Physio rehab

MRI scans - are they necessary?

As a physiotherapist in Singapore, I see two things very often: patients with back pain, and patients with recently acquired MRI results (usually the same people). Why? Well, the prevalence of back pain in Singapore is often because the patients have combined a high pressured, desk-bound job with a lack of exercise and movement in their daily lives.

And their envelope containing their MRI results?  This is usually because the first thing their doctor has done when they reported back pain is to send them for a scan to see ‘how bad it is.’

This is because in Singapore, as in most of the world, MRIs and related high-tech imagery have ballooned into a multi-million-dollar industry to both the providers and the referrers. Indeed, in the United States last year, Medicare paid out over $14 billion dollars for MRIs alone.

 
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The problem is that most patients and many doctors still perceive MRIs as an easily accessible commodity that will provide the answers as to where the pain has come from, and therefore the solution to getting rid of the pain. However, this relies on two massive assumptions:

Assumption 1:   MRI scans are always accurate

The Truth? MRI scans are surprisingly difficult to read, and different radiographers looking at the same scan will often report different findings!

Assumption 2: MRI scans’ findings are always related to the problem

The Truth? Issues found by an MRI scan are often completely misleading, can have nothing to do with the pain you are feeling, and can be a completely normal part of ageing.

Let’s dig a little bit deeper.

So how accurate are MRI scans?

A very recent study conducted by Herzog et al, published in the Spine Journal in April 2017 assessed the accuracy of MRI imaging and reporting, by asking a 63 year old patient with current pain, and a long history of lower back problems to visit ten different MRI centres in succession, and get a report from each one.  The results?

1 Patient

10 MRI Scans

49 different ‘issues’ reported

0 of these ‘issues’ seen across all 10 scans.

This is a scarily clear demonstration that MRIs are not the clear snapshot that patients often believe that they are.

So why is there a difference between different MRI centres? First of all, like with physiotherapists, you can get good, skilled radiographers, and you can get inexperienced or under-skilled radiographers.

Secondly, just like your TV and computer, imaging technology is constantly changing and improving. So an Ultrasound or MRI machine from 10 years ago is going to be very low quality compared to a machine produced in the last two years.

Finally, an uncomfortable aspect of the medical industry: many doctors now own their own imaging machines, and will charge a premium for potentially unnecessary scans to ‘confirm’ their diagnosis. Is there anything a patient can do about this? Not much besides trusting your doctor to refer you to a trusted imaging centre, and hoping for the best.

Are MRI scans even relevant?

In most cases, no. A large systematic review conducted by Brinjikji et al, in 2014, assessed the MRI findings of 3,110 people with No Reported Back Pain. The findings? A significant number of these perfectly fine people were found to have problems, issues, or ‘degradation’ within their spines, which became more common as they got older.

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One third of normal, healthy 20 year olds have ‘degenerative’ signs in their lower back! And two thirds of perfectly healthy 50 year olds were found to have disc bulges! So what does this tell us? Spinal changes are a NORMAL part of ageing. Disc changes are a NORMAL part of ageing. And more importantly, negative changes in your spine are not always associated with pain.

Does this mean we should just throw all MRI machines in the Singapore River, and never speak of them again?

Of course not! MRI machines are an important diagnostic tool, but should not be used alone to figure out where your pain is coming from. They should be used as one element of a thorough assessment by your physio or doctor to figure out what is wrong with your back (or shoulder or knee), and figure out the best treatment strategy moving forward. As the physiotherapy expert Adam Meakins succinctly says, ‘Treat the Man, Not the Scan.’

The good news for you as a back pain patient in Singapore (or anywhere else in the world)?

Even if you have MRI findings that say that you have disc bulges, disc degeneration, and all sorts of issues going on – it is not a death sentence, and you do not need to go under the knife to ‘fix’ the problem!

Find yourself a good physio (quick plug: we have great ones at the UFIT Clinic), or a good doctor (ask us, we know many!) and complete your assessment with them to see what other factors might be contributing to your pain, and what we can do together to get you back on your feet, and back to being fit, healthy, happy and pain-free as quickly as possible!  

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Back and neck pain? Doctor or physio?

Back AND neck pain - doctor or physio: Who should you choose?

The question I constantly encounter here in Singapore is ‘I have a sore back. Should I come see you, or should I see a doctor first?’

Being a physio myself I am obviously biased, but physiotherapists train for four years to get a degree specialising in chronic pain issues and musculo-skeletal breakdowns. We should be involved from the beginning in the treatment and care of any back pain or neck pain issues.

