For back pain, early MRI didn't help, early physical therapy did, studies find

A retrospective study found worse outcomes in patients who received an MRI within six weeks of a visit for back pain, while a randomized trial found that early physical therapy for sciatica resulted in better outcomes than a wait-and-see approach.


MRI scans within six weeks of a first visit for low back pain were associated with excess surgery, higher costs for other care, and worse outcomes, including potential harms from prescription opioids, a study found.

To determine the consequences of early imaging, researchers conducted a retrospective matched cohort study using data from the U.S. Department of Veterans Affairs. They assessed 405,965 patients seeking primary care for nonspecific low back pain without a red flag condition or an encounter for low back pain in the prior six months. Outcomes were lumbar surgery, prescription opioid use, acute health care costs, and last pain score recorded within one year of the index visit. Results were published Sept. 28 by the Journal of General Internal Medicine.

Undergoing an MRI within six weeks of the visit was associated with more back surgery (1.48% vs. 0.12%), greater use of prescription opioids (35.1% vs. 28.6%), a higher final pain score (3.99 vs. 3.87), and greater acute care costs ($8,082 vs. $5,560) versus no early MRI (P<0.001 for all comparisons). It is notable that the association between early imaging and increased utilization was apparent in the VA setting, which is largely unaffected by incentives of fee-for-service care, according to the authors. The results show that reduced imaging cost is only part of the motivation to improve adherence with guidelines on when to use MRI, they said.

A separate study found that starting physical therapy right away, rather than the usual wait-and-see approach, helps improve function and other outcomes for patients experiencing recent-onset back pain with sciatica. The randomized controlled trial was published Oct. 6 by Annals of Internal Medicine.

In the study, 220 adults who consulted their primary care physician for back pain with sciatica were randomly assigned to four weeks of physical therapy or usual care (a wait-and-see approach) for the same duration. Patients reported on their level of pain and its impact on their lives, such as their ability to care for themselves and participate in social activities, after four weeks and then again at six months and one year.

At every point, patients who had completed physical therapy immediately after their primary care visit reported less disability than patients treated with the wait-and-see approach. The differences in outcomes between the two treatment groups were generally large enough to be considered clinically meaningful, the study authors said.

According to an accompanying editorial, the findings provide an evidence-based treatment option for patients who seek care for back pain.

“The results will be of interest to many, including the patients who feel their sciatica is not taken seriously by their primary care providers, the primary care providers making decisions about onward referral, and the growing group of physiotherapists working in first-contact roles in primary care,” the editorial stated.