You don’t need a scan. You need a plan.
Do you really need that X-ray or MRI? No.
At least, probably not. In fact, having an unneccessary scan could do your long-term recovery more harm than good, as we'll explain.
“Abnormalities” on scans are perfectly normal, even in pain free people.
We attach a lot of importance to imaging findings for bones and joints. But how useful are they?
Many imaging studies have been carried out on people who are not experiencing symptoms. The results may surprise you.
In the spine, scans showed that over 70% of people in their 20s had disc bulges in their neck. In the lower back, even without back pain, by the time you reach the 30-39 age bracket you’re more likely to have a disc bulge than not.
A shoulder study found 96% of subjects without symptoms showed “abnormalities” on ultrasound, while another saw that 25% of shoulders in collegiate and professional ice hockey players showed evidence of a labral tear.
Hip labral tears are also surprisingly common, found in up to 85% of individuals without symptoms. The broader term of “hip abnormalities” was found in 73% of asymptomatic patients and 95% of elite academy rugby players.
Knee abnormalities are, somehow, even more common. This study found “abnormalities” in 97% of MRIs of knees showing no symptoms, with meniscal tears and cartilage lesions the most common findings. Arthritis was noted with 43% of asymptomatic knees too.
These are all things that are often cited as the cause of pain. But these studies were done on people with no history of symptoms. Scans are very good at picking up abnormalities. It just turns out that the abnormalities are probably not causing our pain.
What are these things on my scan?
If they’re not dangerous, then what are they? From the spine study above:
Our study suggests that imaging findings of degenerative changes such as disk degeneration, disk signal loss, disk height loss, disk protrusion, and facet arthropathy are generally part of the normal aging process rather than pathologic processes requiring intervention
Translation: they are the visible but harmless effects of normal ageing.
Scans can be useful diagnostic tools, but poor communication can exaggerate normal changes.
These days, we often call them "wrinkles on the inside". Scans should be used judiciously by clinicians and more importantly, their findings should be interpreted and delivered with care. An abnormality may be present but it may not be the source of the problem – in fact the evidence says it’s probably not the source of the problem.
So what’s the harm in getting a scan?
The scans themselves pose very little threat to our health. It’s the explanation of them that can be a problem. In fact, those who have MRIs early on in care have been shown to have longer recovery times. Here's why.
If you’ve already had a scan
There’s a good chance you’ve been told that you have some “degeneration” of some sort. You may also have been told that is why your back/shoulder/knee/hip hurts.
First of all, we have a problem with the term ”degeneration”. It’s a term that, like “wear and tear”, should be retired from use. Arthritis is often described in this way. But we know from the comprehensive studies listed above, that it’s not degeneration, it’s normal. "Wear" yes, "tear"... no.
How we describe someone’s anatomy to them matters. Let’s take two patients with identical spinal X-rays who have back pain with no serious pathology.
We tell Patient 1: “There are signs of arthritis on your spine. This is entirely normal and nothing to worry about, a bit like having wrinkles. It’s likely nothing to do with your pain and it won’t affect your ability to exercise or do any of the things you love doing. In fact moving is the best thing for it.”
While we tell Patient 2: “There are signs of degeneration in your painful spine, like we normally see in old people. It’s progressive and it will never improve, it only can only get worse as you age.”
Remember, their X-rays are identical and crucially, we’ve told both patients the truth. How will each patient react to this? If you’ve had imaging done, how have you reacted in the past?
Different paths
Good communication in healthcare leads to better outcomes
In our experience, Patient 1 will generally take a positive approach to their recovery. Patient 2 leaves with the common belief that arthritis alone is causing their pain, and that their arthritis - and by extension their pain - will never get better. This is a terrifying prospect. Once people believe this it can be very hard to shake.
Believing their condition is hopeless and fragile can also lead to “fear avoidance” behaviour. This is where we avoid doing things (like exercise) that we believe might worsen the condition. People can end up in the vicious cycle of less exercise and less tolerance for exercise. This is doubly tragic when we know that exercise is the best treatment for aches and pains and can help to keep us young. These poor patients do the opposite of what’s needed and damage their long-term outcomes. All because of how they understood the results of a scan.
If you’ve not had a scan but think you need one
Patients frequently attend our clinic with problems, possibly longstanding, with a feeling that “something deeper is going on”. Some come to chiropractors because they know we can refer for a private X-ray or MRI. We refer quickly when necessary. Others come convinced that “really, I think I need surgery”. The nocebo effect tells us that if you really believe you need surgery, nothing short of that will do. The saddest part is, even then it might not be enough. The vast majority of problems don’t require scans or surgery.
We see many patients give up on their recovery just as they're making progress because they’re told that a scan has showed arthritis. Because they’ve had a report of findings like Patient 2 above. It’s robbed them of hope and stopped their recovery in its tracks.
If you’ve had a scan and the results worried you, perhaps get a second opinion. If you’ve not had a scan, make sure it’s clinically necessary and then make sure you ask the right questions when you get the results. We know from the evidence that those X-ray findings likely won't tell you anything useful about your pain.
You probably don’t need a scan – a clinician can tell you for sure. What you definitely do need is a plan.
What’s the plan?
Understand your pain, build your body up, and feel in control again.
First, it helps to have a grounding in what pain actually is. It might seem a ridiculous notion that you’ve lived in your body for all these years and not know what pain means, but spare five minutes and watch the video. You'll be glad you did.
Next, we need to find a way to build tolerance in your body again. Greg Lehman’s philosophy on rehab is beautiful in its simplicity. It has two principal steps:
Calm it down
Build it back up
This means calming the affected area down, allowing it to heal, and then slowly building it up with incrementing exercise so you are stronger than before and able to do more.
The right rehab programme for you will vary according to your individual needs, but bearing these two in mind will stand you in good stead. Having an appreciation of where you are now, where you want to be and a step-by-step plan of how you are going to get there is absolutely key. We know that feelings of control over our condition lead to positive results. This is where a healthcare professional and some objective, repeatable outcome measures can really set you on the right path – and away from the dreaded “fear avoidance”.
An active approach to recovery can put you on the right path
This may be hard to hear if you’ve previously had some pain attributed to one of the above. If it was a long time ago, it can be really hard to untangle chronic pain. But there is hope – and it starts by uncoupling our beliefs about pain from those about damage. Hurt does not equal harm.
We can help. It's what we do. Just book an appointment or drop us a message to find out more.