Persistent Low Back Pain: The Physical Therapist’s Role

Low back pain is the most common cause of disability and lost work time in industrialized countries.   Persistent low back pain is characterized by periods of high and low pain intensity which can persist for years.  Periodic “flare- ups” are common and often result in the seeking of medical treatment.  Medications and surgery are often ineffective and may be harmful in some situations.  Physical therapy is a non-invasive treatment approach which is often considered in those with persistent low back pain.  However, improvements are often short-term for those with longstanding pain.  Similar to surgery and medications, the long-term success of physical therapy treatments for chronic back pain is questionable.

Traditional approaches utilizing physical therapy involve a short, but intense course of treatment such as 12 visits over a 4 to 8 week period.  However, this type of treatment approach is likely insufficient to positively influence a person’s beliefs and behaviors about their pain.  Changing these beliefs and behaviors are crucial if an individual with persistent pain is to self-manage through physical activity and lifestyle changes.

Persistent Low Back Pain is Complex

When pain persists beyond expected time frames, changes occur within our nervous system.  These changes include abnormal pain processing pathways and poor execution of movement patterns.  Because the nervous system is so complex, individual “pain experiences” vary greatly among those with persistent low back pain.  Diagnostic tests and scans, including MRI, are of little help because the primary problem is in the nervous system, not the low back.

The low back muscles of those with persistent pain undergo substantial changes over time.  This is believed to be caused by changes in the central nervous system.  These changes include atrophy (loss of muscle) and deposits of fatty tissue in the place of the lost muscle.  In particular the lumbar multifidus muscle has been shown to be selectively atrophied in many, but not all, individuals with persistent back pain.  Not only does the structure of muscle change with long-standing pain, but so does the nervous system’s ability to activate certain muscles.  Some muscles may become underactive while others become overactive.  These patterns differ among individuals with back pain making symptoms highly variable.   A common strategy is when many muscles of the low back contract simultaneously resulting in an unhelpful stiffening or bracing of the trunk.

Persistent Low Back Pain & Exercise

Altered pain processing pathways in the nervous system and changes in the back muscles leads to difficulty learning low back exercises.  A long term stimulus is likely needed to overcome atrophy of spinal muscles and to regain proper muscle function.  Performing low back exercise several times per week for 1 to 2 months is not adequate dosage.  Therefore, those with persistent pain may require repeated practice for several months in order to master the most basic of exercises.

In order to restore normal movement patterns exercise prescription must be matched to the individual’s beliefs and functional problems.  Ongoing types of cognitive interventions, such as education about the science of pain are beneficial to facilitate participation in exercise and physical activity.  An emphasis on education and a gradual progression of physical activity then becomes the long-term treatment.

The Role of the Physical Therapist in Helping Those with Persistent Low Back Pain

A recent episode of low back pain often responds well to manual therapy treatments such as mobilization, manipulation, or massage.  Sometimes, ice or hot packs can be helpful in these situations. However, passive interventions are of little help for those with persistent pain.  Instead, treatments that effectively involve the patient in long-term performance of physical activity are likely to be most valuable. These approaches seek to empower the patient by emphasizing their own preferred types of physical activities which can be progressed and modified as needed over time by the physical therapist.

There is no one-size fits all approach to prescribing exercise for those with persistent low back pain.  Core stabilization exercise receives a great deal of attention but this form of treatment is only helpful in some.  The same goes for stretching, resistance exercise, and aerobic exercise.  All these forms of exercise can be helpful in some but not all.  Therefore, the physical therapist and the patient should collaborate to develop an exercise plan which the patient finds enjoyable or preferable.  This is the only way the program will be adhered to for the long-term.

Final Thoughts on Physical Therapy for Persistent Low Back Pain

The traditional approach of attending physical therapy sessions 2 to 3 times a week for 4 to 8 weeks is not optimal.  Instead, the physical therapist and patient should seek to develop a long-term working relationship over time.  Initially, physical therapy sessions may occur multiple times a week but only for a few weeks.  Sessions should then be spaced out over time.  The physical therapist can assist the patient in progressing or modifying their exercise program at each session.

The physical therapists primary role is as a coach or guide who empowers the individual to self-manage for the long-term.   The ultimate goal is for the individual to manage and be prepared for fluctuations in their back pain.  Those with persistent back pain are ideally suited to directly access the services of a physical therapist without a physician referral.  In these instances, sessions are best when spaced out every few months or as needed.

