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

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L. Fraser, G. Ardine de Wit, Job van Exel, Peter M. A. Sloot, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8393306/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Low back pain (LBP) is a worldwide problem and people with LPB complaints often demand imaging to find a cause for their pain. However, in 90%-95% of cases, imaging cannot reliably identify the cause for LBP or provide relief to patients. Therefore, most clinical guidelines advise against imaging. Moreover, offering imaging in such cases may result in cascades of unnecessary and potentially harmful follow-up care for patients. In the literature, a multitude of factors have been related to patients' persistent demand for imaging, but little is known about how these factors interact and together shape demand for imaging. This study aims to map all these factors and their relations to contribute to a more comprehensive understanding of demand for imaging among patients with LBP. Methods Group model building (GMB) sessions with LBP patients and professionals from the Netherlands were organized. Participants discussed factors and relations resulting in patients’ demand for LPB imaging. For each GMB session, a causal loop diagram (CLD) was created to visualize the factors and relations driving this demand. These CLDs were subsequently combined into one final CLD. Results Perceived insecurity stemming from the unknown origin of patients’ experienced pain is intrinsic to LBP imaging demand. Repeated failure to identify the cause of LBP was argued to increase dissatisfaction with care, leading to dismissal of evidence-based care recommendations, enhancing consumeristic behaviour, and increasing feelings of insecurity. Conclusions When patients demand LBP imaging, both granting and denying imaging can leave them uncertain and unsatisfied, as the cause of their pain often remains unknown. To reduce unnecessary demand for LBP imaging, future research should focus on addressing patients’ concerns, insecurity and dissatisfaction, providing clear information or education, and building a solid patient-provider relationship. Trial registration: Clinical trial number not applicable. Low back pain imaging demand low-value care complex systems approach Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1. Background Low-back pain (LBP) is often defined as pain between the area of the lower ribs and buttocks. This pain can also be felt in one or both legs and some individuals even experience nerve-related symptoms in their lower limbs (sciatica) [ 20 , 24 , 71 ]. LBP is a frequently occurring symptom that has been found to be the primary cause of years lived with disability worldwide [ 24 ]. In 2020, 619 million people across the globe experienced low back pain, and by 2050 more than 843 million people are estimated to be affected by this problem [ 24 ]. It is expected that 50% to 80% of the adults will experience one or more episodes in their life [ 71 ]. In the Netherlands, approximately 6,6% of the population (i.e., 1.125 million patients) visit their general practitioner (GP) for LBP on a yearly basis [ 41 ]. LBP may be the result of many medical conditions referred to as ‘’red flag’’ causes, such as malignancies, fractures, inflammations and infections [ 27 ]. For these red flags, neurologic deficits, or in case of persistent LBP (pain experienced longer than six weeks after onset) with or without nerve root-related symptoms, imaging of the lower back is recommended [ 9 , 27 , 44 , 61 ]. However, in 90% to 95% of the cases LBP is non-specific [ 31 , 50 ], meaning that none of the previously mentioned conditions are present and that the main cause cannot reliably be identified through imaging (i.e., CT-scans, radiography, MRIs) [ 9 , 27 , 40 , 50 , 56 ]. From this point onward, any reference to LBP or LBP imaging corresponds to the definition of non-specific LBP as previously presented. Although weak associations between some MRI findings and subsequent LBP have been reported, the evidence concerning the added value of imaging remains uncertain [ 29 ]. Furthermore, potential causes detected through imaging were found in both people with and without LBP [ 31 ]. Because imaging techniques in general cannot reliably determine the cause of LBP, imaging may provide limited to no additional health-related information or benefits while posing greater potential harm towards patients in most cases [ 27 , 38 , 45 ]. In fact, imaging may result in cascades of burdensome, costly and even potentially harmful follow-up services requested by patients [ 3 , 26 – 27 , 41 , 45 , 58 ]. For these reasons, in the absence of the conditions mentioned above, imaging as a standard procedure to diagnose LBP has often been referred to as “inappropriate imaging” [ 18 , 51 , 62 , 84 ] that is discouraged by clinical practice guidelines and research [ 9 , 35 , 59 – 60 , 70 , 82 ]. Although imaging for LBP is discouraged, this practice still persists. Data from a study in Nebraska concluded that 51% of LBP imaging was unnecessary and another 35% was likely unnecessary [ 22 ]. A study in Australia found that (20%) of all imaging procedures were considered as inappropriate imaging requests [ 51 ]. For the Netherlands, no precise estimates on the amount of inappropriate LBP imaging are available. However, a study assessing the volumes of imaging in 2016 demonstrated that GPs in the Netherlands ordered at least 41,783 imaging procedures for their patients’ lower back [ 41 ]. More recent primary-care data from 2024 demonstrated that at least 50,200 patients contacted their GP for LBP [ 75 ], suggesting that a substantial number of patients continue to seek medical care for this condition. Patients’ demand was mentioned as a primary driver influencing physicians to provide LBP imaging [ 27 – 28 ]. Patients may seek imaging due to severe or persistent pain, uncertainty about their condition, desire to alleviate anxiety, desire to obtain a diagnosis, or belief that imaging is necessary for treatment [ 12 – 13 , 23 , 28 , 31 , 36 – 37 , 46 , 69 ]. These reasons may interact with each other, potentially further increasing patients’ demand for LBP imaging. For example, patients with unexplained LBP may (continue to) seek imaging, believing it will provide evidence to explain their pain [ 69 ]. Because of the potential interaction between multiple factors, patients’ demand for LBP imaging is considered a multifactorial or complex problem [ 31 , 42 , 57 , 71 , 73 ]. Furthermore, demand for imaging could also be perceived as a multilevel problem, as patients’ preferences may also influence physicians’ imaging practices [ 47 ]. Nonetheless, the specific interactions between these factors have not been explored. Gaining insights into relations and interactions between factors causing patients’ demand for LBP imaging could improve general understanding of LBP imaging demand. Such insights could aid in the development of effective interventions to reduce imaging demand and optimize imaging resource allocation. Therefore, the objective of this study was to explore and map the factors that drive patients’ demand for LBP imaging and their relations, using a complex systems approach. 2. Methods 2.1 General approach Because LBP and patients’ demand for LBP imaging are referred to as complex problems [ 31 , 42 , 57 , 71 , 73 ], we adopted a complex systems approach in this study. This method is frequently adopted to understand complex phenomena that emerge from a set of (underlying) interdependent elements (e.g. factors) that influence one another [ 43 , 53 ]. In this context, patients’ demand for LBP imaging was understood as a complex behavioural outcome formed by multiple interdependent drivers, such as: patient’s pain severity, fear and anxiety of having a serious pathology, and the need for reassurance [ 4 , 12 , 23 ]. Based on this approach, these examples are assumed to interact with one another [ 57 ], and in doing so, influence each other and shape patients’ demand for LBP imaging over time. To identify and map the involved factors and their relations, we selected methods suited to this approach to collect and visualize data on complex problems, such as group model building and causal loop diagramming. Group model building (GMB) was used to primarily collect data, explore, and map the factors that drive patients’ demand for LBP imaging and their relations. GMB can help understand complex problems by gathering participants’ perspectives (based on their experiences, knowledge, and beliefs) on contributing factors and their relations [ 78 ]. We adopted best practices, also described in Scriptapedia ( https://en.wikibooks.org/wiki/Scriptapedia ), to design and conduct the two GMB sessions [ 2 , 33 – 34 , 65 ]. In these GMB sessions, participants identified factors related to LBP imaging demand and their causal relations. This collaborative process aimed to achieve shared understanding and consensus [ 54 ]. Factors for which no consensus was reached were discussed within the research team and assessed based on their relevance, consistency with the existing literature, and potential importance to the overall system. After each session, we documented unanimously agreed factors and relations in causal loop diagrams (CLDs), which were validated individually by participants. A CLD is a model that visualizes factors and their causal relations. The two session-specific CLDs were merged into one final CLD. To provide further validation of the final CLD, we searched the literature for evidence that supports the illustrated relationships in the CLD. 2.2 Selection of participants We aimed to include both patients with LBP (i.e., experts by experience) and healthcare professionals within the field of musculoskeletal disorders, in the two GMB sessions (see Table 1 ). Patients were included if they suffered from LBP for at least one year and represented distinct age-groups, occupations, employment status, and sex. Inclusion criteria for the selection of clinicians and musculoskeletal professionals were: their familiarity with approaches to manage LBP, face-to-face experience with patients’ LBP imaging demand, minimum of 5 years clinical experience, distinct (sub) specializations, and involvement in recommending or interpreting LBP imaging. Clinicians were included because their professional experience allows them to identify recurring patterns of their patients’ imaging-seeking behaviour. Including their perspectives can enrich the sessions, support claims made by patients, and foster deeper exploration or discussions related to this issue. Through convenience sampling, we sampled LBP patients from the Dutch associations “the Spine” and ‘’PAIN’’ (i.e., Pain alliance in the Netherlands). The healthcare professionals of the first session were recruited through purposive sampling. We reached out to our professional networks to identify and approach qualified experts. Healthcare professionals for the second session were recruited by applying snowball sampling. 2.3 Recruitment and information distributed to participants We extended a formal invitation to all participants that demonstrated interest to join the GMB sessions. In the email and at the beginning of the sessions, all participants were informed about the study’s purpose and procedures, their right to withdraw from the study at any time and the fact that data would be anonymized by removing personal or identifiable information. Informed consent was obtained prior to participation, including consent for audio recording of the sessions. Furthermore, to ensure a clear and consistent understanding among participants, definitions used in this study were reiterated and explained in more detail at the beginning of each GMB session and, if needed, during the sessions. For example, the definitions of (non-specific) LBP, demand for LBP imaging, and inappropriate imaging were discussed before and during the sessions. Furthermore, we discussed when imaging of LBP is not appropriate according to the literature. Furthermore, we explained to participants that we were also interested in identifying feedback loops. These are cyclical (causal) relations between factors that are initiated by a change in a certain factor, influencing other factors and, eventually, also the factor that first changed. For example, insecure or uncertain patients may demand LBP imaging to gain information about their health status. However, because the primary cause of most LBP cases often remains unknown, the resulting uncertainty persists, potentially leaving patients even more uncertain about their health status. 2.4 Data collection At the beginning of each GMB session, we encouraged participants to introduce factors and relations that they deemed relevant from their own experiences. When necessary, we used a topic list to actively prompt participants about factors and relations that were found in the literature but not (yet) mentioned during the session (see supplementary materials appendix 1). This topic list was based on a systematic review of factors contributing to patients’ demand for low-value care (i.e., unnecessary or potentially harmful care) in general [ 25 ], and complemented by a scoping literature search to identify any additional factors specifically associated with patients’ demand for LBP imaging (see supplementary materials appendix 2). 2.5 Data analysis Recordings of the GMB sessions were transcribed verbatim. Text fragments containing factors and/or relations agreed by participants to be relevant were highlighted. Next, we extracted these text fragments from the transcripts and converted them into words-and-arrow-diagrams [ 55 ]. These diagrams provide an overview of the factors, the (causal) relations between factors, and the polarity of these relations (i.e., positive, or negative) as identified in each text fragment. Positive polarity indicates that factors were anticipated to change in the same direction, while negative polarity indicates opposite directions in change. We used themes from a systematic review [ 25 ] and from a complementary literature search on LBP imaging (see supplementary materials appendix 2) as a basis to characterize and categorize factors identified during the GMB sessions. For example, the experience of lower back discomfort, strain, tension or soreness was identified as ‘’pain’’ and categorized as a biomedical factor driving patients’ demand for imaging. The (causal) relations and polarities were identified by observing the order in which events where described, and by examining signal words regarding cause and effect as used by participants. For example, “I think that an important driver for inappropriate imaging is the uncertainty that patients feel, when they hear that the cause cannot be determined” (participant G) or “If you want to do something about the additional diagnostics, then you will have to reduce the amount of practice variation” (participant E). We followed the structure of the words-and-arrow diagrams to create a CLD for each session. Next, the CLD of each session was sent to all participants for feedback and validation purposes. They were asked to check whether the mapping and data interpretation of the factors and relations in the CLD aligned with their experiences and beliefs. Following this review by participants, we merged the two CLDs into one final CLD. This was done by first looking for similarities between the CLDs and adopting similar factors and connections in the final CLD. Next, the remaining factors and connections that were mentioned in only one of the sessions were incorporated. For example, in one session, participants stated that severe LBP complaints could result in reduced strength and eventually in disability. In the other session, participants only made the connection that severe LBP complaints could result in disability. When similar factors were mentioned in both sessions but connected in different ways, we incorporated the connections that covered the essence expressed by GMB participants in a more detailed manner. In some cases no clear consensus was reached amongst participants. For example some factors raised by a single participant based on their professional knowledge or unique experiences could not be discussed in detail due to limited expertise of other participants. In these cases we (the authors) reviewed these factors and included them in the CLD if they aligned with the literature, did not conflict with other session insights, and/or were supported by (part of the) other participants. Furthermore, we analyzed the relations and feedback loops to determine how they impact other factors, relations, other feedback loops in the CLD and patients’ demand for LBP imaging in particular. This was done by conducting visual if-then simulations [ 79 ]. That is, suppose we would increase the intensity or impact of one factor (included in a feedback loop), how would it influence the chain of all other factors related to it? We checked and recorded if these impacted factors would increase, decrease, or even reinforce changes, leading to further amplification or reduction of their effects on the CLD. For example, if patients’ perceived insecurity increased, then the factors connected to it should also change. This may cause a feedback loop if the effects of the initial change in insecurity, through the factors affected, eventually affects perceived insecurity itself. Two types of feedback loops exist. Reinforcing feedback loops amplify change in the factors and system as a whole. Balancing feedback loops counteract change in the factors or in the system and lead to stability in the system. Dependent on the type of feedback loop (reinforcing or balancing), all other adjacent feedback loops, factors and their relational effects affected by this loop are either enhanced or mitigated. 