Are imaging studies helpful for those who live with chronic pain? The short answer is yes… and no. Imaging techniques such as X-rays and MRIs are helpful diagnostic tools for physicians when ruling in or out many conditions. Bone fractures, tumors, and internal bleeding are clear as day in imaging reports. But how do we begin to look for conditions that don’t have a clear physical signature? Many painfully chronic musculoskeletal and neurological conditions are not the result of structural changes in the body, but rather chemical and functional changes within our brain and the nerves that run within our body.
The use of imaging in many chronic pain conditions is not only unhelpful but can also be harmful. Have you ever received imaging for your chronic pain? Has a friend or family member recommended that you need an MRI to “see” what’s going on “in there?” Have you ever been tempted to use imaging to try and solve your pain? Before you answer, let’s take a look at the controversies surrounding imaging.
Expensive testing does not equal better care for those with #chronic #pain. Share on X
Pain is Invisible
The pain you feel is real. Living with persistent pain from an autoimmune disorder, old injury, or musculoskeletal condition is energy consuming and frustrating, especially when people don’t believe your pain is truly there. Pain is tricky because every person experiences it differently. We all feel pain in our own unique way. Our response to pain is the only proof of pain we can give someone else. We can’t see it with our bare eyes, and we can’t see it with our best technology either.
Let’s consider the process of diagnosing the source of chronic pain. You may assume that your pain is coming from damaged tissue. Paper cuts hurt, so do fractures. When you’re hurting, we begin to look for the proverbial paper cut. Imaging seems like a tempting solution for our problem. Find the damage; find the source of the pain, right? Wrong. Chronic pain isn’t coming from our body at all. This may seem counterintuitive. But we need to first understand the nature of pain and where it exists within us.
Your pain is all in your brain. This is not to say you have made it up. Pain is an emotional experience that lives within the mind. We have nociceptors in the body that sense a stimulus our brain then interprets as either painful or not. After a motor vehicle accident, there is real damage to our body that our brain is experiencing as acute pain. Our tissue tends to heal within three months [1]. If pain continues past this point, it is labeled as chronic. In chronic pain conditions, the brain has started to perceive non-harmful signals from the healed tissue as painful. This is a process called allodynia.
Allodynia is a sign of central sensitization. This process hypes up our central nervous system and makes us more susceptible to produce pain. Your body is like a racehorse in the starting gates, ready to respond to the slightest touch. Central sensitization is an inflammatory state that can be blamed for just about every chronic pain condition. These physiological changes can trick us into believing that our body is damaged and that movement will hurt us. Yet we can’t see inflammatory mediators in the imaging typically found in hospitals. An overactive nerve will look no different than normal on an MRI or CT scan, no matter how impressive the machine looks.
The Disc Myth
Chronic low back pain is a classic case of imaging over-use. Approximately 42% of people will receive some form of
imaging within one year of a low back pain diagnosis, amounting to over 3 million Americans every year [2]. Half of all patients with low back pain believe that getting imaging is necessary to manage their pain [3]. Are you one of them? Current guidelines from the American College of Physicians state that imaging should only be ordered if you are experiencing severe neurological changes or other clinical “red flags” [1]. A systematic review in 2012 went as far to say that imaging added no benefit or improvements in clinical outcomes [2].
Imaging will only allow us to see structural changes in the spine. You may be tempted to point to a bulging disc or a shrinking joint space and say, “Aha! There’s my pain!” But research consistently shows that imaging results and pain do not correlate. In fact, our bodies naturally degenerate with age. Studies have shown that a significant portion of the pain-free population will show similar changes on an MRI as a patient who complains of back pain [2]. One research group found that number to be as high as 76% of older adults [1]! Another study was not even able to predict which people with whiplash injuries would have the most pain based on radiographic findings [4].
Imaging abnormalities are common in everyone, even those without pain. Share on X
Central sensitization, as discussed before, can explain why people with similar degeneration can present with wildly different symptoms. They may have the same herniated disc sending the same signals to the brain, but one brain is primed to perceive pain while the other is not. Millions of middle-aged adults are walking, running, and working with bulging discs right now and no pain. As scary as structural changes may appear on imaging, they have no statistical relationship with pain! Chronic pain exists in the brain, not the body.
Imaging Inflates Healthcare Costs
We spend $2.8 trillion on healthcare costs every year in the United States [5]. This number rises year after year, as does the cost for treating chronic pain conditions. A portion of our increasing costs can be contributed to advancing medical technology. We have more diagnostic and treatment resources than ever before. Head to a hospital with pain and you may be run through the gamut with X-rays, MRIs, ultrasound, CT scans, DEXA scans, fluoroscopy, and many more! No doubt, this has both saved and prolonged countless lives. But these new technologies are not useful for every patient.
Managing low back pain now averages $2,580 per patient [5]. This is not surprising when we consider that just one MRI or CT scan can cost over $1200. Many insurance plans have large deductibles for imaging. You may find yourself paying $1000 for an MRI before you can stop to ask your doctor, “Is really necessary?” Don’t forget that we as patients are healthcare consumers. You wouldn’t buy a car without doing any research first. Likewise, you must be informed of your healthcare decisions.
Imaging Leads to Poorer Health
Imaging like CT and radiography exposes us to harmful radiation, although to varying degrees [6]. One CT scan provides the same amount of radiation exposure as one hundred radiographs [7]. Scientists estimate that there will be 1,200 additional cancer cases each year as a result of annual CT scans of the lumbar spine [8]. When surveyed, less than 10% of ER doctors believed that CT scans carried an increased risk of cancer [7]. Always discuss your imaging options with your doctor. Don’t forget that not receiving imaging is one of these options.
Imaging is also associated with poorer health outcomes [6]. The results of imaging can easily lead to misdiagnosis. You know now that imaging doesn’t correlate with symptoms. Chronic pain can’t be explained by an anatomic diagnosis. Diagnosing and treating as such will only cause more anxiety, discomfort, and healthcare spending for you. Those who receive routine lumbar spine MRIs face a higher incidence of spinal surgery with no clear benefit in patient outcomes [6].
While it may be tempting to try and use imaging to find a scapegoat for your pain, you won’t be seeing the whole picture. We can’t see chronic pain with imaging. Make informed healthcare decisions and take charge of your own health!