Medications for Low Back Pain: Helpful or Harmful?

It has been estimated that half of Americans will experience low back pain each year.  Approximately 80% will experience low back pain at some point in their lifetime.  Now the good news: It is estimated that about 90% of those who experience back pain will recover well within a few weeks or months.  The other 10% may go on to experience chronic disabling back pain that remains resistant to treatment.   Identifying factors which may lead to chronic pain is a complex matter.   Some believe that controlling the initial intensity of pain is the key.  However, the research does not strongly support this idea.  In fact, efforts to control pain with medication may actually be more harmful than helpful.

Opioids, Low Back Pain, and Depression

Recent practice guidelines published in the European Spine Journal recommend against the use of imaging (MRI or CT scans), injection, anti-inflammatory medications (ibuprofen, etc), and opioids. These same guidelines suggest using patient education, exercise, and manual therapy should be the first treatments used for those with low back pain or sciatica.  Contrary to popular belief, research does not support the use of opioids for short-term pain relief in those with back pain or sciatica.

In the United States, there is a strong association between depression, low back pain, and being prescribed opioid medication.  Individuals with low back pain and a history of depression are more likely to be prescribed opioid medication.  Not only are individuals with depression more likely to be prescribed opioids, but the dosage these individuals are prescribed is twice as high per year compared to those who have no history of depression.  It is then reasonable to theorize that individuals with a history of depression are more likely to develop a dependency or addiction to these powerful medications.   Given the proven benefits of exercise for depression and low back pain, exercise should be used as a first line treatment for these individuals before considering prescription medication.

Muscle Relaxants and Low Back Pain

Muscle relaxants may offer a safer pharmacological option to manage back pain compared to opioids.  Research does suggest a potential short-term benefit to using muscle relaxants when pain is severe.  However, evidence is lacking to support the use of these medications for patients with low back pain lasting greater than 3 months.  Adverse reactions to these medications are usually minimal and similar to those experienced with placebo.

Anti-Inflammatory Medications

The best available evidence suggests a very small and non-significant benefit to using non-steroidal inflammatory medications for back pain and sciatica.  The benefits to using these medications for a new episode of back pain is questionable and the side effects can be severe.  The most serious side effects include ulcers, cardiovascular events (heart attack or stroke), and kidney failure.  If these medications are used, short-term doses should be used in order to minimize risk.

Closing Thoughts

I am not a medical physician.  I cannot prescribe medication and I cannot counsel anyone who is currently taking prescription medication.  However, I do hope that anyone taking prescription medication for low back pain understands the risks, especially with using opioids.  Please carefully discuss these risks with your physician.  Living an active medication-free life, with little or no pain, is possible and always a reasonable goal.

References

  1. Smith JA, Fuino RL, Pesis-Katz I, et al. Differences in opioid prescribing in low back pain patients with and without depression: A cross- sectional study of a national sample from the United States. Pain Reports. 2017;2:1-7.
  2. Ransmussen-Barr E, Held U, Grooten W, et al. Non-steroidal anti-inflammatory drugs for sciatica (Review ). Cochrane Database Syst Rev. 2016;(10):1-53. doi:10.1002/14651858.CD012382.www.cochranelibrary.com.
  3. Shaheed CA, Maher CG, Williams KA, Mclachlan AJ. Efficacy and tolerability of muscle relaxants for low back pain: Systematic review and meta-analysis. Eur J Pain. 2017;21:228-237. doi:10.1002/ejp.907.
  4. Stochkendahl MJ, Kjaer P, Hartvigsen J. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018;27:60-75. doi:10.1007/s00586-017-5099-2.

 

Five Exercises to Train the Abdominal Muscles

Abdominal muscle weakness and poor control of the trunk (or “core”) can negatively influence athletic performance and activities of daily living.  Poor trunk muscle strength has been associated with injuries in baseball players and several other sports.  Also, exercises to improve trunk muscle strength have been shown to improve soccer and distance running performance.  Trunk muscle weakness has also been linked to falls in seniors and low back pain in adults and children.

Exercises to strengthen the abdominal muscles and improve coordination of the trunk should be integrated into a comprehensive total body strength training program.  Training should never focus on any single muscle or body part.  In general, abdominal exercises should start in supported positions, such as supine lying, and progress to more functional positions, such as standing.  Exercises are predominately training for muscular endurance with short sustained holds (8 to 10 seconds) and a progressive number of repetitions.  As exercises become less challenging, the number of repetitions should be increased or the exercise itself should be progressed to a more challenging position.  The five exercises which follow are ordered from the most basic to the most challenging.

