Advertisement

Effect of routine diagnostic imaging for patients with musculoskeletal disorders: A meta-analysis

      Highlights

      • Routine imaging does not yield beneficial effects in knee/low back pain.
      • Clinicians should avoid imaging when serious underlying conditions are ruled out.
      • Clinical decision rules should be used in patients with traumatic knee complaints.
      • Imaging can be used in non-traumatic knee complaints if conservative treatment fails.

      Abstract

      Purpose

      The increasing use of diagnostic imaging has led to high expenditures, unnecessary invasive procedures and/or false-positive diagnoses, without certainty that the patients actually benefit from these imaging procedures. This review explores whether diagnostic imaging leads to better patient-reported outcomes in individuals with musculoskeletal disorders.

      Method

      Databases were searched from inception to September 2013, together with scrutiny of selected bibliographies. Trials were eligible when: 1) a diagnostic imaging procedure was compared with any control group not getting or not receiving the results of imaging; 2) the population included individuals suffering from musculoskeletal disorders, and 3) if patient-reported outcomes were available. Primary outcome measures were pain and function. Secondary outcome measures were satisfaction and quality of life. Subgroup analysis was done for different musculoskeletal complaints and high technological medical imaging (MRI/CT).

      Results

      Eleven trials were eligible. The effects of diagnostic imaging were only evaluated in patients with low back pain (n = 7) and knee complaints (n = 4). Overall, there was a moderate level of evidence for no benefit of diagnostic imaging on all outcomes compared with controls. A significant but clinically irrelevant effect was found in favor of no (routine) imaging in low back pain patients in terms of pain severity at short [SMD 0.17 (0.04–0.31)] and long-term follow-up [SMD 0.13 (0.02–0.24)], and for overall improvement [RR 1.15 (1.03–1.28)]. Subgroup analysis did not significantly change these results.

      Conclusion

      These results strengthen the available evidence that routine referral to diagnostic imaging by general practitioners for patients with knee and low back pain yields little to no benefit.

      Abbreviations:

      SD (standard deviation), CI (confidence interval), IQR (interquartile range), LBP (low back pain), Gen (generic), Spec (specific), QoL (quality of life), I2 (heterogeneity statistic), Df (degrees of freedom), MRI (magnetic resonance imaging), NRS (numeric rating scale), GPE (global perceived effect), SF-36 (Short Form 36 item), KQoL-26 (Knee Quality of Life 26 item), EQ-5D (EuroQol 5 dimensions), SIP (sickness impact profile), VAS (visual analog scale), ALBP (Aberdeen Low Back Pain Score), FABQ (Fear Avoidance Beliefs Questionnaire), HADS (Hospital Anxiety and Depression Scale), US (United States), UK (United Kingdom)

