Rethinking Low Back Pain Diagnosis: You are more than your image

Low back pain (LBP) is a prevalent and often debilitating condition affecting millions of individuals worldwide. While advancements in medical technology have provided us with sophisticated imaging techniques, such as X-rays, MRIs, and CT scans, a surprising paradox has emerged in the realm of low back pain diagnosis. Despite the detailed insights these imaging tools offer, there is a growing body of evidence revealing a poor correlation between imaging results and the actual presentation of symptoms in individuals with LBP.

The Imaging Conundrum

Traditionally, clinicians have relied heavily on imaging results to identify the root causes of low back pain. However, recent research challenges the assumption that abnormalities detected through imaging always correlate with the severity of symptoms or the presence of pain. Numerous studies indicate that a substantial number of individuals with no signs of structural abnormalities on imaging still report significant pain, while others with apparent abnormalities experience no or minimal discomfort.

Structural Abnormalities ≠ Pain

One of the key findings contributing to the debate on the poor correlation is the discovery that structural abnormalities, such as herniated discs, degenerative changes, or spinal stenosis, are not always synonymous with pain. For instance, a study published in the Journal of the American Medical Association (JAMA) found that approximately one-third of participants with no history of LBP exhibited spinal abnormalities on MRI (Brinjikji et al., 2014).

Let’s take a deeper look at their data. Here are their findings.

Structural pathologies identified on MRI in patients without low back pain

A couple of important observations to make here:

• The rates of notable findings increase as we age. Think of these changes as wrinkles on the inside

• You can consider facet degeneration as being equivalent to osteoarthritis

• Many of these findings- disc degeneration, disc bulges, facet degeneration are in more than 50% of people!

• The biggest highlight, NONE of these patients had experienced back pain

Furthermore, when these results were compared to those who did have low back pain, the rates of pathology were comparable. We have to confront the facts here that perhaps there is more to what determines the presence of back pain than our structures themselves.

The Role of Psychosocial Factors

A growing body of evidence highlights the significance of psychosocial factors in the experience of low back pain. Factors like stress, anxiety, depression, and socioeconomic status have been identified as crucial influencers of pain perception. Individuals with similar structural abnormalities may experience vastly different pain levels based on these psychosocial factors, thereby challenging the assumption that imaging results alone provide a comprehensive understanding of the pain experience (Hartvigsen et al., 2018).

Implications for Treatment

The poor correlation between imaging results and symptom presentation in low back pain has significant implications for treatment strategies. Relying solely on imaging findings may lead to unnecessary interventions, surgeries, or medications, without addressing the underlying psychosocial contributors to pain. As a result, there is a growing emphasis on adopting a multidisciplinary approach that considers both the biological and psychosocial aspects of low back pain (Foster et al., 2018).

Moving Forward

The recognition of the poor correlation between imaging results and symptom presentation in low back pain calls for a paradigm shift in the way healthcare professionals approach diagnosis and treatment. Embracing a patient-centered model that incorporates a thorough assessment of psychosocial factors alongside imaging results can lead to more tailored and effective interventions, improving outcomes for individuals suffering from low back pain.

We are not saying we need to throw out imaging altogether. There is a time and place for getting your back imaged. Specifically, your physiotherapist or doctor may recommend imaging as a way to rule out more significant pathologies such as fractures, tumours, or other more serious conditions. Naturally, we would want to identify these types of issues as they would warrant intervention beyond what physiotherapy or massage therapy can provide. To clarify, if your practitioner recommends imaging do not infer they suspect one of these conditions, rather, assume they are simply ruling it out, even if there was a very low chance of that condition being present.

Checklist before you get Imaging

One study that looked into the beliefs of practitioners and patients as related to imaging for low back pain provided the following recommendations for physiotherapists, chiropractors and doctors to discuss with their patients:

1. Did you explain the limited ability of lumbar imaging to locate the source of pain?

2. Did you discuss the potential harms of imaging?

3. Did you explore misperceptions expressed by your patient?

4. Did you give your patient enough time to discuss their concerns and did they feel listened to, valued and believed?

(Sharma et al., 2020)

Context is key. It is important both you as a patient and your medical provider understand the risks and benefits of imaging as well as how the results may influence your understanding of your pain as well as future treatment.

CONCLUSION

As our understanding of low back pain continues to evolve, it is crucial to acknowledge the limitations of relying solely on imaging results for diagnosis and treatment decisions. By recognizing the complex interplay of biological and psychosocial factors in the experience of low back pain, healthcare professionals can adopt a more holistic and patient-centred approach, ultimately improving the quality of care for those grappling with this pervasive condition. Book a consultation with a Victoria Chiropractor or Physiotherapist today.

For a simple one-page handout covering the subject, click here.

References:

1. Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., ... & Jarvik, J. G. (2014). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American Journal of Neuroradiology, 36(4), 811-816.

2. Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., ... & Woolf, A. (2018). What low back pain is and why we need to pay attention. The Lancet, 391(10137), 2356-2367.

3. Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., ... & Woolf, A. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet, 391(10137), 2368-2383.

4. Sharma S, Traeger AC, Reed B, et al (2020). Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis. BMJ, Open 2020;10:e037820. doi: 10.1136/bmjopen-2020-037820.