Understanding diagnostic imaging desire in non-specific low back pain: a qualitative study using interpretative phenomenological analysis

Understanding diagnostic imaging desire in non-specific low back pain: a qualitative study using interpretative phenomenological analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Understanding diagnostic imaging desire in non-specific low back pain: a qualitative study using interpretative phenomenological analysis Ross Mallett, Jade Jenkinson This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8871658/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Diagnostic imaging is frequently requested for non-specific low back pain despite limited clinical value. Patient desire for imaging remains a key driver of low-value referrals, yet little is known about the anticipatory biopsychosocial beliefs that shape this preference. The aim of this study was to explore anticipatory patient beliefs and the underlying psychosocial dimensions that contribute to imaging desire in non-specific low back pain. Methods A qualitative study using interpretative phenomenological analysis was conducted with 10 adults experiencing non-specific low back pain in the UK. Semi-structured interviews explored participants' lived experiences to understand anticipatory beliefs about diagnostic imaging desire. Analysis followed an idiographic–cross case approach, supported by reflexive practices and collaborative interpretation. Results Three interlinked themes were identified. Illness identity and credibility captured how imaging was viewed as objective validation of legitimised symptoms, supported social acceptance, and represented “good care”. Managing c ognitive threat reflected how imaging was used to address fear of missed pathology, uncertainty and unresolved threat. Healthcare navigation illustrated how imaging was perceived as a guide through care pathways, influencing expectations, relationships, and patients’ sense of control. Conclusions Imaging desire in non-specific low back pain is partially driven by complex anticipatory beliefs centred on legitimacy, threat reduction, and navigation needs. Further understanding the influential biopsychosocial dimensions of imaging desire is critical for supporting tailored dialogue, expectation management, and shared decision-making to reduce low-value imaging. Non-specific low back pain Diagnostic imaging Patient beliefs Imaging desire Expectations Shared decision-making Qualitative research Interpretative phenomenological analysis Introduction Low back pain (LBP) is the leading cause of disability worldwide, presenting a significant and growing burden on global healthcare systems ( 1 , 2 ). 9.5 million people in the UK experience back pain annually with over half being classed as severe, collectively causing 1 in 5 to take time off work ( 3 , 4 ). Despite advances in diagnosis, management and understanding, there continues to be a continued rise in healthcare costs, disability rates, and chronicity associated with LBP ( 5 – 9 ). Consultation and examination procedures are often insufficient in pinpointing a definitive LBP diagnosis ( 10 , 11 ), leaving both clinicians and patients without clear answers. The majority of LBP is categorised as non specific with multifactorial determinants spanning patho-anatomical, neuro-physiological, psychological, and social factors that vary for each individual ( 12 ). This variability contributes to the highly individualised experience of LBP( 13 , 14 ) without clear explanations for symptoms. Diagnostic imaging has the potential to identify structural abnormalities; however, its ability to explain symptoms in low back pain is limited and inconsistent, as pain is not solely the result of nociceptive input ( 12 ). Many studies highlight imaging’s diagnostic shortcomings and the presence of ‘degenerative changes’ in asymptomatic subjects ( 15 – 17 ). Clinical guidelines consistently recommend against routine imaging for non-specific low back pain (NSLBP) based on the inadequacy of image findings to effectively guide management pathways ( 19 , 20 ). An estimated 20–50% of imaging globally is considered low-value ( 20 ), offering minimal clinical benefit while contributing to healthcare waste and greenhouse gas emissions ( 21 ). Despite these limitations, imaging volumes and associated costs continue to rise globally, driven by increased utilisation and a shift toward more expensive modalities, among other factors. ( 2 , 9 , 22 ). Within the NHS, MRI activity reached 4.1 million scans in 2022/23, representing a 6.2% increase from the previous year ( 23 ). Multiple drivers and a complex interplay of factors have been identified for the continued increase in costs and referral rates for diagnostic imaging that pertain to clinician reliance, patient demand and systemic healthcare policy or infrastructure ( 24 – 26 ). Between 40–70% of individuals with LBP express a strong desire for it ( 27 ), potentially reflecting a growing reliance on technology in modern healthcare with patients perceiving imaging to be important, necessary for diagnosis, legitimising pain and guiding management ( 27 – 30 ). Much of this evidence, however, is derived from heterogeneous cohorts, limiting its applicability to NSLBP populations. It has been established that 1% of LBP caseloads with serious conditions necessitate imaging according to the guidelines( 5 ) however, in practice, physicians refer around one in three individuals with LBP for imaging ( 31 ). This is mirrored by clinicians’ motivations to request imaging to manage patient expectations, maintain positive clinician-patient relationships and drive favourable clinical outcomes ( 26 , 32 ). Yet the inclusion of imaging in patient pathways has not been shown to improve biopsychosocial outcomes ( 10 , 33 – 35 ), suggesting that while they are anticipated by patients the expected benefit is short lived or fails to materialise. Interventions for reducing inappropriate imaging referrals have been trialled extensively. Decision support tools aimed at clinicians in primary care were helpful in reducing imaging referrals( 41 ). However, a large systematic review identified a lack of patient targeted interventions with multi-component approaches incorporating education to be more effective ( 37 ). Of the 95 studies included, 79 were conducted in the USA, with only 2 originating from the UK. The authors concluded that contextual health care system change is vital for success. This is echoed in a separate review( 38 ) that found poor support for patient education interventions suggesting organisation and policy-level changes were more likely to be effective in reducing referral rates. While system-level change is essential, it does not negate the need for clinicians to manage patient expectations and uncertainty within individual consultations. Understanding the beliefs that drive imaging desire remains essential for supporting shared decision-making and reducing inappropriate imaging in practice. Shared decision-making, a key component of holistic healthcare, is recognised as essential for improving patient outcomes and satisfaction in imaging ( 30 , 39 ). There is an ongoing tension between clinicians adhering to evidence-based guidelines yet utilising imaging to respond to the psychological and social factors that influence healthcare interactions and decision making. Recent reviews conclude further research is needed from both clinician’s and patient’s perspective to address this research gap ( 27 , 30 ). Although considerable literature exploring patient beliefs about diagnostic imaging exists, there remains limited UK-specific evidence examining these issues within low back pain populations. Existing studies have typically sought general perceptions of imaging rather than specifically focusing on drivers of patient imaging desire or preference for it. Understanding these motives is essential to inform how clinicians manage expectations, tailor education, and engage patients in shared decision-making. By identifying what imaging represents to individuals living with low back pain, better support can facilitate the reframing of illness perceptions, promote acceptance, and enhance self-management within a patient-centred model of care. Although patient desire for imaging has frequently been quantified ( 27 , 40 ), qualitative exploration of the underlying beliefs has been comparatively limited. Research emphasizes the importance of understanding the lived experience of the imaging journey from ordering through to receiving results ( 41 ), yet this pathway remains under-examined. Existing studies describe how experiences before, during, and after musculoskeletal imaging are shaped by contextual and relational factors ( 42 ), and demonstrate that patients often attribute greater value to imaging findings than to clinical evaluation alone ( 43 , 44 ). However, much of this work has focused on the impact of results rather than on the anticipatory beliefs shaping the request itself. Imaging findings have been characterised as a ‘diagnostic grail’ offering visual proof of suffering ( 30 ), with studies showing how informational and practical consequences influence perceived value ( 29 ). Despite this body of work, the beliefs driving imaging expectations remain under-explored ( 30 , 45 ). Recent critical perspectives question assumptions about patient demand, suggesting that imaging requests may reflect needs for validation or support rather than explicit insistence on scanning ( 46 ). Together, this literature indicates the need for focused qualitative investigation of how imaging desire is constructed within the lived experience of non-specific low back pain. Therefore, this study aimed to explore patients’ anticipatory biopsychosocial beliefs about diagnostic imaging in the management of non-specific low back pain, and how these beliefs influence desire or preference for imaging within their care. Methods Study Design A qualitative research design using semi structured interviews was chosen to best meet the study aim undertaking Interpretative Phenomenological Analysis (IPA) to understand participants’ lived experiences and how meaning was constructed across accounts ( 47 ). This approach allows for flexibility and exploration of explicit content whilst contextualism recognises individual’s perceptions are shaped by broader societal and cultural influences ( 48 ). This method supported the aim of understanding how patients construct meaning from their healthcare journey to derive a preference stance on imaging and its use in their care. Ethical approval was obtained from a UK University Ethics Committee; (Reference: ER24779843). The study was conducted in accordance with the Declaration of Helsinki. Adherence to the consolidated criteria for reporting qualitative research (COREQ) checklist ensured study and reporting rigour ( 49 ). Participants & Recruitment A purposive sampling strategy was utilised to ensure a small number of participants could be recruited with the relevant exposure to the phenomena in question ( 48 ). The criteria included participants that were age eighteen and above, able to speak and understand the English language, experienced self reported NSLBP and/or referred pain for a minimum of 12 weeks and seeking healthcare input. Participants were excluded if they had a history of spinal surgery or signs of red flag pathology/awaiting spinal consultation. The inclusion criterion was balanced to achieve a variation in participant experiences to better reflect a diverse population hence previous experience of imaging or preference to have imaging was not included in the criteria. A study advertisement was distributed via social media community groups using Facebook and Instagram. Interested individuals contacted the research team and were screened via email correspondence against the inclusion and exclusion criteria. Eligible respondents were provided with a participant information sheet and consent form, and those returning written consent were invited to arrange a mutually convenient interview time. Data Collection An interview topic guide was developed in consultation with nine clinician/researcher stakeholders to ensure alignment with the study aim and to support open and expansive enquiry ( 47 ). An initial interview guide was piloted using one individual to refine the schedule and to optimise technique using researcher reflexivity and peer feedback, this was excluded from analysis. Individual one-to-one interviews were conducted via Zoom video conferencing and lasted 25–40 minutes following the refined guide to allow detailed descriptions of experiences, perspectives and beliefs. Participants were recruited iteratively, with interviews and concurrent analysis continuing until sufficient depth and coherence in the interpretation of accounts were achieved, while preserving nuance across individual cases ( 50 ). Interviews were audio recorded via the conferencing software and transcribed verbatim by the interviewer. Participants were invited to confirm transcript accuracy and representation of their perceptions post interview to enhance rigor. Data Analysis Transcriptions were anonymised using pseudonyms prior to analysis using systematic undertaking of IPA stages. Immersion in the data for each case allowed initial exploratory notes capturing descriptive, linguistic, and conceptual observations. Case by case idiographic analysis with coding was undertaken independently by both researchers before cross-case consideration of experience was explored. The process was iterative and inductive using notes and coding of explicit statements using paper copies and NVivo analysis software (v.12). These notes were then synthesised into emergent themes. One researcher (RM) shaped connections across themes and cases to explore patterns of convergence and divergence to produce a set of superordinate and subordinate themes representing shared experience. Through ongoing discussion and joint interpretation, case themes were reviewed, refined, and developed with consensus to complete a full hermeneutic cycle that is fundamental to IPA analysis ( 47 ). Researcher reflexivity The research team consisted of two members; a male academic with advanced physiotherapy practice background and research experience holding an MSc (RM). He led the study design and overall project oversight, working in partnership on all other aspects including interview schedule development and data analysis. A second female researcher undertaking an MSc (JJ) led the participant interview stage following training and pilot interviews. Participants were not known to the researchers prior to the study. They were informed that the research team was interested in understanding patient experiences of low back pain and healthcare interactions including imaging. Both researchers acknowledged their positions and experiences may influence interpretation. Reflexive notes were maintained throughout data collection and analysis to document assumptions, emerging interpretations, and potential biases, with regular analytic discussions undertaken to challenge and refine interpretations. Results Fifteen respondents were screened to exclude four based on eligibility criteria. Of the eleven eligible participants, ten consented and were interviewed (eight females and two males, aged 20–69 years) (Table 1 ). Four participants had experienced previous imaging for their non-specific LBP. Table 1 Participant Characteristics Participant Age Category Gender Experience of diagnostic imaging History of LBP (Approximate in years) P1 20–29 Female Yes 10 P2 20–29 Female No 10 P3 60–69 Female Yes 20 P4 40–49 Female No 20 P5 20–29 Female No 3 P6 40–49 Female No 2 P7 20–29 Female No 5 P8 50–59 Male No 3 P9 40–49 Female Yes 20 P10 50–59 Male Yes 20 Three superordinate themes were generated through analysis from the interviews: ( 1 ) illness identity and credibility ( 2 ) managing cognitive threat ( 3 ) healthcare navigation. Nine interrelated subthemes emerged (Table 2 ). Table 2 Results of IPA Superordinate theme Subthemes Subtheme coding