The invention or firstly x-ray imagining and then MRI imaging has lead to huge advances in medicine. It’s applications are far ranging and can help guide your physiotherapy treatment. But are there cases where having an x-ray or MRI diagnosis actually be detrimental to your recovery?
I would imagine most readers at this point will be thinking how can this be possible. But the last 13 years of treating thousands of people has led me to the conclusion that imaging can indeed be counter productive. Not one to dodge controversy in this blog I shall attempt to show you why.
Why would I challenge such strongly held beliefs? Simply because I think it will help more people get better. With more focus on what we can do without surgery taking pressure off an already overrun NHS and ultimately giving each individual a better outcome. I hope to dazzle you with a combination of research and anecdotal evidence how such a controversial statement is actually the norm for any experienced physiotherapist or sports therapist.
Why Was X-Ray and MRI Invented?
Human nature drives a lot of our approaches to modern medicine. In many ways this is a good thing. Our desire to understand what is going. Constantly enquiring just what is the cause? This has led to some incredible technological developments in treatment of conditions and illness. This is not what I want to discuss in this article.
What I want to discuss here is how our desire to ‘know’ exactly what is going on can develop into the desire to control and have absolute answers. This is rarely possible with something as complex as the human body. This can only lead to frustration and anger which in turn increases the levels of fear and in so doing the levels of pain.
When Does Imaging Help A Physiotherapist?
This article is not to say X-rays and MRI scans are not a fantastic tool. They are. We’d be lost without them. They have wide ranging applications and are incredibly useful for diagnosing a whole host of conditions. But they do not have all the answers.
In the field of physiotherapy where they are particularly useful is when you’ve just done yourself a mischief. We can see which bones you’ve broken and what ligaments you’ve damaged. We can even now determine the amount of muscle damage that has occurred. As physios and sports therapists we can use this to firstly rule out anything serious and secondly help guide our treatment.
However even with all this knowledge this can never be absolutely conclusive. Pain just doesn’t work that way. Pain is an individual thing. Let’s take a fictitious scenario of two people with the same sprained ankle to demonstrate the point.
Your Beer Swilling Rugby Playing Weekend Warrior – Not that I’m stereotyping in any way! This is an easy stereo type to talk about for me having grown up in Wales. They’ve rolled their ankle playing rugby on a weekend. It hurt like hell at the time. They’ve done it many times previously and they know it will get better in a few weeks. They go to the pub after the game for beers as normal and then run home afterwards as they can’t feel it anymore!
Your Lovely Granny Who’s Stepped Off A Kerb – Poor old granny. She’s not as steady on her feet as she used to be. She got distracted stepping off a kerb. She rolled her ankle and now it really hurts, it’s swollen. She’s worried it’s broken as she might be on the osteoperotic scale due to her age. She’s concerned this will inhibit her movement ongoing and it’s all down hill from here.
Two very human and understandable reactions to the same injury. Both pain experiences will be very different. I can pretty much guarantee you the granny will feel a lot more pain. Mostly due to the fear. (We discuss the psychology of pain in great depth in our 50 Shades Of Pain post). Yes she will take longer to heal but grannies (and granddads) do heal. No matter how old we are we still have the ability to repair. We’re quite clever like that us human beans.
When Can Imaging Be Detrimental To Your Recovery?
So in the example above imaging again could be very useful and reassuring. Getting an x-ray to see if the ankle has been broken. But it’s chronic conditions that can be less clear cut. Lets continue our granny example and call her Ethel. After 6 weeks most physiological healing will be done. Ethel is getting on a bit. So lets add another couple of weeks for good measure so lets say 8 weeks for the damaged tissues to heal.
We’re 3 months post and Ethel is still not very mobile and still in pain. She has an MRI scan which shows something that the consultant thinks ‘might’ be causing the problem. The consultant talks about maybe having to do surgery if the condition doesn’t settle. This makes Ethel more nervous, she’s even more worried about the condition and started altering behaviour. She’s still not able to get to the shops and the injury starts to seriously affect the quality of her life.
This can then spiral. In desperation she goes back to the consultant who performs the operation which takes months to recover from and the pain is no better when fully healed after the operation in fact some days it’s worse. She’s still walking in pain and limping. This throws her biomechanics out and she starts getting a pain in her back and shoulder as well. The cycle goes on.
This is no way intended to be a dig at the NHS or any surgery in fact. The point I try to make is that surgeons now how to operate and not much else. I know how avoid operations at all costs and not much else. We can’t all be right. From a balance perspective there is normally an element of truth in both opinions. Pain may be contributed to by an anatomical anomaly picked up on a scan but when we do our thing of optimising biomechanics you don’t feel it any more.