Dead Bugs

Begin in a supine lying position with the arms held straight up and the feet off the floor.  The hips and knees should be bent to 90 degrees.  Gently flatten the low back into the floor and maintain this abdominal contraction throughout the exercise.  Simultaneously raise the right arm overhead and extend the left leg without touching down.  Hold this position for several seconds and maintain low back contact with the floor.  Reverse the movement back to the starting position. Then, perform the opposite diagonal pattern with the left arm and right leg.  You should alternate sides with each repetition.  Maintain low back contact with the floor throughout the exercise.

Stability Ball Roll-Outs

Begin in a tall-kneeling position with both hands on the ball.  Roll the hands along the ball until the elbows or upper arm contacts the ball.  The elbows should remain extended as the hands and hips move together.  Engaging the gluteus and abdominal muscles help maintain proper position during the exercise.  As you lower the body towards the floor, maintain a neutral spine position and avoid arching the low back.  Hold this position for several seconds before reversing the movement back to the starting position.

Side Plank with Rotation

Begin in a side-lying position resting on one elbow.  Raise the trunk and knee off the floor until you are fully supported by your elbow and feet.  While maintaining the side plank position, reach up and then under and behind the body with the top hand.  This will induce trunk rotation and challenge the oblique abdominal muscles.  Hold this position for several seconds before reversing the movement back to the starting position.

Half-Kneeling Cable Chop

Assume a half-kneeling position next to a cable column or anchored resistance band.  The kneeling position removes contributions from the lower body and increases the demands on the trunk, pelvis and hip musculature.  From a balanced and upright kneeling position, pull the cable or band diagonally across the body towards the opposite hip.  Maintain a neutral spine and trunk position throughout the exercise.  Avoid rotating the body as your arms pull across the body.  Resisting this movement is what activates the abdominal muscles.  Hold this position for several seconds before reversing the movement back to the starting position.

Lateral Lunge with Press and Reach

This advanced exercise starts from a standing position next to a cable column or anchored resistance band.   Holding the handle or band close to the body; initiate the exercise with a lateral lunge.  Once the lunge position is attained, slowly press the arms straight out in front of the body.  The band or weight will induce a rotational challenge to the trunk muscles.  Resisting this movement is what activates the abdominal muscles.  Next, slowly raise the arms straight overhead while maintaining the lunge position.  Maintain a neutral spine and trunk position throughout the exercise.  Hold this position for several seconds before reversing the movement sequentially back to the starting position.

Closing Thoughts on Abdominal Exercises

Abdominal exercises are one component of a comprehensive exercise program targeting total body muscular strength and physical performance.  Abdominal exercises performed in isolation are rarely successful for improving performance or decreasing pain.  When developing your program, consider these five trunk muscle exercises.   Performing each exercise in a controlled fashion, with a focus on proper technique and muscular endurance will elicit the best results for the long-term.

References

  1. Chaudhari AMW, Mckenzie CS, Pan X, Onate JA. Lumbopelvic control and days missed because of injury in professional baseball pitchers.  Am J Sports Med. 2014;42(11):2734-2740. doi:10.1177/0363546514545861.
  2. Granacher U, Gollhofer A, Hortoba T, Kressig RW, Muehlbauer T. The importance of trunk muscle strength for balance, functional performance, and fall prevention in seniors: A systematic review. Sports Med. 2013;43:627-641. doi:10.1007/s40279-013-0041-1.
  3. Reed CA, Ford KR, Myer GD, Hewett TE. The Effects of isolated and integrated “core stability” training on athletic performance measures: A systematic review. Sports Med. 2012;42(8):697-706.

Abdominal Oblique Injuries in Rotational Sports

Abdominal oblique injuries, also known as side strains, are common in rotational sports such as baseball, tennis, golf, and track and field.  These injuries are characterized by a sudden, sharp onset of pain near or on the side of the rib cage.  The injury usually occurs during some type of rotational sports movement such as swinging a bat, club or racket; or throwing a ball.

Trunk rotation plays an important role in generating and transferring power during sport.  It is through the trunk or core, that forces are transferred from the lower body to the shoulder and arms. Activities such as throwing and swinging require the core muscles to both stabilize the trunk and create force in order to transfer power to the upper body.

