DEGENERATIVE OSTEOARTHRITIS AND THE RELATIONSHIP BETWEEN WHAT YOU SEE (OR DON'T SEE) ON X-RAYS OR MRI, TO PAINRead Now
DEGENERATION, PAIN, AND THE RELATIONSHIP BETWEEN WHAT SHOWS UP ON DIAGNOSTIC IMAGING (X-RAY / CT / MRI)
A few days ago, JAMA Internal Medicine (one of the many journals put out by the American Medical Association) published an article titled Low-Value Health Care Services in a Commercially Insured Population. It was filed under under the header, "Less is More". The letter began with the words, "More than $750 billion of US health care spending annually represents waste, including approximately $200 billion in overtreatment." Fortunately for you, if you've spent any time at all on my site, you already know about OVERDIAGNOSIS & OVERTREATMENT, particularly as it relates to things like ANNUAL PHYSICAL EXAMINATIONS or Advanced Imaging (MRI and CAT SCANS).
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.
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)
Overdiagnosis is an expected part of any screening program..... Part of a recent statement by the American College of Radiology (ACR)
Numerous diagnostic tests, particularly those involving ADVANCED DIAGNOSTIC IMAGING, produce false positive results. This is one reason that the old "ANNUAL PHYSICAL" has gone the way of the typewriter and the dodo bird -- way too many false positives ("False Positives" are tests that show you have something wrong with you, when, in fact, you do not). The latest of these studies involves CANCER ---- most particularity Lung Cancer.
A recent study at Duke University Medical Center showed that nearly 1 in 5 cases of Lung Cancer, the CT Scan picked up slow-growing tumors that would not have affected the patient in their lifetime. When questioned about this rate of what is known is the business as "OVERDIAGNOSIS & OVERTREATMENT", the spokespersons for various physicians groups said that these rates were about what they would expect. In other words, this is a common problem.
The Duke Study, published in the most recent issue of JAMA Internal Medicine concluded that, "These overdiagnosis cases represent an important potential harm of screening because they incur additional cost, anxiety, and morbidity associated with cancer treatment". Good idea to be aware of this information if you are ever diagnosed with cancer or are a smoker. By the way, smokers in the "High Risk" category are being advised to have an annual CT.
HUGE NUMBERS OF LUMBAR MRI'S NOT APPROPRIATE
Why does mainstream medicine seem to saying we need to order fewer MRI's for low back pain, even though statistically they are ordering more of them than ever? It is a great question that deserves a truthful answer. There are studies that say much of this is about money. When physicians have a financial interest in the facility where the MRI's are taken, the numbers of MRI's taken seems to explode. But truthfully, most doctors do not have financial interest in the facilities they refer to for imaging (for one thing, it's now illegal in most places). I believe that much of this over-ordering of MRI's has to do with the fact that most doctors ---- particularly "family physicians" as stated above ---- have little understanding of what causes low back pain and how to effectively deal with patients struggling with low back pain.
Case in point is a study on this very subject by a medical doctor ---- Kevin B. Friedman. In the October 1998 issue of the prestigious Journal of Bone and Joint Surgery, Dr. Friedman, a Princeton graduate who happens to be considered one of Philadelphia's top Orthopedic Surgeons / Sports Doctors (knees and shoulders), published a study called "The Adequacy of Medical School Education in Musculoskeletal Medicine". Dr. Friedman created a basic (competency) test of musculoskeletal knowledge. He then contacted the chairs of the Orthopedic Department of 157 different American medical schools and had them rate his questions and tell him what they thought a passing score should be. The test was then administered to Orthopedic Residents. The results were frankly shocking.
82% of the medical residents (M.D.'s who had graduated from medical school and were now in their residency) failed the exam. When the test was re-administered four years later, the number had improved by a whopping 4%. When Chiropractic Students (not yet graduated from school) were given the very same test in their final quarter of school, the pass rate was 70%. I find this telling. You should too --- particularly if you are dealing with low back pain or for that matter; any of THESE OTHER PROBLEMS.
On top of the issue of competency, we have to talk for a moment about ASYMPTOMATIC DISC HERNIATIONS. Another of the dirty little secrets of the medical profession are the huge numbers of DISC BULGES in the general population. According to the link at the top of the paragraph, about half of the adult population is walking around with disc bulges that they are completely unaware of because they have no pain. Do you think that this could cause confusion in the medical community --- particularly if they are searching for the cause of your low back pain? Absolutely! This is why a recent study said that 85% of the people with low back pain cannot be definitively diagnosed as to what tissue their pain is originating from (HERE).
And what about PIRIFORMIS SYNDROME? Even though studies have shown it to be the number one reason for Sciatica (leg pain), it is still all but totally ignored by the medical community. Throw all these ingredients together, stir them up, and you have a recipe for lots of unnecessary MRI's ---- the very thing we currently have in our healthcare system.
NAH, SURELY NOT?
- NUMBER ONE: Numerous conditions that cause pain are "Functional" and not pathological. Fail to understand the difference at your own peril.