2.6 Literature-based validation As a final step, we examined the literature on LBP for examples of evidence for the relationships provided by the participants and depicted in the CLD. These examples of evidence validate to a certain degree whether the included factors and connections in the CLD are substantiated by research or merely tentative claims. However, the majority of the literature does not examine relationships or associations between factors in a causal manner as presented in the CLD. Many studies are exploratory in nature and focus primarily on determining the strength of correlations or relationships between factors. As a result these (exploratory) studies do not always explicitly report the specified polarity or direction of the examined relationships between factors (i.e., whether the relationship is positive or negative). Therefore, we included articles that either explicitly reported relationships between factors as presented in the CLD, or suggested their potential existence through written descriptions or conceptual discussion — even when the polarity of the relationship was not clearly specified. 3. Results 3.1 Participants For the first session, we invited 6 participants that all consented to participate. For the second session 5 participants were invited, however two were willing but not able to participate on the day of the session (See Table 1 ). Therefore, the first GMB session consisted of six participants and the second session of three participants. Both groups consisted of patients and experts within the field of musculoskeletal disorders, in particular LBP. Table 1 Participant domain table Group model building session 1 Fields of expertise / occupation Participant A Female patient with low back pain Participant B Female patient with low back pain Participant C Pain medicine and anesthesiology practitioner and researcher, and male patient with low back pain Participant D Physiotherapist Participant E Orthopedic surgeon Participant F General practitioner, and epidemiologist Group Model building session 2 Fields of expertise / occupation Participant G Male patient with low back pain Participant H Physiotherapist and researcher concerning low back pain Participant I Neurologist 3.2 The causal loop diagram The final CLD contains 32 factors, and 50 relations between them, all expected to drive patients’ demand for LBP imaging (see Fig. 1). Appendix 3 contains the definitions used within this study for each factor in the CLD. The depicted relations were either positive and displayed with a blue arrow (i.e., 43 of 50 relations), or negative and displayed with a red arrow (i.e., 7 of 50 relations). Furthermore, we found eight reinforcing feedback loops (R1 to R8), which will be discussed below accompanied by separate figures highlighting each loop, corresponding factors and relations. In this manner all aspects of the CLD are discussed. Additionally, supporting examples of evidence from the literature were added to the results to validate the relationships in the CLD (see Table 2 ). Table 2 Examples of evidence from the literature Author and year Method Title Causal sequence of connected factors (read from top to bottom) Examples of evidence found in the literature Espeland et al. (2001) [ 23 ] Mixed methods study Patients’ Views on Importance and Usefulness of Plain Radiography for Low Back Pain -Unidentifiable cause -Acute pain or Chronic pain -Severity of low back pain complaints Patients stated that radiologic imaging was necessary because their unidentified pain was long lasting or worsening. Larijana et al. (2021) [ 48 ] Qualitative methods: Interviews and focus groups Development of a Patient-Oriented Intervention to Support Patient-Provider Conversations about Unnecessary Lower Back Pain Imaging -Unidentifiable cause -Acute and/or Chronic pain -Severity of low back pain complaints Patients wanted to find out what was wrong with them, because the low back pain that had gotten worse. Chou et al. 2018) [ 12 ] Systematic scoping review Patients' perceived needs of health care providers for low back pain management: a systematic scoping review -Unidentifiable cause -Acute or Chronic Pain There was a need to obtain a diagnosis and a cause of the experienced pain. Nieminen et al. (2021) [ 56 ] Systematic review Prognostic factors for pain chronicity in low back pain: a systematic review -Unidentifiable cause -Acute or Chronic Pain A Higher intensity of pain was associated as one of the risks factors for chronic low back pain Dionne et al. (2018) [ 21 ] Prospective cohort study Psychological distress confirmed as predictor of long-term back-related functional limitations in primary care settings -Chronic pain -Stress -Severity of low back pain complaints -(Reduced strength and) Disability This study provides evidence that psychological distress can predict long-term severe functional limitations among LBP patients. Tsang et al. (2008) [ 77 ] Cross-sectional study Common chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders -Chronic pain -Stress This study provides evidence that chronic back pain may contribute to mental disorders such as stress that patients experience. Ahmed et al. (2022) [ 1 ] Cross-sectional study Undiagnosed anxiety and depression in patients presenting for evaluation of chronic low back pain -Chronic pain -Stress Chronic pain, physical and psychological distress may lead to or aggravate the major psychological event. Choi et al. (2021) [ 11 ] Cross-sectional study Association between chronic low back pain and degree of stress: a nationwide cross-sectional study -Chronic pain -Stress There exists a significant association between chronic low back pain and stress. Yang and Haldeman (2020) [ 83 ] Cross-sectional study Chronic Spinal Pain and Financial Worries in the US Adult Population -Chronic pain -Severity of low back pain complaints -Income-related concerns Financial concerns were associated with chronic spinal pain. Chiarotto et al. (2019) [ 10 ] Systematic review Measurement Properties of Visual Analogue Scale, Numeric Rating Scale, and Pain Severity Subscale of the Brief Pain Inventory in Patients With Low Back Pain: A Systematic Review -Severity of low back pain complaints -(Reduced strength and) disability There exists a positive correlation between pain severity and disability. Von Korff et al. (1992) [ 80 ] Quantitative longitudinal study for scale development and validation Grading the severity of chronic pain -Severity of low back pain complaints -(Reduced strength and) disability The study acknowledges a relationship between pain intensity and disability. Harahap et al. (2021) [ 30 ] Descriptive correlation study Relationship between pain intensity and disability in chronic low back pain patients -Severity of low back pain complaints -(Reduced strength and) disability The study provides evidence that the intensity of low back pain is related to patients' disability. Zaman et al. (2021) [ 85 ] Review paper: topical review Uncertainty in a context of pain: disliked but also more painful? -Severity of low back pain complaints -Perceived insecurity Uncertainty experienced by patients was related to how they conceive the origin of their pain Reesor and Craig (1988) [ 64 ] Review paper: topical review Medically incongruent chronic back pain: Physical limitations, suffering, and ineffective coping. -Severity of low back pain complaints -Perceived insecurity Not knowing the cause of low back pain is associated with pain intensity. Zhou et al. (2024) [ 86 ] Case-control study with multivariate analysis Recent clinical practice guidelines for the management of low back pain: a global comparison -Severity of low back pain complaints -Perceived insecurity Variability of the (acute or chronic) low back pain was associated with uncertainty. Chou et al. (2018) [ 12 ] Systematic scoping review Patients' perceived needs of health care providers for low back pain management: a systematic scoping review -Severity of low back pain complaints -Adherence to medical guidelines by provider Imaging was associated with the severity of low back pain. Wilson et al. (2001) [ 81 ] Cross-sectional survey Patients' Role in the Use of Radiology Testing for Common Office Practice Complaints -Severity of low back pain complaints -Adherence to medical guidelines by provider The severity of low back pain was associated with imaging utilization. Hall et al. (2021) [ 27 ] Review article: Practices focused Do not routinely offer imaging for uncomplicated low back pain -Knowledge gaps in providers' medical training -Adherence to medical guidelines by provider Lacking awareness and knowledge on how to use the current low back pain guidelines may contribute to imaging usage. Kool et al. (2020) [ 41 ] Cross-sectional survey Assessing volume and variation of low-value care practices in the Netherlands -Adherence to medical guidelines -Denial and/or deferral of imaging by provider Data from 2016 demonstrated that most Dutch healthcare professionals adhered the recommendations for low back pain imaging. Tan et al. (2016) [ 72 ] Retrospective cohort study Variation among Primary Care Physicians in the Use of Imaging for Older Patients with Acute Low Back Pain -Adherence to medical guidelines by provider -Practice variation Physicians imaging ordering behaviour for low back pain may vary substantially. Braeuninger-Weimer et al. (2021) [ 5 ] Prospective cohort study Reassurance and healthcare seeking in people with persistent musculoskeletal low back pain consulting orthopaedic spine practitioners: A prospective cohort study' -Interaction with the provider -Trust in the provider Participants stated that there was poor communication and lack of trust between provider and patient. Blokzijl et al. (2021) [ 4 ] Qualitative methods: Interviews and focus groups Understanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study -Interaction with the provider -Perceived insecurity Clinicians thought that their colleagues could not provide adequate information and reassurance to prevent imaging. Espeland et al. (2001) [ 23 ] Mixed methods study Patients’ views on Importance and Usefulness of Plain Radiography for Low Back Pain -Practice variation -Perceived insecurity A patients wanted imaging because of a disagreement between two physicians concerning the cause of the patient's low back pain. Serbic and Pincus (2014) [ 67 ] Quasi experiment: quantitative mixed factorial designs Diagnostic uncertainty and recall bias in chronic low back pain -Disability -Perceived insecurity Depression and disability were associated with diagnostic uncertainty (i.e., uncertainty of what is happening in the patients' back). Serbic et al. (2016) [ 68 ] Structural Equation modelling Diagnostic uncertainty, guilt, mood, and disability in back pain. -Disability -Perceived insecurity Diagnostic uncertainty was related to disability. Patients were found to be uncertain of exercising, which is an effective treatment to reduce low back pain. Reesor and Craig (1988) [ 64 ] Review paper: topical review Medically incongruent chronic back pain: Physical limitations, suffering, and ineffective coping. -Disability -Perceived insecurity Not being able to identify the source of pain was associated with disability. Chou et al. (2012) [ 13 ] Review paper Appropriate use of lumbar imaging for evaluation of low back pain -Income-related concerns -Perceived insecurity Low back pain imaging is often performed to evaluate a workman's compensation, even if this does not improve the outcomes of the patients. Espeland et al. (2001) [ 23 ] Mixed methods study Patients’ Views on Importance and Usefulness of Plain Radiography for Low Back Pain -Income-related concerns -Perceived insecurity Patients stated that imaging was needed to get sickness certification or a pension for disability. (Even when imaging did not find the cause of the experienced pain). Traeger et al. (2022) [ 76 ] Review paper Low back pain in people aged 60 years and over -Stage of life -Perceived insecurity -Unidentifiable cause -Chronic (low back) pain -Severity of low back pain complaints -(reduced strength) and Disability People of the age of 60 and beyond have a higher probability to experience persisting and incapacitating low back pain. For a majority of the cases the cause of low back pain cannot be found. Blokzijl et al. (2021) [ 4 ] Qualitative methods: Interviews and focus groups Understanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study -Patients' unawareness -Perceived insecurity Clinicians stated that patients had unrealistic beliefs concerning the benefits and low awareness about the potential harms of imaging. Blokzijl et al. (2021) [ 4 ] Qualitative methods: Interviews and focus groups Understanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study -Influence of social network -Perceived insecurity Clinicians believed that patients pressured them to receive imaging from a need of reassurance, and patients could expect imaging based on their relatives. Espeland et al. (2001) [ 23 ] Mixed methods study Patients’ views on Importance and Usefulness of Plain Radiography for Low Back Pain -Influence of social network -Perceived insecurity Some patients had a friend or family member who had a serious illness that doctors overlooked for along time. These relatives stated that it was better to conduct radiography sooner than later. Costa et al. (2022) [ 15 ] Post-qualitative method: Thematic analysis of interviews The ubiquity of uncertainty in low back pain care -Perceived insecurity -Stress Stress and uncertainty were strongly correlated and could affect patients with low back pain. Blokzijl et al. (2021) [ 4 ] Qualitative methods: Interviews and focus groups Understanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study -Perceived insecurity -Confirmation bias Imaging provides certainty about the condition of patients and it can validate their pain. Chou et al. (2018) [ 12 ] Systematic scoping review Patients' perceived needs of health care providers for low back pain management: a systematic scoping review -Perceived insecurity -Confirmation bias Patients believed that imaging provided reassurance and confirmation of physician's diagnosis. Chou et al. (2018) [ 12 ] Systematic scoping review Patients' perceived needs of health care providers for low back pain management: a systematic scoping review -Perceived insecurity -Confirmation bias Imaging was used to legitimise the back pain of patients. When imaging was used to find a physical defect it provided closure and relief to patients. Lim et al. (2019) [ 46 ] Systematic review People with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies: a systematic review -Perceived insecurity -Confirmation bias Through imaging patients were reassured and received confirmation of their diagnosis. Espeland et al. (2001) [ 23 ] Mixed methods study Patients’ views on Importance and Usefulness of Plain Radiography for Low Back Pain -Perceived insecurity -Fear and anxiety Patients with low back pain were uncertain