Should you get an X-Ray or Image?

I was driving around town the other day, doing errands, when I saw a sign with a message on it that I see far too often:

“Taking new patients – get your first chiropractic assessment, with full x-rays!”

Now, before I continue on with this article I want you to know that this is not a slam at chiropractors. They just happened to be the one advertising on this particular sign. This article will refer to some, while many others will agree with what I am saying (and what science is saying).

And what I am saying is this:

If you have pain, an injury, or you just want to have a musculoskeletal assessment so you can be in your best health in most cases you do NOT need an x-ray. In fact getting one, or another type of diagnostic image for pain or check-ups, (and I have the research to support this point) almost always NEGATIVELY influences your outcomes.

Why Getting an X-ray or Image SOUNDS Like a Good Idea:

When we have pain it is natural for us to want to know what the cause is so we can fix it. It is this reason that the thought of getting imaging, like an x-ray (or CT scan, or MRI) sounds like music to our ears. Because it will finally show us what is wrong. What is the cause of our suffering.

I’m sorry to break it to you, but this is all one big fallacy. In fact, most often getting these images leads to more harm than good.

You see, the problem with images – especially as a blanket component of a physical and/or health assessment – is three-fold:

  1. Image findings, including x-rays, very VERY poorly correlate with pain and are NOT often clinically significant
  2. There is almost ALWAYS an “abnormal” finding on x-rays, even in perfectly healthy people
  3. Knowing about these “abnormal” findings almost always leads to increased and longer experiences of pain

Oh, and if you want an additional reason, these images waste a whole lot of health care dollars that could have been better spent elsewhere. Like perhaps in the prevention of disease and injury.

Let’s investigate further:

Imaging Findings do not Correlate to Pain and an “Abnormal” Finding is Almost Always Found

There have been numerous studies conducted that look at the presence of what would be considered abnormal findings on x-rays, ultrasounds, and MRIs in perfectly healthy, uninjured and pain-free individuals. Studies looking at each of these imaging forms have consistently found that a very large number of individuals who are completely healthy and pain-free have what is considered abnormal findings, whereas other individuals in substantial pain can have what would be considered normal findings on an image.

Some studies looking at back pain have shown us that over 50% of asymptomatic individuals between the age of 30-39 were found to have disc degeneration, disc height loss and disc bulges, while these same findings were present in over 90% of individuals over the age of 60.

Other studies have shown positive findings on a shoulder ultrasound in 96% of asymptomatic individuals. 96%! That means 96% of people were found to have a thickening of the bursa, osteoarthritis, tendinosis, a partial tear of one of the rotator cuff muscles, or a labral abnormality, while a “normal” finding was by far the anomaly even though no one who had the ultrasound actually had any pain or injury.

The results of these and more studies are clear: these changes are normal, NOT ABNORMAL, and are not causally related to symptoms. In other words, they should not be considered pathological processes and instead just normal findings that are found with aging and un-associated with pain.

And yet, many people still believe that images are the gold standard in diagnosing pain.

Okay, so they are not effective – but what’s the harm?

X-ray and Image Results Can Lead You Down a Path You Don’t Want to Go:

Even the most logical of people can be scared or put-off by reading a radiology report that says that they are broken. That they have moderate-severe degeneration, a torn rotator cuff muscle, a disc herniation. It is hard to not be so, and reading these results reinforces the idea that something is “broken”. EVEN if the results are in no way clinically significant.

An amazing Ted Talk by pain researcher and expert, Lorimer Moseley, gives us a little more insight in to this. He explains:

“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: what does your brain say when it sees a disc that’s slipped so far out it’s sitting on it’s own? If you’ve ever seen a disc in a cadaver, you can’t slip the suckers – they’re immobile, you can’t slip a disc – but that’s our language, and it messes with your brain. It cannot not mess with your brain”

So, we know these results can mess with people’s brain. And this can in turn make them feel fragile and broken leading to doing less of what is really necessary: moving, strengthening, and rehabilitating the clinical findings, the clinical reasoning for your pain and discomfort.

What does the American College of Physicians and the American Pain Society Recommend?

When looking at back pain, it is recommended by the American College of Physicians and the American Pain Society that:

  • A thorough, focused history and physical examination be done, including assessment of psychosocial risk factors
  • Clinicians should not routinely obtain imaging or other diagnostic tests
  • Clinicians should only perform diagnostic imaging when severe or progressive neurological deficits are present or when severe underlying conditions are suspected and if patients are candidates for surgery or epidural steroid injection

Put simply, clinicians are advised against advanced imaging unless a serious pathology is suspected with severe neurological symptoms who are likely candidates for surgery.

So, WHY are X-rays being Offered as Part of an Initial Assessment by Some Health Professionals?

With all of the above, compelling research against imaging, why is such an antiquated practice still standard for many practitioners?

Truthfully – I’m not sure.