- NUMBER TWO: You need to be aware that in the absence of positive MRI findings (particularly when it comes to your spine) DJD will get undue amounts of credit for your pain.
FUNCTIONAL PROBLEMS -vs- PATHOLOGY
Let's start by talking about the various potential results we can get on an MRI. The first thing we might find out from an MRI is that you are not textbook-normal on the inside. There are an almost endless number of variations of normal anatomy. These are called "anomalies", and are unbelievably common. These can in no ways be confused with pathology. Next we have pathology. Pathology is finding something like a tumor, aneurysm, or ruptured disc. The problem, however, with ruptured discs is that between 50 and 70% of the asymptomatic adult population of America has these, yet does not realize it because they have no pain (YESTERDAY'S BLOG). Thus, it is difficult to truly characterize these as "pathology". It is the fact that the predominance of people's pain is being caused by "Functional Problems" that seems to frequently trip up the medical community.
Functional Problems are just what they sound like ---- problems with function. A perfect example of this are the people found in our PATIENT TESTIMONIAL VIDEOS. Many of these people went through numerous tests, including MRI's ---- some more than once. Doctors look at their scans and tell many of this group of patients that they cannot find anything wrong with them (hey, they have no pathology present). Standard medical fare involves prescribing pain relievers, muscle relaxers, and anti-inflammatory medications. Not only does this not work, it does not sit very will with people who are actually interested in addressing their problem as opposed to simply addressing their pain ---- and yes, there is a huge difference between the two. When joints (whether in the spine, shoulder, wrist, knee, etc,) do not work properly, people will end up with pain. This is the whole point of websites like DESTROY CHRONIC PAIN, DESTROY TENDINOSIS, DESTROY PIRIFORMIS SYNDROME, and SPINAL DECOMPRESSION MISSOURI.
You need to be aware that in the absence of pathology, it is highly likely that you will be told that your problem is due to DJD.
NEGATIVE MRI FINDINGS & DJD
DJD stands for Degenerative Joint Disease, and is the ultra-convenient scapegoat that doctors head for when scans show no pathology in the presence of pain. This is because degenerative findings stick out like a sore thumb. It is too easy to show people things like thin discs, loss of joint space, or bone spurs (all are extremely common); grab the patient's hand, and say something like, "Mrs Jones ----- you're just not as young as you used to be".
I work with degenerative spines all day long. I can tell you with authority that degenerative changes in and of themselves are not usually the cause of pain. I have lots and lots of patients that have very degenerative spines, but for the most part do not have inordinate amounts of pain. On the other hand, I have patients that have seemingly little degenerative changes in their spines, yet have incredible amounts of pain. What gives?
Much of this can be understood in a Review of the Scientific Literature on the subject that was published in JMPT (Journal of Manipulation and Physiological Theraputics) in the summer of 1997. After extensive review of numerous studies on the subject, the authors concluded that, "there is no correlation between pain levels and the extent of degeneration detected by radiographic or physical examination." Believe it or not, this is still the consensus in medicine today, with numerous studies telling us the same thing.
However, the medical community has pulled off a brilliant stroke of marketing (brainwashing might be a better term) by changing the name of these degenerative changes from "Degenerative Osteoarthritis" to "Degenerative Joint Disease" (DJD) ---- thus convincing millions of Americans that they have a "disease" in their spines. Let's take a look at the truth behind most cases of joint degeneration.
Interestingly enough, a know cause of degeneration in any joint, is loss of, or abnormal motion in that joint. This is true whether we are talking about knees, wrists, ankles, spines, etc. If a joint is not moving properly (for any reason), it is wearing; and if it is wearing, it is moving even worse. Repeat this cycle ad finitum, and joint deterioration becomes like a snowball rolling down a mountain. The faster it rolls, the bigger it gets, and the bigger it gets, the faster it rolls. Although doctors know this, they will rarely tell you about it. They will run test after test after test over a period of years, telling you that nothing is wrong with you ---- until one day, these degenerative changes finally show up on an MRI or CT. This is when you will be told you have a "disease".
What you need to understand is that DJD is not a disease in any real sense of the word. It is a mechanical problem that has fed itself to the point is wearing joints out. Bear in mind that most of the time, this is driven not simply by abnormal joint mechanics, but by poor diet, obesity, a sedentary lifestyle, and numerous sources of INFLAMMATION. If you will take the time to understand inflammation, and do the things it takes to control it, you can help your cause tremendously.
The beauty of the approach taken by Dr. Schierling at Schierling Chiropractic LLC, is that the approach is meant to attack joint degeneration on all of the fronts. We break the scar tissue that restricts joint motion, adjust the joints to fire off mechanorectptors to the brain (HERE), and then put people on strengthening, stretching, and rehab programs to restore joint function.
THE EVIDENCE SAYS "WAY TOO MANY"
(Especially if the Doctor owns the Imaging Facility!)
