Taking a picture of back pain

INTRODUCTION: X-RAY’S, MRI’S & WEDDING PHOTOS

Imagine I show you a photo of a wedding I attended years ago with a group of 150 smiling faces.  I ask you “please pick out who’s had the most to drink.” You don’t know anyone in the photo. 

That would be a very tough task and one that you would likely get wrong.  Why?  Because it’s just a picture. 

Surprisingly, this analogy is a good way to help us understand why we can’t confidently use your x-rays or MRI scans to explain back pain.  A picture may be worth a thousand words – but when it comes to pain, it has its limits.

PART 1: PAIN-FREE PEOPLE HAVE “DISK DEGENERATION” TOO

When we feel a symptom, like pain, we want to make sense of that experience. We want to understand why we’re feeling that pain.  “If only we knew what part of my back was causing my pain.  The doctor could better treat the problem” we might think.

For decades healthcare providers have been ordering imaging for back pain sufferers in the hope of identifying the pain provoking structure.  Roughly 25-50% of these scans are deemed inappropriate.

All the new technologies we have for peering into the human body are fantastic.  They give us incredible detail of anatomy.  Imaging techniques have even been saving lives since their invention.  Scans are really good at finding fractures, infections & cancers for example – about 1% of all low back pain cases.  With regard to back pain, why not take a look and see if anything is abnormal?

People are discovering why not. Scanning someone for pain is like a fishing trip, and since no one is perfectly “normal” you tend to find a lot of fish. If you look closely and often enough, almost everyone will have a little “degeneration” here or “disk bulge” there. 

What would we find if we used an MRI machine and scanned a group of people without low back pain? This question was asked by a group of researchers in the U.S. and the study was published in the American Journal of Neuroradiology.  Their results of more than 3000 pain-free people are provided in the image below.

The rows represent “abnormal” features found on the MRI scan and the columns represent the age of the participants.  For example, if we look at the top left box, we see that 37% of pain-free 20-year-olds had “disk degeneration.” 

If we look around the image some more, 50% of pain-free 40-year-old participants had “disk bulges.” 83% of pain-free 80-year-old participants had “facet degeneration.”   

What sticks out is that the older we get, the higher chance we’ll have something found on a scan – even if we don’t have pain. 

Researchers and clinicians are more commonly referring to these changes as “wrinkles on the inside.”  These are normal signs of aging – not pain provoking structural changes to your tissues.  If I start to get more noticeable wrinkles on my face, do I now have “face degeneration?” Will my face start to hurt?     

 It seems these imaging findings we’ve been using to explain someone’s pain doesn’t corelate to pain very well.  It may help explain some specific conditions.  However, for the vast majority of cases, we can’t confidently explain your low back pain based off of what we see on your scan alone.  Why?  Because many pain-free individuals have similar changes to their spines.

Many sober people can look like they’ve had a few cocktails before happy hour.

PART 2: SCANS CAN DO MORE HARM THAN GOOD

The language that’s used on X-Ray and MRI reports is catastrophic.  Disk degeneration disease, disk space narrowing, facet arthrosis.  Healthcare providers just throw these words at the patient like its meaningless.  Meanwhile the patient is thinking “car tire, wear and tear! What do I do? I need to preserve it or replace it. So, I’m going to stop using it (ie avoid physical activity) or I’ll need spinal fusion!”  They’ve got another 40 years on this planet, if their back is degenerating, they better preserve it, right? 

The best recommendations for painful musculoskeletal conditions include exercise.  Exercise is truly medicine.  But exercise as a treatment makes little sense to a person that has been told by a doctor “it’s wear and tear.”  If my back is “degenerating”, exercise would make it worse.  Wouldn’t it?  That is a sensible conclusion from the patient’s perspective.  

Patients, now believing that their body is fragile and vulnerable, become less active.  A vicious cycle of pain and disability begins.  Less physical activity leads to more disability – more disability leads to more pain.  This vicious cycle is a major reason one in five Canadian’s experience persistent pain.

In fact, a massive observational study including over 400,000 participants, published in the Journal of General Internal Medicine, had some eye-opening results. 

Early MRI scanning was associated with higher rates of back surgery, greater use of prescription opioids, higher pain intensity and higher costs for treatment, compared to those without an early MRI scan.  What good is that MRI doing?

PART 3: YOU’RE BROKEN, I’LL FIX YOU

Best practice guidelines for chiropractors recommend only taking x-rays when there are signs and symptoms of what we call “red flags.”  Signs that indicate serious conditions.  In the absence of red flags, X-rays are not recommended.

Yet there is a fraction of chiropractors that use routine X-rays to assess the structure and function of the spine.  A practice dating back to 1910.  Historically, these groups of chiropractors have argued that radiographs are helpful to measure postural abnormalities or identify vertebral misalignment and guide treatment with spinal manipulative therapy.

However, this practice has never been evaluated for its effectiveness.  Considering all the potential harms I’ve discussed previously with imaging, understanding if routine X-ray use is something that chiropractors should continue to do is important.

Recently this has been of particular interest to the Chiropractic College of British Columbia (CCBC).  The mission of the CCBC is to protect the public by regulating British Columbia’s doctors of chiropractic to ensure safe, qualified and ethical delivery of care.  They reviewed the scientific literature to date to find out if routine X-rays were useful in managing patients with spinal pain.

The CCBC’s review concluded that there is “no evidence that the use of routine or repeat radiographs to assess the function or structure of the spine, in the absence of red flags, improves clinical outcomes and benefits patients…we recommend that chiropractors do not use radiographs for the routine and repeat evaluation of the structure and function of the spine.”

This comes to no surprise since we can’t confidently use pictures to explain someone’s pain. 

CONCLUSIONS: PAIN IS COMPLEX & YOU ARE MORE THAN A PICTURE

It’s important to remember that many pain-free individuals have findings on their scan that sound scary, like degenerative disk disease.  This isn’t a disease.  I’m encouraged knowing that there are lot of smart researchers and public health advocates in the world trying to change the language healthcare providers use. 

If you’ve had a scan that was used to explain your current back pain recently, who’s to say those “abnormal” findings weren’t there 2, 5, 10 years before you had pain. 

Pain is extremely complex.  A combination of infinite factors influence pain, like your fitness levels, sleep quality, mental stress, physical stress, mood, occupation, social economic status… the list goes on…. and on.  But as a living, adaptable human-being, we can change the health of our tissues and effectively decrease pain in a variety of ways.

Dr. Iain Harrington is an evidence-based chiropractor with an interest in persistent pain.

To learn more about Dr. Iain, or to book an appointment, please visit the “Your Team“ page of our website.

Dr. Harrington is currently accepting new patients.