Normal low back MRI but still in pain: what now?

Hey clinicians, before we start, I'm going to draw your attention to the premium version of the podcast that we have that we released back in January. It's going very well. It releases once a week and it's all the stuff that you care more about than some of the general conversation you might get in some of these free version podcasts. So it's about 15 minutes long. We do case presentations, all of the stuff that we tried, things that work, things that didn't work, and a little bit more specific to you and the things that you wish might be in there too. It's very affordable. You can quit at any time. There's a link in the description below.

Go check it out. You'll love it. Now onto the podcast. You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. And now, your host, Dr. Sebastian Gonzales. Hey everyone, this is Sebastian, your host with the Restoring Human Movement podcast. Thanks for joining the Movement Movement. This is your first time, Michelle. Welcome. You've missed a lot of the recent episodes based upon low back hip pain and some interesting information that you guys might want to know about. So please go back in the archives and look at those. And we have some really great topic coming up in the future here as well. So this podcast, the intention of it is to make rehabilitation and recovery easy for all the people out there who have the problem. In the past, this podcast was a little bit more centered towards clinicians to improve their clinical reasoning.

But we do have the premium version for that now. So as I go through this topic today, which is called my low back pain, my low back spine MRI is normal, but I have pain. What now? It's based upon the ongoing discussion that I feel like I've had with a lot of the clients that I've worked with. I'm sure a lot of the clinicians out there have also had the same scenario. A new person comes in and they're really kind of thrown out of wits because their MRI should be normal, they say, because they have pain. But it's like everybody's first rodeo through this where they might not have been told some of the facts, at least surrounding it. Now for the clinicians out there, I know there's going to be some people who are just research nerds. I'm not. I'm reading stuff based upon what most people are going to find.

For most of the information that I'm sharing today, it's going to be systematic reviews and meta analysis for the lay public out there. These are basically the higher types of research. There's smaller scale ones, there's single time case studies, and there's ones that kind of collaborate together and say, hey, we're going to look at all this research over the last handful of years or a certain timeline and we're going to decide, or we're just going to ball it up in a nice bow for you guys. And that's what systematic review and meta analysis basically are in a nutshell. So I pulled three of them off of Google Scholar today and I took them from like generally within the last 10 years. The reason why you guys might want to listen further with this podcast is because not all websites, including ours, is necessarily 100% up to date. Even the research takes a little bit of time to get to us. It certainly takes longer to get to you. And so just going through Google Scholar, if you're okay with reading through some of the technical words, is probably a very simple place to start. So you just look up whatever problem you have like low back pain and systematic review or meta analysis. And those are really good places to start. To be transparent, again, not all places, including our office is up to date on some of the recent literature about problems that you have. We tend to see a lot of low backs, a lot of sciatica, a lot of hip, a lot of groin. And so we start, we stay up to date more so on those topics than other ones. But again, to be transparent, I haven't, I haven't looked at these in probably a year or so, you know, like you get busy helping people and you don't always get stuck in the weeds with the theories and so on because the theories change. Last year, we did an update on what we call tendinopathies or tendon disorders. I don't think I've done an update, a research update in our office, probably for the last six, seven years with tendinopathies. So make sure that you, whoever you go, based upon the information that you find in this podcast, if you find it's helpful to you, if you're looking for someone to work with you, make sure they are up to date and just ask them, they might be aware of some of these findings in here. We're always very open when people want to discuss with us about our history of working with certain types of conditions. So this won't be extremely elaborate today. I'm just going to go through some of these research articles, which will be posted within the show notes, and you guys can read them for yourself and decide. So the three major points are, number one is MRI is not 100% predictive of low back pain. The research study we're going to use is, it was called, does magnetic resonance imaging or MRI predict future low back pain, a systematic review. We're also going to go over MRI findings of disc degeneration are more prevalent in adults with low back pain than asymptomatic controls. The last one is going to be degenerative MRI changes in patients with chronical back pain, a systematic review. I know a lot of these words might be a little bit more technical. I'm going to do my very best as I read through these just to pause and give you a little bit better insight of what this is kind of talking about, at least in regards to the specific structures. So a hundred percent, uh, MRI is not a hundred percent predictive of low back pain. This is from the European journal of pain. Um, so this says 90 to 95% of low back pain sufferers are classified as having what they call nonspecific low back pain, reflecting the inability to identify a clear source of pain. That was from a 2006 study. Again, these, these systematic reviews gather a lot of other studies together to, to make their statements, uh, way better than a Google website. Google, uh, Dr. Google is very, very bland. Okay. Uh, if the source of pain could be identified in at least some of these patients, then it's possible that more targeted and effective treatments could be found. MRI has the potential to identify pathology responsible for low back pain.

