Medical Imaging May Not Be The Answer

There is a common belief by many patients and healthcare providers that imaging such as an X-Ray, MRI, or a CT Scan will determine the cause of their pain. Modern medical imaging has undeniably advanced our understanding and treatment of many issues; however, sometimes imaging results may lead to more problems than they solve.

The most common musculoskeletal condition seen is low back pain (LBP). The probability of experiencing LBP during the lifetime is 80%, with an estimated $100 billion in expenses per year associated with LBP. The correlation between degeneration severity (i.e. narrowing of the disc space, disc bulge, and osteophyte formation) found on images and symptom severity of LBP remains unclear. A review looking at over 3,000 individuals with no history or complaint of back pain showed a high prevalence of spine degeneration on imaging. On the other hand, several reports have shown that patients with LBP have no noticeable disc degeneration changes on imaging. Possible causes for individuals showing disc degeneration and arthritis on images while being asymptomatic include increased supportive action and strength of the paraspinal muscular structures.  A person’s overall health, fitness, daily activities, and psychosocial factors, such as relationships with others, personal beliefs, and fears can all affect pain threshold. Since disc degeneration and other degenerative changes are seen with a high prevalence in all age groups, these changes may not be associated with low back pain symptoms and should be interpreted as a part of the normal aging process instead of a pathologic process.

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A study looking at immediate imaging versus conservative care without imaging affected outcomes in people with LBP found no difference between routine, immediate lumbar imaging and usual clinical care without immediate imaging in both short-term and long-term improvements in pain. Healthcare providers are able to recognize “red flags,” which are signs and symptoms that could indicate something more serious during the clinical exam, which would then warrant further investigation through imaging. Clinical care without immediate imaging seems to result in no increased odds of failure in identifying serious underlying conditions in patients without risk factors for these conditions. Routine imaging is also associated with radiation exposure, increased direct expenses for patients, and may lead to unnecessary procedures. Evidence confirms that clinicians should refrain from routine, immediate lumbar imaging in patients with nonspecific LBP with no indications of underlying serious conditions.

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Similar results have been found in other areas of the body. A study on individuals with pain in one shoulder who volunteered to have both shoulders imaged found just as much “pathology” including rotator cuff tendinopathy, ACJ arthritis, bursitis, labral lesions, and partial rotator cuff tears, in the pain free shoulder as the painful shoulder. The main pathology that demonstrated a significant difference between the painful and non-painful shoulder was a full thickness rotator cuff tear. Another study found similar results in painful and non-painful knees, with both knees having as much “pathology” including osteophytes, cartilage degeneration, and meniscal lesions, on MRI findings.

This is not to say that imaging is not useful, nor that it should never be used. In the presence of serious or sinister signs and symptoms, images will help make fast, accurate diagnoses. However, without serious or sinister signs and symptoms, images can lead to overdiagnosis, unnecessary costs, and increased stress levels. Images are to be utilized to exclude the worst of the worst, but when it comes to everything else they cannot and do not tell us where the pain is coming from. Most musculoskeletal aches and pains do not have one specific cause.  Factors such as muscle imbalances, body mechanics, and overuse are all elements to be addressed to decrease pain and improve function. A Physical Therapist will evaluate you as a whole, develop a treatment plan to have a cumulative effect on the tissue, and allow you to live your best life. Contact PTI today to find out how we can effectively diagnose and treat the underlying causes of your lower back pain.