Decrease use of imaging for low back pain

The Physician Alliance is committed to helping provide appropriate use of healthcare services and tests to improve patient care, while also working to lower costs. As part of BCBSM’s Resource Stewardship Initiative, our physician organization identified three key targets for reduction in utilization by our physicians based on current physician scores and TPA’s ranking among other physician organizations in these specific areas. TPA is currently ranked above the BCBSM’s Physician Group Incentive Program (PGIP) average for all physician organizations in these three areas (the goal is to be less than the PGIP average for these initiatives).


Decreasing the use of imaging for low back pain within the first four weeks of symptoms is one of the three focus areas for The Physician Alliance in BCBSM’s Resource Stewardship Initiative, which promotes the use of evidence-based medicine when making health care stewardship decisions.

Keep in mind that a doctor’s recommendation is a major contributing factor to treating patients with conservative treatments and in assuring appropriate indications for imaging studies. According to a 2016 report by the National Business Group on Health, primary care accounts for about 5% of health care spending, but decisions made in the primary care setting influence up to 90% of overall cost and quality through referrals, testing, invasive procedures, and hospitalizations. Routine spinal imaging does not improve clinical outcomes and exposes patients to unnecessary harm (radiation/possible adverse side effect from contrast). The American College of Physicians guidelines for low back pain recommend imaging only for patients who have severe progressive neurologic deficits or signs/symptoms that suggest a serious underlying condition.

The following tips are recommended conversation strategies with patients experiencing low back pain:

  • Don’t do imaging for low back pain within the first four weeks, unless red flags are present (examples include: recent trauma, history of cancer, or loss of feeling/weakness/numbness in the lower limbs, IV drug use, fever, weight loss, or incontinence). Imaging of the lower spine before four weeks does not improve outcomes, but does increase costs and may lead to unnecessary invasive treatments. Use talking points based on evidence based guidelines to educate patients.

  • Suggest an exercise routine to help strengthen the low back and abdominal muscles. Exercise is the best way to relieve low back pain and prevent future attacks. Physical therapy, massage or other pain relief supportive measures may also help reduce pain.

  • Recommend alternatives for patients to relieve the pain:

    • Advise patients to stay active. Walking and moving around help prevent muscles from stiffening. Instruct patients to get up and move every 30 minutes.

    • Apply heat to ease discomfort.

    • Adjust sleeping and sitting positions. Suggest placing a pillow between their legs when sleeping on their side or a pillow under their knees when sleeping on their back to reduce back discomfort.

    • Use over-the-counter pain relievers, NSAIDs, and muscle relaxants.


TPA created a flyer focused on decreasing imaging for low back pain within the first four weeks of diagnosis. Practices are encouraged to post this flyer in waiting areas and exam rooms to help support conversations between patients and physicians.

Choosing Wisely, an initiative of the ABIM Foundation, is a national healthcare campaign to promote important healthcare conversations between physicians and patients. Working with national medical societies, Choosing Wisely has produced numerous tip sheets focused on physician tips and patient tips.


Sources: American College of Radiology; American Academy of Family Physicians; Agency for Health Care Research & Policy;; American College of Physicians