However, importance of findings on MRI remains controversial. Previous studies, uh, reveal high rates of abnormalities on MRI in people without low back pain. Remember that's without low back pain. People also have abnormal things, uh, as well as people who have back pain. Okay. Consequently, it can be difficult to determine whether abnormalities seen MRI are truly, truly the cause of low back pain since morphological changes are common in asymptomatic subjects. So again, it's hard to identify if the MRI findings are really that helpful in identifying what's creating your pain. If people with pain also have that, uh, with and without pain also have that same finding, the lack of widely accepted gold standard tests contributes to the difficulty in assessing the diagnostic accuracy of MRI findings. That one part was from 2012. The present, the presence of pathology and MRI in people without low back pain does not necessarily mean MRI findings are not important. Um, in many other conditions like cardiovascular disease, um, atherosclerosis, uh, it exists in, so in many other conditions, uh, pathology exists in people without current symptoms. However, this pathology has been shown to be very important. Um, uh, MRI findings in asymptomatic people may represent markers for early pre-symptomatic disease. And so, uh, let me ball this up in a little bow again. Uh, a lot of people who have back pain, they, they call it nonspecific low back pain, which is hard to identify the actual clear source. Personally, I think that a lot of, uh, I don't want to say we're better at all, but I really don't think nonspecific low back pain is, is extremely common. Um, I think there is a specific, specific mechanic. Um, and I think McGill covers this and this first, it was the first thing that I actually asked McGill when I, um, Stuart McGill, when I interviewed him, uh, I want to say two years ago, I said, is there anything is, is, uh, like specific non, nonspecific low back pain? Uh, and he, he's like, Oh, you're just gonna go right, go right at it.

Uh-huh. Um, his kind of is his kind of thread of, um, the theory is that you can specifically test to see what is the actual structure or movement that's provoking your pain. MRI doesn't necessarily do that because it's also not movement based. It's a static image. You're not moving within it. Uh, people who are a little bit more keen to what we call the pain science people, um, might say, well, pain is an experience, which means that pictures don't show, um, emotions or experiences. And so it doesn't necessarily, the image doesn't reflect everything back, which is why there might be a disconnect between people who have the actual structures that look like they're in pain, but they're not. So second paragraph, again, ball it up is so it's kind of controversial with MRIs because people who have positive MRI abnormalities have, and don't have low back pain. So it's, uh, not, it's kind of a muck, muddy water. And the reason why I want to bring this topic up with you guys today is because it's so, um, mainstream when people are like, oh, well, I have back pain. I need an MRI to see what's going on. No, you don't. Most people don't because, uh, there is a lot of, um, muddiness about the water.

You do need an MRI possibly to rule out the, remember I said 90 to 95% of low back pain sufferers, which means, which, which indicates that there's actually a percentage of people who will have something, which is big, bad, and scary, which we would classify as sinister pathology. It's stuff that you don't want to have tumors, infections, and so on. So there's other things that we're looking for in an MRI versus, um, the things that you might think, because not all these weird words on your MRI are necessarily indicating that they're symptom generating structures. They're not the cause of your problem. Um, but this study, uh, the systematic review did say that there's, um, maybe some merit, almost like looking at these structures, like arthritis and degenerative disc and, you know, uh, facets and modic changes and things like that, that might be helpful to, uh, manage the condition. Similar to like, if you can see, um, plaque buildup within certain images to indicate heart health or cardiovascular health. And so, uh, I, I do like that analogy that they use because, um, uh, personally, I think that when you have an image, it shows, uh, it shows how you've treated your spine. It shows a picture in time. Uh, it shows that like, if I use my hands a lot and you took a picture of my hands, you'd see calluses on them. The calluses in this case are not necessarily bad, but it shows, it's a reflection of how I've used my hands over the last, um, you know, probably two, three months. If it's a short-term use of the hands, but I use them really aggressively, you'd see blistering, uh, which is why a lot of times people, when they do things like, um, a lot of pull-ups or CrossFit or, um, I think toes to bar and kipping stuff and so on, you'll see them, they have these rips on their hands because the volume was a lot and there wasn't time for adaptation. Um, some of the findings that you might find on MRI are, in my opinion, they're adaptations. They're adaptations that show what the body is trying to do to support the activities or, or loads that you have. So this systematic review reveals that there are, um, relatively few studies that have investigated MRI findings as predictive, as predictors of future low back pain. As a result, it's not possible to draw firm conclusions about the ability of MRI to predict future low back pain. So, uh, I know it was a lot of information there.