Anatomy of the Abdominal Oblique Muscles

The core includes the thoracolumbar, abdominal, pelvic, and hip musculature.  These muscle groups provide trunk stability to allow integrated limb movements, such as throwing and swinging, to occur. The abdominal core muscles include the rectus abdominis, transversus abdominis, internal oblique and external oblique.  Most abdominal injuries occur in the internal and external oblique muscles.  Less commonly, injuries can occur to the intercostal muscles between the ribs themselves.

The Role of the Oblique Muscles in Sport

The internal and external oblique muscles are responsible for flexion and rotation of the trunk, as well as providing trunk stabilization during complex sports movements.    Poor mobility of the hips or thoracic spine can contribute to excessive stress and compensation through the trunk musculature during swinging or throwing.  Rehabilitation often addresses hip mobility with manual therapy techniques performed by the physical therapist.  An imbalance between right and left side oblique muscles are also common is in sports such as golf and baseball.  This may place excessive forces through the lead side oblique musculature.  Finally, the large forces generated by lower body muscles (quadriceps and hamstrings) may overpower the weaker core musculature leading to injury during explosive sports movements.

The incidence of Abdominal Oblique Injuries in Baseball

A 2010 study in the American Journal of Sports Medicine investigated the incidence and trends of abdominal injuries in professional baseball players.  From 1991 through 2010, abdominal strains accounted for approximately 5% of all injuries in Major League Baseball.   Nearly half of these injuries occurred in pitchers.   These injuries occurred most often during the early part of the season.

In both pitchers and position players, the majority of injuries occurred on the side opposite to their throwing arm.  Pitchers missed, on average 35 days on the disabled list, while position players missed 26 days on average.  Players who receive steroid or PRP injections have been shown to miss more time from injury.   More than 1 out of every 10 sustained a re-injury during their career.  Most of these re-injuries occurred during the same or the following season.   As a result of these injury trends, many MLB teams have increased their focus on preemptive core and trunk strengthening exercises for all players.

Closing Thoughts

The incidence of abdominal oblique injuries is on the rise in rotational sports such as baseball and golf.   These injuries can result in substantial loss of playing time.  Proper training can prevent abdominal oblique injuries from occurring.  In a few weeks, I will post an article describing exercises which can help reduce the risk of sustaining an injury.  These exercises can also be part of a comprehensive rehabilitation program to safely return an injured athlete back to sport.

References

  1. Camp CL, Conte S, Cohen SB, et al. Epidemiology and impact of abdominal oblique injuries in major and minor league baseball. Orthop J Sport Med. 2015;5(3):1-8. doi:10.1177/2325967117694025.
  2. Conte SA, Thompson MM, Marks MA, Dines JS. Abdominal muscle strains in professional baseball. Am J Sports Med. 2010;40(3):650-656. doi:10.1177/0363546511433030.
  3. Nealon AR, Kountouris A, Cook JL. Side strain in sport: A narrative review of pathomechanics, diagnosis, imaging and management for the clinician. J Sci Med Sport. 2017;20:261-266.

Try These 5 Row Variations to Strengthen the Shoulders and Core

Anyone interested in strengthening the core and shoulder musculature should be performing some type of row variation as part of their workouts.  The row is a pulling movement which involves flexing the elbow, extending the shoulder, and pulling the shoulder blade back, also known as retraction.  The row challenges the muscles of the upper back (trapezius, rhomboids, and erector spinae) as well as muscles of the core and low back.  Also, when performed in various standing positions, this exercise can train the entire kinetic chain from the lower body, through the trunk, to the upper body.

It is common for the row to be performed seated with the use of exercise machines.  This is fine for those first learning the movement pattern.  However, seated machine rows do little to challenge the core or lower body musculature.  There are much better options for athletes, those with a history of injury, and those looking to take their workouts to the next level.

If absolute strength is the goal, heavy barbell or dumbbell bent over rows are the best options.  However, these row variations require coaching and practice to perfect proper technique.  Performing heavy rows with improper technique makes one susceptible to low back or shoulder injury.  Again, there are better options, especially for those with a history of injury and looks to train in a more specific fashion.  Try the following five row variations and see which ones work best for you.

Standing 1-Arm High Cable Row

Set up a cable system with the cable positioned slightly above the level of the head.  Stand in a lunge position with the left foot in front of the right.  The majority of body weight should be on the front leg with the knee bent approximately 45 degrees.  Start with a palm down grip with the right arm extended out in front.  To begin the movement, pull the cable, bending at the elbow, straight back towards the trunk while maintaining a neutral spine.  Be sure to emphasize scapular retraction which refers to pulling the shoulder blade back and slightly down.  Also, avoid shrugging the shoulders or arching the low back.

