“Patient complaints that originate in the musculoskeletal system usually have multiple causes
responsible for the total picture.” —Drs. Travell and Simons
“The first treatment is to teach the patient to avoid what harms him.” -Karel Lewit, MD
“He who treats the site of pain is lost.” —Karel Lewit, MD
After seventeen years of running a private rehabilitation clinic, I've seen my share of back pain
in my patients. It is one of the most common ailments I see, but it is also one of the most
misunderstood concepts for the patient, mainly because of the confusing, and often negative, language
in the medical field. Patients with back pain—much like pain anywhere in the body—are confused
about why it exists: “How did it happen?” “I woke up with this,” are common statements. When the
healthcare provider informs them “your back is out,” or “you have stenosis,” and “you have
degenerating disks,” the patient assumes the worst ( “I'm degenerating?”). While these physical items
might very well exist, and yes, back pain can be related, chances are the patient's pain has nothing (or
very little) to do with them. Yet the patient is told an MRI is “bad” because a disk is herniated (recent
studies show that patients with herniations have no pain related to them)1 . The patient begins to believe
he or she is doomed. After an MRI is ordered—and they are processed at an alarming and completely
superfluous rate in the United States2— the patient is hit with an onslaught of impossible medical
jargon. Does the patient need to spend time listening to the radiologist so she can have a better
understanding of the issues? Yes, but the delivery of such information needs to be filtered and
converted into more positive and educational bits. Over the years, many MRI reports I've read showed
a myriad of structural changes (spondylolysis, lumbar stenosis, protruding disks, et al), yet in my own
clinical experience most of the patient's pain was not a result of these physical findings. Yet the MRI
places the patient into an anxious mindset for therapy because of these “physical” findings and their
foreboding visuals of “it,” the one thing that is the cause of it all. I've seen it again and again, the
patient in obvious jabbing pain, unable to sit comfortably, pushing the MRI report in front of me
exclaiming, “It's the stenosis.”
The first thing I try to do when a patient brings in an MRI report is help
relieve some of the
anxiety associated with a “bad” MRI. For any therapy to take place, the clinician must establish a
positive mind-set for the patient from the initial evaluation. I do this in part by explaining, in layman's
terms, how soft tissue reacts to stresses of the skeletal system, and how structural changes to the spine
often are not the issues causing the back pain. I try, ultimately, to get her mind off that one thing that
she believes is the problem. For example, I've had many lumbar stenosis patients who do not have
every symptom of pseudoclaudication, but have a thoracolumbar muscle region that is completely
dysfunctional. Yet most physicians overlook this. (And others, too. At a recent physical therapy
symposium I attended, I asked the physical therapist who taught a course on back pain if he ever
considered the sacral ligaments and related soft tissue in his manipulations. “No,” he said, “They really
are not important.” Huh?)
I also explain to the patient that, while we cannot eliminate the
stenosis or structural change, we
can focus on releasing the thoracolumbar area to relieve the pain and postural dysfunction. (That's why
massage therapy is so effective for back pain. See the story on NPR.) I have improved pain and quality
of movement in my patients on this very premise, and have reproduced this result over and over in
patients who thought they were destined for surgery.
So “bad” MRI's are not necessarily a ticket to debilitation and
poor quality of life, and the
patient, once she understands this, is in a remarkable position to improve her dysfunction.
• Your back is not “out.” This is one of
the most common phrases I hear both told to and from
patients, and it's understandable why it is used by the patient. The patient may often feel
something is “out” when the thorocolumer region is in spasm. If disks are misaligned, research
shows they will resolve themselves over time, sometimes with a little self-help. 1
• You are not “degenerating.” Yes, our bones
undergo arthritic changes as we age, which means
we need more muscle stability to help protect them, but we are not literally disintegrating.
Patients are not damaged but have dysfunction!
• It did not happen over night. While it might seem
as though the pain suddenly developed
over night, usually this is not the case. Soft tissue dysfunction has a snowballing effect; it
develops from a single event that gets worse over time. 3
• Does the patient really need an MRI? Getting a second
opinion is always a good idea. I
recently visited a podiatrist to get a mucoid cyst removed from my second toe. He insisted he
must order an MRI, even though it is one of the most common cysts that occur on the hands and
feet. (I refused and the cyst resolved itself.) Radiological films are always a good start, too.
1. Cherkin D, Deyo R, Battie M, Street J, Barlow W. A comparison of physical
manipulation, and provision of an educational booklet for the treatment of patients with low back pain.
N Engl J Med 1998;339:1021-9.
2. Magnetic resonance imaging and low back paincare for medicare patients.
Baras JD, Baker LC.
Health Aff (Millwood). 2009 Nov-Dec; 28 (6):w1133-40
3. Bogduk N, Twomney L. Clinical Anatomy of the Lumbar Spine. Churchill Livingstone