Imaging vs Pain

Posture, imaging, mechanics and structures alone are insufficient to explain the phenomena of pain neuroscience. 

You are NOT your image.

Imaging, in modern science, has shown to be evidentially beneficial in varying conditions and diseases to evaluate pathology. Clinicians routinely order different types of imaging when evaluating acute pain, chronic pain, trauma or under the suspicion of pathology or infection. Through evolutionary advancements, we have been able to visualize internal structures via radiographs, ultrasounds, computed tomography (CT), nuclear medicine and magnetic resonance imaging (MRI), etc to make clinical diagnoses. However, this routine habit has significantly increased, even in the absence of serious pathology or clinical features suggestive of injury. This attraction has led to an ‘overuse’ in imaging, leading to unnecessary radiation, diagnoses and treatment. The reasons why this often occurs is due to its tempting nature to blame ‘objective’ abnormalities on imaging. The conflicting matter with this concept is that it is difficult to confidently say that those findings were always present or have recently occurred, let alone causing the symptoms. The American Academy of Family Physicians recommends withholding imaging within the first 6 weeks of symptoms if red flags are absent. (Rao, D et al 2018) (Tannor, AY 2017) (Lateef, H, & Patel, D 2009). However, some clinicians will use it for assessment purposes, assuming the image will establish a concrete reason of pain origin (Tannor AY 2017). Conversely, it is not that simple. With several research data revealing tissue/structural damage in regions of the body that are both symptomatic and asymptotic, it is unknown whether or not the damage was there before the injury, therefore, it cannot be conclusive to say there is a cause-and-effect phenomenon occurring. We easily tend to oversee this due to the brain’s natural inquisitiveness ability to find ‘closure’, and in this case, a supposed root cause. Focusing attention on this may perpetuate a narrative that not only removes one’s autonomy, but also exposes individuals to unnecessary radiation, as well as labeling a superfluous anatomical diagnosis. A diagnosis that may not be the actual cause of symptoms, and even elucidating incidental findings for probable causes. Image findings are highly contentious. If the obtained information through history, subjective and objective findings do not indicate red flags or serious suspicions of underlying pathology/infection, is it necessary to take images? Would it actually change the course of care? Especially one discovered as an ‘incidental finding’ where the patient is now being punished to learn that they have ‘degenerative disc disease’ or a ‘tear’, that was previously asymptomatic. This is enabling fear-mongering stigmatization associating pain to ‘damage’, or abnormal findings. To forefront, degenerative changes occur as a normal part of aging. As your hair grays with aging, discs degenerate. It is part of the aging process and degenerative changes do not indicate pain. Disc degeneration, facet arthropathy, and disc herniations have been attributed as common causes of back pain, however, these structural changes are present in a large percentage of asymptomatic individuals incidentally increasing with age. (Rao, D et al 2018) (Sasiadek MJ, Bladowska J 2012). This later discussed on the topic of degeneration.  Diagnostic testing lacks the accuracy to make clinical decisions for patient outcomes. There is strong evidence indicating little benefit from requesting radiographic films in individuals in the absence of red flags. (Tannor AY, 2017) In many studies, it has been proven that imaging with clinical care and clinical care without imaging did not differ in short-term or long-term quality of life, mental health or overall improvement since findings correlate poorly with symptoms. For the quality of life, results actually favor non-imaging therapeutics. (Chou, R et al 2009). (Lateef, H, & Patel, D 2009). In addition to this, literature findings concluded that diagnostic evaluation has been dependent on the clinician within their specialty, as opposed to the patient symptoms or findings. Many clinicians have been ordering image studies too soon for patients who do not possess the appropriate clinical implications indicative of such urgency. (Cherkin DC et al, 1994)

 

Here are some examples of the prevalence of symptomatic and asymptomatic individuals who received imaging:

