WHY DO SO MANY CHRONIC PAIN
PATIENTS HAVE "NORMAL" IMAGING?
When I was a student at Logan College of Chiropractic, I had an X-Ray Diagnosis class with Dr. Gary Guebert. --- a Chiropractic Radiologist of some renowned. Dr. Guebert presented a particular lesson in a way that is forever burned into my mind. He had put an x-ray up on the overhead projector (yes, it was the days before laptop computers) and then asked the class to tell him what was wrong with this person. The guesses began to flow like beer at a German Oktoberfest.
Someone would take a stab at this person's diagnosis, and Dr. G would just shake his head. As the minutes went by, the guesses became more bizarre. Before long people were guessing problems that were so rare as to be virtually non-existent. The answer was always, "no" with a request that the student explain how they were logically coming to that particular diagnosis. The class was completely stumped until Dr. Guebert revealed the person's condition.
He systematically went over the x-ray. He began by telling us that the bony alignment was good, and then went on to tell the class that the disc spaces were universally well preserved, there were no degenerative changes present, and no visible pathology. The truth is, he said the the x-ray was rather unremarkable as far as problems were concerned. In fact, he seemed to think that it was about as good a spine as he ever sees --- and he reads x-rays for a living! There was just one slight problem with the patient whose x-ray we were looking at. The person was was dead.
As part of an ongoing research project, Logan College took x-rays of all the cadavers that were brought to the Anatomy Lab. And although this individual had a beautiful spine on x-ray, the fact remained that they also had a severe and irreversible case of something that will affect all of us some day --- Rigor Mortis. Dr. Guebert's lesson in all of this was one that I will never forget; Do not ever rely on diagnostic imaging or tests at the expense of clinically examining and questioning your patient. Dr. Guebert said that while diagnostic imaging is a valuable tool, trying to rely too much on testing will frequently leave you with a misunderstanding of the big picture and what is really going on with the patient. As I have continued in practice, I realize more and more that this seemingly simple idea is true; and often left by the wayside. This is because far too many doctors fail to grasp the differences between......
Pathology as defined by Wikipedia is, "the precise study and diagnosis of disease". The word pathos means "feeling" or "suffering"; and the word logia means "the study of " . When doctors run into patients with Chronic Pain, they will often times (FAR TOO OFTEN) jump immediately to Advanced Diagnostic Imaging techniques such as MRI or CT Scans to try and determine its cause. As far too many of you Chronic Pain Patients understand, the value of these tests leaves a lot to be desired.
Suffering people think to themselves,"My pain is so bad that this problem will show up like a glowing red ball of fire on my MRI." Yet, nothing shows up. The radiology report is essentially unremarkable, and because of this, you are treated like a malingerer, hypochondriac, or drug seeker. Is this common? Not only is it common, but as all of you "Chronic Pain Patients" can attest to, it's Dog Common! I would love to tell you that this phenomenon is an aberration. A rarity. A mistake that let an unfortunate individual slip through the cracks. Unfortunately, far too many of you already realize that this is not the case. In fact, for millions of suffering Americans, it just might be closer to the norm.
After one of his several MRI's, it was suggested to one of my patients that SPINAL SURGERY was the solution to his problem. This is because his MRI Report said, "Mild posterolateral disc bulges at L4-L5 which contribute to mild bilateral foraminal narrowing; Small broad-based posterior central disc protrusion without evidence of central canal stenosis or compromise of the nerve roots." He was also told that surgery for this particular problem could quite possibly cure his pain. Thank God he was smarter than that, even though he was not up on the information in the next link.
Do not kid yourself. Doctors are more than cognizant of the fact that as much as 70% of the adult American population is walking around with the same thing (HERE) ----- and have absolutely no pain or symptoms whatsoever! Sure enough, doctors looked for pathology and they found pathology --- a minimally (and I do mean minimally) RUPTURED DISC. Like the great sports surgeon James Andrews said after noting 30 torn ROTATOR CUFFS on MRI, despite the fact that all 30 of the individuals he tested (professional baseball pitchers) had absolutely no symptoms: (paraphrased) "If you're looking for an excuse to perform a surgery, just do an MRI ".
