DEGENERATION, PAIN, AND THE RELATIONSHIP BETWEEN WHAT SHOWS UP ON DIAGNOSTIC IMAGING (X-RAY / CT / MRI)
Two of the chief areas these "low value" imaging services are found are in the arena of headache and low back pain treatment. Let me give you a simple example of why these tests are considered low value. I see lots and lots of people for CHRONIC HEADACHES (including various sorts of MIGRAINES). The government says that headaches are one of the most common reasons for doctor visits. So, by the time I see them, most of this group has not only been to their doctor, they've frequently been run through all sorts of imaging; usually to rule out brain tumors. How common are brain tumors in the American population? According to the American Brain Tumor Association, "nearly 25,000 primary malignant" tumors are diagnosed each year. The word "primary" means that the tumor started in the brain (as opposed to secondary or 'metastatic' meaning it started somewhere else and then spread to the brain). This means that statistically, one in 12,800 Americans is going to have a primary brain tumor.
The other area that this letter specifically addressed was LOW BACK PAIN, which also has a significant portion of its imaging considered both unnecessary and low value. I'll let you in on a dirty little secret as to why this is true for both backs, necks, and heads (not to mention other areas of the body). There is little correlation --- many would argue no correlation --- between X-ray or MRI findings and a person's pain. This phenomenon is not uncommon elsewhere in the practice of medicine.
For instance, there is absolutely no relationship between heel pain (PLANTAR FASCIITIS) and the presence / absence of a heel spur. You are just as likely to see patients with no pain that have huge heel spurs, as you are to see patients with crippling pain and no heel spur. Likewise, study after study shows that when it comes to WHIPLASH and other injuries sustained in MVA's, there is no relationship between the damage to the vehicle and the amount of injury sustained by occupants. The number one sports surgeon in America, Dr. James Andrews, said the same thing about shoulder problems (HERE). Not surprisingly, we see an almost identical scenario with both back and neck pain.
Follow along as I present you with some 'cherry-picked' tidbits, and you'll see why my brother, an ER physician with many many years of experience (his wife is also an ER doc), says that doing an MRI of your spine or skeleton is a waste of time until you are actually to the point of being ready and willing to have surgery. Why? Because, he says, doctors can always find something that looks bad enough to do surgery on. Here's why this approach has left so many POST-SURGICAL PATIENTS no better, or even worse, than before the operation. Which becomes that much more interesting in light of the post I did on ASYMPTOMATIC DISC HERNIATIONS a few years ago.
- Almost two decades ago, the European Spine Journal published a study called The Relationship Between the Magnetic Resonance Imaging Appearance of the Lumbar Spine and Low Back Pain, Age and Occupation in Males. After looking at men of all ages of five different occupations, both blue collar and white collar, they determined that while the older men had more degeneration in their spines, "There was no relationship between low back pain and disc degeneration. Overall, 45% had 'abnormal' lumbar spines (evidence of disc degeneration, disc bulging or protrusion, facet hypertrophy, or nerve root compression). There was not a clear relationship between the MRI appearance of the lumbar spine and low back pain. Thirty-two percent of asymptomatic subjects had 'abnormal' lumbar spines and 47% of all the subjects who had experienced low back pain had 'normal' lumbar spines. During the 12-month follow-up period, 13 subjects experienced low back pain for the first time. However, there was no change in the MRI appearances of their lumbar spines that could account for the onset."
- In 2006, Nature Clinical Practice Rheumatology (Technology Insight: Imaging Of Low Back Pain) concluded that it all comes down to a coin toss. "Currently available imaging techniques have diagnostic limitations. The literature suggests that 85% of chronic low back pain cannot be diagnosed accurately." However, the author of this particular paper believes that if done properly, "The anatomic diagnosis of low back pain is possible in approximately half of the patients with chronic low back pain." He goes on to reveal why 50% accuracy is as good as it gets. "Compression of adjacent neural structures by protruding material might not be the primary cause of back pain. Structural changes in the discs themselves could be the source of a significant proportion of chronic low back pain." So; what is the mechanism if it's not physical compression? Not surprisingly, it's our dear old friend INFLAMMATION. "Biochemical changes accompany alterations in disc architecture. Inflammatory cytokines, on reaching the more peripheral parts of the disc, can irritate nociceptors [pain receptors] and thus cause low back pain." Even though doctors are prescribing ANTI-INFLAMMATION DRUGS like crazy for these problems, this is like trying to mop / dry your floor with the faucet continually running and the sink continually overflowing. The only way you'll ever get the floor dry is to stop the water at its source.
