Evidence Based Practice

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/

Myth Busting - Running and Joint Health

The common popular opinion is running is bad for your knees and hips.  A recent systematic review from JOSPT shows the is opposite may be true.  This large observational studies shows lower rates of OA in recreational runners.

 

 

Reference:
Alentorn-Geli, Eduard, et al. "The Association of Recreational and Competitive Running With Hip and Knee Osteoarthritis: A Systematic Review and Meta-analysis." journal of orthopaedic & sports physical therapy 0 (2017): 1-36. 

Case Study in Cervical Imaging: The Canadian C-Spine Rule

By Andy Parsons, PT, DPT

The following article was written for Medbridge- an online, video based continuing education based company.

Over the last two months, you’ve treated Jean for weakness associated with MS and radiating low back pain. Today, she presents with a new issue. Over the weekend she fell twice, striking her head and neck against the wall. She now complains of neck pain.

Prior to the falls, she experienced diffuse chronic pain, including some neck pain. Currently, she has numbness down her right upper extremity as well. You note that she is rotating her neck approximately 60 degrees bilaterally but the motion is guarded. Her midline c-spine is tender to palpation.

What’s a clinician to do? Do you refer Jean to imaging due to the neck pain? She’s had numerous falls before and a history of chronic neck pain. Will you be wasting your physician colleague’s time and resources? Or, is this a potentially serious situation that requires imaging?

Using the Canadian C-Spine Rule

There is a well-studied clinical prediction rule (CPR) that can help you make this determination.1,2,3,4 The Canadian C-spine Rule helps you decide if imaging is needed in cases of neck trauma. The sensitivity of the Canadian C-spine Rule is reported between 95% and 100%.1,2 This means the CPR is almost 100% accurate in ruling out pathology if the rule is negative. That’s one powerful screening tool for your toolkit!

 

The rule is broken down into three sections. Jean must pass all three sections in order to defer imaging. Per the rule, Jean has paresthesias in the upper extremity that are worse since the fall, tenderness at mid c-spine, and possible dangerous mechanism; therefore, you would refer the patient for radiography of the c-spine.

Precautions for Implementation

The c-spine rule has gone through several steps of research validation, but it has been studied exclusively in the emergency department. Therefore, applying this rule in an outpatient setting may be considered outside of the rule’s validated use. Mindful application of this clinical prediction rule can still inform clinical decision making.

Expanding Your Toolkit

The Canadian C-spine Rule provides some additional insight and aids your clinical decision making. It’s quick, easy, and improves patient safety for radiography referrals.3,4 Add it to your references and use it when you get a case like Jean.

References

  1. Stiell, Ian G., et al. “The Canadian C-spine rule for radiography in alert and stable trauma patients.” Jama 286.15 (2001): 1841-1848.

  2. Stiell, Ian G., et al. “The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma.” New England Journal of Medicine 349.26 (2003): 2510-2518.

  3. Bandiera, Glen, et al. “The Canadian C-spine rule performs better than unstructured physician judgment.” Annals of emergency medicine 42.3 (2003): 395-402. http://dx.doi.org/10.1016/S0196-0644(03)00422-0

  4. Stiell, Ian G., et al. “Multicenter prospective validation of the Canadian C-Spine Rule.” Academic Emergency Medicine 9.5 (2002): 359.

**  This information is not intended to replace the advice of a physician/ physical therapist. Andy Parsons, PT, DPT disclaims any liability for the decisions you make based on this information.

Ottawa ankle rules: A practical example of EBP in motion

By Andy Parsons, PT, DPT

I find that many clinicians still misunderstand what EBP is and what it can do for them. The following is a practical example of how I used EBP in the clinic the other day to aide quick, quality clinical reasoning. 

I was working with a 76 y/o female on balance and generalized weakness after a recent string of falls. She was progressing well, so we were increasing difficulty of dynamic balance activities. The patient was performing lateral step-overs across a short hurdle (which she had performed many times successfully). Unfortunately, the patient missed and rolled her ankle on the hurdle. She had immediate pain, and had difficulty weight-bearing through her foot. I let her rest about 5 minutes, but she was still ambulating with an antalgic pattern. The question was: Did she sprain her ankle or fracture a bone in her foot or ankle? Did I need to refer her to PCP, ED, or MD? Did she need imaging?

I decided to utilize a clinical prediction rule (CPR) called the Ottawa ankle rules. The Ottawa ankle rules were developed to aide in clinical decision making when assessing if an ankle or foot injury requires radiography. This CPR is extremely well established and has been through 1. preliminary identification of factors 2. validation(1) 3. Impact analysis.(2)  The Ottawa ankle rules has been found to have nearly a 100% sensitivity which means its ability to rule out fracture with a negative result if excellent (1).

Here is what the rule looks like:

My patient had bone tenderness at location C and had difficulty weight bearing. This took much of the guess work out of the equation. I referred her to urgent care because her PCP was booked and she received foot/ankle x-rays. The final images were negative, but the CPR allowed me to make an appropriate referral quickly vs. telling the patient to wait and see how she felt. Even when I was oblivious the the Ottawa ankle rules, I would have referred the patient due inability to weight-bear, but this made the decision more efficient, and gave me something concrete to communicate to the physician. A tool like this can help convince and apathetic patient of what they need as well. 

CPRs are one phenomenal way the evidence can aide in day to day clinical reasoning. Here are a few other examples:

  • Ottawa Knee Rules

  • Well's Clinical Decision rule for DVT

  • The Canadian C-spine rule

Dr. John Snyder has a great list of CPRs most related to PT over at his website.  Just know, that many of these CPRs have not gone through sufficient validation or impact analysis, so the may not be ready for "prime time" use. 

Accessibility is one major barrier against using tools like the Ottawa ankle rules.  My solution is Evernote. Evernote is a multi-platform app that stores just about anything you'd want to remember.  I use a laptop all day for documentation so it's easy to pull up content. I can typically have a resource like the Ottawa ankle rules pulled up within 5-10s. This is especially true if you utilize tagging systems and organize notes into separate notebooks. The same is true for a smart phone or tablet. I have over 2000 personal and work related notes after using it heavily for about 4 or 5 years now. It's a smart tool for any clinician! (Did I mention the basic version is free?)

Disclaimer- I am by no means sponsored by Evernote; I just love their product!


References:

  1. Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review.BMJ : British Medical Journal. 2003;326(7386):417.

  2. Stiell, Ian G., et al. "Implementation of the Ottawa ankle rules." Jama 271.11 (1994): 827-832.

Banner Image: "Broken Ankle- Side X-ray" via Flickr by Jared Zimmerman
Image: "Evidence of Organized Light" via Flickr by Jared Tarbell

 

**  This information is not intended to replace the advice of a physician/ physical therapist. Andy Parsons, PT, DPT disclaims any liability for the decisions you make based on this information.