Diagnostic imaging doesn’t determine your destiny
Diagnostic imaging has seen a large increase in use over the last decade. With rapid improvements in medical technology, doctors use these tools to examine different structures and processes within the body. In orthopedics, radiography (X-rays) and Magnetic Resonance Imaging (MRI) are commonly used to examine tissues of the musculoskeletal system— including muscles, tendons, ligaments, bone, cartilage, and even nerves. These sensitive tests may show signs of early arthritis, disc herniations, or tendon tears leaving those in pain worried about areas of their body they can’t monitor without further imaging. Fortunately, there’s growing evidence that many of these “abnormalities” are not predictive of future degeneration. In fact, they might not be able to tell us much about pain at all.
A recent study, just published in October 2020, sought to determine the extent in which spinal disc degeneration in young patients with low back pain could predict the progression of future structural decline. Starting in 1987, researchers extensively examined and questioned 75 individuals about their back pain symptoms and overall function. MRIs were ordered to evaluate the spinal column. These patients were tracked, monitored, and re-evaluated thirty years later, both by clinician and imaging. After review, researchers concluded that while some cases do progress with time, the level of initial or subsequent degeneration had no correlation to reported pain or loss of function. (1) This study adds to a growing body of evidence that sheds light on the poor correlation between pain and tissue damage of the spine, knees, and shoulders.(2-7)
So, why do things hurt?
Pain is a multidimensional output formed by the interplay between patho-anatomical, physical (general health, lifestyle, movement patterns, physical conditioning) and non-physical (beliefs, emotions, social stressors, culture) factors. Of these, some aspects are modifiable while others are not. However, together they influence each individual’s pain experience.(8) This complex interaction of variables can lead to negative cycles that perpetuate pain and disability.
To understand how tissue degeneration can play a role, Dr. Greg Lehman, physical therapist and pain science expert, equates anatomical changes to fire kindling. While kindling may be a precursor to fire (or pain) there is no accelerant or spark to light it.(9) Once a sensitizing agent is introduced such as over exertion, a lack of sleep, or sudden changes in life stressors, a “spark” can initiate the “fire” of pain. While this might make a specific “cause” difficult to pinpoint, it may feel helpful to remember that if the accelerant can come from a variety of factors so can the solution.
Putting out the Fire of Pain
With this knowledge, our rehabilitative goals do not rely on anatomy for improvement. Instead, we can actively build the body's robust tolerance to load demands by pursuing alternative and modifiable pathways that can affect pain sensitivity. To learn more about the effects exercise can have on pain, read my blog Putting the “Physical” in Physical Therapy.
References:
Sääksjärvi S, Kerttula L, Luoma K, Paajanen H, Waris E. Disc Degeneration of Young Low Back Pain Patients: A Prospective 30-year Follow-up MRI Study. Spine. 2020 Oct 1;45(19):1341-1347.
Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross. Magnetic resonance imaging of the lumbar spine in people without back pain. JS N Engl J Med. 1994 Jul 14;331(2):69-73.
Matsumoto M, FujimuraY, Suzuki N, Nishi Y, Nakamura M, Yabe Y, Shiga H.MRI of cervical intervertebral discs in asymptomatic subjects. J Bone Joint Surg Br. 1998 Jan;80(1):19-24.
Beattie KA, Boulos P, Pui M, O'Neill J, Inglis D, Webber CE, Adachi JD. Abnormalities identified in the knees of asymptomatic volunteers using peripheral magnetic resonance imaging.Osteoarthritis Cartilage. 2005 Mar;13(3):181-6.
Zanetti M, Pfirrmann CW, Schmid MR, Romero J, Seifert B, Hodler J. Clinical course of knees with asymptomatic meniscal abnormalities: findings at 2-year follow-up after MR imaging-based diagnosis. Radiology. 2005 Dec;237(3):993-7.
Connor PM, Banks DM, Tyson AB, Coumas JS, D'Alessandro DF. Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year follow-up study. Am J Sports Med. 2003 Sep-Oct;31(5):724-7.
Miniaci A, Mascia AT, Salonen DC, Becker EJ Magnetic resonance imaging of the shoulder in asymptomatic professional baseball pitchers. Am J Sports Med. 2002 Jan-Feb;30(1):66-73.
Peter B O’Sullivan, J P Caneiro, Mary O’Keeffe, Anne Smith, Wim Dankaerts, Kjartan Fersum, Kieran O’Sullivan, Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain, Physical Therapy, Volume 98, Issue 5, May 2018, Pages 408–423
Greg Lehman. Tissue changes and pain: explaining their relevance. Greg Lehman. http://www.greglehman.ca/blog/2017/3/6/tissue-changes-and-pain-explaining-their-relevance. Published March 6, 2017.