Mechanisms contributing to patients’ demand for low back pain imaging: a complex systems approach

Background Low back pain (LBP) is a worldwide problem and people with LPB complaints often demand imaging to find a cause for their pain. However, in 90%-95% of cases, imaging cannot reliably identify the cause for LBP or provide relief to patients. Therefore, most clinical guidelines advise against imaging. Moreover, offering imaging in such cases may result in cascades of unnecessary and potentially harmful follow-up care for patients. In the literature, a multitude of factors have been related to patients' persistent demand for imaging, but little is known about how these factors interact and together shape demand for imaging. This study aims to map all these factors and their relations to contribute to a more comprehensive understanding of demand for imaging among patients with LBP. Methods Group model building (GMB) sessions with LBP patients and professionals from the Netherlands were organized. Participants discussed factors and relations resulting in patients’ demand for LPB imaging. For each GMB session, a causal loop diagram (CLD) was created to visualize the factors and relations driving this demand. These CLDs were subsequently combined into one final CLD. Results Perceived insecurity stemming from the unknown origin of patients’ experienced pain is intrinsic to LBP imaging demand. Repeated failure to identify the cause of LBP was argued to increase dissatisfaction with care, leading to dismissal of evidence-based care recommendations, enhancing consumeristic behaviour, and increasing feelings of insecurity. Conclusions When patients demand LBP imaging, both granting and denying imaging can leave them uncertain and unsatisfied, as the cause of their pain often remains unknown. To reduce unnecessary demand for LBP imaging, future research should focus on addressing patients’ concerns, insecurity and dissatisfaction, providing clear information or education, and building a solid patient-provider relationship. Trial registration: Clinical trial number not applicable.