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Sharma S1, Traeger A1, Reed BJ2,3, Hamilton M1, O'Connor DA2,3, Hoffmann TC4, Bonner C1, Maher CG1,5, Buchbinder R2,3
1University of Sydney, Sydney School of Public Health, New South Wales, Australia, 2Cabrini Institute, Monash Department of Clinical Epidemiology, Victoria, Australia, 3Monash University, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Victoria, Australia, 4Bond University, Faculty of Health Sciences and Medicine, Centre for Research in Evidence-Based Practice, Queensland, Australia, 5Sydney Local Health District, Institute of Musculoskeletal Health, New South Wales, Australia
Background: Low back pain (LBP) accounts for an estimated 83 million years lived with disability every year, making it the number one cause of disability worldwide. Australian Medicare data suggests that $243 million was spent on spinal radiographs in 2016/17, despite it being unnecessary for the majority of patients. Unnecessary diagnostic imaging places patients at risk of overdiagnosis. This can occur when diagnostic imaging detects normal age-related changes, such as intervertebral disc degeneration, that are common in asymptomatic people. Despite harms of unnecessary imaging, it is unclear what patients, clinicians and general public believe the role of diagnostic imaging is in the management of low back pain.
Purpose: The purpose of this study was to systematically review the qualitative research that has explored clinician, patient and general public beliefs about diagnostic imaging for LBP.
Methods: Studies that used qualitative methods were included if they interviewed the general public about LBP management, clinicians who treat LBP, and/or patients with LBP and explored beliefs about diagnostic imaging for LBP Studies were ineligible if they were not published in English. We searched 5 databases (MEDLINE, EMBASE, CINAHL, AMED, PsycINFO). Two reviewers independently screened articles and extracted data. Synthesis of the results was done by open coding results into key themes and subthemes.
Results: Of 6157 studies from the search, we screened 431 full texts, and 62 studies met our inclusion criteria. Of those included, 21 studies were with clinicians, 25 were with patients, four were with general public, and 12 were with a mixed sample. We identified five key theme:
(1) clinical presentation justifies scanning e.g. severe, worsening, long lasting and relapsing pain warrants scanning;
(2) perception that scans have benefits to clinicians e.g. help make correct diagnosis, locate the source of the pain, reduce risk of litigation if they did not use imaging;
(3) perception that scans have benefits to patients e.g. provide reassurance that there is no serious problem, provide evidence that they are in pain;
(4) scans have potential harms e.g. unnecessary disease labelling, radiation exposure;
(5) health system drivers e.g. ordering tests because health insurance/social security require it.
Conclusion(s): Our review identified that clinicians, patients and community members with LBP have misconceptions about the value of imaging. The belief that imaging is an important diagnostic tool for LBP was commonly expressed among clinicians, patients and community members with LBP. These beliefs are at odds with evidence that diagnostic imaging often adds little value to clinical decision-making or patient outcomes. Therefore, physiotherapists should target mistaken beliefs that imaging is part of standard procedure for the assessment of low back pain and are more informative than clinical evaluation.
Implications: This review will provide a robust picture on how healthcare professionals, patients, and society might view the utility of imaging for low back pain. Understanding such beliefs is critical to helping physiotherapists effectively address patient requests for unnecessary imaging in clinical practice.
Keywords: Low back pain, Imaging, Beliefs
Funding acknowledgements:
This work was supported by an Australian National Health and Medical
Research Council (NHMRC) programme grant.
Purpose: The purpose of this study was to systematically review the qualitative research that has explored clinician, patient and general public beliefs about diagnostic imaging for LBP.
Methods: Studies that used qualitative methods were included if they interviewed the general public about LBP management, clinicians who treat LBP, and/or patients with LBP and explored beliefs about diagnostic imaging for LBP Studies were ineligible if they were not published in English. We searched 5 databases (MEDLINE, EMBASE, CINAHL, AMED, PsycINFO). Two reviewers independently screened articles and extracted data. Synthesis of the results was done by open coding results into key themes and subthemes.
Results: Of 6157 studies from the search, we screened 431 full texts, and 62 studies met our inclusion criteria. Of those included, 21 studies were with clinicians, 25 were with patients, four were with general public, and 12 were with a mixed sample. We identified five key theme:
(1) clinical presentation justifies scanning e.g. severe, worsening, long lasting and relapsing pain warrants scanning;
(2) perception that scans have benefits to clinicians e.g. help make correct diagnosis, locate the source of the pain, reduce risk of litigation if they did not use imaging;
(3) perception that scans have benefits to patients e.g. provide reassurance that there is no serious problem, provide evidence that they are in pain;
(4) scans have potential harms e.g. unnecessary disease labelling, radiation exposure;
(5) health system drivers e.g. ordering tests because health insurance/social security require it.
Conclusion(s): Our review identified that clinicians, patients and community members with LBP have misconceptions about the value of imaging. The belief that imaging is an important diagnostic tool for LBP was commonly expressed among clinicians, patients and community members with LBP. These beliefs are at odds with evidence that diagnostic imaging often adds little value to clinical decision-making or patient outcomes. Therefore, physiotherapists should target mistaken beliefs that imaging is part of standard procedure for the assessment of low back pain and are more informative than clinical evaluation.
Implications: This review will provide a robust picture on how healthcare professionals, patients, and society might view the utility of imaging for low back pain. Understanding such beliefs is critical to helping physiotherapists effectively address patient requests for unnecessary imaging in clinical practice.
Keywords: Low back pain, Imaging, Beliefs
Funding acknowledgements:
This work was supported by an Australian National Health and Medical
Research Council (NHMRC) programme grant.
Topic: Musculoskeletal; Musculoskeletal: spine
Ethics approval required: No
Institution: University of Sydney
Ethics committee: University of Sydney Human Research Ethics Committee
Reason not required: Ethics approval is not required to perform a systematic review.
All authors, affiliations and abstracts have been published as submitted.