I do encourage you to rewind that part. Um, because first understanding that low back pain is not a hundred percent, uh, based upon your MRI findings. I think it gives a lot of people the kind of the mindset of, Oh, that thing that they found on the image doesn't mean that I'm going to have back pain forever. It just means something was there. Um, uh, I've heard a lot of people say, uh, at least in our industry to kind of downplay the findings on the MRI, they call it gray hair of the spine. Like arthritis is gray hair of the spine. Um, I've used that, uh, analogy quite a few times with people because a lot of times people fixate on it. Uh, I remember there was a gentleman that I, uh, we didn't, we did an x-ray for his neck. Um, but easily this, this conversation can happen with someone with an MRI. Um, so we did an x-ray for their neck. And I said, look, before we do the image, I want you to understand, I'm looking for something odd. I was actually looking for, um, I was looking for, for a tumor, uh, cancer, uh, something I can't treat. And, um, so I said, look, before we do this, because you're 60 years old, you're going to, we're going to find a bunch of big words in there. Okay. When it comes back, don't worry about anything unless I tell you there's something to worry about. And so it can, he come, he comes back and, and we talk about this imaging with the itises and osises and opathies and so on. And, um, he, he, he loves to have a good conversation, which I do appreciate about him, but we talked about this thing and his worries associated with the MRI or with the x-ray for about 30 minutes. Um, it was a lot of information that, uh, he might not even need to know to feel better when we were using the image with the x-ray or MRI or MRI. We're looking for things that we can't treat. We're not looking for a smoking gun because in this, uh, systematic review anyways, it says, you're not really going to find a smoking gun. You'll just find things, clues, but it doesn't mean a smoking gun. Now the next one is, I hope you guys like my bedtime reading ability, by the way, I don't have kids. I don't read books to kids. Um, and I usually don't read things out loud. I hate, used to hate that, that, uh, game we had in middle school. It was called popcorn. You'd read a little bit of a, of a book and then you say popcorn. And then you'd say, Hey Joe, go ahead and like read. And they would keep going until someone finally said popcorn again. Uh, I hated it. I hated reading out loud. I hated public speaking.

Um, so I hope you guys will work with me this, at least the best, the best that I can. Now, the second study we're going to go over is MRI findings of disc degeneration are more prevalent in adults than low back pain, uh, with low back pain than asymptomatic controls. Asymptomatic is people who don't currently have the symptoms of low back pain. It doesn't mean they haven't had low back pain in the past. It just means they don't currently have low back pain. They're asymptomatic. And this is from the American journal of, uh, neuroradiology. This meta-analysis of 14 high quality cases, uh, case control studies, including over 3000 individuals demonstrated that many degenerative findings, uh, degenerative spine findings have a higher prevalence in individuals 50 years of age and or you'll or younger with self-reported low back pain as compared to asymptomatic controls. So this one, uh, again, this is kind of almost in contrast to the last one, uh, still a very good, uh, study disc findings, including disc bulges, disc degeneration and disc extrusions and protrusions had significant association with low back pain.

