Information for medical professionals, February 2018: Part 3 – UPRIGHT MRI

It is Tuesday, February 20th, and I have taken a week off with my family at Gålå. I was planning to not do any work here, but that was not to be. After publishing two articles on our website in the Information for Medical Professionals category, the phone has been ringing non-stop. In my career of working with neck injuries for nearly 34 years, I cannot recall ever having had as many hours on the phone as the case has been for the last two weeks.

The phone conversations have been long, most of them over 45 minutes. Either it was patients calling, or their relatives and loved ones. They were in deep despair and plagued with many unanswered questions regarding UPRIGHT MRI.

The common questions asked were: Why should we have this MRI examination done? Is it reliable? What will it help me? Why has Firda Physical Medicine Center voiced their skepticism in regard to this MRI examination?

The common questions asked were: Why should we have this MRI examination done? Is it reliable? What will it help me? Why has Firda Physical Medicine Center voiced their skepticism in regard to this MRI examination?

The first and most important question all involved parties must ask themselves is; Are we really interested in detecting joint ligament damages, capsule damages and other soft tissue damages in your neck, particularly in the transition between neck and head?

One would think that answer would be a resounding YES, but such is not the case. After having worked closely with the Norwegian Public Health system for nearly 34 years where Firda Physical Medicine Center has passed on all knowledge our center has about diagnostics and rehabilitation of neck injuries, it is clear that functional diagnostics in regard to soft tissue damage of the neck is not a prioritized field within the Norwegian Public Health system. Furthermore, it is also very disappointing that none of the private radiological center chains in Norway are active within the field of cervical functional radiological diagnostics.

I will expand on the question I asked in the beginning: Are we really interested in whether you have cervical / neck joint ligament damages, capsule damages / tears, damaged nerves / nerve ganglia et cetera? Are these damages significant? Do they produce symptoms? Is it necessary to know if a joint is overly loose or constricts when used?

At Firda Physical Medicine Center we absolutely say YES!

With this background information, we must go back in time to 2012. Firda Physical Medicine Center was closely following the developments abroad as well as in Norway. We were testing the DMX method - Digital Motion X-ray. X-ray film only shows skeletal parts and not tissue (or tissue damages).

DMX:One encounters two problems; the method is 2D. One struggles with misdiagnosing due to the lack of the crucial comparison of images in 3 dimensions. The other problem is damaging levels of radiation. To get the ionic radiation dose down to an acceptable level, the power has been reduced (as of today to ca 5-6 mS per total examination), thereby also significantly reducing the quality of the X-ray film. At the same time new CT machines brought significantly improved ray efficiency and fantastic image quality, making the CT method (using Aquililon ONE 640 slice CT scanner) a clear cut first choice.

Firda Physical Medicine Center then invented a revolutionary method of customizing neck / head positions for individual patients in 2013, in such a way that a standard series today consists of a selection of 5 positions with a total radiation dosage of 2.2 mS.

CT METHOD: Very important - One cannot position all patients the same way on the CT table for imaging. The patients' injuries are all different - so to be able to see your specific deviations in neck vertebrae positions and movements you must be positioned in accordance with what your case requires.

The CT method must be customized to you - you cannot be customized for the method.

UPRIGHT MRI: To understand the intention behind upright MRI one needs to know a bit more about the recent history of MRI functional diagnostics. Western European medicine has been faithful to the idea that medication cures most ailments. When whiplash injuries became prevalent as a medical issue in the early 1990s, it was quickly realized that the available medicine had very poor effects on these "new" injuries. Then a strong current of psychologizing diagnostics and treatment efforts followed. Psychological treatment of whiplash lost its popularity in the 2000s, followed in part by a cognitive therapeutic understanding of whiplash, which was an extension of The Lightning Process, first and foremost from England. Simultaneously, heavy medications were frequently used in the battle against whiplash ailments in patients whose health conditions were deteriorating due to the use of these extremely heavy pharmaceuticals.

