When people present with back pain, particularly if it is persistent or of high intensity, they will often ask if they require imaging. It is understandable. We want to know why we have pain, what the structure is that is causing pain, and by having greater understanding of the pain, treat the specific cause. 

Imaging for back pain is becoming increasingly common, particularly of advanced investigations such as MRI or CT scans, Downie et al. These high level imaging techniques are particularly good at identifying specific tissue pathology, damage and or inflammatory responses. However they also commonly find degenerative tissue changes in asymptomatic patients, Brinjikji et al 2015. These findings of tissue degeneration in asymptomatic patients present a significant portion of false positive findings. The clinicians are then treating a pathology that may not be causing the symptoms. Further to this, pain is just that, a symptom. The bigger question that needs to be answered, is why did it develop in the first place? What are the capacities that were limited that has led to the overload of the spine? 

With this is mind it is important to highlight that there may be very clear indications for imaging, these are typically neurological compromise, loss of power, feeling or movement in the limbs, unrelenting shooting pain and loss of autonomic control (such as incontinence). Outside of these advanced symptoms, imaging is unlikely to change the management of the back pain. The management will include pain management, progressive return to low velocity, low force activity and progress to tasks of daily activity and then to advanced tasks that require high force and high load. Along this pathway, identification of limitations (strength, range of movement, trunk control,biomechanical factors, psychological) are addressed and a progressive plan of rehabilitation is implemented to reduce the impact of these limitations. 

So do you need imaging for your back pain? 

Probably not, unless you present with significantly advanced symptoms. Pain alone is generally not an indicator for imaging. 

Are athletes healthy? 

Recently I found myself in a commercial gym for the first time in a few years. Given our association with athletes in the work that we do, I could not help but look at what some of the gym attendees were doing. At one stage of the session I noticed what I presume was an athlete who participates in powerlifting, they were squatting at one of the squat racks and gradually piling on the weights. There were two things that I noticed. The first was that they were extremely strong, gradually increasing the numbers on the bar to what looked a minimum of two times body weight. The second was that they were gulping down large cans of energy drinks and a thought came to my mind; although they were strong, they were certainly carrying a significant amount of non functional mass (adipose tissue) and that the energy drinks surely was not the best option for health. Which brought to mind, are we destroying our health to be good at sport?

This topic has been discussed previously and an interesting article was published by Maffetone and Laursen in 2016, that highlights this very idea. Being fit for sport, does not guarantee health. The article identifies that there are often context specific dynamics at play in relation to certain sports, which bring with it behaviours related to food, training intensity, recovery and injury. Having worked in sports such as rowing and running, athletes will often overtrain at the expense of health or injury, as it is a commonly held notion that high training volumes or intensities are to be expected and injury and illness are necessary hurdles in the pursuit of excellence in those sports. Secondary to this, the article highlights that there are often contradictory behaviours associated regarding food in these sports. In rowing the pursuit of high volume training necessitates high calorie consumption, and I have discussed with some of these athletes the type of nutrition associated with this type of training. Some of the athletes have shared that they would routinely eat a whole loaf of bread each day with nutella or peanut butter during heavy training periods. Neither of these foods in moderation may be bad, but consistently eating nutella sandwiches does not scream healthy eating habits. The other side of this is runners, particularly distance runners, significantly under eating to keep their body mass down. This is obviously a terrible idea for someone completing significant training and is likely to reduce the long term training adaptation and health. 

For those interested the article by Maffetone outlines how the mechanisms of the body relating to high volume or intensity training and poor food choices can lead to significant health effects. These may be short term or accumulate to lead to long term health issues. It appears that often the biggest driver of these behaviours is a rush to achieve results prematurely without adequate progression. With this in mind it is certainly possible to achieve elite performance and maintain health, however it does take adequate planning from the athlete and all of the associated support staff (coach, medical, nutrition, strength and conditioning) to get the balance right.