and anxious. Espeland et al. (2001) [ 23 ] Mixed methods study Patients’ views on Importance and Usefulness of Plain Radiography for Low Back Pain -Perceived insecurity -Imperative knowledge bias Patients wanted to know what was wrong with them and why they experienced pain. Espeland et al. (2001) [ 23 ] Mixed methods study Patients’ views on Importance and Usefulness of Plain Radiography for Low Back Pain -Confirmation bias -Imperative knowledge bias Examination was considered to be important to find out what was wrong. Espeland et al. (2001) [ 23 ] Mixed methods study Patients’ views on Importance and Usefulness of Plain Radiography for Low Back Pain -Confirmation bias -Imperative knowledge bias Patients wanted to know what was wrong, why they were in pain, and wanted to put a name to it. Larijana et al. (2021) [ 48 ] Qualitative methods: Interviews and focus groups Development of a Patient-Oriented Intervention to Support Patient-Provider Conversations about Unnecessary Lower Back Pain Imaging -Imperative knowledge bias -Imperative action bias -Low back pain imaging demand Patients considered imaging to be important, because they wanted something to happen with their pain. Espeland et al. (2001) [ 23 ] Mixed methods study Patients’ views on Importance and Usefulness of Plain Radiography for Low Back Pain -Fear and anxiety -Imperative knowledge bias Uncertain or anxious patients considered imaging to be important to stop worrying and receive some answers. Blokzijl et al. (2021) [ 4 ] Qualitative methods: Interviews and focus groups Understanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study -Influence of social network -Entitlement to care -Patients' expectations -Low back pain imaging demand Patients formed expectations to receive imaging based on the information received from their relatives. Blokzijl et al. (2021) [ 4 ] Qualitative methods: Interviews and focus groups Understanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study -Patients' experiences -Patients' expectations Expectations for imaging were based on previous health encounters. Chou et al (2012) [ 13 ] Review paper Appropriate use of lumbar imaging for evaluation of low back pain -Patients' experiences -Patients' expectations Patients that received imaging for an episode of low back pain could expect this for future episodes. Blokzijl et al. (2021) [ 4 ] Qualitative methods: Interviews and focus groups Understanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study -Marketing influences -Patients' expectations Expectations for imaging were based on media sources. Jenkins et al. (2016) [ 37 ] Survey study: Descriptive statistics and multivariate logistic regression Understanding patient beliefs regarding the use of imaging in the management of low back pain -Cultural background -Patients' expectations Patients with a non-European and non-Anglo-Saxon cultural background had an increased belief or need for imaging. Larijana et al. (2021) [ 48 ] Qualitative methods: Interviews and focus groups Development of a Patient-Oriented Intervention to Support Patient-Provider Conversations about Unnecessary Lower Back Pain Imaging -Patients' expectations -Low back pain imaging demand Patients thought that imaging was necessary to diagnose low back pain. Chou et al. (2018) [ 12 ] Systematic scoping review Patients' perceived needs of health care providers for low back pain management: a systematic scoping review -Patients' expectations -Low back pain imaging demand Patients expected to be referred for an x-ray. De Carvalho et al. (2021) [ 19 ] Cross-sectional survey Knowledge of and adherence to radiographic guidelines for low back pain: a survey of chiropractors in Newfoundland and Labrador, Canada -Patients' expectations -Low back pain imaging demand Patients expected to be referred to receive an x-ray. Espeland et al. (2001) [ 23 ] Mixed methods study Patients’ views on Importance and Usefulness of Plain Radiography for Low Back Pain -Patients' expectations -Low back pain imaging demand Patients' expected radiography to help with decisions for follow-up treatment (operations, chiropractic therapy and physiotherapy). Jenkins et al. (2016) [ 37 ] Survey study: Descriptive statistics and multivariate logistic regression Understanding patient beliefs regarding the use of imaging in the management of low back pain -Patients' expectations -Low back pain imaging demand -Low back pain imaging Patients' beliefs may contribute to imaging for low back pain. Espeland et al. (2001) [ 23 ] Mixed methods study Patients’ views on Importance and Usefulness of Plain Radiography for Low Back Pain -Denial and/or deferral of imaging by provider -Patients' dissatisfaction and rejection of evidence and recommended care Patients may be dissatisfied when physicians provide an explanation of their symptom. These patients believed that imaging provides a better explanation of their symptom. Espeland et al. (2001) [ 23 ] Mixed methods study Patients’ views on Importance and Usefulness of Plain Radiography for Low Back Pain -Denial and/or deferral of imaging by provider -Patients' dissatisfaction and rejection of evidence and recommended care Dissatisfied patients said that it was hopeless when you do not know what it is. These patients sought other explanations for their pain, because they wanted to know what it was. Pike et al. (2022) [ 62 ] Qualitative method: Exploratory theoretical domain framework Barriers to following imaging guidelines for the treatment and management of patients with low-back pain in primary care: a qualitative assessment guided by the Theoretical Domains Framework -Denial and/or deferral of imaging by provider -Patients' dissatisfaction and rejection of evidence and recommended care Physicians reported that it was difficult to convince patients that imaging is not necessary. However, the physicians believed that imaging could reduce frustration and anxiety, and improve patient satisfaction. Taylor and Bishop (2020) [ 74 ] Scoping review Patient and public beliefs about the role of imaging in the management of non-specific low back pain: a scoping review -Denial and/or deferral of imaging by provider -Patients' dissatisfaction and rejection of evidence and recommended care -Consumerism -Low back pain imaging demand -Imaging Patients denied imaging sought it elsewhere. Kendrick et al. (2001) [ 39 ] Unblinded Randomised control trial The role of radiography in primary care patients with low back pain of at least 6 weeks duration: a randomised (unblinded) controlled trial -Patients' dissatisfaction and rejection of evidence and recommended care -Perceived insecurity Patients that received imaging were reported to be more satisfied but not less worried or reassured. Chou et al (2018) [ 12 ] Systematic scoping review Patients' perceived needs of health care providers for low back pain management: a systematic scoping review -Patients' dissatisfaction and rejection of evidence and recommended care -Consumerism Dissatisfied LBP patients may seek care from other providers and overutilize healthcare resources. Chou et al. (2011) [ 14 ] Review paper: Clinical guideline Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians - Patients' dissatisfaction and rejection of evidence and recommended care -Low back pain imaging demand -Low back pain imaging When patients express dissatisfaction there is a likelihood that imaging practices increase, Espeland et al. (2001) [ 23 ] Mixed methods study Patients’ views on Importance and Usefulness of Plain Radiography for Low Back Pain -Patients' dissatisfaction and rejection of evidence and recommended care -Low back pain imaging demand Dissatisfied with the explanation of their healthcare providers, patients kept believing that imaging would be better. a The presented factors and connections follow the structure of the CLD from left to right (see Fig. 1). Loop R1 “Non-specific pain and uncertainty” Loop R1 (see Fig. 2 ) depicts how inability to find the cause of the experienced pain leads to stress, increases the severity level of patients’ LBP complaints, disability and perceived insecurity. Interpreting the figure from left to right, the inability to determine the source of patients’ LBP was expected to influence the acute or chronic pain experienced by patients. Chronic LBP could also influence the amount of stress felt by patients, which in turn may influence how severe their LBP complaints are. Both types of pain were considered as common experiences among LBP patients and were expected to contribute to the severity of patients’ LBP complaints. Patients were expected to perceive several insecurities as a result of their LBP. For instance, health-related insecurities were mentioned, and these were often expected to depend on factors associated with the severity of patients’ LBP complaints. For example, the combination of not being able to identify the source of LBP and the persistence of this pain could make patients uncertain about their situation. Furthermore, patients with severe LBP complaints may experience loss of strength in their legs and hips, and the resulting disabilities could make them feel more insecure about what is wrong with them. In addition, comorbidities were also argued to influence patients’ health-related insecurities. LBP patients suffering from other (chronic) diseases, caused by or closely related to their LBP, may experience increased health-related insecurities. Stage of life, which encompasses age and health-related problems associated with aging, was also mentioned as a factor contributing to patients’ perceived health-related insecurities. For example, participants stated that younger patients were often caught off-guard by their LBP complaints as they did not expect to experience LBP at their current stage of life. Patients’ perceived insecurity could also be socially induced, through influences or pressure of friends and family to find out what is wrong. Patients with LBP often do not know what to do with such pressure, and so may become (more) insecure. Patients’ unawareness of the causes of their LBP was also expected to result in increased insecurity. Furthermore, income-related concerns were also argued to influence patients’ perceived insecurity. LBP patients were expected to be less able or sometimes even completely incapable to do their job, resulting in presenteeism, absenteeism, and potentially even unemployment. This loss of work productivity may negatively affect income and worries about present and future income may increase perceived insecurity. Furthermore, patients’ perceived insecurity was also argued to be reliant on the adherence to LBP guidelines by providers. Decreased adherence to guidelines by providers may cause and increase practice variation. While an expansion of available care options may seem positive for patients, it is questionable whether this is the case. Practice variation was considered to influence patients in a negative manner and contribute to patients’ insecurity, because they would hear multiple “truths” of what could cause their pain and how this should be treated. However, in most cases, providers comply to the guidelines and recommend patients to avoid additional diagnostical services (such as imaging), because the cause of non-specific LBP cannot be found. Finally, participants argued that increased perceived insecurity could influence and reinforce factors included in loop R1, through increasing patients’ stress level and, subsequently, the severity of patients’ LBP complaints, and eventually patients’ insecurity itself. Loop R2 ‘’Uncertainty avoidance” Loop R2 (see Fig. 3 ) illustrates the main rationale for patients to demand LBP imaging. Interpreted from left to right, patients’ insecurity could motivate patients in three different ways towards thinking that knowing more about their LBP complaints is better (i.e., the imperative knowledge bias). First, participants argued that patients’ insecurity may directly influence this imperative knowledge bias. Patients with LBP often face uncertainty about the causes and/or consequences of their condition, and tend to think that knowing more is better. Second, this desire to know more may be indirectly influenced by patients’ fear and anxiety about their situation. For example, LBP patients might become immobilized by pain or attempt to restrict movements due to fear of injury or to avoid pain. Third, through the confirmation bias, patients could be inclined to try and seek more information to obtain proof that their pain is real. Additionally, patients’ imperative knowledge bias was argued to depend on patients’ expectations of receiving LBP imaging. These expectations may be the result of influences from their social network. For example, experiences shared by friends, family, and relatives receiving care in similar situations, can create a sense of entitlement and lead patients to expect similar treatment. It was also mentioned that patients’ expectations could be influenced by marketing, the cultural background of patients, and their past experiences with imaging. Marketing could influence expectations, for instance, through stories in magazines of other patients that were able to determine the cause of their pain through imaging. Participants reasoned that these success stories could result in misconceptions among patients that LBP imaging would provide more information about the origin of their pain. Regarding cultural background, participants argued that patients from countries with less strict clinical guidelines and easier access to LBP imaging, may expect to receive the same treatment when seeking care in other countries. Turning to the past experiences, previous experiences with receiving imaging were thought to shape patients' expectations about similar care in the future. Moreover, it was mentioned that patients’ imperative knowledge bias is strongly related to the imperative action bias. More specifically, patients’ tendencies to gain more information about their health status influences them to think that it is better to do something instead of nothing, and hence, demand LBP imaging. However, demand for LBP imaging is usually denied by providers, because clinical guidelines recommended evidence based care. This includes care does not focus on identifying the source of LBP, but focuses on improving daily activities, acceptance of pain (e.g. psychological help), or watchful waiting. Denial of imaging may prompt patient dissatisfaction, as they remain uncertain of the cause of their persisting pain. Conversely, it has been argued that clinicians may provide LBP imaging to increase patient satisfaction. Loop R3 ‘’Dissatisfaction induced demand’’ Loop R3 (see Fig. 3 ) illustrates how imaging demand can be reinforced. In certain cases, demand for LBP imaging may result in LBP imaging. GMB participants expected that, if this happens, most patients will remain undiagnosed, still receiving no clarity about the source of their pain. These patients would then be dissatisfied with the outcomes of imaging and, consequently, remain or become even more insecure. Patients could also immediately demand LBP imaging again, if they believe that initial imaging was conducted incorrectly. Loop R4 “Denial induced Demand” Loop R4 (see Fig. 3 ) depicts how denial of LBP imaging may reinforce demand for LBP imaging. Interpreted from left to right, if providers deny or defer patients' demand for LBP imaging, patients may receive other recommended but non-preferred care, leading to dissatisfaction, rejection of recommended care, and increased demand for LBP imaging. Loop R5 “Patient-provider relations” Loop R5 and Loop R6 (see Fig. 4 ) are closely tied, and it illustrates how the interaction between healthcare providers and patients may result in increased perceived insecurity. In this section we focus on Loop R5 and its adjacent factors. We interpreted the figure starting from the left, moving downward, and then upward. When patients with LBP complaints visit their healthcare provider, they often receive care that aligns with the clinical guidelines concerning LBP. Adherence to the guidelines by providers is dependent on providers’ knowledge of the guidelines, and on the severity of patients’ LBP complaints. For example, patients with severe LBP complaints were expected to be more determined to receive imaging by trying to convince their healthcare provider to deviate from the recommendation in the guidelines. Loop R5 was argued