Monthly Archives: May 2016

A manual therapist NEVER needs an MRI to manage low back pain

This was written by Monica Noy and Alison Sim

A manual therapist NEVER needs an MRI to manage low back pain

– an opinion(ated) piece backed by research!

MRI findings will not change your management strategy

  • There is very little correlation between pain and findings on an MRI or other imaging. Vast numbers of pain free individuals have disc bulges or spinal degenerative changes present on MRI. (Brinjikji, Leutmer, Comstock… et al, 2015; Jensen, Bran-Zawadski, Obuchowski… et al, 1994; Suri, Boyko, Goldberg… et al, 2014)
  • If there are no red flags but you suspect a disc bulge or any form of spinal degeneration or osteoarthritis, an MRI might confirm (or not) those suspicions, but shouldn’t change your management strategy.
  • If there are radicular signs and symptoms (sensory changes in a dermatomal distribution, weakness, loss of reflexes) without progressive worsening, an MRI that has already been conducted tells you where the disc bulge is, or how big it is, but should not change your management strategy.
  • Best practice management in most back pain cases is conservative as illustrated by this handy, up to date guideline of management of acute low back pain with radicular signs and symptoms.
  • Red flags WILL change your management strategy. If there are red flags or if there are no changes to radicular signs and symptoms after 2-4 weeks of conservative approaches, or if there is a continual worsening of symptoms, a referral to the appropriate medical professional is required. They will decide if an MRI is an appropriate course of action to help them make the decisions that need to be made and if more invasive treatments might be warranted.

MRI findings can make people worse

How can a non-invasive imaging modality make someone with LBP worse?

One word – FEAR. Images of jam donuts with bright red jelly exploding out the side, threats of surgery, crumbling, crusty spines, horror stories about uncles, friends or cousins who ended up in wheel chairs or damaged by surgery, or not getting surgery.

Medical and manual therapy culture, and subsequently society at large have alarming things to say about disc bulges and osteoarthritis. But those alarming warnings about slippages and crippling dysfunction do not apply to the majority of LBP sufferers. Still, the myths are pervasive, and have a lot of staying power. The higher the fear, the worse the outcomes.

MRI findings are a waste of money

Not only do these images place a huge financial burden on individuals, health and insurance systems, there is plenty of evidence to show that they drive up both invasive interventions and cost in episodes of low back pain, regardless of the presence of radiculopathy. One study found that having an early MRI cost an average of around $13,000 in subsequent healthcare costs, compared to not having the MRI. (Webster, Bauer, YoonSun Choi, Cifuentes, & Pransky, 2013.)  Just imagine what else could be done with that money!!

If MRI images provide questionably useful information that has no bearing on management or outcome, then we have little to no reason to seek these images, or request that our patient seeks them. (Rainville, Smeets, Bendix… et al, 2011; Webster, Bauer, YoonSun Choi, Cifuentes, & Pransky, 2013; Suri et al, 2014).

MRI findings are not a necessity

If you already reassure patients that their back pain is likely to get better, or assure them that an MRI isn’t necessary and/or follow other current guidelines for management of low back (Chou, Qaseem, Snow… et al, 2007) then your help is needed. We can encourage colleagues who still default to the idea that what they see in MRI or other imaging is going to inform their treatment to engage with the current scientific understanding of MRI imaging, symptom presentation, pain science and outcome management.

Continued discussions about whether the degeneration at L5/SI is causing pain are really unhelpful, for both patients and clinicians.

                       *****  It just doesn’t fit with the science *********




The Science

Images, information and further studies to help educate your patients on these issues:

Brinjikji,W.,  Leutmer, P., Comstock B., … et al (2015).  Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811-816.

Chou, R., Qaseem, A., Snow, V., et al.(2007).  Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal  Medicine, 147,478–91.

Suri, P., Boyko, E., Goldberg, J., Forsberg, C., &  Jarvik, J. (2014).  Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or radicular symptoms: retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (LAIDBACK). BMC Musculoskeletal Disorders, 15,152.

Jensen,  M.,  Brant-Zawadski, M.,  Obuchowski, N., Modic, M., Malkasian, D.,& Ross, J. (1994) Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine, 331(2), 69–73.

Rainville, J., Smeets, R., Bendix, T., Tveito, T., Poiraudeau, S., & Indahl, A. (2011).  Fear-avoidance beliefs and pain avoidance in low back pain–translating research into clinical practice.  Spine Journal, 11(9), 895-903.

Webster, B., Bauer, A., YoonSun Choi, M., Cifuentes, M., & Pransky, G. (2013).  Iatrogenic Consequences of Early Magnetic Resonance Imaging in Acute, Work-Related, Disabling Low Back Pain. Spine, 38(22), 1939-1946.

Evidence Based Management of Acute Lumbar Disc Pain

2018 update: This information was originally for an assignment Alison did as part of the Masters of Pain Management.

We have updated the content and presented it as an infographic.


