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RESEARCH COMMENTARY
Ejona (Ona) Jeblonski, DPT, COMT
Fellow in Training, MAPS Accredited Fellowship in Orthopedic Therapy

Chris R. Showalter, PT, COMT, OCS, FAAOMPT
MAPS Fellowship Program Director

Mobilization Increases Dorsiflexion in Chronic Ankle Instability (CAI) Patients


 
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Is Your Patient a Victim of “VOMIT” or “BARF”?

March 16, 2017

RESEARCH COMMENTARY

Chris Showalter PT, OCS, COMT, FAAOMPT
MAPS Program Director

There is an astounding prevalence of “pathological” findings on lumbar spine MRIs. These findings are so common in ASYMPTOMATIC people that it raises the obvious questions. Does your low back pain (LBP) patient really NEED an MRI? What is the clinical relevance of commonly seen degenerative findings in patients with LBP?   

Richard Hayward, a consultant neurosurgeon in London, published a narrative in the British Medical Journal (BMJ) (Hayward 2003) regarding the overuse of diagnostic imaging. He described two acronyms, namely:

1)    V.O.M.I.T. Victims of Modern Imaging Technology

2)    B.A.R.F. Brainless Application of Radiological Findings

Hayward (2003) suggests:
“For new low back pain (simple aches and pains in the lower back), an MRI is often not required however, these do have their use. Occasionally back pain is caused by something serious rather than a simple mechanical problem. In these cases imaging is useful and can be lifesaving. In these cases, there are usually other situations that go with the back pain that may warrant MRI including:

  • Unexplained weight loss
  • A high temperature and fever over 102° F/ 40 degrees Celsius.
  • Loss of bowel or bladder control
  • Loss of feeling or muscle weakness in the legs
  • A history of cancer
  • Serious trauma
  • Tried conservative treatment (PT/DO/DC) treatment for over 6 weeks with no improvements.

It is also appropriate that our patients and athletes understand not to jump into scans unnecessarily as many are personally funded. MRIs are expensive. They can be a substantial cost to an individual or organisation at ~ £300 per scan (US $500).”

Red hair does NOT cause headaches!

Anatomical coincidence is NOT proof of cause and effect. To assume this would be the same as saying:

"Red hair is not normal in the sense that it is quite uncommon. It is close to the site of your headache. So, your red hair must be the cause of your headache!” (Waddell 1998)

In 21st century medicine, we know that the connection between red hair and headaches is ridiculous. Red hair does NOT cause headaches! The logic is simple, straightforward and, of course, it is undeniable. Red headed people get headaches for the same reasons as the rest of the population including: migraine, tension and cluster types, cervicogenic headaches and others.

HOWEVER, many clinicians from various disciplines (MD, DO, PT, DC etc.) view MRI findings in low back pain (LBP) patients like the redhead with a headache.

"Lumbar disc bulge is not normal in the sense that it is considered pathological. It is close to the site of your LBP. So, your disc bulge must be the cause of your LBP!” 

The logic to the above statement is spurious to say the least, and frustrates many conservative care clinicians.

But don’t MRIs “prove” the clinical significance of pathological findings?

--NO!

Questioning the value of MRIs to determine the source of LBP is not new. As early as 1990 MRI scans were performed (Boden 1990) on sixty-seven asymptomatic individuals who had never had LBP, sciatica or neurogenic claudication. Three neuro-radiologists were blinded to the presence or absence of symptoms. Of those asymptomatic volunteers less than 60 YO, 20% had at least one herniated nucleus pulposis (HNP) and one had spinal stenosis. Those who were 60 years old or older showed abnormal findings in 57% of the MRIs studied, including: 36% with at least one HNP and 21% had spinal stenosis. The authors of the Boden 1990 study concluded:

“In view of these findings in asymptomatic subjects, we concluded that abnormalities on MRI must be strictly correlated with age and any clinical signs and symptoms before operative treatment is contemplated.” 

In 2001, the same research group (Borenstein 2001) performed a follow up study over a 7-year period. Fifty of the sixty-seven original asymptomatic individuals returned questionnaires regarding the development and duration of LBP. The results showed 58% still had no LBP.

The authors concluded:
“The findings on magnetic resonance scans were not predictive of the development or duration of low-back pain. Individuals with the longest duration of low-back pain did not have the greatest degree of anatomical abnormality on the original scans. Clinical correlation is essential to determine the importance of abnormalities on magnetic resonance images.”

Other authors (Jarvik 2001) found high proportions of pathology in 148 asymptomatic subjects, including: disc degeneration 91%, spondylosis 56%, disc bulge 64%, protrusion 32% and annual tear 38%. The authors in this study stated:

“The findings are so common in people without back pain that while we report their presence, they must be interpreted with caution and in context of the clinical situation.”

Does your LBP patient have an “Incidentaloma”?

A made up word, from: Incidental “accompanying but not a major part of something” and Oma “suffix meaning tumor or cancer”

YES…LBP patients have LOTS of incidentalomas!

 

A recent systematic review (SR) of the literature (Brinjikjia 2015) evaluated 33 articles reporting imaging findings for 3,110 asymptomatic individuals. Results were reported stratified by decade of life i.e 20s, 30s, 40s etc. The results are astounding.

Table 2: Age-specific prevalence estimates of degenerative spine imaging findings in asymptomatic subjects

                                                            Age (yr)

Imaging Finding     20       30        40       50       60       70       80

Disk degeneration   37%    52%    68%    80%    88%    93%    96%

Disk signal loss       17%    33%    54%    73%    86%    94%    97%

Disk height loss       24%    34%    45%    56%    67%    76%    84%

Disk bulge               30%    40%    50%    60%    69%    77%    84%

Disk protrusion        29%    31%    33%    36%    38%    40%    43%

Annular fissure        19%    20%    22%    23%    25%    27%    29%

Facet degeneration   4%      9%    18%    32%    50%    69%    83%

Spondylolisthesis      3%      5%      8%    14%    23%    35%    50%

 

(Prevalence rates estimated with a generalized linear mixed-effects model for the age-specific prevalence estimate (binomial outcome) clustering on study and adjusting for the midpoint of each reported age interval of the study.)