Um, monic type changes in spondylolysis, which is, uh, like fractures. Um, it's, it's amongst the, uh, we call the pars area pars interarticularis, which is actually more common with, um, uh, gymnast, uh, kids younger age. Um, and, uh, people who have repetitive load on the backside of the spine elements, they tend to be arching athletes a little bit that even rotational athletes will get it too. Um, uh, uh, anyways, uh, type one monic changes in, in spondylolysis or the fractures, uh, of that certain type also demonstrate significant association with low back pain. While these findings do not prove that disc and end plate related imaging and fractures are, are pain generators, they do suggest the evidence of these findings could be explored as candidates for biomarkers of low back pain. So let me boil that down a little bit. Uh, we talked about the disc bulge, degeneration, extrusion, protrusion. Those are different types of disc injuries. Um, and a lot of the, uh, verbiage that you might find on one of your, um, images that have come back. Uh, one of you guys on this is that you won't actually see any evidence of the actual disc quality with an x-ray. You don't actually see the disc. You can see the scenario where there's a change of disc height, which might insinuate the disc degeneration and other factors like maybe the nucleus or the jelly has come out of a donut. And that's why it's, it's a low, a smaller space, but it doesn't necessarily show anything.

The reason is because x-rays just by nature, they blow through all the soft tissues. That's why you can see bones and you don't see your skin. They blow through all the soft tissues and the harder the tissue is, the more it will show up on the image. So that's why, uh, calcium deposits will show up. Uh, that's why I think kidney stones would probably show up to, um, bones, uh, and even the inside of the bone, which is softer. It's, it's, uh, it's not necessarily the, the firm outer crust won't necessarily, that won't necessarily show up either. It just kind of looks like a hollow box. Um, so you don't really see any evidence of it. I'm mentioning that because I've had a lot of people come in the past who have said, well, I saw it on an x-ray. We saw it on an x-ray. You didn't see a disc on an x-ray. Um, you didn't see a muscle on an x-ray. You didn't see a tendon on an x-ray unless it was calcified or there was some type of really big abnormality with it. Like it was denser than it should be. Um, I think there was a, uh, I'm trying to recall that the thing where, where blood starts to calcify within like a hematoma in a, in a muscle. So you can see like islands of, of densities, which are, which we, you will see on an x-ray. Um, but in most people, you're not going to see a lot of those things. Uh, monic one changes in the spondylolisis. Spondylolisis you could find on an x-ray. It takes, it's, it takes a keen eye to see it. Um, that's a fracture again. It's, that's the, uh, PARS fracture. Um, which by the way, if you have a kid with lower back pain or a high schooler, they should be investigated for this. Um, imaging, uh, more CT is more of a thing that you'd want to see with that. I believe a CT scan, which does have quite a bit of radiation. So it's kind of, do you want to do it with a kid anyways? But the modic one type changes to the end plate, I think that's going to be more of just mainly MRI. Um, I bring all these up because I've had a lot of people, um, really get, uh, all up in arms about all the wording. Cause these sound like a lot of scary words, uh, on the image, you know, it doesn't necessarily have to be. So these are just normal things, you know, but as this, as this meta-analysis says that they don't have, it doesn't mean they're while these findings do not prove disc and plate and fracture the spot, the PARS fracture are pain generators. They do, uh, they do suggest the evidence of these findings could be explored as candidates for biomarkers for low back pain. So they mean something, their information, but they are not, they, they just, cause you have, it doesn't mean that that's the reason for your pain.

Okay. It doesn't mean it's the reason for your pain. And I keep saying that over and over again, because it's seen as believing. I've, I've seen many people have this experience so far. They just get really hung up on the idea that something's in their image and they're like, Oh, that's it. No, it's not. It's just information. Our findings agree with those of other studies examining the association with disc imaging findings and low back pain. Multiple previous studies have demonstrated a higher prevalence of disc findings in people with symptoms than people without symptoms. disc protrusions are not uncommon in asymptomatic adult populations. While prevalence range from 10 to 30% of people at any point in time could be walking around and have a disc protrusant and don't have symptoms depending upon the age, obviously based upon the group studied in general, um, studies demonstrate that the prevalence of disc protrusions and asymptomatic populations increase with age. So as you get older, you're probably going to have a disc protrusion, but it doesn't necessarily mean that it hurts. Our studies have found nearly 20% of asymptomatic patients, 50 years of age or younger had disc protrusions compared to nearly 40% of symptomatic group. So, um, yeah, you could have pain with a disc finding on an image like a protrusion, but it doesn't mean you have to because 10 to 30% in this case, it also had another study reference.

