Which Would You Rather Have?
Many would look at the two spine MRIs above and quickly choose the image on the LEFT as the one they had a choice between the two due to the degenerative changes, bulging discs and arthritis on the one on the RIGHT… but is that necessarily the better of the two?
What if I told you:
The person which the image represents on the RIGHT was;
58 years old,
had one previous episode of back pain which resolved with 5 visits exercise and posture therapy
had full function and no pain with daily activities
was active with hiking, exercising, traveling, working full time, and
slept undisturbed for 7 hours each night
While the person who’s MRI on the LEFT was;
36 years old
had struggled with back and leg pain on and off for over 6 years
had attempted chiropractic care, two injections, medication, rest, and exercise and posture therapy without success
had discontinued their participation in running and cycling more than 4 years ago
had missed work or had to leave work early around 6-8 times each year due to the pain, and
had pain awakening them from sleep multiple times each night
With this information now, most may choose the MRI on the RIGHT.
Some may believe that this scenario of a person feeling bad and functioning poorly and having a nice looking MRI, and another person feeling good and functioning very well yet having a bad looking MRI just couldn’t happen or is very unlikely to happen.
Think again!
Let’s, think of the same question this way…
Walking down a row of cars with their hoods up - Can you have a look and accurately identify which one would be the best to have?
What would tip you off? Would you look for any sign of oil leaks? Would you scan it for any belts or hoses cracked? Or would the one which has dirt or grime built up be your pick?
Most would agree that in order to determine how well a vehicle runs one would need to visually inspect the moving parts, determine if it has good (or any) fuel in it, check the status of the tires, examine its fluids and fluid levels, see whether it will turn over when you try to crank it, etc.
It’s not difficult to understand or a surprise to suggest you can’t just flip the hood up and predict whether or not the car runs well by looking at the engine.
A thorough inspection of a car includes a careful visual survey, a check of its fluids, cranking the car, revving it up, taking it for a spin and testing the acceleration, the breaking, the steering and on and on. Nothing novel here…
And yet, many “experts” in musculoskeletal conditions responsible for pain and disability are essentially basing their decision on a visual image!
Some have criticized this analogy of a machine being likened to the human body and the experience of pain and functional limitation. There certainly must be some limitation of this analogy since the a human is not a machine but perhaps there’s a lesson to learn which does apply.
The invention of the x-ray, the MRI and the CT scan have, no doubt, been amazing advancements in medical examination, however, they’ve been shown to, perhaps, not be the ultimate in diagnosing as was originally thought. They’ve been misleading in many instances and have had negative effects when performed on the wrong patient or on the right patient at the wrong time.
Jerome Groupman, physician and author of, How a Doctor Thinks stated the following about the this topic,
“The MRI scan is a revered technology that strongly constrains a doctor’s thinking.”
For instance, this study showed that in people with no back pain, a large percentage show many abnormalities like herniated discs, degenerative disc disease, arthritis, or spinal stenosis.
And these changes actually show to be progressively more common as we age.
In other studies like this one (below) 98 patients with low back problems related to work were tracked to learn if simply what was done to them through their course of care influenced how long they were out of work and determined to have function limitations.
With similar patients, just what was done TO the patient, or WHO the patient saw made huge differences in how long their problem persisted.
For instance, when a patient:
saw a specialist their length of disability averaged 48 days versus 11 days for those who did not see a specialist.
received an x-ray their average length of disability was 30 days compared to 10 days for those who did not receive the x-ray.
received an MRI their average duration of disability averaged 115 days compared to 13 days for those who didn’t receive an MRI.
And these trends of receiving less in this study weren’t associated with patients who did more poorly - on the contrary, when patients received less they actually had nearly a 4 time greater likelihood to get back to life and work. So, this may suggest that many times, more examination or procedures or “stuff” just complicates the situation.
Some might think, well why WOULDN’T they get an image just to be sure.
I must admit, it makes sense to me too, until we realize that these pictures lead clinicians to begin making assumptions as to what is the source of the problem and what needs to be done to “fix” it. There is risk of an apparent negative psychological impact on a patient when they are informed about abnormal findings on an image like an x-ray or an MRI. This has been appreciated by the general medical community for quite a while now - to the point where the American College of Physicians published recommendations of best care in 2007 (below)
You’ll see that the recommendations include imaging NOT be done on those with pain unless it shows to be progressively worsening and likely to be due to serious pathology, like cancer, infection, spinal cord compression or fracture - all of which are very rare.
So you may be thinking… “Okay, maybe the picture of my painful part isn’t as important or helpful as I thought, but if I don’t get a picture, what SHOULD I do instead?”
I’m glad you asked 😉
If you think about the analogy we began with above, the equivalent of the mechanic who takes a look at the car, cranks it over, revs it up, and takes it for a spin - the same should be done for the person with pain of the musculoskeletal system.
A clinician trained to properly diagnose a patient with movement-related pain does this to their patient through a thorough examination.
What has helped me the most through my 22 years of practice has been the assessment system called The McKenzie Method of Mechanical Diagnosis and Therapy, or MDT.
We identify those who are appropriate and safe and we “take our patient’s body for a spin” - and in a comprehensive way, determine what is relevant and what isn’t, what appears to be playing a role in why the pain is persisting and what isn’t relevant, what is the primary driver of the pain and disability and what isn’t.
So the take-home messages here are:
how the body part looks on a picture does not, necessarily, guide the right care or improve the results of the care as much as we have been led to believe
looking at a picture should not be done on any and all patients who have pain. This is for the patient’s own good, not just to withhold a diagnostic test or avoid money being spent on a patients care.
Getting a patient moving through safe-pain movements and having someone lead the introduction of this movement by someone who understands pain which is influenced by position and activity is key.
As I tell so many who I come across with persisting pain that in most cases it only takes a couple of sessions to make a determination of what is the problem and if they can be taught what to do and how they can learn how to successfully manage their own problem with simple, yet effective self-care strategies.
It actually doesn’t necessarily matter how severe your pain is, if it’s been around for months or years, if you have been told you have the spine or joint of an 80 year old, if you’ve already tried “everything” - we’ve helped many others who’ve said or felt these same things and yet we’ve found solutions for them.
I can share actual patients of mine from over the years who were told and shown the results of their MRI and yet we found solutions to their problem without them having to go through surgery. Patients like Lynn who came to me with a confirmed rotator cuff tear yet found rapid relief and who canceled her surgery the day before it was scheduled. Lynn shares her story with me here: https://youtu.be/ME7WqPWM83Y
Or Zack who had 2 years of back and buttock pain and was told he had a herniated disc and needed surgery and yet we found relief and got back to doing everything he loved doing including running. See Zack share his story here: https://youtu.be/iAQy3DahwdM
The bottom line is, someone with musculoskeletal pain should have someone give a thorough look at their whole situation and not prematurely make a decision just on the image
So… if this message resonates with you - this is your personal invitation to bring yourself into the shop and allow us to take your body for a spin?