An MRI or other imaging study .
What is important to know is that an X-ray or MRI reflects the past in addition to the current situation. So it may show abnormalities that have nothing to do with the current pain. Compare it to scars, these are signs of old injuries but no longer painful or necessary to treat. So the results of a scan or photo should always be compared to the current situation. Do the symptoms really match the results of the examination? Radiologists look very objectively at what can be seen on a photograph and often do not know what the person's physical symptoms are. We know from research that our bodies are subject to aging. Like gray hair and wrinkles, this effect also occurs in our bodies. So from a certain age, we are always going to see abnormalities! In this blog we explain when it becomes wise to have further research done anyway but also when it is better to wait a little longer.
The usefulness of an MRI
Using an MRI at the right time is a fantastic tool to get clarity on someone's medical situation. But we now also know that we see different abnormalities in people without pain symptoms. In study from 2015 in which 3110 subjects without pain symptoms had an MRI or CT scan of the low back, we see that different abnormalities of the low back increase with age. So the older you are the more signs of wear and tear on the back. Again these individuals had NO symptoms. Just like getting wrinkles and gray hair on the outside the body is also subject to aging on the inside.
Thus, the result also shows the past. However, it could possibly be a clue if the lesion that is seen also matches the current symptoms. So the results of your MRI or X-ray could be looked at with a little more nuance. When this is done without any context to the story, unpleasant situations arise. It is dangerous to make a statement about someone's symptoms without ever having seen that person. What can be seen on images does not always correspond to the experienced complaints.
For serious conditions, an MRI is certainly a godsend. Current technology makes it possible to get a clear picture of deeper structures. Necessary when quick action is needed. Only problem is that quite often they are false alarms. Again when radiological reports are prepared without any context, communication goes wrong. In this way, the results of an examination are often presented as a kind of diagnosis. With regard to low back pain, we can hardly find an explanation for the pain through a result of an MRI or X-ray (extreme cases aside).
In physical therapy, we use questionnaires to score the degree of pain and impairment. Research shows that in a large group of people the experienced pain and limitations actually increase after an MRI. This can be explained by the nocebo effect (opposite of placebo). The bottom line is that when we look for abnormalities in the low back, they can always be found. If pain-free people can see anything on an MRI, so can people with back pain. The result of (too) much examination is that people become anxious and panic. In the long run, this often causes unnecessary anxiety and panic.
When is it necessary to look further, though?
Guidelines indicate that an MRI is a logical choice in people with low back pain with the presence of red flags. There is always a small risk of reassuring people where further investigation is actually needed. But in 99% of cases, it is appropriate to wait and see. Most back pain feels worse than it is.
When do you know if you are dealing with an exception?
1% of low back pain cases involve a condition where acute medical intervention is necessary. These serious conditions stand out and are therefore rarely but missed. The rule of thumb is that further investigation may be necessary when symptoms persist for more than 6 weeks these symptoms can absolutely NOT be reduced by changing positions and the pain increases over time....
When these symptoms are present, you should also not wait to investigate further:
- Sensation of numbness in the pubic area and/or incontinence symptoms
- When you have been in an accident where the forces are great enough to possibly cause a fracture of your spine
In all other cases, further examination is not necessary. Even when you experience pain in the leg along with numbness of the skin or tingling in the leg. Also when you have clearly strained your back while lifting your car, for example. Your back is not as vulnerable as you think! Even when a herniated disc is suspected (based on the symptoms present), waiting is the best choice. In the first month of a herniated or stenotic disc, we see that on average the symptoms decrease by 50%. Should significant symptoms still be present after this month, it is always possible to have an MRI. In extreme cases, surgery or an injection can be a solution. But in most cases a herniated disc or a similar image recovers within 3-4 months. Another factor in deciding whether or not to have an MRI/photo is that in most cases the treatment plan is not going to change. Whether you have an MRI or not, pain relief, advice, exercise therapy and possibly some treatment are the chosen treatment plan. So with or without a result the same thing happens in practice. When we know that the anxiety increases after an MRI, it is better NOT to do it.
When severe signs of symptoms (red flags) do occur or there are symptoms that do not diminish over time, or even get worse, an MRI is a good choice. Most importantly, the results of different scans should always be interpreted in the proper context. It is NOT an abnormality when it does not match the person's perceived symptoms. Thus, aging of the body is normal.
But why don't we just put everyone under an MRI or X-ray? Why is it so important to do imaging studies at the right time for people with low back pain?
No one likes a false alarm. X-rays and MRIs are often exciting. And there is nothing more dangerous for people with low back pain than fear! Fear of what might be going on in that back contributes negatively to low back pain. When you type low back pain into Google, we also get grimy about what you see coming up.
It adds nothing in most cases. A mountain of scientific research shows that much examination of the low back actually leads to more symptoms and limitations(1). At this point it becomes annoying to the person themselves and they are only further from home. This person is going to be treated or perhaps examined further for something that is not the reason for their symptoms. Low back pain is no longer being dealt with appropriately. This is why healthcare costs for people with low back pain are so incredibly skyrocketing.
Sure, there are exceptions. Sometimes it is really necessary to have a scan or photo to prevent worse. As I explained above. But it is often a poor way to try to find an explanation for your symptoms.
What can you do yourself?
Despite many new studies coming out indicating that X-rays and MRIs should be taken with a grain of salt, people still get all kinds of diagnoses thrown at them. Another example is a back scan that is usually done at the chiropractor's office. This scan says absolutely nothing about your back pain! Posture and certainly minimal abnormalities have nothing to do with pain or even health. In an ideal situation, all health professionals would be better trained in either advising, reading and explaining imaging studies. Unfortunately, these things always take time.
What you can do yourself:
- Refuse early imaging! When you get back pain and your physical therapist, family doctor or chiropractor directs you to have imaging studies, thank kindly but don't act on it. Most symptoms will subside structurally within 6-12 weeks.
- Take results of imaging studies with a large grain of salt! Keep thinking logically and don't let yourself be talked into anything unnecessarily.
- In specific cases, a dynamic recording of the back or a different position of the spine is possible. This will probably show a different image than the standard position of an MRI or X-ray. If you have pain with a bulging back and the MRI is taken in a neutral position this does not show the correct image of the painful structure.
Low back pain is often a difficult subject. If we really had a clear answer to low back pain there wouldn't be so many people with back pain. Often we often want to explain back pain bottom-up. That is, we think the pain comes primarily from the back. While we have very much scientific evidence that the degree of back pain and especially chronic back pain is strongly influenced by our brain, top-down. Believe in recovery, keep moving and don't panic unnecessarily!
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