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to European Journal of Internal Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Bussières A.
        • Peterson C.
        • Taylor J.A.
        Diagnostic imaging practice guidelines for musculoskeletal complaints in adults an evidence-based approach: introduction.
        J Manipulative Physiol Ther. 2007; 30: 617-683
        • Baker L.
        • Atlas S.W.
        • Afendulis C.C.
        Expanded use of imaging technology and the challenge of measuring value.
        Health Aff. 2008; 27: 1467-1478
        • Fisher E.
        • Welch H.G.
        Avoiding the unintended consequences of growth in medical care: how might more be worse?.
        JAMA. 1999; 281: 446-453
        • Moyniham R.
        • Doust J.
        • Henry D.
        Preventing overdiagnosis: how to stop harming the healthy.
        Br Med J. 2012; 344: e3502
        • Wassenaar M.
        • van Rijn R.M.
        • van Tulder M.W.
        • Verhagen A.P.
        • van der Windt D.A.W.M.
        • Koes B.W.
        • et al.
        Magnetic resonance imaging for diagnosing lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic review.
        Eur Spine J. 2012; 21: 220-227
        • van Rijn R.
        • Wassenaar M.
        • Verhagen A.P.
        • Ostelo R.W.
        • Ginai A.Z.
        • de Boer M.R.
        • et al.
        Computed tomography for the diagnosis of lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic review.
        Eur Spine J. 2012; 21: 228-239
        • Boden S.
        • Davis D.O.
        • Dina T.S.
        • Patronas N.J.
        • Wiesel S.W.
        Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation.
        J Bone Joint Surg Am. 1990; 72: 403-408
        • Jensen M.
        • Brant-Zawadzki M.N.
        • Obuchowski N.
        • Modic M.T.
        • Malkasian D.
        • Ross J.S.
        Magnetic resonance imaging of the lumbar spine in people without back pain.
        N Engl J Med. 1994; 331: 69-73
        • Lurie J.
        • Birkmeyer N.J.
        • Wernstein J.N.
        Rates of advanced spinal imaging and spine surgery.
        Spine. 2003; 28: 616-620
        • Maniadakis N.
        • Gray A.
        The economic burden of back pain in the UK.
        Pain. 2000; 84: 95-103
        • Miller P.
        • Kendrick D.
        • Bentley E.
        • Fielding K.
        Cost-effectiveness of lumbar spine radiography in primary care patients with low back pain.
        Spine. 2002; 27: 2291-2297
        • Oei E.
        • Nikken J.J.
        • Ginai A.Z.
        • Krestin G.P.
        • Verhaar J.A.
        • van Vugt A.B.
        • et al.
        Costs and effectiveness of a brief MRI examination of patients with acute knee injury.
        Eur Radiol. 2009; 19: 409-418
        • Chou R.
        • Fu R.
        • Carrino J.A.
        • Deyo R.A.
        Imaging strategies for low-back pain: systematic review and meta-analysis.
        Lancet. 2009; 373: 463-472
        • Brealy S.
        • DAMASK (Direct Access to Magnetic Resonance Imaging: Assessment for Suspect Knees) Trial Team
        Effectiveness of GP access to magnetic resonance imaging of the knee: a randomized trial.
        Br J Gen Pract. 2008; 58: e1-e9
        • Bryan S.
        • Weatherburn G.
        • Bungay H.
        • Hatrick C.
        • Salas C.
        • Parry D.
        • et al.
        The cost-effectiveness of magnetic resonance imaging for investigation of the knee joint.
        Health Technol Assess. 2001; 5: 1-95
        • Patel N.
        • Bucknill A.
        • Ahearne D.
        • Denning J.
        • Desai K.
        • Watson M.
        Early magnetic resonance imaging in acute knee injury: a cost analysis.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 1152-1158
        • McDonald I.
        • Daly J.
        • Jelinek V.M.
        • Panetta F.
        • Gutman J.M.
        Opening Pandora's box: the unpredictability of reassurance by a normal test result.
        Br Med J. 1996; 313: 329-332
        • Van Ravesteijn H.
        • van Dijk I.
        • Darmon D.
        • van de Laar F.
        • Lucassen P.
        • Hartman T.O.
        • et al.
        The reassuring value of diagnostic tests: a systematic review.
        Patient Educ Couns. 2012; 86: 3-8
        • Verhagen A.
        • de Vet H.C.
        • de Bie R.A.
        • Kessels A.G.
        • Boers M.
        • Bouter L.M.
        • et al.
        The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus.
        J Clin Epidemiol. 1998; 51: 1235-1241
        • Verhagen A.
        • de Vet H.C.
        • de Bie R.A.
        • Boers M.
        • van den Brandt P.A.
        The art of quality assessment of RCTs included in systematic reviews.
        J Clin Epidemiol. 2001; 54: 651-654
        • Tulder M.V.
        • Suttorp M.
        • Morton S.
        • Bouter L.M.
        • Shekelle P.
        Empirical evidence of an association between internal validity and effect size in randomized controlled trials of low-back pain.
        Spine. 2009; 34: 1685-1692