This exercise challenges the core by activating the trunk musculature to resist rotation as the arm and scapula produce the row movement.  This makes the 1-arm high cable row a good option for those who are looking to train anti-rotational trunk muscle endurance.  This high-cable position and lunge stance set-up have also been shown to result in favorable muscle activation patterns of the lower and upper trapezius.  This is important for overhead athletes or those with a history of shoulder problems.

Cable Lawnmower Pull

This exercise begins with the trunk flexed and rotated to the opposite side of the exercising arm.  The hand of the exercising arm starts at the level of the opposite knee. To begin the movement, the trunk is rotated toward the exercising arm while extending the hip and trunk to a vertical position.  The exercise ends with the arm at waist level with the shoulder blade retracted as if placing the elbow in the back pocket.  Pause for 1 or 2 seconds then slowly reverse the movement returning to the starting position.

The lawnmower pull is a multi-joint functional exercise performed in a diagonal pattern replicating many movements in sport.  The exercise incorporates the transfer of force from the lower body through the trunk to the upper body.  It has been shown to activate the trapezius and serratus anterior muscles at low to moderate levels.  These muscles are important for maintaining shoulder health in overhead athletes (i.e., baseball players) and those with a history of shoulder pain.  The exercise can be performed with a cable system, resistance band, or dumbbell.

1-Arm Band Rotational Row

Set up a resistance band anchored at approximately waist to belly button level.  Position the front leg with the foot facing towards the anchored band.  The rear leg will begin facing the same direction but must be free to pivot once the exercise commences.  The right arm begins extended and the majority of body weight begins on the left leg.  The movement occurs with the simultaneous coordination of an upper-body row, trunk rotation, and weight shift to the rear leg.  Pause in the end position for  1 to 2 seconds before reversing the movement in a slow and controlled fashion.

This row variation is ideal for rotational athletes such as baseball players.  It incorporates the coordinated activity of the lower body, trunk, and upper body.  Controlling the eccentric, or negative, part of the exercise is important.  This exercise also teaches weight transfer and weight acceptable from the rear to lead leg and vice versa.  Be sure to perform the exercise from both sides to avoid reinforcing any side to side asymmetries which are common in athletes.

Suspension Trainer Row

Anchor a suspension trainer, such as a TRX, in an overhead position.  Grasp both handles with the arms extended.  Position the feet in front of the body spread slightly wider than shoulder-width apart.  Your body should be maintained in a neutral position with your head, trunk,  and legs forming a straight line.  Perform the row movement and pause at the top position for 1 to 2 seconds before returning to the start position in a slow and controlled fashion.  Maintain the trunk in a rigid position throughout the exercise. To increase the challenge of this exercise position your feet further away from your upper body to assume a more inverted position.

The inverted position assumed in the suspension trainer row elicits high activation of the abdominals,  latissimus dorsi, upper back muscles, and hip extensor muscles (glutes and hamstrings). This exercise produces lower levels of lumbar spine muscle activity due to lower spine loads incurred from the suspended position.  These factors make the suspension trainer or inverted row a good option for patients with a history of low back pain.

Dumbbell Renegade Row

Hold two dumbbells and assume a push-up position with the feet spread slightly wider than shoulder-width apart.  Align the head, trunk, and lower body in a straight line and maintain this position throughout the exercise.  Initiate a row with one arm while maintaining stability through the trunk and lower body.   Control the descent of the load back to the floor.  Be sure to alternate sides with each repetition.  Light loads are recommended when first learning this exercise.

The push-up position utilized in the renegade row increases challenges to the abdominal musculature.   Furthermore, 1-arm row variations have been shown to elicit great oblique abdominal muscle activity compared to rows performed with both arms simultaneously.   This is a more advanced row variation so it may be best to start with cable or suspension rows before embarking on the renegade row.

Closing Thoughts

There are many variations to the row exercise and I have described only five.  For beginners, it is best to start with cable row variations and suspension trainer rows.  The lawnmower pull and rotational row are more complex movements which require total body coordination.  Thus, these exercises are more challenging to master.  To really challenge the core and shoulder stability, the renegade row is a higher level option.  The most important points are that you choose the most appropriate variation for your level of training and that your technique is as close to perfect as possible.

