We are accustomed to getting immediate and exact answers to our questions these days. Google brings satisfyingly fast and direct responses to so many of our questions. When we need help in the medical world, we hope to have a similar experience. Yet we go to clinician after clinician seeking answers to the pain that is beginning to secure an unbelievably firm grip in our lives. No one is offering good answers, and maybe they do not even believe we are physically experiencing pain. We can tell they are beginning to think that we are making it up. Time to get an MRI right? A picture of our insides will show everyone, including ourselves, the truth of what is happening.
Imaging and pain
Before we dig into some of the research, let’s come to terms with what we get from the common methods of imaging, specifically x-rays and MRIs. These are static pictures of an individual who is consciously holding a specific, unloaded posture. Our lives certainly do not happen without motion, and many times we have to carry some sort of load, from backpacks to children to plates of food. Rarely does a picture ever tell a full story, yet with x-rays and MRIs that is what we get, a series of pictures from a few different angles. Is it fair to ask these pictures, and those who interpret these few pictures, to reveal the truth concerning our body and the complex pain that is plaguing us?
When consulting research, healthcare’s general reliance on imaging to provide answers and solutions to pain becomes even more perplexing. In just one example, a few researchers conducted a study demonstrating that MRI results could not predict low back pain. In their research, they defined an “abnormal” spine as demonstrating various pathologies including disc bulges or degeneration, facet hypertrophy, and nerve root compression. Crazy enough, 32% of the individuals in the study without back pain demonstrated “abnormal” spines in the imaging, and 47% of the individuals who were experiencing back pain revealed “normal” spines or a negative result of significant findings for causes of their pain. This one example illustrates what many other studies and my clinical experience reveals: that MRI results do not correlate with and cannot predict your musculoskeletal pain experience.
Let’s get to know a friend of mine, a real-life example
So what does this look like in real life? A friend, whom I will call Tito for fun, comes for help with his back pain and hands me his MRI. To his surprise, I complete the full hour of examination and treatment before looking at the MRI, because I know it will not give me good information about his pain experience. I look at the MRI at the end of our session and this is how it reads:
- L5-S1: right paramedian annular fissure, broad-based protrusion to the right, ligamentum flavum thickening, facet arthrosis, mild right and left neural foraminal narrowing. Mild spinal canal stenosis with slight lateral recess narrowing.
- L4-L5: right paramedian annular fissure, disc bulge, ligamentum flavum thickening, facet arthrosis. Mild left and right neural foraminal narrowing. Minimal spinal canal stenosis.
- L3-L4: Disc bulge, ligamentum flavum thickening, facet arthrosis. Right and left neural foraminal narrowing. Minimal spinal canal stenosis.
- Grade 1 retrolisthesis L4 on L5 and L5 on S1.
- Mild degenerative spondylotic changes at L3-S1.
Whether you understand all of these terms or not, you are probably wondering how this person is even walking from that daunting report! Yet he still works full time and enjoys running regularly as he is training for an upcoming marathon, but he has been experiencing a recent bout of back pain that continues to linger and progress. He is finding that his back aches terribly by the end of his workday and he is finding it hard to stay in a good mood after work, much more train for a marathon! This is why he went in for an MRI, looking for answers. Now, I can’t tell you what happened to Tito yet because I want you to finish reading this until the end.
What happens if the MRI is positive?
I am a spine guy, so let’s stick with examples of spine pathologies, specifically lumbar (for increased emphasis, I am going to switch to second-person now. Sorry English majors, I know you are going to loathe me for switching mid-article). You have been experiencing low back pain for several months now with no help, and your employer is starting to get annoyed with your complaints and constant standing breaks from your desk. Finally, you get your MRI showing you have degenerative disc disease and some arthritis in your spine. Aha! Answers at last! But as we established before, who doesn’t have these conditions? The real answers you need are how to resolve your pain, and that expensive MRI didn’t help you or your physician understand how to answer that question, which is your real question. So what now?
