502- Upright vs Recumbent MRI: New Insights for Chiropractors

Welcome to the Evidence Based Chiropractor, where each week we deliver the latest chiropractic research and marketing strategies, all in the time it takes to get to your office. Now, here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I am your host, Dr. Jeff Lengmaid. On today's episode, we are back with more research. Brand new study all about MRI positioning, upright versus recumbent. What do we find? What's different? What's better? How can you discuss this with your patients? We will dive into all of that and more on today's episode. And a special shout out to everybody who participated in our 500th episode giveaway. If you left a rating or review for this podcast screen, grabbed it and emailed it to me, your gift pack has now shipped. I was fortunate enough to spend most of the month of July out in Park City, Utah. However, I am back here in Tampa, Florida and that means your gifts have shipped. So be on the lookout if you're here in the United States in the next few days. If you are abroad, it might take a few extra days to get there. But thank you so much to everybody who contributed to the 500th episode giveaway. Also, before we get started, big shout out to leander tables. If you are in the market for a new table, they are what I recommend and you could save $1,000 off series 950 by using the code EBC 2025 or visiting the page in the show notes. Fantastic flexion distraction tables. But as I said at the top, today's episode all about MRI positioning. And we're going to explore one of the most intriguing systematic reviews on imaging that I probably have ever seen. And this is comparing upright versus recumbent mri. And again we're going to discuss what this means for clinical practice, patient outcomes, the future of spinal diagnostics. And my goal is that you walk away with some practical insight and hopefully a new appreciation for how gravity really changes things and how in many ways there are so many limitations to those recumbent MRIs, which is really important for you and I as people who are usually ordering them as a result of spinal issues. So that's what we're gonna talk about today. And if you have ever looked at an MRI report and said this does not match what I am seeing clinically, this episode is probably for you. Again, we'll drop a link down in the show notes. So this was a systematic review published in the Spine Journal, big leading research journal. It included 19 studies and over 5,200 participants, most of whom had low back pain. The question they asked was actually really, really simple. Do upright and recumbent MRI scans produce systematically different results and which better correlates with pain? And big spoiler alert here is yes, they do differ. And yes, an upright MRI might be more clinically relevant, but we're gonna get into the details because the details really matter. Now why does this matter? This matters because traditional recumbent MRIs have been the gold standard in imaging for about an eon. And that's something that you probably have experienced. Depending upon where you practice, you might still have like 1.5T, 15 Tesla recumbent MRIs. Some of you listening might have a bunch of 3T imaging around you. Some of you might have seated MRIs, some of you might have even I've seen seated motion MRIs. And many of you maybe have these upright top tier machines coming in your neck of the woods. And if so, that's awesome because if you think about your typical patient, many are not experiencing pain when they're lying on your table, but they hurt when they're standing, walking, moving around, and ultimately what we can call weight bearing. Big deal. Just think about that. So when you're putting somebody into position where they're experiencing less symptomatology, this is not mutually exclusive or absolutes, but generally speaking, that's because the physiology has changed slightly. And if it is not due to chemical irritation, which might be less influenced, so to speak, by positioning. If it's mechanical, and much of it is mechanical, as we know, when you're lying down and feeling all right, you have to sit there. Think about sitting in an MRI to sit there for 15, 20, 25 minutes, whatever it might be for that specific machine, somebody that's an 8 out of 10 pain is not going to be able to sit there for that long, or I should say lie there for that long. So by definition, you know, the symptomatology is going down by the fact that they were able to withstand stand laying down for that recumbent mri. And this is why all these reasons are why the upright MRI has gained so much attention and notoriety. Now, these machines, you know, unless you own an imaging center, you know, this might not be the biggest deal for you, but if you own an imaging center, it's a big deal. Why? Because upright MRIs have traditionally cost way more money. Those machines are really expensive, and I'm going to say they're really expensive not only by themselves, but also to get good quality. I think we've all probably seen really great quality recumbent MRIs then we've seen really really poor quality seated or weight bearing or upright MRIs. And that is changing rapidly. But these machines are still really really expensive, these imaging modalities and diagnostics. So if it hasn't made it your way yet, or if you have an upright MRI