• Systematic Review: 3,110 discogenic changes (degenerative, protruding/bulging disc, annular fissures) have presented in majority of patients, with and without symptoms. Disc degeneration alone presented in 37% of 20+ year olds, and up to 96% of 80+ year olds. Disc bulges and protrusions were found in a total of 59% of 20+ year old individuals and increasing to 84% of those above 80 years. This systematic study concluded that the increased prevalence in asymptomatic patients are likely part of the natural aging progression. (Brinjiki 2014).
• Systematic Review: this study imaged shoulders to evaluate the prevalence of rotator cuff abnormalities increases in age in asymptomatic individuals, general population, patients post shoulder dislocation and symptomatic individuals. This review revealed that rotator cuff pathologies had an increasing contingency to age. Patients 20 years and younger averaged to 9.7% of the population increasing to 62% in those above the age of 80 years. This study stated that the findings in asymptomatic individuals were high enough to state that degeneration of the rotator cuff may also be part of the aging process. (Teunis, T 2014)
• A Controlled Case Study on shoulder MRI abnormalities on asymptomatic little league baseball players was conducted to evaluate the prevalence of pathologies seen in young athletes. This study was done on 23 players, aged 10-12 years and performed a bilateral shoulder MRI. The findings were not surprising here either; the dominant arm was 8.5x more likely to have an abnormality on imaging compared to the non-dominant arm. In total, 52% (12 players) had 17 abnormal findings in their throwing shoulder, including edema, increased width of the proximal humeral physis, labral tears, partial rotator thickness tears, AC joint abnormalities, subacromial bursitis and cystic changes of the greater tuberosity. This further exemplifies that imaging abnormalities are likely to be present in the absence of symptoms. (Pennock, AT 2018)
• A Cohort study evaluated MRI of 40 (20 athletes) asymptomatic shoulders of overhead athletes and found a high incidence of partial-or full thickness rotator cuff abnormalities (40%) and Bennett’s lesion (25%) in dominant shoulders. Of the 40 shoulders, 36 (90%) of them had joint effusion, and 19 (47.5%) had sclerotic or cystic changes in the greater tuberosity, and 3 (7.5%) had findings consistent with partial tears of the anteroinferior or superior glenoid labrum. Additionally, images showed no significant differences between dominant and non-dominant shoulders regarding joint effusion, subacromial fluid, AC joint arthrosis and signal changes of the greater tuberosity. To further exemplify the point, researchers conducted a 5-year follow up and abnormalities remained asymptotic. (Connor, PM 2003)
• A Case Series study on collegiate basketball players after one season of playing was conducted to examine MRI findings on asymptomatic knees. This study evaluated 24 asymptomatic knees (12 male, 12 female) pre- and post- season. Each knee in this study had at least one structural imaging abnormality in both pre and post season. This included pre- and post- season fat pad edema (75% and then 81%), patellar tendinopathy (83% and then 90%), and quadriceps tendinopathy (75% and then 90%). Intrameniscal signal changes were observed in 50% of pre-season knees and 62% of post-season knees, bone marrow edema was seen in 75% pre- and 86% post season. Lastly, cartilage findings were seen in 71% pre- and 81% post season. The high prevalence in pathology in asymptomatic knees in young athletes suggest that structural changes does not have such an implication on symptoms as we once believed. (Pappas, GP 2016)
• Systematic review: this study was aimed to determine radiographic findings of femoroacetabular impingement (FAI) in asymptomatic individuals. A total of 2114 hips were imaged, in which findings revealed a CAM deformity in 37%, a Pincer deformity in 67%, and labral pathology in 68%. This further exemplifying the notion that structural morphology does not equate pain. (Frank JM, 2015)
• The variability in diagnostic errors is another gap in interpretation. In a study, one patient with low back pain scanned at 10 different MRI centers over the course of 3 weeks and imaging interpretations revealed a total of 49 reported findings. This study highlights the variability and high interpretive errors. With such a poor agreeance across radiologists, we can infer that there is a direct impact on diagnosis, subsequently altering choice of treatment and the clinical outcome recommendations. (Herzog, R 2017).

Since (non-specific) low back pain is the most common global complaint of individuals (84% of the population has admitted to experiencing low back pain) and diagnosis amongst all clinicians, I’ll give an evolutionary example of trends through institutionalized modern introductions to imaging.