When doctors find pathology, they tend to get excited. Oh, they're not so callous as to be excited about the fact that you are sick or in pain. They get excited about the fact that your problem has a visible / tangible quality to it. My brother is an ER doctor. He told me once that doctors would much rather deal with certain severe problems than others that maybe seemed less severe. The example he gave was of a compound fracture. A patient comes to him with a broken arm that has jagged edges sticking two inches out of the arm. There is blood everywhere and the kid is howling in pain. My brother said that this type of problem is a "Hero Maker" and is frequently easier to deal with than people who come in with HEADACHES or CHRONIC BACK or NECK PAIN. Sure, doctors can run tests and prescribe drugs ----- and then refer to "specialists" who do more of the same. But all too often, no one even bothers to try and understand why these people are having problems.
Like Arnold Schwarzenegger's line from the classic movie Predator, "It bleeds. We can kill it," doctors frequently take a similar attitude. When they find pathology, they often get all excited and point wildly to the viewbox or computer screen saying, "We found your problem. We can fix it". However, these same doctors are painfully aware that all too often, this is not the case. Unfortunately, DANGEROUS DRUGS, CORTICOSTEROID INJECTIONS, and SPINAL SURGERIES that are just as likely to leave one worse than better, tend to cover symptoms without as much as even making the attempt to figure out the underlying cause, or "Functional Deficit". These are the problems that are known in the medical field as Functio Laesa ---- aka Loss of Function --- the fifth feature of INFLAMMATION.
LOSS OF NORMAL FUNCTION -vs- GROSS PATHOLOGY
Your body is created and designed to function in a very specific manner, within very strict parameters. When it doesn't function within these parameters, bad things start to happen. The problem is, most of the time, these underlying problems are not Pathological, they are Functional. This means that according to the tests, all the parts are present and in a condition that seemingly should allow your body to work properly. There is no pathology present on the x-ray or MRI. Is this a common phenomenon? There is a strong probability that if you are reading this post, you realize that what I am saying is true. And sometimes, Functional Deficits can actually cause Pathology (HERE). The good thing is that restoring Function frequently rids the body of the associated Pathology.
But what about the sneaky ways that the Medical community has twisted problems that are largely Functional, and turned them into "Pathology"? For example, let's think about Degenerative Arthritis for a moment. The known cause of local (as opposed to systemic) degeneration, is abnormal joint function over time. Although there are several contributing factors, we know what causes joint deterioration. The longer a joint or Spinal Disc functions improperly, the more degeneration you will find in that joint. Abnormal joint motion is the known cause of degeneration, and degeneration causes abnormal joint motion. It's a wicked vicious cycle.
Although it's not the first time that the Medical Profession has CHANGED THE NAME of a health issue to fit their needs, this one was particularly sly. Over a decade ago, the medical profession realized that if they could slightly change the name of this problem, tack the work "Disease" onto the end, and then do everything humanly possible to scare the fire out of people; if they played their cards right, they could prescribe far more of the things I spoke of a few paragraphs ago. The quintessential example of this is DJD.
Instead of a DEGENERATIVE DISC being used as a diagnostic tool to show where abnormal joint motion is taking place, it has simply become a disease. What do I mean? Degenerative Discs or Degenerative Joints are no longer referred to as such. In a brilliant stroke of marketing that I can only assume is designed to lead people toward a lifetime of drugs and worthless surgeries, we now have DJD (Degenerative Joint --- "Disease") and DDD (Degenerative Disc --- "Disease"). Hey Doc, my M.D. told me I have a "disease" in my spine. Surgery anyone?
