MRIS AND PAIN
There has been a great deal of research looking into the relationship between MRI’s and pain. Most of the studies have shown that no matter where you image you can find something wrong. These problems can be found regardless of pain. Below are a few studies for each major body region so you can better understand the relationship between MRI’s and pain.
Backs
In one very well known study, MRIs were performed on volunteers without any present pain. 52% of the volunteers had at least one disc bulge or other spinal “abnormality”. Surgery is often recommended for disc bulges and the other “abnormalities” found. Based on the data collected the authors concluded:
“the discovery of MRI of bulges or protrusions in people with low back pain may frequently be coincidental”
In another popular study, MRI’s were again taken of people who had NEVER had an episode of low back pain. The MRI’s revealed 1 out of every three had “substantial” spinal abnormalities. It was also found that 20% of those under the age of 60 had disc herniation’s.
Hips
A study was performed taking MRI’s of pain free hockey players. It was found that 70% of the players had some sort of abnormal pelvis or hip. Also 54% of the players had labral tears of the hip.
of pain free hockey players, seventy percent were found to Based on the data the authors stated:
“this study shows the limitations of depending too heavily on an MRI. A surgeon may see something in the image, but it isn’t causing a problem.”
Knees
A study took 44 volunteers from 20-68 who had no history of knee pain. The MRI’s showed that 60% had abnormalities in at least three of the four knee regions. Based on their findings the authors concluded:
“meniscal degeneration or tears…are highly prevalent in asymptomatic individuals.”
Shoulders
It was found in this study that 23% of those who had an MRI presented with rotator cuff tears despite having no pain. The suthors felt that 23% is “astonishingly high”. They also concluded:
“rotator cuff tears must to a certain extent be regarded as “normal” degenerative attrition, not necessarily causing pain and functional impairment.”
Overhead athletes are notorious for having problematic shoulder. In this study they took MRI’s of the shoulders of overhead athletes who reported having no pain. It was found that 40% of dominant shoulders showed partial or full thickness tears of the rotator cuff. In contrast 0% of non-dominant shoulders showed any signs of rotator cuff tear. Another key piece of data from this research is that for 5 years following the study the volunteers reported no shoulder pain.
MRIS CAN BE MISLEADING
I hope that it is clear from the few studies quoted above that MRI’s don’t tell the whole story. Another big misconception is that physicians and surgeons are aware of this. In the cases of MRI’s too much information may hurt more than help. That being said there are obvious situations where MRI’s are indicated.
With the amount of surgeries that are taking place in the U.S. it is clear that Physicians are placing too much emphasis on imaging. Abnormal findings in imaging aren’t as abnormal as we thought.
A great article from the New York Times describes the over emphasis of MRI’s:
. . . patients who are in pain often demand scans hoping to find out what is wrong, doctors are tempted to offer scans to those patients, and then, once a scan is done, it is common for doctors and patients to assume that any abnormalities found are the reason for the pain. . . . “A patient comes in because he’s in pain,” said Dr. Nelda Wray, a senior research scientist at the Methodist Institute for Technology in Houston. “We see something in a scan, and we assume causation. But we have no idea of the prevalence of the abnormality in routine populations.” . . . “Every time we get a new technology that provides insights into structures we didn’t encounter before, we end up saying, ‘Oh, my God, look at all those abnormalities.’ They might be dangerous,” said Dr. David Felson, a professor of medicine and epidemiology at Boston University Medical School. “Some are, some aren’t, but it ends up leading to a lot of care that’s unnecessary.”
In a different New York Times article they discuss how some physicians are standing up to the overuse of MRI’s. One of these physicians is well known sports medicine Dr. James Andrews. Dr. Andrews has done research of his own on imaging and pain. He scanned the shoulders of 31 pain free professional baseball pitchers. It was found that 90% had abnormal cartilage and 87% had abnormal rotator cuff tendons. In his research Dr. Andrews concluded:
“If you want an excuse to operate on a pitcher’s throwing shoulder, just get an M.R.I.”
Getting an MRI soon after experiencing back pain may actually make outcomes worse. This study found that MRI’s are actually associated with increased likelihood of disability.
It isn’t exactly understood why this happens. One possible reason is that MRI’s can be misinterpreted leading to unnecessary surgery. Another possibility is that can create more fear increasing pain and disability. This phenomenon is referred to as nocebo, the opposite of placebo.
NOCEBOS
Pain is an opinion of the brain that it uses when threat levels reach certain levels. The body, specifically the brain uses pain to encourage change and decrease threat. The brain has to consider insane amounts of information when making a decision. Your brain is constantly identifying potential danger and threat so it can protect you. When creating a pain experience your brain uses sensory information, past memories, emotions, social and medical support, and future demands. Your brain may judge situations differently such as when a stranger in a white coat tells you you have a bulged disc and how “abnormal”. This is likely to increase the threat you brain is perceiving.
Pain scientist Lorimer Moseley shares some great advice in his TED Talk Why Things Hurt. He explains why he hates when helathcare professionals display plastic spine models that show a bulging red disc:
Any piece of credible evidence that they are in danger should change their pain … And they are all walking into a hospital department with models like this on the desk: … it messes with your brain. It cannot not mess with your brain.
The big problem happens when healthcare providers try and “find out what is going on in the tissues”. This can really scare people making their pain and disability worse. I have worked with people who have been told they are “bone on bone”, have a bulging disc, or the (body part) of a 90 year old. None of these saying have any real meaning. By saying the above statements a strong impression can become a permanent part of someones self image. It can create a lifelong nocebo!
CONCLUSION
Please do not misunderstand MRIs are obviously useful and sometimes completely necessary. MRI is a tool that can be used to do a lot of good things. Just like any tool, MRI’s can be abused, and based on my experience it seems that there is an epidemic of MRI abuse.
Ben Toolson Physical Therapy 