to occur when providers adhere to the guidelines and deny imaging. Patients were anticipated to lose trust in their provider and experience their interaction with them as negative. This cycle was expected to continue and to reinforce itself, possibly as long as imaging is not provided. Loop R6 “Doubt” Loop R6 functions as an intermediary loop, connected to loops R5 and R7 (see Fig. 4 ). This loop depicts how negative interactions with providers and patients’ insecurity mutually influence each other. Participants stated that persistent insecurity about what causes their pain is a primary reason for patients to value interactions with care providers negatively. These patients were reasoned to remain or become even more insecure from the interactions with their care provider, reinforcing their perception of the interaction with their provider to be negative or unhelpful. Loop R7 “Dissatisfaction escalation’’ Loop R7 illustrates how perceived insecurity and patients’ dissatisfaction and rejection of evidence and care recommended by the provider mutually influence and reinforce each other (see Fig. 4 ). Participants argued that patients who feel insecure about their situation believe that identifying the cause of their pain should be part of the treatment plan before any suggestions towards recovery are made. However, during primary care consults, pain complaints of patients are often not adequately acknowledged by care providers and no diagnosis is provided, making patients feel that they have not received a solution for their problem. Thus, in this scenario, patients remain uncertain and become increasingly dissatisfied with the evidence-based recommendations of their care provider, who in their perception do not focus on identifying the source of their pain, and these factors may continue to reinforce each other. Loop R8 ‘’Shopping for validation’’ Loop R8 (see Fig. 5 ) provides insights into why patients shop around to receive their preferred care. Providers following medical guidelines may deny or defer LBP imaging, recommending other treatments or watchful waiting first. Patients were expected to reject recommended care and evidence of medical guidelines, believing treatment is only effective if the cause of their pain is identified. Dissatisfied, they may seek LBP imaging or non-conventional treatments, while remaining or becoming more dissatisfied, and continue to shop for answers. Participants reasoned that some patients could be satisfied in the short term with shopping for non-conventional care, even when this care does not detect the cause of their pain. This was suggested to be often done after receiving no LBP imaging referral from their healthcare provider. These patients were argued to view consumption of non-conventional care as a checklist of available options, hoping one of them could help. However, these non-conventional care options will not help in the long term, resulting in dissatisfaction and continuation of shopping for preferred care. 3.3 Literature-based validation We found 34 sources that discuss the relationships in the CLD and support the findings from the GMB sessions (See Table 2 ). These sources include quantitative and qualitative research articles, and scoping and systematic reviews. Articles presenting findings of empirical research applied either quantitative methods (i.e., 18 of 34), qualitative methods (i.e., 5 of 34), or mixed methods (i.e., 1 of 34). Articles focusing more on the literature were either systematic reviews (i.e., 6 of 34) or other assessments of the literature (i.e., 4 of 34). These sources contained examples of evidence for 49 of the 50 relations depicted in the CLD. The single connection that could not be underpinned with literature was the connection between the factors comorbidity and perceived insecurity. 4. Discussion The aim of this study was to explore and map factors that drive patients’ demand for LBP imaging and their relations. Intrinsic to this problem is that for most patients the cause of the pain they experience cannot be identified, which results in insecurity about their situation and dissatisfaction with healthcare providers. Two GMB sessions were organized with patients and healthcare professionals, and a final CLD was developed providing insight in how psychological, socio-cultural, system and biomedical factors drive patients’ demand for LBP imaging. Additionally, the CLD offers insight in reinforcing loops that contribute to this demand for imaging. The final CLD consists of 32 factors, 50 relations, and eight reinforcing loops concluded to drive LBP patients’ demand for imaging. The factors included in the CLD correspond to factors found in the literature on drivers concerning patients’ demand for LBP imaging [ 12 – 13 , 46 , 50 , 69 , 74 ] (see also Appendix 1). In addition, the potential existence of 49 of the 50 relations depicted in the CLD were also supported by evidence from the literature (see Table 2 ). Furthermore, many of the factors, relations and feedback loops found in this study correspond to those found in a similar study that focused on patients’ demand for low-value care (see supplementary materials appendix 4). Therefore, this study provides case-specific evidence on unnecessary LBP imaging supporting generic evidence of factors contributing to patients’ demand for unnecessary or potentially harmful care. These findings may point towards the existence of certain universal patterns explaining demand for low-value care that possibly are also relevant in other case-specific contexts [ 53 ]. Although, such universal patterns may exist, particular factors and relations may be relevant in specific contexts. For example, in this study, the factors connected to the unidentifiable cause, denial and/or deferral of imaging, patients’ dissatisfaction and rejection of evidence and recommended care, and the relations connected to this factor were essential for understanding patients’ demand for LBP imaging. These factors and relationships may only exists or have a significant role in imaging-related contexts where patients demand unnecessary imaging, such as demand for imaging in headache disorders without alarming symptoms [ 63 ]. Moreover, through the CLD we understand that factors originally anticipated to reduce demand for imaging may function counterintuitively and, instead, foster demand. For instance, providers tend to adhere to medical guidelines and evidence-based care, which indicate against imaging. However, this adherence (i.e., the denial of imaging) was argued to enhance patients’ feelings of insecurity and dissatisfaction with care. Imaging does not reveal the source of their pain, and may provoke patients’ preference for LBP imaging and/or other non-conventional interventions. This process eventually resulted in a reinforced demand for imaging (see loops R4 and R7). On the other hand, non-compliance with guidelines may result in clinical practice variation and encourage patients to shop around for imaging or other non-conventional care, reinforcing their feelings of insecurity (see loops R3, R7-R8). Thus, it becomes conceivable that some providers are faced with a dilemma to either comply or deviate from the guideline when both options may lead to the same undesirable result. Determining which of the two scenarios will prevail in practice is a matter for empirical follow-up research. Notwithstanding the insights drawn from this study, it is important to acknowledge a few limitations. First, the final CLD may not provide a complete overview of all the factors and relations that have an influence on patients’ demand for LBP imaging. The CLD was primarily based on introspections of and consensus between participants in the two GMB sessions. They provided insights from their experiences as a patient or as a healthcare professional of factors and relations contributing to patients’ demand for LBP imaging. Moreover, many of the factors and relations mentioned were also found in the literature. Still, it is possible that other participants − from the Netherlands but perhaps especially from countries with other healthcare systems and practices − would have mentioned other factors and relations. Furthermore, the CLD does not inform about the strength of the different relations, feedback loops, and the time needed for these relations to effectuate. Despite this, the current CLD should be seen as a basic framework that provides information about the complex system of demand for LBP imaging and can be used to formulate hypotheses about factors and relations that could be further explored or empirically tested [ 8 ]. Through testing and validation of these factors and relations, the current CLD can be used as a stepping-stone to better understand imaging demand by creating more accurate CLD’s and gain more insight in potentially effective leverage points for reducing the demand for imaging. Second, one might argue that the overlap between this study’s findings and existing literature is a result of using a topic list that was partially derived from previous studies. However, we refrained from using the topic list to steer participant input until no participant input emerged. This underscores the predominantly participant-driven nature of the data even when researchers’ prompts were introduced. The topic list was primarily used as a reference to identify relevant factors and relations that could summarize the broad discussions during the sessions. The third limitation is related to the knowledge gaps of participants to identify and/or specify how some factors precisely work and are related to each other. For example, GMB participants remained uncertain of whether and why patients with different cultural backgrounds may have different expectations of LBP imaging. Although a diverse group of participants with distinct backgrounds were included in the GMB sessions, the nature of this specific relation remained unclear. Therefore, it seems worthwhile to explore this relation in more detail in a larger and diverse sample (e.g., using a survey). The fourth limitation concerns the sample size of the study. While the sample size is modest (i.e., six participants in the first sessions and 3 in the second session), it does reflect deliberate focus on participants experiencing LBP and healthcare professionals with substantial domain expertise on this topic. Therefore, our sampling strategy focused on inviting and selecting knowledgeable key actors who are involved in this issue. This strategy proved successful, as it enabled us to engage relevant disciplines and participants with varying experiences. For example, all included healthcare professionals draw on various knowledge sources, such as their basic medical training, years of experience interacting with patients seeking imaging, and literature or research as some are also researchers. Other indications proving our strategy to be successful are related to the identified factors during the sessions. We found that the factors and relationships identified in the existing sessions closely align with the results of our scoping literature study (see supplementary materials appendix 2) and the broader literature on why patients demand low-value care interventions [ 25 ], including non-specific LBP imaging. To minimize our selection or sampling bias we asked participants at the end of each session to recommend us the names of individuals or occupations that should be involved in the study. We found however that occupations or names of participants that were already involved were named again. Lastly, although the CLD provides insight in the variety of factors that influence demand for LBP imaging and their relations, it remains challenging to identify leverage points for interventions in this complex system, where small changes in the system are expected to result in significant reductions of demand for imaging [ 52 ]. Previous research using network analysis to identify such leverage points based on the structure of CLDs showed that factors that are highly connected, have the shortest path to others factors, or factors that are connected to other important factors, may seem as promising intervention points in complex systems [ 7 , 16 – 17 ]. Alternatively, in system dynamic modelling (SDM) approaches factors with strong measured feedback loop effects or factors with large observed effect sizes are often identified as important leverage points in complex systems. However, system dynamic modelling (SDM) typically requires empirical data or expert estimates to define the strength of the causal relations or influences between factors in the system. When such information is unavailable, we propose a sensitivity analysis or binary SDM as alternative method to identify leverage points in complex systems. By defining a standardized minimum and maximum range effect size for each factor, the changes and impact of each factor over time can be explored through computational simulations. Despite providing some insights on the potential behaviour of the factors within the system, this approach may result in oversimplified relational effects and limited insight when used to identify effective leverage points. Despite these limitations, the findings of this study provide valuable recommendations for policymakers and healthcare providers to reduce demand for imaging by LBP patients from a complex systems approach. Policymakers could focus on tackling patients’ expectations to receive imaging, or dissatisfaction of (not) receiving imaging, and rejection of recommended care through education and continued use of awareness campaigns. There is already some evidence that campaigns focusing on explaining common misconceptions that LBP patients have about imaging, and how this may lead to cascades of low-value care, can be successful [ 6 ]. Furthermore, policymakers could enforce adherence to LBP guidelines through implementation of financial incentives that limit provision of inappropriate imaging, steer patients away from initially demanding this, and reduce shopping around for other harmful or unnecessary care substitutes. Based on the CLD, providers should focus on developing effective communication strategies to tackle patients’ insecurity, dissatisfaction, avoid preference for imaging, and convince patients of recommended evidence-based care options. Furthermore, these strategies should focus on building a solid patient-provider relationship where patients may argue but eventually follow the recommendations, authority and experience of their provider [ 32 , 49 , 66 , 87 ]. 5. Conclusions To conclude, this study shows that patients’ demand for LBP imaging primarily originates from a combination of chronic or acute pain, of which the cause in most cases cannot be identified. This results in insecurity about their situation, dissatisfaction with healthcare providers and rejection of evidence-based care. These factors interact with psychological, social, system and biomedical factors, potentially reinforcing demand for LBP imaging through various feedback loops. As evidence about causal relations within this complex system is still missing, targeting factors and relations associated with these feedback loops appear to be the most promising leverage points for policy makers and healthcare providers to intervene in the system and reduce demand for LBP imaging. Although it may be challenging to implement these changes in the short term, a collective and consistent approach could shift expectations of appropriate care among LBP patients. Abbreviations LBP Low back pain GP(s) General practitioner(s) CT-scans Computed Tomography scans MRI(s) (multiple) Magnetic Resonance Imaging (scans) GMB Group Model Building CLD(s) Causal loop diagram(s) PAIN Pain Alliance In the Netherlands Declarations Ethics approval The Centre for Clinical Expertise (CCE) at the National Institute for Public Health and the Environment (RIVM) in the Netherlands exempted this research from further review by a medical ethics committee. The current study does not fulfill the specific conditions as stated in article one of the Dutch law for Medical Research Involving Human Subjects (WMO) or with the EU Clinical Trial Directive (2001/20/EC). Informed consent was obtained prior to participation, including consent for audio recording of the sessions. All participants were informed about the study’s purpose and procedures, their right to withdraw from the study at any time and the fact that data would be anonymized by removing personal or identifiable information. Informed consent was obtained prior to participation, including consent for audio recording of the sessions. Consent for publication Written and oral consent from the participants concerning the purpose (including intent for publication) of the study was obtained prior to the start of each GMB session. Availability of data and materials The analysis of the GMB sessions has not been made publicly available and currently exists only in Dutch, limiting its accessibility to non-Dutch-speaking audiences. However, it can be made available upon request. Besides this all data generated or analysed during this study are included in this published article and its supplementary information files. Competing interests The authors declare that they have no competing interests. Funding This study was funded by the National Institute for Public Health and the Environment, grant number S/080001 Demand. Author contributions Conceptualization: Gillroy R.L. Fraser, Mattijs S. Lambooij, G. Ardine de Wit, Peter M.A. Sloot, Raymond W.J.G. Ostelo. Data curation: Gillroy R.L. Fraser. Formal analysis: Gillroy R.L. Fraser, Mattijs S. Lambooij, G. Ardine de Wit, Job van Exel. Funding acquisition: G. Ardine de Wit. Investigation: Gillroy R.L. Fraser, Mattijs S. Lambooij, G. Ardine de Wit, Peter M.A. Sloot. Methodology: Gillroy R.L. Fraser, Mattijs S. Lambooij, G. Ardine de Wit, Peter M.A. Sloot. Resources: Gillroy R.L. Fraser, Mattijs S. Lambooij, G. Ardine de Wit, Peter M.A. Sloot. Visualization: Gillroy R. L. Fraser. Supervision: Mattijs S. Lambooij, G. Ardine de Wit, Job van Exel, Raymond W.J.G. Ostelo, Frenk van Harreveld, Peter M.A. Sloot. Writing - original draft preparation: Gillroy R.L. Fraser. Writing - review & editing: Gillroy R.L. Fraser, Mattijs S. 