Low back pain drives increasing numbers of patients to visit their family physicians. It is the fifth most common reason patients visit providers, and reported cases of low back pain have increased over the years in adults 45 and older (CDC). With so many patients seeking answers and relief for such a ubiquitous problem, what is the best practice for family physicians and advanced practice providers?
Hold off on Imaging
“Don’t do imaging for low back pain within the first six weeks, unless red flags are present.” This recommendation comes from the American Board of Internal Medicine (ABIM) and the American Academy of Family Physicians (AAFP) as part of their Choosing Wisely campaign.
This initiative was established to promote dialogue regarding unnecessary testing, treatments, and procedures. Their position on low back pain imaging and other recommendations are listed in the AAFP’s Twenty Things Physicians and Patients Should Question.
The ABIM and AAFP stress that early imaging does not improve outcomes for patients with low back pain and instead, increases health risks.
Increased Risk of Imaging
While imaging can give family physicians detailed insight into their patients’ conditions, often, imaging can do more harm than good. According to clinical recommendations from AAFP, studies show imaging can result in unnecessary radiation exposure, patient labeling (which can affect sense of well-being), high imaging costs, and increased rate of surgery. Further, in the Journal of Orthopaedic & Sports Physical Therapy, Flynn, et al. report that imaging may lead patients with low back pain to catastrophizing and fear-avoidance behaviors that can support chronicity.
Recovery from Low Back Pain
Fortunately, many patients recover quickly from low back pain – further reducing the need for imaging and the associated risks. According to metadata research from Pengal et al., in most cases, recovery from back pain occurs quite rapidly, and most disk herniations will resolve within eight weeks. While serious back issues may require more comprehensive examination such as imaging or referral to a specialist, most patients with minor back pain may benefit from conservative treatment methods that do not include imaging.
Don’t Ignore Red Flags
The Choosing Wisely recommendations are quick to mention that doctors should not ignore red flags, which do warrant imaging and include:
- Sudden back pain with spine tenderness, especially with history of cancer, osteoporosis, or steroid use
- Severe or progressive neurologic deficits such as bladder or bowel function or saddle paresthesia
- Serious underlying conditions
They also emphasize that physicians should investigate other possible causes of back pain that do not involve the spine such as:
- Penetrating ulcer disease
- Gastrointestinal disease
- Pelvic disease
Recommendations for Treatment
The AAFP recommends family physicians communicate with their patients by:
- Giving clear recommendations
- Eliciting patient’s questions and beliefs
- Empathizing with concerns
- Overcoming barriers
Increase Awareness About Low Back Pain Imaging
There is more work to be done. Through the Choosing Wisely campaign, ABIM and AAFP have indeed increased awareness among physicians and patients about unnecessary imaging for back pain. However, in a study published in the Journal of the American College of Radiology of CT and MRI exams ordered by primary care physicians, 26 percent of medical images ordered were inappropriate. This statistic speaks to the need to expand knowledge of best practices for family physicians in imaging of low back pain.
Help increase awareness within your network by sharing this information about low back pain imaging. And also, take a look at some of our exciting locum tenens opportunities with Medical Doctor Associates today!