Low back pain is among the most common musculoskeletal problems. It is also a leading cause of disability and visits to the doctor’s office (Deyo, et al.). It does not come as a big surprise that more and more health care dollars are spent on research, diagnosis, treatment and preventative medicine for low back pain. One study documented over a 10-year period: a 629% increase in Medicare expenditures for epidural steroid injections, a 423% increase in expenditures for opioids for back pain, a 307% increase in number of lumbar MRIs among Medicare beneficiaries and a 220% increase in spinal fusion surgery rates. (Deyo, et al).
With the longer days and warmer weather approaching, many are thinking of home projects such as yard cleanup, improvements, and painting. While these are all different types of activities, they all involve a degree of bending, lifting, and twisting of the spinal column. All of this loaded spinal movement may stir up an all too familiar sensation of stiffness and/or pain in the spinal column and more specifically in the lower back.
You finally decide to go to the doctor’s office once your home remedies have failed. After many questions and poking and prodding, your physician prescribes anti-inflammatories and advises you to attend therapy. You leave the office disappointed because your doctor told you there is no need for an MRI. You really wanted an MRI, so why won’t the doctor order it?
MRIs have become mainstream to help diagnose and guide treatment for low back pain. It is interesting to note that in 90-95% of people with disabling low back pain, there is not one cause of symptoms that can be determined from an MRI. (Deyo et al). In fact, imaging findings on MRIs have a weak to moderate association with disabling low back pain (Deyo, et. al.) Another interesting fact about MRI is that multilevel degenerative disc disease and spondylosis are common findings in those with disabling low back pain and those that are aging and pain free.
As a physical therapist I often hear the question from patients “Shouldn’t I have an MRI, won’t that help in your treatment planning as well?” The short answer is no. This is because we do not treat MRI findings. A physical therapist identifies impairments related to your back pain (i.e., mobility, core strength, flexibility, posture) and develops a plan of care based off of his/her findings. We do not need an MRI to conduct an evaluation or treat low back pain. The spine is a very complex structure and has many generators of pain including bones, tendons, muscles, ligaments and nerves. It is most likely there are several areas that need attention and your therapist can help guide and educate you as to which activities are safe and how to manage pain.
There are instances, however when an MRI is warranted such as numbness, tingling, weakness, radiating pain into the lower extremities especially past the knee, failure of conservative treatment and /or if your doctor suspects other causes for your symptoms. There also may be situations that require immediate medical attention (red flags) especially when there are bowel/bladder changes, weight loss that accompanies back pain, loss of balance, and direct trauma to the spine. An MRI is also indicated to plan for spinal injections and/or surgery after conservative treatment (rest, NSAIDS, physical therapy) has been exhausted.
There is not one magic bullet to cure chronic low back pain, and patients should beware of any gimmicks that make this claim. There are however several studies that conclude graded exercise is important in the management of low back pain (Deyo, et al.) There are also lifestyle modifications that you can make to improve the frequency and intensity which low back pain may occur. Some of these include: participation in a graded exercise program that includes stretching, strengthening and cardiovascular activity, group support, maintaining a healthy weight/diet, stress management and smoking cessation.
Some advice while performing your home projects would include:
• Avoid bending at the waist while raking. Use a staggered stance and upright posture while performing repetitive movements.
• Use proper lifting techniques. When performing low lifts, using a hip hinge pattern will alleviate the load on your spine.
• Stay flexible. Yard work entails multiplane movements of the spine. Stretching before and afterward will improve your performance and help with muscle soreness.
• Stay hydrated. This will help with muscle cramping.
• Take rest breaks. If you find yourself in a crouched position for a long period of time, take breaks every 20 to 30 minutes to redistribute spinal loads.
You should always consult your physician to determine if it is safe for you to exercise especially if you have other comorbidities or any of the red flag items previously mentioned.
Remember that an MRI is a valid diagnostic tool, however it will not take your pain away and does not always point to one definitive cause for back pain. Back pain is multi-factorial and taking an active role in your recovery will improve the healing process.
Deyo, R.A., Mirza, S.K., Turner, J.A. and Martin, B.I. Over treating chronic back pain: time to back off? Journal of American Board of Family Medicine. 2009; 22(1): 62-88.