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Supplementary Files SupplementaryMaterialsAppendix14.docx Appendix1TopicListbasedonscopingreview.docx Appendix2Topiclistbasedonliteraturesearch.docx Appendix3DefinitionsoffactorsinCLDonLBPimaging.docx Appendix4FactorsincludedinthefinalCLDonpatients.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 12 Feb, 2026 Reviews received at journal 01 Feb, 2026 Reviews received at journal 30 Jan, 2026 Reviewers agreed at journal 27 Jan, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviewers agreed at journal 21 Jan, 2026 Reviewers invited by journal 21 Jan, 2026 Editor invited by journal 24 Dec, 2025 Editor assigned by journal 22 Dec, 2025 Submission checks completed at journal 22 Dec, 2025 First submitted to journal 18 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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2","display":"","copyAsset":false,"role":"figure","size":73743,"visible":true,"origin":"","legend":"\u003cp\u003eLoop R1 Non-specific low back pain and uncertainty\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8393306/v1/2e280a7175c32a01e4f9f456.png"},{"id":101075075,"identity":"98d52000-7803-4e05-b6fc-75fb025d4f8b","added_by":"auto","created_at":"2026-01-25 10:24:55","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":97512,"visible":true,"origin":"","legend":"\u003cp\u003eLoop R2 Uncertainty avoidance, Loop R3 Dissatisfaction induced Demand, and Loop R4 Denial induced demand\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8393306/v1/89adb2b210e0792ffb2e2022.png"},{"id":101205286,"identity":"6ce1204f-8c79-4981-85c0-399f9b8cee58","added_by":"auto","created_at":"2026-01-27 09:48:51","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":81311,"visible":true,"origin":"","legend":"\u003cp\u003eLoop R5 Patient-provider relations, R6 Doubt, and R7 Dissatisfaction escalation\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8393306/v1/235b77089707993a22df54c4.png"},{"id":101205419,"identity":"79ca79dc-f885-4b8e-8f50-cbd21eaa2cf8","added_by":"auto","created_at":"2026-01-27 09:49:21","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":41838,"visible":true,"origin":"","legend":"\u003cp\u003eLoop R8 Shopping for validation\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8393306/v1/facc5fbaffc5269cc1cb1338.png"},{"id":102294879,"identity":"28c24344-ee86-403f-88c8-ee25d29a8295","added_by":"auto","created_at":"2026-02-10 10:02:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2300608,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8393306/v1/77912ac8-4631-43b3-9902-0062d6555d9e.pdf"},{"id":101075137,"identity":"3b1e2cb3-5419-4da6-8ec8-bad0a80743c4","added_by":"auto","created_at":"2026-01-25 10:25:02","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":325052,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterialsAppendix14.docx","url":"https://assets-eu.researchsquare.com/files/rs-8393306/v1/203b19ce8d27be1d4bd36984.docx"},{"id":101075143,"identity":"52045db5-e197-4c67-9c97-085418bc82d6","added_by":"auto","created_at":"2026-01-25 10:25:02","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":18682,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1TopicListbasedonscopingreview.docx","url":"https://assets-eu.researchsquare.com/files/rs-8393306/v1/e8a8d1da534f14702b2ade98.docx"},{"id":101075132,"identity":"34baf277-9a55-4438-80c8-8cc88e702068","added_by":"auto","created_at":"2026-01-25 10:25:02","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":131932,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix2Topiclistbasedonliteraturesearch.docx","url":"https://assets-eu.researchsquare.com/files/rs-8393306/v1/4493808c826483f0cdeac93f.docx"},{"id":101075144,"identity":"fb7e9110-89b8-4e7e-ac58-460a0dd4c4bb","added_by":"auto","created_at":"2026-01-25 10:25:03","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":19183,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix3DefinitionsoffactorsinCLDonLBPimaging.docx","url":"https://assets-eu.researchsquare.com/files/rs-8393306/v1/f233995b97769467c318642c.docx"},{"id":101075079,"identity":"8c2e2631-d761-4d1b-89fa-0aae15a00918","added_by":"auto","created_at":"2026-01-25 10:24:56","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":206353,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix4FactorsincludedinthefinalCLDonpatients.docx","url":"https://assets-eu.researchsquare.com/files/rs-8393306/v1/23b43b64ad42d767c9de5284.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Mechanisms contributing to patients’ demand for low back pain imaging: a complex systems approach","fulltext":[{"header":"1. Background","content":"\u003cp\u003eLow-back pain (LBP) is often defined as pain between the area of the lower ribs and buttocks. This pain can also be felt in one or both legs and some individuals even experience nerve-related symptoms in their lower limbs (sciatica) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. LBP is a frequently occurring symptom that has been found to be the primary cause of years lived with disability worldwide [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In 2020, 619\u0026nbsp;million people across the globe experienced low back pain, and by 2050 more than 843\u0026nbsp;million people are estimated to be affected by this problem [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. It is expected that 50% to 80% of the adults will experience one or more episodes in their life [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. In the Netherlands, approximately 6,6% of the population (i.e., 1.125\u0026nbsp;million patients) visit their general practitioner (GP) for LBP on a yearly basis [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLBP may be the result of many medical conditions referred to as \u0026lsquo;\u0026rsquo;red flag\u0026rsquo;\u0026rsquo; causes, such as malignancies, fractures, inflammations and infections [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. For these red flags, neurologic deficits, or in case of persistent LBP (pain experienced longer than six weeks after onset) with or without nerve root-related symptoms, imaging of the lower back is recommended [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. However, in 90% to 95% of the cases LBP is non-specific [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], meaning that none of the previously mentioned conditions are present and that the main cause cannot reliably be identified through imaging (i.e., CT-scans, radiography, MRIs) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. From this point onward, any reference to LBP or LBP imaging corresponds to the definition of non-specific LBP as previously presented. Although weak associations between some MRI findings and subsequent LBP have been reported, the evidence concerning the added value of imaging remains uncertain [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Furthermore, potential causes detected through imaging were found in both people with and without LBP [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBecause imaging techniques in general cannot reliably determine the cause of LBP, imaging may provide limited to no additional health-related information or benefits while posing greater potential harm towards patients in most cases [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. In fact, imaging may result in cascades of burdensome, costly and even potentially harmful follow-up services requested by patients [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. For these reasons, in the absence of the conditions mentioned above, imaging as a standard procedure to diagnose LBP has often been referred to as \u0026ldquo;inappropriate imaging\u0026rdquo; [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e] that is discouraged by clinical practice guidelines and research [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough imaging for LBP is discouraged, this practice still persists. Data from a study in Nebraska concluded that 51% of LBP imaging was unnecessary and another 35% was likely unnecessary [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. A study in Australia found that (20%) of all imaging procedures were considered as inappropriate imaging requests [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. For the Netherlands, no precise estimates on the amount of inappropriate LBP imaging are available. However, a study assessing the volumes of imaging in 2016 demonstrated that GPs in the Netherlands ordered at least 41,783 imaging procedures for their patients\u0026rsquo; lower back [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. More recent primary-care data from 2024 demonstrated that at least 50,200 patients contacted their GP for LBP [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e], suggesting that a substantial number of patients continue to seek medical care for this condition. Patients\u0026rsquo; demand was mentioned as a primary driver influencing physicians to provide LBP imaging [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Patients may seek imaging due to severe or persistent pain, uncertainty about their condition, desire to alleviate anxiety, desire to obtain a diagnosis, or belief that imaging is necessary for treatment [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. These reasons may interact with each other, potentially further increasing patients\u0026rsquo; demand for LBP imaging. For example, patients with unexplained LBP may (continue to) seek imaging, believing it will provide evidence to explain their pain [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBecause of the potential interaction between multiple factors, patients\u0026rsquo; demand for LBP imaging is considered a multifactorial or complex problem [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. Furthermore, demand for imaging could also be perceived as a multilevel problem, as patients\u0026rsquo; preferences may also influence physicians\u0026rsquo; imaging practices [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Nonetheless, the specific interactions between these factors have not been explored. Gaining insights into relations and interactions between factors causing patients\u0026rsquo; demand for LBP imaging could improve general understanding of LBP imaging demand. Such insights could aid in the development of effective interventions to reduce imaging demand and optimize imaging resource allocation. Therefore, the objective of this study was to explore and map the factors that drive patients\u0026rsquo; demand for LBP imaging and their relations, using a complex systems approach.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 General approach\u003c/h2\u003e \u003cp\u003eBecause LBP and patients\u0026rsquo; demand for LBP imaging are referred to as complex problems [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e], we adopted a complex systems approach in this study. This method is frequently adopted to understand complex phenomena that emerge from a set of (underlying) interdependent elements (e.g. factors) that influence one another [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. In this context, patients\u0026rsquo; demand for LBP imaging was understood as a complex behavioural outcome formed by multiple interdependent drivers, such as: patient\u0026rsquo;s pain severity, fear and anxiety of having a serious pathology, and the need for reassurance [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Based on this approach, these examples are assumed to interact with one another [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e], and in doing so, influence each other and shape patients\u0026rsquo; demand for LBP imaging over time. To identify and map the involved factors and their relations, we selected methods suited to this approach to collect and visualize data on complex problems, such as group model building and causal loop diagramming.\u003c/p\u003e \u003cp\u003eGroup model building (GMB) was used to primarily collect data, explore, and map the factors that drive patients\u0026rsquo; demand for LBP imaging and their relations. GMB can help understand complex problems by gathering participants\u0026rsquo; perspectives (based on their experiences, knowledge, and beliefs) on contributing factors and their relations [\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e]. We adopted best practices, also described in Scriptapedia (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://en.wikibooks.org/wiki/Scriptapedia\u003c/span\u003e\u003cspan address=\"https://en.wikibooks.org/wiki/Scriptapedia\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), to design and conduct the two GMB sessions [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. In these GMB sessions, participants identified factors related to LBP imaging demand and their causal relations. This collaborative process aimed to achieve shared understanding and consensus [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Factors for which no consensus was reached were discussed within the research team and assessed based on their relevance, consistency with the existing literature, and potential importance to the overall system. After each session, we documented unanimously agreed factors and relations in causal loop diagrams (CLDs), which were validated individually by participants. A CLD is a model that visualizes factors and their causal relations. The two session-specific CLDs were merged into one final CLD. To provide further validation of the final CLD, we searched the literature for evidence that supports the illustrated relationships in the CLD.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Selection of participants\u003c/h2\u003e \u003cp\u003eWe aimed to include both patients with LBP (i.e., experts by experience) and healthcare professionals within the field of musculoskeletal disorders, in the two GMB sessions (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Patients were included if they suffered from LBP for at least one year and represented distinct age-groups, occupations, employment status, and sex. Inclusion criteria for the selection of clinicians and musculoskeletal professionals were: their familiarity with approaches to manage LBP, face-to-face experience with patients\u0026rsquo; LBP imaging demand, minimum of 5 years clinical experience, distinct (sub) specializations, and involvement in recommending or interpreting LBP imaging. Clinicians were included because their professional experience allows them to identify recurring patterns of their patients\u0026rsquo; imaging-seeking behaviour. Including their perspectives can enrich the sessions, support claims made by patients, and foster deeper exploration or discussions related to this issue. Through convenience sampling, we sampled LBP patients from the Dutch associations \u0026ldquo;the Spine\u0026rdquo; and \u0026lsquo;\u0026rsquo;PAIN\u0026rsquo;\u0026rsquo; (i.e., Pain alliance in the Netherlands). The healthcare professionals of the first session were recruited through purposive sampling. We reached out to our professional networks to identify and approach qualified experts. Healthcare professionals for the second session were recruited by applying snowball sampling.