Are Pictures Really Worth A Thousand Words?

 In Injuries, Tips and Tricks, Treatment

Clients who have back and neck pain often ask us “Do I need an X-ray?” and “Can an MRI tell me what’s wrong?” In this blog we hope to help answer those questions and put you at ease that your physiotherapist has your best interest, health, and safety in mind when we decide whether or not to refer you for imaging.

Is Imaging Really Needed?

About 98% of all patients with back pain have benign musculoskeletal pain that does not require medical or surgical intervention. This means that out of 100 people who come in to see us, only about 2 should have further medical testing. Your physiotherapist knows the signs and symptoms of something more serious, and will ask the right questions to ensure nothing is slipping through the cracks.

Some general questions you might hear form your physiotherapist are:

  • Do you have constant pain that is not improved with rest or being in different positions?
  • Do you have recent unexplained weight loss or gain?
  • Do you have night sweats?

Some back pain questions include:

  • Have you had any recent bowel or bladder incontinence?
  • Do you have numbness in your saddle region?

Some neck pain questions include:

  • Do you have trouble speaking or swallowing?
  • Do you have double vision?
  • Do you randomly faint?

Imaging Results

What Shows Up On Imaging May Not Be The Problem

In the American Journal of Neuroradiology, an article published in 2014 found that the majority of people with NO LOW BACK PAIN had “abnormal findings” on MRI – such as a disc bulge, disc degeneration, or arthritis. Furthermore, in an article published in Spine in 2015, over 70% of people with NO NECK PAIN have at least one disc bulge on MRI. Therefore, the pain in your back or neck is likely not to be caused by what is on you MRI unless you present with one of the cardinal signs or “Red Flags” that your physiotherapist is looking for.

Some clients tell us “I would just like to get an x-ray to be reassured that it’s nothing serious”. As we know from research, it is likely nothing serious, and your physiotherapist knows when imaging is warranted. Furthermore, having an x-ray can actually slow your recovery. A 2001 study compared people with low back pain who either did or did not have an x-ray. While people who had an x-ray were satisfied with their healthcare, they also had increased disability, more doctors visits, and were more likely to have pain in 3 months than their counterparts who had no x-ray. In a nutshell, X-Rays, MRIs, and CT scans are not helpful in the management of acute or recurring back pain unless there is a risk of serious pathology. Having an x-ray can make you needlessly afraid of movement, more likely to use prescription painkillers, and less likely to have a healthy active lifestyle.

One of the best parts about being a physiotherapist is that we get to spend real time with our clients. We are not rushing to see the next patient 10 minutes after your treatment session starts. If you had an MRI or x-ray and the results were not well explained to you, a physiotherapist can take to time to review these findings with you and go over treatment options. Let’s change the thought process and discussion around back and neck pain. Instead of asking ourselves if we need an x-ray or MRI, why don’t we start asking what kinds of activities we can do to increase our health and function, and decrease our pain levels!



Brinjikji,W., (2014). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology 36(4): 811–816.

CORE (Clinically Organized Relevant Exam) Back Tool (2016); Centre for Effective Practice, Toronto ON.

Jarvik, J., et al. (2001) The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) Study: baseline data. Spine 26(10)):1158–1166.

Nakashima, H. et al. (2015) Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1211 Asymptomatic Subjects. Spine 40(6): 392-392.

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