Imaging: Friend or Foe?

A day in the life of…

Imagine that you are a healthy 30 something male who is regularly active in outdoor hiking and the gym. You notice minimal pain occasionally at the lower back, but it is not consistent and subsides for a couple of days with rest. Lately, the pain has become a little more irritating and lasts longer then it has in the past. It’s not limiting, but it is somewhat worrisome that it has the potential to get worse. You make an appointment with your primary care practitioner (PCP) to get some advice.

At your appointment an x-ray is ordered. The nurse relays the results of your imaging stating that it shows some potential disc space narrowing. To gain a better understanding, the doctor orders an MRI. The results of the MRI show a protruding disc and that leaves you with more questions. How did this happen? How long it’s been like this?

A Dad playing a game of soccer with his child takes a tumble and tweaks his back. At first it’s a little tender, but doesn’t seem to be too debilitating. He decides it would be a good idea to pack up the kids and go home. When at home, he grabs the frozen peas and heads for a rest with the hope that it will be better in the morning. Unfortunately, the next morning he finds his pain is significantly worse and it takes the maximum effort to just move from his bed to the bathroom. An appointment with the PCP is in order to find some relief from the pain.

The PCP orders an x-ray. The results of the x-ray show arthritic changes in the lumbar spine. Your instructions are to take the medication your PCP prescribed and follow up in a couple of weeks if the pain has not changed. Again, you are left with unanswered questions …… What is an Arthritic change? What do I do now? Have I always had it? Did I create the arthritic change when I fell?

A physical therapist’s perspective

As a physical therapist (PT), when we consider these two situations we find that the diagnosis and reported symptoms do not clearly tell us the whole story, only part of the story.

One thing we know for sure is that there are varying degrees of severity of disc protrusion that may or may not lead to low back pain. Severe bulging discs can sometimes come into contact with the nerve roots that leave the spine resulting in numbness, pain and tingling down the limb. This can lead to nerve damage when not addressed in a timely manner. Less severe discs may be bulging so insignificantly that it does not come into contact with any adjacent structures to cause any type of pain.

Arthritic changes are a bit different. Arthritic changes rarely come from a small fall and are more progressive on onset. They are a consistent low level pain that always seem to be present and often make the patient feel stiff and achy.

A meta-analysis review done by Brinjikji et al. (2015) looked at the presence of multiple pathological dysfunctions in the lumbar spine using magnetic resonance imaging (MRI) or CT in persons without pain. They found that 37% of 20 year olds, 80% of 50 year olds and 96% of 80 year olds had some severity of disc degeneration without the presence of pain. That’s a staggering amount for each age range!

In addition, they found that 30% of 20 year olds, 60% of 50 year olds and 84% of 80 year olds have some level of disc bulging without ever experiencing back pain.

Other studies have also shown the fluidity of our systems. These studies compared MRI results of participants taken in the morning to those taken in the afternoon of the same day. It demonstrated that some patients had no dysfunction noted on the image in the morning, but did have some limited bulging discs by the second image in the afternoon.

Imaging does not always give a complete picture.

What does this mean?

Imaging shows only a portion of the full picture and certainly is helpful in some situations, but don’t let imaging rule your life! There are other avenues to consider when pain is restrictive.

The body is heavily equipped to handle the load of everyday activities. Posture, joint restriction, muscle restriction, and strength deficits all contribute to pain and decrease function in regular daily habits. Skilled guidance by a licensed physical therapist will help. Guidance in movement and strength training decrease pain and help to prevent future pain even in the presence of arthritis or anatomical anomalies shown on imaging. These improvements allow for the continuation of daily functions without creating pain.

Take control of present and future pain by making a PT appointment so you can return to what you want to be doing without pain. Call today to make an appointment. 503.353.1278.

Dr. Ashley Billingsley, DPT
NW Therapy