description 1.Illness identity and credibility Validation and legitimacy Participants describe imaging as proof their pain is real or justified. Desire for explanation or visualisation Curiosity or need to 'see' what is causing the pain. Imaging as part of good care Belief that imaging is part of competent or complete care. 2.Managing cognitive threat Fear of missing something serious Concern that something medically important is being overlooked without imaging. Imaging as reassurance or closure Desire for imaging to reduce anxiety or bring certainty. Persistent uncertainty and doubt Ongoing worry, frustration, and doubt when reassurance was unmet 3.Healthcare navigation Socially shaped care expectations Expectations shaped by previous imaging experiences or influenced by others Relationship with healthcare Imaging access influences patient engagement with clinicians and systems Imaging as a guide to care Belief that imaging is required to access further treatment or progress care. Theme 1: Illness identity and credibility Participants consistently described struggling to understand the origins of their pain and to make sense of what it meant for them and their healthcare expectations. Participants described using imaging to help make sense of their symptoms and situation, with accounts clustering across three inter-related subthemes. Validation and legitimacy Participants described imaging as tangible evidence that justified their pain experiences and helped them feel more credible, often speaking about wanting their pain to be taken seriously, particularly when explanations were unclear. Participants frequently associated imaging with validation of their pain experiences. For many there was a sense that finding an origin or reason for their pain confirmed it was real and supported being able to move forwards with acceptance and management of it. “it gave you reason for the pain... I mean anyone can just say that they’ve got pain. But if they knew like what it was and where it was then they would be able to progress on that instead of just taking my word for it.” (Participant 2) “I knew the x-ray and that there was actually something wrong, I persevered with it more … it made me happier knowing that there was an answer and a reason.” (Participant 5) Desire for explanation or visualisation The most evident theme that evolved from all participants was a desire to see and understand what was happening inside their bodies. This was often described as identifying what was wrong or had become damaged with a sense that the information gleaned was irrefutable. “Imaging is fact... I always feel better after I’ve had an x-ray or an MRI because you can physically see it for yourself... that has settled me now, I feel a lot better about it because I can see.” (Participant 4) Visualising something tangible was described as helping participants make sense of uncertainty by turning the unseen into something they could understand, often accompanied by feelings of reassurance and control. “I felt like when I could see it... it made more sense to me, and I was less worried.” (Participant 9) Imaging as part of good care Participants often spoke as if imaging would simply be included when seeking assessment for their back pain. Accounts suggested that, without imaging, assessments were perceived as incomplete, with participants describing imaging as a definitive or ‘gold standard’ way of investigating their pain, particularly given its perceived availability. “I would include the imaging in the comprehensive assessment, I would expect it if it was a thorough assessment and an investigation into something, I would assume that that would have been included.” (Participant 1) “[imaging] would be nice... because it’s just the quickest and easiest method of finding out what is wrong.” (Participant 2) Together, these accounts suggest that expectations about imaging shaped both how participants judged the adequacy of their care and how they felt when those expectations were met or unmet. Theme 2: Managing cognitive threat Participants revealed feelings of fear, reassurance, and uncertainty as prominent features of their experiences pain and diagnostic imaging. Across three subthemes, accounts showed how expectations, lived experience, and emotional responses changed and interacted in ways that were individual and often fluid. Fear of missing something serious The accounts show many participants want imaging to reduce their anxiety related to sinister pathology or worsening problems. Here, imaging was positioned as a safeguard against uncertainty, reducing anxiety linked to the possibility that something serious or progressive might be missed. “to see abnormalities … or anything else going on in there, which sort of gives you an image if there’s anything sinister going on inside.” (Participant 8) At times this was offered in the context of monitoring deterioration that only imaging could reveal. “it was quite relieving to know, yes you’ve got this issue, you’re coping with it, it’s not going to deteriorate over time, nothing is going to get worse and it’s nothing serious.” (Participant 1) Participants suggested imaging as reducing worry and uncertainty, especially when concerns about serious or progressive pathology were present. Imaging as reassurance or closure Many participants described the desire to see or be told information that confirmed a clear source or non-serious cause for their pain. In these accounts, reassurance functioned less as protection from risk and more as a form of emotional closure, enabling acceptance and decisions about ongoing management. “If I could see an image of my spine it would give me a different opinion about what it was and how it affected me… it would put my mind at ease because I would know exactly what it was.” (Participant 4) Participants with prior experience of imaging described receiving information that helped them move from uncertainty towards acceptance and decisions about managing their pain. “it’s nothing to be worried about, it’s just that I need to manage it the best way I can” (Participant 9.) “I haven’t been to the doctors since or tried to push anymore scanning…I know there’s nothing majorly wrong.” (Participant 10) Persistent uncertainty and doubt Some participants described feelings of ongoing anxiety, doubt, or frustration when imaging was not offered as anticipated. Unlike accounts where imaging provided reassurance or a sense of closure, these participants described uncertainty that remained unresolved. “I could be living with something that’s fixable… I’m managing but I don’t know the full history and I can’t see what’s happening, I’m managing it without imaging. I would rather not” (Participant 4) In some accounts, uncertainty persisted even after imaging had been received and results had not fully explained the pain experience. “If they were like oh there’s nothing wrong, you’re absolutely fine, I would have been…can I have that scan again please?” (Participant 5) Theme 3: Healthcare navigation Three subthemes represent how participants spoke about imaging in relation to navigating healthcare, including how it influenced their engagement with clinicians, expectations of care, and decisions about seeking help. Socially shaped care expectations Participants described expectations about imaging that were informed by their previous experiences and by comparisons with the experiences of others. These accounts often expressed shared expectations about what constituted thorough or appropriate care, including whether imaging should be part of that process. “everybody expects, well go for an x-ray or go for a scan, you know that will show you…although you’re all trained in your own capacities…I think the general public think no, I would need imaging first.” (Participant 3) Relationship with healthcare Participants frequently described how access to imaging influenced the way they related to clinicians and the healthcare systems they encountered. Across accounts, participants described the act of being offered imaging as influencing their sense of trust in clinicians, sometimes more than the information that followed. When imaging outcomes aligned with expectations, participants described increased trust and acceptance of proposed management. “it’s there in black and white, if it’s showing up on the image and its guided by a specialist or a physio … I have no reason not to trust them.” (Participant 8) Conversely, when imaging was not suggested or expectations were not met, participants described frustration, reduced trust, and disengagement from healthcare. “[imaging] that’s what I understand what you pay national insurance for …I went back; I didn’t seem to get the answers what I was looking for… I thought well that was a waste of time, why bother going?” (Participant 3) Imaging as a Guide to Care Participants described imaging as helping to guide decisions about the direction of their care. “It gives you an answer more than anything because there is proof in a picture, so you and the doctor know how to treat it better.” (Participant 5) For some participants, imaging was also described as influencing perceptions of urgency, with a sense that their care progressed more quickly. “if they didn’t have it then we would have been going around in circles … I could have been trying different things … it would have just been a much longer process, so the imaging made it a lot quicker. (Participant 7) Across accounts, participants described imaging as reducing uncertainty and helping them feel more confident in treatment decisions or accepting of clinical advice. In contrast, when imaging was absent, care was often described as a slower and more iterative process lacking direction. Discussion This study found that patients’ desire for diagnostic imaging in NSLBP was shaped not only by the pursuit of diagnosis but also by the need for validation, reassurance, and direction within their care. Across accounts, imaging was described as serving multiple functions, including legitimising symptoms, managing uncertainty, and helping individuals navigate healthcare decisions. Together, these findings suggest that imaging desire is embedded within emotional and social coping processes, extending beyond expectations focused solely on diagnosis or information provision. By exploring patient beliefs in depth, this qualitative study identified three interrelated themes and nine subthemes that provide new insight into imaging desire in NSLBP. These findings add a UK perspective to a growing international evidence base, highlighting interactions between patients and healthcare systems. The identified illness identity and credibility theme highlights how imaging functioned as a means for patients to obtain objective evidence that their health problems were genuine, both for themselves and for those around them. This included the desire to visualise sources of symptoms and to seek explanations that validate their pain, findings that echo existing literature ( 30 , 41 , 42 , 51 ). While imaging has previously been shown to provide reassurance( 27 ) and confirm ‘real’ biomedical symptoms( 52 ) the present findings suggest that its role extends beyond individual validation into broader social contexts that include family members, clinicians and health systems. The perception that imaging represents good care, reported here and earlier across numerous settings ( 28 , 40 , 53 ), appeared to further reinforce beliefs about its value at both individual and societal levels. Taken from the theme this could be interpreted as imaging being seen as a measure of credible and thorough care. Within the accounts analysed, imaging carried significant weight in shaping perceptions of validation and legitimacy. However, participants did not describe imaging as a means of legitimising sickness certification or access to financial support; in contrast to reports elsewhere ( 54 , 55 ). These findings emphasise some of the social mechanisms through which imaging contributes to illness credibility. The second theme, management of cognitive threat , highlights how participants sought to reduce uncertainty and perceived danger through imaging. Threat-based models emphasise that pain related behaviours are shaped by cognitive appraisals of danger, uncertainty, and the need for protection, rather than tissue damage alone ( 56 , 57 ). Using this framing, imaging was frequently positioned as a means of reducing or mitigating such threat by providing reassurance, reducing uncertainty, or offering a sense closure. Although threat is understood to be individualised and shaped by multiple biopsychosocial influences, fear of serious pathology and uncertainty regarding an unidentified biological cause featured most prominently within participants’ accounts. The subthemes of missing serious pathology and imaging as reassurance within the current study’s results closely reflect findings elsewhere ( 30 , 58 ), and together represent anticipatory attempts to manage cognitive threats through health risk appraisal and access to objective information. This is also potentially shared by clinicians, who often use imaging as a safeguard for defensive medicine purposes ( 21 , 24 ). In contrast, p ersistent uncertainty and doubt reflected failed or incomplete management of threat. Several narratives described imaging as a potential “key” to unlocking their problem yet found that the information received did not always precisely fit their expectations. This partially mirrors descriptions of cognitive dissonance reported previously ( 59 ), where making sense of inconsistent and changing information may challenge patient’s beliefs leading to continuous reassessment of their situation ( 46 ). Notably, participants did not described imaging as intensifying anxiety or reinforcing worry, and concerns about radiation exposure were mentioned only briefly and dismissively, contrasting with previous reports( 20 , 56 ) ,57). Overall, this theme supports existing evidence that imaging is commonly sought for reassurance and anticipated threat reduction. It also highlights that reassurance is neither uniform nor guaranteed, and may persist or be reshaped when information conflicts with existing beliefs ( 61 , 62 ). Taken together, these findings suggest that imaging desire reflects broader processes of making sense and seeking safety in the context of ongoing uncertainty. The perceived objectivity of diagnostic imaging by patients potentially seems a way of gaining a sense of control. Expectations of imaging were seen to be formed through prior personal experiences, the experiences of others, and cultural assumptions that imaging should be included as standard. Socially shaped expectations of imaging have been previously documented ( 53 , 63 ), however, previous work has often drawn on clinician perspectives of clinical encounters. Participants in the present study did not describe media information as shaping their expectations, aligning with evidence that public-facing imaging information has not substantially reduced imaging rates for musculoskeletal pain in the UK ( 64 ) although media campaigns have been shown to have some impact ( 26 , 56 ). The third theme explores how imaging was consistently described as playing a role in shaping participants' relationships with healthcare and their navigation of complex care pathways. Across accounts, access to imaging appeared to shape how participants interpreted their interactions with healthcare professionals; influencing perceptions of engagement and confidence in clinical advice. It has been shown that a strong existing patient and clinician relationship can influence whether patients accept advice against their expectations for imaging ( 53 ). In this study, at times the absence of imaging was interpreted as an indication that care was not progressing or that concerns were not being sufficiently addressed. This suggests participants found imaging a helpful aid to assess momentum and commitment within the healthcare relationship. The absence of imaging was associated with trial-and-error treatment approaches, positioning