MRI or No MRI? The Truth About Back Pain That No One Talks About

Is Your Back Pain a Sign of Something Serious?

The situation is all too common: you bend over to pick up something simple, and suddenly, your back seizes up, leaving you barely able to move. Your first instinct might be to assume the worst—that you’ve done some irreparable damage. However, you are far from alone. Around 80% of people will experience significant back pain at some point in their lifetime. Yet, not 80% of people are walking around in severe, chronic pain, illustrating the fact that most acute back pain tends to resolve relatively quickly.

Given the intensity of the pain, consider seeing your doctor or PT or going to the ER. When you’re in such pain, it seems obvious an MRI or X-ray should be ordered immediately. However, current medical guidelines strongly advise against routine imaging unless certain red flags are present, such as bladder incontinence or leg weakness so severe that you cannot bear weight.

The Limitations of Imaging

You might think, “ I’d just feel better knowing exactly what’s going on.” While that sentiment is understandable, it does not consider the limitations of imaging techniques like MRIs. Studies have shown that MRIs frequently produce false positives, detecting abnormalities that are not clinically significant. For example, many people without any back pain at all have bulging discs or degenerative changes on MRI scans. When such incidental findings occur in a case of back pain that would have naturally improved, they can create unnecessary anxiety and lead to invasive procedures, such as surgery or injections, that may not be needed (Chou et al., 2007; Jarvik et al., 2003).

In fact, healthcare providers are often doing patients a favor by not ordering imaging right away. Clinical guidelines consistently recommend against routine imaging for uncomplicated low back pain because it does not improve outcomes and can sometimes be harmful by prompting unnecessary interventions (Chou et al., 2009; Talmage et al., 2011).  In other words, most people improve without these tests, saving time and money while avoiding more invasive techniques that may not be necessary!

Are You Just Jumping Through Hoops?

As a physical therapist, I frequently hear this frustration from patients: I feel like I’m just jumping through hoops because my insurance company won’t approve an MRI until I do therapy first. While insurance policies can sometimes feel like an obstacle, in this case, they are actually aligned with best-practice care. Clinical research and guidelines from organizations such as the American College of Physicians (ACP), the American Pain Society (APS), and the National Institute for Health and Care Excellence (NICE) all emphasize that early imaging does not improve long-term outcomes for most people with acute low back pain (Chou et al., 2007; NICE, 2009).

If your symptoms persist beyond 30 to 60 days, or if you develop new concerning signs like those mentioned earlier, imaging may become necessary. Otherwise, getting an MRI or X-ray too soon may actually be detrimental to your recovery.

Evidence-Based Guidelines on Imaging for Low Back Pain

This recommendation is consistent across multiple professional organizations and clinical guidelines:

• American College of Radiology (2011) – ACR Appropriateness Criteria® for low back pain.

• American College of Physicians & American Pain Society (2007) – Joint clinical practice guideline emphasizing that imaging should only be used when serious conditions are suspected (Chou et al., 2007).

• Systematic Review & Meta-Analysis (2009) – Found that routine imaging does not improve clinical outcomes for most patients with low back pain (Chou et al., 2009).

• JAMA Randomized Controlled Trial (2003) – Demonstrated that rapid MRI versus radiographs for low back pain did not improve treatment outcomes (Jarvik et al., 2003).

• Occupational Medicine Practice Guidelines (2011) – Reiterated that early imaging is not beneficial in most low back pain cases (Talmage et al., 2011).

• NICE Low Back Pain Guideline (2009) – Advised against unnecessary imaging in the absence of red-flag symptoms.

The Bottom Line

If your doctor does not immediately order an MRI or X-ray for your back pain, it is not because they are dismissing your concerns. Instead, they are following evidence-based guidelines designed to ensure you receive the safest, most effective care. Early imaging often leads to overdiagnosis and unnecessary procedures, which can ultimately do more harm than good.

What is your best course of action? Follow your healthcare provider’s recommendations, engage in appropriate physical therapy, and allow time for natural healing. If your symptoms persist or worsen, then imaging may be needed. But in most cases, patience and conservative care are the best medicine.

Photo by Photo By: Kaboompics.com: https://www.pexels.com/photo/doctor-examines-woman-s-back-4506109/

My Shoulder Hurts. Now What?

By Andy Parsons, PT, DPT - Board-Certified Orthopedic Specialist

Shoulder pain is a common problem affecting many people across the lifespan.  Lifetime prevalence of shoulder pain is as high as 66% in the general population.  Pain in the shoulder can come from many different sources including arthritis, rotator cuff problems like tears and strains, or issues deep in the joint with the labrum. These are just a few of the potential sources of pain at the shoulder. 

