X-Rays, CT scans and MRIs are useful tools when your doctor is trying to determine what is physically damaged or degenerated inside your body. They can give you tangible evidence of something physical that you can blame your pain on, but they often detract from the process of trying to determine why that structure is damaged. A significant finding on a diagnostic test can tend to stop the clinician’s critical thinking process required to push past what is injured and instead figure out why it got injured. This concept is particularly relevant in chronic pain issues that don’t stem from a traumatic accident, but is also important in cases that started with a trauma, but the person didn’t heal or improve along the expected time line.
An over reliance on hands off diagnostic tests is a fundamental reason why the medical model doesn’t deal very well with people with persistent pain issues and why experienced manual therapists like physios and osteopaths simply speak a different language than doctors. Doctors will look at the pictures of inside of you, or commonly just read the report that another doctor wrote about the pictures of inside of you and then tell you what they believe to be wrong. A good manual therapist will feel, watch and experience your movements with you to try and understand the movie that is happening in your body instead of the pictures of the aftermath. A significant finding on an MRI or EMG study can be a red herring and distract you from what the underlying problem really is.
A healthy body is one that has good physiological movement in the joints, muscles, nerves and organs. Tests that don’t assess the body in vertical or during functional movements shouldn’t be relied on too heavily to conclude what is or isn’t wrong with a person. I have seen people that move well and have no pain, but horrific looking spinal X-rays, as well as people that are functionally crippled but don’t show anything on MRIs or EMGs. Medical tests should be taken into consideration after a proper and thorough physical exam has been performed that involves functional movements and skilled palpation.
The physiotherapist’s skill set lies in understanding the interconnection between the boney, muscular, fascial and visceral systems as they relate to movement. Not having the ability to freely order tests, inject painkillers or prescribe medications has required physiotherapists to expand their tool box to understand and treat the body in a physical and conservative manner. Conversely, family physicians tend to lean on tests and medications and can roll their eyes at the mention of a physio working on the mobility of a specific rib to fix a shoulder problem or releasing fascia around the small intestine to decrease back pain. Manual therapy is a profession that lends itself more to clinical mastery than evidence based practice and unfortunately this has created a communication barrier between doctors and physios.
Evidence based medicine suggests that doctors only utilize treatments that have the highest levels of evidence as proven by rigorous studies and clinical trials. It is a practice that makes sense and one that I support, but it is a process that is too black and white for the subtleties of physiotherapy to be evaluated upon. The physiotherapy approach to pain requires dealing more with the person whereas the medical approach to pain tends to deal more with the symptoms and objective findings; sometimes you need one, sometimes you need the other, but usually you need both.
When I assess someone that has already had X-Rays or an MRI, I prefer to put the reports aside and get a sense of how the person moves, functions and feels before considering what the pictures say. Remember that X-rays largely just look at bones, MRIs visualize soft tissue, EMGs test nerve conductivity, ultrasounds can show your organs, but there isn’t really a test that can evaluate how well your systems are or aren’t working together. The trained human eye and hands can many times give you a better sense of what is going on than a series of disconnected diagnostic tests.
My point is that you should take every diagnostic test related to your pain with a grain of salt; they can be helpful but they can also be misleading. The body is a series of interconnected systems that requires more than a black and white picture to diagnose. Consider relying more on an experienced manual therapist to help you with your pain before trudging through the medical system with your discomfort. You will likely end up with a better understanding of why things hurt and how you can deal with them conservatively as opposed to medications, tests, injections and surgeries.
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