The Power of Images

Resolution of HerniationI speak frequently about the continued overutilization of diagnostic imaging in the management of musculoskeletal disorders.  As humans we are use to looking at wrinkles on the outside.  Some of us may choose to inject the wrinkes with a poison to paralyze the surrounding musculature in order to “flatten” them.  However, most agree that in and off themselves these wrinkles on the outside are pain free and a normal part of this wonderful journey we call life.  As humans we are not nearly as comfortable peering inside the body and seeing wrinkles on the inside.  This is not at all surprising as MRIs are a very recent invention (like while I was in high school and I am not that old). The vast majority of us have never even peered inside of our body except occasionally within our mouth and perhaps our nose (PS this trimmer has a light).   Those of us without visual deficits are used to seeing our reflection in a mirror and are not startled into making poor choices.  However, we need to look no further than wild animals (see here) who react strongly in various ways when confronted with this foreign image of self which is often scary.

At Manipalooza this past weekend in Denver I was surrounded by passionate PTs who are making a difference.  However, I continue to hear far too many stories about patients who are increasingly younger with musculoskeletal pain being “scared” into a surgery by showing a foreign image (i.e. an MRI of their body) and told that bad things will happen if they don’t act quickly with a surgical intervention.  It is not surprising that patients are scared sick.   Hopefully the recent image shown above in this short article from the New England Journal of Medicine will have an impact.  The article described a 29-year-old woman with new-onset right leg pain and paresthesia. There were no bowel or bladder symptoms. Magnetic resonance imaging (MRI) of the lumbar spine revealed a lumbar disk herniation resulting in substantial spinal stenosis and nerve-root compression. She elected conservative treatment with physical therapy and an epidural injection of glucocorticoids. A second MRI at 5 months showed resolution of the herniation.  Please share this example liberally, make posters on your wall, and send it to family members. Images are more powerful than words.   All surgery is not bad, however it should be a rare event when it comes to low back pain.


11 responses to “The Power of Images

  1. Tim, beat me to the post! You forgot to mention their post also states the woman had some conservative PT! Most likely would’ve resolved in time as well but doesn’t hurt literally to mention that to patients as well.

  2. Sean O'Reilly says:

    Hi Tim,
    Nice post, I agree with “scared sick” comment. I thought of “Jack” Peter O’Sullivans patient and how he fits the essence of your post well. There are numerous articles addressing early or improper imaging and subsequent morbidity amd increased strain on the healthcare system example, Webster, 2013 Iatrogenic consequences of Early MRI. Continued education of patients, therapists, and other healthcare practitioners is needed. Thanks for the post.

  3. Juan López says:

    We have the same results with the POLD Method of manual therapy, without infiltrations. #pold

  4. I’m mostly amazed that the insurance company allowed a repeat MRI at 5 months. Do you know what symptoms remained, if any? Reduction in the size of a disc herniation is common over time, as shown by numerous studies. This doesn’t point to a treatment result by itself, and any assertion that a manual technique would create this response would be purely speculative.

  5. Paul Potter says:

    I’m amazed at the body’s ability to self-repair and healing too. It’s a powerful force to cooperate with.

  6. Perfect, Tim! I just saved the images to my computer desktop. I know that it will provoke some conversations.

  7. Chris York says:

    Surly any self respecting PT could have diagnosed the disc prolapse without the need for an expensive MRI?

  8. Michael Carr, PT says:

    Not to mention the fact that about 50% of 50 year olds have a asymptomatic disc bulge on MRI.
    Differential physical exam is very lacking, there is still too much reliance on MRI by medicine, but a lot is patient driven looking for a quick fix

  9. Jamie, RN says:

    Please remember, though, that there are exceptions to the rules. Connective tissue disorders are an example. I have Ehlers-Danlos, tried time and aggressive PT before I elected to have surgery. However, I still had to resort to surgery because of a decline in my physical abilities. And, being an RN myself, I did understand the risks. Not all bodies are made the same. Remember that when you are treating your patients.

  10. Tim, great post here. I agree with your “scared sick” comment. We see this all the time where we are at.

  11. bautrockner says:

    Hmm is anyone else experiencing problems with the images on this
    blog loading? I’m trying to determine if its a problem on my end or if it’s the blog.

    Any feed-back would be greatly appreciated.

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