Low back pain (LBP) is the leading cause of “years lived with disability” and the second most common reason for a physician visits. Even with the prevalence of LBP not changing, the cost of managing LBP and the use of imaging for LBP continue to increase. The use of imaging for patients with LBP from 2002 to 2006 increased from 3.2% to 9.6%. Despite mounting evidence to the contrary, the general public and clinicians often believe that low back pain (LBP) diagnosis and management are enhanced through the use of MRI and CT imaging. In the USA alone, nearly $6 billion is spent on spinal MRI scans annually, stretching limited resources. The Magnetic Resonance Imaging (MRI) machine was first introduced in the 1970s and 1980s. It has come a long way in its quality and use in medicine over the past 40 years. The advantages of these high tech imaging tools is that they can rule out serious pathology. Unfortunately there is a downside to all these medical diagnostic tools such as the MRI, CT scanner and x-rays. When these tools are used for routine exams of a patient experiencing low back pain, neck pain or headaches, the results can be overwhelming.
Take my patient, Joanne (not really here name) a 62-year-old professional who was referred to PT due to an acute episode of back and referred leg pain (i.e. sciatica). She stated her physician first prescribed some medications and referred her to the radiologist for x-rays. After a month of continued pain and limited duties at work and not being able to exercise her physician ordered an MRI. Another few weeks pass with minimal to no changes in her symptoms so she was sent to physical therapy (PT). Now six weeks after the onset of her back pain Joanne was very worried and frightened to do anything because of the “results” of her MRI. She stated her MRI findings demonstrated “extensive damage” to many of her vertebrae, joints in the spine and 3 of her discs in her vertebrae where “crushed” and called degenerative disc disease (DDD). I spent a great deal of time talking Joanne “off the cliff”. She was already exhibiting fear and avoidance of moving and low expectations of recovery. After explaining to Joanne that these MRI findings of her back are actually quite normal age related changes to her spine. I used the metaphor of the wrinkles on an elderly persons face is a normal age related change and we don’t call that degenerative skin disease. The MRI machine is so sensitive that it picks up every single “wrinkle” on the spine. I told her that was the most expensive “selfie” you have ever taken of your spine. I explained that people with no history of back pain have the same looking findings on MRI. We all have wrinkles on our spine and if you are 60+ years old you’re going to have lots of these normal age related changes to the spine. She slowly came down from her anxiety and started to understand that these new imaging techniques are great for finding cancer and real serious stuff but her MRI results where actually quite normal. Within a month Joanne was back to full recovery, exercising daily and hiking on the weekends with her husband. On her last visit she stated to me, “I wish I would have never had that MRI. Because I still think of those discs being crushed and wondering when that pain will come back.” As you can see, for Joanne and many people with back pain the first line of treatment according to the peer reviewed literature is to get Physical Therapy first. She still has some fear but will get through it with continued focus on movement and not focus on “structure”. Physical Therapy can provide the patient with a safe environment to get moving in a cost effective manner.
Research has shown that getting an MRI before physical therapy can cost $4,793.00 more than getting PT first. I keep this poster in my clinic for quick reference. The MRI imaging for routine back and neck pain is so over used that even the major medical journals in the world are changing the guidelines for managing patients with LBP to include physical therapy first and only get imaging if conservative treatment fails. Lastly, several studies have demonstrated that early MRI without indication has a strong iatrogenic effect (patients begin to experience LBP after seeing their MRI results) in acute LBP regardless of radiculopathy (leg pain) status. Physicians and patients should be made aware that when early MRI is not indicated, it provides no benefit, and worse outcomes are likely.