To Scan or Not to Scan… That is the Question

To Scan or Not to Scan… That is the Question

Have you ever wondered if a scan will help your diagnose your pain or your injury? Does everyone need one so a physiotherapist can treat you?

A common question patients ask me is do I need a scan? The answer is not a simple YES or NO.

“50% of all  50 year olds will have a lumbar disc bulge on MRI-BUT not all will have pain”

The question should be, “will having a scan change my treatment plan and long term health and wellbeing goals?”

Before deciding a number of factors are taken into consideration -a thorough history and physical examination is carried out. A scan will usually just confirm what diagnoses the physiotherapist is treatment you for.

5 Reasons NOT to scan:

  1. With the fantastic advancements in imaging technology – scans can identify issues that can be NORMAL as well as ABNORMAL.

Low back pain- Do all my patients that present to me with low back pain get referred for an Xray or to a GP/specialist to get an MRI? No they don’t- SO how do I decide? If a patient presents with acute back pain – nil leg or bladder or bowel symptoms- having a scan immediately will not improve or speed up recovery. The research tells us that appropriate advise and education is of benefit straight away including appropriate exercise therapy and manual therapy.

2. There is well documented poor relationship between imaging findings and an individuals symptoms

As physiotherapists we don’t necessarily rely very heavily on the typing of an MRI/Xray/CT/Ultrasound report -we should however always read the reports and review the scans if you go to the trouble of bringing them in- we always take your pain and symptoms very seriously. 

“87% of all 20-70 year olds will have a disc bulge in their Neck- however they all do not have neck pain nor need surgery to FIX it”

3. Scans don’t diagnose pain

By definition, pain is an unpleasant feeling that is conveyed to the brain by sensory neurons- pain is also an unpleasant and emotional experience associated with actual or potential tissue damage in the acute ( recent) setting- chronic ( more longer term pain) is ongoing after the actual or potential tissue damage is gone. People can have nil pain and have grossly abnormal pain and vise versa people can have a high pain level and have normal scans

4. Side effects of the scan- the risk can  outweigh the benefits

Depending on the type of scan will potentially pose some risk- for example the radiation associated with X-rays/Bone scan etc or the impact on Intravenous contrast may have on someone’s kidneys if they have impaired renal ( kidney function)

Emotional/ stress & anxiety related side effects- most scan reports if read by the patient first ( this being not advised)- the medical jargon may place unwarranted stress on an individual- minor findings on scans can be of little to no value in helping to explain the majority of aches and pains we see in the clinic. Not only are they unhelpful but studies have suggested that they can even be harmful psychologically- especially when a patients scan reports says things like- disc disease, tendon tear and arthritis.

5. Financial cost

Plain X-rays can be usually. Bulk billed however an MRI can be >$200-$400 depending on who refers you and where you go for the scan. This money could potentially be better spent on early physiotherapy intervention.

5 Reasons TO scan:

1. To exclude red flags- or sinister pathology

For example cancer etc usually your health care practitioner will already be assessing you both subjectively ( asking questions- like have you had any unexplained weight loss or night pain) and objectively ( examining you) to determine your risk of this-a scan is just one part but by all means not the only part of the assessment process

2. To assist in the diagnosis:

If conservative therapy is not progressing the patient at the usual level or rate of recovery- for example if a simple ankle sprain -does not improve with  physiotherapy and exercise therapy over X amount of time then we may consider referring for some scans an MRI perhaps to exclude a taller dome fracture -this scan would then change the course of treatment- may require a BOOT and a longer immobility time and convalescence.

3. To see if supplementary/additional therapy for example an ultrasound guided injection would potentially be of benefit

For example in reference to a patient with shoulder pain- not all patients require or would benefit from a cortisone injection-this dose come with some potential risk- however if a patient has confirmed bursitis in the shoulder and the patient cannot tolerate a course of anti-inflammatories due to gut, kidney or blood pressure issues then a targets ultrasound guided injection ( under the experienced) hands may be of benefit .. however if the patient and physiotherapist are not working together as a team to modify the potential risk factors that contribute to the development of bursitis then the pain most likely will return 

4. To assist in determining if the patient and his or her condition are a suitable candidate for a surgical procedure
For example a shoulder MRI in anticipation of rotator cuff repair in a 43 year old male plumber. Scans can confirm clinical findings which may suggest a specialist doctor review and a possibility of surgery

5. To assess the rate of disease deterioration

I recently saw a new patient 62 female, Mrs R with L sided hip/groin/buttock pain- her hip examination was directing me to a diagnosis of severe hip OA ( she had an X-ray 2 years ago which showed moderate)- unfortunately MRs R put on 10 kg due to COVID ( not uncommon -unfortunately) and her pain was becoming extremely disabling-Having had the X-ray orders during my initial consultation and subsequent early pre-habilitation has commenced whilst awaiting an orthopaedic surgical review 

Yes scans can be a valuable assessment tool- however please DO NOT WAIT for a scan prior to starting treatment.

Case Study-Mrs C is a relatively active 70 year old who presented to the Emergency department with acute knee pain- she was kept in hospital for 10 days waiting for an MRI (largely on bed rest)- the medical staff wanted to see if she had a meniscal ( cartilage tear) I her knee-please note that > 19 % of those aged over 40 will have a tear and 43% arthritis. AS a result of the 10 days immobility Mrs C deteriorated- she got weaker, stiffer, put on weight, lost muscle and as at a high risk of DVT and pneumonia-Mrs C did have a meniscal tear- After an intensive 2 weeks of physiotherapy and hydrotherapy MRs C is now 50% better. She has also seen a surgeon who does not want to operate.

If you have pain or any musculoskeletal condition- please do yourself a favour and see us sooner rather than later- we do definitely refer for scans if indicated. WE do not want you to have to wait for them before you start treatment as delaying treatment will delay your return to your usual life and goals.

Please call us on 02 9529 8600 for further information or to book a consultation with us.

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