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1. Findings from radiology exams will show issues within the body but it does not always indicate if those findings are the cause of pain or dysfunction. These findings should be correlated with orthopedic testing.
2. It is difficult to change our minds, but there has been emerging evidence that there are other potential mechanisms involved with the sensation and perception of pain.
3. We have the potential to improve.
There is evidence to show that osteoarthritis, spinal discs, joints, and etc. are not consistently the cause of nontraumatic pain. There is a relationship with pain, but it is not completely clear.
For example, there are cases when a spinal disc issue may be increasing pressure on a nerve resulting in neurological signs that may need to be surgically mediated. But there also cases where disc issues completely heal. For others, there can be disc issues without any pain or symptoms.
What does this mean?
First of all, we must rule out Red Flags, a list of signs and symptoms that may indicate a serious medical condition. This requires an appointment with a medical professional and there are many cases when surgery or other medical intervention may be the only option.
But what if it is not??? There are other potential things to look at.
What this means is that we do not know 100% for sure if our pain is related to findings from x-rays, MRIs, and CT scans. So if we assume that findings from an imaging report is causing pain, there is nothing we can do about it. If we assume that there may be other reasons promoting pain, it gives us the option to try to find what that is. Then there is an opportunity to decrease pain by trying various treatments based on the science of pain. For example, there is evidence that pain can be related to injury, sensitivity, the immune system, protective mechanisms, stress, the expectation of pain, changes in the nervous system, and the “memory” of pain. Researchers are constantly trying to figure things out and these issues associated with pain can be treated!
Let’s look at osteoarthritis (OA) as another example:
Osteoarthritic changes may make the body move differently, but it does not mean that it has to be painful. There are people with OA and no pain or people with pain in both knees but the knee with less pain has more OA changes. This may be a difficult concept to grasp and it’s completely understandable because most are taught that osteoarthritis and pain go hand in hand.
If we think about the past, most believed that the Earth was flat and if we sailed off to the horizon, we would fall off the edge of the Earth. We now know that this is not true. Many believe that osteoarthritis is causing pain. But there is evidence indicting that it may not or last least not all the time.
This is not common knowledge and people will not believe it whether it is true for not. So another purpose of this website is to share information that people do not know about, or do not understand in order to help us get out of our pain rut.
Here are some examples of research studies and what have been published:
“The discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental.” Published by Jensen MC. 1994
“The relationship between the radiological findings, pain and dysfunction remains unclear.” Published by Ranson CA 2005
“Visually assessed severity of lumbar spinal canal stenosis is paradoxically associated with leg pain and objective walking ability. There is no straightforward association between the stenosis of dural sac and patient symptoms or functional capacity. These findings indicated that dural sac stenosis is not the single key element in the pathophysiology of lumbar spine stenosis” Published by Kuittinen P in 2014
“In typical patients with low back pain (LBP) or radiculopathy, MR imaging does not appear to have measurable value in terms of planning conservative care. Patient knowledge of imaging findings does not alter outcome and is associated with a lesser sense of well-being” Published by Modic MT. 2005
“Lumbar spine radiography in primary care patients with low back pain of at least 6 weeks duration is not associated with improved functioning, severity of pain or overall health status, and is associated with an increase in GP (general practitioner) workload” Published by Kendrick D 2001
“The large proportion of asymptomatic abnormalities (in the lumbar spines of pain free, adolescent, elite tennis players) underlines the poor specificity of these findings, and other sources of pain should be considered.” Published by Ayala F 2006
“Almost half of young Finnish adult aged 21 years had at least one degenerated disc, and a quarter had a bulging disc. Modic changes and disc herniations were, however, relatively rare.” Published by Takatalo J. 2009
Based on a systematic review: “Although there may be an association between degenerative MRI changes and chronic low back pain(CLBP), it is unknown if these estimates accurately represent the association given the quality of included studies, lack of a direct link between degenerative MRI changes and CLBP, and heterogeneity across studies. Thus, a strong recommendation against the routine use of MRI for CLBP evaluation is made. Since there are no data evaluating the efficacy of the surgical treatment of degenerative MRI changes, a strong recommendation is made against the surgical treatment of CLBP based solely upon degenerative MRI changes. Published by Chou D. 2011
“The results of this study suggest that, although some whiplash associated disorders patients are more likely to suffer from long-lasting neck pain, MRI findings cannot explain the symptoms.” Published by Matsumoto M. 2010
“Degenerative changes in the thoracic spine on MRI was observed in approximately half of the asymptomatic subjects” Published by Matsumoto M 2010
“88.5% of subjects in the non-painful group had degenerative changes in cervical discs” Published Okada E. 2011
“Magnetic resonance images of asymptomatic participants revealed abnormalities in 73% of hips, with labral tears being identified in 69% of the joints.” Published by Register B. 2012
Meta-analysis demonstrates that MR imaging evidence of disc bulge, degeneration, extrusion, protrusion, Modic 1 changes, and spondylolysis are more prevalent in adults 50 years of age or younger with back pain compared with asymptomatic individuals. Published by Brinjikji W. 2015
“This study documents the high prevalence of anatomical irregularities, including herniation of a disc and deformation of the spinal cord, on the magnetic resonance images of the thoracic spine in asymptomatic individuals” Published by Wood KB 1995
“Our research suggests that type I Modic changes, disc degeneration, endplate defects, disc herniation, spinal
canal stenosis, nerve compression, and muscle fat infiltration have the highest probability to be related to LBP. These can be used to improve clinical decision-making for patients with LBP based on MRI.” van der Graaf JW 2023
