Chronic lower back pain: why imaging often does not help

MRI scans of asymptomatic spines (people with no back pain) consistently show disc bulges, facet degeneration, and other structural changes at high rates. These findings increase with age, in people over 50, the majority of asymptomatic spines show "abnormal" findings on imaging. A 2015 systematic review of 3,110 people with no back pain found disc degeneration on imaging in 37% of 20 year olds, rising to 96% of 80 year olds (Brinjikji and colleagues, American Journal of Neuroradiology).

When a person with back pain has an MRI and receives a report listing disc bulges and degeneration, it is often unclear whether these findings are causing their pain or are incidental, present in most people their age regardless of symptoms.

A nocebo effect is the inverse of placebo: a negative health outcome caused by belief or expectation rather than direct physical cause. In chronic lower back pain, the nocebo effect from imaging language is clinically significant.

When clients are told they have a "crumbling disc" or "severe degeneration," they often begin avoiding movement, which makes the pain worse. They catastrophise about their spine's capacity, which also makes the pain worse. The imaging language produced the disability, not the finding itself.

Functional lower back pain means the pain is produced by how the spine is loading, not by structural damage to it. The disc, facet, or muscle is not broken; it is being asked to work in a way that produces pain. Changing how it loads changes the pain.

This is addressable: hip mobility, glute activation, reduced hip flexor tension, thoracic extension, these change the load distribution through the lumbar spine. Progressive exercise through range restores capacity. Soft tissue therapy addresses the accumulated tissue restriction that limits that range.

Imaging is appropriate when red flags are present: pain at rest that does not change with position, fever, unexplained weight loss, bowel or bladder symptoms, history of cancer, trauma with suspected fracture, or neurological symptoms (weakness, numbness, foot drop). In the absence of these flags, imaging for non-specific lower back pain rarely changes the clinical management.