Treating Your Low Back Pain: But my MRI says….

By Joseph Holmes, PT, DPT, CDN, FNCP

The likelihood that any adult in the United States will experience some form of low back pain each year is 1.5%-36%. Moreover, about 25% of adults report having at least 1 day of low back pain in the past 3 months (1). There are many factors that affect the likelihood of this happening (2). Most people assume that when back pain occurs, whether it is aggravating or debilitating, an x-ray or MRI is needed and that they should be prescribed muscle relaxers and/or painkillers. However, updated guidelines from the American College of Physicians recently announced that, “doctors should avoid prescribing opioid painkillers for relief of back pain and suggest that before patients try anti-inflammatories or muscle relaxants, they should try alternative therapies like exercise, acupuncture, massage therapy or yoga” (3). Furthermore, previous guidelines stated that imaging, such as an MRI, demonstrated no value to the patient and can also lead to worse and more costly outcomes. Thus, imaging should only be prescribed if severe neurological symptoms are present (4).

To address the growing demand for treatment of the increasing number of people who have low back pain, physical therapists have created the Low Back Pain clinical practice guidelines. These are rigorous guidelines which synthesize all the available evidence on low back pain assessment, diagnosis, and intervention/treatment. The most recent version of the guidelines, published in 2012 by the American College of Physicians, stated that people need an active intervention in order to show the quickest improvement in healing their pain and returning to normal function. Often low back pain will heal on its own eventually, that is, if the proper actions are taken.

Physical therapists, guided by the clinical practice guidelines, use the most up to date information to help the approximately 30-50 million Americans who experience low back pain every year. Because most back pain cannot be directly associated with a specific cause of injury, this leads to many inaccurate findings on MRIs, CT scans, and X-rays, including people with no back pain symptoms whatsoever being diagnosed with “abnormal” findings of the lumbar spine 32% of the time (5). Thus, the best available evidence supports a classification approach that de-emphasizes the importance of identifying specific anatomical lesions after red flag screening is completed. There is still so much that experts do not understand about low back pain. What we do know is that the best physical therapists will diagnose and treat your back pain based on your individualized symptoms and reported limitations.  We will work with you to create goals and interventions that will help to alleviate your pain and allow you to return back to your regular function.

The 2012 Low Back Pain Clinical Practice Guidelines utilized the four treatment-based classifications to categorize low back pain that were created in 2007 (6). They are as follows:

  • Manipulation (based on strong evidence from the Flynn et al Clinical Prediction Rule):
    • A person is a great candidate for manipulation if they meet most of these criteria:
      • No symptoms below your knee
      • Recent onset of symptoms less than 16 days
      • Low fear avoidance based off a validated questionnaire (FABQ-work <19)
      • At least 1 stiff/hypomobile segment of the lumbar spine
      • At least 35 degrees of internal rotation, a measurement of hip rotation, in 1 hip
    • Stabilization:
      • A person is a great candidate for the stabilization if they meet most of these criteria:
        • <40 years old
        • Post-partum or straight leg raise >90 degrees
        • Positive prone instability test
        • Poor rhythm of bending over and flexing the spine
      • Specific Exercise, Centralization, or Directional Preference:
        • A person is a great candidate for specific exercise if they meet most of these criteria:
          • Symptoms below the buttock
          • Older age
          • Preference to bend over in to flexion or back into extension to get relief
        • Traction:
          • A person is appropriate for intermittent traction if they meet most of these criteria:
            • Signs and symptoms of nerve root compression, weakness, or crossed SLR
            • Peripheralization of symptoms or worsening of symptoms in the legs with both bending forwards and backwards

            After your physical therapist categorizes your clinical presentation into one of these four categories, your individualized program will be created using the support of the best evidence available combined with years of clinical expertise. Additionally, the low back pain clinical practice guideline recommends the following interventions which best match your treatment-based classification (7). A is considered the best evidence and E is the worst evidence.

            • (A): Manual therapy such as soft tissue mobilization, core stabilization, directional preference, and progressive endurance training and exercise.
            • (B): Patient Education: Do NOT increase patient’s fear or perceived threat
            • (C): Flexion or bending forward for lumbar stenosis: people with lumbar stenosis should be performing strengthening, stretching, and increased endurance activities
            • (D): Lumbar traction: If a person is classified in to the above traction classification, then traction can be slightly helpful, otherwise it is of no benefit
            • Not listed: no grade or recommendation was made towards heat, ice, electrical stimulation, or dry needling

            Physical Therapy First

            At Physical Therapy First, you are provided with more individualized time in your initial evaluation and treatment sessions than with any other provider in the region. Our physical therapists perform 60 minute 1-on-1 initial evaluations and all follow up sessions are 1-on-1 for 60 minutes with your physical therapist. We provide the best care in the region with the highest qualified clinicians. Call or email any of our four locations in the Greater Baltimore area to set up your appointment today.


            1. Deyo RA , Mirza SK , and  Martin BI . Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine (Phila Pa 1976). 2006;31:2724-7. [PMID: 17077742]
            2. Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010;24:769-781.
            3. Amir Qaseem, Timothy J. Wilt, Robert M. McLean, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med.2017;166:514-530. [Epub ahead of print 14 February 2017]. doi:10.7326/M16-2367
            4. Chou R, Qaseem A, Snow V, et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med.2007;147:478-491. [Epub ahead of print 2 October 2007]. doi:10.7326/0003-4819-147-7-200710020-00006
            5. Savage RA, Whitehouse GH, Roberts N. The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. Eur Spine J. 1997;6:106-114.
            6. Fritz, JM, Cleland, JA, Childs, JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther. 2007;37:290–302.
            7. Delitto A, George SZ, Van Dillen L, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ. Low Back Pain: Clinical Practice Guidelines. J Orthop Sports Phys Ther 2012;42(4):A1-A57. doi:10.2519/jospt.2012.42.4.A1