“The results suggest that some MRI findings may have weak associations with future LBP; however, larger high-quality studies are needed to resolve uncertainty…. In mixed populations, no pooling was possible; however, single studies demonstrated that Modic type 1, 2 or 3 changes and disc herniation were each associated with worse pain in the long term.” Published by Han CS 2023
The Upper Extremities:
“Labral tears can occur without symptoms.” Published by Schmitz MR 2012
“The severity of atraumatic rotator cuff tears are not associated with the pain level. Factors associated with pain are comorbidities, lower education level, and race.” Published by Dunn WR 2014
“Structural tendon changes (tendinosis) may be encountered in the symptom free (healthy), normal population” Published by Ustuner E 2013
“Magnetic resonance imaging identified a high prevalence of tears of the rotator cuff in asymptomatic individuals. These tears were increasingly frequent with advancing age and were compatible with normal, painless, functional activity. The results of the present study emphasize the potential hazards of the use of magnetic resonance imaging scans alone as a basis for the determination of operative intervention in the absence of associated clinical findings.” Published by Sher JS 1995
“40% of elite overhead athletes had findings consistent with partial- or full-thickness tears of the rotator cuff. 25% dominant shoulders had magnetic resonance imaging evidence of Bennett’s lesions compared. None of the athletes interviewed 5 years later had any subjective symptoms or had required any evaluation or treatment for shoulder-related problems during the study period.Magnetic resonance imaging alone should not be used as a basis for operative intervention in this patient population.” Published by Connor PM 2003
The Lower Extremities:
“There is evidence of a weak association between joint space width (JSW) of the hip and symptoms, of predictive validity for subsequent joint replacement, and of moderate responsiveness of metric measurement of JSW.” Published by Chu Miow Lin D 2011
“Given the high prevalence of MRI findings in hips of asymptomatic hockey players, it is necessary to cautiously interpret the significance of these findings in association with clinical presentation” Published by Silvis ML 2011
“Knee pain is an imprecise marker of radiographic knee osteoarthritis but this depends on the extent of radiographic views used. Radiographic knee osteoarthritis is likewise an imprecise guide to the likelihood that knee pain or disability will be present. Both associations are affected by the definition of pain used and the nature of the study group. The results of knee x rays should not be used in isolation when assessing individual patients with knee pain.” Published by Bedson J. 2008
“Our results demonstrate that the presence of a plantar calcaneal spur may be an indicator of foot pain independent of plantar fasciitis. Although spurs may not cause foot pain themselves, they may be an indication of other associated conditions.” Published by Moroney PJ. 2014
What these research studies have found is that many people with pain and without pain have structural issues. So if we experience pain and get an x-ray, MRI, or CT scan that shows a structural problem. It does not tell us if the problem found is causing pain. It may have been there before experiencing pain! It would be helpful to correlate radiological findings with orthopedic testing.
For example, findings of L4-5 disc herniation on an MRI with changes in sensation, muscle strength, tone, and reflexes an L4-5 pattern would be a stronger indicator that the disc herniation is involved compared to someone without the same changes.
To have even a larger perspective of the relationship of arthritis, discs and degenerative joint disease, the Advanced Physical Therapy Education Institute has created a poster that shares information regarding MRIs, CT scans, and X-rays that can be purchased on their website. Click here to check it out. When the page loads up, click on the “larger image” wording under the poster to get an up close look at it.
To summarize, many studies have found that diagnostic testing can find issues within your body, but it does not tell us if it is effecting your pain. There was a time in the 2000’s when total body scans were popular. It turned out that there was a high rate of false positive findings which led to more unnecessary and invasive tests.
There can also be increased stress, anxiety, fear avoidance behaviors that are associated with pain.
Here are quotes from studies that discusses this exact topic:
“Patient knowledge of imaging findings do not alter outcome and are associated with a lesser sense of well-being.” Published by Ash LM. 2008
“Results suggest that iatrogenic effects (consequence of medical treatment) of early MRI are worse disability and increased medical costs and surgery, unrelated to severity.” Published by Webster BS 2010
“Early MRI without indication has a strong iatrogenic effect (consequence of medical treatment) in acute LBP, regardless of radiculopathy status. Providers and patients should be made aware that when early MRI is not indicated, it provides no benefits, and worse outcomes are likely.” Published by Webster BS 2013
“The American College of Physicians has found strong evidence that routine imaging for low back pain by using radiography or advanced imaging methods is not associated with a clinically meaningful effect on patient outcomes.” Published by Chou R. 2011
“The rate of lumbar spine magnetic resonance imaging in the United States is growing at an alarming rate, despite evidence that it is not accompanied by improved patient outcomes. Over utilization of lumbar imaging in individuals with low back pain correlates with, and likely contributes to, a 2- to 3-fold increase in surgical rates over the last 10 years. Furthermore, a patient’s knowledge of imaging abnormalities can actually decrease self-perception of health and may lead to fear-avoidance and catastrophizing behaviors that may predispose people to chronicity.” Published by Flynn TW. 2011
Here is a blog at this site http://www.bodyinmind.org/spinal-mri-and-back-pain/ that discussed this topic as well. There is a lot of feed back from various health care providers in this blog post.
Here is the kicker. Researchers conducted a study on Aboriginal Australians and explained MRI findings in one group and not in the other. Here is there conclusion:
“Findings are consistent with research in other populations and support that disabling chronic low back pain may be at least partly iatrogenic. This raises concerns for all populations exposed to Western biomedical approaches to examination and management of low back pain. The challenge for healthcare practitioners dealing with people with low back pain from any culture is to communicate in a way that builds positive beliefs about low back pain and its future consequences, enhancing resilience to disability.” (Published by Lin IB in 2013)
The most important point here is to understand that “problems” found in a diagnostic test doesn’t mean that we are doomed and that we will not improve!!! We may still have the potential to recover!
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