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Evidence-Based Physiatry

Evidence-Based Physiatry

Managing Low Back Pain Wisely

Paganoni, Sabrina MD, PhD

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American Journal of Physical Medicine & Rehabilitation: November 2018 - Volume 97 - Issue 11 - p 855
doi: 10.1097/PHM.0000000000001020
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Axial low back pain (LBP) is one of the most common symptoms that physiatrists are asked to manage, and its management is associated with high healthcare resource utilization and costs. When evaluating patients with axial LPB, how do we achieve the dual goal of improving clinical outcomes while reducing waste? How do we select the diagnostic tests that are truly necessary and not duplicative?

The Choosing Wisely campaign is a unique initiative in that it provides practical evidence-based tools to support clinical decision-making.1 These tools include both physician resources and patient-friendly downloadable handouts that can facilitate a dialogue with patients and support high-value shared decisions ( Given the high prevalence of axial LBP and associated potential for overuse or misuse of healthcare resources, it is not surprising that many Choosing Wisely recommendations from several specialty societies address the diagnosis of LBP.


A diverse set of medical societies weighed in on the role of spinal imaging for acute axial LBP and their recommendations are remarkably consistent. The American College of Emergency Physicians recommends against spinal lumbar imaging in the emergency department for adults with nontraumatic LBP unless the patient has “red flags” such as severe or progressive neurologic deficits or is suspected of having a serious underlying condition (such as infection or cancer with bony metastases). Along the same lines, the American College of Occupational and Environmental Medicine advises against obtaining x-rays for injured workers with acute nonspecific LBP, unless “red flags” are present. There is no medico-legal reason to obtain spine x-rays as a “baseline” for work-related injuries. These recommendations are echoed by the American College of Physicians, the North American Spine Society, the American Academy of Physical Medicine and Rehabilitation, the American Association of Neurological Surgeons, and the American Society of Anesthesiologists. Imaging decisions should be based on a thorough history and physical examination. Spine imaging should not be performed in patients with nonspecific acute axial LBP (<6 weeks' duration) and without red flags because in this setting it does not improve outcomes but does increase costs. Red flags that provide an indication for spine imaging are described in the recommendations from several professional societies and include, but are not limited to, focal neurologic deficit and progression of symptoms, history of trauma or cancer, unintentional weight loss or fevers, use of steroids or immunosuppression, intravenous drug use, and known aortic aneurysm. In the presence of these red flags, imaging may be appropriate and may include plain x-rays or advanced imaging (e.g., magnetic resonance imaging or computed tomography scan).


Both the American Academy of Physical Medicine and Rehabilitation and the North American Spine Society recommend against the use of electromyography to determine the cause of axial LBP. Electromyography studies have good specificity for the detection of lumbosacral radiculopathy when appropriate electrodiagnostic criteria are used,1 but its use for axial LBP is not supported.


Physiatrists should be familiar with current evidence-based recommendations for the judicious use of diagnostic tools for LBP. In the setting of acute axial LBP, with no red flags by history or physical examination, spine imaging and electromyography studies are unlikely to provide meaningful benefit to patients.


1. Paganoni S: Evidence-based physiatry: learning to choose wisely. Am J Phys Med Rehabil 2018;97:602–3
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