In the development of imaging, radiographs were first introduced in 1895 (Howell, JD 2016). In observance, radiographic images have shown to reveal bony morphology diagnoses, regarding anatomic variations, fractures, arthritic, degenerative, metabolic, infections, tumor and cancer changes. Considering low back pain and the use of x-rays, facet degeneration and sacroiliac disease were all to blame in the early 1900s and were then followed by an increasing amount of sacroiliac fusions, facetectomies and lumbosacral fusions. (Allan DB, Waddel G 1989) (Adams, ZB 1910) (Danforth MS, Wilson, PD 1925). By the early-mid 1900s, the dynasty of discs evolved. At this time, visual screens of decreased disc height and neurological signs were sufficient for diagnosis. (Mixter WJ et al, 1949) (Barr, JS 1977( Camp, JD 1939) (Allan DB, Waddel G 1989). This been a convenient tool in medicine for reasons that it is readily available and low cost. (Lateef, H, & Patel, D 2009). Progressing through history, in the 1970-80’s era, CT scans followed by MRI’s became a diagnostic thriller. This later turned into an upsurge of soft-tissue (including discs, ligaments, tendons, spinal cord etc) diagnoses when MRI’s came out. MRI has been preferred over CT since it does not require radiation exposure and provides better visualization of soft tissue and spinal canal, however, a CT is of lower cost and more readily available. (Carey, TS 1996). CT’s and MRI’s are recommended in patients with severe or progressive neurological deficits, or with serious underlying pathologies such as infection, tumor or cancer. During this movement, clinically there was an increase in discogenic-related diagnoses in the cause of low back pain. (Lateef, H, & Patel, D 2009) (Carey, TS 1996). This dramatic increase in detection sensitivity allowed invaluable evidence to support disc herniations, bulges, protrusions, extrusions and sequestrations as a causative link to low back pain and lower extremity symptoms. (Beattie PF, Meyers SP 1998). The breakthrough in the 1990’s emerged when functional MRIs (fMRI) led to remarkable discoveries in biomedical research. fMRI’s illustrate temporal changes in brain activity to identify pain regions during examination by eliciting a painful stimulus (via movement), which was then used to substantiate grounds that pain is ‘in your head’, literally. (Apkarian AV et al 2001) (Ng SK, et al 2017)

 

 

What is seen on imaging may also represent normal adaptations to sport, work, life or common age-related incidental findings that are inappropriately being labeled as justification for symptoms. As imaging has evolved, we have presumed new waves of diagnoses best suitable for means of justification. Though, these extraordinary inventions have saved lives, allowed us to appropriately manage cases and provided us with noteworthy information, there is a time and place for each of them. Structural changes seen on imaging have a minimal correlation to symptoms, as we know images have shown pathological changes in asymptomatic individuals.

 

In the absence of progressive neurological deficits, red flags, or suspicion of underlying pathology such as infection, tumor or cancer, the use of imaging for pain is not necessitated as long as it does not considerably change management. Interpretation of images should be geared to be informative on findings, but reassuring and educational to change the patient’s perception. Proper communication and delivery of information is as important as a patient presenting symptoms. Upon interpretation, framing narratives can either perpetuate fear and hinder progress, or can be used to educate the patient about common findings and its true relevance to their symptoms. As opposed to telling a patient that they have X findings on their images, clinicians should take the initiative to reframe this conversation into an education platform. Reassuring them that their findings are likely seen in both asymptomatic and symptomatic patients, as well as providing them the appropriate information regarding their symptoms and the neuroscience of pain. As opposed to leaving a patient stranded after being delivered a jargon of medical terminology that comes off threatening, the goal is to gear the focus on minimizing symptoms and changing the perception of their experience. Having confidence in understanding the factors contributing to one’s experience may be the catalyst to effectively transition into self-efficacy. The goal is to appropriate practitioner behavior in an attempt to reduce unnecessary labeling of symptoms and reduce exposure, to better manage patients during their experience of pain.

  

 

 

 

 

Red flags in the setting of lower back pain is shown below: (Rao D, 2018)

 

 

 

 

 

 

 

 

 

 

 

REFERENCES

1. Herzog R, Elgort DR, Flanders AE, Moley PJ. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. Spine J. 2017;17(4):554–561. doi:10.1016/j.spinee.2016.11.009

2. Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Avins, A. L., James, K., Wald, J. T., Kallmes, D. F., & Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations.  American journal of neuroradiology, 36(4), 811–816. https://doi.org/10.3174/ajnr.A4173

3. Teunis T, Lubberts B, Reilly BT, Ring D. A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. J Shoulder Elbow Surg. 2014;23(12):1913–1921. doi:10.1016/j.jse.2014.08.001

4. Pennock, A. T., Dwek, J., Levy, E., Stearns, P., Manning, J., Dennis, M. M., Davis-Juarez, A., Bastrom, T., & Taylor, K. S. (2018). Shoulder MRI Abnormalities in Asymptomatic Little League Baseball Players. Orthopaedic journal of sports medicine, 6(2), 2325967118756825. https://doi.org/10.1177/2325967118756825