imaging to move beyond generic management and facilitate access to subsequent care decisions, referrals, or treatments. This pattern is consistent with findings in non-specific low back pain and broader musculoskeletal conditions( 51 , 65 ). Importantly, the value of imaging in guiding care was consistently derived from what imaging enabled, rather than from the imaging results alone. Regardless of whether imaging identified a clear biomedical cause, it shaped care journeys by influencing how participants interpreted clinician engagement, signalled progression, and enabled movement between care stages. Framed in this way, imaging as a guide to care connects directly with the preceding themes. It extends legitimacy beyond personal validation into a means of navigating healthcare systems, while also serving to support progression through healthcare when uncertainty persists despite investigation. This study supplements existing recommendations by identifying ways in which clinicians can and should engage with patients using tailored dialogue to understand individual’s meaning attached to imaging preference across the three interlinked themes. Building on previous recommendations( 30 ) clinicians should validate patient’s pain experiences and explore whether the search for legitimacy stems from internal uncertainty or external drivers. Our findings emphasise current acceptance that patient education alone, especially generic education, is insufficient to address the complex psychosocial drivers of imaging desire in NSLBP. Existing recommendations stress research informed imaging practices ( 41 , 66 ), thorough clinical assessment and clear explanation of clinical reasoning ( 63 ). Others have highlighted the pivotal role of therapeutic relationships, emphasising joint narratives and open discussion of both the potential benefits and harms of imaging (30,51,53,65,67). Clinician reassurance to patients is recommended to help mitigate cognitive threat ( 27 , 29 , 53 ). Our findings support others in suggesting both emotional and cognitive support may be more effective (68). Clinicians can support patients by emphasising 'certainty talk', focusing on what is known and stable about their condition, while acknowledging that reassurance and residual uncertainty may coexist. This approach recognises that patients' concerns may shift as they make sense of their situation. To establish realistic expectations of healthcare navigation, clinicians should engage in open discussion about imaging's role in guiding care pathways ( 53 ) and explore how patients perceive imaging to shape their engagement and relationships within the system. Recognising imaging desire as an expression of threat, uncertainty, and sought credibility enables clinicians to move beyond information giving towards more patient centred, empathic conversations that reduce unnecessary imaging. The key strength and current distinctiveness of this study is the identified biopsychosocial dimensions that form patients’ desire for diagnostic imaging in NSLBP. Further strengths include collaborative analysis of the data adhering to an analytical participant experiential approach ( 47 ). The more experienced researcher was distanced from data collection to reduce potential bias. Reflexive discussions were used throughout data collection and analysis to maintain awareness of researcher influence ( 48 ). The findings have been compared with existing evidence to situate the identified themes, and methodological decisions have been explained where findings diverge from prior work. There are notable limitations to this study. Generalisability is limited however, the depth of IPA allows for theoretical transferability when participant contextual factors are considered and findings align with existing evidence. Further limitations exist due to self-selecting participants engaged in healthcare and demonstrating a good level of health literacy. Yet minimal inclusion criteria relating to the participant’s NSLBP, imaging and healthcare experience were applied to reflect known populations. Also, the findings will not be theoretically transferable to acute populations, or potentially outside the UK. As discussed within the imaging reassurance theme, previous imaging had an impact on the narratives. Future investigation may wish to isolate previous imaging experience to better understand this key component. Our interview guide focus toward ‘desire’ led to findings where few barriers of imaging desire were described. This should be considered as inherent to the concept of desire and explored fully in the future. It is acknowledged that in the current study we opted not to seek narratives relating to the influence of clinician communication and relationship despite this being highly influential. Future research This study highlights important avenues for future research into the psychosocial dynamics of imaging desire in non-specific low back pain. Although recent work has strengthened understanding of shared decision making, communication, and patient-reported outcomes in imaging, little is known about the anticipatory processes that precede imaging requests. What patients believe imaging will provide, rather than the outcomes it ultimately delivers, influences patient behaviour within consultations. While outcome-based research is fundamental to understanding the efficacy of imaging, it does not capture how desire, interaction dynamics, and referral decisions unfold. Closer examination of these anticipatory dimensions and how they shape shared decision-making interactions is essential. Future research should therefore examine both anticipatory and outcome-related dimensions of imaging, ideally through longitudinal or causal designs that track how imaging beliefs influence a range of outcomes. Identifying discrete psychosocial constructs of imaging desire is crucial and should be sought, however comprehensive capture may prove elusive. Measuring the deeper attributes these constructs represent, such as perceived control, threat, and legitimacy, may be more feasible and meaningful for developing predictive models or for the development of consultation support tools that facilitate tailored, patient-centred dialogue within shared decision-making. Conclusion This study reinforces and deepens understanding of how patients with non-specific low back pain construct meaning around diagnostic imaging. Imaging desire appears to be shaped by anticipatory beliefs that reflect the need for validation and threat reduction as much as, and often more than, diagnostic necessity. When these needs are not fully met, imaging may also take on a procedural role in helping patients navigate care pathways, signal progress, and access further input. A clearer understanding of these anticipatory drivers is needed in future research to identify which psychosocial dimensions most strongly influence imaging desire and how they can be addressed within consultations, joint narratives, and shared decision making to reduce inappropriate imaging referrals. Abbreviations COREQ: Consolidated criteria for reporting qualitative research IPA: Interpretative phenomenological analysis LBP: Low back pain MRI: Magnetic resonance imaging NHS: National Health Service NSLBP: Non-specific low back pain UK: United Kingdom USA: United States of America Declarations Clinical trial number Not applicable Ethics approval and consent to participate This study was approved by Sheffield Hallam University Ethics Committee (Reference: ER24779843) and conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent prior to participation. Consent for publication All participants provided informed consent for publication of anonymised interview data. No individual participant details, images, or videos are included in this manuscript. Availability of data and materials The interview transcripts generated and analysed during this study are not publicly available to protect participant confidentiality. Anonymised excerpts and supporting quotations are available as supplementary materials. Additional data are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no known competing financial interests or personal relationships that influenced the work reported in this paper. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions CRediT authorship contribution statement : RM: Conceptualization, Methodology, Validation, Formal analysis, Resources, Data curation, Writing – original draft, Visualization, Writing – review & editing, Supervision, Project Administration. JJ: Methodology, Validation, Formal analysis, Investigation, Resources, Data curation, Writing – review & editing. Both authors read and approved the final manuscript. Acknowledgements The authors wish to thank all participants for their willingness to share their experiences and for making this research possible. We also thank Professor George Peat and Dr Sarah Hardcastle for their constructive guidance and valuable discussions, which supported the refinement of this work. The authors used Claude.ai for feedback on manuscript clarity of message; all research content, data analysis, and interpretation were conducted and verified by the authors. References Ferreira ML, De Luca K, Haile LM, Steinmetz JD, Culbreth GT, Cross M, et al. Global, regional, and national burden of low back pain, 1990–2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol [Internet]. 2023 Jun 1 [cited 2025 Oct 22];5(6):e316–29. Available from: https://www.thelancet.com/action/showFullText?pii=S266599132300098X Stewart WF, Yan X, Boscarino JA, Maeng DD, Mardekian J, Sanchez RJ, et al. Patterns of health care utilization for low back pain. Taylor & FrancisWF Stewart, X Yan, JA Boscarino, DD Maeng, J Mardekian, RJ Sanchez, MR Von KorffJournal of pain research, 2015•Taylor & Francis [Internet]. 2015 Aug 12 [cited 2025 Oct 22];8:523–35. Available from: https://www.tandfonline.com/doi/abs/10.2147/JPR.S83599 Office for National Statistics. Population estimates for England and Wales - Office for National Statistics [Internet]. [cited 2025 Oct 22]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/bulletins/populationestimatesforenglandandwales/mid2023 Arthritis UK. Arthritis and other musculoskeletal conditions in numbers. Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum [Internet]. 2009 Oct 1 [cited 2025 Mar 22];60(10):3072–80. Available from: https://onlinelibrary.wiley.com/doi/full/10.1002/art.24853 Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis [Internet]. 2014 Jun;73(6):968–74. Available from: http://dx.doi.org/10.1136/annrheumdis-2013-204428 Williams CM, Maher CG, Hancock MJ, McAuley JH, McLachlan AJ, Britt H, et al. Low back pain and best practice care: A survey of general practice physicians. Arch Intern Med [Internet]. 2010 Feb 8 [cited 2025 Mar 24];170(3):271–7. Available from: https://pubmed.ncbi.nlm.nih.gov/20142573/ Tan A, Zhou J, Kuo YF, Goodwin JS. Variation among Primary Care Physicians in the Use of Imaging for Older Patients with Acute Low Back Pain. J Gen Intern Med [Internet]. 2016 Feb 1 [cited 2025 Mar 24];31(2):156–63. Available from: https://pubmed.ncbi.nlm.nih.gov/26215847/ Kjelle E, Brandsæter IØ, Andersen ER, Hofmann BM. Cost of Low-Value Imaging Worldwide: A Systematic Review. Vol. 22, Applied Health Economics and Health Policy. Adis; 2024. p. 485–501. Modic MT, Obuchowski NA, Ross JS, Brant-Zawadzki MN, Grooff PN, Mazanec DJ, et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology. 2005 Nov;237(2):597–604. Chou R. Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Ann Intern Med [Internet]. 2011;154(3):181. Available from: http://dx.doi.org/10.7326/0003-4819-154-3-201102010-00008 Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. What low back pain is and why we need to pay attention. Vol. 391, The Lancet. Lancet Publishing Group; 2018. p. 2356–67. O’Sullivan P. Diagnosis and classification of chronic low back pain disorders: Maladaptive movement and motor control impairments as underlying mechanism. Man Ther [Internet]. 2005 Nov 1 [cited 2025 Oct 24];10(4):242–55. Available from: https://www.sciencedirect.com/science/article/pii/S1356689X05001104 O’Sullivan P, Caneiro JP, O’Keeffe M, O’Sullivan K. Unraveling the Complexity of Low Back Pain. https://doi.org/102519/jospt20160609 [Internet]. 2016 Nov 1 [cited 2025 Oct 24];46(11):932–7. Available from: /doi/pdf/10.2519/jospt.2016.0609 Jenkins HJ, Hancock MJ, Maher CG, French SD, Magnussen JS. Understanding patient beliefs regarding the use of imaging in the management of low back pain. European Journal of Pain (United Kingdom). 2016 Apr 1;20(4):573–80. Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American journal of neuroradiology : AJNR [Internet]. 2015 Apr;36(4):811–6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25430861 Hancock M, Kjaer P, Kent P, Jensen R, Spine TJ, 2017 undefined. Is the number of different MRI findings more strongly associated with low back pain than single MRI findings? journals.lww.comMJ Hancock, P Kjaer, P Kent, RK Jensen, TS JensenSpine, 2017•journals.lww.com [Internet]. [cited 2025 Oct 22]; Available from: https://journals.lww.com/spinejournal/_layouts/15/oaks.journals/downloadpdf.aspx?an=00007632-201709010-00008&casa_token=ti6wTDKCoJIAAAAA:j9bEww3I9rkw08YwU_FvqexpRHEPNwDNQmlsEdPM2ZDRys2iWi8-KvQzfkrozUw1F389_VJBrk9IonV5UDY Kasch R, Truthmann J, Hancock MJ, Maher CG, Otto M, Nell C, et al. Association of Lumbar MRI Findings with Current and Future Back Pain in a Population-based Cohort Study. Spine (Phila Pa 1976) [Internet]. 2022 Feb 1 [cited 2025 Oct 22];47(3):201–11. Available from: https://journals.lww.com/spinejournal/fulltext/2022/02010/association_of_lumbar_mri_findings_with_current.4.aspx Oliveira CB, Maher CG, Pinto RZ, Traeger AC, Lin CWC, Chenot JF, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. European Spine Journal [Internet]. 2018 Nov 1 [cited 2025 Mar 24];27(11):2791–803. Available from: https://link.springer.com/article/10.1007/s00586-018-5673-2 NICE. Low back pain and sciatica in over 16s: assessment and management | Guidance | NICE. Kjelle E, Andersen ER, Krokeide AM, Soril LJJ, van Bodegom-Vos L, Clement FM, et al. Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review. BMC Med Imaging. 2022 Dec 1;22(1). Kjelle E, Brandsæter I, Andersen ER, Hofmann B. Sustainability in healthcare by reducing low-value imaging – A narrative review. Vol. 30, Radiography. W.B. Saunders Ltd; 2024. p. 30–4. Brady AP, Bello JA, Derchi LE, Fuchsjäger M, Goergen S, Krestin GP, et al. Radiology in the Era of Value-based Healthcare: A Multi-Society Expert Statement from the ACR, CAR, ESR, IS3R, RANZCR, and RSNA. https://doi.org/101148/radiol2020209027 [Internet]. 2020 Dec 21 [cited 2025 Oct 24];298(3):486–91. Available from: /doi/pdf/10.1148/radiol.2020209027 Spinal Imaging in Primary Care (Remedy BNSSG ICB) [Internet]. [cited 2025 Mar 24]. Available from: https://remedy.bnssg.icb.nhs.uk/adults/radiology-imaging/spinal-imaging-in-primary-care/ Slade SC, Kent P, Patel S, Bucknall T, Buchbinder R. Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: A systematic review and metasynthesis of qualitative studies. Clinical Journal of Pain [Internet]. 2016 [cited 2025 Oct 22];32(9):800–16. Available from: https://journals.lww.com/clinicalpain/fulltext/2016/09000/barriers_to_primary_care_clinician_adherence_to.8.aspx Brandsæter IØ, Andersen ER, Hofmann BM, Kjelle E. Drivers for low-value imaging: a qualitative study of stakeholders’ perspectives in Norway. BMC Health Serv Res. 2023 Dec 1;23(1). Lam J, Pickles K, Stanaway F, research KBB health services, 2020 undefined. Why clinicians overtest: development of a thematic framework. SpringerJH Lam, K Pickles, FF Stanaway, KJL BellBMC health services research, 2020•Springer [Internet]. 2020 Dec 1 [cited 2025 Mar 25];20(1). Available from: https://link.springer.com/article/10.1186/s12913-020-05844-9 Taylor S, Bishop A. Patient and public beliefs about the role of imaging in the management of non-specific low back pain: a scoping review. Vol. 107, Physiotherapy (United Kingdom). Elsevier Ltd; 2020. p. 224–33. Espeland A, Baerheim A, Albrektsen G, Korsbrekke K, Larsen JL. Patients’ Views on Importance and Usefulness of Plain Radiography for Low Back Pain [Internet]. Vol. 26, SPINE. 