Since the 80s, an advanced imaging technology, Magnetic Resonance Imagining (MRI) has been wildly used to help doctors and therapists to make diagnoses. The idea of it is to help make a better judgment clinically; however, there are a lot of situations that doctors and therapists rely too much on this imaging and forgot about we are treating a human being, not the image. It is human nature that we want to see some pictures of our body and try to understand what is happening inside that causes someone that much pain. As a result, MRI is very popular these days.
In our city, there are a lot of people complaining about the doctors’ management of their treatment, and therefore, to provide solid evidence of a medical diagnosis, there are more and more doctors and therapists requiring a patient to take an MRI before treatment. Is it a good practice, it depends. To me, it’s optional because I’m seeing a person on the treatment table, and the scan acts as an aid merely.
I have been working in this field for more than 20 years and I have encountered many discogenic back problems, such as “slipped disc”. A lot of them with the MRI in hand asked me what I could do to fix their slipped disc.
I remembered that I upset a patient and she never returned after the first treatment session because I said MRI scan was just a reference for making a diagnosis. I don’t need an MRI for making judgments. But she considered her MRI report as a golden standard for her back problem and she was very unhappy about my comment. Since then, I will “seriously” look at the MRI report whenever possible, but that doesn’t mean that I will make my clinical judgment based on the report of the scan.
There are already reports saying that we all have disc problems and it is normal to have degeneration changes (clinic this link for more information). It happens to all of us. This means that even if we have a “disc problem” shown on the MRI, we may not have a real disc problem and hence low back pain. Clinically I have to make my judgment based on the patient’s symptoms, contributing factors, movement, and so on. This is obvious that making a correct diagnosis is not that simple.
Yet, there is a recent study reporting that the MRI can pick up some signals and physical examinations cannot detect (click here for more information). In this dilemma, should we still need an MRI or not?
Our training equipped us to make a diagnosis and perform treatment effectively. In case of a slow progression of treatment and there is not a logical improvement within the timeframe, an MRI may be required.
Recently I had a patient with a disc inflammation in his low back. He had multiple episodes of back pain for the past 10 years. He was having severe low back pain and sciatica nine months ago and he had recovered very well after roughly 10 to 12 treatment sessions in three months. He was pretty good for a couple of months. Last month, he had another injury again. He bent forward to get a bag of groceries in his car and he strained his back.
This time the pain was so severe that he could barely walk with a stick and he could not stand upright. So he went to an orthopedic doctor and was ordered to have another MRI scan. The doctor found the result overwhelming because the MRI a year ago showed a worse slipped disc compared to this time, but the pain from this injury was far more intense. Additionally, medication could not help to ease the pain at all.
Again this patient came for treatment. Based on his injury and symptoms this time, I concluded that he was having a severe back muscle spasm plus an acute inflammation around his nerve root near the old slipped disc.
The principle of management remains the same — to get a muscle spasm relaxed, realign his spinal curve, and promote blood supply to the corresponding area. I did passive mobilization, muscle energy technique, ligamentous articular technique, McKenzie mobilization, nerve mobilization, and so on. Once he was able to move more, I taught him and encourage him to do more core stability training and deep breathing exercises. After approximately 8 to 10 sections of treatment, he was pain-free as long as he did not sit for more than three hours consecutively. This patient could have been operated on if it were 10 years ago when a majority of the orthopedic doctors opted to do surgery.
Surgery is a lifesaver in some severe situations or life-threatening conditions. But most of the time, low back pain requires no surgery but physiotherapy treatment.
In reality, there are many conditions that we cannot make a diagnosis of based on an MRI scan. For example, muscular tension or incorrect movement pattern couldn’t be seen by an MRI study. Practically when I put my hand on the patient’s body, I can feel the fascia tension. It is a matter of tissue quality and this valuable information couldn’t be picked up simply by having an MRI scan alone.
I lately have a patient who complains about consistent pins and needles and reduced sensation at the right lateral thigh. Neurological tests reviewed nothing and it’s not related to femoral nerve or sciatic nerve at all. Theoretically, I can send her for an MRI scanning to see what is the cause of the symptoms. But before that move, I put my hand on her tummy and felt that there was a fascial restriction around her caecum. And a sustained stretch on the caecum surrounding ligaments of the caecum would re-produce her pins and needles sensation down the thigh. With manual treatment to loosen up the restricted structures her symptoms gone. If I have sent this patient for an MRI scan, she would only get a degenerative spine with some disc bulging. From here, a medical professional would probably stick to the MRI diagnosis, and the chance to resolve her restriction would diminish.
Meanwhile, I will also suggest that an MRI scan is crucial when we cannot match the symptoms with our assessment. Again we shouldn’t blindly make judgments purely based on the MRI scan.