- A study published in a 2010 issue of the Annals of Rheumatic Diseases (Magnetic Resonance Imaging for Low Back Pain: Indications and Limitations) came to similar conclusions. "Magnetic resonance imaging (MRI) is the preferred investigation for most spinal diseases and is increasingly requested for people with low back pain. However, determining the cause of back pain is complicated as it is often multifactorial, and anatomical abnormalities are common in the spine and may not necessarily translate into clinical symptoms." Because they are such low hanging fruit, doctors love to point out anomalies to patients as the cause of their pain. This is almost never the case.
- Another 2010 offering, this one from the journal Physical Medicine Rehabilitative Clinics of North America (Imaging the Back Pain Patient) revealed that, "The primary role of imaging is the identification of systemic disease as a cause of the back or limb pain." Talking out of the other side of their mouth, the authors turned around and in the very next sentence said that, "Systemic disease as a cause of back or limb pain is, however, rare." The authors did, though, go on to let readers know what does cause back pain. "Most back and radiating limb pain is of benign nature, owing to degenerative phenomena." The problem is, I've already shown you that there is almost no relationship between degeneration as seen on MRI, CT, or plain film X-ray, and pain. Which is why we are finally told that, "There is no role for imaging in the initial evaluation of the patient with back pain in the absence of signs or symptoms of systemic disease." Pay close attention to what the authors say next. "Imaging can well depict disc degeneration and disc herniation. Imaging can suggest the presence of discogenic pain, but the lack of a gold standard obviates [eliminates] any definitive conclusions. There is very poor correlation between imaging findings of disc herniation and the clinical presentation or course." I showed you this earlier in the link I provided on Asymptomatic Disc Herniations.
- A year later, a large group of renowned doctors and researchers got together and created 'Standards of Care' for imaging the low back, which were published in the Annals of Internal Medicine. They pretty much spelled it out when they stated that, "Low back pain is very common, and many patients with low back pain receive routine spinal imaging, despite evidence-based recommendations [against this practice]. Diagnostic imaging is indicated for patients with low back pain only if they have severe progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition. Evidence indicates that routine imaging is not associated with clinically meaningful benefits but can lead to harms. More testing does not equate to better care." This phenomenon of ignoring the "evidence" and doing whatever the heck they want, is a common theme in the practice of medicine (HERE), which is easily seen in any number of areas of practice, including prescription habits for DIABETES MEDS, STATINS, ANTIDEPRESSANTS, ANTIBIOTICS, PPI's, certain popular VACCINES, and even "safe" OTC drugs such as ACETAMINOPHEN.
- The American Association of Family Physicians (AAFP) published their current guidelines for imaging (Imaging For Low Back Pain: Recommendation) in accordance with research done by the COCHRANE REVIEW. "Don't do imaging for low back pain within the first six weeks, unless red flags, which include, but are not limited to: severe or progressive neurologic deficits (e.g., bowel or bladder function), fever, sudden back pain with spinal tenderness, trauma, and indications of a serious underlying condition (e.g., osteomyelitis, malignancy), are present. Most patients with radicular symptoms will recover within several weeks of onset. The imaging of the lumbar spine before 6 weeks does not improve outcomes, but it does increase costs" By the way, "radicular symptoms" in this context refers to SCIATICA. Most of the time, 'red flags' are fairly easy to spot (HERE is an example).
All of this is why, about three years ago, I stopped taking X-rays in my clinic after over two decades of doing so. It was all but totally impossible to correlate patient complaints to what I saw on their films. It was very easy for me to say, "There's your problem Mrs. Jones. It's those nasty bone spurs, calcium build up, and thin discs. Your problem is that your spine is simply wearing out." But the next person that came in might have even worse degeneration --- sometimes so severe you wondered how they were ambulatory --- but never really had pain until recently. Or they may have had severe pain with a "normal" looking x-ray. There was no rhyme nor reason. I just found a viable explanation for this phenomenon.
DEGENERATIVE ARTHRITIS (OSTEOARTHRITIS)
HAS COMPONENTS OF CENTRAL SENSITIZATION
It just so happens that the current issue of Practical Pain Management arrived on my desk yesterday, and is titled Osteoarthritis: Beyond the Joint Neurobiology and Pain. An article by Dr. Anne Marie Malfait (Uncovering the Sources of Osteoarthritis Pain) began by saying, "Pain is the hallmark symptom of osteoarthritis (OA) and the most common reason why people with arthritis seek medical care. Osteoarthritis pain is associated with functional impairment, reduced quality of life, and a host of psychological comorbidities, including depression, anxiety, pain catastrophizing, and sleep disorders. Studies indicate that joint damage is not the only factor correlated with OA pain, leading investigators to search for other mediating factors."
