Clinical practice guidelines recommend against getting scans for most cases of low back pain unless serious problems like fractures or tumours are suspected.

And yet many people think that getting X-rays, MRIs or CT scans can show them what's causing their pain. They often ask for these tests, even when they're not needed, and believe these tests are harmless.

The truth is, that routine imaging for back pain doesn't improve back pain. And the negative effects include:

• exposure to harmful radiation
• higher treatment costs
• fear of moving
• catastrophising
• more back surgeries
• the use of strong, potentially harmful painkillers, and
• chronic pain.

A study shows how prevalent these non-evidence-based beliefs are and reinforces the importance of education when managing patients with low back pain. 

About the study

159 patients with non-specific low back pain in an outpatient physical therapy clinic in Brazil (a middle-income country) were asked if they agreed with 2 statements: 

• X-rays or scans are necessary to get the best medical care for low back pain.
• Everyone with low back pain should have spine imaging. 

What the study found

Nine out of 10 patients believed spine imaging is needed to get the best medical care for low back pain. 

And 6 in 10 patients believed that everyone with low back pain should have spine imaging.

A lower education level and the belief that low back pain has inevitable consequences were associated with the belief that everyone with low back pain should have spine imaging.

This study supports previous studies in Germany and Australia which also found that education level and beliefs about the consequences of low back pain were linked to incorrect beliefs about imaging.

Why aren’t evidence-based messages getting through?

Incorrect beliefs about imaging can stem from:

• unreliable internet information
• financial incentives in healthcare systems that may encourage excessive use of medical services, including imaging
• patients’ personal experiences and those of friends and family members that promote the belief that scans are useful and needed, even if they’re not supported by scientific evidence. 

Barriers in the healthcare system

Clinical practice guidelines recommend addressing beliefs that are inconsistent with current evidence as the first-line intervention for patients with low back pain. 
However, many health professionals themselves still believe that diagnostic imaging is an important tool for finding the source of non-specific low back pain or may lack the skills to address patients' misconceptions.

Other barriers are the lack of time to discuss the risks and harms of imaging with the patient or the concern that a failure to suggest a scan could leave them vulnerable to a medical malpractice lawsuit. 

What can clinicians do to educate patients?

Clinicians can:

• accurately identify when it is appropriate to request a scan
• consider how to effectively inform patients of the results of those scans. For example, they should avoid terms like ‘disc degeneration’ and ‘disc dehydration’ because
• these terms can lead to fear and catastrophising
• provide appropriate education and reassurance about imaging results.

The underuse of imaging for patients for whom imaging is indicated can also influence or reinforce beliefs about imaging because cases of misdiagnosis and inappropriate or insufficient care often receive media attention. So clinicians must use good clinical judgment to discern when imaging is necessary to rule out a severe condition. 

The takeaway messages

Education is crucial when managing low back pain patients. 

To avoid excessive unnecessary use of imaging, educational strategies should target patients with lower education levels and focus on developing materials that explain to patients when imaging is necessary and deconstruct common myths about low back pain. 

Original research

Diniz, L. M., Lemes, Í. R., Freire, A. P., Guimarães, A. F., Ferreira, L. A., Franco, M. R., ... & Pinto, R. Z. Beliefs regarding the use of imaging among patients with low back pain: A cross-sectional study in the context of a middle-income country. PM&R.