They were 20% under the age of 50, didn't have any pain with it. So which one are you, you know, um, disc extrusions are rare in asymptomatic, uh, populations. The prevalence of disc extrusions range from zero to 4% in asymptomatic populations. And most studies have reported prevalence rates under 2%. Uh, on the contrary, prevalence of disc extrusions range from five to 10% in symptomatic populations, meaning that it's more common to have a disc protrusion creating your pain than it is an extrusion. Extrusions are much more related to having pain and it's, it's going to be more rare to have some walking around. Huh? Yeah, I got a disc extrusion. I feel pretty good though. Um, if you find an extrusion on an image, it's going to be a little bit more of a smoking gun. Now we're going to go into the last study here. Um, again, I don't know if you guys can tell, I'm trying to read these verbatim because there's going to be someone out there just policing all of these, uh, things that I'm saying because they want to make sure that the research is there. Again, if you want to do your own research, you're completely welcome to those endless amounts of research coming out every single day and you can always find whatever you're looking for to validate whatever thing that you're talking about. I tried to pull a variety of studies in here with high, um, uh, with high dependability, uh, just so you can guys get an idea that there is a lot of information there that does contra, uh, contradict and there are other variables. The whole point is there are other variables, just like the colorblind people.

So this third one is a degenerative, uh, degenerative MRI, degenerative MRI changes in patients with low back pain, uh, a systematic review. This one's out of the spine journal. Uh, I don't, I don't recall what year, but you guys can click on the link chronic low back pain. I've actually, I thought this one was a really good read. Um, as I was reading, I was thinking, huh, uh, I can try it. This is actually when I was reading this one, I thought I can just regurgitate all this stuff because this is very well written. I think it's very late, late public written. If you guys are going to read one, this is the one to read. So chronic low back pain is a difficult problem to treat and diagnose, um, of its exact, uh, root cause because it can be elusive. Although terms describe it, although terms describe symptoms, not diagnosis, this one symptom, this one symptom nevertheless represents the, uh, I don't even know that word. It costs constellation of diagnostic and therapeutic difficulties of a disease. I'm just going to say things aren't always super easy. Again, I told you, I hated that popcorn game. Chronic low back pain is defined as low back pain lasting for three months or more that does not, um, clearly is not clearly defined from a pathological entity such as deformity, fracture, neural compression, neoplasm, or infection. Um, symptomatic neural compression causing buttocks pain or back pain may mimic chronic lower back pain, but because it's actually neurologic and root cause, uh, it's excluded from the definition of low back pain, at least in this type, uh, in this research we're talking about right here. Difficulties with managing chronic low back pain lie in both diagnosis and treatment. The term, the diagnostic dilemma stems from the inability to localize and identify the source of pain. The big question usually poses in low back and chronic low back pain is where's the pain coming from? The pain or the treatment dilemma arises from the lack of well-defined and reproducible treatment modalities that can definitively and reliably alleviate chronic low back pain. So they're trying to find out where's the pain coming from to be able to treat it effectively. Uh, I think the verbiage they're using is actually very good because you want to figure out what's the low hanging fruit and be able to treat it from that source. Uh, let's just say if it was a psychological type of low back pain, I know a lot of people have been told that it's like, oh, it's in your head, which by the way, I don't think it's in your head. Um, you know, if that was a viable source of pain, if it was, if it was brain driven, then sometimes people treat it from a brain perspective. If it was from a disc driven type of pain, the disc protrusion type of pain, then you would drive it. Then you would treat it from a disc perspective. If it was a facet or an arthritis one, you'd treat it from that type of approach. And so, um, you need to know where the pain is coming from. A lot of times stress testing can do that, which is a lot of what McGill's work derived from. Um, from the diagnostic perspective, workup of a patient with chronical back pain many times includes MRI and often degenerative changes are seen. The radiologist interpretation of these MRI findings, such as comments as annular tears, disc degeneration, end plate changes, facet arthropathies, which is arthritis, basically, uh, bulging disc. These official reports many times put the patient and the treating professional in a quagmire both may wonder if these multiple degenerative changes are, are the source of pain. By the way, all those things that mentioned, because a lot of time it's very common that the images will actually show, they'll say annular tear, disc degeneration, end plate changes, facet, arthropathy. Which one are you treating?