and the quality is just so poor, you know, hopefully I'm hope for you that they'll be able something your way pretty soon. So the upright MRI has been a big deal because gravity changes everything. And the authors of this study noted quote, Recumbent MRIs underestimate gravity dependent image findings due to the dynamic nature of some entities such as disc herniations and scoliosis. Talk about speaking to us as chiropractors. Functional and structural issues right there in a nutshell. Now I've been involved in imaging in the past. AOMC Spinal Diagnostic Imaging still is my company and it is, we do vertebral motion analysis. So we do upright cervical range of motion utilizing full size C arms to really analyze translation angulation and disc height to a tenth of a millimeter or a tenth of a degree. Massively impactful and powerful in the personal injury space. If you want more information, please be sure to hit me up. But I'm very familiar with the imaging world world because we had half a dozen locations spread all throughout the United States with the vertebral motion analysis. Now that business has sold, but I know a lot about it. I was deeply embedded in this for a long period of time. And the MRI is really, I'm gonna say the kissing cousin. It's really the brother or sister, so to speak to that VMA technology. The VMA sees things that an MRI doesn't and an MRI sees things that a VMA doesn't. But upright weight bearing and ideally even throughout motion. Really as I used to say when I'd be speaking to doctors about this, it's not about finding things that aren't there. It's about seeing what actually is. And that's the big deal. Now upright MRIs are not brand new. They've been around, they're just advancing quickly. But this is the first major systematic review comparing it directly to those old fashioned recumbent MRIs. So previous research in 2007 did conclude that upright MRIs were experimental as I said in 2007. But new tech and this analysis totally changes that. They're no longer experimental by any means. And here's a line from this study. This study represents a turning point offering the most comprehensive review to date on how gravity changes what we see in the spine. And gravity does dramatically alter spinal findings. The authors of this study, they kind of predefined their expectations based upon biomechanics, compression, dis expansion, et cetera, and then checked against the data. And guess what? The real world findings matched their expectations nearly to a T. So here are some examples of expected increases, you know, seeing this more often, so to speak, in upright MRIs. What kind of findings are we talking about? Disc bulging, ligamentum flavum, thickness, spondylolisthesis, spinal stenosis. Now the expected decreases were in disc height, dural sac size, and neural foraminal dimensions. This shows that upright MRIs are not just different, it's predictably different based upon load bearing physiology. When, when patients are upright, when your patients are upright, we see a lot more of the truth. It's like looking at the spine with the lights on. Again, you don't want to have people in abject pain. This is not a discogram. You're not trying to cause discomfort by having an upright mri. But what you are trying to do is actually visualize what was going on. And I can tell you, sitting with literally 10,000 patients, you can do the math. 20 a day, five days a week. For three, four years at the orthopedic group, I was at looking and reviewing CTs and MRIs. There was just such discrepancy. Like 30% of the time the patients would be coming in saying one thing, the images would show another, or the reports would show another. I'd like to look at both, but that's a massive problem. And unless you're willing to really dive deep, and let's be frank, most traditional doctors out there are not. They're willing to spend a few minutes and they're looking for what is the A plus B equals C. Are you coming in? Have you done medication? Do medication? Have you, have you not taken medication? Let's do an injection. Have you done an injection? Let's do surgery. It's very algorithmic as opposed to, I'm gonna say the benefit of what you and I provide, which is the ability to take our time, the ability to understand the balance between structure and function, and, and the ability to analyze imaging in a holistic way where we can actually provide meaningful movement based, evidence based care for these individuals. So let's highlight some of the key findings across nearly 40 different MRI parameters from this study. Most of those parameters, upright MRI showed more pronounced pathology, especially for super important things for us and the patient, like Disc herniation, ligamentous thickening, spinal instability. Out of 24 of the parameters measured on a continuous scale, upright scan showed expected increases again in disc bulging, ligamentum flavum, thickening and spondylosthesis parameters like disc height, canal area, neuroforaminal dimensions decreased with gravity. Totally what we'd expect, right? The size of the disc height is getting smaller because of gravity, the canal area smaller, the neuroforaminal dimensions smaller, but because it's under load now, in 13 of the 14 scale comparisons, upright scans were more likely to be upgraded in severity. So that means somebody had mild finding recumbent. It was maybe