2001. Available from: http://journals.lww.com/spinejournal Sharma S, Traeger AC, Reed B, Hamilton M, O’Connor DA, Hoffmann TC, et al. Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis. BMJ Open. 2020 Aug 23;10(8):e037820. Downie A, Hancock M, Jenkins H, Buchbinder R, Harris I, Underwood M, et al. How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years. Br J Sports Med [Internet]. 2020;54:642–53. Available from: http://dx.doi.org/10.1136/bjsports-2018-100087 Sears ED, Caverly TJ, Kullgren JT, Fagerlin A, Zikmund-Fisher BJ, Prenovost K, et al. Clinicians’ Perceptions of Barriers to Avoiding Inappropriate Imaging for Low Back Pain—Knowing Is Not Enough. JAMA Intern Med [Internet]. 2016 Dec 1 [cited 2025 Jan 9];176(12):1866–8. Available from: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2569281 Lemmers GPG, van Lankveld W, Westert GP, van der Wees PJ, Staal JB. Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work. Vol. 28, European Spine Journal. Springer Verlag; 2019. p. 937–50. Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009 Feb;373(9662):463–72. Van Ravesteijn H, Van Dijk I, Darmon D, Van de Laar F, Lucassen P, Olde Hartman T, et al. The reassuring value of diagnostic tests: A systematic review. Vol. 86, Patient Education and Counseling. 2012. p. 3–8. Krousel-Wood M, Peacock E, David Bradford W, Mohundro B, Craig LS, O’connell S, et al. Time Preference for Immediate Gratification: Associations With Low Medication Adherence and Uncontrolled Blood Pressure. Am J Hypertens [Internet]. 2022 [cited 2025 Mar 25];35(3). Available from: https://doi.org/10.1093/ajh/hpab175 Manizia L, Borah T, Bhattacharjee R, Saikia J, Dutta A, Boruah J. Instant Gratification and The Digital Natives: A Pilot Study. Educational Administration: Theory and Practice. 2023; Luhmann CC. Temporal decision-making: Insights from cognitive neuroscience. Vol. 3, Frontiers in Behavioral Neuroscience. 2009. Jenkins HJ, Hancock MJ, French SD, Maher CG, Engel RM, Magnussen JS. Effectiveness of interventions designed to reduce the use of imaging for low-back pain: a systematic review. CMAJ [Internet]. 2015 Apr 7 [cited 2025 Mar 22];187(6):401–8. Available from: https://pubmed.ncbi.nlm.nih.gov/25733741/ Kjelle E, Andersen ER, Soril LJJ, van Bodegom-Vos L, Hofmann BM. Interventions to reduce low-value imaging – a systematic review of interventions and outcomes. BMC Health Serv Res. 2021 Dec 1;21(1). Belavy DL, Tagliaferri SD, Buntine P, Saueressig T, Samanna C, Mcguckian T, et al. Reducing Low-Value Imaging for Low Back Pain: Systematic Review With Meta-analysis. Vol. 52, Journal of Orthopaedic and Sports Physical Therapy. Movement Science Media; 2022. p. 175–91. Larijani MM, Dumba C, Thiessen H, Palen A, Carr T, Vanstone JR, et al. Development of a Patient-Oriented Intervention to Support Patient-Provider Conversations about Unnecessary Lower Back Pain Imaging. International Journal of Environmental Research and Public Health 2021, Vol 18, Page 2786 [Internet]. 2021 Mar 9 [cited 2024 Oct 25];18(5):2786. Available from: https://www.mdpi.com/1660-4601/18/5/2786/htm Smith JA., Flowers Paul, Larkin Michael. Interpretative phenomenological analysis : theory, method and research. 2009;225. Brocki JM, Wearden AJ. A critical evaluation of the use of interpretative phenomenological analysis (IPA) in health psychology. Psychol Health [Internet]. 2006 Feb [cited 2025 Nov 12];21(1):87–108. Available from: https://www.tandfonline.com/doi/pdf/10.1080/14768320500230185 Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care [Internet]. 2007 Dec 1 [cited 2025 Nov 12];19(6):349–57. Available from: https://dx.doi.org/10.1093/intqhc/mzm042 Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant [Internet]. 2018 Jul 1 [cited 2025 Nov 12];52(4):1893–907. Available from: https://pubmed.ncbi.nlm.nih.gov/29937585/ Armitage A, Harland N. The’Lived Experience’of patients having a Cervical or Lumbar MRI scan. Pain and Rehabilitation-the Journal of Physiotherapy Pain Association. 2020;2020(49):57–62. Barbosa MM, Dos Santos AJM, Galli N, Vidal RVC, Grande GHD, Oliveira CB. Perceptions of medical doctors and patients about imaging for people with low back pain: A qualitative study. PM&R. 2024;16(12):1317–23. Bourke S, Taylor WJ, Doyle AJ, Gott M, Dalbeth N. The patient experience of musculoskeletal imaging tests for investigation of inflammatory arthritis: a mixed-methods study. Clin Rheumatol [Internet]. 2018;37(8):2261–8. Available from: https://research.ebsco.com/linkprocessor/plink?id=c4aedc11-6c99-3560-b7eb-56fc3469e6e7 Toye F, Seers K, Hannink E, Barker K. A mega-ethnography of eleven qualitative evidence syntheses exploring the experience of living with chronic non-malignant pain. BMC Medical Research Methodology 2017 17:1 [Internet]. 2017 Aug 1 [cited 2025 Nov 11];17(1):1–11. Available from: https://bmcmedresmethodol.biomedcentral.com/articles/10.1186/s12874-017-0392-7 Diniz LM, Lemes ÍR, Freire APCF, Guimarães AF, Ferreira LAC, Franco MR, et al. 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 [Internet]. 2025;17(2):178–86. Available from: https://research.ebsco.com/linkprocessor/plink?id=41792209-505c-3f86-8e49-d810b7de9b1a Robinson CA, Gosdin MM, Cipri CS, Fridman I, Weinberg G, Jerant A, et al. Facilitators and barriers to deferring imaging for acute low back pain: a qualitative study. BMC primary care [Internet]. 26(1):204. Available from: https://research.ebsco.com/linkprocessor/plink?id=7bf4462f-fd2b-39cb-9be8-90385579f0a2 Chou L, Ranger TA, Peiris W, Cicuttini FM, Urquhart DM, Sullivan K, et al. Patients’ perceived needs for medical services for non-specific low back pain: A systematic scoping review. PLoS One [Internet]. 2018 Nov 1 [cited 2024 Oct 25];13(11):e0204885. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0204885 Alhowimel A, Alotaibi M, Coulson N, Radford K. Psychosocial consequences of diagnosing nonspecific low-back pain radiologically: a qualitative study. Physiother Theory Pract [Internet]. 2022 Jul 3 [cited 2024 Oct 31];38(7):890–6. Available from: https://www.tandfonline.com/doi/abs/10.1080/09593985.2020.1802799 Plante J, Kucksdorf J, Ruzich J, Young JL, Rhon DI. Do Maladaptive Imaging Beliefs Predict Self-Reported Pain Interference and Physical Function in Patients With Musculoskeletal Disorders? J Orthop Sports Phys Ther [Internet]. 2024 Sep 1 [cited 2024 Oct 17];54(9):1–10. Available from: https://www.jospt.org/doi/10.2519/jospt.2024.12625 Lullo G, Giannotta G, Tamborrino A, Mourad F, Esposto M, Giovannico G, et al. “Do I need an imaging?” Exploring why patients with non-specific chronic low back pain request diagnostic instrumental evaluation: a phenomenological qualitative study. Musculoskelet Sci Pract [Internet]. 2025 Sep;103416. Available from: https://linkinghub.elsevier.com/retrieve/pii/S246878122500164X Thompson MJ, Suchsland MZ, Hardy V, Lavallee DC, Lord S, Devine EB, et al. Patient-centred outcomes of imaging tests: recommendations for patients, clinicians and researchers. BMJ Qual Saf [Internet]. 2023 [cited 2025 Mar 21];32:536–45. Available from: http://becertain.org/partnerships/ Hoffmann TC, Del Mar CB, Strong J, Mai J. Patients’ expectations of acute low back pain management: Implications for evidence uptake. BMC Fam Pract [Internet]. 2013 Jan 8 [cited 2024 Oct 25];14(1):1–6. Available from: https://bmcprimcare.biomedcentral.com/articles/10.1186/1471-2296-14-7 Holt N, Pincus T, Vogel S. Reassurance during low back pain consultations with GPs: a qualitative study. Br J Gen Pract [Internet]. 2015 Oct;65(639):e692–701. Available from: https://pubmed.ncbi.nlm.nih.gov/26412846 Pincus T, Holt N, Vogel S, Underwood M, Savage R, Walsh DA, et al. Cognitive and affective reassurance and patient outcomes in primary care: A systematic review. Pain [Internet]. 2013 Nov 1 [cited 2025 Nov 13];154(11):2407–16. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0304395913003874 Malliaras P, O’Keeffe M, Ridgway J, Whale R, Vasan V, L’Huillier P, et al. Patient experiences of rotator cuff-related shoulder pain and their views on diagnostic shoulder imaging: a qualitative study. Disabil Rehabil. 2024;46(21):5021–8. Blokzijl J, Dodd RH, Copp T, Sharma S, Tcharkhedian E, Klinner C, et al. Understanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: A qualitative study. Emergency Medicine Journal. 2021 Jul 1;38(7):529–35. Cuff A, Jesson T, Yeowell G, Dikomitis L, Foster NE, Littlewood C. Recommendations on patient-facing websites regarding diagnostic imaging for low back, knee, and shoulder pain: A scoping review. Vol. 1, PEC Innovation. Elsevier B.V.; 2022. Tanner L, Saywell NL, Adams T, Niazi IK, Hill J. Factors influencing imaging clinical decision-making in low back pain management. A scoping review. Vol. 22, Musculoskeletal Care. John Wiley and Sons Ltd; 2024. Myburgh C, Larsen TB, Kjaer P. ‘when the picture does not really tell the story’– a qualitative exploration of the MRI report of findings as a means for generating shared diagnostic meaning during the management of patients suffering from persistent spinal pain. Patient Educ Couns [Internet]. 2022;105(1):221–7. Available from: https://hallam.idm.oclc.org/login?url=https://www.proquest.com/docview/2529334288?accountid=13827&bdid=116648&_bd=CDsuGMk%2Bg84gVlM33FWqLFv0GAM%3D Haslam-Larmer L, Norman KE, Patey AM, Thomas IM, Green ME, Grimshaw JM, et al. “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. BMC Primary Care. 2025 Dec 1;26(1). Additional Declarations No competing interests reported. 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Despite advances in diagnosis, management and understanding, there continues to be a continued rise in healthcare costs, disability rates, and chronicity associated with LBP (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e). Consultation and examination procedures are often insufficient in pinpointing a definitive LBP diagnosis (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e), leaving both clinicians and patients without clear answers. The majority of LBP is categorised as non specific with multifactorial determinants spanning patho-anatomical, neuro-physiological, psychological, and social factors that vary for each individual (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e). This variability contributes to the highly individualised experience of LBP(\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e) without clear explanations for symptoms.\u003c/p\u003e \u003cp\u003eDiagnostic imaging has the potential to identify structural abnormalities; however, its ability to explain symptoms in low back pain is limited and inconsistent, as pain is not solely the result of nociceptive input (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e). Many studies highlight imaging’s diagnostic shortcomings and the presence of ‘degenerative changes’ in asymptomatic subjects (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e). Clinical guidelines consistently recommend against routine imaging for non-specific low back pain (NSLBP) based on the inadequacy of image findings to effectively guide management pathways (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e). An estimated 20–50% of imaging globally is considered low-value (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e), offering minimal clinical benefit while contributing to healthcare waste and greenhouse gas emissions (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e). Despite these limitations, imaging volumes and associated costs continue to rise globally, driven by increased utilisation and a shift toward more expensive modalities, among other factors. (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e). Within the NHS, MRI activity reached 4.1\u0026nbsp;million scans in 2022/23, representing a 6.2% increase from the previous year (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMultiple drivers and a complex interplay of factors have been identified for the continued increase in costs and referral rates for diagnostic imaging that pertain to clinician reliance, patient demand and systemic healthcare policy or infrastructure (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e). Between 40–70% of individuals with LBP express a strong desire for it (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e), potentially reflecting a growing reliance on technology in modern healthcare with patients perceiving imaging to be important, necessary for diagnosis, legitimising pain and guiding management (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e). Much of this evidence, however, is derived from heterogeneous cohorts, limiting its applicability to NSLBP populations. It has been established that 1% of LBP caseloads with serious conditions necessitate imaging according to the guidelines(\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e) however, in practice, physicians refer around one in three individuals with LBP for imaging (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e). This is mirrored by clinicians’ motivations to request imaging to manage patient expectations, maintain positive clinician-patient relationships and drive favourable clinical outcomes (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e). Yet the inclusion of imaging in patient pathways has not been shown to improve biopsychosocial outcomes (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e), suggesting that while they are anticipated by patients the expected benefit is short lived or fails to materialise.\u003c/p\u003e \u003cp\u003eInterventions for reducing inappropriate imaging referrals have been trialled extensively. Decision support tools aimed at clinicians in primary care were helpful in reducing imaging referrals(\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e). However, a large systematic review identified a lack of patient targeted interventions with multi-component approaches incorporating education to be more effective (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e). Of the 95 studies included, 79 were conducted in the USA, with only 2 originating from the UK. The authors concluded that contextual health care system change is vital for success. This is echoed in a separate review(\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e) that found poor support for patient education interventions suggesting organisation and policy-level changes were more likely to be effective in reducing referral rates. While system-level change is essential, it does not negate the need for clinicians to manage patient expectations and uncertainty within individual consultations. Understanding the beliefs that drive imaging desire remains essential for supporting shared decision-making and reducing inappropriate imaging in practice.\u003c/p\u003e \u003cp\u003eShared decision-making, a key component of holistic healthcare, is recognised as essential for improving patient outcomes and satisfaction in imaging (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e). There is an ongoing tension between clinicians adhering to evidence-based guidelines yet utilising imaging to respond to the psychological and social factors that influence healthcare interactions and decision making. Recent reviews conclude further research is needed from both clinician’s and patient’s perspective to address this research gap (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e). Although considerable literature exploring patient beliefs about diagnostic imaging exists, there remains limited UK-specific evidence examining these issues within low back pain populations. Existing studies have typically sought general perceptions of imaging rather than specifically focusing on drivers of patient imaging desire or preference for it. Understanding these motives is essential to inform how clinicians manage expectations, tailor education, and engage patients in shared decision-making. By identifying what imaging represents to individuals living with low back pain, better support can facilitate the reframing of illness perceptions, promote acceptance, and enhance self-management within a patient-centred model of care.