As a clinical physiotherapist who has been treating patients with low back pain for over 24 years, Dr. Panagopoulos recalls a period when MRI was not available.
Then, in the early 2000s, people began showing up to their appointments with these new scans. Of course, we were all ecstatic. There were a lot of soft tissue, discs, and other anatomies to examine!
The resolution of MRI technology has increased to the point that we can now detect a lesion as small as 2 mm in length. This technique has proven important in cancer therapy, as it serves as a vital diagnostic tool.
Understandably, the usage of MRI has skyrocketed, as has the expense to governments and the public health budget.
In recent years, researchers have begun to look more closely at the use of MRI in low back pain and have questioned, "Has MRI truly benefited us, physiotherapists, in the diagnosis of low back pain?"
The answer is dependent on what you want to use it for. To understand this, it is important to understand pain.
For many years, we assumed that all pain was experienced by our brains from the bottom up, similar to burning your finger on a hot skillet. That is, when a person's finger contacts a hot plate, it activates some kind of pain receptor, which then stimulates pain centers in the brain, and the person feels pain.
However, pain perception is not that straightforward, and research over the past 15 years has shown that pain is generated in collaboration with the brain.
Depending on the context of the pain experience (for example, being bitten by a poisonous snake several miles from assistance vs a paper cut), the individual may view the pain as very threatening and a big emergency or as a little annoyance. This also applies to low back pain.
New research found that as we age, more degenerative changes in our spines may be detected using MRI. Importantly, these results have no correlation with pain or impairment and are found as often in individuals with low back pain as in those with no pain.
In layman's words, this implies that as you grow older, your spine develops what I call "kisses of time," and that detecting these results on MRI is most likely unimportant.
One of the discoveries during Dr. Panagopoulos’ Ph.D. days was that most results occurred equally often in individuals with and without low back pain, with the exception of three important findings.
Disc herniations, nerve root compressions, and annular fissures were the culprits. In other words, these three results were significantly more frequent in individuals who were in pain. We conclude that these are most likely not simply age-related alterations, but actual pain-producing discoveries.
The current recommendations for the use of MRI in patients with low back pain are reasonable, recommending that MRI be avoided in all patients save those with suspected severe disease, such as a fracture or cancer.
MRI should also be explored in patients with persistent sciatica (nerve pain in the leg) since these symptoms are likely caused by disc herniations, annular fissures, or nerve root compressions.
Understanding the degree of disease here may be essential in your patient's treatment, thus the use of MRI is useful in helping you with your patient's management.
Another intriguing side note about using MRI in patients with low back pain is that it may potentially make your patients feel worse.
This is due to the severe language used in MRI reporting since the radiologist is required to record anything they observe on the scan, whether clinically significant and relevant to you or not.
Researchers studying this have shown that when patients read their report and see terms like "compression," "degeneration," or "arthropathy," they begin to think that their spine is in much worse condition than it is.
And, as a result of this impression, they have a worse sense of pain than individuals who have not had access to an MRI (and its accompanying report).
So, if patients are treated for low back pain and they ask whether they need an MRI to "see what's going on," remember that the answer is usually no unless they have leg pain that isn't responding to therapy.
In Dr. Panagopoulos’ opinion, informing patients about the study results on this topic is very beneficial, as it provides context for why the physiotherapist would advise against sending them for a scan.
If physiotherapists don't educate patients, it's quite possible that they'll go to their doctor or another therapist for an MRI regardless.
