Abstract
To the Editor,
We read the article by Taylor and Bishop, “Patient and public beliefs about the role of imaging in the management of non-specific low back pain: a scoping review” [1]. This review determined that although sparse, evidence suggests patients perceive imaging for low back pain (LBP) as positive, and a patient’s desire for a definitive diagnosis for their pains is the driver of this.
Indeed, patients desire a confirmed diagnosis for their LBP [2]. Problematically, of 12 studies reviewed [1], all were either performed by, or questioned clinicians/patients of medical doctors (MDs) in general (9 studies), or involved questioning the public and compared their knowledge to MD-based perceptions of LBP (i.e. Deyo’s 7 myths of LBP – 3 studies). Typically, MDs use imaging for ruling out ‘red flags’ or pathologies requiring immediate medical treatment (fractures, malignancies, infections, etc.). Overutilization of imaging in general medicine is occurring as the information gained from imaging, largely, does not alter the management procedures of the majority of medical practitioners (i.e. low probability of red flag/serious disease entity).
Factions within healthcare, however, utilize important biomechanical information from imaging, which has significant and immediate impacts on procedural approaches [3, 4, 5]. This includes spine surgery and non-surgical structural rehabilitation techniques aimed at reducing spine deformities. In fact, evidence shows manual therapy practices can reduce scoliotic deformity, thoracic hyperkyphosis, anterior head translation, and increase cervical and lumbar lordosis [4, 5]. Further, relatively common bone anomalies/pathologies (i.e. congenital fusions, asymmetries, severe osteoarthritis, etc.) can alter approaches to conservative spinal rehabilitation procedures (manipulation/mobilization, etc.) [5].
Regarding LBP, it is well substantiated through meta-analysis that lumbar hypolordosis is strongly associated and causative for LBP [6, 7]. Several recent randomized trials have demonstrated successful methods to increase the lumbar lordosis in LBP patients with loss of curvature [8, 9], and that these methods lead to better outcomes versus traditional ‘cookie-cutter’ generic approaches not based on radiographic determined altered alignment [8, 9, 10]. Thus, in certain circles, immediate imaging for patients with LBP is warranted, offers important biomechanical information, leads to altering management strategies, and is an alternate evidence-based approach to treating LBP [4, 5, 8, 9, 10].
The misuse of medical practice data for the argument of overutilization of imaging in manual therapies has been pointed out recently [11]. Perhaps patients deserve better biomechanical diagnoses from those who specialize in LBP rehabilitation treatment rather than suggesting their needs are unwarranted based on general medicine practice data that disregards the biomechanical needs of the individual.