\u003c/p\u003e \u003cp\u003eAlthough patient desire for imaging has frequently been quantified (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e), qualitative exploration of the underlying beliefs has been comparatively limited. Research emphasizes the importance of understanding the lived experience of the imaging journey from ordering through to receiving results (\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e), yet this pathway remains under-examined. Existing studies describe how experiences before, during, and after musculoskeletal imaging are shaped by contextual and relational factors (\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e), and demonstrate that patients often attribute greater value to imaging findings than to clinical evaluation alone (\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e). However, much of this work has focused on the impact of results rather than on the anticipatory beliefs shaping the request itself. Imaging findings have been characterised as a ‘diagnostic grail’ offering visual proof of suffering (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e), with studies showing how informational and practical consequences influence perceived value (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e). Despite this body of work, the beliefs driving imaging expectations remain under-explored (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e). Recent critical perspectives question assumptions about patient demand, suggesting that imaging requests may reflect needs for validation or support rather than explicit insistence on scanning (\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e). Together, this literature indicates the need for focused qualitative investigation of how imaging desire is constructed within the lived experience of non-specific low back pain.\u003c/p\u003e \u003cp\u003eTherefore, this study aimed to explore patients’ anticipatory biopsychosocial beliefs about diagnostic imaging in the management of non-specific low back pain, and how these beliefs influence desire or preference for imaging within their care.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eStudy Design\u003c/p\u003e\u003cp\u003eA qualitative research design using semi structured interviews was chosen to best meet the study aim undertaking Interpretative Phenomenological Analysis (IPA) to understand participants’ lived experiences and how meaning was constructed across accounts (\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e). This approach allows for flexibility and exploration of explicit content whilst contextualism recognises individual’s perceptions are shaped by broader societal and cultural influences (\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e). This method supported the aim of understanding how patients construct meaning from their healthcare journey to derive a preference stance on imaging and its use in their care. Ethical approval was obtained from a UK University Ethics Committee; (Reference: ER24779843). The study was conducted in accordance with the Declaration of Helsinki. Adherence to the consolidated criteria for reporting qualitative research (COREQ) checklist ensured study and reporting rigour (\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eParticipants \u0026amp; Recruitment\u003c/p\u003e\u003cp\u003eA purposive sampling strategy was utilised to ensure a small number of participants could be recruited with the relevant exposure to the phenomena in question (\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e). The criteria included participants that were age eighteen and above, able to speak and understand the English language, experienced self reported NSLBP and/or referred pain for a minimum of 12 weeks and seeking healthcare input. Participants were excluded if they had a history of spinal surgery or signs of red flag pathology/awaiting spinal consultation. The inclusion criterion was balanced to achieve a variation in participant experiences to better reflect a diverse population hence previous experience of imaging or preference to have imaging was not included in the criteria. A study advertisement was distributed via social media community groups using Facebook and Instagram. Interested individuals contacted the research team and were screened via email correspondence against the inclusion and exclusion criteria. Eligible respondents were provided with a participant information sheet and consent form, and those returning written consent were invited to arrange a mutually convenient interview time.\u003c/p\u003e\u003cp\u003eData Collection\u003c/p\u003e\u003cp\u003eAn interview topic guide was developed in consultation with nine clinician/researcher stakeholders to ensure alignment with the study aim and to support open and expansive enquiry (\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e). An initial interview guide was piloted using one individual to refine the schedule and to optimise technique using researcher reflexivity and peer feedback, this was excluded from analysis. Individual one-to-one interviews were conducted via Zoom video conferencing and lasted 25–40 minutes following the refined guide to allow detailed descriptions of experiences, perspectives and beliefs. Participants were recruited iteratively, with interviews and concurrent analysis continuing until sufficient depth and coherence in the interpretation of accounts were achieved, while preserving nuance across individual cases (\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e). Interviews were audio recorded via the conferencing software and transcribed verbatim by the interviewer. Participants were invited to confirm transcript accuracy and representation of their perceptions post interview to enhance rigor.\u003c/p\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eTranscriptions were anonymised using pseudonyms prior to analysis using systematic undertaking of IPA stages. Immersion in the data for each case allowed initial exploratory notes capturing descriptive, linguistic, and conceptual observations. Case by case idiographic analysis with coding was undertaken independently by both researchers before cross-case consideration of experience was explored. The process was iterative and inductive using notes and coding of explicit statements using paper copies and NVivo analysis software (v.12). These notes were then synthesised into emergent themes. One researcher (RM) shaped connections across themes and cases to explore patterns of convergence and divergence to produce a set of superordinate and subordinate themes representing shared experience. Through ongoing discussion and joint interpretation, case themes were reviewed, refined, and developed with consensus to complete a full hermeneutic cycle that is fundamental to IPA analysis (\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eResearcher reflexivity\u003c/p\u003e\u003cp\u003eThe research team consisted of two members; a male academic with advanced physiotherapy practice background and research experience holding an MSc (RM). He led the study design and overall project oversight, working in partnership on all other aspects including interview schedule development and data analysis. A second female researcher undertaking an MSc (JJ) led the participant interview stage following training and pilot interviews. Participants were not known to the researchers prior to the study. They were informed that the research team was interested in understanding patient experiences of low back pain and healthcare interactions including imaging. Both researchers acknowledged their positions and experiences may influence interpretation. Reflexive notes were maintained throughout data collection and analysis to document assumptions, emerging interpretations, and potential biases, with regular analytic discussions undertaken to challenge and refine interpretations.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFifteen respondents were screened to exclude four based on eligibility criteria. Of the eleven eligible participants, ten consented and were interviewed (eight females and two males, aged 20\u0026ndash;69 years) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Four participants had experienced previous imaging for their non-specific LBP.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExperience of diagnostic imaging\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHistory of LBP (Approximate in years)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u0026ndash;69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u0026ndash;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u0026ndash;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThree superordinate themes were generated through analysis from the interviews: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) illness identity and credibility (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) managing cognitive threat (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) healthcare navigation. Nine interrelated subthemes emerged (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of IPA\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuperordinate theme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubthemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubtheme coding description\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e1.Illness identity and credibility\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValidation and legitimacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants describe imaging as proof their pain is real or justified.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDesire for explanation or visualisation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCuriosity or need to 'see' what is causing the pain.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImaging as part of good care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBelief that imaging is part of competent or complete care.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e2.Managing cognitive threat\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFear of missing something serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConcern that something medically important is being overlooked without imaging.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImaging as reassurance or closure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDesire for imaging to reduce anxiety or bring certainty.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePersistent uncertainty and doubt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOngoing worry, frustration, and doubt when reassurance was unmet\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e3.Healthcare navigation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocially shaped care expectations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExpectations shaped by previous imaging experiences or influenced by others\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelationship with healthcare\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImaging access influences patient engagement with clinicians and systems\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImaging as a guide to care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBelief that imaging is required to access further treatment or progress care.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTheme 1: Illness identity and credibility\u003c/p\u003e \u003cp\u003eParticipants consistently described struggling to understand the origins of their pain and to make sense of what it meant for them and their healthcare expectations. Participants described using imaging to help make sense of their symptoms and situation, with accounts clustering across three inter-related subthemes.\u003c/p\u003e\n\u003ch3\u003eValidation and legitimacy\u003c/h3\u003e\n\u003cp\u003eParticipants described imaging as tangible evidence that justified their pain experiences and helped them feel more credible, often speaking about wanting their pain to be taken seriously, particularly when explanations were unclear. Participants frequently associated imaging with validation of their pain experiences. For many there was a sense that finding an origin or reason for their pain confirmed it was real and supported being able to move forwards with acceptance and management of it.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;it gave you reason for the pain... I mean anyone can just say that they\u0026rsquo;ve got pain. But if they knew like what it was and where it was then they would be able to progress on that instead of just taking my word for it.\u0026rdquo;\u003c/em\u003e (Participant 2)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I knew the x-ray and that there was actually something wrong, I persevered with it more \u0026hellip; it made me happier knowing that there was an answer and a reason.\u0026rdquo;\u003c/em\u003e (Participant 5)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eDesire for explanation or visualisation\u003c/h3\u003e\n\u003cp\u003eThe most evident theme that evolved from all participants was a desire to see and understand what was happening inside their bodies. This was often described as identifying what was wrong or had become damaged with a sense that the information gleaned was irrefutable.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Imaging is fact... I always feel better after I\u0026rsquo;ve had an x-ray or an MRI because you can physically see it for yourself... that has settled me now, I feel a lot better about it because I can see.\u0026rdquo;\u003c/em\u003e (Participant 4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eVisualising something tangible was described as helping participants make sense of uncertainty by turning the unseen into something they could understand, often accompanied by feelings of reassurance and control.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I felt like when I could see it... it made more sense to me, and I was less worried.\u0026rdquo;\u003c/em\u003e (Participant 9)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eImaging as part of good care\u003c/h3\u003e\n\u003cp\u003eParticipants often spoke as if imaging would simply be included when seeking assessment for their back pain. Accounts suggested that, without imaging, assessments were perceived as incomplete, with participants describing imaging as a definitive or \u0026lsquo;gold standard\u0026rsquo; way of investigating their pain, particularly given its perceived availability.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I would include the imaging in the comprehensive assessment, I would expect it if it was a thorough assessment and an investigation into something, I would assume that that would have been included.\u0026rdquo;\u003c/em\u003e (Participant 1)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;[imaging] would be nice... because it\u0026rsquo;s just the quickest and easiest method of finding out what is wrong.\u0026rdquo;\u003c/em\u003e (Participant 2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTogether, these accounts suggest that expectations about imaging shaped both how participants judged the adequacy of their care and how they felt when those expectations were met or unmet.\u003c/p\u003e \u003cp\u003eTheme 2: Managing cognitive threat\u003c/p\u003e \u003cp\u003eParticipants revealed feelings of fear, reassurance, and uncertainty as prominent features of their experiences pain and diagnostic imaging. Across three subthemes, accounts showed how expectations, lived experience, and emotional responses changed and interacted in ways that were individual and often fluid.