Magnetic resonance imaging (MRI) allows us to see a clear image of soft tissues and deep structures inside our bodies. They can create high-resolution images of the entire musculoskeletal structures, including bones, tendons, muscles, ligaments, and nerves. MRIs are valuable as they show details when there are red flags. But MRIs also show natural changes due to aging, and they cannot decipher painful from non-painful structures. Too often, misdiagnoses are made based on such findings, and the actual cause of pain is overlooked. MRIs lead to misdiagnosis and over treatment.
When used correctly, MRIs are an important tool, but they are overused and have lead to over-medicalization.
If you take a picture of the inner mechanics of your cell phone it may show water damage, etc., but only by using your phone can you tell if it actually works. An MRI takes a great picture, but only by moving and using your muscles and joints can you tell if they are painful and function correctly.
The use of MRIs in the US continues to grow at an alarming rate despite evidence that improved patient outcomes do not accompany it. Overutilization of imaging in individuals with low back pain has been correlated with a 2- to 3-fold increase in surgical rates over the last ten years and probably the same with other joints not yet studied. MRIs act like a sales funnel. Being told that something is wrong causes anxiety and fear. You then seek treatment as you search for a “fix”.
MRIs are harming many by causing fear and often a misdiagnosis, both leading to unnecessary treatments and a higher rate of chronicity.
If MRIs Show a Clear Picture of Underlying Structures – How can They Lead to Misdiagnosis and OverTreatment?
Research has shown that 43% of isolated extremity symptoms originate in the spine. If you have pain in your shoulder, elbow, wrist, hip, knee, ankle, etc., there is a high likelihood that your symptoms actually come from a problem in your spine. Getting an MRI of your painful joint will likely uncover natural age-related changes and, 43% of the time, not the actual cause of pain. Instead, a problem where the pain is located will be unearthed and falsely confirmed as your diagnosis.
Age-related changes are part of the natural process, like wrinkles on your face and gray hair, and do not cause pain. Signs of degeneration are present in very high percentages of healthy people with no problem. Asymptomatic 20-year-olds have a 37% chance of degenerative disc disease and a 30% chance of disc bulge. Many imaging-based degenerative features are likely part of normal aging and are not a cause of pain.
Disc degeneration, bulging, and even herniations are often found in those with no back pain.
Cancer, infection, and problems within your internal organs often refer pain to the spine. An MRI is performed where the symptoms are located will more than likely show changes, and the true cause of the problem will be overlooked.
Mechanical Assessment Instead of an MRI for Precise Diagnosis
Rather than a costly MRI, a simple Mechanical Assessment should be performed to uncover the underlying cause of pain.
A mechanical assessment identifies problems within your musculoskeletal system by the affect of movement on your muscles and joints and if there is a change in your symptoms. This starts by first ruling out your spine, no matter where your symptoms are located – even for pain in your toes. You simply move the spine to see if it affects your symptoms. After the spine is ruled out, the clinician will assess the muscle and joints around where your pain is located. Musculoskeletal problems are mechanical in nature and must be aggravated or relieved with movement
. If positions or movements do not affect the symptoms, then testing for non-mechanical such referred symptoms from internal organs or cancer must be investigated.
Medical guidelines “strongly” discourage using MRI and X-rays in diagnosing low back pain because they produce many false alarms.
Over fifteen years ago, the American College of Physicians and the American Pain Society strongly recommended against imaging for managing low back pain without suspicion of underlying serious pathology (e.g., cancer, infection, or fracture). Their 2007 guidelines for the management of low back pain. recommendations:
- Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain
- Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected based on history and physical examination
MRIs are a gateway to Surgery and Increase Healthcare Spend!
When you are in pain, you want to know what is wrong, and every patient wants an MRI because they believe it will clearly show the underlying problem.Almost 25% of those with low back pain will still receive imaging, even though it is not following current guidelines.
Imaging improves patient satisfaction, but numerous studies have shown that improper use of MRIs is also associated with misdiagnosis, poorer patient outcomes (persistent pain and chronicity), increased downstream healthcare utilization (increased back surgeries, opioids, injections, treatments), and increased healthcare costs (1, 2,3,4,5,6,7)
MRIs often Cause Fear and Lead to Chronic Pain.
The knowledge that an abnormality is found would cause anyone to feel that something is wrong, and they will do whatever is needed to fix it. Hence the increase in treatments, injections, and surgery linked to those that have received MRIs. Not only do MRIs increased healthcare utilization, but they also install fear. Fear leads to avoidance behavior and is the oxygen to chronic pain. When you are scared of causing more pain, you stop moving and lack of movement leads to unhealthy stagnation and initiates the chronic pain cycle. An MRI must be used wisely, and the patient is educated on the findings and rates of natural aging to decrease their fear.
MRIs have a vital role, but they must only be used with wisdom – after a thorough mechanical assessment and red flags are found.
Are MRIs Reliable?
We naturally assume that MRI is a reliable technology, but they are just a picture that can have a shadow and require education and experience to interpret correctly. Researchers had a 63 yo volunteered go to 10 different MRI centers in a short period to compare the interpretations from different MRIs and radiologists. The researchers determined that each radiologist made numerous errors. 49 distinct findings were gathered, and not one was found in all reports -adding a question to the reliability of the testing we hold as a gold standard.
The most common reason to obtain an MRI is for low back pain, and a common abnormality found is spinal stenosis. Researchers sought to find if radiographic findings would match clinical findings for stenosis. Radiologic and clinical impressions did not correlate. The MRI could not determine if spinal stenosis is a cause of pain. MRIs are a powerful tool and can clearly show spinal canal narrowing, the basis of diagnosing spinal stenosis with MRI. It questions then the assumption a narrowed spinal canal alone can cause back pain.
Another researcher performed MRIs on those with no low back pain and then a repeat MRI if a patient did develop an episode. 84% of those that developed pain had unchanged or actual improved imaging after their pain developed.
90% of the initial MRIs showed significant negative findings, even though they had no low back pain and included:
- 50% had either disc protrusion or extrusion, nearly
- 30% had annular fissures
- 2% potential root irritation.
Many have positive MRI findings even though they have no pain, so instead of being a positive finding they should be notes as natural changes.
MRIs Must Come with Education
Our bodies have an amazing way of healing. For instance, 67% of disc herniations spontaneously reabsorb, and the larger they are, the more likely they are to be reabsorbed.
Patients are not provided education or explained that some MRI findings are part of natural aging or that degenerative changes found might be meaningless. Our bloodwork comes with ranges. MRIs should also come with notes about the percent of natural degenerative changes seen in asymptomatic individuals as we age. Instead, MRIs often lead to additional tests, follow-ups, and referrals and are a gateway to invasive procedures of questionable benefit.
VPT’s clinicians know that it is challenging to counteract negative consequences following an imaging finding of degenerative disc disease, herniated disc, rotator cuff tear, or arthritis, to name a few. A patient will typically focus on this adverse finding as to the source of the problem and feel that they are broken until surgery can fix it. In reality, these findings often have nothing to do with the pain they are experiencing, and instead, these changes were there long before the symptoms appeared. It takes a long time after the patient is symptom-free to convince them they are ok despite their MRI.
Degenerative changes are often a natural part of aging, like wrinkles and gray hair, and do not cause pain.
