Q: How do I know if I should ask for X-rays? I've had low back pain for three months now and it's not going away. Maybe knowing what's wrong would help me figure out what to do. On the other hand, I don't really want to expose myself to radiation. What do you think?

A: You are absolutely right -- many people think X-rays or other imaging studies are the answer when we should really be evaluating each patient on an individual basis. In 2007, the American College of Physicians and the American Pain Society published three basic guidelines to help with the decision of when to get X-rays.

Their recommendations were based on numerous quality randomized clinical trials and remain appropriate today. Despite these evidence-based recommendations, studies show that one-third to one-half of all referrals for advanced imaging are inappropriate.

So, what are the guidelines? First, physicians are advised not to order X-rays (or other imaging studies) routinely. Second, diagnostic imaging studies should not be ordered unless there are strong clinical signs that surgery or steroid injections may be needed. And third, imaging studies should be used when there are severe neurologic signs and symptoms that could result in permanent neurologic damage (including permanent loss of strength, sensation, or even paralysis).

Exposure to radiation is an everyday occurrence. There is radiation all around us, and radiation exposure has been linked with diseases including cancer. This alone is why we must limit additional excess exposure to radiation. To give you an idea of what we now know about radiation exposure, one X-ray of the lumbar spine exposes the human body to the same dose you would receive from background radiation over a six-month period of time. And one lumbar spine X-ray is equal to 75 chest X-rays.

To determine what treatment might be best for you, the Virginia Mason Medical Center in Seattle has studied and now practiced a helpful diagnostic model that is evidence-based and will reduce costs. Anyone with low back pain is seen by a physiotherapistfirst.

Therapists have done their own research and developed evidence-based strategies for evaluation and treatment of low back pain patients. So they know what type of conservative (nonoperative) care is likely to work best for each patient based on the history and physical examination.

Physiotherapists know how to screen patients for these more serious problems (e.g., tumors, fractures, infection) and what to look for that might suggest a higher likelihood of any of these problems. Anyone with low back pain can be confident that seeing a physiotherapist first will save them money in the long-run. The therapist also monitors patients over a period of time and can see changes (or lack of change) to help assist in the decision-making process.

Reference: Timothy W. Flynn, PT, PhD, et al. Appropriate Use of Diagnostic Imaging in Low Back Pain: A Reminder That Unnecessary Imaging May Do As Much Harm As Good. In The Journal of Orthopaedic and Sports Physical Therapy. November 2011. Vol. 41. No. 11. Pp. 838-846.

Kitchener Physiotherapy & Wellness provides services for physiotherapy in Kitchener.