American Academy of Physical Medicine and Rehabilitation

Five Things Physicians and Patients Should Question

Released September 29, 2014; Last reviewed 2021

  1. 1

    Don’t order repeat epidural steroid injections without evaluating the individual’s response to previous injections.

    Utilization of repeat epidural steroid injections has not been shown to improve patient outcomes. Physicians should consider patient re-evaluation prior to repeat epidural steroid injections.

  2. 2

    Don’t order an EMG for low back pain unless there is leg pain or sciatica.

    Utilization of EMG studies for diagnosis of low back pain without leg pain is not supported. EMG studies have good specificity for the detection of lumbosacral radiculopathy in sciatica patients when appropriate electrodiagnostic criteria are used.

  3. 3

    Don’t prescribe bed rest for acute localized back pain without completing an evaluation.

    Prolonged bed rest (more than 2 days) in acute localized low back pain has not been shown to improve long term function or pain. Bed rest prescriptions should be limited to less than 48 hours in patients with non-traumatic acute localized low back pain in the absence of traditional red flag signs, including, but not limited to, tumors, neurological issues, and weakness.

  4. 4

    Don’t order an imaging study for back pain without performing a thorough physical examination.

    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 increases costs.

  5. 5

    Don’t prescribe opiates in acute disabling low back pain before evaluation and a trial of other alternatives is considered.

    Early opiate prescriptions in acute disabling low back pain are associated with longer disability, increased surgical rates, and a greater risk of later opioid use. Opiates should be prescribed only after a physician evaluation by a licensed health care provider and after other alternatives are trialed.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The American Academy of Physical Medicine and Rehabilitation (AAPM&R) is proud to be a partner in the Choosing Wisely® campaign. AAPM&R is the national medical society representing more than 8,000 physiatrists, physicians who are specialists in the field of physical medicine and rehabilitation. Physiatrists treat adults and children with acute and chronic pain, persons who have experienced catastrophic events resulting in paraplegia, quadriplegia, traumatic brain injury, spinal cord injury, limb amputations, rheumatologic conditions, musculoskeletal injuries, and individuals with neurologic disorders or any other disease process that results in impairment and/or disability. With appropriate rehabilitation, many patients can regain significant function, live independently, and lead fulfilling lives.

To learn more about the AAPM&R, please visit

How This List Was Created

The American Academy of Physical Medicine and Rehabilitation (AAPM&R) established a Choosing Wisely® task force to develop its list of recommendations. To ensure broad representation across our diverse specialty, members of this group were selected from varying practice settings and subspecialties within physical medicine & rehabilitation. The task force developed a list of topics they felt had the most impact on the field, which were then rated based upon their relevancy to the Choosing Wisely® campaign. Based on the task force ratings and a literature review, candidate recommendations were sent to relevant AAPM&R committees, councils and subject matter experts for review and comment. The task force reviewed this feedback and voted on the final “Top Five” recommendations, which were approved by the Evidence Based Practice Committee; Quality, Practice, Policy and Research Committee; and the Board of Governors.

AAPM&R’s disclosure and conflict of interest statements can be found at


  1. Novak S, Nemeth WC. The basis for recommending repeating epidural steroid injections for radicular low back pain: a literature review. Arch Phys Med Rehabil. 2008 Mar;89:543–52.

  2. Tong HC. Specificity of needle electromyography for lumbar radiculopathy in 55- to 79-yr-old subjects with low back pain and sciatica without stenosis. Am J Phys Med Rehabil. 2011 Mar;90(3):233–8.

  3. Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low -back pain and sciatica. Cochrane Database Syst Rev. 2010 Jun 16;(6):CD007612.

  4. Chou, Qaseem A, Owens DK, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011 Feb 1;154(3):181–9.

  5. Webster BS. Verma SK. Gatchel RJ. Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine. 2007 Sep 1;32(19):2127–32.