Importance of Clinical Exam - Balance with Imaging

I am motivated to write this article for my chiropractic colleagues on this Thursday, December 14, 2017.

In didactic lecture I have taught that the clinical examination is more important than diagnostic imaging in diagnosing a patient’s source of pain; even going so far as to say that MRI should actually confirm the clinical examination impression. Well, this week Karran et al (1) said the same, namely that not to do and MRI of low back pain patients, but rather explain normal MRI findings before ordering the MRI; however explain in detail the clinical examination findings and the clinical impression of what the problem in their spine is. If an MRI is ordered, which is not ordered until 6-8 weeks of specialized spinal manipulation treatment, the patient will see the normal changes seen on an MRI that do not really cause their pain problem. Why is this important? Because 76% of people show disc degeneration and herniation that are not even symptomatic; and to show the patient the MRI and explain all these non contributory findings to their sets up a confused and often depression mental image of their health. DO NOT BLAME PATIENT’S SYMPTOMS ON SPINAL CHANGES THAT DO NOT CAUSE THEIR PAIN. Explain the examination findings in an enhanced reporting strategy. Intervention strategies such as enhanced reporting methods and the provision of quality information (without imaging) have the potential to improve the outcome of patients with recent-onset low back pain. As spinal specialists, we have studied together and I have taught that we treat patients, not mris.

As taught in our certification course, it is the thorough orthopedic, neurological, and physical examination that gives the diagnosis in the majority of patients. Do this examination as we present and all else follows. Ordering MRI or even plain xray diagnostic imaging will decrease as suggested by the Choosing Wisely movement of medicine today.

Respectfully submitted,

James M. Cox, DC, DACBR

(1) Karran EL, Medalian Y, Hillier SL, Moseley GL. The impact of choosing words carefully: an online investigation into imaging reporting strategies and best practice care for low back pain. Peer J. 2017 Dec 6;5:e4151. doi: 10.7717/peerj.4151. eCollection 2017.