Posted on April 6, 2019
In 1996, researchers traveled to Western Australia and interviewed people from a few different Aboriginal tribes. They found about 50% of them had low back pain, but very few reported any disability because of it.1 Fast forward to 2013, researchers returned with a similar study design and their findings demonstrated mass disability related to low back pain.2
What changed? More westernized medicine had arrived to the area with x-ray and MRI scans. When patients received imaging for their back pain they were told things such as, “that doc said I had a slipped disc… it (getting worse) all depends on you move or lift” and “if you overdo it, you just, you know, you might eventually end up in a wheelchair for the rest of your life.”
We’ve all heard of the placebo effect, but this demonstrates the scary power of the nocebo effect. The only variable that changed in this series of studies was people being told that their bodies were broken. Their actual “broken” bodies didn’t change at all, just their perception of it.
So, where’s the line between appropriately investigating pain with tests including imaging versus other interventions? In general, imaging tends to be a poor correlate for your pain. That said, there are very appropriate times to image your body when clinical signs point to more sinister possibilities such as cancer, fracture, or complete tissue tear; however, many other times it will show a fair amount of wear that isn’t the cause of your pain.
The most recent primary care physician guidelines in 2018 reported that 90-95% of all cases of low back pain are non-specific.3 This means that your physician could run all tests available, including MRI, and ultimately not have an exact diagnosis at the specific cause of your pain. Pain is a very complex sensory experience of which many variables contribute, not just tissue damage.
While that is true, it’s also true that as we age, there’s a normal wear to expect in our body tissues. Just like we all develop more and more wrinkles as we get older and just like those wrinkles don’t cause you pain, your other body tissues don’t have to either. Again, don’t misconstrue, they can cause pain, but often they don’t! So, how much do we wrinkle on the inside? Quite a bit!
At the highest level of literature, Brinjikji and colleagues performed a systematic review of imaging of individuals without low back pain.4 The findings shown in table 2 are quite remarkable. Starting at age 30, in people without low back pain, it’s more common for imaging to show disc degeneration than not! After age 50, if you don’t have low back pain and you have a pulse (you’re alive), you have an 80% chance of imaging showing disc degeneration. So, some of these changes are normal, they’re more common as we age, and don’t result in pain; just like the wrinkles of our skin.
With a review of the literature, you will find similar results in pain free people in nearly every joint of the body. See the picture for a summary of just a few of the studies out there. I’ll use one last specific example from Schwartzberg and colleagues in which they studied 53 males, 45-60 years old, who reported their shoulders as pain free. They found that 55-72% of them demonstrated SLAP tears (a type of labral tear in the shoulder).5 Again, you’d be more abnormal not to have positive findings on imaging; wrinkles on the inside.
Here’s another great explanation of our “wrinkles on the inside” (warning: the last 30 seconds of the video uses adult language while quoting what someone said about pain):
So, what do we make of this?
- Pain is very complex and often doesn’t correlate with imaging (remember, 90-95% of low back pain is non-specific).
- Some level of arthritis and soft tissue “injury” is a normal part of the aging process just like wrinkles on the inside. Often these changes don’t cause pain.
- Exercise is one of the best treatments for any age related wrinkles (usual wear and tear).
With this in mind, if you’re struggling with pain, first try to be as active as you can with exercise that doesn’t make it worse and see if it improves. If it doesn’t improve, and it’s a pain problem, schedule an evaluation with your Physical Therapist. Most insurances don’t require a physician referral for Physical Therapy (other than Medicare). Your PT will perform a comprehensive evaluation and determine if you’re appropriate for Physical Therapy, which is the majority of cases. If you do show signs of systemic or sinister problems, we are trained to recognize these and will refer you to the appropriate provider for further assessment, which may or may not include imaging. We always ensure you have your regularly scheduled annual visit with your primary care physician.
Remember, your imaging does not define you. Sometimes it is very necessary, but most the time it will just show you an inside look at your wrinkles. Pain is a normal part of the human experience and usually gets better on it’s own. Regular exercise can help expedite the process and decrease risk for future pain. If you need help, a Physical Therapist at Corvallis and Albany Sport and Spine is an excellent place to start! We love helping our community work, live, and play again! Keep moving and don’t worry too much about those wrinkles; we all have them!
Dane Happeny, PT, DPT, OCS
Board Certified Orthopedic Specialist
- Honeyman PT, Jacobs EA. Effects of culture on back pain in Australian Aboriginals. 1996; 21:841–843.
- Lin IB, O’Sullivan PB, Coffin JA, Mak DB, Toussaint S, Straker LM. Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians. BMJ Open 2013; 3:e002654. doi:10.1136/bmjopen-2013-002654.
- Oliveira CB, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: un updated review. Eur Spine J. 2018; 27:2791–2803; https://doi.org/10.1007/s00586-018-5673-2.
- Brinjikji W, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. Am J Neuroradiol. 2015; 36(4): 811-816; DOI: https://doi.org/10.3174/ajnr.A4173.
- Schwartzberg R, Reuss BL, Burkhart BG, Butterfield M, Wu JY, McLean KW. High prevalence of superior labral tears diagnosed by MRI in middle aged patients with asymptomatic shoulders. Orthop J Sports Med. 2016; 4(1), DOI: 10.1177/2325967115623212.