moderate or severe when they were upright. This provides clear evidence for systematic differences between the upright and recumbent positions. And this is really big. Again, 19 studies, 5,200 participants, 38 total parameters analyzed, very robust sample size for spinal imaging research, which makes it super credible. Again, 13 out of the 14 comparisons showed upgrades in the upright position. And when patients stand up, their spine just tells a different story. And again, in 13 of the 14 comparisons, it wasn't good news in terms of the patient, but it's actually really good news in some ways because it can be accurately diagnosed and therefore better taken care of. Additionally, correlation with pain was stronger in upright mri, especially for the oswestry disability index and walking tolerance. Dural sac AP diameter had a 0.39 higher correlation with disability when measured upright. So there is just a lot to this study highlighting the fact that upright MRIs show a lot of of things that are not seen on recumbent. And even when pathology is seen on recumbent, the extent of that pathology might often not be fully realized or visualized until you get people upright. Here's a quote from the study. I like performing an mri. Upright instead of recumbent may increase the correlation with pain. And here's another one. Patients need a better understanding of the cause of their pain and more effective management treatment strategies. I think we all can absolutely agree on that. So what are some clinical takeaways and how can you apply this in your practice? Number one, be cautious with MRI findings in the supine or recumbent position. They might be missing some really key gravity dependent changes. That's not to say everything needs to be done upright tomorrow, but just be aware of this. So as you are looking at the images, you're able to accurately discuss this with your patients. And they don't, you know, bluntly. There's a lot of patients that think they're crazy. They take a recumbent mri, there's not any findings. They're, you know, in a significant amount of pain and dysfunction. That's confusing and it doesn't need to be if it's explained to them properly. Even if you can't, then go ahead and shoot that upright mri. Now, if you suspect instability, stenosis, discogenic pain worsened by weight bearing, then it's a really good idea to consider recommending an upright mri. I'm going to say especially when the symptomatology does not match the existing imaging, really using this as a sounding board can be a really good idea in terms of really gaining a lot of specificity of what's going on. And it's also important to reinforce the limitations of static imaging. So using this research to remind them why your hands on exam, why your functional based testing is also critical. As I always used to like to say and still say today, images are a part of the story. And while images so everything that's not perfect, it's, it's the doctor and the chiropractor's job to figure out what the problems are. Amongst a hundred not perfects, There might be one or two problems. There might be 50 or 60 problems. The doctor's job is to separate the not perfects from the problems. Cause the problems are what you want to address. The not perfects are, okay, nobody's perfect and degeneration happens and gravity and time are undefeated. But the more you can do proactively, especially when somebody's in pain and now you're reactive, to help guide them in the most linear fashion with the best information, with the clearest explanations, that is where you want to be as a provider because ultimately your patients are going to get the best results possible. So again, I Recommend Considering upright MRIs when imaging doesn't match patient symptoms, when there's instability that's questioned or stenosis, and also when chronic low back pain worsens with sitting, standing or axial load. So you know, as chiropractors, we are in the trenches with all these patients who hurt when they move, not necessarily when they lie, lie still. So upright MRIs can align much better with the real world biomechanics. And this review is a really great one and it proves that imaging world, the imaging world is finally starting to catch up, I'm going to say, with some of the functional testing that we've relied on for a long time. So I love this study. Hopefully this was an eye opener for you. Probably not anything super surprising, but it really adds, I'm going to say to my confidence when understanding the differences between upright and recumbent and just having that literature there is really, really nice. Now before we wrap up, I want to say a few words about TurnCloud. TurnCloud has created an intuitive application where no one needs a user manual. You can learn more. Connect with their team@TurnCloud.com again that is TurnCloud.com if you decide to do a demo with them, let them know you listened on this podcast. They will hook you up with their best offer. That is what you get as a benefit of tuning in each and every week. And we have some additional sponsors coming on that I'm super excited about that you are going to be hearing from very, very soon. Other than that, I want to say thank you so much for tuning in. Thank you for being a chiropractor. Have a fantastic week in practice and I will talk to you soon.

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