The Case for Patient-friendly MRI

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 - Women's and Children's Hospital
The pediatric MRI suite becomes a soothing place of fun and wonder at Women’s and Children’s Hospital in Adelaide, South Australia. For Rebecca Linke, MD, chief of radiology, and Nick Zabanias, chief technologist, the ‘immersive experience’ means faster scans and less anesthesia.
Source: Women’s and Children’s Hospital
Consider MRI from the patient's perspective. You're trapped in a coffin-like enclosure and subjected to an earsplitting racket of up to 120 decibels. You're in an uncomfortable position and possibly in pain, but you know that if you move, you will have to start all over again.  

The experience is the antithesis of patient-friendly imaging. And it can hinder workflow, threaten patient safety and take a bite out of the bottom line.

In a recent study at Humboldt University in Berlin, 39 percent of patients balked when preparing for head-first placement in a short-bore MR scanner—and cited claustrophobia as the reason. The fear factor was so high that 26 percent had the same reaction when offered open MR. "We expected a higher potential to reduce claustrophobia, especially regarding the MR scanner with the vertical, open configuration," explains lead author Judith Enders, MD.

According to the study published in PLoS One in August, nearly 15 percent of participants either required sedation to complete a scan or out-and-out refused to go through with one in either type of scanner.

Enders' study participants were selected for their higher-than-average proneness to claustrophobia as revealed in a pre-scan questionnaire. But the persistence of their resistance added grist to the conclusions of previous studies, including one published in the Journal of Magnetic Resonance Imaging in 2007 that showed 2.3 percent of patients refusing to complete an MR scan once it started.

Newer systems, including open MR scanners, "cannot prevent claustrophobia," concluded Enders et al, "suggesting that further developments to create a more patient-centered MR scanner environment are needed."

Vendors and providers alike are scrambling for, and deploying, new systems and processes to tackle the challenge.

Beyond claustrophobia

Claustrophobia is not the only source of patient difficulties with MRI. Some patients have a hard time staying still when they're in pain and placed in awkward positions for extended periods. Children have a hard time staying still, regardless.

Also, patient comfort and image quality are not the only issues, as these can cut into the bottom line. Humboldt researchers have estimated that two million global MR scans are aborted annually by patients, costing imaging centers untold dollars.

At Thomas Jefferson University Hospital (TJU) in Philadelphia, William B. Morrison, MD, director of musculoskeletal radiology, wields an MR that no patient refuses out of fear or discomfort. It provides high-quality MR images for his specialty—and gives TJU a competitive edge. Morrison's secret weapon: the latest in high-field extremity MR.

"If you get a wrist imaged at our competitor's, you have to go into a closed scanner and put your arm in a weird position," he says. "Athletes don't like going in for an elbow scan and coming out with shoulder pain after holding still in the 'Superman position,' hand above head. Here, they can sit back and read a book throughout the procedure." That's because the only body part inside the gantry is the arm, leg, hand or foot being imaged. It's out with the hard, flat table and in with a cushy reclining chair.

Morrison says he was impressed with early iterations of this technology, and it has improved in both power and design. "You can take advantage of all kinds of physics that you can't access in a whole-body scanner," he says. "You can get higher gradient strength, slew rates and amplitudes, so that you can actually make it better per Tesla than the 3T whole-body scanner." He adds that the design makes it easier for technologists to hit the "sweet spot," where the target tissue structure is centered within the bore.

It is a money saver, too. With a traditional MR scanner, "you might have to buy anywhere from four to six coils just for musculoskeletal, which cost around $20,000 each," says Morrison. The extremity scanner comes with six transmit/receive RF coils—one each for optimal hand, wrist, elbow, foot, ankle and knee position—so there's no need to purchase coils as add-ons.

Magnetic distractions

Pediatric MR finds radiologists and technologists scrambling for toys and techniques to mesmerize young minds. "Children tend to be daredevils, so the main problem isn't getting them not to be scared; it's getting them to stay still," says Rebecca Linke, MD, chief of radiology at Women's and Children's Hospital in Adelaide, South Australia.

To that end, Linke's department has been using goggles to show the child his or her choice of video while in the scanner. "If you stick a child in front of TV even at home or if he or she is watching a favorite movie or cartoon, they tune everything else out," she says.

The department recently added a sophisticated projection system that turns the entire suite into an immersive video theater. Playful fish frolic on the walls, puffy clouds float by or one of nearly 20 other scenarios play out in soft lighting accompanied by kid-friendly music. The patient chooses the movie and the environment.

Linke points out that most children under age 5 require sedation prior to an MRI scan, but the movie goggles have reduced the need for anesthesia by 30 to 40 percent in her patient population—and she believes the immersive theater experience will drive that number higher still, in the process improving workflow. She also notes general anesthesia increases total scan cost by more than 50 percent—while increasing risk of death in children with pre-existing conditions, according to a study at the Royal Children's Hospital in Melbourne.

Help on the way

Other developments show promise for decreasing patient discomfort with MR.

Parallel imaging, which reduces scan times by using complex algorithms to reconstruct signals from multiple channels, is gaining acceptance in MR.

In September, Johns Hopkins researchers pinpointed the cause of MR-related vertigo: the magnetic force pushing fluid that circulates in the inner ear's balance center. The discovery may lead to a solution for patients prone to this not-uncommon problem.

Earlier this year, a small study at Monmouth Medical Center in Long Branch, N.J., showed that a pre-scan session with a certified therapy dog can reduce or eliminate the need for anti-anxiety drugs in skittish MR patients.

Enders looks to better predict claustrophobic events to "facilitate interventions and prevent the waste of valuable examination time. One approach is cognitive behavioral treatment, as by exposure to claustrophobic stimuli," she says. Pointing to developments in the use of "empathic attention by trained staff and instruction of patients in self-hypnotic relaxation," she cites the 2009 book, Patient Sedation Without Medication.

Meanwhile, Linke likes the results she's seen prepping pediatric patients with a toy scanner. "The child puts a little elephant through the scanner and an image comes up on a screen showing what's wrong," she says. "It lets children play the part of the doctor, which both prepares them for what they're about to go through and helps them understand why they need to go through with it."

From sophisticated psychodynamics to toy scanners, the pieces are falling into place to hasten the day when no MR patient is left behind.