My patients often bring a CD to their first visit that has MRI studies of their problem area, usually the low back. The images are really breathtaking from a health care standpoint — you can scroll through images of the spine, seeing “slices” at regular intervals, from left to right, then top to bottom. The report from the radiologist lists the flaws seen on the films, typically disc bulging and degeneration, and some joint degeneration as well.
The downside is, for most patients, this information is of little use in treating their low back pain. In fact, it can actually be counter productive. A review of more than 3,200 cases of acute low-back pain suggests that for patients with similar problems, those who had magnetic resonance imaging scans early on in their care had a worse outcome, more surgery, and higher costs than those who didn’t.
How can that be? Isn’t more and better technology a sure sign of progress in health care?
The problem with this technology is that it gives the impression that if you have an MRI, it will show you the cause of the pain. This is simply not the case.
MRIs are great at showing structure; spinal discs, joints and muscles are visible in impressive detail. This information is very useful in diagnosing diseases like cancer. But by far the most common cause of back pain is “functional,” meaning the pain is caused by joints and muscles that do not work properly. The bulging discs and degenerated joints that light up on an MRI are “structural” and usually red herrings that have little to do with the patient’s pain.
Several studies have shown that the majority of people without any low back pain at all have these same bulging discs and joint wear, especially over the age of 50. Most patients’ problems can be effectively treated despite the changes seen on MRI. But once you have seen these structural changes on MRI, it starts you down the path of treating them, which means more aggressive treatments like cortisone shots, strong painkillers and surgery.
When I was in chiropractic school, we spent a semester training to feel the function of the individual joints of the spine. We started at the top of the neck, and evaluated the joint between the skull and the first vertebra for restrictions or abnormal positioning. We continued on down the spine until we covered every joint, and then went on to study the shoulder, wrist, ankle, etc. This skill takes quite a bit of practice; I continue to improve on it today. We also palpated for muscle spasm, inflammation, and the patient could tell us if the area was tender to touch. We were trained to look for “red flags” that might indicate diseases or severe pinched nerves that can be a true emergency. (They are not very common.)
None of this shows up on MRI.
Physical therapists are also trained to evaluate patients with low back pain for muscular and joint dysfunction, and to watch for red flags as well. Certain core muscles get tight and others become weak and inhibited, eventually leading to back pain. Therapists check for tight hamstrings, faulty movement patterns, etc.
None of this shows on MRI, either.
Acupuncturists evaluate chi flow, energy balance, the feel of the tissues, and ask about the character and patterns of the pain. Needless to say, none of this shows up on any high-tech test, including MRI.
These types of low-tech, “hands-on” testing all look at the function of the spine, as opposed to MRI, which shows only the structure. These “functional” problems are not only the cause of the majority of back pain cases, but also other similar problems like shoulder pain (which is not usually due to torn rotator cuffs) and neck pain.
Research strongly supports the conservative approach to treating back pain, as opposed to the high-tech approach. A 1993 report commissioned by the government of Ontario recommended that chiropractic doctors see all cases of low back pain first; if that were to be done, the savings in that province alone could total hundreds of millions of dollars annually.
If you have a low back MRI and the doctor uses words like “bulging disc,” “torn tendon,” or “arthritis,” remember you are in good company. It is a rare adult who does not have these changes, and they are likely not the true cause of your pain. My advice is to forego the MRI, unless there is a high chance of a disease process, and use low-tech, conservative care first. If one approach does not work, try a different one.
Once you start down the high-tech path, it is difficult to get off it. I have seen far too many patients who have been through the more aggressive, structure-based treatments first, only to try chiropractic — the only treatment that addressed their function, the true cause of their problems — last.
Dr. Michael Noonan practices chiropractic, acupuncture and other wellness therapies in Old Town.