A picture is not always worth a thousand words…

The saying “a picture is worth a thousand words” is often used to explain how a complex situation, idea, or thought can be conveyed better with a picture. There are many examples when this is true, such as a piece of art or a well-taken photograph expressing a range of emotions and feelings far better than any written words can. 

There are also many examples when pictures can convey information more effectively within healthcare, such as the use of infographics and graphs to help disseminate scientific research or literature, like the excellent Yann Le Meur  @YLMSportScience and Chris Beardsley @SandCResearch do so very well. There are also times when images can express an idea or message far quicker and easier than a blog or a podcast can such as my own ‘physio treatment pyramid‘ or my ‘road to recovery‘ pictures that I use a lot.

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However, there are also many times when a picture is NOT worth a thousand words and when it does NOT covey complex information very well. Instead, some pictures can oversimplify, mislead, add more confusion and be more harmful than helpful. For example, in healthcare images of crumbling bones, red raw arthritic joints, and jam shooting out of a doughnut are often used in a belief they are helpful educational aids informing people about osteoporosis, arthritis, and spinal disc herniations, when in fact they are more likely to be harmful by painting misleading nocebic ideas about these conditions.

And these harmful misleading nocebic effects are not just seen with posters and infographics in healthcare, they are also, unfortunately, a very common side effect of many medical images used in healthcare such as Xrays, CT scans, MRI’s and Ultrasounds.

xray

Now there is no doubt that advances in medical imaging and technology have helped modern healthcare hugely. From the first accidental discovery of the X-Ray by Wilhelm Roentgen back in 1895 being quickly put to good use by battlefield surgeons to locate bullets and shrapnel in wounded soldiers, to the development of CT scans, MRIs, and ultrasounds to identify serious life-threatening diseases, illnesses, and injury’s much faster and so have undoubtedly saved millions of lives. Simply put modern medical imaging has and will continue to be an invaluable tool… when used appropriately.

However, where medical imaging is failing many people is when it is being used inappropriately and incorrectly to explain why some things hurt in some people. This is due to many clinicians and patients thinking that pain and disability can be explained simply when a structural irregularity is seen on a scan such as a bulging or herniated disc, a misshapen or degenerative joint, or a torn or inflamed tendon, this, unfortunately, is just not true.

Now it can be this simple at times, for example, if you twist your ankle badly and have a lot of pain and can’t walk on it, you get an X-ray that finds a broken bone, then the pain is undoubtedly due to your broken bone. However, there are also a lot of times when it’s not this simple, such as when the pain starts without any clear injury or mechanism.

There is growing evidence that many things seen on scans in those with non-traumatic pain are found very commonly in people with NO pain and NO disability. We are beginning to recognise and understand that what we thought was pathology and sources of pain and other symptoms may just be normal variations in normal anatomy or natural ageing process.

For example, Guermazi et al (2012) demonstrated that ALL the common pathologies are seen in knee scans such as meniscal lesions, synovitis, and articular cartilage damage are found just as much, if not more often in subjects WITHOUT pain as those with pain. Also, Brinjiki et al (2014) showed that there is a high prevalence of structural irregularities of the lumbar spine seen on MRIs of more than 3000 people aged between 20 to 80 years olds who again had NO pain, disability or any other issues.

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We also have a study by Nakashima et al (2015) who showed again high amounts of structural irregularities believed to cause pain and disability in the necks of over 1200 subjects who all again had NO symptoms or complaints. Then in the shoulder, we have Grisih et al (2011) who found a staggering 96% of subjects had at least one so-called pathology on their US scans yet zero pain or disability.

Again in the shoulder, we have Teunis et al (2015) who showed an increasing prevalence of rotator cuff tears with increasing age but more than 65% of them had no pain or disability. Then there is Schwartzberg et al (2016) who showed 72% of middle-aged subjects have non-symptomatic superior labral lesions, then Le Goff et al (2010) showed over 50% of those with calcific deposits in their rotator cuff tendons also had no pain or symptoms, and finally, Lesinak et al (2013) highlighting that nearly 50% of young elite-level professional baseball pitchers have full-thickness cuff tears and/or superior labral lesions with no pain or any adverse effect on their performance.