References

  1. De Mey K, Danneels L, Cagnie B, Lotte VDB, Johan F, Cools AM. Kinetic chain influences on upper and lower trapezius muscle activation during eight variations of a scapular retraction exercise in overhead athletes. J Sci Med Sport. May 2012:6-11. doi:10.1016/j.jsams.2012.04.008.
  2. Fenwick CM, Brown SH, McGill SM. Comparison of different rowing exercises: Trunk muscle activation and lumbar spine motion, load, and stiffness. J Strength Cond Res. 2009;23(5):1408-1417.
  3. Harris S, Ruffi E, Brewer W, Ortiz A. Muscle activation patterns during suspension training exercises. Int J Sport Phyiscal Ther. 2017;12(1):42-52.
  4. Saeterbakken A, Andersen V, Brudeseth A, Lund H, Fimland MS. The effect of performing bi- and unilateral row exercises on core muscle activation. Int J Sports Med. 2015;36:900-905.
  5. Wattanaprakornkul D, Halaki M, Cathers I, Ginn KA. Direction-specific recruitment of rotator cuff muscles during bench press and row. J Electromyogr Kinesiol. 2011;21:1041-1049. doi:10.1016/j.jelekin.2011.09.002.
  6. Youdas J, Keith J, Nonn D, Squires A, Hollman J. Activation of spinal stabilizers and shoulder complex muscles during an inverted row using a portable pull-up device and body weight resistance. J Strength Cond Res. 2016;30(7):1933-1941.

Low Back Pain: How Helpful is an MRI?

It’s not often that I am in agreement with health insurance companies but they seem to be getting one thing right as of late. We have noticed an increase in patient’s referred to our clinics for low back pain that have not undergone advanced diagnostic imaging techniques, such as MRI. It appears that large insurance companies are denying authorization for these MRI’s until the patient has undergone a course of physical therapy (more on the topic). Physical therapists are certainly on board with these decisions but some of our patients are often confused or annoyed by their insurance company dictating their care. So, should patients with an acute onset of low back pain undergo routine MRI or undergo a course of physical therapy first? Why not be safe and undergo the MRI first? How can a physical therapist offer treatment without knowing what the problem or diagnosis is?

Physical Therapy or MRI First?

A recent study published in the journal Health Services Research investigated this question. Researchers found that those patients seeking primary care services for low back pain and were referred for an early MRI underwent higher health care utilization at increased costs compared to those receiving early physical therapy. The additional cost of receiving the MRI first was nearly $5000 more than receiving early physical therapy. Earlier research studies show that consulting a physical therapist early results in decreased odds of undergoing diagnostic imaging (here) and decreased odds of undergoing future surgery for low back pain (here). Delaying physical therapy has also been associated with increased prescription opioid (narcotic pain medication) use and most of us are aware of how big of an epidemic this is becoming (more here).

Why Not Play it Safe and Undergo the MRI First?

A 2003 study in the Journal of the American Medical Association compared the use of early MRI vs. early x-ray for patients with a new episode of low back pain. One year later, pain levels and disability were no better in those undergoing the MRI. Of note, the group receiving the early MRI was more likely to undergo back surgery. This is not surprising given the high likelihood of pathological findings in asymptomatic subjects (no low back pain) who undergo advanced diagnostic imaging. A 2015 systematic review reported the prevalence of disc degeneration in asymptomatic individuals ranged from 37% of 20-year olds to 96% of 80-year olds. Similar rates were reported for asymptomatic disc bulges. If so many people without low back pain have these findings on MRI we cannot confidently conclude that these findings are the true cause of symptoms. Making erroneous assumptions based on MRI findings often leads to over treatment. The more testing and treatment a patient undergoes the more likely factors such as fear and anxiety come into play and these are the factors that have been associated with persistent or chronic low back pain.

Physical Therapy Treatment without Imaging

MRI or further medical work up is always indicated in situations where serious pathology is suspected or when response to initial treatment is poor. However, low back pain emanating from serious pathology has been estimated to occur in less than 2 percent of cases. Doctor’s of physical therapy are trained in screening for these signs and when there are any suspicions of non-musculoskeletal problems prompt referral is indicated. In most cases these problems are ruled out based on a detailed interview and medical history. Physical therapists then base their examination and treatment on the individual patient’s signs and symptoms; not based on a diagnosis or MRI scan. Physical therapists are concerned with how movement affects symptoms and how symptoms affect movement.

In most cases of low back pain delaying the MRI is the best approach.