Don’t I need to have an MRI before you can help me in physical therapy so that you know where my low back pain is coming from?
That is a common question that we as physical therapists will get when beginning treatment of a person with low back pain. The answer to that question is a resounding NO! In the absence of serious signs that we call red flags, imaging is NOT necessary and can in fact be counter productive. Once someone is told that they have a specific pathology and have seen the images of their pathology, that person can develop fear and anxiety about moving or doing activities of daily life. This can lead to worsening pain, depression, and chronic pain. By doing a thorough examination, we can determine our physical therapy treatment plan based on the person’s presentation. We can also make some assumptions about the underlying pathology based on our examination findings and the person’s response to initial treatments. This process will also avoid the unnecessary expense of imaging. See the image below of the “musculoskeletal funnel” taken from Richard Zhao and Jim Hoyme.
With early imaging here is also a high risk of false positive findings due to the large presence of abnormal findings on MRI’s and CT Scans of asymptomatic people. See the table below taken from an article in the American Society from Neuroradiology based on advanced imaging of 3,110 asymptomatic individuals. (Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations by W. Brinjikji et al. in Nov 27, 2014 as 10.3174/ajnr.A4173).
Additionally, disc pathology has the potential to heal without surgery and should be given the change to heal prior to advanced imaging in the absence of red flag symptoms. A recent article in the New England Journal of Medicine (Images in Clinical Medicine: Resolution of Lumbar Disk Herniation without Surgery by Jennifer Hong, M.D., and Perry A. Ball, M.D. N Engl J Med 2016; 374:1564 April 21, 2016DOI: 10.1056/NEJMicm1511194) showed a MRI of a large disk herniation (Image A below) resulting in substantial spinal stenosis (narrowing of the spinal canal) and nerve root compression in a 29 year old female who was presenting with low back pain and right leg pain with paresthesia (tingling). This patient elected not to have surgery and her symptoms resolved with conservative management including physical therapy and a steroid injection. Five months after her original MRI, a second MRI was done which showed resolution of the disc herniation (Image B below).
In this case, if physical therapy was tried first (through direct access to physical therapy or early referral to physical therapy by her primary care medical doctor) then the expense of the MRI and injection could have been potentially avoided. That of course assumes that this person would have gotten better with physical therapy alone. If she would have accessed physical therapy early and was not getting significantly better within 2-4 weeks, or if her symptoms were to rapidly worsen during initial treatments, or if red flag symptoms became present, then the physical therapist would have had her consult with her medical doctor who would have likely then recommended medication(s), advanced imaging, and injections based on the results of the imaging. This person ultimately had an MRI, an injection, and physical therapy, and her symptoms resolved. The second MRI image also proves that a lumbar disk herniation can heal/resolve without surgery.
If you are having low back, please contact me or another one of our many skilled physical therapists at OSI Physical Therapy. We will help you recover from your low back pain with a proven, efficient, and cost effective treatment.
– Steve Schneider, PT, MSPT, CMPT.
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