Editorials Editorials

It is time to stop causing harm

obtain full-text articles containing the Funding AGC is supported by a European Union
latest research. In attempts to overcome Seventh Framework Programme (FP7-PEOPLE-2013-ITN;
KNEEMO) under grant agreement number 607510.
unknown.
remains lower
ingsdemographic
Therefore,
that maystudy. hold
only average:
than the university
Austclinical
reporting
J Physiother
a nd-
2008;54:6571.
relevance
4 Chartered Society of Physiotherapy. Specialisms and
will

with inappropriate imaging for low

the barriers to enrolment faced by busy
clinicians, it is encouraging that an Competing interests None declared.
make reports more meaningful
specialists: guidance for developing the clinical
threatening.
specialist role.For example,
Chartered Society offractures,
and
Physiotherapy,
less
stress

back pain
increasing number of masters degree pro- Provenance and peer review Not commissioned;
grammes are being offered as distance- externally peer reviewed.
reactions,
London, 2001.
5plate
Gosling
changes
severe disc degeneration, end
S. Physiotherapy
(modic and type postgraduate
follow-up discussion paper. Physiotherapy
1) and disc study: her-
a
learning, online-learning courses with niations with nerve compression are more
1 2 1999;85:11721.
Ben Darlow,
short blocks of Bruce B Forster,
intensive Kieran OSullivan,3 Peter OSullivan4
in residence 6strongly
Green A,correlated
Perry J, Harrison with
K. TheLBP and/or
inuence of a leg
periods. pain, and should
postgraduate be reported
clinical masters within
qualication in manualthe
6
context
therapyof on the clinical
the careers situation. However,
of physiotherapists in the
Inappropriate imaging for low back pain disability.
To cite Culvenor Early
AG. Bruse of Med
J Sports MRI for LBP
2016;0:00. the United
fact thatKingdom.
these Manual Ther 2008;13:13947.
ndings generally have a
HOW
(LBP) CAN BJSMharm
can cause HELP?
in three ways: results in increased disability, poorer per- 7 Sran MM, Murphy S. Postgraduate physiotherapy
Accepted 7 April 2016 positive natural history should be made
As
1. part of BJSMs commitment
Misinterpretation of results to byeduca-
clini- ceived prognosis and a greater chance of training: interest and perceived barriers to participation
8 Br J Sports Med 2016;0:00. clear
in ainclinical
reports.
mastersIndegree
contrast, moderate
programme. Physiother disc
tion,cianswe resulting
will review Master of advice,
in unhelpful Sports back surgery. 1
Patient interpretation of
doi:10.1136/bjsports-2016-096221 degeneration, disc bulges and protrusions,
Canada 2009;61:23443.
Physiotherapy
needless coursessubsequent aroundinvestigations
the globe to images, the accompanying report and 8 Pluim BM. Are youdiscgetting the most out of BJSMlow-
annular ssures, space narrowing,
help(downstream
busy clinicians testing) becomeand invasiveeasily explanation of their meaning can lead to education? Br J Sports Med 2014;48:1522.
REFERENCES grade spondylolisthesis and facet joint
informed of course
interventions, curriculum,
including surgery;duration
1
beliefs that their spine is damaged and 9 Culvenor AG. Cardiff Metropolitan University: the
1 Centre for Workforce Intelligence. Physiotherapy arthrosis correlate
latest academic and practicalpoorly within a LBP.
developments
andMisinterpretation
2. cost and particular focus by
of results areas and
patients structurally vulnerable, resulting in fear
workforce review. UK, 2010. http://www.cfwi.org.uk/ Reporting
Masters of that these
Sport and Medicinemay
ndings
Exercise not be
(continuing
strengths. Many of the courses
resulting in catastrophisation, fear and are pre- andpublications/cfwi-physiotherapy-workforce-review
subsequent avoidance and protective clinically relevant
professional due to
development their
series) Br Jprevalence
Sports Med in
dominantly
avoidance being of movement delivered online,
and activity, behaviours. 2
2 Canadian Institute As forpatient portals develop,
Health Information. 2016:12. doi:10.1136/bjsports-2016-096474
asymptomatic populations should be
opening
and low doors to study at
expectations of many different
recovery; 2 Physiotherapists
allowing patients in Canada, 2011National
increased access to andtheir
9 Jurisdictional Highlights. Ottawa, Ontario, 2012. considered.5 6
institutions internationally.
3. Side effects such as exposure to We encourage reports, this effect is likely to further
https://secure.cihi.ca/estore/productSeries.htm? Radiologists will be better placed to
institutes
radiation.that3 offer Master of Sports increase.
pc=PCC439 provide meaningful interpretations if
Physiotherapy
Problems associated programmes withto excessive
contact 3 McMeeken J, Gratnt R, Webb G, et al. Australian
referrers provide comprehensive informa-
BJSM to facilitate
imaging for LBP potential
are wellreview.recognised LETphysiotherapy
US MAKEstudent intake is increasing
IMAGING REPORTS and attrition
tion about the patient, their presentation