And this is just some of the evidence in the shoulder joint alone, I could go on and on presenting study after study conducted on pain-free, fully able subjects that shows so-called pathology in all areas of the body such as the hip, knee, foot, elbow and of course the spine! This large body of evidence available proves that many things we see on scans in those with pain and other symptoms are also seen just as often, if not more in those without any pain or symptoms.

Things often labelled as pathology on scans are often just normal variations in anatomy or morphology, or just normal signs of age. It is not as simple as just seeing a worn-out, misshapen, or torn structure on a scan and assuming it is the source of someone’s pain.

A nice comparison here is looking at a photo of a wedding where everyone is grouped around the happy couple. In this photo, everyone is smiling and looking happy, but you cant determine who actually is happy just by looking at the photo. This is the same as when looking at an MRI of someone’s spine or shoulder, we may see things that look unhappy on the scan, but we can’t actually tell if it is actually unhappy just by looking at the scan.

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This is why we should always medical imaging with a thorough physical examination and of course a full and detailed history from the patient. It’s when all of these things combined fit together can we have more certainty and probability of what may or may not be contributing to someone’s pain and disability.

Now, whilst we are on the subject of medical imaging I want to also talk about if scans can help reassure patients who have unexplained pains and other symptoms. Well, there is no doubt that if there is any significant probability that someone’s pains and symptoms are coming from something serious or sinister that could adversely affect their quality of life or even threaten their life, then of course imaging can have a hugely important role here.

However, fortunately, these cases are rare and rarely are there any strong signs and symptoms of serious or sinister pathology in those we see with most musculoskeletal pains and disabilities. So should we send these people for scans anyway just to reassure them?

Well, simply no… there is little evidence that scans help reassure patients (ref), in fact, there is more evidence they can do the opposite and cause more fear, angst, and harm (ref). However, as always there is some nuance and shades of grey here.

The common misconception here is that it’s the scan that is or isn’t reassuring, when in fact it’s actually the information and explanations given from the scan that is or isn’t helpful or harmful. To put this as bluntly as I can… scans don’t reassure or scare patients, clinicians explaining scan results do.

If scans are explained rationally and reasonably with the findings described in clear and easy-to-understand language, and most importantly put into context for the patient’s age and their current situation, then yes I find scans can be really reassuring. However, if scan findings are read to patients using unclear and confusing medical terms without any context then they can absolutely scare the living shit out of people.

For example, there is a huge difference in telling a 65-year patient that their knee MRI has shown degenerative changes to their medial femoral condyle and a number of meniscal lesions, to their knee is showing normal age-related changes and no significant pathology that requires any invasive or surgical procedures.

When medical images are explained this way it has been shown in the research that patients are far less likely to progress onto unnecessary treatments and procedures and their prognosis and outcomes can be significantly better. And other research has shown that rewording scan reports with simpler terms such as changing the word tear for high signal, and degenerative for age-related it improves patient understanding and satisfaction.

So in summary we can see that pictures and images used in healthcare have both positive but also negative effects. I think all healthcare professionals have a responsibility to try and maximize the positive and reduce the negative when it comes to medical imaging. Clearly, medical imaging has a role, but it needs to be used wisely and sensibly.

I will leave you with the brilliant acronyms first used by Richard Heyward in his editorial on the issues of medical imaging in the British Medical Journal back in 2003 here. When it comes to medical imaging and scans do not B.A.R.F and create V.O.M.I.T, which stands for do not use Brainless Application of Radiological Findings and create Victims Of Modern Imaging Technology

Or more simply never treat a scan, always treat the human!

As always thanks for reading

Adam

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  1. Well done article. It makes me think that an entrepreneurial enterprise would be to create software that includes epidemiological data of imaging findings to amend the reported findings and reduce the nocebo effect, which, as we all know, is very difficult to undue.
    One suggestion, please amend your last line to, “don’t treat the scan, treat the man, or woman. ” thank you 🙂

    • Thank you for your comments.
      The saying don’t treat the scan treat the man, is merely a metaphor than a literal statement. It’s not meant to be sexist but rather a just a saying. If it’s changed it won’t have the same ring or appeal to it!