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Unfortunately, here in Singapore (and in many countries around the world) the medical insurance companies require a doctor’s referral in order for physiotherapy claims to be approved, so the answer is usually ‘Go see a doctor, and ask them to refer you to me.’ If that seems like a complete waste of your time, and the insurance company’s money, then you would be correct. It now appears that we have good reason to be frustrated by this out-dated approach:

A recent study conducted by Cook et al., published in October 2017, investigated the amount spent and the overall recovery outcomes of patients with back or neck pain who went to either physiotherapists first, or to their local doctor. In total, they reviewed cases for 603 patients who reported neck and back pain between 2012 and 2014.

The results? Those that selected to see the physiotherapists straight away saved BIG on medical costs. In fact, each patient saved an average of $1,543 USD a year (over $2,000 SGD) compared to their counterparts who chose to visit a doctor first. And their outcomes one year later? No difference between the two groups. So, in effect, the group that went to see the physio got the EXACT same outcome, for significantly LESS cost.

Why is this? It may be due to the doctor’s reliance on imaging. For more on this, check my blog on the topic here.

So back to the question: ‘I have a sore back. Should I go see a physio or a doctor?’  

The answer: A physio – we’ll help your back and your wallet. The science says so…

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To discuss an issue with your friendly local physio in Singapore, please contact us here.

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ABOUT THE AUTHOR

DECLAN HALPIN, UFIT CLINIC DIRECTOR

Declan is passionate about helping his patients achieve their long term goals by identifying their weaknesses and imbalances, and developing a strategy to eradicate them. Declan has always maintained a strong sporting interest, and previously worked as an Academy Physiotherapist for Crystal Palace Football Club (a professional football club in London), and as a Rehabilitation Coach for the Western Province Stormers Academy (professional rugby club from Cape Town). Within Asia, he consults to the Indonesian Athletics Association as a Performance coach and physiotherapist. In Singapore, Declan has worked as both physiotherapist and strength and conditioning coach to the Singapore National Rugby team (who achieved bronze medal at the SEA Games). 

QUALIFICATIONS 

  • BSc Sport and Exercise Science 
  • MSc Physiotherapy 
  • AAP Dry Needling Certification 
  • L1 Crossfit Trainer 
  • Senior Medical Educator World Rugby 

From surgery to CrossFit in six months

In May 2017 James Metcalfe slipped in his condo carpark and shattered his elbow. It needed surgery and for two whole weeks he couldn't move his arm at all. He sought help from UFIT Clinic physio Paul Doohan - and fast forward six months does Personal Training with Melanie Lim at UFIT Tanjong Pagar three times per week.

Before that he had never stepped foot inside a gym before, and is now flawlessly lifting and doing sled pulls each session, and has complete use of his elbow and arm again. Thanks to Mel's advice he has also cut back on his beers and is losing weight and getting fitter and stronger every day.

Find out how he got back on the mend so quickly ...  

What was your injury and what did you do about it? 

I shattered my elbow. I got a spiral fracture of the radial head, dislocated elbow joint and tore all of the ligaments and tendons connecting to my bicep and tricep. 

 
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I was referred to Paul by an ex-UFIT employee who I know socially. She initially passed me to Declan who I saw twice before he went off on his one-north adventure leaving me in Paul’s hands.

How often did you see PAUL and were you able to train much then?

I saw Paul once a week every week for six months. I was totally unable to train at the beginning, I couldn’t move my left hand or arm at any angle. That progressed to picking up a simple day to day object, to developing the flexion and extention to being able to feed myself with that arm’s hand and doing up my buttons on a shirt which was a good test of progress. An extra button a week!

This built up slowly over a couple of months and I was then able to lift a light dumbell which is when I asked if he could refer me to a trainer and that's how I found Mel.  

What kind of rehab did you have?

The painful but quick kind. It was really a combination of many things, the technical terms you will have to ask Paul. From shocking the bicep muscle with electro pads at the beginning of each session to making them remember they were still there, and they were needed for the bottom half of my arm to work, through to massaging the joint and lots and lots of Paul distracting me with talking about the Premier League while pushing, pulling and increasing my range of motion.

 
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What have you enjoyed most about doing rehab with Paul?

He communicates directly like me, was sympathetic to the pain I was going through both physically and mentally, and is very obviously knowledgable in his field and I trusted him. We both played sport and both getting married within a couple of months of each other so time during the sessions went quickly. Beyond liking Paul as a bloke, he got results and quickly, so going back for the next session never felt like a trial. 

How is your training now? 