\u003c/p\u003e\n\u003ch3\u003eFear of missing something serious\u003c/h3\u003e\n\u003cp\u003eThe accounts show many participants want imaging to reduce their anxiety related to sinister pathology or worsening problems. Here, imaging was positioned as a safeguard against uncertainty, reducing anxiety linked to the possibility that something serious or progressive might be missed.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;to see abnormalities \u0026hellip; or anything else going on in there, which sort of gives you an image if there\u0026rsquo;s anything sinister going on inside.\u0026rdquo;\u003c/em\u003e (Participant 8)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAt times this was offered in the context of monitoring deterioration that only imaging could reveal.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;it was quite relieving to know, yes you\u0026rsquo;ve got this issue, you\u0026rsquo;re coping with it, it\u0026rsquo;s not going to deteriorate over time, nothing is going to get worse and it\u0026rsquo;s nothing serious.\u0026rdquo;\u003c/em\u003e (Participant 1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants suggested imaging as reducing worry and uncertainty, especially when concerns about serious or progressive pathology were present.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eImaging as reassurance or closure\u003c/h2\u003e \u003cp\u003eMany participants described the desire to see or be told information that confirmed a clear source or non-serious cause for their pain. In these accounts, reassurance functioned less as protection from risk and more as a form of emotional closure, enabling acceptance and decisions about ongoing management.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If I could see an image of my spine it would give me a different opinion about what it was and how it affected me\u0026hellip; it would put my mind at ease because I would know exactly what it was.\u0026rdquo;\u003c/em\u003e (Participant 4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants with prior experience of imaging described receiving information that helped them move from uncertainty towards acceptance and decisions about managing their pain.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;it\u0026rsquo;s nothing to be worried about, it\u0026rsquo;s just that I need to manage it the best way I can\u0026rdquo;\u003c/em\u003e (Participant 9.)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I haven\u0026rsquo;t been to the doctors since or tried to push anymore scanning\u0026hellip;I know there\u0026rsquo;s nothing majorly wrong.\u0026rdquo;\u003c/em\u003e (Participant 10)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePersistent uncertainty and doubt\u003c/h3\u003e\n\u003cp\u003eSome participants described feelings of ongoing anxiety, doubt, or frustration when imaging was not offered as anticipated. Unlike accounts where imaging provided reassurance or a sense of closure, these participants described uncertainty that remained unresolved.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I could be living with something that\u0026rsquo;s fixable\u0026hellip; I\u0026rsquo;m managing but I don\u0026rsquo;t know the full history and I can\u0026rsquo;t see what\u0026rsquo;s happening, I\u0026rsquo;m managing it without imaging. I would rather not\u0026rdquo;\u003c/em\u003e (Participant 4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn some accounts, uncertainty persisted even after imaging had been received and results had not fully explained the pain experience.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If they were like oh there\u0026rsquo;s nothing wrong, you\u0026rsquo;re absolutely fine, I would have been\u0026hellip;can I have that scan again please?\u0026rdquo;\u003c/em\u003e (Participant 5)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTheme 3: Healthcare navigation\u003c/p\u003e \u003cp\u003eThree subthemes represent how participants spoke about imaging in relation to navigating healthcare, including how it influenced their engagement with clinicians, expectations of care, and decisions about seeking help.\u003c/p\u003e\n\u003ch3\u003eSocially shaped care expectations\u003c/h3\u003e\n\u003cp\u003eParticipants described expectations about imaging that were informed by their previous experiences and by comparisons with the experiences of others. These accounts often expressed shared expectations about what constituted thorough or appropriate care, including whether imaging should be part of that process.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;everybody expects, well go for an x-ray or go for a scan, you know that will show you\u0026hellip;although you\u0026rsquo;re all trained in your own capacities\u0026hellip;I think the general public think no, I would need imaging first.\u0026rdquo;\u003c/em\u003e (Participant 3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eRelationship with healthcare\u003c/h2\u003e \u003cp\u003eParticipants frequently described how access to imaging influenced the way they related to clinicians and the healthcare systems they encountered. Across accounts, participants described the act of being offered imaging as influencing their sense of trust in clinicians, sometimes more than the information that followed. When imaging outcomes aligned with expectations, participants described increased trust and acceptance of proposed management.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;it\u0026rsquo;s there in black and white, if it\u0026rsquo;s showing up on the image and its guided by a specialist or a physio \u0026hellip; I have no reason not to trust them.\u0026rdquo;\u003c/em\u003e (Participant 8)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eConversely, when imaging was not suggested or expectations were not met, participants described frustration, reduced trust, and disengagement from healthcare.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;[imaging] that\u0026rsquo;s what I understand what you pay national insurance for \u0026hellip;I went back; I didn\u0026rsquo;t seem to get the answers what I was looking for\u0026hellip; I thought well that was a waste of time, why bother going?\u0026rdquo;\u003c/em\u003e (Participant 3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eImaging as a Guide to Care\u003c/h2\u003e \u003cp\u003eParticipants described imaging as helping to guide decisions about the direction of their care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It gives you an answer more than anything because there is proof in a picture, so you and the doctor know how to treat it better.\u0026rdquo;\u003c/em\u003e (Participant 5)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFor some participants, imaging was also described as influencing perceptions of urgency, with a sense that their care progressed more quickly.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;if they didn\u0026rsquo;t have it then we would have been going around in circles \u0026hellip; I could have been trying different things \u0026hellip; it would have just been a much longer process, so the imaging made it a lot quicker.\u003c/em\u003e (Participant 7)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAcross accounts, participants described imaging as reducing uncertainty and helping them feel more confident in treatment decisions or accepting of clinical advice. In contrast, when imaging was absent, care was often described as a slower and more iterative process lacking direction.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study found that patients\u0026rsquo; desire for diagnostic imaging in NSLBP was shaped not only by the pursuit of diagnosis but also by the need for validation, reassurance, and direction within their care. Across accounts, imaging was described as serving multiple functions, including legitimising symptoms, managing uncertainty, and helping individuals navigate healthcare decisions. Together, these findings suggest that imaging desire is embedded within emotional and social coping processes, extending beyond expectations focused solely on diagnosis or information provision. By exploring patient beliefs in depth, this qualitative study identified three interrelated themes and nine subthemes that provide new insight into imaging desire in NSLBP. These findings add a UK perspective to a growing international evidence base, highlighting interactions between patients and healthcare systems.\u003c/p\u003e \u003cp\u003eThe identified illness identity and credibility theme highlights how imaging functioned as a means for patients to obtain objective evidence that their health problems were genuine, both for themselves and for those around them. This included the desire to visualise sources of symptoms and to seek explanations that validate their pain, findings that echo existing literature (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). While imaging has previously been shown to provide reassurance(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) and confirm \u0026lsquo;real\u0026rsquo; biomedical symptoms(\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e) the present findings suggest that its role extends beyond individual validation into broader social contexts that include family members, clinicians and health systems. The perception that imaging represents good care, reported here and earlier across numerous settings (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e), appeared to further reinforce beliefs about its value at both individual and societal levels. Taken from the theme this could be interpreted as imaging being seen as a measure of credible and thorough care. Within the accounts analysed, imaging carried significant weight in shaping perceptions of validation and legitimacy. However, participants did not describe imaging as a means of legitimising sickness certification or access to financial support; in contrast to reports elsewhere (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). These findings emphasise some of the social mechanisms through which imaging contributes to illness credibility.\u003c/p\u003e \u003cp\u003eThe second theme, \u003cem\u003emanagement of cognitive threat\u003c/em\u003e, highlights how participants sought to reduce uncertainty and perceived danger through imaging. Threat-based models emphasise that pain related behaviours are shaped by cognitive appraisals of danger, uncertainty, and the need for protection, rather than tissue damage alone (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). Using this framing, imaging was frequently positioned as a means of reducing or mitigating such threat by providing reassurance, reducing uncertainty, or offering a sense closure. Although threat is understood to be individualised and shaped by multiple biopsychosocial influences, fear of serious pathology and uncertainty regarding an unidentified biological cause featured most prominently within participants\u0026rsquo; accounts. The subthemes of \u003cem\u003emissing serious pathology\u003c/em\u003e and \u003cem\u003eimaging as reassurance\u003c/em\u003e within the current study\u0026rsquo;s results closely reflect findings elsewhere (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e), and together represent anticipatory attempts to manage cognitive threats through health risk appraisal and access to objective information. This is also potentially shared by clinicians, who often use imaging as a safeguard for defensive medicine purposes (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn contrast, p\u003cem\u003eersistent uncertainty and doubt\u003c/em\u003e reflected failed or incomplete management of threat. Several narratives described imaging as a potential \u0026ldquo;key\u0026rdquo; to unlocking their problem yet found that the information received did not always precisely fit their expectations. This partially mirrors descriptions of cognitive dissonance reported previously (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e), where making sense of inconsistent and changing information may challenge patient\u0026rsquo;s beliefs leading to continuous reassessment of their situation (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Notably, participants did not described imaging as intensifying anxiety or reinforcing worry, and concerns about radiation exposure were mentioned only briefly and dismissively, contrasting with previous reports(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e) ,57). Overall, this theme supports existing evidence that imaging is commonly sought for reassurance and anticipated threat reduction. It also highlights that reassurance is neither uniform nor guaranteed, and may persist or be reshaped when information conflicts with existing beliefs (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e). Taken together, these findings suggest that imaging desire reflects broader processes of making sense and seeking safety in the context of ongoing uncertainty. The perceived objectivity of diagnostic imaging by patients potentially seems a way of gaining a sense of control.\u003c/p\u003e \u003cp\u003eExpectations of imaging were seen to be formed through prior personal experiences, the experiences of others, and cultural assumptions that imaging should be included as standard. Socially shaped expectations of imaging have been previously documented (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e), however, previous work has often drawn on clinician perspectives of clinical encounters. Participants in the present study did not describe media information as shaping their expectations, aligning with evidence that public-facing imaging information has not substantially reduced imaging rates for musculoskeletal pain in the UK (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e) although media campaigns have been shown to have some impact (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe third theme explores how imaging was consistently described as playing a role in shaping participants' relationships with healthcare and their navigation of complex care pathways. Across accounts, access to imaging appeared to shape how participants interpreted their interactions with healthcare professionals; influencing perceptions of engagement and confidence in clinical advice. It has been shown that a strong existing patient and clinician relationship can influence whether patients accept advice against their expectations for imaging (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). In this study, at times the absence of imaging was interpreted as an indication that care was not progressing or that concerns were not being sufficiently addressed. This suggests participants found imaging a helpful aid to assess momentum and commitment within the healthcare relationship. The absence of imaging was associated with trial-and-error treatment approaches, positioning imaging to move beyond generic management and facilitate access to subsequent care decisions, referrals, or treatments. This pattern is consistent with findings in non-specific low back pain and broader musculoskeletal conditions(\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eImportantly, the value of imaging in guiding care was consistently derived from what imaging enabled, rather than from the imaging results alone. Regardless of whether imaging identified a clear biomedical cause, it shaped care journeys by influencing how participants interpreted clinician engagement, signalled progression, and enabled movement between care stages. Framed in this way, imaging as a guide to care connects directly with the preceding themes. It extends legitimacy beyond personal validation into a means of navigating healthcare systems, while also serving to support progression through healthcare when uncertainty persists despite investigation.