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Recruitment and information distributed to participants\u003c/h2\u003e \u003cp\u003eWe extended a formal invitation to all participants that demonstrated interest to join the GMB sessions. In the email and at the beginning of the sessions, all participants were informed about the study\u0026rsquo;s purpose and procedures, their right to withdraw from the study at any time and the fact that data would be anonymized by removing personal or identifiable information. Informed consent was obtained prior to participation, including consent for audio recording of the sessions. Furthermore, to ensure a clear and consistent understanding among participants, definitions used in this study were reiterated and explained in more detail at the beginning of each GMB session and, if needed, during the sessions. For example, the definitions of (non-specific) LBP, demand for LBP imaging, and inappropriate imaging were discussed before and during the sessions. Furthermore, we discussed when imaging of LBP is not appropriate according to the literature.\u003c/p\u003e \u003cp\u003eFurthermore, we explained to participants that we were also interested in identifying feedback loops. These are cyclical (causal) relations between factors that are initiated by a change in a certain factor, influencing other factors and, eventually, also the factor that first changed. For example, insecure or uncertain patients may demand LBP imaging to gain information about their health status. However, because the primary cause of most LBP cases often remains unknown, the resulting uncertainty persists, potentially leaving patients even more uncertain about their health status.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data collection\u003c/h2\u003e \u003cp\u003e At the beginning of each GMB session, we encouraged participants to introduce factors and relations that they deemed relevant from their own experiences. When necessary, we used a topic list to actively prompt participants about factors and relations that were found in the literature but not (yet) mentioned during the session (see supplementary materials appendix 1). This topic list was based on a systematic review of factors contributing to patients\u0026rsquo; demand for low-value care (i.e., unnecessary or potentially harmful care) in general [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and complemented by a scoping literature search to identify any additional factors specifically associated with patients\u0026rsquo; demand for LBP imaging (see supplementary materials appendix 2).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Data analysis\u003c/h2\u003e \u003cp\u003eRecordings of the GMB sessions were transcribed verbatim. Text fragments containing factors and/or relations agreed by participants to be relevant were highlighted. Next, we extracted these text fragments from the transcripts and converted them into words-and-arrow-diagrams [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. These diagrams provide an overview of the factors, the (causal) relations between factors, and the polarity of these relations (i.e., positive, or negative) as identified in each text fragment. Positive polarity indicates that factors were anticipated to change in the same direction, while negative polarity indicates opposite directions in change. We used themes from a systematic review [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and from a complementary literature search on LBP imaging (see supplementary materials appendix 2) as a basis to characterize and categorize factors identified during the GMB sessions. For example, the experience of lower back discomfort, strain, tension or soreness was identified as \u0026lsquo;\u0026rsquo;pain\u0026rsquo;\u0026rsquo; and categorized as a biomedical factor driving patients\u0026rsquo; demand for imaging. The (causal) relations and polarities were identified by observing the order in which events where described, and by examining signal words regarding cause and effect as used by participants. For example, \u0026ldquo;I think that an important driver for inappropriate imaging is the uncertainty that patients feel, when they hear that the cause cannot be determined\u0026rdquo; (participant G) or \u0026ldquo;If you want to do something about the additional diagnostics, then you will have to reduce the amount of practice variation\u0026rdquo; (participant E).\u003c/p\u003e \u003cp\u003eWe followed the structure of the words-and-arrow diagrams to create a CLD for each session. Next, the CLD of each session was sent to all participants for feedback and validation purposes. They were asked to check whether the mapping and data interpretation of the factors and relations in the CLD aligned with their experiences and beliefs. Following this review by participants, we merged the two CLDs into one final CLD. This was done by first looking for similarities between the CLDs and adopting similar factors and connections in the final CLD. Next, the remaining factors and connections that were mentioned in only one of the sessions were incorporated. For example, in one session, participants stated that severe LBP complaints could result in reduced strength and eventually in disability. In the other session, participants only made the connection that severe LBP complaints could result in disability. When similar factors were mentioned in both sessions but connected in different ways, we incorporated the connections that covered the essence expressed by GMB participants in a more detailed manner. In some cases no clear consensus was reached amongst participants. For example some factors raised by a single participant based on their professional knowledge or unique experiences could not be discussed in detail due to limited expertise of other participants. In these cases we (the authors) reviewed these factors and included them in the CLD if they aligned with the literature, did not conflict with other session insights, and/or were supported by (part of the) other participants.\u003c/p\u003e \u003cp\u003eFurthermore, we analyzed the relations and feedback loops to determine how they impact other factors, relations, other feedback loops in the CLD and patients\u0026rsquo; demand for LBP imaging in particular. This was done by conducting visual if-then simulations [\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e]. That is, suppose we would increase the intensity or impact of one factor (included in a feedback loop), how would it influence the chain of all other factors related to it? We checked and recorded if these impacted factors would increase, decrease, or even reinforce changes, leading to further amplification or reduction of their effects on the CLD. For example, if patients\u0026rsquo; perceived insecurity increased, then the factors connected to it should also change. This may cause a feedback loop if the effects of the initial change in insecurity, through the factors affected, eventually affects perceived insecurity itself. Two types of feedback loops exist. Reinforcing feedback loops amplify change in the factors and system as a whole. Balancing feedback loops counteract change in the factors or in the system and lead to stability in the system. Dependent on the type of feedback loop (reinforcing or balancing), all other adjacent feedback loops, factors and their relational effects affected by this loop are either enhanced or mitigated.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Literature-based validation\u003c/h2\u003e \u003cp\u003eAs a final step, we examined the literature on LBP for examples of evidence for the relationships provided by the participants and depicted in the CLD. These examples of evidence validate to a certain degree whether the included factors and connections in the CLD are substantiated by research or merely tentative claims. However, the majority of the literature does not examine relationships or associations between factors in a causal manner as presented in the CLD. Many studies are exploratory in nature and focus primarily on determining the strength of correlations or relationships between factors. As a result these (exploratory) studies do not always explicitly report the specified polarity or direction of the examined relationships between factors (i.e., whether the relationship is positive or negative). Therefore, we included articles that either explicitly reported relationships between factors as presented in the CLD, or suggested their potential existence through written descriptions or conceptual discussion \u0026mdash; even when the polarity of the relationship was not clearly specified.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Participants\u003c/h2\u003e \u003cp\u003eFor the first session, we invited 6 participants that all consented to participate. For the second session 5 participants were invited, however two were willing but not able to participate on the day of the session (See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Therefore, the first GMB session consisted of six participants and the second session of three participants. Both groups consisted of patients and experts within the field of musculoskeletal disorders, in particular 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 domain table\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup model building session 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFields of expertise / occupation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale patient with low back pain\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale patient with low back pain\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePain medicine and anesthesiology practitioner and researcher, and male patient with low back pain\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysiotherapist\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant E\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrthopedic surgeon\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral practitioner, and epidemiologist\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGroup Model building session 2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFields of expertise / occupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant G\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale patient with low back pain\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant H\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysiotherapist and researcher concerning low back pain\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeurologist\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.2 The causal loop diagram\u003c/h2\u003e \u003cp\u003eThe final CLD contains 32 factors, and 50 relations between them, all expected to drive patients\u0026rsquo; demand for LBP imaging (see Fig.\u0026nbsp;1). Appendix 3 contains the definitions used within this study for each factor in the CLD. The depicted relations were either positive and displayed with a blue arrow (i.e., 43 of 50 relations), or negative and displayed with a red arrow (i.e., 7 of 50 relations). Furthermore, we found eight reinforcing feedback loops (R1 to R8), which will be discussed below accompanied by separate figures highlighting each loop, corresponding factors and relations. In this manner all aspects of the CLD are discussed. Additionally, supporting examples of evidence from the literature were added to the results to validate the relationships in the CLD (see 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\u003eExamples of evidence from the literature\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=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor and year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMethod\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTitle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCausal sequence of connected factors \u003c/p\u003e \u003cp\u003e(read from top to bottom)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExamples of evidence found in the literature\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEspeland et al. (2001) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u0026rsquo; Views on Importance and Usefulness of Plain Radiography for Low Back Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Unidentifiable cause\u003c/p\u003e \u003cp\u003e-Acute pain or Chronic pain\u003c/p\u003e \u003cp\u003e-Severity of low back pain complaints\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients stated that radiologic imaging was necessary because their unidentified pain was long lasting or worsening.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarijana et al. (2021) [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative methods: Interviews and focus groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDevelopment of a Patient-Oriented Intervention to Support Patient-Provider Conversations about Unnecessary Lower Back Pain Imaging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Unidentifiable cause\u003c/p\u003e \u003cp\u003e-Acute and/or Chronic pain \u003c/p\u003e \u003cp\u003e-Severity of low back pain complaints\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients wanted to find out what was wrong with them, because the low back pain that had gotten worse.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChou et al. 2018) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic scoping review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients' perceived needs of health care providers for low back pain management: a systematic scoping review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Unidentifiable cause \u003c/p\u003e \u003cp\u003e-Acute or Chronic Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThere was a need to obtain a diagnosis and a cause of the experienced pain.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNieminen et al. (2021) [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrognostic factors for pain chronicity in low back pain: a systematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Unidentifiable cause \u003c/p\u003e \u003cp\u003e-Acute or Chronic Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA Higher intensity of pain was associated as one of the risks factors for chronic low back pain\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDionne et al. (2018) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProspective cohort study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePsychological distress confirmed as predictor of long-term back-related functional limitations in primary care settings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Chronic pain\u003c/p\u003e \u003cp\u003e-Stress\u003c/p\u003e \u003cp\u003e-Severity of low back pain complaints\u003c/p\u003e \u003cp\u003e-(Reduced strength and) Disability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThis study provides evidence that psychological distress can predict long-term severe functional limitations among LBP patients.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTsang et al. (2008) [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommon chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Chronic pain\u003c/p\u003e \u003cp\u003e-Stress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThis study provides evidence that chronic back pain may contribute to mental disorders such as stress that patients experience.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAhmed et al. (2022) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUndiagnosed anxiety and depression in patients presenting for evaluation of chronic low back pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Chronic pain\u003c/p\u003e \u003cp\u003e-Stress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChronic pain, physical and psychological distress may lead to or aggravate the major psychological event.