A few weeks ago I had a brief conversation over the phone with a patient who had been referred to therapy with low back pain. Early on in our conversation, he asked a question that I found to be very intriguing, “Is it normal for you to be sent to physical therapy before they know what is wrong with your back?” The patient was skeptical of what physical therapy could offer him without first having an x-ray or an MRI to “see what was going on.”
If you have been one of the 31 million Americans who experiences low back pain at any given point in time, then you more than likely considered an MRI or had a friend or family member do so. We can’t see what’s under our skin causing the pain so we would want the MRI to show us. The problem is that the MRI doesn’t always tell the full story. ‘Abnormal’ findings on an MRI are very common for people without any pain and ‘normal’ findings are also common for those who do have pain. For that reason, as well as the simple cost of the procedure, we need to tread lightly down the path of diagnostic imaging because it often doesn’t “diagnose” anything at all.
Research has shown that up to 30% of people in their 20’s without symptoms have disc bulges in their neck, and this incidence only increases with age.1 The same goes for the low back. We use detailed image
The same goes for the low back. We use detailed images from an MRI and can easily find things different between individuals because everyone’s body is unique. These minor differences are often considered ‘abnormal’ but do not necessarily cause pain, and more importantly, these likely don’t have any bearing on your treatment plan. More than 60% of the 98 people included in a study from The New England Journal of Medicine had disc abnormalities at least at one level, 34% had disc abnormalities at more than one level, and 0% of those people had back pain.2 With this in mind, knowing the true issue and source of pain can be confusing and be overwhelming for individuals to think about.
Physical therapy has seen a shift away from strictly considering individual joints and muscles to form diagnoses; instead, we look at movement patterns. It’s important to view how your entire body moves and then break it down and go from there. With that in mind, dysfunction can present in different ways and can cause pain for different reasons. Low back and neck pain are extremely common in a society where we spend more time than ever sitting and looking at computers and cell phones. What is also common are issues with the hips, thoracic spine and shoulders which cause low back and neck pain. For reasons like this, it’s important to step away from the idea of imaging the spine as means of diagnosing a patient’s problems and instead to assess their overall movement, target areas where they may not be moving as well as they should and then correct movements with exercise.
I’ve encountered patients who have walked into the clinic with MRI results from a neurosurgeon that showed significant disc herniation, but the patient had very infrequent low back pain. So infrequent that the surgeon told him he wouldn’t even consider operating, “because he doesn’t treat the MRI, he treats the patient”. I’ve also seen the other end of the spectrum, having a patient limp into the clinic, hunched over, clutching her low back and in tears due to pain. Her MRI results came through the fax machine 48 hours later with “no acute findings”. What we need to remember is that while an MRI can definitely serve a purpose, we should probably choose another route first, especially with any issues related to the spine.
http://www.drrahiminejad.com/Files/MyDocuments/Image/20167995646cervical%20MRI.pdf
http://www.nejm.org/doi/full/10.1056/NEJM199407143310201#t=article
