You Are NOT Your X-Ray

The use of and hyper-focus on diagnostic imaging in Western medicine (such as x-rays, MRIs (Magnetic Resonance Imaging) and CAT scans (Computerized Axial Tomography) is raising alarms in some sectors of the field of medicine.

An x-ray or MRI is just one piece of information that must be interpreted in the greater context of a comprehensive clinical exam and is made up of many factors. An overreliance on ordering imaging for musculoskeletal disorders and how we talk about imaging findingswith patients could be harming them instead of enhancing their diagnosis and treatment.

In an online blog from Sapiens Moves (sapiensmoves.wordpress.com) titled “You Are NOT Your X-Ray,” the author argues that “the time is ripe for a similar paradigm shift in medicine and also in physical therapy to prioritize function and behaviors not an image.”

Here is an edited version of the blog:

In our Western culture and media, we are very focused on image and outward appearance. Even in the wellness industry that claims to promote health, there is a stereotyped image and the implicit message that obtaining this look is what it means to be “healthy” (i.e., low body fat, blemish-free skin, muscle definition etc.).

However, this perpetuation of a certain “ideal look” can have detrimental effects. For example, a well-known study, conducted in the 1990s investigated the negative influence that the introduction of Western television had on girls’ body image. Sadly, body image dissatisfaction and disordered eating drastically increasedafter the introduction of Western media and these behaviors seemed to correspond with the girls’ reports of a desire to look like and emulate the characters they saw on television.

Exposure to these media images was harmful and much has been written since about the detrimental effects that media can have on body image and eating behaviors.

What if exposure to diagnostic imaging (e.g., X-rays, MRIs) was equally as damaging to our “body images” and how people feel about their worth and ability?

What we are beginning to understand is that this is not far from the truth. An overreliance on ordering imaging for musculoskeletal disorders and how we talk about imaging findings with our patients could be harming them instead of enhancing our diagnosis and treatment.

Another useful analogy taken from research on body image is that of the undue focus on body weight or body mass index (BMI) as indicators of health. Though these two measurements can be useful as parts of a broad examination of health, they are in no way a complete picture of the health of an individual. Likewise, an x-ray or MRI is just one piece of information that must be interpreted in the greater context of a comprehensive clinical exam (made up of many factors!). As a reminder, this exam should focus MOST SIGNIFICANTLY on FUNCTION!

During my time working in research and prevention of eating disorders, part of our mission was to shift the focus from the culturally reinforced “Thin-Ideal Look” to a more appropriate “Healthy-Ideal” that emphasizes engaging in behaviors that promote physical health, mental health, and quality of life. The time is ripe for a similar paradigm shift in medicine and also in physical therapy to prioritize function and behaviors not an image!

The first step in this paradigm shift is to acknowledge the shortcomings of diagnostic imaging (X-rays, MRIs) and the ways in which images can harm instead of help. With that direction in mind, here are two points that I think are worth making:

  1. Imaging findings do not automatically mean something needs “fixed”!<
  2. Overreliance on imaging can be harmful and costly!<

So-called “pathological” findings on imaging studies do not mean something needs “fixed.” There are many examples of populations of individuals who are asymptomatic (read: functioning just fine!) that have “pathological” findings on imaging studies.

Also, just because your imaging findings come back “negative” does not mean nothing is wrong. The image is only as good as our technology that represents this “look” inside the body and there are human beings interpreting these images, and human beings make mistakes. Evidence of this concept is that radiologists may miss fractures (i.e., broken bones) or other musculoskeletal pathology such as dislocations that could be diagnosed via imaging techniques such as x-rays or MRIs.

Our best current evidence for management of non-specific low back pain suggests that imaging should NOT be ordered unless red flag symptoms are present (e.g., progressive neurologic deficits), serious underlying pathology is suspected (e.g. cancer or fracture), or a patient is a surgical candidate or not responding to conservative care. Furthermore, research suggests that many cases of non-specific low back pain do NOT have a pathoanatomical cause and the overwhelming majority of individuals with low back pain do NOT require diagnostic imaging. Despite these recommendations and evidence, diagnostic imaging for low back pain continues to be over utilized and may be recommended or obtained in OVER 50% of inappropriate cases.

This over reliance and inappropriate use of imaging cannot be taken lightly as it affects not only our health care costs as a society, but can actually be harmful to patients’ physical and psychological health! In fact, some patients with “pathological” imaging findings of their spines, yet NO SYMPTOMS have undergone surgery seemingly due to the imaging findings alone!

Research has demonstrated that risks associated with overusing imaging include exposure to radiation, overutilization of surgical techniques and diagnostic “labelling” with pathoanatomic diagnoses that may be inaccurate at best and pathologize what may be best described as normal, age-related changes. Physical therapists have a key role to play in how imaging is viewed and used by patients. A recent study conducted on patients with low back pain, found that those that saw a physical therapist first were less likely to obtain expensive imaging studies.

As these findings suggest, we must be diligent with our conversations regarding the benefits or risks of pursuing imaging studies as well as the limitations of imaging. We must be especially cautious in order to avoid creating iatrogenic or nocebo effects with our patients (i.e., the medical adage of “primum non nocere” or “First, do no harm”).

With this in mind, a simple reminder may be in order to our patients: You are not your X-Ray!

For a longer version of this blog, with graphs, charts and footnotes, go to: https://sapiensmoves.wordpress.com/2019/09/22/you-are-not-your-x-ray/