        • Higgins J.
        • Thompson S.G.
        Quantifying heterogeneity in a meta-analysis.
        Stat Med. 2002; 21: 1539-1558
        • Cohen J.
        Statistical power analysis for the behavioral sciences.
        Lawrence Earlbaum Associates, Hillsdale, NJ1988
        • Members P.P.
        Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions: overview and methodology.
        Phys Ther. 2001; 81: 1629-1640
        • Higgins J.
        • Green S.
        (editors) Cochrane handbook for systematic reviews of interventions.
        The Cochrane Collaboration. 2011; (Available from www.cochrane-handbook.org)
        • Guyatt G.
        • Oxman A.D.
        • Vist G.E.
        • Kunz R.
        • Falck-Ytter Y.
        • Alonso-Coello P.
        • et al.
        GRADE: an emerging consensus on rating quality of evidence and strength recommendations.
        Br Med J. 2008; 336: 924-926
        • Furlan A.
        • Pennick V.
        • Bombardier C.
        • Tulder M.V.
        • on behalf of the Editorial Board of the Cochrane Back Review Group
        Updated method guidelines for systematic reviews in the Cochrane Back Review Group.
        C.B.R.G.E. Board Editor, 2008
        • Ash L.
        • Modic M.T.
        • Obuchowski N.A.
        • Ross J.S.
        • Brant-Zawadzki M.N.
        • Grooff P.N.
        Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain.
        Am J Neuroradiol. 2008; 29: 1098-1103
        • Cohen S.
        • Gupta A.
        • Strassels S.A.
        • Christo P.J.
        • Erdek M.A.
        • Griffith S.R.
        • et al.
        Effect of MRI on treatment results or decision making in patients with lumbosacral radiculopathy referred for epidural steroid injections.
        Arch Intern Med. 2012; 172: 134-142
        • Deyo R.
        • Diehl A.K.
        • Rosenthal M.
        Reducing roentgenography use. Can patient expectations be altered?.
        Arch Intern Med. 1987; 147: 141-145
        • Djais N.
        • Kalim H.
        The role of lumbar spine radiography in the outcomes of patients with simple acute low back pain.
        APLAR J Rheumatol. 2005; 8: 45-50
        • Gilbert F.
        • Grant A.M.
        • Gillan M.G.
        • Vale L.
        • Scott N.W.
        • Campbell M.K.
        • et al.
        Does early imaging influence management and improve outcome in patients with low back pain? A pragmatic randomised controlled trial.
        Health Technol Assess. 2004; 8: 1-131
        • Kendrick D.
        • Fielding K.
        • Bentley E.
        • Kerslake R.
        • Miller P.
        • Pringle M.
        Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial.
        Br Med J. 2001; 322: 400-405
        • Kendrick D.
        • Fielding K.
        • Bentley E.
        • Miller P.
        • Kerslake R.
        • Pringle M.
        The role of radiography in primary care patients with low back pain of at least 6 weeks duration: a randomised (unblinded) controlled trial.
        Health Technol Assess. 2001; 5: 1-69
        • Kerry S.
        • Hilton S.
        • Dundas D.
        • Rink E.
        • Oakeshott P.
        Radiography for low back pain: a randomised controlled trial and observational study in primary care.
        Br J Gen Pract. 2002; 52: 469-474
        • Kerry S.
        • Hilton S.
        • Patel S.
        • Dundas D.
        • Rink E.
        • Lord J.
        Routine referral for radiography of patients presenting with low back pain: is patients' outcome influenced by GPs' referral for plain radiography?.
        Health Technol Assess. 2000; 4: 1-119
        • Bryan S.
        • Bungay H.P.
        • Weatherburn G.
        • Field S.
        Magnetic resonance imaging for investigation of the knee joint: a clinical and economic evaluation.
        Int J Technol Assess Health Care. 2004; 20: 222-229
        • Modic M.
        • Obuchowski N.A.
        • Ross J.S.
        • Brant-Zawadzki M.N.
        • Grooff P.N.
        • Mazanec D.J.
        • et al.
        Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome.
        Radiology. 2005; 237: 597-604
        • Garratt A.M.
        • Brealy S.
        • Gillespie W.J.
        • DAMASK (Direct Access to Magnetic Resonance Imaging: Assessment for Suspect Knees) Trial Team
        Patient-assessed health instruments for the knee: a structured review.
        Rheumatology (Oxford). 2004; 43: 1414-1423
        • Brealy S.
        • Atwell C.
        • Bryan S.
        • Coulton S.
        • Cox H.
        • Cross B.
        • et al.
        The DAMASK trial protocol: a pragmatic randomised trial to evaluate whether GPs should have direct access to MRI for patients with suspected internal derangement of the knee.
        BMC Health Serv Res. 2006; 6https://doi.org/10.1186/1472-6963-6-133
        • Brealy S.
        • DAMASK (Direct Access to Magnetic Resonance Imaging: Assessment for Suspect Knees) Trial Team
        Influence of magnetic resonance of the knee on GPs' decisions: a randomised trial.
        Br J Gen Pract. 2007; 57: 622-629
        • Brealy S.