  2. I recently had to go see a doctor for lateral epicondylitis and he insisted on Xray for my neck and told me I would “never get better” with my elbow because my neck showed “severe degenerative arthritis” the “worst he’d ever seen”. My neck doesn’t hurt, my elbow is better with strengthening and that doctor is the worst kind of idiot. Enough said.

  3. Great post. We’re dealing with this on a daily basis with the chronic pain population. Over the last decade, prescriptions for opioids, MRI scans, spinal injections and surgery levels for back pain have risen by 20-30%, disability levels for lower back pain have increased by 15-20%, with a chronicity prevalence of 80% and life time prevalence reaching 60-70%! Even more alarmingly, back pain prevalence among adolescents and children have also risen, being 3-4 times higher in Western Europe compared to the rest of the world. 133 million work days are lost annually in the UK with lower back pain listed as the most prevalent cause. That is a not only a huge loss of productivity and cost, but a damning presentation of what could be called a failing model of health care.
    Just like a nocebo effect, patients being told their scans shows “damage” or “crumbling”, or their back is “worn out”, “looks like that of a 70 year old” or is “stiff”, “immobile”, “out of alignment”, often end up with further fear of movement, increasing tension and stiffness, persisting pain, sleeplessness, health anxiety, low mood which again affects their ability to work or stay in employment – affecting financial health and further increasing anxiety in a never ending evil circle. And here we are, we’ve succeeded in transforming our patient into a nice, big VOMIT.
    Only after people have been through packets of medication with ever increasing strength – from painkillers to antidepressants and gastro protectors, then eventually ending in repeated injections of corticosteroids – only then does the patient end up in a pain clinic, where they more often than not are told their pain cannot be taken away and they need to learn how to live with it. Can you imagine the impact that this can have on someone’s self efficacy and rehab potential? Only then they might be introduced to mindfulness, pacing, the actual importance of diet and exercise, sleep hygiene, talking therapy, movement retraining, education and advice about what is actually happening in their nerves, muscles and brain. And whilst it is never too late to improve someone’s symptoms, it is certainly much more difficult once all aspects of the patient’s life have been affected, and significant health care beliefs have been formed.
    Never treat the scan, always treat the man indeed!

  4. I am brand new to your blog and can already tell you are my kind of therapist. I deal with this every day, despite the fact that I work with a great team of doctors and radiologists. My explanations usually get through, but it can be difficult. The latest thing I am seeing a lot is patients coming to therapy because their MRI will not be approved until they have a trial of therapy. While I still believe that insurance companies are evil, I have to say that I am not completely opposed to this. It gives me another tool in my arsenal to explain to the patient that even if the MRI showed the worst, that a trial of therapy would still be the best course of action. And very often, after I get them moving for a couple of weeks, they end up not needing the MRI.
    Great article. Keep it up!

  5. Hi Adam. If you are who I think you are I am saddened, disappointed and extremely angry at your comments. As a radiologist and clinician I find your comments rather u professional. Have you spent 5 years at medical school? Have you practiced medicine and surgery after that and gained a further degree in medicine or surgery? Have trained in CLINICAL DIAGNOSTIC RADIOLOGY? I think not. I am diagnostic radiology clinician. We so take histories and examine. Ita what we are trained to do. It is very dangerous to pick up a prime and say I’m going to learn this by going on a short course ans then claim to be an expert. So you work un the NHS most of the time? I believe not. So you thought ill make money this way. There are good docs and there are not so good docs. A radiologist can provide an examination amd report that is meaningful amd clinical based on their years of medical training and knowledge. Who do you go to when u have a difficult case?