To begin to understand this whole phenomenon, let's look for a moment at what Neurologist, Dr. J Kassicieh said in a recent article he wrote concerning a study published in the prestigious New England Journal of Medicine ---- nearly 20 years ago:
For patients that do get MRI studies, it is not uncommon to find spine MRI abnormalities. The important fact is that these abnormal MRI findings do not necessarily explain the pain that that individual is experiencing. To account for an individual’s back pain or sciatica (leg pain), the MRI findings must correlate exactly with the patient’s symptoms and neurological exam to have clinical significance. MRI studies of normal individuals without back pain or sciatica have been done. The results have shown that approximately 55% had bulging discs at one or more levels, 28% had disc herniation on the MRI scans. More than 70% of the MRI scans showed abnormalities and yet the patients had no symptoms!
These MRI scans were done on patients who never had any back or leg pain – 70% of the MRIs were “abnormal.” The conclusion that just because the MRI scan shows “something”, does not mean that the findings are the cause of any given patient’s back or leg pain. (These are known as ASYMPTOMATIC DISC BULGES)
In other words, well over 50% of the adult American population is walking around with disc bulges in their spines ---- and they do not even have any idea, because they have no pain. This research has been verified in the peer-reviewed literature many times over.
In a paper that was E-published in the October 31, 2011 issue of Orthopedic Sports Physical Therapy, it was stated that, "It [MRI & CT] may not be able to pinpoint the specific source of your pain..... Increased use of unnecessary imaging may lead to less than favorable results." This begs the question of exactly what is meant by the term, "less than favorable results"? If you have a test done that tells you that you have a problem, but you really do not have the problem they say you have; this is called a false positive. False positives lead to dangerous treatments that are completely unneeded.
A perfect example of this phenomenon was dealt with in a recent editorial by renowned surgeon, Dr. Malcom Kell, in the British Medical Journal, concerning advanced diagnostic imaging for breast cancer. "Magnetic resonance imaging (MRI) scans of the breasts are so sensitive that they detect large numbers of non-cancerous tumors and lead to unnecessary breast removal surgeries". When you have a surgeon editorializing this problem in one of the most prestigious medical journals on the planet, you know that the problem is significant (current research says that greater than one in ten breast MRI's produce false positives).
Earlier this month, Johns Hopkins University Medical School jumped into the fray with a press release titled, Costly Diagnostic MRI Tests Unnecessary for Many Back Pain Patients. The most prestigious medical institution on the planet verified what I have been telling you ----- that routine MRI imaging does not improve treatment outcomes and does not play a role in a physician's decision to give epidural steroid injections, the most common procedure performed at pain clinics in the U.S. “Our results suggest that MRI is unlikely to avert a procedure, diminish complications or improve outcomes,” said study leader Steven P. Cohen, M.D., an associate professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine. But unfortunately, the problem is not confined to backs and BREASTS.
One of the world's most well known sports medicine orthopedic surgeons (Dr. James Andrews) wanted to test his suspicion that shoulder M.R.I.s might not be telling the whole story. He scanned the shoulders of 31 perfectly healthy professional baseball pitchers --- players with no pain and no throwing problems. What did he find? He found abnormal shoulder cartilage in 90 percent of these players and abnormal rotator cuff tendons in 87 percent of them. What was his conclusion? “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an M.R.I.” This is exactly what I have been telling people for well over a decade. Just go DESTROY CHRONIC PAIN, and look at our pages on SHOULDER TENDINOSIS, and ROTATOR CUFF PROBLEMS!
When I went to a recent seminar in Chicago put on by Dr. Jay Kennedy, he verified all of this using numerous scientific studies fro the past 15 or so years. The conclusion of the medical community is that MRI & CT do not do what the general public has been led to believe that they do! So, why does the charade continue. It has always been my opinion that it has to do with a five letter word that starts with "M" ---- MONEY. Biiiiiiiiig money!
These scans cost roughly $2,000 a pop and, at least in the case of CT scans (computerized tomography), can subject patients to serious levels of radiation (Google "CT RADIATION"). But they're giant moneymakers for hospitals and specialty clinics, which often heavily advertise the high-tech scanners in order to cultivate a "state-of-the-art" image among potential patients. Of course, the machines are also expensive, which creates incentives for doctors to use them as frequently as possible, and then stick insurers or the federal government with the bill.
Dr. Schierling completed four years of Kansas State University's five-year Nutrition / Exercise Physiology Program before deciding on a career in Chiropractic. He graduated from Logan Chiropractic College in 1991, and has run a busy clinic in Mountain View, Missouri ever since. He and his wife Amy have four children (three daughters and a son).
Brain Based Therapy
Can You Help
Cardio Or Strength
Cold Laser Therapy
Death By Medicine
Degenerative Joint Disease
D's Of Chronic Pain
Evidence Based Medicine
Gluten Cross Reactivity
Ice Or Heat
Jacks Fork River
Leaky Gut Syndrome
Number One Health Problem
Platelet Rich Therapy
Post Surgical Scarring
Re Invent Yourself
Rib And Chest Pain
Scar Tissue Removal
Sleeping Pills Kill
Stay Or Go
Stretching Post Treatment
Tensegrity And Fascia
The Big Four
Thoracic Outlet Syndrome
Whole Body Vibration