We experienced a steadily stronger desire for more precise and targeted diagnostics of neck injuries. The public health care system and publicly governed private radiological milieus showed a lack of interest in this kind of diagnostics. So, patients suffering with debilitating injuries searched around the globe for alternatives. There were small groups that pioneered open MRI, where one could take MR images of the neck in different poses while in a sitting position, and there was much enthusiasm around this method. At last, one would get the long looked after diagnostic answer to what was wrong with the neck. Meanwhile, I was already a seasoned conference participant abroad and had built up international contacts and cooperation. I examined and visited the upright MRI milieus of Hamburg, Munich, Vienna, London (2 places) and in the USA. In 2010 I had experienced the image quality of the new standard 1.5 T MRI machines. Tesla value has an impact on image quality, in combination with the quality of the software. Another challenge in the early days of upright MRI, was that one did not have sufficiently adapted sequences for the upper neck region. The MRI waves react differently to bone, different soft tissue types, fluids in vessels, fat etc. This problem becomes apparent when visualizing a small area with multiple different tissue types of differing density. One realized that one must improve the work of developing sequences for imaging of the neck. There are still many improvements to be made in this area. Another challenge with positional MRI is the time the neck / head must stay placed in one position and the recording time per position. In such positions you must stay PERFECTLY STILL, with no form of vibration, swallowing and similar movements. The images become blurry with any kind of movement. The recording time per position with 0.5 T is about 6-7 minutes, and with 3.0 T about 3 minutes. This is a crucial difference.

I was also extensively into upright MRI for 3 years. I also believed that this was the start of an amazing time with regards to precise diagnostics. Firda Physical Medicine Center spent a lot of time and money on this. In hindsight, I can see that we paid a high price for this wisdom. But all knowledge is beneficial, if you learn what works and what doesn't. However, we accepted defeat when it came to upright MRI. We licked our wounds and started looking towards the future.

We then encountered groups that worked with MRI 3.0 T - with a new main coil (the helmet you lay with your head in). It creates a magnetic field in closer proximity - which gives improved image quality. And it had enough space to fit the head in the positions that we wanted!

The magnet was stronger, 3.0 T, compared to the 0.5 T of upright MRI - since it was not open and smaller, it was easier to cool. Do not be fooled by those who say that software can compensate for the low Tesla values. The image quality can never be better that what the raw materials are. One can retouch images through software, but that just means increasing the distance to the real and original image material.

When we at the same time encountered fantastically skilled MRI radiographers in London, where we were still getting sequences for the neck developed, the future path for diagnostics was set. There is still a significant potential for further developments here. We can take images of high quality with your neck in different positions, while you are lying down. Fantastic!

More information about this will soon be published. Follow us on our homepage!

Finally, an example of image quality from two examinations in London - both from machines with 0.5 T and 3.0 T.

To see the details in these images we must magnify them on the PC screen or in the paper version. About like this (remember that the images always will look better on the PC screen directly from CD-ROM than they do on paper):

0.5 T Upright MRI 3.0 T MRI (The Firda Phys Med Model)

Both images show a projection of the neck seen from the side. The image quality is clearly superior in the right image, showing a 3.0 T MRI. Even if the upright MRI image shows the neck / head tilted forward, there is not much we can say about potential tissue damages, due to the low pixel density, and the transitions between different tissue structures become blurred due to low sensitivity and specificity.

The choice is easy:

CT for joint positions and bone structures.

MRI 3.0 T - with neck positions customized based on your neck injury.

But always first: A thorough clinical examination, including high-end ultrasound. Only then do we have the best foundation for assessing whether you require the CT and MRI 3.0 T examinations in London.

In closing, I would like to address you directly as a patient:

Make informed decisions about your further diagnostics. Require that the professionals who are to help improve your life have sufficient knowledge about the consequences.

Follow us on our homepage – – for the next article in this series: “Part 4: Cervical (neck) positional CT”


Please note: From Jan 1st 2018 we no longer accept credit cards. Only debit cards can be used.

User survey results

Question: "How do you rate the treatment you had at Firda Physical Medicine Centre relative to any treatment you had before coming to us?