Is Imaging the Way? How Patients Can Manage Lower Back Pain through Education

From a physical therapy perspective, causes of back pain can range from simple to complex, depending on a lot of variables and factors. “Simple” causes are those that we can easily identify the moment of injury and tissue involved such as a lumbar muscle strain from overloading the muscle with repetitive and exaggerated movements like frequently bending over, lifting something too heavy too fast, or any other movement or stress that surpasses the threshold the muscles can support. Healing these injuries can be more predictable and straightforward when compared to more complex cases of lower back pain. Lower back pain can be considered complex if you have been experiencing back pain for >3 months (yes *just* 3 months!!), if the pain started with no significant cause or event, if the pain is more chronic or more unpredictable, and if the pain extends beyond the back to the hip, behind the knee, or to the foot.

If you've experienced lower back pain, you may have seen your orthopedist, neurologist, or spine surgeon and been recommended to get an x-ray and MRI. When they are looking at an MRI they are looking for specific changes to the tissue, joints, and discs such as arthritis in the joints of the spine, narrowing of the spaces between the vertebrae, scoliosis, osteoporosis or bone loss in the vertebrae, a herniated disc which is when the contents in the disc bulge out of the surrounding ligament, and pinched nerves. However, and I cannot emphasize the following enough…just because there is something that shows up on your x-ray or MRI does NOT mean that is the primary cause of your pain. I’ll get back to this shortly so put a mental bookmark there.

Many times, the primary culprit of low back pain is due to habits. Usually, it's the activity or posture you do the most that is a major contributing factor to your pain. For example: sitting with your spine rounded the entire day as you stare at a computer screen, leaning on one side of your hip when you’re commuting, wearing the wrong shoes, carrying and feeding your baby on one side all day, sleeping on one side, repetitive twisting and bending without using your core, I could go on forever!

Another major reason for the increasing trend in low back pain is the work from home phenomenon. Many people “Macgyvered” a workstation out of their kitchen tables and kitchen bars, creating a perfect slouching, sitting, and forward head posture environment…a PT’s nightmare! Studies show that sitting creates up to 20-40% more load on the spine, which is increased even more with slouching. Sitting isn't the new smoking like we've been told, but sitting without changing positions and moving throughout the day definitely won't help your spine health. All this may seem obvious, but reflecting on your movement, posture, and habits could save you the hassle of visiting the doc.

"up to 97% of patients without symptoms of low back pain have bulging discs or degenerative disc disease"

Okay, now back to imaging, ready for this rant? Brace yourself! Imaging is not necessarily the answer. In a 2020 study by Jacobs et. al, the authors concluded that patients who had an MRI performed earlier in their episode of lower back pain had a higher rate of undergoing spinal surgery and taking prescribed opioids. Even worse is that these participants reported a higher intensity of pain one year after surgery versus those who did not have an MRI early in their care. Interestingly, other studies have indicated that up to 97% of patients without symptoms of low back pain have bulging discs or degenerative disc disease, indicating that positive findings on imaging do not correlate with pain. A positive finding on an MRI isn't necessarily the source of your pain because these findings are so common in the general population. Two other large studies concluded that patients that received imaging without sufficient indication for it did not have better outcomes in terms of pain, function, and quality of life as compared to control groups who did not receive imaging.

Another interesting fact is that 6 out of 10 asymptomatic middle-aged people who receive imaging have positive findings such as disc bulges, but would never know otherwise. Basically, what we know based on the evidence is that positive findings on an MRI are totally normal. Changes to our connective tissue are normal. That's why so many people have positive findings on their MRIs, even when they don't have any back pain, sciatica, or changes in function. Changes to our ligaments, discs, and joints are as normal and expected as getting wrinkles on our skin as we age.

individuals who chose advanced imaging instead of physical therapy were more likely to undergo surgery, receive injections, have more ER visits, and to consult with multiple specialists

When you're considering getting an MRI for your back pain, consider what that image will tell you. If you have a herniated disc or "pinched nerve," are you going to go straight for surgery? Especially if we consider that these positive findings may not even be the source of your pain. Or are you going to try conservative, non-invasive care first? In a study by Fritz et. al, individuals who chose advanced imaging instead of physical therapy were more likely to undergo surgery, receive injections, have more ER visits, and to consult with multiple specialists. Going to physical therapy (PT) first can save you time and money.

How does PT help?

The primary (and not so obvious) component is educating our patients on their source of symptoms, how to optimize healing, what to expect as their rehabilitation progresses. It’s natural and understandable to have anxiety about the unknown cause of your pain, how long it will last, and what you should do about it. Studies indicate that anxiety-promoting information (such as advice to never swing a golf club again! or don't bend over, it's bad for you back!) can increase sensitivity to pain, delay recovery, and promote disability, thus worsening your symptoms. If the pain has been chronic, meaning you've had it for >3 months, brain activity for pain can be rewired to more emotional centers in our brain. This means you may avoid a movement that has provoked pain in the past, and your brain now associates that movement with fear, anxiety, and harm because your nervous system has been communicating this information to your brain for so long. 

Therefore, as physical therapists, our role is to provide patient-centered care and educate on the cause(s) of pain, thoroughly review treatment options, methodically and strategically expose patients to movement that has been historically painful, and most importantly, involve patients in decision making about their plan of care. It has been reported that patients have felt dismissed by healthcare providers, thereby breaking trust and willingness to comply with suggested treatment interventions. Many studies have also indicated that when patients were provided with validations of their symptoms, there was a higher success rate of adherence, patient satisfaction, and reduction of stress.

I’ll give you a real-life scenario. My husband begged for an MRI of his shoulder from years of playing competitive volleyball. It cost around $500 out of pocket. Results revealed a full tear of his supraspinatus, one of the rotator cuff muscles, tendon, and he immediately scheduled surgery as suggested by the orthopedic doctor. As most PTs know, spouses are the worst patients, and this decision was made before I even discussed conservative treatment options. Over the weeks leading up to his surgery, with more independent research, physical therapy strengthening, and lengthy discussions about his pain, his pain disappeared and he canceled his surgery. I am happy to report that he continues to be pain free 2 years later!

Imaging is expensive and unnecessary, and patient education is imperative to healing and managing pain. This saved my husband from unnecessary surgery that would have entailed pain medications, absence from work, reduced function for at least 3 months (but likely much more), and he would have needed at least 6 months of PT if he had followed through with surgery, as opposed to his few weeks of physical therapy without surgery.

The estimated annual cost of low back pain was $100 billion annually, attributed to low productivity and lost pay. The ultimate goal of PT is to promote self-management, providing patients with inexpensive tools to resolve pain, improve movement patterns, and you know it…educate on WHY we are doing these interventions. I hope you wouldn’t just take any medication if you didn’t know WHY you were taking it. For PT, movement is our medication and prescription, so it’s also extremely important for patients to understand the rationale behind it.

Works Cited:

Epidemiology and Natural History of Low Back Pain

Back Pain

Observational Study of the Downstream Consequences of Inappropriate MRI of the Lumbar Spine

Do not routinely offer imaging for uncomplicated low back pain

Reducing the prevalence of low‐back pain by reducing the prevalence of psychological distress: Evidence from a natural experiment and implications for health care providers

Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits

Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis

Physical Therapy or Advanced Imaging as First Management Strategy Following a New Consultation for Low Back Pain in Primary Care: Associations with Future Health Care Utilization and Charges

The effectiveness of patient education in improving pain, disability and quality of life among older people with low back pain: A systematic review

Person-centred education and advice for people with low back pain: Making the best of what we know

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