Running down the field as fast as they can and pop, they slow down and grab at their leg. They have strained a hamstring, it is obvious to everyone, including the athlete. But inevitably the first thing they will say to me as they leave the field is, “its not torn, its just a strain”. At this point why does the label of the severity of the injury seem to matter so much to the athlete? Without realizing it the athlete is trying to downgrade the label that is attached to the injury, because if the label is bad, the outcome and return to sport is going to be more difficult. But does it matter what the label is? This is a question that has been posed and discussed by health practitioners at an increasing rate. How important is a diagnosis, a label and the specific identification of an injury site? Well increasingly it appears as though it depends on whether it will help or hinder or treatment approach. And sometimes more information can hinder more than it helps.
When we see a health professional, we want to know what is wrong. Otherwise why would we go to see them in the first place? But is it possible that them giving us a specific diagnostic answer may actually lead to a worse outcome?
This discussion is the topic of a recent British Journal of Sports Medicine Editorial article. We know that every action has multiple effects, and not all of them may be positive. In areas of healthcare such as the use of medication, we are clearly aware that there are side effects of using medications, and the recent Astra Zeneca COVID vaccine blood clot findings highlight this. So it is clear that the application of healthcare has positive benefits but it may also have negative effects (often termed iatrogenics in healthcare). These are the negative unintended or undesired consequences associated with the application an intervention. What is often not always highlighted, especially to patients is that communication and detailed investigations (such as MRI imaging) have both positive and negative effects. They may give you an accurate diagnosis, tell you exactly what pathology is present (broken bone, stress fracture, muscle tissue strain grading, ligament injury) and this is important to determine the most beneficial clinical approach. For instance if you are getting pain in your foot while training for a marathon, and there is a suspected stress fracture, an MRI may be a major determiner of whether you can continue your training or need to significantly alter your overground running training.
So when does this spill over to the dark side of communication?
The negative effects of labels often occur when individuals attach to labels or diagnoses that are considered poor prognosis, especially in the absence of clinical features. The most common of these scenarios is the imaging of the spine or a painful joint, particularly the knee and osteoarthritic changes. The scenario is common, the patient has back pain that is non specific in nature and is making progress, but is frustrated with the timeline of improvement and decides to have an MRI of their spine. The MRI shows multiple levels of degeneration or disc injury, that are often mild to moderate, but suggest a reasonable level of pathology. As soon as the patient is aware that there is visible damage to their vertebral discs, the symptoms and patients clinical picture degrades.
Why? The reason is that these patients have a belief that disc injuries are debilitating, non changing and the diagnosis has sentenced them to a lifetime of back pain. What is worse is that the symptoms that they are experiencing do not match those of clear mechanical disc pain. The clinical picture from this point can sometimes get murky and the patient behavior shifts towards activity reduction and avoidance as they fear they will increase the pathology and damage to these vertebral discs.
So does this mean we should never label or do imaging investigations? Clearly this is not what we or the authors of the editorial are advocating.
The authors of the editorial put forward some questions for healthcare professionals to consider before labeling or giving very specific patho-anatomical diagnoses. They provide some instances where it is relevant, such as an acute traumatic incident, and suggest to patients that they may need to consider whether more information will help them to recover faster or potentially increase their fear about the pathology that may or may not be present.
They include:
- Is it an acute or chronic problem that requires evidence-based treatment?
- Is my label a specific tissue pathology or structural descriptor that may be unhelpful for the patient’s understanding of their symptoms?
- If I label, will I be encouraging additional potentially costly and harmful investigations or interventions?
- If I label, will I be helping or impeding recovery?
- Who is the beneficiary of my words?
For healthcare professionals and patients alike, there is a need to understand that we are all searching for certainty. A diagnosis that is clear and identifies the exact area that is injured creates comfort in our minds about what the best course of action may be. But before we jump to a specific patho-anatomical diagnosis and further investigations, we must be willing to question whether it will benefit the recovery and application of healthcare or is it just making both parties more comfortable. Although they may influence each other, they are not the same thing.