Explainer: Why Occupational Health Care Delays Most Back Pain MRIs for Weeks

Michelle Hopkins

Don’t rush to the use of imaging for low back pain

One of the most common and costly occupational disorders – low back pain – accounts for up to 33 percent of workers’ compensation costs.1 While low back pain will indeed affect a majority of adults in their lifetime, claims costs for acute low back pain are disproportionately high, in part because of the default use (and inappropriate overuse) of magnetic resonance imaging (MRI), a diagnostic radiology exam.2

Concentra® discourages the early use of MRIs for acute low back pain when not medically indicated (by a severe neurological condition or spinal instability, for example). “When MRIs are performed routinely at the start of a case, they can result in unwarranted costs and surgeries, identify benign abnormalities that are not the cause of pain but now must be addressed, and leave the actual source of pain unidentified and untreated.3,4  Most episodes of back pain will resolve in two to four weeks from the onset of pain. Practice guidelines frequently recommend MRIs only at six to eight weeks after pain begins and then only if the patient is not improving,” says Maja Jurisic, MD, CPE, Concentra vice president and medical director of strategic accounts.

Early use of MRIs often is not only unnecessary but may be detrimental. Research published in February 2021 found that early use of imaging, opioid pain medication, or specialist referrals (all of which Concentra discourages unless medically indicated) was substantially associated with a transition from acute to chronic lower back pain, which is more difficult to manage.5

Another research study found that imaging was overused inappropriately up to 35 percent of the time.6 And this is nothing new. An article published in the journal Radiology in 2010, entitled “Addressing Overutilization in Medical Imaging,” acknowledged that overuse was a factor in the popular growth of medical imaging.7 Why would overuse persist for decades if evidence-based research concludes that early use of imaging is needed only in targeted cases that meet certain criteria? Dr. Jurisic provides insights to demystify MRIs and correct misconceptions.

Replacing MRI culture and myths with facts

There is considerable popular fascination with how the body works, so medical television dramas attract a broad and diverse audience.8 Unfortunately, these shows also perpetuate all kinds of myths about imaging.9 When television doctors pursue the answer to a case, it’s common for the show’s producers to add dramatic flourish by having doctors wheel the patient into an MRI machine and, in a following scene, gather around the image for their a-ha moment – and another “difficult case” is solved.

“Portrayals like this and beliefs of friends and relatives that are not based in science create fear and a tendency to think catastrophically. An injured employee may imagine that any back pain, even residual pain, will progress to such a degree that ending up in a wheelchair or paralyzed is inevitable,” says Dr. Jurisic. When someone engages in catastrophic thinking, the next step is often to insist that the doctor perform an MRI. Doctors have been known to acquiesce to their patients’ wishes, even when the science shows that an MRI for uncomplicated acute back pain is unneeded in the first six-to-eight weeks.10

Dr. Jurisic addresses three prominent and persistent myths about MRIs:

  • MYTH: An MRI is good at pinpointing the source of pain.

“Our brains create the experience of pain. They are not just passive computers that receive and register pain signals. They can shrink or grow pain. A person in pain can literally grow pain just by thinking about how terrible the pain is, and this is why Concentra developed an alternative to the traditional pain scale that I discussed in a webinar, Shifting Focus from Pain to Function, in February 2020. MRIs are useful for ruling out things like tumors and certain diseases, but they are not good at finding the specific reason for pain conditions,” says Dr. Jurisic.

Advanced imaging is unreliable and an unnecessary cost when nerve irritation is producing the sensation of pain in one part of the body while the pain originates in a different area and is unlikely to show up on an MRI. Jeff Rogers, DPT, PT, director of therapy operations for Concentra, addressed this scenario in, “Going to the Root of Nerve Pain to Avoid Needless Imaging, Surgery.”

  • MYTH: If something abnormal shows up on an MRI, that has to be what’s causing the pain.

“For most people, imaging will show changes in the musculoskeletal system, especially with age. Structural abnormalities, such as disk degeneration, disk bulges, and disk protrusions are common. Research has shown that about one-third of 20-year-old adults will experience these abnormalities while presenting no symptoms at all. This gradually increases with age. Among 80-year-olds, 96 percent  have signs of disk degeneration, 84 percent have disk bulges and 43 percent have disk protrusions – again, all without any symptoms.11,12 These things happen, so just because they show up on an MRI doesn’t mean they are the source of back pain; thus, addressing them will not eliminate the pain,” says Dr. Jurisic.

  • MYTH: Pain won’t stop until you treat and “fix” abnormalities on an MRI.

“If abnormalities on an MRI are not the actual cause of pain, a decision to pursue surgery – unnecessary and costly surgery – will not reduce the pain; in fact, surgery potentially may leave the patient worse off than before,” says Dr. Jurisic. “Surgery for chronic back pain actually makes the pain worse as much as 40 to 60 percent of the time.”

If not early imaging, what approach is recommended?

