Research Review By Dr. Joshua Plener©

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Date Posted:

June 2021

Study Title:

The catastrophization effects of an MRI report on the patient and surgeon and the benefits of ‘clinical reporting’: results from an RCT and blinded trials

Authors:

Rajasekaran S, Raja S, Pushpa B, et al.

Author's Affiliations:

Department of Orthopaedics and Spine Surgery, Ganga Hospital; Department of Radiology, Ganga Hospital, India

Publication Information:

European Spine Journal 2021; 30: 2069-2081.

Background Information:

Despite the natural history of low back pain being generally favorable, several invasive treatment modalities, including surgery, are increasingly being offered every year (1-3). Furthermore, there is an increase in MRI use, which can have a negative impact on patients due to its nocebo effect, resulting from the negative interpretation of incidental changes such as degeneration, tears, ruptures, and neural compression (4-8). These interpretations can result in patients and clinicians/surgeons feeling that an intervention is required for the spine to return to normal.

The negative impact that MRI reports can have on patients and the health care professionals providing primary care for LBP had not been formally assessed (yet, we have all seen this in practice!). The purpose of this study was three-fold: 1) the authors performed a randomized control trial to study the effect of routine MRI reports on the perception of the patient and treatment functional outcomes; 2) they devised a clinical method of MRI reporting to avoid fear and catastrophization in patients; and 3) the authors conducted a blinded study to assess the effect of reporting on the perception of the spine condition and subsequent decision making by various health care providers.

Pertinent Results:

Phase 1:
Following patients being exposed to the MRI report, group A (who received the full, factual, regular findings) had a decrease in pain self-efficacy which resulted in a negative perception and catastrophization of their spine, while group B (who received the more reassuring version) had an improvement in the perception of their spine. These between group differences were significantly different (p = 0.002). Following conservative therapy for 6 weeks, group A had an increase in pain scores and a continued deterioration regarding their negative perception of their pain, while group B had an improvement in pain self-efficacy and pain intensity. Functionally, group A deteriorated over the course of treatment while group B demonstrated improvements. Overall, patients who were not alarmed about their MRI report had improved perception of their spine condition and demonstrated greater functional improvement during the same treatment period.

Phase 2:
Through assessing words and responses that resulted in greater catastrophization, alternative methods were reported to reduce the negative impact of these words. Some of these changes included using the modified pfirrmann grading instead of disc degeneration, dehydration, desiccation, and bulge; the utilization of high-intensity zone instead of annular tears and fissures; the use of ‘close proximity without compression’ to indicate nerve root impingement or abutment. In other words, the authors attempted to avoid confusing or highly technical terminology, without losing scientific clarity.

Phase 3:
The severity of pathology, choice of treatment, and perceived probability of requiring surgery were considerably different between ‘routine’ and ‘clinical reporting’ of the same patient. For orthopaedic surgeons, orthopaedic residents and physical therapists, ‘clinical reporting’ significantly reduced the severity assessment of the disease (fascinating!). Furthermore, ‘clinical reporting’ resulted in a treatment decision to shift to a decrease in invasiveness (also fascinating!). However, these changes were not observed in spine surgeons. One possibility is that spine surgeons read and interpret MRI’s themselves rather than depend on the report to the same degree as a resident or physiotherapist does.

Clinical Application & Conclusions:

The natural history of LBP for most individuals is positive, with few becoming chronic or requiring surgery (9). Despite this, the number of interventions provided to patients and the incidence of surgeries has continuously increased over the years (3-6, 9-11). Concurrently, MRIs have been utilized with higher frequency and there has been a corresponding transition of LBP being thought as a disease that requires invasive treatment (12-15). However, in a significant number of asymptomatic individuals, an MRI demonstrates findings that may be construed as pathological in nature (8). This study demonstrates that the words used in an MRI report for LBP can have nocebo and harmful effects on patients, as well as health care professionals.

This study demonstrated that reassuring patients that their MRI was within normal limits and consistent with age-related changes and incidental findings can significantly improve pain, function and catastrophization (remember, these patients had no serious red flag findings). Patients who didn’t receive this reassurance failed to improve and were more willing to undergo an invasive procedure to avoid potential deterioration and future complications to return back to ‘normal’. Furthermore, this study demonstrated that replacing terminology that typically results in an increase in anxiety and fear, such as degeneration, tears, fissures, and nerve compression, can lead to a significant reduction in perceived disease severity, greater conservative interventions prescribed and a lower probability of undergoing surgery.

The results of this study bring to light the negative impact an MRI report can have on the patient and health care professional. First, clinicians should strive to reduce the use of unnecessary imaging; second, radiologists should report findings using improved terminologies to reduce catastrophization; and third, clinicians should provide patients with proper education and reassurance.

EDITOR’S NOTE: I have always thought there should be two versions of a radiology report – one written for medical professionals, containing all the ‘lingo’, and a patient-facing version containing simple language and even some degree of reassurance in warranted cases. I know this is not likely to happen, but it could prevent much of the angst and miscommunication that occurs because of imaging for LBP patients. This study further reminds us how powerful our words, and those contained in imaging reports, can be and how they can directly influence patient outcomes in both the short and long terms.