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChoi et al. (2021) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAssociation between chronic low back pain and degree of stress: a nationwide cross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Chronic pain \u003c/p\u003e \u003cp\u003e-Stress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThere exists a significant association between chronic low back pain and stress.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYang and Haldeman (2020) [\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChronic Spinal Pain and Financial Worries in the US Adult Population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Chronic pain\u003c/p\u003e \u003cp\u003e-Severity of low back pain complaints\u003c/p\u003e \u003cp\u003e-Income-related concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFinancial concerns were associated with chronic spinal pain.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChiarotto et al. (2019) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMeasurement Properties of Visual Analogue Scale, Numeric Rating Scale, and Pain Severity Subscale of the Brief Pain Inventory in Patients With Low Back Pain: A Systematic Review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Severity of low back pain complaints\u003c/p\u003e \u003cp\u003e-(Reduced strength and) disability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThere exists a positive correlation between pain severity and disability.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVon Korff et al. (1992) [\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuantitative longitudinal study for scale development and validation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGrading the severity of chronic pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Severity of low back pain complaints\u003c/p\u003e \u003cp\u003e-(Reduced strength and) disability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe study acknowledges a relationship between pain intensity and disability.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHarahap et al. (2021) [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescriptive correlation study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRelationship between pain intensity and disability in chronic low back pain patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Severity of low back pain complaints\u003c/p\u003e \u003cp\u003e-(Reduced strength and) disability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe study provides evidence that the intensity of low back pain is related to patients' disability.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZaman et al. (2021) [\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview paper: topical review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUncertainty in a context of pain: disliked but also more painful?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Severity of low back pain complaints\u003c/p\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUncertainty experienced by patients was related to how they conceive the origin of their pain\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReesor and Craig (1988) [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview paper: topical review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedically incongruent chronic back pain: Physical limitations, suffering, and ineffective coping.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Severity of low back pain complaints\u003c/p\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot knowing the cause of low back pain is associated with pain intensity.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZhou et al. (2024) [\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase-control study with multivariate analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRecent clinical practice guidelines for the management of low back pain: a global comparison\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Severity of low back pain complaints\u003c/p\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVariability of the (acute or chronic) low back pain was associated with uncertainty.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChou et al. (2018) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic scoping review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients' perceived needs of health care providers for low back pain management: a systematic scoping review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Severity of low back pain complaints\u003c/p\u003e \u003cp\u003e-Adherence to medical guidelines by provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eImaging was associated with the severity of low back pain.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWilson et al. (2001) [\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-sectional survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients' Role in the Use of Radiology Testing for Common Office Practice Complaints\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Severity of low back pain complaints\u003c/p\u003e \u003cp\u003e-Adherence to medical guidelines by provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe severity of low back pain was associated with imaging utilization.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHall et al. (2021) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview article: Practices focused\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDo not routinely offer imaging for uncomplicated low back pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Knowledge gaps in providers' medical training\u003c/p\u003e \u003cp\u003e-Adherence to medical guidelines by provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLacking awareness and knowledge on how to use the current low back pain guidelines may contribute to imaging usage.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKool et al. (2020) [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-sectional survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAssessing volume and variation of low-value care practices in the Netherlands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Adherence to medical guidelines\u003c/p\u003e \u003cp\u003e-Denial and/or deferral of imaging by provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eData from 2016 demonstrated that most Dutch healthcare professionals adhered the recommendations for low back pain imaging.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTan et al. (2016) [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVariation among Primary Care Physicians in the Use of Imaging for Older Patients with Acute Low Back Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Adherence to medical guidelines by provider\u003c/p\u003e \u003cp\u003e-Practice variation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePhysicians imaging ordering behaviour for low back pain may vary substantially.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBraeuninger-Weimer et al. (2021) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProspective cohort study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReassurance and healthcare seeking in people with persistent musculoskeletal low back pain consulting orthopaedic spine practitioners: A prospective cohort study'\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Interaction with the provider\u003c/p\u003e \u003cp\u003e-Trust in the provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eParticipants stated that there was poor communication and lack of trust between provider and patient.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlokzijl et al. (2021) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative methods: Interviews and focus groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderstanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Interaction with the provider\u003c/p\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClinicians thought that their colleagues could not provide adequate information and reassurance to prevent imaging.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEspeland et al. (2001) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u0026rsquo; views on Importance and Usefulness of Plain Radiography for Low Back Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Practice variation\u003c/p\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA patients wanted imaging because of a disagreement between two physicians concerning the cause of the patient's low back pain.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerbic and Pincus (2014) [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuasi experiment: quantitative mixed factorial designs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiagnostic uncertainty and recall bias in chronic low back pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Disability \u003c/p\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDepression and disability were associated with diagnostic uncertainty (i.e., uncertainty of what is happening in the patients' back).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerbic et al. (2016) [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStructural Equation modelling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiagnostic uncertainty, guilt, mood, and disability in back pain.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Disability\u003c/p\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDiagnostic uncertainty was related to disability. Patients were found to be uncertain of exercising, which is an effective treatment to reduce low back pain.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReesor and Craig (1988) [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview paper: topical review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedically incongruent chronic back pain: Physical limitations, suffering, and ineffective coping.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Disability\u003c/p\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot being able to identify the source of pain was associated with disability.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChou et al. (2012) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview paper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAppropriate use of lumbar imaging for evaluation of low back pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Income-related concerns\u003c/p\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLow back pain imaging is often performed to evaluate a workman's compensation, even if this does not improve the outcomes of the patients.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEspeland et al. (2001) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u0026rsquo; Views on Importance and Usefulness of Plain Radiography for Low Back Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Income-related concerns\u003c/p\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients stated that imaging was needed to get sickness certification or a pension for disability. (Even when imaging did not find the cause of the experienced pain).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraeger et al. (2022) [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview paper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow back pain in people aged 60 years and over\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Stage of life\u003c/p\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003cp\u003e-Unidentifiable cause \u003c/p\u003e \u003cp\u003e-Chronic (low back) pain\u003c/p\u003e \u003cp\u003e-Severity of low back pain complaints\u003c/p\u003e \u003cp\u003e-(reduced strength) and Disability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePeople of the age of 60 and beyond have a higher probability to experience persisting and incapacitating low back pain. For a majority of the cases the cause of low back pain cannot be found.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlokzijl et al. (2021) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative methods: Interviews and focus groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderstanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Patients' unawareness \u003c/p\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClinicians stated that patients had unrealistic beliefs concerning the benefits and low awareness about the potential harms of imaging.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlokzijl et al. (2021) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative methods: Interviews and focus groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderstanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Influence of social network \u003c/p\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClinicians believed that patients pressured them to receive imaging from a need of reassurance, and patients could expect imaging based on their relatives.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEspeland et al. (2001) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u0026rsquo; views on Importance and Usefulness of Plain Radiography for Low Back Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Influence of social network \u003c/p\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSome patients had a friend or family member who had a serious illness that doctors overlooked for along time. These relatives stated that it was better to conduct radiography sooner than later.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCosta et al. (2022) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-qualitative method: Thematic analysis of interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe ubiquity of uncertainty in low back pain care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003cp\u003e-Stress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStress and uncertainty were strongly correlated and could affect patients with low back pain.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlokzijl et al. (2021) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative methods: Interviews and focus groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderstanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003cp\u003e-Confirmation bias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eImaging provides certainty about the condition of patients and it can validate their pain.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChou et al. (2018) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic scoping review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients' perceived needs of health care providers for low back pain management: a systematic scoping review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003cp\u003e-Confirmation bias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients believed that imaging provided reassurance and confirmation of physician's diagnosis.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChou et al. (2018) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic scoping review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients' perceived needs of health care providers for low back pain management: a systematic scoping review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003cp\u003e-Confirmation bias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eImaging was used to legitimise the back pain of patients. When imaging was used to find a physical defect it provided closure and relief to patients.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLim et al. (2019) [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePeople with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies: a systematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003cp\u003e-Confirmation bias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThrough imaging patients were reassured and received confirmation of their diagnosis.