Welcome back to SpineIQ’s Back Blog! Last week, we summarized the overarching literature surrounding clinicians’ beliefs of barriers and facilitators for guideline concordant imaging of low back pain. Many of the results surrounded clinician beliefs about patient expectation for low back pain.1,2 A systematic review by Sharma et al. was conducted to assess whether these beliefs by clinicians are concordant with patients’ beliefs about imaging for low back pain.3 This study titled, “Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis” found 69 studies that explored patient or general public beliefs about diagnostic imaging for low back pain and compared the beliefs to clinician beliefs about patients. In this blog, we summarize the findings and discuss the clinically relevant results.
After screening 6109 studies, 69 studies were included and analyzed in this systematic review. Several themes were found throughout the studies with moderate to high confidence. These themes found beliefs that were concordant and discordant between patient and clinician.
Concordant beliefs between patient and clinician:
- Imaging is helpful to find and locate the pathoanatomical source of low back pain (high confidence)
- Findings on imaging legitimized (patient belief) and reassured (clinician belief) the low back pain experience
Discordant beliefs between patient and clinician
- Some clinicians were aware that imaging is not helpful for diagnosing non-specific low back pain, but patients were not aware of this
- Some clinicians believed that patients would be reassured by a negative test, however, negative tests distressed patients since it “showed nothing”
- Patients felt scared if the findings of the imaging were described as permanent, degenerative, or irreversible and some clinicians were unaware of this possibility
These findings add context to our blog summarizing clinicians’ beliefs about barriers and facilitators to guideline concordant low back pain imaging. There are 5 patient beliefs that were high or moderate confidence with 2 of them concordant and 3 discordant with clinicians’ beliefs. While some clinicians were aware that imaging is not a helpful diagnostic tool and can lead to negative consequences (e.g., radiation or waste of resources), not all clinicians were aware of this, and no patients were aware. In order to inform patients, informational one-page handouts, posters in waiting area, and evidence-based information on the website or through patient facing weekly blogs may increase patient awareness of the evidence surrounding low back pain imaging.4 For clinicians that are not aware of the most up-to-date evidence surrounding low back pain imaging, it is possible that dissemination of evidence for the busy clinician may be useful.5 Clinics with numerous clinicians can dedicate a weekly time to discuss evidence or give presentations in order to stay up-to-date with the current evidence. Finally, clinicians were not aware that both “inconclusive” and “degenerative” findings could lead to stress for patients. This is a negative consequence that clinicians should be aware when deciding whether to order imaging for low back pain and should communicate the possibilities of these findings with their patient prior to ordering the imaging. Through conversation about the low correlation between imaging findings (whether inconclusive or degenerative) and prognosis for low back pain, the patient may be less stressed and uncertain when imaging results return or best-case scenario, patient chooses to not want imaging since the findings are unlikely to provide useful information on management or prognosis.
- Emery DJ, Shojania KG, Forster AJ, Mojaverian N, Feasby TE. Overuse of Magnetic Resonance Imaging. JAMA Intern Med. 2013;173(9):823-825. doi:10.1001/jamainternmed.2013.3804
- Downie A, Hancock M, Jenkins H, et al. How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years. Br J Sports Med. 2020;54(11):642-651. doi:10.1136/bjsports-2018-100087
- Sharma S, Traeger AC, Reed B, et al. Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis. BMJ Open. 2020;10(8):e037820. doi:10.1136/bmjopen-2020-037820
- Sharma S, Traeger AC, Tcharkhedian E, Middleton PM, Cullen L, Maher CG. Effect of a Waiting Room Communication Strategy on Imaging Rates and Awareness of Public Health Messages for Low Back Pain. Int J Qual Health Care. 2021;(mzab129). doi:10.1093/intqhc/mzab129
- Chou R, 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;154(3):181-189. doi:10.7326/0003-4819-154-3-201102010-00008