By September 11, 2014 2 Comments Read More →

In Pursuit of Pathology

I have recently attended a couple of seminars that have mentioned how newer and better MRI units will begin to be used in the attempt to identify pathology in patients with musculoskeletal pain.

Now this sounds a fantastic and a worthwhile cause, especially if it enables us to identify symptomatic pathology in a patient population which can then lead towards a successful treatment (finding a successful treatment being an entirely separate issue by the way!).

I do however wonder if the findings from newer and more advanced imaging procedures will actually help us as at all. I ponder this because when we look into studies on asymptomatic patients we consistently see that many of the “bad and nasty” findings on scans are actually common to see in pain free normally functioning people. Even elite athletes!! Many findings are also not related to pain and disability! There are numerous examples in the literature in relation to this topic, but here are a few I dug up quickly:

“Professional pitchers develop degenerative changes over time in both the shoulder and elbow of their dominant (pitching) arm due to chronic repetitive stresses placed across the joints. These findings do not predict time spent on the Major League Baseball disabled list”. Wright et al (2007)

“Asymptomatic shoulder abnormalities were found in 96% of the subjects. Ultrasound showed subacromial-subdeltoid bursal thickening in 78% of the subjects, acromioclavicular joint osteoarthritis in 65%, supraspinatus tendinosis in 39%, subscapularis tendinosis in 25%, partial-thickness tear of the bursal side of the supraspinatus tendon in 22%, and posterior glenoid labral abnormality in 14%. Girish et al (2011)

“We conclude that unenhanced magnetic resonance imaging of the shoulder in asymptomatic high performance throwing athletes reveals abnormalities that may encompass a spectrum of “nonclinical” findings”. Miniaci et al (2002)

“Magnetic resonance images of asymptomatic participants revealed abnormalities in 73% of hips, with labral tears being identified in 69% of the joints”. Register et al (2012)

“MRI findings of disc protrusion, nerve root displacement or compression, disc degeneration, and high intensity zone are all associated with LBP, but individually, none of these abnormalities provides a strong indication that LBP is attributable to underlying pathology. This limits their value in refining epidemiological case definitions for LBP”. Endean et al (2011)

“High prevalence of ‘abnormal’ findings on MRI in pain-free populations (disc degeneration [91%], disc bulges [56%], disc protrusion [32%], annular tears [38%])”. McCullough et al (2012)

“The association between severe Disc Degeneration (DD) and LBP ceases to be significant when adjusted for Modic Changes and disc protrusion/hernia. These results do not support DD as a major cause of chronic LBP”. Kovacs et al (2014)

“……vertebral endplate changes are not associated with chronic LBP”. Kovacs et al (2012)

“An MRI total score (0-10) for findings was calculated for Modic type I and/or II changes, a posterior high intensity zone in the disc, dark/black nucleus pulposus signal, and ≥40 % disc height decrease. We analyzed the relationship of the MRI total score to the Oswestry Disability Index (ODI) and LBP intensity scores using multiple linear regression and adjusting for age, gender, body mass index, smoking, and anxiety/depression. The combined MRI findings were not related to the degree of disability or the intensity of LBP. These degenerative MRI findings cannot explain variation in pre-treatment disability and pain in patients with chronic LBP accepted for disc prosthesis surgery”. Berg et al (2013)

“MRI performed at 1-year follow-up in patients who had been treated for sciatica and lumbar-disk herniation did not distinguish between those with a favorable outcome and those with an unfavourable outcome. A favorable clinical outcome was defined as complete or nearly complete disappearance of symptoms at 1 year”. el Barzouhi et al (2013)

“Tendon pain remains an enigma. Many clinical features are consistent with tissue disruption (the pain is localised, persistent and specifically associated with tendon loading), whereas others are not (investigations do not always match symptoms and painless tendons can be catastrophically degenerated). As such, the question ‘what causes a tendon to be painful?’ remains unanswered”. Rio et al (2014)

“The results of this study suggest that, although some Whiplash Associated Disorders patients are more likely to suffer from long-lasting neck pain, MRI findings cannot explain the symptoms”. Matsumoto et al (2010)

“While Modic changes became more common in whiplash patients in the 10-year period after the accident, they occurred with a similar frequency in control subjects. We did not find any association between Modic changes and the nature of the car accident in which the whiplash occurred. Modic changes found in whiplash patients may be a result of the physiological ageing process rather than pathological findings relating to the whiplash injury”. Matsumoto et al (2013)

This study demonstrated that progression of degenerative changes of the cervical spine on MRI was not associated with clinical symptoms during the 10-year period after whiplash injury. Ichihara et al (2009)

“The number of levels of cervical degeneration and the severity of degeneration in the discs, facets, and uncovertebral joints are not related to the levels of pain and disability” Peterson et al (2003)

“Full-thickness focal chondral defects in the knee are more common in athletes than among the general population. More than one-half of asymptomatic athletes have a full-thickness defect. Further study is needed to define more precisely the prevalence of these lesions in this population”. Flanigan et al (2010)

Let me clarify!!!

