To scan or not to scan – questions about back pain

September 4 marks the start of National Physiotherapy Back Week – a time to highlight a condition that affects most people at least once in their lives.

he majority of people with back pain should experience a full recovery, yet it has become one of the biggest disability burdens in the Western world.

Navigating the terrain of back pain can be stressful and uncertain, particularly if you know someone who has been disabled by pain. Everyone seems to have an opinion and it is understandable that many with back pain want to have a scan to find the source of their pain.

But is it really so simple?

Our ability to scan the human body has saved countless lives and yet for back pain, we have found that routine X-rays, MRI and CT scans may be causing more harm than good.

Our spines naturally change as we age. Even young people often have disc bulges and degenerative changes with no back pain symptoms. Increasingly, we are seeing that degenerative changes in the spine should be thought of as “wrinkles on the inside” and not predictors of pain. While it is easier to explain back pain as a result of joints being “bone on bone” or disc degeneration, the science just doesn’t add up.

But surely it can’t hurt just to check? Unfortunately, it can. Aside from the obvious issue of cost, early scans can lead to prolonged disability, higher medical costs, increased risk of surgery and overall worse outcomes. In public health, unnecessary referrals result in long waiting periods for those who really do need a scan. With all of this evidence, the American College of Physicians now states that routine imaging for back pain is not associated with “clinically meaningful benefits but can lead to harm.”

The best evidence we currently have suggests that a good assessment is far more important than a scan. This includes a conversation with your healthcare provider about your pain, function and context, as well as a thorough physical examination. For more than 85% of people with back pain, a specific diagnosis cannot actually be made as the cause is usually a combination of factors.

The best treatment must focus on how to remain active, as well as good information about back pain and how to help manage it yourself. A foundation of exercise and education is vital to a good outcome.

If your healthcare provider refers you for a scan, it is worth ensuring that you understand why. Perhaps they are simply not aware of the published guidelines. Perhaps the intensity of your pain is causing them to doubt their judgement.

It is your health at stake – engage with your clinician and ensure that their rationale makes sense.

Back pain, for the majority, does not have to be debilitating. Get help quickly if you need it. Make sure that you are well assessed, but let’s keep scans as the lifesaving discovery that they are, not the cause of a global rise in unnecessary disability.

To find a physiotherapist, go to saphysio.co.za/find-a-physio/ For those with chronic lower back pain, you can find a practitioner trained in complex pain management at
www.trainpainacademy.co.za or contact the Pain Management Physiotherapy Group at info@pmpg.co.za

Sally Jane Shannon is the chairperson of the Western Cape branch of the Pain Management Physiotherapy Group, a special interest group of the South African Society of Physiotherapy. She researched the work of various medical experts for this article.