Probabilities…changing the conversation

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How understanding normal ageing and the role of medical imaging might just improve our outlook on life. By Ryan Bonney.

In the not-so-distant past, a creaky or clicky knee was often subjected to an arthroscopy – what was casually referred to as a “clean out”. While these seemed benign enough, the research highlighted a very important fact – they didn’t really do a whole lot regarding symptoms and function. In fact, the placebo group often did better than the surgical cohort.

This revelation poked a well-timed hole in an age-old paradigm that “degeneration causes pain and dysfunction”. This article lays out common findings in us humans… once we’ve been on the earth for more than a few decades. Hopefully it won’t scare you (it may even empower you!) to see your bumps and bruises, your tears and herniations and spurs, as akin to ‘wrinkles’. Wrinkles never hurt anyone…they’re more of a testament to your longevity and resilience!

Did you know that…

  • 50% of patients over 65 with a symptomatic “full thickness” tear of their rotator cuff in the shoulder, will also have an asymptomatic full thickness tear on the opposite side.
  • 85% of adults have knee arthritis that does NOT cause pain.
  • Meniscal tears of the knee were found in 73% of asymptomatic 65-year-old study participants, and another study showed a 76% prevalence!
  • In uninjured, asymptomatic adults, the rate of osteoarthritic features rises from 4% (under 40 years) to 43% (over 40 years). With no corollary pain.
  • Approximately 1/3 of all people who have heel spurs have NO pain.
  • Labral tears of the hip were identified in 62% of those with hip and/or groin pain; but were also found in 54% of those without any pain at all.
  • Femoroacetabular impingement (FAI) of the hip was found in up to 54% of the athletic population and 23% of the general population. And yes, this was the asymptomatic population; not those in pain.

And some lower back stats…

  • Lumbar disc degeneration is present in 40% of individuals under the age of 30, and is present in 90% of those above the age of 50!
  • In healthy 20-22 year old adults with NO back pain, 48% had at least one degenerated disc, and 25% had a bulging disc.
  • 60% of people over the age of 50 who have never experienced back pain will have a disc bulge, while 80% will have disc degeneration.
  • 80% of those aged in their 40s-60s, who had a disc bulge visible on MRI, had no pain.

An important caveat to make, is that while these findings can be asymptomatic, they can also be uncovered as a pain source. The key take-home is that pain is multifactorial and looking at images will NEVER give you the whole story. As we’ve said before on this blog, “a picture of a telephone cannot tell you if it’s ringing or not”. This analogy holds true with the pain experience.

If those statistics haven’t sent you cross-eyed, well done, we’re almost finished.

So what conversation are we trying to change here?

We need to change the conventional understanding that things uncovered on medical imaging – regardless of how scary the terminology sounds – are not always a death sentence, nor a ‘pain sentence’ for that matter! Medical imaging is a fantastic resource for clinicians in confirming suspected diagnoses, but like some other good things, their ubiquitous use may have developed into a dependence rather than a resource. This has lead to some health professionals searching for a prospective pain source, rather than simply substantiating their findings.

As you can see from the above statistics, this is probably not a helpful approach… and may just lead to a lot of worried patients, with not a whole lot to worry about!

So a few reminders regarding your scans:

  • The findings were probably there before your pain began and will probably be there after your pain is gone. i.e. they don’t illustrate the amount of pain you should be feeling.
  • They certainly don’t dictate your ability to function. For example, while your neighbour might have a herniated disc that prevents him from doing the dishes, you may have a herniated disc that does NOT prevent you from sky diving!
  • Age related changes are more like “internal wrinkles” and should not be feared.

Our manual health professionals at Connect Healthcare have extensive training in reading and interpreting diagnostic imaging. We will explain to you what might be important, what is irrelevant, and what findings are helpful in diagnosing your condition.

Hopefully this piece has disarmed a few unhelpful beliefs, and has gone some way to changing future conversations…

References

  • R Brignardello-Peterson, G Guyatt et al. Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ Open (2017)
  • J Heerey, J Kemp et al. What is the prevalence of imaging-defined intra-articular hip pathologies in people with and without pain? A systematic review and meta-analysis. Br J Sports Med (2018)
  • T Bhattacharyya, D Gale et al. The clinical importance of meniscal tears demonstrated by magnetic resonance imaging in osteoarthritis of the knee. J Bone Joint Surg Am (2003)
  • W Brinjikji, F Diehn. MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis. AJNR (2015)
  • W Brinjikji, PH Luetmer et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology (2015)
  • A Culvenor et al. Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. Br J Sports Med (2019)
  • J Frank, J Harris et al. Prevalence of Femoroacetabular Impingement Imaging Findings in Asymptomatic Volunteers: A Systematic Review. Arthroscopy (2015)
  • E Karran et al. A quasi-randomised, controlled, feasibility trial of GLITtER (Green Light Imaging Interpretation to Enhance Recovery)—a psychoeducational intervention for adults with low back pain attending secondary care. PeerJ (2018)