Author: By Aloiya Earl, MD
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Choosing Wisely is an initiative of the American Board of Internal Medicine. It is supported by multiple medical societies, including the American Medical Society for Sports Medicine. Each supporting society was asked to contribute five diagnostic tests or treatments of which both physicians and patients should question the utility. The highlight for this quarter is AMSSM’s fourth recommendation:

Don’t order imaging for low back pain within the first six weeks of symptoms unless “red flags” are present. Examples of concerning red flags are severe or progressive neurological deficits or symptoms suspicious for serious underlying conditions like osteomyelitis (bone infection). For patients, this could mean new-onset numbness, tingling, weakness, bladder or bowel incontinence, unexplained weight loss or fever.

Red flags could also be found in patients’ histories; patients with a history of cancer should be assessed for tumor metastases and patients with an identifiable trauma near the location of the current pain should be evaluated for fractures. Low back pain is the fifth most common reason for all physician visits. Patients often request an X-ray or MRI of the lower back to identify the exact cause of the pain. It can feel frustrating and inconclusive for patients to leave their appointments without an imaging study. However, in typical cases of low back pain without red flags, imaging of the lower spine before six weeks does not improve outcomes, but it does increase costs.

The six-week cut-off is not an arbitrarily selected time frame; most cases of low back pain will improve in this amount of time regardless of whether targeted therapy is employed. In other words, a precise diagnosis with a very specific corresponding treatment plan is not necessary for symptomatic improvement.

In fact, the initial conservative course of treatment prescribed will be the same, because these recommendations envelop the majority of the most common causes of low back pain in adults (like muscle strains, ligament injuries and inflammation around the joints or discs). For this reason, it makes the most sense for patients to save their money and forgo unwarranted early imaging studies (the cost of which can range between $67 to $1,019 depending on the test, according to Further, imaging can sometimes lead to expensive, potentially superfluous procedures that could be avoided with a proper trial of conservative treatment modalities.

Oftentimes, the best initial management approach for the most common causes of low back pain is early return to normal physical activity. Bed rest has not been proven to be helpful and this inactivity can actually make the problem worse by leading to deconditioning (weakening) of the core muscles. The body responds with poor posture and compensated movements, which can make the initial injury worse and further exacerbate pain. Other conservative treatments to try during the initial weeks of pain include stretching, application of heat (like heating pads or warm baths to ease tension in the lower back muscles) and anti-inflammatory medications (like ibuprofen or naproxen). Progressive muscle relaxation, adjustments in sleep posture (like sleeping with a pillow between the knees) and massage can also provide relief.

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