It’s not often that we are in agreement with insurance companies but they seem to be getting one thing right as of late. We have noticed an increase in patients referred to our clinics for low back pain that has not had an MRI. It appears that large insurance companies are denying authorization for these MRIs until you undergo a course of physical therapy (more on the topic).
It is no fun when insurance companies dictate your care. This is understandable. However, when it comes to back pain physical therapists are on board with these decisions. So, should patients with an acute onset of low back pain undergo routine MRI? Or are you better off undergoing 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?
We’ll answer these questions and more below.
Physical Therapy or MRI First?
A recent study published in the journal Health Services Research investigated this question. Researchers found people referred for an early MRI need more care in the long run. This occurs at increased costs compared to those receiving early physical therapy. The additional cost of receiving the MRI first is 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 higher 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 people with a new episode of low back pain. One year later, pain levels and disability were no better in those undergoing the MRI. But how about this! The group receiving the early MRI was much more likely to undergo back surgery. This is not surprising given the high likelihood of abnormal findings in people with no low back pain.
A 2015 systematic review reported the prevalence of disc degeneration in asymptomatic people ranged from 37% of 20-year olds to 96% of 80-year olds. Similar rates have been reported for asymptomatic disc problems. If so many people without low back pain have these findings on MRI we cannot confidently say that these findings are the true cause of your symptoms.
Making erroneous assumptions based on MRI findings often leads to overtreatment. The more testing and treatment a patient undergoes the more likely factors such as fear and anxiety come into play. These are the factors that have been associated with persistent or chronic low back pain.
Physical Therapy Treatment without MRI
MRI is needed when serious pathology is suspected or when the response to treatment is poor. However, low back pain caused by serious pathology occurs in less than 2 percent of cases. Doctors of physical therapy are trained to identify these signs. When there are any suspicions you will be quickly referred to your doctor.
These problems are usually ruled out after a detailed interview and medical history. Physical therapists then base their examination and treatment on your signs and symptoms; not based on your diagnosis or MRI. Physical therapists are concerned with how movement affects pain and how pain affects movement.
In most cases of low back pain delaying the MRI is the best approach. If you would like your physical therapist to evaluate your movement and make recommendations, give us a call.