You can't take a picture of your pain.

by Mark Cooper

It may surprise you to know that two out of every three people you meet today walking your local streets of Northcote, Fairfield or Alphington will have some kind of abnormality of their spine, be it bony change, disc bulge or spinal curve, and they will have absolutely NO PAIN!  

That's right folks, they are getting on with their inner-north-hipster-cold drip coffee culture lives totally oblivious to the changes in their low backs. I hear you ask "How can this be?"

These changes are, for the most part, a normal process of ageing and the body is very good at adapting. What the research boffins know is that without a doubt MRI, CT scan and X-ray results DO NOT predict the amount of pain you will be in or even that you will experience pain at all.

I outright avoid sending people for scans.  There is a time and a place to order them, especially if there are serious indicators, however, there is an ever growing issue regarding the amount of medical imaging being ordered across all facets of health care. But I'll focus on my niche area - LOW BACK PAIN.

A systematic review and meta-analysis (that is the bees knees of research thoroughness) was done on imaging strategies for low back pain in 2009 and published in the Lancet Journal (that's a seriously good place to land your research study). The findings were as follows:

"Lumbar imaging for low back pain without indications of serious underlying conditions DOES NOT (my emphasis) improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low back pain and without features suggesting a serious underlying condition." (1)

Have you heard the one about the man with low back pain who walks into the Osteopath/Chiropractor/Physiotherapists' clinic? From the history and examination there is no indication of anything sinister. Three treatments later with no change to the patient's pain experience, he is starting to get concerned and lose faith in the practitioner's ability to help him. The practitioners ego is taking a battering so they need to bump up their authority with the words "better get a scan" and "this doesn't look good". Low and behold the scan report has some big foreign words in it. Words like osteophytes, foraminal encroachment, decreased lumbar lordosis - could it be any worse? This confirms the patient's fears and they immediately start to feel negative about their prospects of making a full recovery. Their mind starts racing with black cloud scenarios like, "I'm going to have to stop running, I'm only 45 and how am I going to play with my kids?" Crotchety Uncle Brian appears in his mind, fast asleep in his wheelchair at Christmas after his third back surgery, drooling from the mix of codeine and alcohol in his system. Often all the practitioner has to offer is "I told you so - it's bad - you're going to need to see me a lot in the future." The patient is disempowered from every angle.

There are real dangers of associating findings on an X-ray to a patient's experience of pain. Pain is complicated (ouch, there is that word again).  It hurts my brain how complex pain is, no wonder patients and practitioners across the board avoid explaining it properly.  Pain is a process driven by the brain and negative reinforcement of a patient's pain may be extremely detrimental to their recovery. 

Scans can also be used against you in a massive sales pitch from dodgy practitioners. Treatment plans will usually involve 'straightening' your spine with manipulation three times a week for six months and 'oh, could you pay for that up front'. Other practitioners might show you how to strengthen your core in any number of ways - most of them will be expensive and involve you handing all sorts of power over to them.

The best evidence suggests that most cases of serious low back pain resolves within weeks. A bit of reassurance, good advice and pain relief from a competent practitioner might help and leading an active, healthy lifestyle should be the primary prescription going forward.

At Fairfield Osteopathic Clinic we are always cautious when ordering scans for patients. Even when patients present with scans (that we didn't order) we try to use positive language to explain the results and findings, as the pictures of your insides do not reflect the way someone is feeling on the outside. Remember you can't take a picture of your pain.

1. Dr Roger Chou MD, Rongwei Fu PhD John A Carrino MD, Prof Richard A Deyo MD -  The Lancet, Volume 373, Issue 9662, Pages 463 - 472, 7 February 2009

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