PRACTICE RECOMMENDATIONS
• Avoid imaging in cases of uncomplicated low back pain (unless there are specific clinical indications). A
• Use acetaminophen, nonsteroidal anti-inflammatory drugs, or muscle relaxants for short-term relief of acute nonspecific low back pain. A
• Consider matching specific physical therapy options to the patient’s history and exam findings. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE A 50-year-old construction worker comes in for an office visit because he’s been experiencing intermittent low back pain that’s been occurring more frequently. He says he has not been injured and that he always takes care on the job to minimize physical risk. He reports no symptoms other than the back pain.
How would you proceed with this patient’s care? Would you order a plain radiograph to be sure nothing dire is causing the patient’s pain—or would you skip it? And would you know how to match your patient’s history and exam findings with specific physical therapy interventions?
The following review brings the latest guidelines and research to bear on these questions—and others—as you care for patients with nonspecific low back pain.
Categorizing low back pain to direct your investigation
The 2007 Joint Clinical Practice Guideline issued by the American College of Physicians and the American Pain Society encourages clinicians to perform a focused history and physical exam to classify patients into 1 of 3 broad categories: nonspecific low back pain (LBP), LBP potentially associated with radiculopathy or spinal stenosis, or LBP potentially associated with another specific spinal cause.1
Patients in the last category often exhibit findings in the history and physical examination suggestive of severe or progressive neurologic defi cits. Refer these patients for further diagnostic testing.
Patients presenting with persistent (>4 weeks) LBP and signs and symptoms of radiculopathy or spinal stenosis are best referred for, preferably, magnetic resonance imaging (MRI) or for computed tomography (CT)—but only if the patient is a candidate for surgery or epidural steroid injection.
For patients with nonspecific LBP, which accounts for most cases, practice guidelines recommend against routine use of imaging or other diagnostic procedures.1
Unfortunately, however, some clinicians still use routine imaging in the absence of significant findings or without clear indication.2 One argument used to justify this action—particularly by some who consider nonspecific LBP to be a diagnosis of exclusion —is the desire to rule out a serious underlying spinal condition.
What the research tells us about routine imaging
A recently published systematic review and meta-analysis compiled data relevant to more than 1800 subjects from 6 randomized controlled trials (RCTs). The authors examined early, routine use of lumbar imaging (radiography, MRI, or CT) in patients with acute or subacute LBP. They found that, without clear indication from findings in the history and physical examination, immediate imaging does not improve clinical outcomes (ie, diminish pain or improve daily function).3
Another study took a closer look at advanced imaging for LBP. In an RCT including more than 300 patients with a mean age of 53 years, investigators compared outcomes for patients receiving either plain radiographs or rapid MRI. No differences were noted in outcomes for back-related disability, pain, health survey results, preference scores, satisfaction, or costs at 12 months.
Furthermore, patients receiving rapid MRI were more likely to undergo surgery, which also failed to improve outcomes. As a result, the authors cautioned against unnecessary use of advanced imaging, as it could increase costs of care and possibly increase surgical intervention without improved outcomes.4 These studies substantiate practice guidelines regarding the use of imaging for patients with nonspecific LBP.
Not helpful, and perhaps harmful?
When imaging is unwarranted, it unnecessarily exposes patients to ionizing radiation, especially objectionable for younger women.1 Imaging can also lead to the identifi cation of pathology unrelated to a patient’s LBP.1,5
As mentioned above, patients receiving rapid MRI were more likely to receive surgical intervention that did not improve outcomes.4 This observation may reflect, in part, findings of pathoanatomical abnormalities that have little or no correlation with patient symptoms. In a random sample of 148 subjects ages 36 to 71 years—nearly half of whom had never experienced back pain—Jarvik and colleagues5 found MRI evidence of annular tears, disc bulges, disc protrusions, facet joint degeneration, end plate changes, and mild spondylolisthesis. The authors concluded that such MRI findings are therefore of limited diagnostic value.5
Labeling can be harmful, too. Identification of pathology that could well be unrelated to LBP can result in a specific, presumed diagnosis, possibly inducing a phenomenon known as the labeling effect. The search for a specific diagnosis or label for patients with nonspecific LBP could cause them to perceive their low back condition as being more serious than it actually is. Patients may then develop distorted beliefs regarding the true nature of their health status. The labeling effect could even alter the natural course of an otherwise benign condition.6,7