  • Australian Acute Musculoskeletal Pain Guidelines Group. (2003). Evidence based management of acute musculoskeletal pain. Accessed at:
  • Anichini, G., Landi, A., Caporlingua, F., Beer-Furlan, A., Brogna, C., Delfini, R., Passacantilli, E. (2015) Lumbar endoscopic microdiscectomy: Where are we now? An updated literature review focused on clinical outcome, complications and rate of recurrence. Biomedical Research International. Epub 2015 Nov 24.
  • Cohen, S., Hanling, S., Bicket, M., White, R., Veizi, E….et al. (2016). Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: multicenter randomized double blind comparative efficacy study. British Medical Journal. 350, h1748.
  • Goldberg, H., Firtch, W., Tyburski, M., Pressman, A., Ackerson, L…. et al. (2015). Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. Journal of the American Medical Association, 19, 313(19), 1915-1923.
  • Kasimcan, O., & Kaptan, H.(2010). Efficacy of gabapentin for radiculopathy caused by lumbar spinal stenosis and lumbar disk hernia. Neurologica Medico- Chirurgica, 50,1070–3.
  • Kreiner, D., Hwang,S., Easa, J., Resnick, D., Baisden, J., ….. et al. (2014). An evidence based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine Journal, 14(1), 180-91.
  • Koes, B., van Tulder, M., Chung-Wei, C., Luciana, M., McAuley, J., & Maher, C. (2010). An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. European Spine Journal, 19(12): 2075-2094.
  • Manchinkanti, L., Knezevic, N., Boswell, M., Kaye, A., & Hirsch, J. (2016). Epidural injections for lumbar radiculopathy and spinal stenosis: A comparative systematic review and meta-analysis. Pain Physician, 19(3):E365-410.
  • Nice Guideline (Draft): Low back pain and sciatica: management of low back pain and sciatica. Assessment and non invasive treatments. Feb 2016. Up To Date: Approach to Acute Lumbosacral Radiculopathy. Accessed 4/4/2010
  • Weinstein, J… et al. (2006). Surgical vs nonoperative treatment for lumbar disk herniation: The spine patient outcomes research trial (SPORT): A randomized trial. Journal of the American Medical Association, 296(20), 2441-2450.
  • Williams, C., Maher, C., Latimer, J., McLachlan, A., Hancock, M., Day, R., & Lin, C. (2014). Efficacy of paracetamol for acute low back pain: a double blind, randomized controlled trial. Lancet, 384(9954), 1586-96.

Why the “WHY?” is so important

I’m sitting in a café, trying to mark exams (and stop procrastinating) and the ladies opposite me are having a fairly public and loud “nutrition consult”.  One is paying the other for her advice and is listening intently.  I promise I am trying hard not to listen… but it is so loud… and so….. interesting:

Client: So that is why my knees are giving me so much trouble?  Because of my diet?

“Nutrition” lady: Absolutely – your diet is so inflammatory, it is 100% causing your knees to get sore and probably also causing all sorts of other problems –  heart problems, digestive problems…..

Client: ooooooooooohhhhhh.  Woooooooooow!

“Nutrition” lady: you need to eat more Kale, melon, spinach, beans.  But NEVER eat raw broccoli and avoid pumpkin and cooked cauliflower – you can eat it raw but never cooked.  Eat blueberries and raspberries but NEVER strawberries – those babies are so bad for you………………  And it all must be organic…..

On and on it went.  The client left a little bewildered with a strange and random list, heading home via the organic shop to infuriate her family, friends and facebook friends with her new nonsense diet that was going to cure her knee pain and toxic liver.

Now can you see why I couldn’t concentrate?

The “why” behind our pain can tend to drive us to do some strange things – it is a big component of “the search” for the quick and easy answer to our pain.  If we can just find out the why, then we can do something about it and there is our answer.  Hooray!!!!!  If only it was that easy.

Looking for answers seems to be part of our culture – we are quick to blame, rather than attend to the problem in front of us.  My own example of this is my tension headaches – they come on occasionally, perhaps a couple of times a year, usually when I am burning the candle at both ends.  They tend to last a week or so and they suck!  They are a good empathy check for me to help deal with patients in pain.  My natural tendency is to go looking for a specific reason as to why they might have popped up this time – is it lack of sleep, stress, too much work on etc. Sometimes, I just can’t pin down a reason at all and I find this situation the most distressing – if I can’t even figure out what I have done to bring them on, how do I stop it from coming on again?  The desire to be in control in all aspects of my life is obviously a dominant one!   I have begun to reason with myself that perhaps I can’t be in control of these things – and that is OK!  I can generally keep doing what I need to do WITH a headache and I know it will go away in the near future.

Disengaging the patient away from looking for the “why” is a massive part of pain education.  Its also often the hardest part to shift – people have usually latched onto a “why” that may be incorrect but has meaning or makes sense to them.  They will often have fitted it into a rule type situation that looks like this:

When I _____________________________, ____________________________ happens.

For example,

When I  eat cooked cauliflower, my knees get really sore

Devil cauliflower

These are often incorrect and unhelpful understandings about a person’s individual situation.  Myth busting in these cases is an important part of pain education.  How we go about that is probably going to be the key to success or failure.  For example, laughing until you fall on the floor about the cauliflower probably isn’t going to work well as a rapport building exercise.  We need to remember that the desire to know why can be a powerful driver and disentangling that needs to be done delicately.  We also need to recognise that if we take away someone’s long held assumptions, we need to replace it with something that is accurate, tangible, reassuring  and helps them to look forward towards function, rather than keep looking for answers.  This is the essence of good pain education.