Welcome back to SpineIQ’s Back Blog! This week, we want to discuss an innovative, low cost, and clinically relevant study conducted by Sharma et al.1 This study titled “Effect of waiting room communication strategy on imaging rates and awareness of public health messages for low back pain” looked to see if informational posters in the reception room about low back pain could influence decision-making by patients compared to other (non-low back pain related) information posted on the walls. Although this study was conducted in an emergency room, most clinicians have reception rooms where patient information (posters, TVs etc.) can be displayed on their walls. This study indicates that such information has the potential to lead to important clinical conversations that may influence decision making.

Purpose of this study

Evidence from systematic reviews suggests that patients can be influenced by audio/visual aids in waiting rooms and these strategies have been incorporated to improve guideline adherence in conditions such as influenza and cancer.2 Recently, The Choosing Wisely initiative attempted to raise awareness of low diagnostic yield procedures for low back pain by advising patients to ask 5 questions during their time with a doctor.3 This initiative led to long-term reductions in imaging.3 Clinical practice guidelines consistently recommend against imaging for low back pain unless sinister or serious pathology is suspected.4 However, imaging in low back pain is still widely overused so additional effective interventions to reduce unnecessary imaging is warranted.5 This study tried to address imaging rates for low back pain using messages on the TV screen in the waiting room.


Throughout a 5-month period, all adults presenting to the emergency department with low back pain were included in this study. The emergency room alternated every week displaying the intervention or control posters in their waiting room. The control posters were standard messaging usually shown in the waiting room. Since this was during the COVID-19 pandemic, the images in the waiting room were COVID related. The intervention posters were created by a communication company with the purpose of “scan your options, not your back.” The posters in the intervention group were in 5 different languages (English, Arabic, simple Chinese, and Vietnamese) and were at a 7th grade reading level. The primary outcome was the number of people who received low back pain related imaging (x-ray, CT, or MRI) during the study.


There was a total of 337 patients that came to the emergency department with a primary complaint of low back pain during this study. Overall, 28% (94/337) received low back pain related imaging. The intervention group was less likely (OR = 0.83, 95% CI 0.49 to 1.41) to receive low back pain related imaging and received 4% less images than the control group (29% vs 25%).


The results of this study demonstrate that information passively transferred to patients via posters have the potential to influence their behavior, which suggests that patients are attentive of the information posted on your clinic walls, including audio-visual displays. Although this study focused on imaging, it is likely that it applies to other topics relevant to evidence-based spine care, such as the benefits of conservative care. We encourage you to spend some time thinking about what information is important for your patients to know that may help increase guideline concordant care in your clinics.


  1. 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
  2. Berkhout C, Zgorska-Meynard-Moussa S, Willefert-Bouche A, Favre J, Peremans L, Van Royen P. Audiovisual aids in primary healthcare settings’ waiting rooms. A systematic review. Eur J Gen Pract. 2018;24(1):202-210. doi:10.1080/13814788.2018.1491964
  3. Hong AS, Ross-Degnan D, Zhang F, Wharam JF. Small Decline In Low-Value Back Imaging Associated With The “Choosing Wisely” Campaign, 2012-14. Health Aff Proj Hope. 2017;36(4):671-679. doi:10.1377/hlthaff.2016.1263
  4. National Guideline Centre (UK). Low Back Pain and Sciatica in Over 16s: Assessment and Management. National Institute for Health and Care Excellence (UK); 2016. Accessed June 11, 2021. http://www.ncbi.nlm.nih.gov/books/NBK401577/
  5. 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