What if a patient with a history of trauma, cancer, or inflammatory conditions experiences worsening pain with physical therapy, should we stop physical therapy and proceed with diagnostic imaging, such as an MRI, instead?

When to Stop Physical Therapy and Proceed with MRI for Worsening Pain

If pain worsens during physical therapy in patients with a history of trauma, cancer, or inflammatory conditions, you should immediately stop physical therapy and obtain MRI imaging to rule out serious underlying pathology before resuming any conservative treatment. 1, 2

Red Flag Assessment Requiring Immediate MRI

Your patient's history of trauma, cancer, or inflammatory conditions constitutes critical red flags that mandate urgent diagnostic imaging when pain worsens rather than improves with therapy. 2

Stop physical therapy immediately and obtain MRI if:

• History of cancer - This is the strongest predictor of malignancy with spinal cord compression and requires prompt imaging regardless of symptom duration 2
• Progressive neurologic deficits - Rapidly worsening motor weakness, multifocal deficits, or new sensory changes during therapy 2
• Suspected infection - Fever, immunosuppression, IV drug use, or recent spinal procedure combined with worsening pain 2
• Inflammatory conditions - Known ankylosing spondylitis, psoriatic arthritis, or inflammatory bowel disease with unclear disease activity 3
• Trauma history - Any significant trauma mechanism, especially with osteoporosis risk factors 3

Critical Distinction: When Physical Therapy Causes Harm

The standard recommendation to complete 4-6 weeks of conservative therapy before imaging does not apply when red flags are present. 1, 2, 4 Continuing physical therapy in the presence of serious pathology can lead to catastrophic outcomes including:

• Pathologic fracture progression in undiagnosed malignancy 2
• Neurologic deterioration from unrecognized cord compression 2
• Delayed diagnosis of infection leading to sepsis or epidural abscess 3
• Worsening structural damage in inflammatory spondyloarthropathies 3

Imaging Protocol for Red Flag Patients

MRI lumbar spine (or appropriate region) without IV contrast is the preferred initial study for patients with red flags and worsening pain during therapy. 2

Add IV contrast when:

• Infection/osteomyelitis is suspected 2
• Known history of cancer (to assess for metastatic disease) 2
• Inflammatory conditions require assessment of active inflammation 3

Common Pitfall to Avoid

Do not delay imaging based on symptom duration alone when red flags are present. 2, 5 The 6-week conservative treatment threshold applies only to uncomplicated, nonspecific back pain without red flags. 4 Studies show that 65.6% of patients with red flags inappropriately do not receive indicated imaging, representing dangerous underuse of diagnostic tools. 5

Inflammatory Conditions: Special Considerations

For patients with known ankylosing spondylitis or non-radiographic axial spondyloarthritis experiencing worsening pain during therapy, MRI can provide critical information about disease activity when clinical assessment is unclear. 3

However, note the important caveat: The location of MRI inflammation may not correlate with the location of pain, and the degree of inflammatory change may not correlate with treatment response. 3 Despite this limitation, MRI remains valuable when deciding whether to modify treatment in patients with unclear disease activity. 3

When to Resume Physical Therapy

Only resume physical therapy after:

• MRI excludes serious pathology requiring different intervention 2
• Any identified condition has been appropriately treated 1
• The patient's pain trajectory shows improvement rather than progression 4

The fundamental principle: In patients with red flags (trauma, cancer, inflammatory disease), worsening pain during physical therapy is a warning sign requiring immediate diagnostic evaluation, not continued conservative treatment. 2, 5