Article Text

Download PDFPDF

Original research
Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis
  1. Sweekriti Sharma1,2,
  2. Adrian C Traeger1,2,
  3. Ben Reed3,4,
  4. Melanie Hamilton1,2,
  5. Denise A O’Connor3,4,
  6. Tammy C Hoffmann5,
  7. Carissa Bonner2,
  8. Rachelle Buchbinder3,4,
  9. Chris G Maher1,2
  1. 1Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
  2. 2School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
  3. 3Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
  4. 4Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
  5. 5Faculty of Health Sciences and Medicine, Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
  1. Correspondence to Sweekriti Sharma; sweekriti.sharma{at}


Objective Overuse of diagnostic imaging for patients with low back pain remains common. The underlying beliefs about diagnostic imaging that could drive overuse remain unclear. We synthesised qualitative research that has explored clinician, patient or general public beliefs about diagnostic imaging for low back pain.

Design A qualitative evidence synthesis using a thematic analysis.

Methods We searched MEDLINE, EMBASE, CINAHL, AMED and PsycINFO from inception to 17 June 2019. Qualitative studies that interviewed clinicians, patients and/or general public exploring beliefs about diagnostic imaging for low back pain were included. Four review authors independently extracted data and organised these according to themes and subthemes. We used the Critical Appraisal Skills Programme tool to critically appraise included studies. To assess confidence in review findings, we used the GRADE-Confidence in the Evidence from Reviews of Qualitative Research method.

Results We included 69 qualitative studies with 1747 participants. Key findings included: Patients and clinicians believe diagnostic imaging is an important test to locate the source of low back pain (33 studies, high confidence); patients with chronic low back pain believe pathological findings on diagnostic imaging provide evidence that pain is real (12 studies, moderate confidence); and clinicians ordered diagnostic imaging to reduce the risk of a missed diagnosis that could lead to litigation, and to manage patients’ expectations (12 studies, moderate confidence).

Conclusion Clinicians and patients can believe that diagnostic imaging is an important tool for locating the source of non-specific low back pain. Patients may underestimate the harms of unnecessary imaging tests. These beliefs could be important targets for intervention.

PROSPERO registration number CRD42017076047.

  • qualitative research
  • back pain
  • magnetic resonance imaging

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Twitter @SweekritiSharma

  • Contributors Study concept and design: ACT, BR, DAO, TH, CB, RB and CM. Acquisition, analysis, or interpretation of data: all authors. Drafting of the manuscript: SS and ACT. Critical revision of the manuscript for important intellectual content: all authors. Analysis: all authors. Obtained funding: CM and RB. Study supervision: ACT and CM.

  • Funding ACT is supported by an Australian Government National Health and Medical Research Council (NHMRC) Early Career Fellowship (APP1144026). DAO is supported by an NHMRC Translating Research into Practice Fellowship (APP1168749). TH is supported by an NHMRC Senior Research Fellowship (APP1154607). RB is supported by an NHMRC Senior Principal Research Fellowship (APP1082138). CM is supported by an NHMRC Principal Research Fellowship (APP1103022), a Programme Grant (APP1113532) and Centre for Research Excellence Grant (APP1113532).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as online supplementary information.