Now I am sure some of you will accuse me of bias (aren’t we all to some degree?) but before you do that let me make a couple of points:

  1. I AM NOT SAYING THAT THE ABOVE FINDINGS CANNOT BE SYMPTOMATIC. I am sure they are in some patients and I am sure there is literature available suggesting this. Out of interest the ability to be able to diagnose many of these structures as a source of pain (with clinical tests) is highly debatable. Please see some of my other posts for information relating to clinical tests for the Hip, Knee Meniscus, Patellofemoral Pain, Shoulder and the Spine.
  2. What I am trying to point out is that if these types of findings can be asymptomatic in normally functioning people then:
    1. WHY SHOULD OUR PATIENTS WITH SIMILAR FINDINGS NOT BE ABLE TO BECOME PAIN FREE WITH CONSERVATIVE MANAGEMENT? The “scan findings” should have little bearing on them becoming pain free or not. Surely a trial of conservative treatment should be undertaken before proceeding to more invasive treatment options.
    2. We should be very mindful of creating or contributing to incorrect beliefs relating to findings on our patients scans. In my clinical practice I see many patients that have INCORRECT BELIEFS related to their scans based on their own thoughts, beliefs of family and friends, and/or beliefs of their health care providers! Given what we can see above we should be re-assuring patients that pain free, highly functioning people also have these findings. This in turn will greatly minimise the likelihood of development of factors such as Fear of using the injured area. Fear and Fear Avoidance, amongst other factors, are significant predictors of poor outcome and development of chronicity. Please also see this and this for further information relating to poor prognostic factors.

So I hope that in the future that there is some better way of diagnosing actual symptomatic pathology, but that needs to be balanced with comparisons of asymptomatic patients. That way we shouldn’t have any false starts.

Thanks for reading.

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Sessional Academic at Curtin University. The views expressed on this blog are his own.

2 Comments on "In Pursuit of Pathology"

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  1. Rod Whiteley says:

    More or less fair enough comments, except that I reckon you are falling for the trap of saying that since pathology can exist without symptoms in some people, it is of no use in any people.
    This is a conditional probability error.
    In short, if the guy in front of me has a sore knee, and his MR has a plausible reason for this, I will pay attention to the MR, if he has no pain, I will ignore the MR and this is fair enough.
    If the car alarm goes off, and I am looking at the car while it isn’t being stolen then I won’t call the police, but if I have the car outside in a high crime area and it goes off, I will get out of bed and go and have a look. It’s not sensible to assume that since car alarms often go off with no good reason, they are always useless and we should abandon their use.
    This, in not so many words, is the essence of Bayesian Reasoning.
    For sure too many people have had their pain incorrectly blamed on an MR, and their belief systems are getting in the way of them becoming pain free when someone tells them that if they bend over their ruptured disc could compress their spinal cord.
    Similarly though, the guy with a physeal injury misdiagnosed as a tendinopathy will be told to load things up to make it better if no one bothers to check for this pathology. When that fails, he will either be on the path to chronic pain management, or the inject/operate merry-go-round.
    These (MRI findings) are just more pieces of information that should not be used in isolation, but rather combined in a clinical reasoning framework to find out the best way forward for the guy in front of you with the sore leg (or whatever).
    Just my 2 cents,

    • Mark Gibson says:

      Hi Rod,

      Thanks for taking the time to comment.

      I have re-read my post and am quite unclear where I am “falling for the trap of saying that since pathology can exist without symptoms in some people, it is of no use in any people” and/or suggesting we abandon the use of imaging……

      To summarise my post:
      1. You will get no arguments from me that structures on scan can be symptomatic. My point was why should they not have the be able to become pain free given the high prevalence of similar findings in asymptomatic patients i.e. lets try some conservative management with these people rather than more invasive treatments immediately (it happens unfortunately and I am sure we have both seen it occur).
      2. Not educating patients on what is normal to see on scan is a gross error that many clinicians make. We (the health profession) then end up creating patient situations where they become avoidant to use their shoulder, back, knee etc because they have some “wear and tear”. Granted we don’t want to encourage them to start pushing their shoulder, back, knee etc through the pain barrier because “nothing is wrong and it is all in their head” but we need to ensure they are aware that their scan in most cases should not be holding them back from getting better and it is safe to move and load the area, with appropriate guidance.
      3. I am not saying that we don’t scan certain patients. There are valid reasons to do so… some patients. But in most there isn’t much reason to scan them early on in the presentation. As you mentioned clinical reasoning critically comes into play. As in your example of the physeal vs tendinopathy patient the critical issue in the first place is the misdiagnosis i.e. missing subjective and objective findings that might suggest a diagnosis different to tendinopathy. The clinical reasoning leads to the decision to scan or not. The decision to scan is not based purely on the patient having some pain somewhere.

      Clinical reasoning is critical and I like your example of the car alarm. Where examples like that fall apart in our profession is when the clinician cannot differentiate between a false alarm or not, even when looking at the car whilst the alarm is going off! That in turn can then start to trigger all sorts of false alarms for the patient.

      Thanks again for your input. Much appreciated.


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