(http://www.choosingwisely.org) and useful CLEAR FOR CLINICIANS AND and the reason for the investigation. This
evidence-based guidelines have been devel- PATIENTS would help radiologists to prioritise nd-
Shoulder pain: can one label
oped to help clinicians determine when
satisfy
investigation is appropriate.3 However,
The myriad of terms used when reporting
Consistent language communication
ings which are between
sionals and
context
relevant to
andthetopatients
health profes-
the clinical
provideage.homogeneous
everyone and everything?
currently, 42% of patients with LBP
on lumbar imaging is confusing both for
receive an X-ray, CT or MRI within 1 year
patients and for clinicians. For example,
patient groups in treatment outcome
studies. 2 3
THE WAY FORWARD For that reason, clinicians as
of diagnosis, and of these, 80% receive the distinction between a disc protrusion, well as researchersprofessionals
continue theare attempt
Sports medicine high
Ann M within
imaging Cools,11month Lori AofMichener
presentation. 2 4 extrusion or herniation is often unclear to classify patients
users of imaging and quick adoptersinto subgroups under-of
The uptake of imaging guidelines is likely and interpreted variably by different radi- neath the umbrella of provides
commonanshoulder
to be similarly insufcient among the ologists. Many terms, such as degener- innovation. The latter oppor-
symptoms.
tunity to leadMany the way alternatives
in reducinghave been
the harm
The
sportslabelling
medicineofcommunity,
non-traumatic whereshoulder
lumbar rationaleannular
ation, for clinical
tear,tests,
discsurgical
bulgeproce-
and formulated,
associated with allinappropriate
with their imaging opportunities refer-
pain
imaging related to the structures
is frequently used. of the suba- dures and rehabilitation protocols.
herniation, can enhance threat and con- and limitations.
rals and threatening Referring
imagingtoreports,
the subacro-
which
cromial
As well space has been debated
as recognising for many
when imaging is tribute to negative beliefs that are poten- mial
can lead to the misconception has
conict, terminology that shifted
LBP is
years. Historically, labelling
appropriate, evidence-based reporting of shoulder
and tial barriers to ABOUT
recovery.THE It LABEL
is time for
CONTROVERSY from
alwaysSIS causedto subacromial
by structuralpain syndrome
pathology. An
diagnoses
interpretation andofexploring
imaging ndingstheories isaboutcrit- consistent, patient-focused terms to be
SIS (SPS).
important rst step would be referrers
the
ical.underlying
The contents causes of of shoulder
imaging pain are
reports developed thewhich
However, labelcommunicate
of SIS is nowinvestiga-
contro- SPS, rotator
demanding clear, cuffevidence-informed
disease, rotator-cuff- and
interrelated.
strongly inuence Many authors
clinicians usebeliefs,
the phrase the tion ndings in aevidence
clear and minimally
versial, as recent suggests that related shoulder painnot
clinically relevant reports which a singleincludelabel
advice they provide
syndrome describing a combination
patients and the clin- of threatening
this conceptmanner.
does not Consistent
fully explainlanguage
the to satisfy everyone
age-specic and everything.
epidemiological information
ndings, often occurring
ical management decisionstogether,
they withmake,an could be organised
mechanism. 13
Until a in fewa years
standardised,
ago, SIS Theon
based SPS label implies
radiological studiesthatofthe shoulder
asymptom-
unknown
which in turn or heterogeneous
impact on patient underlying
beliefs checklist like accepted
fashion (as is the case
was a widely umbrella termwith
for pain is attributed
atic individuals. 5 8solely to subacromial
Work needs to be
pathogenesis.
and behaviours. AsWhile
such, imaging
Dr CharlesprovidesNeera synoptic
a numberreporting)
of possibletounderlying
enable better use of
structural structures (bursa,
undertaken to developrotatora cuff, structural
taxonomy of
introduced the diagnostic
detailed description of a persons spinallabel of suba- data for clinical research. 7
cromial impingement
structures, so-called abnormal syndrome (SIS) are
ndings of
or biomechanical causes. Throughout the appropriate report terms which areacromial
abnormalities at the level of the accept-
years, the description progressed from SIS arch),informative
able, but does not and reect
helpful many other
for radiolo-
the shoulderprevalent
increasingly in 1972. withThis age label
in asymp-was
Epidemiological
to impingementinformation
related shoulder pain, causes of shoulder pain located outside
based on
tomatic the mechanism
populations 5 of structural
and correlate poorly gists, sports medicine professionals and
Mandatory reporting of that
age-matched the subacromial
with a persons level of ofpain
impingement of the structures the suba-
and
with the growing opinion impinge- patients alike. In space.addition, Others suggest
imaging 4 appro-
the
prevalence rates of
ment represents imagingofndings
a cluster symptoms for label of rotator cuff disease, which