When managing shoulder pain, you have many choices including the wait and see approach, anti-inflammatory medications, steroids, injections, physical therapy, and even surgery.  You can initiate care through your primary care physician, your physical therapist, or your orthopedic surgeon in most cases. Some avenues will require prescriptions and some specialists may require referral.  Treatment should ultimately be chosen based on the diagnosis. Rotator cuff tendinopathy and tears are among the most common problems at the shoulder. In many cases, it makes sense to manage shoulder pain conservatively with a physical therapist prescribing stretching and progressive strengthening/loading strategies.  X-rays and MRI tests are generally not indicated as a first line of assessment unless there was a specific traumatic injury. These tests can lead to false positive results if performed too frequently or too early in care. A good orthopedic exam from your physical therapist or orthopedic surgeon can give you much information and options for management. Working your way from most conservative treatment up to the most invasive is appropriate with most musculoskeletal problems.

In people aged 60-80 years old, 20-30% have rotator cuff tears at any given time. Typically, one third of the tears are symptomatic and two thirds are asymptomatic.  About half of the asymptomatic tears may become painful over time. Recent quality studies show that people with rotator cuff tears that do not undergo surgery get similar results to those that opt for surgery.  This outcome may depend if the tear was traumatic or more chronic in nature. Arthritis in the shoulder generally responds to stretching, hands on manual therapy, and NSAID drugs. Total shoulder replacements are a more invasive option if more conservative measures have failed.  Multiple factors determine what care path you choose including your preferences, diagnosis, and what treatment you have tried in the past. Either way, you have options to improve your condition.

Andy Parsons is a physical therapist at ProMedica Defiance Total Rehab at ProMedica Defiance Regional Hospital. You can call 419-783-6943 for more information.

Images source: CDC [Public domain], via Wikimedia Commons

**  This information is not intended to replace the advice of a physician/ physical therapist.

Dizzy? Physical Therapy can help with Dizziness and Unsteadiness!

By Andy Parsons, PT, DPT, Board-Certified Orthopedic Specialist, Vestibular Rehab Certified

When you look up into the cupboard, wash your hair, roll over in bed, or bend to look into a low cupboard does your world spin around you?   Do you feel more unsteady with walking, or do you feel like you're being pushed over? Is it difficult for you to walk down the aisle of the supermarket? Do you feel like you're intoxicated even though you haven't had any alcohol?   If you had any or some of these experiences, then you might be suffering from an inner ear problem. Dizziness often comes from a portion of the inner ear called the vestibular system. Issues in this area of the ear can cause the above symptoms or many other problems.

In fact, 35% of people forty and older have experienced a vestibular problem at some point in their lives.  Luckily, there are good treatment options for folks that are having inner ear dysfunction. The most common type of inner ear dizziness called benign paroxysmal positional vertigo (BPPV) creates a sensation of spinning when moving from sitting to lying, rolling over, or looking up for example. Some people complain of unsteadiness with this condition as well. One out of ten people 75 years and older have this problem. The gold standard treatment for this condition is a series of specific physical positions that reposition loose calcium particles in the inner ear.  Studies report success rates between 75-90% for this type of treatment. Medication is not generally helpful for this condition. This treatment is supported by the American Neurotology Association, the American Academy of Family Physicians, and the American Physical Therapy Association among others. Physical therapists with additional training often perform these positioning treatments for people with dizziness. This is generally accomplished in between 2-4 sessions.

Alternatively, the inner ear system can lose function from a variety of issues like infections, viruses, or diseases specific to the inner ear. People with these class of conditions may complain of increased unsteadiness, bouncing vision, falls, and slower walking. Vestibular rehabilitation can be very effective for these people to increase balance and stability with walking by training the brain to compensate for the inner ear problem. Guidelines recommend around 6-8 weeks of treatment for this type of vestibular problem.

Dizziness is a complex subject. Not all dizziness comes from the inner ear.  Lightheadedness is the most common issue that is generally not responsive to physical therapy.  Talk to your doctor or physical therapist about whether or not this type of treatment would be appropriate for you.

Andy Parsons is a physical therapist at ProMedica Defiance Total Rehab at ProMedica Defiance Regional Hospital. He is certified in Vestibular Rehabilitation and has nearly 9 years of experience working with “dizzy” patients. You can call 419-783-6943 for more information.

References:

1. BPPV: Experts Update Best Practices for Diagnosis and Treatment. Am. Academy of Otolaryngolgy- Head and Neck Surgery. https://www.entnet.org/content/bppv-experts-update-best-practices-diagnosis-and-treatment

2. Vestibular.org

3. Image source: Pixabay via Kalhh. https://pixabay.com/photos/trees-away-nature-eddy-turn-dizzy-358418/