You are still in pain, surgery can’t guarantee anything but a long and painful recovery for your situation, and your clinicians are just telling you to rest and not lift anything remotely heavy. The only guarantee you have at this point is an image that shows that your spine looks like it’s been dealing with gravity for several decades. Not much of a surprise. That right there is one of the biggest issues I see with imaging for low back pain. I listen to people talk about their low back pain like it’s an incurable disease: “I have degenerative disc disease. That is what it showed on the MRI so now I am stuck with it forever.” It is unfortunate that these patients have been educated about back pain like this, but this is how most of us understand it. The only service the MRI provides to the patient experiencing pain is a mental roadblock to their recovery! They reference that image as a confirmation to the death of their spine and succumb to an inevitable future of nerve ablations and vertebral fusions.
What happens if the MRI is negative?
This result, a negative MRI, can be devastating. You are experiencing intense pain and are so excited to finally have answers and proof of your pain, but everything in that picture looks normal. The scariest thing I see from this result is clinicians telling their patients that their pain is in their head. Yes, there are psychological pathologies that may lead to an experience of pain that isn’t musculoskeletal in origin, but that is out of my scope and also not what I am talking about. I am talking about a clinician who relies too heavily on imaging and wants to move on to the next patient telling a person dealing with actual musculoskeletal pain that it’s in their head simply because they do not understand it themselves. This may be one of the most terrifying implications of the misuse of imaging. Now the patient is still experiencing pain, is being doubted by their employer, family, friends, and at last finds themselves without any hope for relief and now questioning their sanity. We must do better than this for these patients.
When is imaging needed?
To re-emphasize an already emphasized message, imaging is NOT your go-to when you are seeking answers to musculoskeletal pain. That being said, the advances in medical imaging are incredible and there are certainly times when imaging is indicated and beneficial. Maybe you are wondering if the pain you are experiencing is musculoskeletal or something systemic and possibly more serious, what do you do then? A good clinician will perform a proper evaluation of you and your symptoms (which we’ll discuss a little more about next), and they will be able to identify certain red flags that may prompt the need for imaging and possible surgical intervention. You can read a full breakdown of the red flags in the article I just linked in the previous sentence, but most of these red flags pertain to signs of serious neurological pathology, which present with what we call “hard” neurologic symptoms. Imaging also does wonders for evaluating non-musculoskeletal pathologies, but the focus of my writing is to warn you of imaging as it pertains to musculoskeletal injury and symptoms.
Now I feel hopeless. Who can help me?
Congratulations on making it to the last section of my article where you finally get to read about what happened with Tito. By the end of that first one-hour session, Tito reported feeling 80% better. With just 3 visits over 6 weeks, our friend Tito reported feeling no pain and was back to full training, with the tools and knowledge of how to manage his back pain if it ever dared to return. If the moral of this story is not obvious, I want you to know that your spine is resilient and incredible and can heal and recover! You are not doomed by that MRI diagnosing you with arthosis or degeneration or whatever it says.
So who is going to help you? The best words to begin to answer this question come from expert spine researcher Dr. Stuart McGill:
We have found that a thorough assessment reveals the cause of pain better than any image.
I know this answer probably is not as concrete as you were hoping for, but McGill’s words truly are the foundation of the answer you are looking for. You are looking for someone who will conduct a thorough assessment of you and your pain. You need a clinician who will ask you several questions and listen intently to your pain experience to better understand your situation, who then performs a thorough physical examination to narrow the possible diagnosis, and who proves that they understand your pain during the session by using safe treatment methods to improve your pain right then and there, intrasession. Then they will walk you through their understanding of your situation, the diagnosis they believe is indicated from the results of the exam, and they will reveal a clear plan and prognosis for your recovery.
You’ll finally walk out of a clinical appointment with increased understanding, answers, and hope! If all continues to progress well and that clinician helps you truly heal and recover from your pain, then you’ve found your real-life version of a Dr. Google and you’ll be back to full activity, working towards your life goals yet again.
Dr. Hampton PT
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