Which one is your clinician and you treating? As a team approach, which one are you guys treating? Because they are probably not all symptom generators. It's probably going to be one. Um, you know, it's probably going to be one. Um, I knew, and I know, I know in our office, we talk about intolerances. Um, if your flexion or extension intolerant is your back extension intolerant. Does it tolerate extension? Um, uh, that way it's a little bit more of a, uh, verse, we will diagnose people. We'll also, it's, it's figuring out the mechanics of, of how your body fares and exposing it to what it likes. Um, and you can find that out in testing. You can get stress testing and figure out, uh, imaging doesn't necessarily give that information either. Uh, because again, it's a snapshot in time, uh, going on. However, it's unclear if any changes are truly associated with low back pain. I'm going to reread that because I should have just kept going. Annular tears, disc degeneration, end plate, uh, changes for set arthropathy and bulging disc.

These are, uh, these official reports can many times put patients and treating, uh, professionals in a, in a quagmire wondering about if these multiple degenerative changes are the source of pain. However, it's unclear if such changes are truly associated to pain. Again, that was kind of, is that what the last study said? Who knows? There are patients without back pain who have degenerative MRI changes. There are patients with back pain who do not have such changes. On the contrary, studies have shown that patients with back pain tend to have more degenerative changes than patients without back pain. Moreover, treatments such as degenerative MRI, uh, moreover treatments of such degenerative MRI changes, specifically degenerative disc disease by surgical intervention can be controversial. It's not, it's not clearly, it's not entirely clear that surgical treatment of degenerative disc disease may result in a decrease of back pain. Uh, these are all referenced, uh, as other studies, by the way, you can always read these if you want. Thus, there can be a comorbidity associated with obtaining MRIs in patients with chronic low back pain. Um, I'm going to pause with the reading for a moment that there's a risk reward to everything in life. Um, and sometimes showing people their image when the image is not a hundred percent needed can make them fixate on the things within the image. And so that is the negative or the risk that comes with it. People will fixate on parts of their body. They will start to internalize things. Um, they're like, Oh, I feel like my bones are rubbing together. I feel like the disc material is pushing out backwards. Uh, I know I have back pain because I had the disc herniation 30 years ago. Uh, they'll start to focus on structures when that's not always the best thing to do. So here we go on. Once the MRI is done, the patient now has a radiologist report documenting a multitude of changes in their back in hopes of alleviating back pain. Many patients will seek to have such degenerative changes addressed clinging to the notion that these changes are indeed the cause of their pain, which again, earlier we said it necessarily wasn't, uh, the time and resources devoted to addressing these changes, uh, either through subspecialist consultation, patient counseling, injections, or even surgery can be significant, uh, whether or not an alleviation is, uh, whether or not, uh, an innovation intervention is performed. Such much of this morbidity may be related to the patient and the primary care providers expectations. While patients, uh, while the patient presents with back pain and an MRI is obtained, the radiologist dictate dictated interpretation yield yields a multiple findings of normal and age related degenerative changes. And these may be, what is that?

Connoted? It's funny earlier. I said, this is a great one to read, but I mean, I, I know I got a B in English one time, but what the heck does connoted mean? Uh, connote, uh, employer suggests, want you to say supplier, what you guys are doing sometimes. Okay. So these may suggest to the patient, I'm going to back up, uh, when patients present with back, uh, with a back pain and MRI and the MRI is obtained, the radiologist dictates, uh, dictated interpretation yields multiple findings of age, uh, and normal, uh, degenerative changes. And these may suggest to the patient and the primary care provider that these findings are indeed, uh, the cause of pain. This subsequently may result in spine, uh, spine surgeon referral with expectations that a solution can be found within. In fact, surgery may not be any better than non-surgical care. In addition, this may lead to the unintended labeling of the patient as such having structural abnormalities when in fact, they merely have natural age-related degenerative findings. Uh, patients labeled such, uh, uh, with such degenerative changes may tend to worry more, avoid therapeutic exercise, and focus on minor back symptoms hampering improvement. Thus obtain an MRI with treating patients with chronic low back pain is not always, is not without morbidity in consequence.

