What is the effective way to diagnose Mechanical Low Back Pain?
Low Back Pain (LBP) is commonly encountered problem. Around 80-90% of population might have suffered from LBP at some point in their life (Raspe 1993). Research has shown that around 85% – 92% of LBP are mechanical in nature; means they are due to certain postures, positions, movements and functions and only 8%-15% are non-mechanical (Spitzer et al 1987; Hefford 2007). Hence most of LBP has non-specific cause and very few have specific. It seen that 80-90% of attacks of mechanical LBP recover in 6 weeks (Waddell 1987); but around 75% of them may not be symptom free at the end of even 1 year (Croft et al 1998), which tells us that disability due to LBP persists. Well, one should remember that LBP is a Symptom, not a diagnosis. Also, LBP is a recurrent problem, so as clinicians we should empower patients to control their own aches and pain.
Do I need to undergo MRI or CT scan to know the cause of my pain?
Well, despite the technological advances that have been made in recent years, we are still unable to identify the origin of LBP in majority of patients. Even the advanced imaging technology, such as Magnetic Resonance Imaging (MRI) or Computerised Axial Tomography (CAT) scan, our ability to identify the precise structure that generates symptoms and exact nature of the pathology affecting it remains limited (McKenzie and May 2003).
I’m worried, my scan shows I got prolapsed disc!!!
The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals (Brinjikji et al 2014). Bulging or protruded discs have been found in over 50% of asymptomatic individuals (Jensen et al 1994; Weinreb et al 1989), those over 60 years 21% had spinal stenosis (Boden et al 1990). Also, patient knowledge of imaging findings do not alter outcome and are associated with a lesser sense of well-being (Ash et al 2008). Many imaging-based degenerative features are likely part of normal aging and may be unassociated with pain and routinely done yield little to no benefit (Karel et al 2015). Hence, there may be high chances of false-positive and false-negative findings.
My scan is normal; do I need to undergo invasive procedure to find the source of problem?
Some have highlighted the use of intra-articular or disc stimulating injections to find source of pain (Bogduk et al 1996), however these diagnosis rely upon invasive procedures involving significant exposure to x-rays, which are costly and require high level of skill. The Discogram is a reliable way to find disc as a source of symptoms, but its validity is still not proven (April 1992). Also it requires high skill and very costly.
What about McKenzie assessment and treatment?
As discussed earlier, mechanical LBP are due to certain postures, positions, movements and functions; it can rightly diagnosed and managed through certain postures, positions, movements and functions. The McKenzie method or Mechanical Diagnosis and Therapy (MDT) is one of the physical therapy approach which emphasizes on repeated end-range movements and positions to sub-group a patient in to different mechanical syndrome. The approach has been rigorously researched way round the world and is considered to be the most reliable and valid approach (Razmjou 2000, Kilpikosky 2002, Clare 2005). It allows the clinician to identify a patient who would respond to physical therapy or not; thus saving time and money of a patient. With this approach the clinician can rightly judge time of recovery the patient would take. It just does not focus only on pain, but also onto activity limitations. The best part of the method is it involves the patient himself to be a part of recovery process (Also called as Patient-Centered Approach) and thus making them independent to take control on their own pain; and managing future episode, if any. This is important because research has shown that LBP in particular has a tendency to recur and recurrences often occur with increased severity. Preventing recurrence is therefore more important than supplying short term relief through passive treatment. An important component of the assessment is that clinicians who are well trained in MDT are able to recognise patients with pathologies unsuitable for mechanical therapy such as Red flags, non-mechanical pathologies, which do requires investigations. These patients can be immediately referred for further medical evaluation to the appropriate specialist.
Hence, in many parts of world MDT is first line assessment process for many clinicians which is very safe and reliable way to find the mechanical and non-mechanical nature of LBP.