From the flip side – only fair in our balanced discussion – we may be able to remove people’s pain using our biomechanical wizardry but the pain may come back with days or hours. This may well be due to the ‘thing’ that has been identified on the scan and that thing is causing compensation and overuse in certain tissues which then elicits pain. We can do our wizardry all we like but we need to remove what the problem is.
I fear I may have been waffling here but my point is lets just have a go. In most cases conservative treatment does the trick. At least that’s my experience. So why not give it a try. If things don’t work out then it’s time to consider surgical options.
If You Look Hard Enough You Will Always Find Something
We all have anatomical anomalies. Features as I like to call them as it sounds a lot less threatening than anatomical anomalies.
After the last sections waffle let talk simple. You wake up one day with back pain. Where has it come from? Did you break a vertebrae during the night? Did you slip a disc overnight? Unlikely. My question is this: Reasonably speaking, without any catastrophising, has anything dramatically changed? For the vast majority of us the answer is no. I which case doing an MRI or x-ray doesn’t help us.
It may pick up something that has always been there that hasn’t previously affected anything. It may or may not be relevant to your pain but chances are the name will sound scary. Just because we see something on MRI doesn’t mean this is where the symptoms are coming from. This is shown in the table to to left here which is an excerpt of this fabulous piece of research. It’s slightly technical but what it shows is that conditions that we previously thought to be the source of peoples pain can exist without any symptoms at all. So if the MRI scan picks up one of these findings as therapists we have to question if this really is ‘the’ source of your pain?
Back in the day surgeons would have been in there quicker than you can tie up your shoelaces. But now we all have a more rounded view. Especially in regard to back surgery which has inherent risks.
What is more useful is understand you as a person to get to the underlying cause of the pain. Maybe your stress levels have increased – we feel things more when we are stressed. Maybe you’ve increased your level of activity a little too quickly. Maybe you’ve been doing a lot less – use it or lose it as we like to say. What we do know is the more that we fear things the more pain we feel. So catastrophising about some scary latin term will just make you feel more pain. Chances are what you’re catastrophising about may not be all that bad anyway according to this new insight.
So in these example do we need to have a scan? I would suggest not. For me a scan is a last resort when a conservative approach isn’t working. It should not be used as a magical panacea that will immediately gives answers to all of life’s questions. Sorry to break that to you!
Some Real Life Examples
So Ethel isn’t real. But her story is not made up. At our clinics we’ve seen many similar stories. A gentleman in his 40s who couldn’t move his shoulder as freely as he should with pain and limitation. Written off as arthritis and told he’d just have to live with it he’s now dancing the funky chicken to his hearts content.
Another gentleman in his mid 60s told by a consultant he would be back in a matter of weeks begging for surgery on both knees as the result of his x-ray. Now walking around pain free happily tinkering with his collection of cars in his retirement.
A lady who had been walking round like a T-rex for most of her life – it’s a long story! Diagnosed with grade 4 (that’s the worst kind) arthritis in both hips. She had been pain free until she had the x-ray. Then all of a sudden when she was told she need two new hips suddenly there was pain and she couldn’t get around anymore. 4 sessions later she was walking pain free again. And actually less like a T-rex. Still not the most flexible, but you can’t have everything!
Another lady who had confirmed two slipped discs causing pins and needles down her leg. She was walking around in fear that the slightest movement would bring on excruciating pain. This had come on after a reasonably innocuous fall which is not the right mechanism to slip a disc. A few sessions and a lot of encouragement later no pain and full range of movement. Had I cured her disc problem. Of course not. I believe her disc was prolapsed some time ago. The fall just threw her out of kilter and meant the discs came into play.
Very satisfying cases but you judge for yourself. Did the imaging help or hinder their recovery from the pain and discomfort they were in? I know what my belief is. I was in the room trying re-assure these people that the results of the scan was not the nail in the coffin for their condition.
How Should Imaging Be Used In Conjunction With Physiotherapy?
To answer the question of this post. Yes imaging does help physiotherapists and sports therapists in many incidences. However, with chronic conditions in particular it needs to be understood, by the therapist and client, that any findings from any scan are not absolute. Scans should be used to rule out anything that is very obviously wrong. Bones snapped in two, things in wrong place. That kind of thing.
Aside from that they can be used as a guide as a potential stumbling block in terms of someones recovery but one that in the vast majority of cases can be overcome with the appropriate treatment.
If you’ve been written off, or written yourself off as the result of a scan of some kind we’d love to hear from you. We do love a challenge and we’d love to get you moving again. Call a therapist now on to see if there is hope for you!