The Clinical Necessity of Imaging

Author: Melissa A. Bartoszewski, DC /Monday, May 23, 2016/Categories: August 2014

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By Melissa A. Bartoszewski, DC 

IT IS OFTEN SAID THAT A PICTURE is worth a thousand words, but not necessarily in the clinical world of advanced imaging. The United States spends more on healthcare than any other country, yet we are the sickest, for numerous reasons. Doctors of chiropractic (DCs) treat a wide variety of musculoskeletal conditions that typically do not involve any invasive procedures and resolve in a reasonable amount of time with conservative treatments.

Treat the Patient Not The Image

In a January 2014 article on Spine-Health.com (a peer reviewed site), common mistakes that can worsen back pain are investigated. One big mistake is focusing on the imaging results, such as an MRI. It is important to remember that pictures do not show pain. In fact, you may have a patient in terrible pain and an MRI or x-ray that shows a normal-looking spine, or you may have an MRI that shows a large bulging disc, yet no pain; there is not always a direct correlation.1

A recent study published by The Journal of Manipulative and Physiological Therapeutics found that there was a “90% improvement with lumbar disc herniation confirmed on MRI with chiropractic side posture adjustments.2

But while having an MRI of your lumbar spine performed may be quick and painless, it can lead to unneeded surgeries, complications, poor outcomes and chronic pain. The New England Journal of Medicine recently published a study performed to see if having an MRI can predict whether or not someone needs surgery. Surgical patients were once thought to get better faster than conservative care patients. This new study revealed that 84 percent of all patients got better after one year, whether they had surgery or conservative treatments. Using imaging and confirming a disc injury does not predict a better outcome.3

Some research suggests that acute and chronic low back pain, disc injuries and other conditions will demonstrate improvement — with chiropractic care and exercise found to be the best healing options.

Catastrophizing


Catastrophizing is defined as “To view or talk about an event or situation as worse than it actually is, or as if it were a catastrophe.” Th is form of coping can actually delay one’s recovery, according to a recent article in Th e Spine Journal.4 Seeing x-ray or MRI results can cause a patient to make too much out of insignificant findings, experience more pain, delay recovery and more. Many people may have a mild scoliosis or 1-2mm disc bulges; but once they are told they have them, suddenly the patients experience increased or prolonged pain. Patients focus on the results of the images, even if they don’t correlate with their symptoms or in reality are insignificant. “Across a wide range of clinical conditions, from lower back pain to heart surgery, patients who felt they would do well in recovery did. Patients who were scared or pessimistic about their recoveries did not recover as quickly as the optimists or as well.5” Positive attitudes about care, recovery and expectations play important roles just as the actual hands-on treatments do.

Google, WebMd and countless other online sources have allowed patients to search their symptoms and focus on the worst-case scenarios, using that information to justify unnecessary x-ray, MRI, or CT. “Pinched” nerves or other soft tissue injuries cannot be seen on plain films. Many patients have been conditioned to believe that if they don’t have an X-ray taken, that the doctor is not acting in their best interest. Patients also don’t realize that an X-ray isn’t always required, that radiation poses risks or that an X-ray won’t change their treatment.

Is Radiation That Bad?


Many pathologies have been caught on x-rays taken by chiropractors, that other providers did not, or even missed. It is only the irresponsible use of radiation that needs to be curtailed. When unnecessary, it certainly is not the standard of care.

Radiation protection is a significant issue that must be addressed. A 2008 study published in the American Journal of Epidemiology showed the increased risk of developing cataracts due to ionizing radiation of the eyes. The study finds, “The lowest cataractogenic dose is substantially less than previously thought. Significant association between history of 3 or more diagnostic x-rays to the face or neck and increased risk of cataract.6” It continues, “Computed tomography scans are significantly associated with posterior subscapular cataract. 6”A separate study in the same journal on thyroid risk found that, “thyroid cancer is one of the most strongly linked to radiation exposure. 7

According to the British Columbia Medical Journal, “Avoiding radiographs for those patients where the results are predicted to be normal translates to significant savings to our medical system and a reduction in the exposure of patients to ionizing radiation.8

CT and MRI Overuse

JAMA Internal Medicine published an analysis regarding the overuse of CTs and MRIs. Dr. Brian Callaghan, assistant professor of neurology at the University of Michigan, led the study. Over a span of 3 years, 51 million visits were documented for headache-related problems. Twelve percent of those patients were sent for advanced imaging, even though various guideline sources state that serious pathologies are uncommon. These unnecessary scans were estimated to cost $3.9 billion ($1.5 billion just for migraines). Sciatica-type symptoms cost roughly $50 billion each year, but typically resolve within a couple of months with conservative care.9 Conservative care is less invasive, has less risk, and is less expensive.

“Our scan-happy habits not only waste money,” Dr. Callaghan says, but “expose us to harm that can come from putting a healthy head in a scanner.” There’s needless radiation exposure from a CT, for one. And MRIs often turn up false positives — things that though they look odd will never cause any harm, yet can prompt a cascade of tests and invasive procedures. Instead, the overwhelming majority of headaches are tension headaches or migraines. “Previous research has shown that only 1-3 percent of brain scans of headache patients uncover a malignant growth or problem with the blood vessels in the brain. Also, of these issues found by scans, many do not require immediate treatment. Both doctors and patients are to blame for the brain-scan craze,” Dr. Callaghan says.9

Doctors need to stop ordering unnecessary scans, and they need to educate patients about why one is not warranted at that time. Patients need to stop expecting advanced imaging to rule out worst-case scenarios without enough clinical evidence and symptoms to warrant them.10

Footnotes

1. www.spine-health.com/blog/ six-mistakes-can-worsen-your-back-pain

2. www.ncbi.nlm.nih.gov/pubmed/24636109

3. www.huffingtonpost.com/richard-c-senelick-md/ sciatica-_b_4098475.html

4. www.sciencedirect.com/science/article/pii/ S1529943014002435

5. abcnews.go.com/Health/story?id=117317

6. www.ncbi.nlm.nih.gov/pubmed/18664497

7. http://aje.oxfordjournals.org/content/157/7/652.full.pdf+html

8. www.bcmj.org/article/ whiplash-role-imaging%E2%80%94-x-ray-or-not

9. www.medicalnewstoday.com/articles/274185.php

10.www.npr.org/blogs/health/2014/03/18/291044766/yes-its-a-headache-no-you-dont-need-abrain-scan?ft=1&f=1128&utm_source=health&utm_ campaign=nprnews&utm_medium=twitter



Chad D. Warshel, DC, DACBR, Associate Professor, New York Chiropractic College Director, M.S. in Diagnostic Imaging Residency Radiologist, NYCC Diagnostic Imaging. 

Dr. Bartoszewski is owner of Big D Chiropractic in Dallas, Texas. She is a graduate of New York Chiropractic College and a native of Syracuse, N.Y. Her passions include nutrition and evidence-based care.

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