5. Pappas, G. P., Vogelsong, M. A., Staroswiecki, E., Gold, G. E., & Safran, M. R. (2016). Magnetic Resonance Imaging of Asymptomatic Knees in Collegiate Basketball Players: The Effect of One Season of Play. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine, 26(6), 483–489. https://doi.org/10.1097/JSM.0000000000000283

6. Tannor A. Y. (2017). Lumbar Spine X-Ray as a Standard Investigation for all Low back Pain in Ghana: Is It Evidence Based?.Ghana medical journal, 51(1), 24–29. doi:10.4314/gmj.v51i1.5

7. Lateef, H., & Patel, D. (2009). What is the role of imaging in acute low back pain?.Current reviews in musculoskeletal medicine, 2(2), 69–73. doi:10.1007/s12178-008-9037-0
8. Rao, D., Scuderi, G., Scuderi, C., Grewal, R., & Sandhu, S. J. (2018). The Use of Imaging in Management of Patients with Low Back Pain.Journal of clinical imaging science, 8, 30. doi:10.4103/jcis.JCIS_16_18
9. Sasiadek MJ, Bladowska J. Adv Clin Exp Med. 2012 Mar-Apr; 21(2):133-42.
10. Chou, R., Fu, R., Carrino, J. A., & Deyo, R. A. (2009).Imaging strategies for low-back pain: systematic review and meta-analysis. The Lancet, 373(9662), 463–472.doi:10.1016/s0140-6736(09)60172-0 
11. Cherkin, D. C., Deyo, R. A., Wheeler, K., & Ciol, M. A. (1994).Physician Variation in Diagnostic Testing for Low Back Pain. Who You See Is What You Get. Arthritis & Rheumatism, 37(1), 15–22.doi:10.1002/art.1780370104 
12. Howell J. D. (2016). EARLY CLINICAL USE OF THE X-RAY.Transactions of the American Clinical and Climatological Association, 127, 341–349.

13. Barr, JS. Lumbar disk in retrospect and prospect. Clin Orthop 1977;129:4-8.

14. Danforth MS, Wilson PD. Sacral region in relation to sciatic pain. J Bone Joint Surg 1925;7:109-160.

15. Adams ZB. A case of scoliosis relieved by operation on the transverse process of one of the vertebrae. Amer J Ortho Surg 1910;8:229-305.

16. Camp JD. The roentogenologic diagnosis of intraspinal pro- trusion of intervertebral disks by means of radiopaque oil. J h e r Med Assoc 1939;113:202&2029.

17. Mixter WJ. Rupture of the intervertebraldisk. A short histo- ry of its evolution as a syndrome of importance to the sur- geon. J Amer Med Assoc 1949;140:278-282. 

18. Beattie, P. F., & Meyers, S. P. (1998).Magnetic Resonance Imaging in Low Back Pain: General Principles and Clinical Issues. Physical Therapy, 78(7), 738–753.doi:10.1093/ptj/78.7.738  

19. Apkarian, A. V., Krauss, B. R., Fredrickson, B. E., & Szeverenyi, N. M. (2001).Imaging the pain of low back pain: functional magnetic resonance imaging in combination with monitoring subjective pain perception allows the study of clinical pain states. Neuroscience Letters, 299(1-2), 57–60.doi:10.1016/s0304-3940(01)01504-x  

20. Ng, S. K., Urquhart, D. M., Fitzgerald, P. B., Cicuttini, F. M., Hussain, S. M., & Fitzgibbon, B. M. (2017).The Relationship between Structural and Functional Brain Changes and Altered Emotion and Cognition in Chronic Low Back Pain. The Clinical Journal of Pain, 1.doi:10.1097/ajp.0000000000000534 

21. Connor, P. M., Banks, D. M., Tyson, A. B., Coumas, J. S., & D’Alessandro, D. F. (2003). Magnetic Resonance Imaging of the Asymptomatic Shoulder of Overhead Athletes: A 5-Year Follow-up Study. The American Journal of Sports Medicine, 31(5), 724–727.

22. Frank JM, Harris JD, Erickson BJ, et al. Prevalence of Femoroacetabular Impingement Imaging Findings in Asymptomatic Volunteers: A Systematic Review. Arthroscopy. 2015;31(6):1199-1204. doi:10.1016/j.arthro.2014.11.042

23. Carey, T. S. (1996). Patterns of Ordering Diagnostic Tests for Patients with Acute Low Back Pain. Annals of Internal Medicine, 125(10), 807. doi:10.7326/0003-4819-125-10-199611150-00004