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Why we should beware of scans and diagnoses for back pain

January 19, 2018

Humans are story-telling creatures. Over the course of history we have come up with stories ranging from the sublime to the outlandish to explain what we see in the world around us and about events in our own lives and the causative factors underlying them. And we do this using the best information which is available to us.

When we are struck down by pain or illness we have a desperate need to know what is happening and why it is happening. Giving our problem a name removes our sense of uncertainty - even if the name ends up being a rather bad one. And we want to know “what caused this?”

 

When it comes to back pain the same story-telling instinct is in play. The trouble is that the stories we are told, or that we tell ourselves has have consequences in themselves. And there is no lack of practitioners who will have an answer to that question - and the answers may well be different with different practitioners. And if we think we have a "buggered back" we will have. 

 

Back pain may be attributed to spinal stenosis (narrowing of the channel occupied by the spinal cord), a subluxation (a slight misalignment of the vertebrae) a scoliosis, a kyphosis, an over-straightened spine, degeneration, wear and tear, a prolapsed or ruptured disc, arthritis, ligament strain and so on.

 

Sometimes MRI’s or X-rays are used to diagnose the nature and cause of the pain. Doctors are often under a lot of pressure from patients to prescribe an MR. However clinical guidelines are quite clear that MRI’s should not be used routinely, but only “for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination.”1 Unfortunately these guidelines are frequently not followed.

 

In addition it has been known for many years that- “ Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain.”  2, 3 The fact that we have back pain may have little or nothing to do with what is shown on a scan.

 

And what is even more alarming (or amusing) is that specialists interpreting the results of scans can come up with conflicting results. Take the case of a study in which a woman visited 10 different radiologists. The study found (1) marked variability in interpretive findings and (2) a broad range of interpretive errors. The authors conclusion: This study found marked variability in the reported interpretive findings and a high prevalence of interpretive errors in radiologists' reports of an MRI examination of the lumbar spine performed on the same patient at 10 different MRI centers over a short time period. As a result, the authors conclude that where a patient obtains his or her MRI examination and which radiologist interprets the examination may have a direct impact on radiological diagnosis, subsequent choice of treatment, and clinical outcome. 4

 

And furthermore it is well known that the very fact of having imaging done can cause  iatrogenic (doctor caused) harm to the back pain sufferer. This is not just a minor effect.. Early MRI without indication has a strong iatrogenic effect in acute LBP, regardless of radiculopathy status. Providers and patients should be made aware that when early MRI is not indicated, it provides no benefits, and worse outcomes are likely.5

 

People with chronic or recurring back pain often come to Alexander Technique lessons with a well entrenched story regarding their problem.  Stories and images are powerful, and once we have internalised a particular image of our back or spine, which may have come from a scan it develops a power of its own. But it is not only from X-rays or MRI’ s that people form their images – it can just as often be stories which they have been told by different clinicians. Stories like  “you have one leg shorter than the other” or “your pelvis is twisted” and so on.

The cause of the back pain may then attributed to a particular pathology over which the patient has no control or which needs to be managed by ongoing treatments/manipulations. He or she has a buggered back, A chiropractor, physiotherapist, acupuncturist or other practitioner may be able to provide symptomatic, temporary relief, but the underlying cause is visualised as being outside of the sufferer’s control.

 

Stories and images of structural damage or abnormality impinge deeply on people’s subconscious adding to the complex mixture of processes which make up the perception of and reaction to pain sensations. They are part of the ecosystem which forms our overall “use” of ourselves– posture, movement, overall reactivity, tension patterns, emotions and beliefs. They are part of what restrict and constrain us.

 

Recently I asked a chiropractor who was at a stall offering free spinal checks, whether they had come accross anyone with a "normal" spine that day. I already knew the answer which was "No",  Usain Bolt the fastest man in the world doesn't have a "normal" spine: he has a scoliosis. But over  time he developed the use of himself which took him to the top of the sprinting world. Have a look here at the evolution of his running style over time. 

Like Usain Bolt the task is to develop a coordination which respects and works with our own unique physical makeup.

 

In Alexander technique lessons many students begin to experience ease,  release of tension and lessening of pain  by changing the overall pattern of posture and movement and by learning to respond to everyday tasks and demands of daily living in a more effective way. The work does not focus on specific areas of the body which may be blamed for causing their pain. Nor is the work an attempt to put the body into some "correct" mechanical alignment, but to bring about a coordination which is not imposed as a result of some predetermined idea of what is "good posture." 

 

 

 

  1. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society – Clinical Guidelines, 2 October, 2007

  2. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations

  3. Spinal stenosis, back pain, or no symptoms at all? A masked study comparing radiologic and electrodiagnostic diagnoses to the clinical impression.

  4. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period.

  5. Iatrogenic Consequences of Early Magnetic Resonance Imaging in Acute, Work-Related, Disabling Low Back Pain

 

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