In relationship to what we've already learned about medical imaging as it pertains to pain, we shouldn't wonder that Malfait speaks of mediating factors beyond simple joint damage. Dr. Don Goldenberg, a Rheumatologist with three decades of experience, then stepped up to the plate and knocked it out of the park with his explanation in an article titled Osteoarthritis and Central Pain. In it he revealed that.....
"Studies now confirm that osteoarthritis pain is affected not just by structural and inflammatory joint changes but also by central pain sensitization. Traditionally, osteoarthritis (OA) has been considered to be a peripheral pain disorder, related to progressive cartilage and bone damage, with little evidence for tissue inflammation. During the last decade, however, there has been greater appreciation of the inflammatory aspects of OA. Pain sensitivity and intensity are magnified in OA. In fact, patients with OA, compared with normal controls, report increased pain intensity in widespread areas, including referred and radiating pain."
To understand what Goldburg is saying here, we need to understand just a bit about Central Sensitization. Fortunately for you, I have two posts on the subject (HERE and HERE). In an over-simplified nutshell, these are people who have "learned" chronic pain. Allow me to explain. The more you do something, whatever it is, the better you get at it. This is because practice allows you develop the neural pathways that can make something as complex as SHOOTING FREE THROWS, routine and automatic.
Unfortunately, your brain has the potential to learn pain as well. Thus, things that should not cause pain can cause pain (allodynia) and things that should cause a small amount of pain can cause huge amounts of pain (hyperalgia). The same phenomenon can happen in the peripheral nerve system and as you might imagine, is called Peripheral Sensitization and also leads to hypersensitivity to pain. Dr. Goldberg concludes his paper by saying, "There is strong evidence that osteoarthritis has components of both peripheral and central sensitization."
He actually wrote what I was thinking as I began reading his paper --- that this is an excellent explanation for what the title of my post is about; the fact that it is virtually impossible to correlate the results of diagnostic imaging with a person's pain. In the section of his paper filed under the header Why Joint Images Don’t Always Match OA Pain. Dr. G writes......
"In OA, the pain intensity often correlates poorly with the severity of peripheral joint damage. For example, 30% to 50% of individuals with moderate-to-severe radiographic changes of OA are asymptomatic, and 10% to 20% of individuals with moderate-to-severe knee pain have normal findings on radiography. In one study that examined this paradox, the investigators found significantly heightened pain sensitivity in high pain / low knee OA subjects, while the low pain / high knee OA group were less pain-sensitive. The results suggest that central sensitization in knee OA is especially apparent among patients who report high levels of clinical pain in the absence of moderate-to-severe radiographic evidence of pathologic changes of knee osteoarthritis."
I believe that if you swapped anatomical parts (traded knees for hips, backs, necks, wrists, thumbs, etc), this information is, for the most part, still true and applicable. In other words, what's true of your hips, is probably true of your knees, ankles, wrists, and back as well. All of which is great information to know as far as PREVENTION of these sorts of problems is concerned, but seems rather incomplete. It begs the real question for those of you already suffering with debilitating pain caused by Osteoarthritis. How do you fix it --- or at least address it?
Doctors talk about what they know. And unfortunately, the only thing that Goldberg spent significant time on was joint replacement (he did briefly mention the drug Duloxetine aka CYMBALTA). Let me first say, that I am not an anti-joint replacement person. I have seen plenty of people try to soldier through years of worn out hips or knees, only to say after finally having the surgery that they wish they would have done it 10 years earlier. I've also seen a fair number of people permanently messed up by joint replacement gone awry. One other thing Dr. G mentioned is that people with FIBROMYALGIA (another issue associated with both Central Senstitization and Neuropathy --- HERE) tend to have, "poorer long-term pain relief after total knee and hip replacements..... higher fibromyalgia survey scores were independently predictive of less improvement in pain."
What would I recommend you try first? Glad you asked. There are any number of modalities / therapies that are helpful ---- ACUPUNCTURE, CHIROPRACTIC, REMODELING SCAR TISSUE, LOW LEVEL LASER THERAPY, WHOLE BODY VIBRATION, as well as ANY NUMBER OF OTHERS. If you truly have CS -- a malfunctioning of your Central Nervous System --- you may even consider seeing a FUNCTIONAL NEUROLOGIST. The bottom line is that whatever you do, if you want to help yourself, you are going to have to cut INFLAMMATION (probably without drugs); sometimes in ways that might seem downright radical --- even crazy.
Rather than me delve into these in this post, I'll give you the two posts that I already created for you on this very topic; the first being The Top Ten Ways to Lick Chronic Back Pain (HERE), and the second, Solutions for Chronic Pain and Chronic Illness: Fortunately they're the Same (HERE). Don't ever forget that ADHESED FASCIA is a common explanation for arthritic pain as well --- and much easier to deal with than Central Sensitization. As always, blessings on your journey. I wish you well my friend.