providers with unusual symptoms and rare diseases every day. So why would anyone not want an image to guarantee you're treating the right thing?

If a photo that was taken while lying completely still could accurately guide me to the correct structures causing my patient's pain, I would be all in. The problem is that they cannot guarantee me anything and often give healthcare providers and patients a false path to follow with treatment. Studies have been performed that took symptom-FREE patients off the street and performed MRIs. They found that the prevalence of degenerative changes which include disk degeneration, facet hypertrophy, and disk protrusion increased in these patients as they age. This is fairly basic, the older you are the more degeneration you have. The problem lies in the fact that these people did not have any pain.

These facts had never been so clear as when I started working at a spine-only facility. Every patient we saw had at minimum an x-ray and many also had an MRI. They would always have a diagnosis in their heads, and many had already talked to Doctor Google about the best options for treatment. Some had been through treatment with other facilities and failed to improve. One of the biggest reasons I have found is that the treatments they describe are designed for what their imaging report says, not for what is actually causing their pain.

Physical Therapy | X-Ray | New Braunfels, TX

How can I be confident enough to say that? I listen, I examine, I test, and I re-test and if things do not add up, I use what we got during testing to determine where to go next. If someone comes to me and describes their symptoms and it sounds discogenic and I test and they do respond like they have a disc issue, but their imaging is clear of a disc problem, why would I treat them for anything other than a disc issue? Now what can happen is that things can change but what is great is that the symptoms will guide any adjustments that may need to be made.

One study published back in 2015 in Radiographics titled Understanding and confronting our mistakes: the epidemiology of error in radiology and strategies for error reduction notes that these error rates were first documented in the 60s and have not improved since. I don’t feel there is a quantifiable way to change these rates because they are human error which is inevitable. So what needs to change? The simple answer is that healthcare providers have to be aware of this and MUST take the time to listen and examine patients. Sounds easy right? Tell that to the doctor having to see 30 patients a day to afford to keep his practice because the reimbursement rates are so low.

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