Fear, anxiety and phobia are common terms used to indicate different feelings, often used interchangeably, but they have different meaning.
- Anxiety represents a future-oriented response focused on a diffuse menace.
- Fear is a present-oriented response to an identifiable threat.
- Phobia is an intense and irrational fear of one or more things/situations.
- Claustrophobia is an intense and irrational fear of confined or enclosed spaces.
As all we know, MR environment is a potential generator of these feelings, particularly referring to the scanner gantry, coils shape, scan time, the necessity to maintain the position for the entire duration of the scan, acoustic noise, thermal discomfort, etc.
Despite the medical and technical advances in terms of gantry geometry (length and size), software and hardware innovations with a significant scan time reduction, acoustic noise reduction and so on, patients continue to have negative experiences before and during the MR scanning. Up to 35% of individuals experience anxiety during MRI scans, with a 37% incidence rate of claustrophobia [1].
In fact, based on a recent systematic review about the responses of patients to MRI [2] conflicting articles have been written: some articles suggested that such technological advancements may have brought about improvements in patient experience; others have still reported high levels of distress, and related procedural issues of patients examined in modern MRI scanners, questioning the benefit of new MRI designs. In practice, advancements of MRI technology alone may not be sufficient to eliminate anxiety in patients undergoing MRI and related unexpected behaviours.
The Impact on MRI Efficiency and Outcomes
Anxiety and discomfort in general, may not only affect the patient experience , buy may also affect efficiency of healthcare providers. Anxious patients tend to move more, inducing motion artifacts on the acquired images and the need to repeat scans, generating prolonged procedural times.
In the case of severe anxiety, a scan might be terminated prematurely with difficulties in patient management and rescheduling. Claustrophobia during scans is associated with early termination of scans in up to 10% of patients.
Patient who experienced severe anxiety terminating prematurely, will almost certainly need a sedation to complete the scanning.
All the concepts explained above, are particularly true in the case of brain MRI.
Based on the “birdcage” coil shape and the position in the middle of the scanner bore, brain MRI remains one of the more challenge MR examination in the case of anxiety or claustrophobia.
For this reason, all the possible tools should be applied to complete the scan with the highest quality image possible, free from motion artifacts, considering sedation as a last resort.
The Strategy to manage patients
The first step to get the patient relaxed, reducing the amount of anxiety, in the preparation and instruction, both for the patients who access to the MR unit for the first time and patients who had bad experiences during the precedent MR examination.
The correct use of words by the MR Radiographer and from all the professionals who take part in MRI process, talking with empathy, is a very powerful tool which shouldn’t be underestimate.
The second step is the correct patient positioning in terms of patient comfort, compatible with the anatomy under examination. The patient comfort is basilar not only to reduce the anxiety variables but to limit the risk of having motion artifacts as well.
In fact, talking in general, motion occur in 29% of inpatient/emergency department exams and 7% of outpatient studies [3] , having a stimate cost of $115,000 loss annually per scanner due to motion artifact [4].
In order to reduce motion artifacts, discussing the technical parameters at the console, different approach could be applied [5]:
- Scan time reducing through techniques like parallel imaging, compressed sensing, simultaneous multi-slice, artificial intelligence etc. With this approach, motion artifacts are less likely to occur;
- Saturation bands to delete signal from moving anatomies;
- Trigger/gating systems to synchronize patient physiological movement with the scanner;
- Radial K-space filling to correct movement during the image reconstruction through central K-space oversampling and specific algorithms;
- Specific immobilization and stabilization tools like Inflatable pads.
Discussing the last point, inflatable pads are a very powerful tool both for the patient immobilization and for the anxiety reduction during the head MR examination, with the aim of completing the MR acquisition, free from motion artifacts.
Fig.1: Inflatable pads MULTIPAD Ear model by Pearl Technology AG
The inflatable pads give the possibility to modulate pressure, optimizing the patient comfort and reducing the risk of movement. At the same time, the patient has an extra element of control over his environment.
For example, when used in combination with a head coil, the MR radiographer can initially inflate the pads based on the patient tolerance, and then give the patient control of the ball and release valve, to ease off the pressure if they must.
This approach, in combination with active communication during the scanning, can help to reduce the anxiety level, increasing the image quality.
Fig.2: Inflatable pads MULTIPAD Ear model combining with head coil
The inflatable pads I use during the MR head scanning of anxious patients are provided by Pearl Technology AG, MULTIPAD Ear model.
I tried on plenty of anxious and claustrophobic patients with good result in terms of anxiety control, the possibility to complete the scanning and motion artifacts reduction.
I compared the patient reaction with the external ear protection providing by the scanner producer and the inflatable pads in combination with internal ear protection. Almost all the patients I tried on had a better feeling with inflatable pads due to the pressure balancing and the control on release valve.
Fig 3: External ear protection (left), internal ear protection with MULTIPAD Ear.
Conclusion
Ultimately, inflatable pads are a powerful tool to take into account during the patient positioning and instruction to control anxiety and to prevent motion artifacts during the head MR examination. They should be used together others psychological and physical tools with the goal of good image quality in anxiety controlling.
It is necessary to know that, in some circumstances with high level of anxiety or phobia, the only one way to perform MR examination might be the patient sedation.
Author: Luca Bartalini, MSc
Specialist MRI consultant
[1] Advances in Magnetic Resonance Technology and Applications. Volume 6. ISSN 2666-9099. https://doi.org/10.1016/B978-0-12-824460-9.00010-8
[2] Linda Becker PhD et al. The Psychological, Physiological, and Behavioral Responses of Patients to Magnetic Resonance Imaging (MRI): A Systematic Review and Meta-Analysis.
JMRI, Volume59, Issue2, February 2024, Pages 675-687
https://doi.org/10.1002/jmri.29134
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J Magn Reson Imaging 2015;42(4):887–901. https://doi.org/10.1002/jmri.24850 PMC 4517972. PMID:
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[4] Melendez JC, McCrank E. Anxiety-related reactions associated with magnetic resonance imaging examinations.
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