Time to Break-Up with your MRI Report

Your patient storms through the exam room carrying 3 MRI discs and two X-ray films demanding you take a look to confirm how bad their back really is. “I’ve got 12 lumbar disc bulges!”, they exclaim. It’s inevitable you will hear this on a weekly or even daily basis. It seems that at this point in time diagnostic imaging has become something that we have a tendency to live and die by. Patients often times appear to develop a relationship with these scans and use them as an identity. An identity to justify the pain they have, and validate the way they feel and the way they live their lives. The imaging report seems to take on a personality of an naggy overbearing boyfriend or girlfriend who dictates everything you can and can’t do in your life. “You know you can’t bend forward! That’ll ruin your back.  You aren’t allowed to bowl anymore! You”ll be laid up in bed for days.”

Time and time again, people say, “my mom had a bad back, my aunt had a bad back, so I’m going to have a bad back.”

If you haven’t caught on yet, I’m being facetious.  But there are clients, who after reading a MRI report, can become very overwhelmed with the results they have just received.  For someone who is in pain and has many unanswered questions, trying to absorb and retain accurate information can be a daunting task.

I find myself on a daily basis speaking with clients or patients about their imaging.  Whether it be a x-ray, MRI, CT scan, you name it, we’ve discussed it.  People come in with their CDs or e-mail me their results of their imaging and by the sounds of it, many times people feel it is a death sentence.  A rotator cuff tear or disc bulge may not be a true death sentence, but to this person sitting in front of you or me, it could create a high degree of fear and dramatically take control of their life.  You are now at crossroads in the management of this patient. Do you take the role of the relationship counselor? Or do you instead continue to allow the MRI to control this individual's life by instilling fear and controlling aspect of their life.

We’ve all been through many years of schooling.  Some of us have more degrees than a thermometer while others have fewer degrees and have been practicing for more years than some new grads have been alive.  We learn about human anatomy and physiology, neuro, etc.  But one thing we don’t learn about is usually the relationship between imaging and pain.

Many studies have been conducted looking at imaging and level of pain.

Courtesy of GetPT1st.com

This is just one study out of many that have looked at the relationship between structural damage and pain.  We need to be educating our patients on changes that occur in the body and how they are NOT related to pain and dysfunction.

Nakashima et al. found that there were cervical disc bulges present on MRI in 1211 healthy, normal pain free subjects.

Brinkukji et al. found abnormal findings on lumbar spine MRI and CT imaging in healthy pain free subjects.

In the following image, the left shows someone in pain with an abnormal finding on imaging.  Conversely, the image to the right is the same person 2 years later, disc healed and  completely pain free and asymptomatic.

Now that you understand that “abnormal” findings can be found in symptomatic and asymptomatic individuals, we need to, as a profession, start educating our patients on the importance of movement quality and not being “married to their MRI.” It’s time to help patients get rid of the “ole ball and chain” that is weighing them down and get on with living their lives to the fullest.

The question is how we can help our patients move away from this destructive relationship? We can start by watching our language and avoiding using the terms disc bulges, stenosis, osteoarthritis, bone on bone, and the like.  Personally, I will show the aforementioned images to clients and patients to show them that the imaging is only a piece of the puzzle.  It tells us something.  It doesn't tell us everything.

By conducting a thorough movement based evaluation and educating the client on how to be their own advocate is paramount in not only helping your client move and feel better, but also to dispel the myths behind being heavily invested in their imaging.  Teaching your clients and patients about pain science and how pain and structural damage aren’t directly related is imperative in preventing prolonged fear avoidance behavior and decreasing the likelihood and progressing into chronicity.

This can empower people to feel that they have control and can stay ahead of their symptoms.  By providing inputs to the Central Nervous System through manual therapy, educating the client about positions that may threaten the nervous system, and then instructing them on correctives to improve and maintain optimal movement quality, we empower our clients 100% where they are in control of their bodies.

Without going into too much detail, pain is an output from the brain.  The brain and central nervous system detect a threat and cause pain to inform the person that there is a threat to the system.  This “pain” does not mean there is damage occurring.  It is to inform the person to change the position or situation they are in to decrease the threat.

For example, a guy is running across the street.  He is dodging traffic.  A bus full of people is approaching him as he is running across the street.  Suddenly, he sprains his ankle.  He narrowly escapes the oncoming bus and makes it safely to the sidewalk.  Five minutes surpass and then his ankle starts to hurt.

This is an example of how the nervous system picks which threat is greater at a certain point in time.  Either the gentleman rolls his ankle, it hurts, he can’t run to the sidewalk, and he gets hit by the bus OR he rolls his ankle, doesn’t notice it, keeps running to the sidewalk, and narrowly avoids the bus to live another day.  This is the body’s way of weighing the greater threat, the bus, and getting him to safety.

Another example is when someone falls and breaks their arm.  Their arm hurts very badly.  They are in writhing pain.  They go to the ER and they are casted to help their fracture heal.  A day or two goes by.  Their fracture is still fractured.  It has not healed yet.  Does their arm hurt anymore?  Typically, no, because the cast that was placed on their arm has mitigated the threat to the central nervous system and informed the CNS that there is no more threat and in turn, the pain is gone.

Imaging is important in several cases such as if someone presents with unremitting pain, foot drop, bowel or bladder compromise, etc.  We just need to make sure we are using imaging appropriately and at the right time. Help your patients take the step in cutting the “relationship ties” with their imaging. Help them break up with their MRI.  

Andrew Millett is a practicing physical therapist in the field of orthopedic and sports medicine physical therapy. He helps to bridge the gap between physical therapy and strength and conditioning. By evaluating and treating his clients using multiple lenses, such as the Selective Functional Movement Assessment (SFMA), Postural Restoration Institute (PRI), etc. The main goal for all of his clients are for them to move and feel better and to keep their body functioning at high levels.

You can learn more from Andrew on his website AndrewMillettPT.com

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