- IT'S NOT WHERE THE BIG MONEY LIES: Let's be honest with each other. There is big money in medicine. Very few doctors will treat or test patients in ways that insurances do not cover, or cover poorly ---- regardless of what might be in the patient's best interest. If you keep your ear to the ground, you realize pretty quickly that the most often-prescribed tests and procedures just happen to be the tests and procedures that insurances reimburse the best for. Although most would argue that the situation is the other way around, I have my doubts.
- IT IS DIFFICULT AND TIME CONSUMING: Ask yourself a question. Which is easier; sending your patient over to another building to let someone else run a boatload of diagnostic testing and Advanced Imaging for you, or doing an incredibly thorough Functional Neurological & Functional Orthopedic Exam? The later is both difficult and time consuming --- especially when compared to the bigger money makers such as Advanced Imaging (CT & MRI). It is far easier to test and prescribe than to learn how to evaluate Functional Deficits --- and then take the time to do it.
- I DO NOT KNOW WHAT I AM LOOKING FOR: I realize that this is stepping on some toes, but what's new? What if your doctor does not really understand things like GLUTEN SENSITIVITY & THE RELATIONSHIP TO AUTOIMMUNE DISEASES? What if they think it's impossible to have a Thyroid Dysfunction AS LONG AS YOUR THYROID TESTS "NORMAL"? What happens to their heart, liver, kidneys, and connective tissues, when the doctors continue prescribing dangerous anti-inflammatory drugs instead of teaching patients about INFLAMMATION and the various ways to deal with it naturally? What if they do not realize that ANTIBIOTICS DO NOTHING TO STRENGTHEN YOUR IMMUNE SYSTEM or that 80% OF YOUR ENTIRE IMMUNE SYSTEM IS FOUND IN THE GUT? And we all know that not one in a hundred doctors truly understands (or for that matter, cares to understand) FASCIAL ADHESIONS or TENDINOSIS.
The truth is, while most doctors are brilliant at diagnosing pathology, their methods of treatment for dealing with these same pathologies frequently leaves something to be desired. How is it that Americans use 2/3 of the world's drugs and spend more dollars on healthcare than any other nation, yet are so ridiculously and chronically sick? But I regress, we are talking here about Functional Deficits and not Pathology. Just understand that it is important to understand that "Functio Laesa" is an area of weakness for most doctors. Think I'm exaggerating? Continue on.
Thanks to Dr. Marks and Dr. Painter for compiling the following information:
A series of articles reporting on the lack of medical training in musculoskeletal disorders was published between 1998 and 2002 by orthopedic surgeon, Kevin B. Freedman MD. It seems that the department chairs of several hospital-based orthopedic residency programs designed a basic examination on musculoskeletal competency and gave it to their residents. A whopping 82% of medical school graduates failed the examination. Four years later the test was simplified and, once again, 78% of the examinees failed to demonstrate basic competency in musculoskeletal medicine. When this test was given to final quarter chiropractic students 70% of them passed the exact same exam!
The differences between these two student groups should be noted. The medical group had already graduated from medical school (as MDs) and had completed their rotations through various hospital departments. Not only this, but they had been accepted into an orthopedic residency program ---- the pinnacle of medical musculoskeletal specialists. The chiropractic students however were still just that ---- students. 80% medical failure versus 70% chiropractic success. Quite astonishing when you think about it!
And for those of you who still think that this whole Functional -vs- Pathology is a bunch of hooey, Duke University recently reported that in less than 15% of the people suffering with Chronic Low Back Pain, could the tissue of the origin of the pain ever be definitively identified. It's all a big guessing game if you have to rely on technology and advanced imaging techniques to figure this stuff out! And to top it all off, there are many experts that are saying that our medical reliance on technology is making our doctors poor diagnosticians. If the test says you're sick, you're sick; and if the test says you are not sick ---- well, you're fine. If you have experienced this, shout amen.