It's great! I train with Melanie Lim at UFIT Tanjong Pagar and haven't felt this physically fit in the four years that I have lived in Asia, and I could not have imagined training like this six months ago immediately after the accident. Mel kicks my ass three times a week at CFTP, but she does more than just make me sweat, she encourages me to believe in the power of the mind and that with self discipline and self belief so much is possible. 

 

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I’m so grateful to everyone that I have met, both at the Clinic and CFTP. For picking me off the ground seven months ago as a broken man, both mentally and physically, for telling me it’s going to be OK and giving me that adult cuddle that I needed, and equally for getting me fit, pushing me to do better and giving me a huge smile walking (lungeing & squatting more like), into getting married next month and finishing what has been a crazy year as a very happy man. 

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Let's hear it from PAUL THE physio ...

Paul Doohan, James' UFIT Clinic physio adds: "James had a pretty complex elbow fracture, after an accident in his condo. He was struggling a lot after his surgery, as he was unable to even button his shirts due to his pain and stiffness. This affected his activities of daily living massively. 

For a condition of this nature, the first thing we needed to do was to make James trust his elbow again. As an area of the body that is heavily innervated (remember hitting your funny bone?), an injury of this magnitude meant the whole arm was highly sensitive. Naturally patients like James are very protective of the fractured area, but very quickly this overprotection can cause more issues. Helping James move his arm and regain his strength wasn’t the difficult part, it was helping him trust his arm to allow him to do a press up, or catch a cup that was falling. 

When you have something that affects your life as much as James’ injury did, it was vitally important that we were on the same page from day one. He responded very well to his initial treatment, and was always diligent with the tasks I asked him to complete in his own time.

We set small goals, for instance monitoring how many buttons he could fasten on his shirt, to demonstrate the improvements he was making. Eventually, we got a position where we both agreed that he no longer needed to come, as he had met the goals he outlined when we started.

That handshake of a patient who has come such a long way is one of the most rewarding moments as a physiotherapist, and I was very pleased when that day came.

For James, having a patient with an honest and strong work ethic made my job a lot easier. I was able to provide the framework and knowledge on how he was going to get better, but it was his attitude in doing the at times monotonous work that means he has made such a good recovery. It was a pleasure to have the opportunity to work with James, and I can only see him continuing going from strength to strength.

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OVER TO MEL, JAMES' PERSONAL TRAINER

“Working with James has been an absolute joy - he’s hardworking, patient and inquisitive. I’m grateful for the trust he’s put in us as a team - together, our goal is continue to help him lose body fat, while rehabbing the injured elbow as much as possible.  

We believe in the importance of balance - loving what we do, and achieving results simultaneously. In the lead up to his wedding, we’ve progressed from static/isometric exercises in the trunk, to adding eccentric work and finally now, we are doing concentric exercises like squatting and bench pressing. A huge feat considering just months ago, he was in a sling! 

On Fridays, we do strongman training - anything from harnessed bear crawls, sled pushes, rope pulls. Due to his injury, we have had to be creative about programming work that may cause structural damage. Much of the hours James have put in are boring, cyclical aerobic work that the general population would not deem exciting - but it is his dedication to the goal, and positivity that keeps us on track. 

I've recommended some changes to his diet, including cutting out beers and tracking his meals. We are seeing the weight fall off, and his body composition change dramatically. Our secret goal is to get James to support his own bodyweight in a plank by the end of the year, and move up to push-ups.

Training James has thought me so much about the power of keeping a positive and growth-oriented mindset, regardless of the circumstance. He’s one of a kind."

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His determination and willpower is fantastic and will see him get the results he wants.

JAMES' dream team: his physio and personal trainer

Paul Doohan   is a musculoskeletal physiotherapist, and has extensive experience in professional sport, private physiotherapy and in the public hospital sector. Possessing certification with the Titleist Performance Institute, Paul specialises in the assessment and treatment of golfers, delivering effective results in injury management and prevention, as well as performance improvement.

Paul Doohan is a musculoskeletal physiotherapist, and has extensive experience in professional sport, private physiotherapy and in the public hospital sector. Possessing certification with the Titleist Performance Institute, Paul specialises in the assessment and treatment of golfers, delivering effective results in injury management and prevention, as well as performance improvement.

Melanie Lim   is a certified CrossFit coach and personal trainer, accumulating over 200 hours of coaching in various landscapes in Asia.  She has experience building boxes and communities around the common goal of achieving fitness, and finds motivation in seeing her clients desire and pursue change aggressively.  

Melanie Lim is a certified CrossFit coach and personal trainer, accumulating over 200 hours of coaching in various landscapes in Asia.

She has experience building boxes and communities around the common goal of achieving fitness, and finds motivation in seeing her clients desire and pursue change aggressively.