Welcome back to SpineIQ’s BackBlog! As most of you know, we are strong advocates for appropriate care for spinal pain as outlined in numerous evidence-based guidelines. Such guidelines have been created by a variety of organizations with the goal of assisting clinicians in in adhering to best practices for care.1 The majority of clinical practice guidelines have recommended conservative care, such as manual therapy and exercise, as first-line treatment for spinal pain.2 Another consistent recommendation is to avoid imaging (x-ray or MRI) for the majority of patients who are likely experiencing non-specific low back pain, defined as low back pain with no specific cause.3,4 Studies have shown that nearly half of the imaging currently ordered for low back pain is unnecessary, leading the Choosing Wisely campaign chose it as one of its aims to reduce low value care.4,5 In this week’s BackBlog, we summarize the research on barriers and facilitators to following clinical practice guideline recommendations on imaging. Our goal is to ensure that this critically important but overused diagnostic tool is only utilized in those instances when it is appropriate, such as suspicion of underlying disease.

Barriers and Facilitators

Several studies have qualitatively assessed clinicians’ thoughts on barriers and facilitators to appropriate low back pain imaging. These studies have been conducted in different health care settings (e.g., primary care and emergency department) and different countries. However, the same themes of barriers and facilitators are reported, including the following:

  • Patients want imaging and pressure clinicians into providing it (barrier)
    • Alternative – patients may be reassured by education on why imaging is not necessary in their particular situation
  • Reassuring the patient (barrier)
    • Alternative – patients may be reassured by the confident evidence-based approach to diagnosis and treatment taken by the clinician
  • Lack of time to inform patients that imaging is not needed (barrier)
    • Alternative – indicating that imaging is not needed initially but may be considered later may reassure the patient that the clinician is aware of other diagnostic options.
  • Fear of missing a serious illness (barrier)
    • Alternative – it is important that the benefits vs risks be considered for each individual patient. The benefit of catching a rare underlying condition must be weighed against the risk to the patient of unnecessary imaging (cost and the potential for worse outcomes)5
  • Using one-page patient handouts to help inform the patient in a timely manner (facilitator) Patient information sheets that are discussed with the patient and noted in the chart demonstrates that imaging was not overlooked but rather not deemed appropriate at this particular time.
  • Staying up-to-date with the evidence increases confidence in not ordering imaging (facilitator).


There are numerous self-reported barriers and facilitators that influence a clinician’s imaging behaviors related to low back pain. While some patients are likely to want imaging regardless, there are things that clinicians can do to lower this expectation. For example, purposefully using the poster and wall area in the clinic to hang informational posters focused on evidence-based information about when imaging is unnecessary and the cascade of unnecessary care that can happen when inappropriate imaging is ordered can help inform patients while they’re waiting.6 Clinicians can also have one-page handouts ready for patients to inform them in a timely manner. While clinicians report that they believe patients will be reassured by imaging, studies show that this is often not the case. Instead, patients are often confused when imaging does not identify a specific cause for their pain.7 While ordering imaging may be faster in the short run, the time saved from ordering the imaging may be lost due to future conversations explaining why imaging findings don’t strongly correlate with symptoms or prognosis. Finally, some clinicians use imaging as a “fail-safe” to protect themselves from missing something. It is important, not only for the patient, but for the clinician to remember that less than 1% of low back pain is due to a threatening disease.8


  1. 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/
  2. Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79-86. doi:10.1136/bjsports-2018-099878
  3. 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
  4. 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
  5. Delitto A, Patterson CG, Stevans JM, et al. Stratified care to prevent chronic low back pain in high-risk patients: The TARGET trial. A multi-site pragmatic cluster randomized trial. eClinicalMedicine. 2021;34. doi:10.1016/j.eclinm.2021.100795
  6. 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
  7. 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
  8. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. The Lancet. 2018;391(10137):2356-2367. doi:10.1016/S0140-6736(18)30480-X