Does X-Ray and MRI Paint the Whole Picture of Pain?
Routine x-rays have long been associated with chiropractic clinical examination with the stated purpose to visualize spinal alignment. In the last few decades, evidence-based care has transitioned from traditional chiropractic’s static mechanical model, as visualized by X-ray, to a patient centered model operating within a biopsychosocial model.
So, what the heck does this mean?
Evidence has moved away from diagnosing and treating individuals based off of stand-still 2D image. We have begun to find more value in diagnosing and treating individuals as moving creatures with pain that is influenced by many factors like movement patterns, nutrition, sleep, and stress.
When seeking imaging, we like to picture a big red exclamation mark that points us towards exactly what the problem is. Health professionals are notorious for finding the most degenerated, arthritic, nasty segment on imaging and telling you that’s your source of pain. While sometimes that may be true, we know that imaging is generally a very poor predictor for identifying the source of pain, because any structure innervated is a potential source of back pain. Even if we could pinpoint the problem area, this information isn’t helpful to conservative practitioners because don’t have the ability to direct exercise or manual therapy to isolate treatment to specific spinal structures.
Just because a structure has some degenerative or arthritic wear and tear doesn’t necessarily mean it has to be painful. We know this because 68% of asymptomatic 40 years olds and 88% of asymptomatic 60 year olds are walking around with some form of disc degeneration. This suggests that degenerative findings are a normal and expected part of aging, and not necessarily a reliable source of pain.
Unnecessary early imaging also comes with some cons. Excessive radiation exposure, overdiagnosis, low-value investigation, and increased costs are all risks of routine imaging. In most cases the potential benefits from routine imaging of spinal X-rays, do not outweigh the potential harms.
Current research states, “the use of spinal x-rays should not be routinely performed in chiropractic practice, and should be guided by clinical guidelines and clinician judgment.” Research is recommending the use of imaging be limited to cases of underlying serious pathology or trauma. In summary, current research is saying routine spinal imaging is out, and clinical judgment is in, and it’s the time to shine for conservative care practitioners.
To sum it all up:
Image findings of degeneration are present in very high proportions of asymptomatic individuals, and these findings only increase with age. This leads us to believe that these findings are a *normal* part of aging and *unassociated* with pain. Of course, image findings must be interpreted in the context of the patient’s clinical history.
Pain is incredibly complex and influenced by much more than your degenerative findings on a still 2D image. The goal should be to treat people as a whole living, breathing, and MOVING human. Acquiring the info that allows you to treat people as such builds a much better clinical picture than x-ray images ever could!
Advanced imaging is never going to offer the WHOLE picture. If you’re curious about a multi-factorial pain approach, our clinician has you covered and would love to help!
Sources:
Current evidence for spinal X-ray use in the chiropractic profession: a narrative review: https://pmc.ncbi.nlm.nih.gov/articles/PMC6247638/Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations: https://pmc.ncbi.nlm.nih.gov/articles/PMC4464797/#:~:text=Thirty%2Dthree%20articles%20reporting%20imaging,those%2080%20years%20of%20age.