I truly hope that it is not an intentional form of fear mongering. I remember one of my clients coming to me once with the copy of her x-ray result from a practitioner who highlighted all of the “abnormal” findings and wrote next to the findings that she would require twice weekly visits of 6 months in order to correct them. I also remember that this particular client saw me for about three or four sessions and then felt amazing and no longer needed active treatment.

Because an x-ray cannot tell us what is clinically significant. It cannot tell us how a person will respond to treatment. How they will progress. What their outcome will be. How their pain will change. Yes there is a time and place for images, but it that time and place is far less frequent than you think.

So, remember this when you go to a practitioner who insists that x-rays or images need to be a part of your routine assessment. Ask them why they feel it is necessary and what the general recommendations are. And please, proceed with caution and don’t blindly believe what they tell you.

Because you are NOT broken. You are NOT fragile. Don’t let an image ever make you think you are!

Works Cited:
Brinjikiji, W et al. 2015. Systematic literature review of imagine features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4): 811-816.
Chou R, et al. 2007. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147:478–491. doi: 10.7326/0003-4819-147-7-200710020-00006
Girish, G., Lobo, L., Jacobson, J., Morag, J., Miller, B., and Jamadar, D. 2011. Ultrasound of the shoulder: asymptomtic findings in men. American Journal of Roentgenology, 197(4): W713-719.
Jensen, M., Brant-Zawadzki, B., Obuchowski, N., Modic, M., Malkasian, D., Ross, J. 1994. Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain. New England Journal of Medicine, 331: 69-73.

First Sleep, then Coffee.

The Newest Research Links Pain and Sleepiness.

coffee-mug

A new research study from Harvard Medical School brought together researchers from a pain and sleep background to look at an area not yet well studied: does sleep, or lack thereof, influence pain?

Researchers from Boston Children’s Hospital and Beth Israel Deaconess Medical Centre determined that decreased sleep increases pain sensitivity, though this isn’t all too surprising. What was surprising, however, was the role of alertness in pain sensitivity.  You see, researchers found that even with sleep loss, the more alert subjects were (for example had they been given caffeine), the less sensitive to pain they were.

In other words, the more sleep subjects had the less sensitive to pain they were; however, if they were deprived of sleep they experienced less sensitivity to pain than their other sleep deprived counterparts if they were given medications that promoted wakefulness, such as caffeine. Not only that, but these medications promoting wakefulness actually worked better than standard pain medications such as ibuprofen and morphine!

Let’s go through in more details:

The Study

Researchers looked at normal sleep cycles using EEG and EMG readings in mice. They then proceeded to deprive the mice of sleep. In a unique methodology, however, they tried to mimic the way most humans would lose sleep: they entertained them!

Essentially what this means is that they kept the mice subjects awake in a non-stressful manner (as opposed to making them run on the treadmill or fall off platforms as other studies frequently have done). Subject mice got to play with toys and do fun activities (similar to how us human counterparts may scroll through facebook, or watch late night TV). During there sleep deprived entertainment, researchers monitored the mice’s sleepiness, their levels of stress hormones (to make sure the mice weren’t stressed out) and tested their response to both painful and non-painful stimuli.

Pain sensitivity was measured by how long it took the subject to move away from a painful stimulus (heat, cold, pressure, or capsaicin – the agent in hot chili peppers), while non painful stimuli included looking at the subjects startle response to loud noises.

The Results

Findings of the study demonstrated that in otherwise healthy mice even just five consecutive days of moderate sleep deprivation significantly exacerbated pain sensitivity. This was specific to pain and common painkillers including ibuprofen and even morphine, a strong painkiller, did not block the pain hypersensitivity that was induced by the sleep loss.

However, researchers did find an interesting result that caffeine and modafinil, drugs that promote wakefulness, successfully blocked the pain hypersensitivity caused by both acute and chronic sleep loss.

What it All Means

This study is a great example of learning more about the sometimes complicated ties of lifestyle to both chronic and acute pain and tells us a lot about some new future areas of study.

Sleep is critical in all areas of our life, including managing our pain. Even acute sleep deprivation can worsen pain and can lead to a vicious cycle of pain and poor sleep quality. Therefore working on your sleep hygiene and ensuring you get sleep and avoid the distractions before bedtime can play an important role in feeling better.

Does this study mean you should go out and pump yourself up with wakefulness promoting drugs, like caffeine? No – remember, so far this study has only been done on mice – but it is an interesting note to think about. Because perhaps it is something we will need to consider in the future, as according to the authors, “This represents a new kind of analgesic that hadn’t been considered before, one that depends on the biological state of the animal…. Such drugs could help disrupt the chronic pain cycle, in which pain disrupts sleep, which then promotes pain, which further disrupts sleep.”

Key Takeaways

  • Acute and chronic sleep deprivation increases pain sensitivity
  • Painkillers such as ibuprofen and morphine may not block this hypersensitivity from sleep loss
  • Caffeine, and other wakefulness promoting agents, did seem to improve pain sensitivity when sleep deprivation had occurred.

Read the full study here, or read a bit more about the importance of sleep on injury and performance with a previous article of mine, here.

Questions, let me know!