Determining Functional Deficit is not about who can use the greatest amount of technology. Nor is it about having the latest electronic gadget. While a certain amount of this "stuff" is nice (hey, I use some of it myself), it's all about using a detailed knowledge of the body's function to figure out people's problems! In my hands, a wrench is a piece of stainless steel that I can loosen or tighten a nut with. In the hands of my mechanic, it is a tool that he uses to fix my broken vehicle. In my hands, a paintbrush is something that I use to make my deck look nice. In the hands of Michelangelo, a paintbrush was something used to create masterpieces that have been admired for hundreds of years. It is not just about the technique, it is about the doctor who is practicing the technique!
Don't believe me? Why does my wife go the particular person that she does to have her hair done? She could go anywhere, but she goes to Angela. It's certainly not because Angela uses some sort of technologically advanced scissors, new-fangled shampoo, or space aged blow dryer. All hair dressers use essentially the same "stuff" don't they? Ahh, but it's not really about the stuff.
A recent patient with Pifriormis Syndrome came to me saying that his problem started after he pulled his groin. Most practitioners fail in their treatment not because of their tools or technology (or lack thereof), but because they cannot think logically or outside the box. No one looked at this person's groin even though he told them repeatedly that this was his "Ground Zero". I barely have the heart to tell him that it wouldn't have mattered whether they looked at it anyway. Unless you understand "Loss of Function" they wouldn't have "gotten" it. Gross pathology? No. Functional Deficits? Absolutely --- and severe! If I was not aware that in over 50% of the adult population, the long head of the biceps femoris attaches to itself to the Sacrotuberous Ligament --- or that this problem started with PULLED GROIN MUSCLE, we would have never gotten anywhere with this problem.
My advice to you is to firstly do what it takes to educate yourself. The only reason that people I treat are either completely better or on the road to recovery is that they spent significant time researching and learning about their particular problem. Several evenings of study, and you can know as much about your particular problem as most doctors do. Even after five years of hell, and being less than three weeks away from a scheduled Piriformis Release Surgery, he never stopped looking. I am telling all of you who suffer with Chronic Pain this ---- someone out there has the answer for you----but you cannot give up. Here are the very words of Jesus Christ from Matthew 7. "Ask and it will be given to you; seek and you will find; knock and the door will be opened to you." Unfortunately Jesus did not qualify this verse with the word, "immediately".
Secondly, you need to find a doctor that understands at least some of the concepts in this blog. Guess what? If you keep heading down the same path you are on, you will end up with the same predictable results ---- results you will not likely be happy with. If your doctor does not understand the difference between Functional Problems and Pathology, it might be time to find a new doctor.
Thirdly, talk to me. Send me an email with a history attached. If you want, we can take a few minutes and talk on the phone. If it looks like something that I can either help with or point you in the right direction, I will tell you. If it does not, I will save you the time and expense of a visit here or elsewhere. My reputation is on the line with each and every patient that I treat. I only accept patients that I believe in my heart I can help. If I think I might be able to help, but it is iffy, I will tell you that also.
Here is an email I got this morning from yet another person I recently saw with Piriformis Syndrome (yesterday). Thanks for the note Linda, and hang in there! I just had the best sleep I've had in a long time. My husband could tell because I wasn't shifting to relieve pain all night like usual. He was impressed the minute he arrived home from work yesterday to find me walking around so much easier! No cane! No limp! My three year-old granddaughter said, "Is your back all better, Nana?" when she saw me walking around without my cane. God Bless you Linda. Hang in there!
I had an old professor who liked to say that the only thing "cured" was ham. I will never guarantee you a cure. What I will guarantee you is that I will listen to you, think through your problem, and if I believe there is a good chance that it can be taken care of successfully, do everything I can possibly do to help you get your life back (HERE)! A huge focus of my practice is Fascia, which is arguably the single most pain-sensitive tissue in the body. Couple that with the fact that you cannot see it on MRI, and you can see where nightmares begin! Functional Deficit -vs- Pathology. It's time that you talked to someone who understands this concept.