“The important first step is listening, providing a complete, hands-on physical examination, and explaining how the best care does not require an MRI – in fact, advanced imaging may be counterproductive or harmful if performed when not medically indicated,” says Dr. Jurisic. The American Academy of Physical Medicine and Rehabilitation, among other medical professional organizations, agrees: “A thorough history and physical examination are necessary to guide imaging decisions. Ordering spine imaging without obtaining a history and physical examination has not been shown to improve patient outcomes, and it increases costs.”13

Below is what three professional medical associations recommend.14

“Avoid imaging studies for acute low back pain without specific indications.” – American Society for Anesthesiologists – Pain Medicine “Imaging for low back pain in the first six weeks after pain begins should be avoided in the absence of specific clinical indications (e.g., history of cancer with potential metastases, known aortic aneurysm, progressive neurologic deficit, etc.). Most low back pain does not need imaging and doing so may reveal incidental findings that divert attention and increase the risk of having unhelpful surgery.”

“Don’t do imaging for low back pain within the first six weeks, unless red flags are present.” – American Academy of Family Physicians. “Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected. Imaging of the lower spine before six weeks does not improve outcomes but does increase costs. Low back pain is the fifth most common reason for all physician visits.”

“Don’t obtain imaging studies in patients with non-specific low back pain.” – American College of Physicians. “In patients with back pain that cannot be attributed to a specific disease or spinal abnormality following a history and physical examination (e.g., non-specific low back pain), imaging with plain radiography, computed tomography (CT) scan, or MRI does not improve patient outcomes.”

“Concentra promotes clinician interactions with the injured employee that, through genuine concern and active listening that was mentioned earlier, help reduce fear and catastrophic thinking so that understanding of the MRI’s limited purpose and use can be fully understood and accepted. Taking imaging off the table is a best-in-class decision and an aspect of high-quality, patient-centric care when doing it would not change the treatment plan or improve outcomes,” says Dr. Jurisic.

Epidemiologist Richard Deyo, MD, has said that simply telling patients they need an MRI increases their belief that they must suffer from a serious medical condition. Patients will become overwhelmingly preoccupied with what they see on the scan, unable to accept (or not have the background, knowledge, and context to accept) that what appears on the scan is perfectly normal and would appear the same for most people.15

Besides occupational injury (back strain by twisting or lifting improperly), two of the most consistent factors associated with lower back pain are non-occupational in nature: a prior history of lower back pain and aging. Other risk factors that have been reported include smoking, obesity, height, high triglycerides, hypertension, genetic factors, poor general health, poor sleep, pain-related fear, prolonged driving, deconditioning, physical inactivity, and lack of exercise.16 These factors can be identified in a quality physical exam and engaged clinician-patient interaction. But none of them will show up on an MRI.


Knowledge about excessive, unnecessary use of imaging has been around for many years. Come to Concentra for care that puts MRI research into practice to achieve the best possible medical outcomes for employees, while reducing costs to employers and payors.


  1. Hegmann KT, et al. ACOEM Practice Guideline: Diagnostic Tests for Low Back Disorders. Journal of Occupational and Environmental Medicine. April 2019; 61(4): e155-168. 
  2. The Problem with MRIs for Low Back Pain,” by Lola Butcher. Undark. August 26, 2019.
  3. “Evidence-based Medicine Trumps Medical imaging in Reducing Costs in Workers’ Comp Claims.” Claims Journal. April 28, 2015.
  4. Chou R, Qaseem A, Owens DK, et al. Diagnostic Imaging for Low Back Pain: Advice for High-Value Care from the American College of Physicians. Annals of Internal Medicine. February 1, 2011.
  5. Stevans JM, Delitto A, Khoja SS, et al. Risk factors Associated with Transition from Acute to Chronic Low Back Pain in US Patients Seeking Primary Care. JAMA Network Open. February 16, 2021.
  6. Jenkins HJ, Downie AS, Maher CG, Moloney NA, Magnussen JS, Hancock MJ. Imaging for low back pain: is clinical use consistent with guidelines: A systematic review and meta-analysis. Spine Journal. December 2018; 18(12):2266-2277.
  7. Hendee WR, Becker GJ, Borgstede JP, Bosma J, Casarella WJ, Erickson BA, Maynard CD, Thrall JH, Wallner PE. Addressing overutilization in medical imaging. Radiology. October 2010; 257(1):240-245.
  8. Why are medical dramas so popular?” BBC News. November 10, 2012.
  9. Radiologists on TV: What to believe and what not to believe. Association of Alexandria Radiologists.
  10. Nevedal AL, Lewis ET, Wu J, Jacobs J, Jarvik JG, Chou R, Barnett PG. Factors Influencing Primary Care Providers’ Unneeded Lumbar Spine MRI Orders for Acute, Uncomplicated Low-Back Pain: a Qualitative Study. Journal of General Internal Medicine. April 2020; 35(4):1044-1051.
  11. Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Devo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology. April 2015; 36(4):811-816.
  12. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine. July 1994; 331(2):69-73.
  13. Choosing Wisely. Clinician Lists for “Back Pain”
  14. Ibid.
  15. Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery. Cathryn Jakobson Ramin. May 9, 2017. P. 46.
  16. Hegmann KT, et al. ACOEM Practice Guideline: Diagnostic Tests for Low Back Disorders. Journal of Occupational and Environmental Medicine. April 2019; 61(4): e155-168.