PDF of the original article can be found here: http://www.ajnr.org/content/36/4/811.full.pdf+html

 

The Brinjikji 2015 authors concluded:

Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain. These imaging findings must be interpreted in the context of the patient’s clinical condition.”

Take a look at the table again. Suppose you are in your mid-40s, have no back pain and have an MRI today…you have 50% chance of being diagnosed with a disc bulge …that’s the same chance as tossing a coin, without paying $500 plus for an MRI!

 

What about the cost of MRIs?

Fritz and colleagues (Fritz 2015) evaluated the comparative cost of advanced imaging vs physical therapy following a new primary care consultation for LBP. In their study of 406 cases, advanced imaging recipients had higher charges for care by an average of $4,793 (95% Confidence Interval (CI): $3,676, $5,910) compared to physical therapy.

 

Summary

SO…”abnormal” MRI findings (or MRI findings with pathology) are so prevalent in asymptomatic lumbar spines that it may be more reasonable to consider these findings part of a continuum of “normal” findings, or at the very least “common degenerative conditions that are frequently asymptomatic”. These incidentalomas often do not have clinical relevance.

If a 40 year old asymptomatic subject has a 50% chance of showing a disc bulge, then the next 40 YO LBP patient you see with MRI scan result of “disc bulge” has a 50% chance that the bulge is meaningless to their LBP! 

Pathological findings are so common in the pain free population that attributing a patient’s LBP to a particular MRI finding may actually be unreasonable (i.e., the red hair causes headaches argument) and in the absence of clinical reasoning, potentially lead to unnecessary, expensive and often ineffective interventions.

It is pertinent to consider that most of the articles quoted were published in physician oriented peer reviewed journals, namely:

Hayward (2003)                                 British Medical Journal

Boden (1990) & Borenstein (2001)    Journal of Bone and Joint Surgery 

Jarvik (2001)                                      Spine

Brinjinki (2015)                                   American Journal of Neuroradiology

Thus physicians, who order MRIs, and surgeons who perform surgery, should be aware of how commonplace incidental findings are in LBP. The literature has demonstrated this for 27 years!

 

IMPORTANT TAKE-HOME MESSAGES  

1)    MRIs of the lumbar spine demonstrate significantly high prevalences of “abnormal” findings in asymptomatic subjects

In other words, the abnormal pathological findings are so common they could be considered normal degenerative changes…in the pain free population!

2)    MRI findings of pathology may not be meaningful in your patients

An MRI finding of pathology may not actually determine the patient’s pain generating structures…the MRI finding may effectively be a false positive!

3)    Most authors agree that MRI findings MUST be correlated with clinical presentation to determine subsequent management

Therefore, Clinical Assessment and Clinical Reasoning (CR), are CRITICAL to determine the relative value of the MRI findings and their relevance (if any) to the patient’s clinical presentation…That is true Evidence-Based Practice (EBP)!

4)    Use Clinical Assessment and Clincal Reasoning (CR) to treat the symptom generating structures NOT the incidentalomas!


Cheers and Enjoy

Chris R. Showalter PT, OCS, COMT, FAAOMPT 
© Chris R. Showalter and Maitland Australian Physiotherapy Seminars

 

Not to be reproduced, copied or retransmitted in any manner without author’s express written permission. 
Directing others to the MAPS website (www.ozpt.com) is permissible.

 

Articles

http://www.bmj.com/content/326/7401/1273.1

1)    Hayward, R, (2003) VOMIT (victims of modern imaging technology)—an acronym for our times. (n.d.). Retrieved March 16, 2017, from http://citeweb.info/20030141880 

2)    Waddell G, The Back Pain Revolution 1st Ed.. Edinburgh: Butterworth-Heinemann; 1998.

3)    http://www.ncbi.nlm.nih.gov/pubmed/2312537

Boden SD1, Davis DO, Dina TS, Patronas NJ, Wiesel SW Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990 Mar;72(3):403-8

4)    http://www.ncbi.nlm.nih.gov/pubmed/11568190

Borenstein DG1, O'Mara JW Jr, Boden SD, Lauerman WC, Jacobson A, Platenberg C, Schellinger D, Wiesel SW. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects : a seven-year follow-up study. J Bone Joint Surg Am. 2001 Sep;83-A(9):1306-11.

5)    http://www.ncbi.nlm.nih.gov/pubmed/11413431

Jarvik JJ1, Hollingworth W, Heagerty P, Haynor DR, Deyo RA. The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) Study: baseline data. Spine (Phila Pa 1976). 2001 May 15;26(10):1158-66.

6)    http://www.ajnr.org/content/36/4/811.full.pdf+html 

W. Brinjikji, P.H. Luetmera, B. Comstockb,c, B.W. Bresnahanc, L.E. Chenc, R.A. Deyof, S. Halabig, J.A. Turnerd, A.L. Avinsh,i, K. Jamesc, J.T. Walda, D.F. Kallmesa and J.G. Jarvik Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR 2015 36: 811-816

7)    http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12301/abstract;jsessionid=0BAE251A27722E47719DCA102BF362D4.f04t01

Fritz JA, Brennan GP, Hunter SJ Physical Therapy or Advanced Imaging as First Management Strategy Following a New Consultation for Low Back Pain in Primary Care: Associations with Future Health Care Utilization and Charges. Health Ser. Res. 2015, 50 (6): 1927-1940

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