By Clare Ryan and and Dr Lisa Roberts
Background to the study: As an advanced physiotherapy practitioner in spines, I work at the interface between primary and secondary care and radiculopathy (sciatica) is a large part of my caseload. The term radiculopathy refers to a collection of leg signs and symptoms, referred from the back, caused by compromise of a lumbo-sacral nerve root. These include pain, altered sensation and weakness. Radiculopathy differs to somatic or referred leg pain, which is caused by structures other than the nerve, such as the joint, ligament or muscle. Radiculopathy is an important condition to manage well as people can experience severe pain and poor outcomes, with at least a third reporting significant, on-going symptoms 12 months after onset.
The decision whether to request investigations for people with radiculopathy is often a difficult one. Existing research tells us that diagnosing this condition accurately, using clinical assessment or imaging is problematic .1;2;3 History taking may not clarify whether the patient’s symptoms constitute radiculopathy, examination may not exclude other causes, and investigations may not detect a structural cause. There is also concern that investigations may result in patients and/or clinicians focusing unnecessarily on largely irrelevant findings, making recovery slower4 and increasing the likelihood that patients will undergoing treatment such as injections or surgery, based on scan findings that may well not account for symptoms (and are therefore much less likely to respond to treatment).5 Whilst clinical guidelines suggest that investigations should be used only when likely to change the patient’s management,6;7 in practice a fine line exists between under and over imaging. Particular difficulty can occur when patient and clinician differ about how important investigations are to managing the patient’s symptoms, and when the reasons for patients wanting a scan may be primarily psychosocial e.g. to provide reassurance, address concerns or fears, to provide legitimisation for absence or altered activity, or for medico-legal reasons.
For this research, we particularly wanted to explore the patients’ perspective of investigations for radiculopathy and to understand how this information could be used to improve current practice. Although two existing studies have explored the perceptions of people with low back pain who have undergone investigations 8;9 these studies are more than 10 years old, do not identify the perceptions of people with radiculopathy and refer to investigations such as x-rays and myelograms, investigations now rarely used in radiculopathy. Importantly however, one of these studies8 identified that the concordance (or match) between investigation findings and clinical presentation might influence people’s experiences of investigations.
The aims of this study were to explore how people experience investigations for radiculopathy and how the concordance between clinical presentation and investigation results affects this.
Method: We interviewed people who had recently had investigations for a clinical diagnosis of radiculopathy (based on Kongsted et al’s (2012)10 criteria). We located the study in a UK, primary care, NHS, musculoskeletal service, in a spinal interface clinic. We asked participants about their clinical diagnosis, their initial thoughts about having investigations, how the results compared with their expectations and what, if anything, investigations added to their care.
What did we find? The study included 14 participants, who had experienced radiculopathy for between 3 months and 9 years (average 13 months). Everybody who took part had been investigated using MRI. Half of the participants had investigations results that were concordant their clinical presentation (i.e. clear evidence of nerve root impingement at the level and side of their symptoms), a further 5 had potentially relevant findings (such as an annular tear or foraminal narrowing at the level and side corresponding with symptoms) and 2 had no relevant findings.
We identified three key themes about how people with radiculopathy experience investigations: accessing investigations, why investigations were wanted and the effect of investigations.
Why investigations are wanted: People wanted investigations to gain an accurate, certain diagnosis that explained the cause of their symptoms, and excluded a serious cause, such as cancer. They felt that having an accurate diagnosis would enable treatment to be more effective and would inform their understanding of their prognosis. Some patients had ben advised by another health care professional (such as their physio or GP) that a scan was the next step in their care; others needed ‘evidence’ to support claims for financial support or legitimise sickness absence. There was little evidence in this study that participants recognised the limitations of investigations.
In line with previous research, these findings highlight that people with radiculopathy want to undergo investigations to increase the certainty of their diagnosis, to help them make sense of their symptoms and prognosis, and to inform treatment decision-making. These findings are important, as the informative role of investigations is not currently recognised in clinical guidelines. There is clearly a need to better educate patients about the limitations of investigations. However, due to the limitations of other methods of diagnosing radiculopathy, we suggest that future policy considers the informative role of investigations within accepted referral criteria. To be most useful, this would require changes to the way images are reported, to focus on findings that correspond to the patient’s presentation, and to make clear where changes fit within the normal range of age-related changes, and/or are unlikely to be relevant.
Accessing investigations: Participants found accessing investigations to be slow and difficult. Whilst people wanted to access scans early in their care, they had to instead attend and fail a course of physiotherapy before they would even be offered investigations. Participants waited an average of 9.5 months to access a scan. They also found it difficult to contribute to the decision that their clinician made, about whether a scan should occur. People described finding ways to ‘play’ the system, with over half attending physiotherapy solely to gain access to a scan.
These findings present a some-what bleak picture of clinicians struggling to manage the tension between prescriptive, guideline-based care and shared decision-making, and that physiotherapy is not being offered as a choice but a required aspect of management in a series of steps rather than a coherent care pathway. The findings also reflect that practice in this study does not align with the most recent NHS England (2017) guidance7 that people with severe radiculopathy have access to a clinical specialist opinion within 6-8 weeks (NHS England 2017) (or prior to this where patients have particularly severe symptoms) and that physiotherapy is no longer required prior to investigations being undertaken. Whilst the data for this study were collected prior to these guidelines being released, they indicate the need for a shift in practice and for clinicians to ensure that their practice aligns with current evidence and clinical guidelines and that the systems are in place to facilitate this.