    • Dear Dr Chahil
      Thank you for your comments, however I am a little confused at your angst and slightly upset and disappointed at your allegations. First as my profile clearly states I am both an ESP for the West Hertfordhsire Hospital Trust as well as a clinical lead for a private healthcare company in Hertfordshire. And I do work over 50% of my time within the NHS as a front line autonomous clinician in three busy general hospitals, and if you think I make any money from my blogs you are very much mistaken, and I resent the accusation that this or any other of my blogs are doing this
      Next I am at a loss as why or how you think this blog is unprofessional. I make it very clear if you read again that I have many radiologist colleagues and friends who do an invaluable job and who help me both professionally and personally a great deal. This is not in question. Nor have I stated otherwise.
      However, what is in question is that many clinicians, that is both radiologists, physios, doctors, etc etc still confuse pathology with morphology and think pain is simply explained with what is seen on scans. It is not this simple and the many papers I quote highlight this, and I will not apologize for raising this issue and making more aware of it, as I routinely have to correct patients who have been misinformed by others that their scan shows X and this explains Y and need Z, when this is not the case.
      Also I am trained in radiology, and physiology, and anatomy, and pain science, and history taking, and clinical examination etc etc. but I do not have a degree in medicine or surgery, I don’t need one to know who needs, or doesn’t need onward referral for medicine or surgery.
      Finally your appeal to authority and experience is tiresome and mistaken. Just because you have years of practice, this shouldn’t be confused with equal years of knowledge. I have only a years knowledge, but this has been refreshed every year for the last 15 years.
      I would however be interested in your views on the recent Herzog et al MRI reliability study in the case of the patient with low back pain and the lack of consensus between radiologists.
      Kind regards
      Adam

  6. Hi Adam, thanks a lot for the blog – a crucial issue and I’m sure a day-to-day sticking point for physiotherapists the world over. I strongly agree with your message however I fear that this can be taken too literally by some clinicians i.e. that a scan is always irrelevant to understanding why someone has pain (beyond the assessment for red flag pathology). For example, you quote the Guermazi et al (2012) study showing a high prevalence of ‘abnormalities’ in asymptomatic knees on MRI. However, it should be noted that patients with any evidence of radiographic OA were excluded in this study. From pooled data which included that same cohort, Neogi et al (2009) actually showed a strong correlation between signs of radiographic OA and knee pain. Serbian (2016) also produced similar findings examining patients with bilateral knee OA, that cartilage loss emerged as an independent predictor of both pain intensity and WOMAC score.
    I feel caution is needed our interpretation of the research here. Neogi et al provide a good discussion of the research and discrepancies between studies in their paper. Pain and function can be closely related to scans in some joints/circumstances and I wonder if we will see replication of the above knee example in other joints such as the foot/ankle. However, as clinicians, we are told not to use terms such as “wear and tear” or “degeneration,” nor to give them negative prognoses, even when the clinical picture suggests such. How then, to communicate these findings honestly in a way that avoids, or at least minimises, distress in the patient in addition to avoiding medical jargon? This is a clinical challenge and I’d be grateful for your thoughts.

    • Hi Mike thanks for your comments and I was not aware of the Neogi paper so thanks for pointing me towards that.
      You make excellent points, and I do try to stress that medical imaging is useful and needed when appropriate and in conjunction with a good history and physical exam!
      As for words to use when we explain these findings and the pain patients experience this is not a simple answer, and think it needs to be done on a case by case basis. Personally I don’t see much wrong in calling arthritis arthritis, as for other terms e.g. Wear and tear, degenerative joint disease etc well these can induce fear and threat in SOME patients so caution with these terms is important!
      Cheers
      Adam

  7. ” what radiologists are not is diagnostic clinicians”
    You lack the knowledge that the actual job title is a ‘clinical radiologist’, following formal trainingin both medical and/ or surgical specialties prior to radiology training. I would encourage you to go through 5+ years of medical school followed by a minimum of 7 but usually 10+ years of postgraduate training and countless exams to become a consultant. You would then be qualified to offer an opinion on imaging and patient management at the same level. You seem to hold yourself to the same regard as a consultant sports physician/ orthopaedic surgeon etc in terms of your understanding of the ‘clinical picture’. I wish you and your patients all the best.

    • I do not hold myself in any regard Sumeetra. I know there are clinical radiologists however I also wonder how many clinical radiologists do actually take a full history and do a full physical examination including functional testing etc, as well as then have the time to conduct the imaging tests requested?

  8. Well said! So incredibly frustrating. Especially when you combine these image findings with the highly anxious (and obsessed) patient.