So, uh, I think that's the important part with this. I mean, now that we, um, we will start to close very soon here, but, uh, as I wanted to do this topic here, obviously I'm reading a bunch of stuff from research. That's okay. I'm hoping that you guys are good with that. Um, but the main takeaway is, is it, is it common to have a normal MRI of your low back and still have pain? Yes. But if you have an abnormal finding on your low back, don't fixate on it and think that's the reason why you're always going to have pain because you probably won't. Um, just the fact that you had imaging done is not necessarily a bad thing. It's really up to your healthcare provider. If they need to screen out to find other things that they shouldn't be treating that they need to suggest that you go elsewhere for, um, maybe, uh, a, um, um, uh, a doctor who works with cancers or, or a, uh, infectious disease doctor, other weird things. Like we're looking for other weird things, but in the search of finding those other weird things just to be comprehensive with, um, with care, this can happen.

All of a sudden you start worrying about these normal age related degenerative changes. Again, earlier I said gray hair of the spine, it's gray hair of the spine. It doesn't hurt, but if you start focusing on it, people tend to worry. They tend to avoid therapeutic exercise. They tend to not do the things they like. They don't play baseball anymore. They don't play soccer. And all of a sudden they become, uh, in, in my, in my opinion, older, older, not by age, but older by activity level. So, um, there's everything has a pro and con in life. And so if you decide to get imaging done, there is a con, uh, and sometimes I think most of the time low back pain, sciatica, um, sacral pain, SI joint, many of them can be treated without having an image done.

Okay. I mean that from the bottom of my heart. Uh, some of you will wait months and months and months to have this MRI done to only find gray hair in your spine that people fixate on and send you to a spine surgery when you don't need it. Um, you don't always need it. And what, what's happening is, uh, too, when you wait, as I mentioned in one of these other, uh, in one of these research articles, we said chronic low back pain is defined as low back pain lasting for three months or more. Once you go a little bit further into having longer durations of pain, there are other variables that come into play. Um, there there's many books that can talk about this. Uh, it's called the biopsychosocial aspect of pain. Uh, and the longer you have it, uh, it's not impossible to get out of.

It just makes a little bit harder. There's other variables involved. So this study had a couple takeaway points. I think that you guys might like, um, one is in the absence of deformity or symptomatic neural compression. There's no evidence to demonstrate that surgical treatment of degenerative MRI changes leads to improved outcome over non-operative care. Okay. I don't know how many times I've heard people say this. Ah, if this doesn't work, then I'm just going to do surgery. Yeah, but that's not a better option. It might not be any better. As I said, I'll read it again in the absence of deformity or, or symptomatic neural compression, by the way, those are, those are in other, like other situations. Uh, not, it's not the 95%. Uh, there's no evidence to demonstrate the surgical treatment of degenerative MRI changes lead to improved outcomes over non-operative care. Okay. Try the, try the non-operative stuff first, commit to it, work with someone that you really like and trust. And I think you'll find the changes that you're looking for. Um, if they think that you're that 5% that needs to be referred out, they will probably tell you. I know I would. This, the other point I thought you'd like is strong recommendation, strong recommendations are made against routinely using MRIs for the workup of chronic low back pain and against the surgical treatment of chronic low back pain based solely upon degenerative MRI changes. So this study really doesn't like the idea of giving people MRIs to kind of randomly look at stuff routinely, unless you really need to, and you're screening out other things. Uh, and it, and your soul, uh, the reason for surgery should not be based on a hundred percent on degenerative changes found in the MRI. Okay. There's other things as I've told a lot of people in the past is most of the time, at least my, I'm not a surgeon. I guess I should give you that note.