The effect of investigations: The third key theme was the effect of investigations. When scan findings were concordant with or potentially relevant to the patient’s clinical presentation, patients were relieved that a ‘real’ cause had been found and that it was not serious. They were able to make sense of their symptoms. In these circumstances people felt they were able to self-manage their symptoms better and to actively contribute to decisions about their care. They also felt that the results acted as a turning point, enabling decisive decision-making and for their care to move forward. People were however frustrated if a long wait to access treatment (such as investigations or surgery) followed, or when their prognosis remained unchanged.
When the scan failed to show relevant findings in this study, participants were unable to make sense of their symptoms. They felt compelled to keep searching for the cause of their symptoms and did not know where in the healthcare system to turn to next.
These findings reveal the empowering effect investigation findings can have when concordant with the patient’s clinical presentation. They also reveal how distressing it can be for patients when nothing is found on a scan to explain their symptoms. These findings suggest that as clinicians we must help to manage patients’ expectations about the possible and likely outcomes of scans (before they are undertaken). Also, so patients are not left in limbo, we must proactively support people to legitimise their symptoms, help them understand why ‘no relevant findings’ have been identified, what this means for their clinical diagnosis, and what the next steps in their care might be.
Take away messages for clinical practice
For patients with severe radiculopathy we need to:
- Ensure that practice aligns with the most recent clinical guidelines6;7 [NICE (2016); NHS England (2017)] so that patients have access to a specialist opinion at 6-8 weeks (following symptom onset) to discuss management options, including investigations. Physiotherapy prior to investigations should be a choice, not a requirement.
- Provide accessible patient information about the role and limitations of investigations.
- Enable patients to be involved in the decision whether to investigate. This should include asking the patient’s perspective, sharing information about the limitations of investigations and discussing the possible and likely outcomes of investigations.
- Be proactive in providing support and a structured pathway of care for people who have a scan that fails to identify a structural cause. This should include helping patients to make sense of the scan findings, legitimising their symptoms and outlining the care options now available
Implementing the findings into practice
I loved almost every minute of undertaking this research, finding it fascinating (and at times humbling and inspiring) to better understand the patients’ perspective. However, achieving change in practice is what it’s all about, and the most challenging aspect of this project has been using the findings to achieve impact and improve patient care.
Over the past year I’ve shared the findings with clinicians and managers and encouraged them to think about how this might affect their individual practice, and about how the systems within our service could work better. The findings resonated with staff in different ways. For some the most important message was that patients believed that investigations would provide a definitive diagnosis. They have worked harder to help patients understand why scans often don’t help with making a diagnosis. For others, what stood out was how distressing ‘no relevant findings’ could be. This has helped them to better select patients for imaging, managing patients differently when scans are less likely to identify a structural cause. For me, it’s been about always asking about and exploring patients’ preferences about imaging, educating patients about the limitations of investigations and then having the courage to negotiate.
At a service level, we’ve undertaken work to help us to identify patients with severe radicular symptoms and to improve the speed with which they can move through the musculoskeletal pathway, to a specialist (physiotherapy) opinion, imaging and where appropriate into partner organisations for treatment such as injections. We’re also in the process of putting together patient information about the use of imaging. This work is ongoing and managing patients with radiculopathy remains a challenge – both to help alleviate their (often distressing) symptoms and to align their expectations, so that they are aware that investigations are only helpful in identifying whether a structural cause for radiculopathy exists (which could be a target for treatment) and that they often fail to identify a likely cause at all.
- Van Der Windt, D. A., Simons, E., Riphagen, Ii, Ammendolia, C., Verhagen, A. P., Laslett, M., Deville, W., Deyo, R. A., Bouter, L. M., De Vet, H. C. and Aertgeerts, B. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane Database Syst Rev, 2010: CD007431. DOI:10.1002/14651858.CD007431.pub2
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- Tawa, N., Rhoda, A. and Diener, I. Accuracy of magnetic resonance imaging in detecting lumbo-sacral nerve root compromise: a systematic literature review. BMC Musculoskelet Disord 2016: 17, 386. DOI:10.1186/s12891-016-1236-z
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- National Institute For Health And Care Excellence (NICE). Low back pain and sciatica in over 16s: assessment and management (NG59) 2016. Available from: https://www.nice.org.uk/guidance/ng59
- National Health Service (NHS) England. National low back and radicular pain pathway 2017. Available from: http://www.ukssb.com/assets/PDFs/2017/February/National-Low-Back-and-Radicular-Pain-Pathway-2017_final.pdf
- Rhodes, L. A., Mcphillips-Tangum, C. A., Markham, C. and Klenk, R. 1999. The power of the visible: the meaning of diagnostic tests in chronic back pain. Soc Sci Med 1999: 48, 1189-203.
- Espeland, A., Baerheim, A., Albrektsen, G., Korsbrekke, K. and Larsen, J. L. 2001. Patients’ views on importance and usefulness of plain radiography for low back pain. Spine 2001: 26, 1356-63.
- Kongsted, A., Kent, P., Albert, H., Jensen, T. S. and Manniche, C. Patients with low back pain differ from those who also have leg pain or signs of nerve root involvement – a cross-sectional study. BMC Musculoskelet Disord. 2012:13, 236. DOI:10.1186/1471-2474-13-236