        • DAMASK (Direct Access to Magnetic Resonance Imaging: Assessment for Suspect Knees) Trial Team
        Cost-effectiveness of magnetic resonance imaging of the knee for patients presenting in primary care.
        Br J Gen Pract. 2008; 58: e10-e16https://doi.org/10.3399/bjgp08X342660
        • Brealy S.
        • Andronis L.
        • Dale V.
        • Gibbon A.J.
        • Gilbert F.J.
        • Hendry M.
        • et al.
        The effect of waiting times from general practitioner referral to MRI or orthopaedic consultation for the knee on patient-based outcomes.
        Br J Radiol. 2012; 85: e1134-e1139https://doi.org/10.1259/bjr/12729937
        • Laisné F.
        • Lecomte C.
        • Corbière M.
        Biopsychosocial predictors of prognosis in musculoskeletal disorders: a systematic review of the literature.
        Disabil Rehabil. 2012; 34: 355-382
        • Ramond A.
        • Bouton C.
        • Richard I.
        • Roquelaure Y.
        • Baufreton C.
        • Legrand E.
        • et al.
        Psychosocial risk factors for chronic low back pain in primary care—a systematic review.
        Fam Pract. 2011; 28: 12-21
        • Pincus T.
        • Burton A.K.
        • Vogel S.
        • Field A.P.
        A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain.
        Spine. 2002; 27: E109-E120
        • Steenstra I.
        • Verbeek J.H.
        • Heymans M.W.
        • Bongers P.M.
        Prognostic factors for duration of sick leave in patients sick listed with acute low back pain: a systematic review of the literature.
        Occup Environ Med. 2005; 62: 851-860
        • Schulz K.
        • Grimes D.A.
        Blinding in randomised trials: hiding who got what.
        Lancet. 2002; 359: 696-700
        • Kent W.
        Randomization and blinding in clinical trials.
        WebmedCentral Clin Trials. 2012; 3: WMC003289
        • Malý M.
        • Vondra V.
        Generic versus disease-specific instruments in quality-of-life assessment of chronic obstructive pulmonary disease.
        Methods Inf Med. 2006; 45: 211-215
        • Bombardier C.
        • Melfi C.A.
        • Paul J.
        • Green R.
        • Hawker G.
        • Wright J.
        • et al.
        Comparison of a generic and a disease-specific measure of pain and physical function after knee replacement surgery.
        Med Care. 1995; 33: AS131-AS144
        • Pengel L.H.
        • Herbert R.D.
        • Maher C.G.
        • et al.
        Acute low back pain: systematic review of its prognosis.
        Br Med J. 2003; 327: 323
        • Rinkus K.M.
        • Knaub M.A.
        Clinical and diagnostic evaluation of low back pain.
        Semin Spine Surg. 2008; 20: 93-101
        • Wheeler A.H.
        Diagnosis and management of low back pain and sciatica.
        Am Fam Physician. 1995; 52: 1333-1341
        • Davis P.C.
        • Wippold F.J.
        • Cornelius R.S.
        • Angtuaco E.J.
        • Broderick D.F.
        • Brown D.C.
        • et al.
        ACR Appropriateness Criteria® low back pain. [online publication].
        American College of Radiology (ACR), Reston (VA)2011 ([8 pp.])
        • Van der Waal J.M.
        • Bot S.D.
        • Terwee C.B.
        • Van der Windt D.A.
        • Scholten R.J.
        • Bouten L.M.
        • et al.
        Course and prognosis of knee complaints in general practice.
        Arthritis Rheum. 2005; 53: 920-930
        • Belo J.N.
        • Berg H.F.
        • Klein Ikkink A.J.
        • Wildervanck-Dekker C.M.J.
        • Smorenburg H.A.A.J.
        • Draijer L.W.
        Clinical guideline 'traumatic knee complaints' from the Dutch College of General Practitioners (Dutch).
        Huisarts Wetenschap. 2010; 54: 147-158
        • Bauer S.J.
        • Hollander J.E.
        • Fuchs S.H.
        • Thode Jr., H.C.
        A clinical decision rule in the evaluation of acute knee injuries.
        J Emerg Med. 1995; 14: 611-615
        • Seaberg D.C.
        • Jackson R.
        Clinical decision rule for knee radiographs.
        Am J Emerg Med. 1994; 12: 541-543
        • Stiell I.G.
        • Wells G.A.
        • Hoag R.H.
        • et al.
        Implementation of the Ottawa Knee Rule for the use of radiography in acute knee injuries.
        JAMA. 1997; 278: 2075-2079
        • American College of Radiology ACR
        Appropriateness Criteria; nontraumatic knee pain.
        Radiology. 2000; 215 ([Suppl.]): 1-1511
        • Oei E.H.
        • Nikken J.J.
        • Verstijnen A.C.
        • Ginai A.Z.
        • Hunink M.G.
        MR imaging of the menisci and cruciate ligaments: a systematic review.
        Radiology. 2003; 226: 837-848
        • Crawford R.
        • Walley G.
        • Bridgman S.
        • Maffuli N.
        Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review.
        Br Med Bull. 2007; 84: 5-23
        • Mackenzie R.
        • Palmer C.R.
        • Lomas D.J.
        • Dixon A.K.
        Magnetic resonance imaging of the knee: diagnostic performance studies.
        Clin Radiol. 2006; 51: 251-257