\u003c/p\u003e \u003cp\u003eThis study supplements existing recommendations by identifying ways in which clinicians can and should engage with patients using tailored dialogue to understand individual\u0026rsquo;s meaning attached to imaging preference across the three interlinked themes. Building on previous recommendations(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) clinicians should validate patient\u0026rsquo;s pain experiences and explore whether the search for legitimacy stems from internal uncertainty or external drivers. Our findings emphasise current acceptance that patient education alone, especially generic education, is insufficient to address the complex psychosocial drivers of imaging desire in NSLBP. Existing recommendations stress research informed imaging practices (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e), thorough clinical assessment and clear explanation of clinical reasoning (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e). Others have highlighted the pivotal role of therapeutic relationships, emphasising joint narratives and open discussion of both the potential benefits and harms of imaging (30,51,53,65,67).\u003c/p\u003e \u003cp\u003eClinician reassurance to patients is recommended to help mitigate cognitive threat (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). Our findings support others in suggesting both emotional and cognitive support may be more effective (68). Clinicians can support patients by emphasising 'certainty talk', focusing on what is known and stable about their condition, while acknowledging that reassurance and residual uncertainty may coexist. This approach recognises that patients' concerns may shift as they make sense of their situation. To establish realistic expectations of healthcare navigation, clinicians should engage in open discussion about imaging's role in guiding care pathways (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e) and explore how patients perceive imaging to shape their engagement and relationships within the system. Recognising imaging desire as an expression of threat, uncertainty, and sought credibility enables clinicians to move beyond information giving towards more patient centred, empathic conversations that reduce unnecessary imaging.\u003c/p\u003e \u003cp\u003eThe key strength and current distinctiveness of this study is the identified biopsychosocial dimensions that form patients\u0026rsquo; desire for diagnostic imaging in NSLBP. Further strengths include collaborative analysis of the data adhering to an analytical participant experiential approach (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). The more experienced researcher was distanced from data collection to reduce potential bias. Reflexive discussions were used throughout data collection and analysis to maintain awareness of researcher influence (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). The findings have been compared with existing evidence to situate the identified themes, and methodological decisions have been explained where findings diverge from prior work.\u003c/p\u003e \u003cp\u003eThere are notable limitations to this study. Generalisability is limited however, the depth of IPA allows for theoretical transferability when participant contextual factors are considered and findings align with existing evidence. Further limitations exist due to self-selecting participants engaged in healthcare and demonstrating a good level of health literacy. Yet minimal inclusion criteria relating to the participant\u0026rsquo;s NSLBP, imaging and healthcare experience were applied to reflect known populations. Also, the findings will not be theoretically transferable to acute populations, or potentially outside the UK. As discussed within the imaging reassurance theme, previous imaging had an impact on the narratives. Future investigation may wish to isolate previous imaging experience to better understand this key component. Our interview guide focus toward \u0026lsquo;desire\u0026rsquo; led to findings where few barriers of imaging desire were described. This should be considered as inherent to the concept of desire and explored fully in the future. It is acknowledged that in the current study we opted not to seek narratives relating to the influence of clinician communication and relationship despite this being highly influential.\u003c/p\u003e \u003cp\u003eFuture research\u003c/p\u003e \u003cp\u003eThis study highlights important avenues for future research into the psychosocial dynamics of imaging desire in non-specific low back pain. Although recent work has strengthened understanding of shared decision making, communication, and patient-reported outcomes in imaging, little is known about the anticipatory processes that precede imaging requests. What patients believe imaging will provide, rather than the outcomes it ultimately delivers, influences patient behaviour within consultations. While outcome-based research is fundamental to understanding the efficacy of imaging, it does not capture how desire, interaction dynamics, and referral decisions unfold.\u003c/p\u003e \u003cp\u003eCloser examination of these anticipatory dimensions and how they shape shared decision-making interactions is essential. Future research should therefore examine both anticipatory and outcome-related dimensions of imaging, ideally through longitudinal or causal designs that track how imaging beliefs influence a range of outcomes. Identifying discrete psychosocial constructs of imaging desire is crucial and should be sought, however comprehensive capture may prove elusive. Measuring the deeper attributes these constructs represent, such as perceived control, threat, and legitimacy, may be more feasible and meaningful for developing predictive models or for the development of consultation support tools that facilitate tailored, patient-centred dialogue within shared decision-making.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study reinforces and deepens understanding of how patients with non-specific low back pain construct meaning around diagnostic imaging. Imaging desire appears to be shaped by anticipatory beliefs that reflect the need for validation and threat reduction as much as, and often more than, diagnostic necessity. When these needs are not fully met, imaging may also take on a procedural role in helping patients navigate care pathways, signal progress, and access further input. A clearer understanding of these anticipatory drivers is needed in future research to identify which psychosocial dimensions most strongly influence imaging desire and how they can be addressed within consultations, joint narratives, and shared decision making to reduce inappropriate imaging referrals.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCOREQ: Consolidated criteria for reporting qualitative research\u003c/p\u003e\n\u003cp\u003eIPA: Interpretative phenomenological analysis\u003c/p\u003e\n\u003cp\u003eLBP: Low back pain\u003c/p\u003e\n\u003cp\u003eMRI: Magnetic resonance imaging\u003c/p\u003e\n\u003cp\u003eNHS: National Health Service\u003c/p\u003e\n\u003cp\u003eNSLBP: Non-specific low back pain\u003c/p\u003e\n\u003cp\u003eUK: United Kingdom\u003c/p\u003e\n\u003cp\u003eUSA: United States of America\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eClinical trial number\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eEthics approval and consent to participate\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis study was approved by Sheffield Hallam University Ethics Committee (Reference: ER24779843) and conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent prior to participation.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eAll participants provided informed consent for publication of anonymised interview data. No individual participant details, images, or videos are included in this manuscript.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe interview transcripts generated and analysed during this study are not publicly available to protect participant confidentiality. Anonymised excerpts and supporting quotations are available as supplementary materials. Additional data are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that influenced the work reported in this paper.\u003c/p\u003e\n\u003ch2\u003eFunding\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003e\u003cem\u003eCRediT authorship contribution statement\u003c/em\u003e: RM: Conceptualization, Methodology, Validation, Formal analysis, Resources, Data curation, Writing \u0026ndash; original draft, Visualization, Writing \u0026ndash; review \u0026amp; editing, Supervision, Project Administration. JJ: Methodology, Validation, Formal analysis, Investigation, Resources, Data curation, Writing \u0026ndash; review \u0026amp; editing. Both authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe authors wish to thank all participants for their willingness to share their experiences and for making this research possible. We also thank Professor George Peat and Dr Sarah Hardcastle for their constructive guidance and valuable discussions, which supported the refinement of this work. The authors used Claude.ai for feedback on manuscript clarity of message; all research content, data analysis, and interpretation were conducted and verified by the authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFerreira ML, De Luca K, Haile LM, Steinmetz JD, Culbreth GT, Cross M, et al. Global, regional, and national burden of low back pain, 1990\u0026ndash;2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol [Internet]. 2023 Jun 1 [cited 2025 Oct 22];5(6):e316\u0026ndash;29. Available from: https://www.thelancet.com/action/showFullText?pii=S266599132300098X\u003c/li\u003e\n\u003cli\u003eStewart WF, Yan X, Boscarino JA, Maeng DD, Mardekian J, Sanchez RJ, et al. Patterns of health care utilization for low back pain. Taylor \u0026amp; FrancisWF Stewart, X Yan, JA Boscarino, DD Maeng, J Mardekian, RJ Sanchez, MR Von KorffJournal of pain research, 2015\u0026bull;Taylor \u0026amp; Francis [Internet]. 2015 Aug 12 [cited 2025 Oct 22];8:523\u0026ndash;35. Available from: https://www.tandfonline.com/doi/abs/10.2147/JPR.S83599\u003c/li\u003e\n\u003cli\u003eOffice for National Statistics. Population estimates for England and Wales - Office for National Statistics [Internet]. [cited 2025 Oct 22]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/bulletins/populationestimatesforenglandandwales/mid2023\u003c/li\u003e\n\u003cli\u003eArthritis UK. Arthritis and other musculoskeletal conditions in numbers. \u003c/li\u003e\n\u003cli\u003eHenschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum [Internet]. 2009 Oct 1 [cited 2025 Mar 22];60(10):3072\u0026ndash;80. Available from: https://onlinelibrary.wiley.com/doi/full/10.1002/art.24853\u003c/li\u003e\n\u003cli\u003eHoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis [Internet]. 2014 Jun;73(6):968\u0026ndash;74. Available from: http://dx.doi.org/10.1136/annrheumdis-2013-204428\u003c/li\u003e\n\u003cli\u003eWilliams CM, Maher CG, Hancock MJ, McAuley JH, McLachlan AJ, Britt H, et al. Low back pain and best practice care: A survey of general practice physicians. Arch Intern Med [Internet]. 2010 Feb 8 [cited 2025 Mar 24];170(3):271\u0026ndash;7. Available from: https://pubmed.ncbi.nlm.nih.gov/20142573/\u003c/li\u003e\n\u003cli\u003eTan A, Zhou J, Kuo YF, Goodwin JS. Variation among Primary Care Physicians in the Use of Imaging for Older Patients with Acute Low Back Pain. J Gen Intern Med [Internet]. 2016 Feb 1 [cited 2025 Mar 24];31(2):156\u0026ndash;63. Available from: https://pubmed.ncbi.nlm.nih.gov/26215847/\u003c/li\u003e\n\u003cli\u003eKjelle E, Brands\u0026aelig;ter I\u0026Oslash;, Andersen ER, Hofmann BM. Cost of Low-Value Imaging Worldwide: A Systematic Review. Vol. 22, Applied Health Economics and Health Policy. Adis; 2024. p. 485\u0026ndash;501. \u003c/li\u003e\n\u003cli\u003eModic MT, Obuchowski NA, Ross JS, Brant-Zawadzki MN, Grooff PN, Mazanec DJ, et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology. 2005 Nov;237(2):597\u0026ndash;604. \u003c/li\u003e\n\u003cli\u003eChou R. Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Ann Intern Med [Internet]. 2011;154(3):181. Available from: http://dx.doi.org/10.7326/0003-4819-154-3-201102010-00008\u003c/li\u003e\n\u003cli\u003eHartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. What low back pain is and why we need to pay attention. Vol. 391, The Lancet. Lancet Publishing Group; 2018. p. 2356\u0026ndash;67. \u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Sullivan P. Diagnosis and classification of chronic low back pain disorders: Maladaptive movement and motor control impairments as underlying mechanism. Man Ther [Internet]. 2005 Nov 1 [cited 2025 Oct 24];10(4):242\u0026ndash;55. Available from: https://www.sciencedirect.com/science/article/pii/S1356689X05001104\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Sullivan P, Caneiro JP, O\u0026rsquo;Keeffe M, O\u0026rsquo;Sullivan K. Unraveling the Complexity of Low Back Pain. https://doi.org/102519/jospt20160609 [Internet]. 2016 Nov 1 [cited 2025 Oct 24];46(11):932\u0026ndash;7. Available from: /doi/pdf/10.2519/jospt.2016.0609\u003c/li\u003e\n\u003cli\u003eJenkins HJ, Hancock MJ, Maher CG, French SD, Magnussen JS. Understanding patient beliefs regarding the use of imaging in the management of low back pain. European Journal of Pain (United Kingdom). 2016 Apr 1;20(4):573\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003eBrinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American journal of neuroradiology : AJNR [Internet]. 2015 Apr;36(4):811\u0026ndash;6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25430861\u003c/li\u003e\n\u003cli\u003eHancock M, Kjaer P, Kent P, Jensen R, Spine TJ, 2017 undefined. Is the number of different MRI findings more strongly associated with low back pain than single MRI findings? journals.lww.comMJ Hancock, P Kjaer, P Kent, RK Jensen, TS JensenSpine, 2017\u0026bull;journals.lww.com [Internet]. [cited 2025 Oct 22]; Available from: https://journals.lww.com/spinejournal/_layouts/15/oaks.journals/downloadpdf.aspx?an=00007632-201709010-00008\u0026amp;casa_token=ti6wTDKCoJIAAAAA:j9bEww3I9rkw08YwU_FvqexpRHEPNwDNQmlsEdPM2ZDRys2iWi8-KvQzfkrozUw1F389_VJBrk9IonV5UDY\u003c/li\u003e\n\u003cli\u003eKasch R, Truthmann J, Hancock MJ, Maher CG, Otto M, Nell C, et al. Association of Lumbar MRI Findings with Current and Future Back Pain in a Population-based Cohort Study. Spine (Phila Pa 1976) [Internet]. 2022 Feb 1 [cited 2025 Oct 22];47(3):201\u0026ndash;11. Available from: https://journals.lww.com/spinejournal/fulltext/2022/02010/association_of_lumbar_mri_findings_with_current.4.aspx\u003c/li\u003e\n\u003cli\u003eOliveira CB, Maher CG, Pinto RZ, Traeger AC, Lin CWC, Chenot JF, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. European Spine Journal [Internet]. 2018 Nov 1 [cited 2025 Mar 24];27(11):2791\u0026ndash;803. Available from: https://link.springer.com/article/10.1007/s00586-018-5673-2\u003c/li\u003e\n\u003cli\u003eNICE. Low back pain and sciatica in over 16s: assessment and management | Guidance | NICE. \u003c/li\u003e\n\u003cli\u003eKjelle E, Andersen ER, Krokeide AM, Soril LJJ, van Bodegom-Vos L, Clement FM, et al. Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review. BMC Med Imaging. 2022 Dec 1;22(1). \u003c/li\u003e\n\u003cli\u003eKjelle E, Brands\u0026aelig;ter I, Andersen ER, Hofmann B. Sustainability in healthcare by reducing low-value imaging \u0026ndash; A narrative review. Vol. 30, Radiography. W.B. Saunders Ltd; 2024. p. 30\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eBrady AP, Bello JA, Derchi LE, Fuchsj\u0026auml;ger M, Goergen S, Krestin GP, et al. Radiology in the Era of Value-based Healthcare: A Multi-Society Expert Statement from the ACR, CAR, ESR, IS3R, RANZCR, and RSNA. https://doi.org/101148/radiol2020209027 [Internet]. 2020 Dec 21 [cited 2025 Oct 24];298(3):486\u0026ndash;91. Available from: /doi/pdf/10.1148/radiol.2020209027\u003c/li\u003e\n\u003cli\u003eSpinal Imaging in Primary Care (Remedy BNSSG ICB) [Internet]. [cited 2025 Mar 24]. Available from: https://remedy.bnssg.icb.nhs.uk/adults/radiology-imaging/spinal-imaging-in-primary-care/\u003c/li\u003e\n\u003cli\u003eSlade SC, Kent P, Patel S, Bucknall T, Buchbinder R. Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: A systematic review and metasynthesis of qualitative studies. Clinical Journal of Pain [Internet]. 