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“It’s hard to trust an individual, it’s easier to trust an image”-patients with low back pain want imaging as a means of coping with uncertainty

Review written by Dr Jarod Hall info

Key Points

  1. Despite decades of evidence and guideline messaging that routine imaging does not improve outcomes for non-specific low back pain, patients continue to want it, and strongly.
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BACKGROUND & OBJECTIVE

Low back pain (LBP) affects millions of individuals worldwide and is a significant burden on healthcare systems (1). In Ontario, many individuals experience recurrent or chronic LBP episodes that can severely impact their quality of life, often persisting for years or decades. This prolonged pain can lead to ongoing discomfort, limited mobility, and psychological distress (2,3). Guidelines worldwide warn against routine imaging for LBP because it rarely improves pain, function, quality of life, or treatment decisions (4-7). Yet imaging remains overused, and more importantly, patients actively seek it.

The authors aimed to understand why patients want imaging, but through a more structured theoretical frame: the Common-Sense Self-Regulation Model, which highlights how people interpret illness, cope with it, and evaluate their responses over time. Because LBP is often recurrent, patients accumulate beliefs from past episodes, online information, social circles, and interactions with clinicians. These beliefs become potent drivers of what they feel they “need” in the next episode.

The purpose of this study was to explore the narratives, beliefs, and coping behaviors surrounding imaging expectations in patients with LBP, and to describe how those beliefs evolve over time.

Guidelines worldwide warn against routine imaging for low back pain because it rarely improves pain, function, quality of life, or treatment decisions.
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Clinicians must replace the perceived certainty of imaging with a better, more durable form of certainty: a clear understanding of the condition, a rationale that makes sense to the patient, and consistent messaging that holds up long after the appointment ends.

METHODS

  • This was a qualitative study nested within a larger prospective cohort (“Back ON”). Interviews were analyzed using Reflexive Thematic Analysis guided by the CSSRM, allowing the researchers to interpret how patients perceived their pain, what actions they took, and how
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