cromial space. This concept has been the priateness can be improved by point-of-care
asymptomatic
and a possiblepopulations
mechanismhas forthethepoten- might cover rotator cuff-related
dominant theory of injury to the rotator
pain, decision5 support which embeds shoulder
red ag
tial
ratherto than
educate clinicians and diagnose
a pathoanatomic patients pain, but these labels fail to referrals.
take into9
cuff tendons and other structures in the symptom recording in electronic
1
while decreasing the threat associated account
itself. The recent tendency to expel SIS as Together,many theseother structuresmay that leadpos-
Department of Primary Health Care and General
subacromial
Practice, space,
University andWellington,
of Otago, has served as the
New Zealand; measures to
with these ndings.
a diagnostic label on Simply
the one including
hand allows an sibly contribute to shoulder pain of and
the
2
Faculty of Medicine, Department of Radiology, a reduction in the disability burden
epidemiological statement with MRI subacromial space, like
University of British Columbia, Vancouver, British
us to critically review our perspectives on distress related to LBP . the labrum or the
1
Department
Columbia, 3
of Rehabilitation
Canada; University Sciences
of Limerick,
and Ireland and reports
shoulderhas beenbutfound
pain, to decrease
on the other hand the biceps complex. Moreover, since many
Aspetar
Physiotherapy,
Orthopaedic
Ghent and
University,
Sports Gent,
Medicine
Belgium;
Hospital, use
leadsofto narcotic medication
uncertainties about the forumbrella
patients rotator
Competing cuff tears None
interests seemdeclared.
to be asymptom-
2 4 8
Division
Doha, of Biokinesiology
Qatar; School of Physiotherapy
and Physicaland
Therapy,
Exercise with
we usedLBPtoorclassify
radiculopathy.
patients. atic, it is likely
Provenance and peer inappropriate to attribute
review Not commissioned;
Science,
UniversityCurtin
of Southern
University,
California,
Perth, Western
Los Angeles,
Australia, Diagnostic labels based on tissue- shoulder
externally peer pain to structural damage of the
reviewed.
Australia
California, USA
Assessment of relevance
specic pathology fail to accurately clas- cuff. Finally, the labels anterolateral
Correspondence to Dr Professor
Ben Darlow,
Ann MDepartment
Cools, of
Primary
DepartmentHealth
of Rehabilitation
Care and GeneralSciences
Practice,
and University of
sify thedifferentiation
The patient into subgroups
betweenfor normal
clinical shoulder pain and shoulder pain of
Otago,
Physiotherapy,
23 MeinGhent
Street,University,
Newtown,DeWellington
Pintelaan 185,
6021, decision-making.imaging
age-appropriate Diagnostic
ndingslabels
and thoseare unknown aetiology have been advocated.
New
Gent Zealand;
9000, Belgium;
ben.darlow@otago.ac.nz
ann.cools@ugent.be intended
which maytobeguide treatment,
clinically relevantto isfacilitate
largely These labels are very ambiguous and are
414
416 Br J Sports Med March 2017 Vol 51 No 5 Br J Sports Med March 2017 Vol 51 No 5
 Editorials
To cite Darlow
DarlowB,B,Forster
ForsterBB,
BB,OSullivan
OSullivanK,K,etetal.al. 3 Chou R, Qaseem A, Owens DK, et al. Diagnostic back pain? A cross-sectional study of candidates for
Br J Sports
Sports Med
Med 2017;51:414415.
2016;0:00. imaging for low back pain: advice for high-value lumbar disc prosthesis. Skeletal Radiol
health care from the American College of Physicians. 2013;42:1593602.
Accepted 30 September 2016
Ann Intern Med 2011;154:1819. 7 Schwartz LH, Panicek DM, Berk AR, et al. Improving
Published Online First 20 October 2016
Br J Sports Med 2016;0:00. 4 Ivanova JI, Birnbaum HG, Schiller M, et al. communication of diagnostic radiology ndings
Br J Sports Med 2017;51:414415.
doi:10.1136/bjsports-2016-096741 Real-world practice patterns, health-care utilization, through structured reporting. Radiology
doi:10.1136/bjsports-2016-096741 and costs in patients with low back pain: the long 2011;260:17481.
road to guideline-concordant care. Spine J 2011;11: 8 McCullough BJ, Johnson GR, Martin BI, et al. Lumbar
REFERENCES 62232. MR imaging and reporting epidemiology: do
1 Webster BS, Cifuentes M. Relationship of early 5 Brinjikji W, Luetmer PH, Comstock B, et al. epidemiologic data in reports affect clinical
magnetic resonance imaging for work-related acute Systematic literature review of imaging features management? Radiology 2012;262:9416.
low back pain with disability and medical utilization of spinal degeneration in asymptomatic 9 Goldzweig CL, Orshansky G, Paige NM, et al.
outcomes. J Occup Environ Med 2010;52:9007. populations. AJNR Am J Neuroradiol 2015;36: Electronic health recordbased interventions for
2 Sloan TJ, Walsh DA. Explanatory and diagnostic labels 81116. improving appropriate diagnostic imaging: a systematic
and perceived prognosis in chronic low back pain. 6 Berg L, Hellum C, Gjertsen , et al. Do more MRI review and meta-analysis. Ann Intern Med
Spine 2010;35:E11205. ndings imply worse disability or more intense low 2015;162:55765.

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