Study Methods:

This study was conducted over three distinct phases:
  1. Phase 1: 44 patients with chronic non-specific mechanical LBP of a minimum 12 weeks, with no red flags or serious pathology and a general health questionnaire (GHQ-12) score of < 10 (signifying minimal anxiety or depression), were randomized to two groups. Group A was provided with a factual explanation of the pathologies reported in their MRI report, and group B patients were reassured that their MRI was completely normal with only incidental and age related findings present. The severity of pain, perception of the patient’s status of their spine, and functional status were measured at the first consult, after exposure to the MRI report, and six weeks after undergoing similar conservative therapy.
  2. Phase 2: An alternative method of ‘clinical reporting’ was developed to replace ‘routine reporting’, avoiding terminologies that were demonstrated to cause concern and anxiety to patients. This was achieved through google searching in order to capture the online information available to patients.
  3. Phase 3: 20 LBP patients underwent an MRI with forty health care professionals – consisting of spine surgeons, general orthopaedic surgeons, orthopaedic residents, and physical therapists – assessing the MRI in a blinded fashion. The health care professionals were asked to provide their opinion on three factors based on ‘routine reporting’ compared to ‘clinical reporting’ which was developed in phase 2. The three factors were their assessment of the severity of the spinal condition, their choice of treatment between conservative therapy, injection and surgery, and the probability that the patient will require surgery. A change from surgery to injection/conservative management was considered a decrease in invasiveness, while a shift in the opposite direction was considered an increase in invasiveness.
Outcomes and Statistical Methods

The severity of pain (visual analogue scale [VAS]), the perception of spine and disease status (Pain Self Efficacy Questionnaire [PSEQ-2]) and functional status (Short-Form Survey 12 [SF-12]) were measured at the first consult, after exposure to the MRI report and at 6 weeks of similar conservative therapy.
 
For phase 1, the minimum sample size was calculated with the pain self-efficacy questionnaire as the primary variable for a minimum clinically significant difference of 1.5 using a 90% power. T-test and chi-square tests were used to assess the between group comparisons. In phase 3, the severity of degeneration and probability for surgery was analyzed using paired t-tests and the change in treatment opinions were analysed by comparing the percentage of an increase or decrease in levels from conservative to surgery using Fisher’s exact test.

Study Strengths / Weaknesses:

Strengths:
  • This study provides an understanding of the negative impact an MRI report can have on both patients and health care professionals – this has not been well studied overall and reflects what we commonly see in practice.
  • This study not only demonstrated the negative impact an MRI report can have, but provides and assesses a tangible solution to this problem.
Weakness:
  • This was a single centre study, and future research should assess this in a multicentre study.
  • The replaced terms that were developed and used still require validation through future studies.

Additional References:

  1. Chou R, Qaseem A, Snow V et al.Diagnosis and treatment of low back pain: a joint clinical practice guideline from the american college of physicians and the american pain society. Ann Intern Med 2007; 147:478–491.
  2. Andersen JC. Is immediate imaging important in managing low back pain? J Athl Train 2011; 46:99–102.
  3. Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery. Spine 2003; 28:616–620.
  4. Mafi JN, McCarthy EP, Davis RB, Landon BE.Worsening trends in the management and treatment of back pain. JAMA Intern Med 2013; 173:1573–1581.
  5. Weinstein JN, Lurie JD, Olson PR et al.United States’ trends and regional variations in lumbar spine surgery: 1992–2003. Spine 2006; 31:2707–2714
  6. Shreibati JB, Baker LC. The relationship between low back magnetic resonance imaging, surgery, and spending: impact of physician self-referral status. Health Serv Res 2011; 46:1362–1381.
  7. Verrilli D, Welch HG. The impact of diagnostic testing on therapeutic interventions. JAMA 1996; 275:1189–1191
  8. Emery DJ, Shojania KG, Forster AJ et al. Overuse of magnetic resonance imaging. JAMA Intern Med 2013; 173:823–825.
  9. Majid K, Truumees E. Epidemiology and natural history of low back pain. Semin Spine Surg 2008; 20:87–92.
  10. Tonosu J, Oka H, Higashikawa A et al. The associations between magnetic resonance imaging findings and low back pain: a 10-year longitudinal analysis. PLoS ONE. 2017
  11. Webster BS, Bauer AZ, Choi Y et al. Iatrogenic consequences of early magnetic resonance imaging in acute, workrelated, disabling low back pain. Spine 2013; 38:1939–1946.
  12. Galambos A, Szab. E, Nagy Z et al. A systematic review of structural and functional MRI studies on pain catastrophizing. J Pain Res 2019; 12:1155–1178.
  13. Lehnert BE, Bree RL. Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support? J Am Coll Radiol JACR 2010; 7:192–197.
  14. Flynn TW, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther 2011; 41:838–846.
  15. Chou R, Deyo RA, Jarvik JG. Appropriate use of lumbar imaging for evaluation of low back pain. Radiol Clin N Am 2012; 50:569–585.

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