Is Medical Imaging Always Necessary for Pain Treatment?

With the myriad of factors that can cause pain, it only seems natural that we can’t figure it out by looking at someone on the outside. Surely we need X-rays, MRIs and the like to illuminate what’s really going on.

Surely a highly trained healthcare practitioner can look at your spine, for example, and get a crystal clear picture of why you’re feeling lower back pain and therefore give you the exact solution to become pain-free.

If it seems too good to be true, it is. I can’t tell you how many times I’ve had clients consult with me long after they’ve seen every doctor and physio they can and gotten every scan possible, and still have no answers.

Here’s an example of why. It has been observed that as we age, we see the prevalence of disc bulges and signs of disc degeneration increase. However, this has proven to be a poor predictor of low back pain.

Can we see pain in an image?

We see people who have disc bulges on an MRI and have absolutely no pain, and then we see people who have no signs of bulging or herniations that are suffering from lower back pain.

We end up with two disappointing scenarios here. In one case, you get diagnosed with a disc bulge, told it’s the sole cause of your pain, and are either sent to physio or are told to lie down and rest. Or you come up squeaky clean in scans with no sign of spinal or disc pathology, even though you're in pain, and are sent on your way with shrugged shoulders.

Either way, we’re letting people down because we’re falling into the fallacy that pain is caused solely by what’s physically and structurally going on. We used to think that pain is a direct result of tissue damage, and physically treating that damage would cure your pain.

We now know that this model has become outdated because of how many factors we now realize cause pain. If we rely on scans to tell us exactly what’s wrong when they can only see physical characteristics, we’re telling people who have clean scans that the pain is all in their heads.

And for those that do have “pathological” scans, we’re again neglecting all the other factors that could be causing them pain and only treating physical factors.

An underappreciated aspect of getting a scan is what it does to your psyche.

The unintended side-effect

Kinesiophobia is one of the most extreme forms of fear of pain due to movement or re-injury. The correlations between kinesiophobia, disability, and quality of life are statistically significant. A study found that lower back pain patients show a worsening prognosis due to the fear of moving, negative thoughts and having to take leave of work due to their pain.

It’s important to note that the persistence of lower back pain could not be explained by objective clinical findings due to the complexity of factors that are related to low back pain. For example, 73% of patients with chronic low back pain suffer from depression, and psychosocial factors like anxiety, fear, and stress have negative impacts on lower back pain.

The main takeaway from this study is that kinesiophobia is associated with pain intensity, disability, and quality of life and, therefore, should be considered when planning treatment for someone with lower back pain.

Back to scans. Many things seen on MRIs and X-rays in those with pain are also seen in those without pain. For example, in people in their 20s, 37% were shown to have signs of disc degeneration, again with zero pain. MRIs are not “tunnels of truth” when it comes to finding out why you’re in pain. It can be one piece of the puzzle, but it’s definitely not the whole picture. Even calling some of these findings “pathological” isn’t entirely true.

A great post by Dr. Susie Spirlock on the research rates of these findings

If we insist on sending people for unnecessary scans every time they show signs of pain, we create a problem. The research shows that these scans are unreliable for finding a cause. But what often happens is that they see something “pathological” (even though research shows that these “signs” are pretty normal), and tell you something is wrong with you.

This creates feelings of fear, which leads to less movement, which leads to more pain. And that’s not just because we’re not moving as much, but because of the fear, stress, and anxiety that come with it. It’s a vicious cycle.

The reality of imaging

Having an MRI unnecessarily for your back pain can delay your recovery by an extra four months, a study found. Having an MRI unnecessarily for your back pain can lead to a higher risk of chronic pain. Having an MRI unnecessarily for back pain can lead to more opioid use, injections, and surgery. Kinesiophobia, caused in part by getting these scans, has a lousy prognosis.

But don’t MRIs provide any valuable information? Many different things can be seen on an MRI of the same person by different specialists. One study asked one person with back pain to have an MRI at 10 different locations, meaning 10 different specialists looked at the same MRI results. 49 different pathological findings were found by these specialists, but none of these findings were seen or reported on by all 10 specialists.

In other words, what is seen on MRIs is often uncertain and often not agreed upon.

Like every headache doesn’t need a brain scan, not every case of lower back pain needs an MRI. Oftentimes, scans show normal age-related changes that are unlikely to be the sole cause of your pain. And from a treatment perspective, it doesn’t often tell people like me anything valuable about how to help you.

But then, in what cases would you recommend someone get an MRI or other scan for their pain? If they show symptoms of serious or sinister pathology. You should seek imaging if you have pain and are also having trouble urinating, or show signs of cancer, infection, or severe neurological damage. This accounts for less than 10% of pain cases.

The bottom line, you probably don’t need a scan to fix your pain. And in most cases, it can cause more harm than good. Consult your doctor or physician, of course, but go into it educated and asking the right questions.

To your good health,

Coach Stephen

References:

Brinjiki et al (2015) PMID: 25430861

Sharim et al (2021) PMID: 34819061

Anderson (2011) PMID: 21214357

Herzog et al (2017) PMID: 27867079

---

P.S.

Whenever you’re ready, here are a few additional ways that I may be able to help you.

Free:

Instagram: @CoachStrumos

*I share tons of bite-sized lessons and tips here

Paid:

1-on-1 Pain Management and Strength Coaching: Apply here