2016 [cited 2025 Oct 22];32(9):800\u0026ndash;16. Available from: https://journals.lww.com/clinicalpain/fulltext/2016/09000/barriers_to_primary_care_clinician_adherence_to.8.aspx\u003c/li\u003e\n\u003cli\u003eBrands\u0026aelig;ter I\u0026Oslash;, Andersen ER, Hofmann BM, Kjelle E. Drivers for low-value imaging: a qualitative study of stakeholders\u0026rsquo; perspectives in Norway. BMC Health Serv Res. 2023 Dec 1;23(1). \u003c/li\u003e\n\u003cli\u003eLam J, Pickles K, Stanaway F, research KBB health services, 2020 undefined. Why clinicians overtest: development of a thematic framework. SpringerJH Lam, K Pickles, FF Stanaway, KJL BellBMC health services research, 2020\u0026bull;Springer [Internet]. 2020 Dec 1 [cited 2025 Mar 25];20(1). Available from: https://link.springer.com/article/10.1186/s12913-020-05844-9\u003c/li\u003e\n\u003cli\u003eTaylor S, Bishop A. Patient and public beliefs about the role of imaging in the management of non-specific low back pain: a scoping review. Vol. 107, Physiotherapy (United Kingdom). Elsevier Ltd; 2020. p. 224\u0026ndash;33. \u003c/li\u003e\n\u003cli\u003eEspeland A, Baerheim A, Albrektsen G, Korsbrekke K, Larsen JL. Patients\u0026rsquo; Views on Importance and Usefulness of Plain Radiography for Low Back Pain [Internet]. Vol. 26, SPINE. 2001. Available from: http://journals.lww.com/spinejournal\u003c/li\u003e\n\u003cli\u003eSharma S, Traeger AC, Reed B, Hamilton M, O\u0026rsquo;Connor DA, Hoffmann TC, et al. Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis. BMJ Open. 2020 Aug 23;10(8):e037820. \u003c/li\u003e\n\u003cli\u003eDownie A, Hancock M, Jenkins H, Buchbinder R, Harris I, Underwood M, et al. How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years. Br J Sports Med [Internet]. 2020;54:642\u0026ndash;53. Available from: http://dx.doi.org/10.1136/bjsports-2018-100087\u003c/li\u003e\n\u003cli\u003eSears ED, Caverly TJ, Kullgren JT, Fagerlin A, Zikmund-Fisher BJ, Prenovost K, et al. Clinicians\u0026rsquo; Perceptions of Barriers to Avoiding Inappropriate Imaging for Low Back Pain\u0026mdash;Knowing Is Not Enough. JAMA Intern Med [Internet]. 2016 Dec 1 [cited 2025 Jan 9];176(12):1866\u0026ndash;8. Available from: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2569281\u003c/li\u003e\n\u003cli\u003eLemmers GPG, van Lankveld W, Westert GP, van der Wees PJ, Staal JB. Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work. Vol. 28, European Spine Journal. Springer Verlag; 2019. p. 937\u0026ndash;50. \u003c/li\u003e\n\u003cli\u003eChou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009 Feb;373(9662):463\u0026ndash;72. \u003c/li\u003e\n\u003cli\u003eVan Ravesteijn H, Van Dijk I, Darmon D, Van de Laar F, Lucassen P, Olde Hartman T, et al. The reassuring value of diagnostic tests: A systematic review. Vol. 86, Patient Education and Counseling. 2012. p. 3\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eKrousel-Wood M, Peacock E, David Bradford W, Mohundro B, Craig LS, O\u0026rsquo;connell S, et al. Time Preference for Immediate Gratification: Associations With Low Medication Adherence and Uncontrolled Blood Pressure. Am J Hypertens [Internet]. 2022 [cited 2025 Mar 25];35(3). Available from: https://doi.org/10.1093/ajh/hpab175\u003c/li\u003e\n\u003cli\u003eManizia L, Borah T, Bhattacharjee R, Saikia J, Dutta A, Boruah J. Instant Gratification and The Digital Natives: A Pilot Study. Educational Administration: Theory and Practice. 2023; \u003c/li\u003e\n\u003cli\u003eLuhmann CC. Temporal decision-making: Insights from cognitive neuroscience. Vol. 3, Frontiers in Behavioral Neuroscience. 2009. \u003c/li\u003e\n\u003cli\u003eJenkins HJ, Hancock MJ, French SD, Maher CG, Engel RM, Magnussen JS. Effectiveness of interventions designed to reduce the use of imaging for low-back pain: a systematic review. CMAJ [Internet]. 2015 Apr 7 [cited 2025 Mar 22];187(6):401\u0026ndash;8. Available from: https://pubmed.ncbi.nlm.nih.gov/25733741/\u003c/li\u003e\n\u003cli\u003eKjelle E, Andersen ER, Soril LJJ, van Bodegom-Vos L, Hofmann BM. Interventions to reduce low-value imaging \u0026ndash; a systematic review of interventions and outcomes. BMC Health Serv Res. 2021 Dec 1;21(1). \u003c/li\u003e\n\u003cli\u003eBelavy DL, Tagliaferri SD, Buntine P, Saueressig T, Samanna C, Mcguckian T, et al. Reducing Low-Value Imaging for Low Back Pain: Systematic Review With Meta-analysis. Vol. 52, Journal of Orthopaedic and Sports Physical Therapy. Movement Science Media; 2022. p. 175\u0026ndash;91. \u003c/li\u003e\n\u003cli\u003eLarijani MM, Dumba C, Thiessen H, Palen A, Carr T, Vanstone JR, et al. Development of a Patient-Oriented Intervention to Support Patient-Provider Conversations about Unnecessary Lower Back Pain Imaging. International Journal of Environmental Research and Public Health 2021, Vol 18, Page 2786 [Internet]. 2021 Mar 9 [cited 2024 Oct 25];18(5):2786. Available from: https://www.mdpi.com/1660-4601/18/5/2786/htm\u003c/li\u003e\n\u003cli\u003eSmith JA., Flowers Paul, Larkin Michael. Interpretative phenomenological analysis : theory, method and research. 2009;225. \u003c/li\u003e\n\u003cli\u003eBrocki JM, Wearden AJ. A critical evaluation of the use of interpretative phenomenological analysis (IPA) in health psychology. Psychol Health [Internet]. 2006 Feb [cited 2025 Nov 12];21(1):87\u0026ndash;108. Available from: https://www.tandfonline.com/doi/pdf/10.1080/14768320500230185\u003c/li\u003e\n\u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care [Internet]. 2007 Dec 1 [cited 2025 Nov 12];19(6):349\u0026ndash;57. Available from: https://dx.doi.org/10.1093/intqhc/mzm042\u003c/li\u003e\n\u003cli\u003eSaunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant [Internet]. 2018 Jul 1 [cited 2025 Nov 12];52(4):1893\u0026ndash;907. Available from: https://pubmed.ncbi.nlm.nih.gov/29937585/\u003c/li\u003e\n\u003cli\u003eArmitage A, Harland N. The\u0026rsquo;Lived Experience\u0026rsquo;of patients having a Cervical or Lumbar MRI scan. Pain and Rehabilitation-the Journal of Physiotherapy Pain Association. 2020;2020(49):57\u0026ndash;62. \u003c/li\u003e\n\u003cli\u003eBarbosa MM, Dos Santos AJM, Galli N, Vidal RVC, Grande GHD, Oliveira CB. Perceptions of medical doctors and patients about imaging for people with low back pain: A qualitative study. PM\u0026amp;R. 2024;16(12):1317\u0026ndash;23. \u003c/li\u003e\n\u003cli\u003eBourke S, Taylor WJ, Doyle AJ, Gott M, Dalbeth N. The patient experience of musculoskeletal imaging tests for investigation of inflammatory arthritis: a mixed-methods study. Clin Rheumatol [Internet]. 2018;37(8):2261\u0026ndash;8. Available from: https://research.ebsco.com/linkprocessor/plink?id=c4aedc11-6c99-3560-b7eb-56fc3469e6e7\u003c/li\u003e\n\u003cli\u003eToye F, Seers K, Hannink E, Barker K. A mega-ethnography of eleven qualitative evidence syntheses exploring the experience of living with chronic non-malignant pain. BMC Medical Research Methodology 2017 17:1 [Internet]. 2017 Aug 1 [cited 2025 Nov 11];17(1):1\u0026ndash;11. Available from: https://bmcmedresmethodol.biomedcentral.com/articles/10.1186/s12874-017-0392-7\u003c/li\u003e\n\u003cli\u003eDiniz LM, Lemes \u0026Iacute;R, Freire APCF, Guimar\u0026atilde;es AF, Ferreira LAC, Franco MR, et al. 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 [Internet]. 2025;17(2):178\u0026ndash;86. Available from: https://research.ebsco.com/linkprocessor/plink?id=41792209-505c-3f86-8e49-d810b7de9b1a\u003c/li\u003e\n\u003cli\u003eRobinson CA, Gosdin MM, Cipri CS, Fridman I, Weinberg G, Jerant A, et al. Facilitators and barriers to deferring imaging for acute low back pain: a qualitative study. BMC primary care [Internet]. 26(1):204. Available from: https://research.ebsco.com/linkprocessor/plink?id=7bf4462f-fd2b-39cb-9be8-90385579f0a2\u003c/li\u003e\n\u003cli\u003eChou L, Ranger TA, Peiris W, Cicuttini FM, Urquhart DM, Sullivan K, et al. Patients\u0026rsquo; perceived needs for medical services for non-specific low back pain: A systematic scoping review. PLoS One [Internet]. 2018 Nov 1 [cited 2024 Oct 25];13(11):e0204885. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0204885\u003c/li\u003e\n\u003cli\u003eAlhowimel A, Alotaibi M, Coulson N, Radford K. Psychosocial consequences of diagnosing nonspecific low-back pain radiologically: a qualitative study. Physiother Theory Pract [Internet]. 2022 Jul 3 [cited 2024 Oct 31];38(7):890\u0026ndash;6. Available from: https://www.tandfonline.com/doi/abs/10.1080/09593985.2020.1802799\u003c/li\u003e\n\u003cli\u003ePlante J, Kucksdorf J, Ruzich J, Young JL, Rhon DI. Do Maladaptive Imaging Beliefs Predict Self-Reported Pain Interference and Physical Function in Patients With Musculoskeletal Disorders? J Orthop Sports Phys Ther [Internet]. 2024 Sep 1 [cited 2024 Oct 17];54(9):1\u0026ndash;10. Available from: https://www.jospt.org/doi/10.2519/jospt.2024.12625\u003c/li\u003e\n\u003cli\u003eLullo G, Giannotta G, Tamborrino A, Mourad F, Esposto M, Giovannico G, et al. \u0026ldquo;Do I need an imaging?\u0026rdquo; Exploring why patients with non-specific chronic low back pain request diagnostic instrumental evaluation: a phenomenological qualitative study. Musculoskelet Sci Pract [Internet]. 2025 Sep;103416. Available from: https://linkinghub.elsevier.com/retrieve/pii/S246878122500164X\u003c/li\u003e\n\u003cli\u003eThompson MJ, Suchsland MZ, Hardy V, Lavallee DC, Lord S, Devine EB, et al. Patient-centred outcomes of imaging tests: recommendations for patients, clinicians and researchers. BMJ Qual Saf [Internet]. 2023 [cited 2025 Mar 21];32:536\u0026ndash;45. Available from: http://becertain.org/partnerships/\u003c/li\u003e\n\u003cli\u003eHoffmann TC, Del Mar CB, Strong J, Mai J. Patients\u0026rsquo; expectations of acute low back pain management: Implications for evidence uptake. BMC Fam Pract [Internet]. 2013 Jan 8 [cited 2024 Oct 25];14(1):1\u0026ndash;6. Available from: https://bmcprimcare.biomedcentral.com/articles/10.1186/1471-2296-14-7\u003c/li\u003e\n\u003cli\u003eHolt N, Pincus T, Vogel S. Reassurance during low back pain consultations with GPs: a qualitative study. Br J Gen Pract [Internet]. 2015 Oct;65(639):e692\u0026ndash;701. Available from: https://pubmed.ncbi.nlm.nih.gov/26412846\u003c/li\u003e\n\u003cli\u003ePincus T, Holt N, Vogel S, Underwood M, Savage R, Walsh DA, et al. Cognitive and affective reassurance and patient outcomes in primary care: A systematic review. Pain [Internet]. 2013 Nov 1 [cited 2025 Nov 13];154(11):2407\u0026ndash;16. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0304395913003874\u003c/li\u003e\n\u003cli\u003eMalliaras P, O\u0026rsquo;Keeffe M, Ridgway J, Whale R, Vasan V, L\u0026rsquo;Huillier P, et al. Patient experiences of rotator cuff-related shoulder pain and their views on diagnostic shoulder imaging: a qualitative study. Disabil Rehabil. 2024;46(21):5021\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eBlokzijl J, Dodd RH, Copp T, Sharma S, Tcharkhedian E, Klinner C, et al. Understanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: A qualitative study. Emergency Medicine Journal. 2021 Jul 1;38(7):529\u0026ndash;35. \u003c/li\u003e\n\u003cli\u003eCuff A, Jesson T, Yeowell G, Dikomitis L, Foster NE, Littlewood C. Recommendations on patient-facing websites regarding diagnostic imaging for low back, knee, and shoulder pain: A scoping review. Vol. 1, PEC Innovation. Elsevier B.V.; 2022. \u003c/li\u003e\n\u003cli\u003eTanner L, Saywell NL, Adams T, Niazi IK, Hill J. Factors influencing imaging clinical decision-making in low back pain management. A scoping review. Vol. 22, Musculoskeletal Care. John Wiley and Sons Ltd; 2024. \u003c/li\u003e\n\u003cli\u003eMyburgh C, Larsen TB, Kjaer P. \u0026lsquo;when the picture does not really tell the story\u0026rsquo;\u0026ndash; a qualitative exploration of the MRI report of findings as a means for generating shared diagnostic meaning during the management of patients suffering from persistent spinal pain. Patient Educ Couns [Internet]. 2022;105(1):221\u0026ndash;7. Available from: https://hallam.idm.oclc.org/login?url=https://www.proquest.com/docview/2529334288?accountid=13827\u0026amp;bdid=116648\u0026amp;_bd=CDsuGMk%2Bg84gVlM33FWqLFv0GAM%3D\u003c/li\u003e\n\u003cli\u003eHaslam-Larmer L, Norman KE, Patey AM, Thomas IM, Green ME, Grimshaw JM, et al. \u0026ldquo;It\u0026rsquo;s hard to trust an individual, it\u0026rsquo;s easier to trust an image\u0026rdquo;\u0026mdash;patients with low back pain want imaging as a means of coping with uncertainty. BMC Primary Care. 2025 Dec 1;26(1).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Non-specific low back pain, Diagnostic imaging, Patient beliefs, Imaging desire, Expectations, Shared decision-making, Qualitative research, Interpretative phenomenological analysis","lastPublishedDoi":"10.21203/rs.3.rs-8871658/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8871658/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDiagnostic imaging is frequently requested for non-specific low back pain despite limited clinical value. Patient desire for imaging remains a key driver of low-value referrals, yet little is known about the anticipatory biopsychosocial beliefs that shape this preference. The aim of this study was to explore anticipatory patient beliefs and the underlying psychosocial dimensions that contribute to imaging desire in non-specific low back pain.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative study using interpretative phenomenological analysis was conducted with 10 adults experiencing non-specific low back pain in the UK. Semi-structured interviews explored participants' lived experiences to understand anticipatory beliefs about diagnostic imaging desire. Analysis followed an idiographic\u0026ndash;cross case approach, supported by reflexive practices and collaborative interpretation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThree interlinked themes were identified. \u003cem\u003eIllness identity and credibility\u003c/em\u003e captured how imaging was viewed as objective validation of legitimised symptoms, supported social acceptance, and represented \u0026ldquo;good care\u0026rdquo;. \u003cem\u003eManaging\u003c/em\u003e c\u003cem\u003eognitive threat\u003c/em\u003e reflected how imaging was used to address fear of missed pathology, uncertainty and unresolved threat. \u003cem\u003eHealthcare navigation\u003c/em\u003e illustrated how imaging was perceived as a guide through care pathways, influencing expectations, relationships, and patients\u0026rsquo; sense of control.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eImaging desire in non-specific low back pain is partially driven by complex anticipatory beliefs centred on legitimacy, threat reduction, and navigation needs. Further understanding the influential biopsychosocial dimensions of imaging desire is critical for supporting tailored dialogue, expectation management, and shared decision-making to reduce low-value imaging.\u003c/p\u003e","manuscriptTitle":"Understanding diagnostic imaging desire in non-specific low back pain: a qualitative study using interpretative phenomenological analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-22 17:57:21","doi":"10.21203/rs.3.rs-8871658/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-15T09:27:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"299187154604395994560735157102142176695","date":"2026-04-15T08:12:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-15T04:42:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-26T10:21:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-24T02:40:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-24T02:39:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2026-02-13T11:56:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"841c81e6-d196-4907-bf15-030fa947efb8","owner":[],"postedDate":"April 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T17:57:21+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-22 17:57:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8871658","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8871658","identity":"rs-8871658","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}