Don't Get Hung Up on Imaging

In school, many students are taught about the clinical significance of imaging, but how many end up utilizing it clinically? It seems like I rarely go a day when I don't hear a patient or clinician mention how bad the patients' MRI findings are and how that is the reason for the patient's symptoms. "So and so blew out a disc lifting a heavy box," "I have 3 slipped discs in my neck," or "the MRI revealed impingement at C4." The list goes on and on; however, my personal favorite is "my knees are bone on bone!" Sure the MRI can pick these things up, but do they matter? While I support the use of imaging to help rule out various non-musculoskeletal pathologies and life-threatening symptoms, there is quite a bit of evidence that says we should not rely on imaging for things like determining the significance of herniate discs, stenosis, bone spurs, and more (Boden et al, 1990 & Jensen et al, 1994). What these studies reveal is that quite a few people without any symptoms or complaints have the same MRI findings as those with pain. What does this mean? While it is theoretically possible that findings like stenosis, bone spurs, and discs can create various symptoms, just because we see something on an MRI does not mean that it is the source of our patient's symptoms. This is why I get frustrated when I hear patients (or PT's) start to list off their findings or when patients and health care practitioners are pushing for surgery. As clinicians, we should regularly educate our patients on just how insignificant some imaging results can be in regard to orthopaedic complaints.

What we have discussed thus far does not even touch upon our understanding of modern pain science. Having recently completed Butler and Moseley's Explain Pain, my understanding of what "pain" actually means and how it develops has changed drastically. We don't actually have pain receptors. We have an intricate system of "danger" (noci-) receptors. This system is influenced by different cultural upbringings, our surroundings, and much more. It can even adapt to affect and be affect by other parts of the nervous system! What we feels as pain often occurs for a reason, to warn us. However, the nervous system can become hypersensitive and lead to various types of chronic pain. Think about diagnoses such as Chronic Regional Pain Syndrome. These patients actually visualize the affected body part as being enlarged! How is it that someone with horrendous pain from a "blown disc" can immediately get near 100% within a couple days with something like repeated motions? We aren't pushing the disc back into place; we are affecting the nervous system! This ties right back in with abnormal imaging findings. We cannot let the results of an MRI impact our clinical decisions and treatments based on this. I am not advocating against the use of MRI's (or other types) in general, but I believe we do a disservice to our patients by biasing their mind with MRI results before even giving therapy a shot. This thought process alone can affect how the patient perceives their disability and affects the function of the nervous system. With the right treatment technique (repeated motions, manual therapy, chronic pain education), most patients should see improvement.

-Chris

---

Reference:

Boden SD1, Davis DO, Dina TS, Patronas NJ, Wiesel SW. (1990). Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990 Mar;72(3):403-8. Web. 24 Aug 2014.

Butler D & Moseley L. (2013). Explain Pain: 2nd Edition. NOI Group. 2013 Sept. Print.

Jensen MC1, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. (1994). Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994 Jul 14;331(2):69-73. Web. 24 Aug 2014.