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I would say that the biggest thing that I took from the course is that we should utilize imaging like we would utilize a special test. It should not be used in isolation, but rather taken in the context of our larger clinical examination. Imaging may reveal pathology that is unrelated to the symptoms that our patients are experiencing, which is a concept that is well supported by our literature. We could all benefit from practicing our explanation to patients that the results of imaging can be misleading. Ultimately, we can use an image to guide the rigor of our intervention and to determine whether or not a patient’s pain may be coming from a more insidious source.
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-“Do no harm”, imaging is often overused, do not order/recommend if they are not of diagnostic importance. However, can be beneficial to link the radiological signs with the patient history and examination findings when appropriate.
-Imaging can be an important component of your comprehensive evaluation. PTs can play an important role with our examination to ensure common mistakes are not made, such as: areas of referred pain imaged, missing associated injuries, and finding irrelevant pathology.
-Use of the ABCs system for radiographic evaluation.
-Understanding of specificity and sensitivity in imaging. If you pre test probability is high – more sensitive testing may be needed. -
Some of these pearls listed were main points and some were side notes that I found interesting. Please feel free to correct me if I misrepresent a point.
2 simple questions to consider before suggesting imaging:
-Is it in the patient’s best interest?
-Will it guide treatment?30% Rule – X-rays are not sensitive to early changes in bone
“1 view is no view” – an A/P radiograph can look normal while the lateral view may show an obvious fracture, or vice versa.
Multiple Myeloma is a “cold” process vs. “hot” so it may not show up on a bone scan.
CT scans: Each time an organ is scanned, that organ’s lifetime risk of cancer doubles.
Femoral neck stress fractures: more likely to displace if on the tensile side of the neck vs. the compressive side.
If a scaphoid fracture is suspected, early MRI may be appropriate as x-rays 4 weeks after injury still miss scaphoid fx’s 40-50% of the time.
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I think one thing I took away from this course the second time is the apparent lack of utility for an oblique view of the lumbar spine. I have a patient right know, whom I suspect may have a spondylolisthesis, and I was under the impression an oblique view would be the best image for this type of patient. However as mentioned above, Dr. Deyle’s emphasis of “do no harm” and performing only images in the best interest of the patient has caused me to second guess the necessity of that particular view, as opposed to perhaps a flexion and extension set of lateral views.
I think I definitely got more out of this course by going through it a second time, I always learn better when I have examples of patients to apply new knowledge to as I am learning the material. Last year I was just trying to keep my head above water ;) -
One of the main clinical pearls that I was able to take from this weekend was how to communicate to patients that imaging is not the gold standard of determining where pain is originating from. I think this course made a great point in emphasizing that even though an abnormality is seen on an image it is not necessarily the cause of the specific pain that patient is experiencing and how to express this to the patient. Additionally, I think it re-opened my eyes to the fact that imaging is exposing a person to harmful radiation and it should only be used if it is necessary. Sending a person for imaging is expensive and harmful and can be avoided if a full comprehensive physical exam is performed. This is especially important when conservative approaches will be the main means of treatment regardless of the findings shown on the image.
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