And I have referred people to surgeons before I've referred people up the chain or up the ladder, as we say to, to specialists that I think would be better fit for the people with back pain. But generally if function is normal, there's no change in bowel or bladder function and there's no numbness in anywhere that you wipe. When you go to the bathroom, um, there's probably not a big need based upon, uh, um, uh, at least, uh, baseline levels for surgery. Um, those are more surgical types of scenarios where we're looking at function as it might go down or they have rapid, uh, loss of strength or rapid loss of function. Um, I know for hands and, uh, people who have hand numbness, we're looking at does is, can they use their fingers? If they can't use their fingers, there's a rapid need for some type of intervention. In this case, probably a symptomatic neural compression, but, um, pain is not the reason for low back pain surgery. It's function. So again, you talk to your surgeon though. Uh, I'm not a surgeon, but that's just based upon my understanding, uh, from what I've learned over the years anyways. So, uh, if you guys do need help digesting down where you're at, uh, what you should do, um, do your MRIs have any association with what's going on with you. Um, you can always come see us. Uh, we are in California. We can give you some suggestions to do if you come see us and let us test you. Uh, we do have virtual options for coaching. Um, but as always with virtual stuff, we don't, uh, you can't do all the tests. Um, virtual options have become more prevalent over the years. Um, obviously for good reason, but there are certain tests that you can't do. Um, so we try to encourage everybody who's looking for a really firm answer and, um, give a re like, we can give the best opinion that we possibly can. If you come see us in person, you don't have to see us every time in person, but to get all the information that we need in person is all is usually the best. Um, and other podcasts, I think it described this as playing Sherlock Holmes and Dr. Watson. Um, we have to be on a team to figure out the information that's relevant for your low back pain. Um, that might require us to do things in person. It might be useful to have an MRI, but we don't know. We have to assess the situation first. And after that, we together can make a decision about what is the best route for you to take. Um, uh, things change sometimes over the course of weeks to months. Uh, I had a great email recently. This isn't for back necessarily, but we, I saw someone, uh, last week with, um, with hip pain. Uh, and, uh, he, he, uh, he said, he sent an email and he said, I can't believe it. I woke up today and had zero hip pain whatsoever. It was fantastic. And so that was over the course of a week. Not everybody's like that, but what happens is when things change, also your treatment or your program might change slightly because now there's more options. Uh, if your hair is on fire, like we're probably not going to talk about, you know, going to the mountains and skiing, but now that your hair is not on fire, we can talk about skiing and going hiking. Like there's other things that you have other options to do. Exercises might reveal themselves as being helpful. Uh, some core work might reveal themselves as being helpful. Um, but as long as things are super flied up, sometimes there's things that are off the table. I never grew up playing a ton of video games, at least ones where you had access to like these different little like levels, but sometimes you just get enough points and all of a sudden you get access to the sword. Um, when pain reduces significantly, you get access to other options, some other exercises, some other activities that you no longer have to avoid anymore or, or even over be overcoached.

But coaching in the beginning is very important. So, uh, I hope this, uh, this was helpful to everybody, or at least to expose the idea that, that the research is out there. Um, it changes all the time. Uh, I'm sure this podcast will probably be obsolete in a couple of years because there's going to be other information out there. I encourage everybody to do their own research that includes, uh, clinicians as well. Go ahead and do your own research as we do. Uh, we read everything that we possibly can and make decisions based upon the person in front of us. So, uh, you are a unique person. You have unique variables of what's going on with you, uh, and your program is going to be unique as well. Oh, before I go, actually, uh, I should note that within the podcast description, there's a couple low back books that I actually wrote. Um, one, uh, there's part one, two, and three. I know you might think, why didn't you just write one book?

I did. Uh, it was too big and some people didn't open it there. We actually had a beta group where, uh, I said, Hey, read the book and tell me what you think. And there was exercises and stuff in it. And so people were so overwhelmed by the, by the sheer size of the book. They didn't actually open it. And so these are broken down into chunks of more digestible types of, uh, of, uh, lengths. Uh, there's a book I really liked. It was called old man in the sea. Um, and so it was broken down into about a hundred page chunk. And so these books are broken down under a hundred pages each. Um, I encourage you to get all three. Uh, the first one is kind of a, uh, lays out a basic framework of what tends to work with conservative care with people with low back pain, chronic or not chronic, even, um, it teaches you how to use pain as your guide. And, um, part two is about diagnosis.

I left it out for a very good reason in part one. Uh, it covers diagnosis like disc herniations, protrusions, sciaticas, piriformis, you name it. Everything that you probably possibly could have read on Dr. Google. I'm keeping it updated. Okay. Third one is treatments that work for most people. What, when stretches might tend to work when ice and heating and so on like, but when, when all the, when all the treatments that you've read about tend to work in what scenarios. So please take advantage of those. I wrote them specifically for you guys, clinicians. You're not going to get much from them because you already know the stuff hopefully. Um, but, um, lay public, you guys, I think will really benefit from it. So please take advantage of that.

Thanks for being part of the movement movement subscribe. I'll see you next time.