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEspeland et al. (2001) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u0026rsquo; views on Importance and Usefulness of Plain Radiography for Low Back Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003cp\u003e-Fear and anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients with low back pain were uncertain and anxious.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEspeland et al. (2001) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u0026rsquo; views on Importance and Usefulness of Plain Radiography for Low Back Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003cp\u003e-Imperative knowledge bias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients wanted to know what was wrong with them and why they experienced pain.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEspeland et al. (2001) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u0026rsquo; views on Importance and Usefulness of Plain Radiography for Low Back Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Confirmation bias \u003c/p\u003e \u003cp\u003e-Imperative knowledge bias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExamination was considered to be important to find out what was wrong.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEspeland et al. (2001) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u0026rsquo; views on Importance and Usefulness of Plain Radiography for Low Back Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Confirmation bias \u003c/p\u003e \u003cp\u003e-Imperative knowledge bias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients wanted to know what was wrong, why they were in pain, and wanted to put a name to it.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarijana et al. (2021) [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative methods: Interviews and focus groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDevelopment of a Patient-Oriented Intervention to Support Patient-Provider Conversations about Unnecessary Lower Back Pain Imaging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Imperative knowledge bias \u003c/p\u003e \u003cp\u003e-Imperative action bias\u003c/p\u003e \u003cp\u003e-Low back pain imaging demand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients considered imaging to be important, because they wanted something to happen with their pain.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEspeland et al. (2001) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u0026rsquo; views on Importance and Usefulness of Plain Radiography for Low Back Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Fear and anxiety\u003c/p\u003e \u003cp\u003e-Imperative knowledge bias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUncertain or anxious patients considered imaging to be important to stop worrying and receive some answers.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlokzijl et al. (2021) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative methods: Interviews and focus groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderstanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Influence of social network\u003c/p\u003e \u003cp\u003e-Entitlement to care\u003c/p\u003e \u003cp\u003e-Patients' expectations\u003c/p\u003e \u003cp\u003e-Low back pain imaging demand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients formed expectations to receive imaging based on the information received from their relatives.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlokzijl et al. (2021) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative methods: Interviews and focus groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderstanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Patients' experiences\u003c/p\u003e \u003cp\u003e-Patients' expectations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExpectations for imaging were based on previous health encounters.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChou et al (2012) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview paper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAppropriate use of lumbar imaging for evaluation of low back pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Patients' experiences\u003c/p\u003e \u003cp\u003e-Patients' expectations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients that received imaging for an episode of low back pain could expect this for future episodes.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlokzijl et al. (2021) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative methods: Interviews and focus groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderstanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Marketing influences\u003c/p\u003e \u003cp\u003e-Patients' expectations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExpectations for imaging were based on media sources.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJenkins et al. (2016) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurvey study: Descriptive statistics and multivariate logistic regression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderstanding patient beliefs regarding the use of imaging in the management of low back pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Cultural background\u003c/p\u003e \u003cp\u003e-Patients' expectations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients with a non-European and non-Anglo-Saxon cultural background had an increased belief or need for imaging.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarijana et al. (2021) [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative methods: Interviews and focus groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDevelopment of a Patient-Oriented Intervention to Support Patient-Provider Conversations about Unnecessary Lower Back Pain Imaging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Patients' expectations \u003c/p\u003e \u003cp\u003e-Low back pain imaging demand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients thought that imaging was necessary to diagnose low back pain.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChou et al. (2018) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic scoping review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients' perceived needs of health care providers for low back pain management: a systematic scoping review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Patients' expectations \u003c/p\u003e \u003cp\u003e-Low back pain imaging demand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients expected to be referred for an x-ray.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDe Carvalho et al. (2021) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-sectional survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKnowledge of and adherence to radiographic guidelines for low back pain: a survey of chiropractors in Newfoundland and Labrador, Canada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Patients' expectations \u003c/p\u003e \u003cp\u003e-Low back pain imaging demand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients expected to be referred to receive an x-ray.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEspeland et al. (2001) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u0026rsquo; views on Importance and Usefulness of Plain Radiography for Low Back Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Patients' expectations \u003c/p\u003e \u003cp\u003e-Low back pain imaging demand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients' expected radiography to help with decisions for follow-up treatment (operations, chiropractic therapy and physiotherapy).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJenkins et al. (2016) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurvey study: Descriptive statistics and multivariate logistic regression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderstanding patient beliefs regarding the use of imaging in the management of low back pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Patients' expectations\u003c/p\u003e \u003cp\u003e-Low back pain imaging demand\u003c/p\u003e \u003cp\u003e-Low back pain imaging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients' beliefs may contribute to imaging for low back pain.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEspeland et al. (2001) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u0026rsquo; views on Importance and Usefulness of Plain Radiography for Low Back Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Denial and/or deferral of imaging by provider\u003c/p\u003e \u003cp\u003e-Patients' dissatisfaction and rejection of evidence and recommended care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients may be dissatisfied when physicians provide an explanation of their symptom. These patients believed that imaging provides a better explanation of their symptom.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEspeland et al. (2001) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u0026rsquo; views on Importance and Usefulness of Plain Radiography for Low Back Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Denial and/or deferral of imaging by provider\u003c/p\u003e \u003cp\u003e-Patients' dissatisfaction and rejection of evidence and recommended care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDissatisfied patients said that it was hopeless when you do not know what it is. These patients sought other explanations for their pain, because they wanted to know what it was.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePike et al. (2022) [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative method: Exploratory theoretical domain framework\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarriers to following imaging guidelines for the treatment and management of patients with low-back pain in primary care: a qualitative assessment guided by the Theoretical Domains Framework\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Denial and/or deferral of imaging by provider\u003c/p\u003e \u003cp\u003e-Patients' dissatisfaction and rejection of evidence and recommended care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePhysicians reported that it was difficult to convince patients that imaging is not necessary. However, the physicians believed that imaging could reduce frustration and anxiety, and improve patient satisfaction.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTaylor and Bishop (2020) [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScoping review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatient and public beliefs about the role of imaging in the management of non-specific low back pain: a scoping review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Denial and/or deferral of imaging by provider \u003c/p\u003e \u003cp\u003e-Patients' dissatisfaction and rejection of evidence and recommended care\u003c/p\u003e \u003cp\u003e-Consumerism\u003c/p\u003e \u003cp\u003e-Low back pain imaging demand\u003c/p\u003e \u003cp\u003e-Imaging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients denied imaging sought it elsewhere.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKendrick et al. (2001) [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnblinded Randomised control trial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe role of radiography in primary care patients with low back pain of at least 6 weeks duration: a randomised (unblinded) controlled trial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Patients' dissatisfaction and rejection of evidence and recommended care\u003c/p\u003e \u003cp\u003e-Perceived insecurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients that received imaging were reported to be more satisfied but not less worried or reassured.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChou et al (2018) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic scoping review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients' perceived needs of health care providers for low back pain management: a systematic scoping review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Patients' dissatisfaction and rejection of evidence and recommended care\u003c/p\u003e \u003cp\u003e-Consumerism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDissatisfied LBP patients may seek care from other providers and overutilize healthcare resources.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChou et al. (2011) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview paper: Clinical guideline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e- Patients' dissatisfaction and rejection of evidence and recommended care\u003c/p\u003e \u003cp\u003e-Low back pain imaging demand\u003c/p\u003e \u003cp\u003e-Low back pain imaging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWhen patients express dissatisfaction there is a likelihood that imaging practices increase,\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEspeland et al. (2001) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u0026rsquo; views on Importance and Usefulness of Plain Radiography for Low Back Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-Patients' dissatisfaction and rejection of evidence and recommended care \u003c/p\u003e \u003cp\u003e-Low back pain imaging demand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDissatisfied with the explanation of their healthcare providers, patients kept believing that imaging would be better.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003ea\u003c/sup\u003e The presented factors and connections follow the structure of the CLD from left to right (see Fig.\u0026nbsp;1).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eLoop R1\u003c/b\u003e \u003cb\u003e\u0026ldquo;Non-specific pain and uncertainty\u0026rdquo;\u003c/b\u003e\u003c/p\u003e \u003cp\u003eLoop R1 (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e) depicts how inability to find the cause of the experienced pain leads to stress, increases the severity level of patients\u0026rsquo; LBP complaints, disability and perceived insecurity. Interpreting the figure from left to right, the inability to determine the source of patients\u0026rsquo; LBP was expected to influence the acute or chronic pain experienced by patients. Chronic LBP could also influence the amount of stress felt by patients, which in turn may influence how severe their LBP complaints are. Both types of pain were considered as common experiences among LBP patients and were expected to contribute to the severity of patients\u0026rsquo; LBP complaints.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePatients were expected to perceive several insecurities as a result of their LBP. For instance, health-related insecurities were mentioned, and these were often expected to depend on factors associated with the severity of patients\u0026rsquo; LBP complaints. For example, the combination of not being able to identify the source of LBP and the persistence of this pain could make patients uncertain about their situation. Furthermore, patients with severe LBP complaints may experience loss of strength in their legs and hips, and the resulting disabilities could make them feel more insecure about what is wrong with them.\u003c/p\u003e \u003cp\u003eIn addition, comorbidities were also argued to influence patients\u0026rsquo; health-related insecurities. LBP patients suffering from other (chronic) diseases, caused by or closely related to their LBP, may experience increased health-related insecurities. Stage of life, which encompasses age and health-related problems associated with aging, was also mentioned as a factor contributing to patients\u0026rsquo; perceived health-related insecurities. For example, participants stated that younger patients were often caught off-guard by their LBP complaints as they did not expect to experience LBP at their current stage of life.\u003c/p\u003e \u003cp\u003ePatients\u0026rsquo; perceived insecurity could also be socially induced, through influences or pressure of friends and family to find out what is wrong. Patients with LBP often do not know what to do with such pressure, and so may become (more) insecure. Patients\u0026rsquo; unawareness of the causes of their LBP was also expected to result in increased insecurity. Furthermore, income-related concerns were also argued to influence patients\u0026rsquo; perceived insecurity. LBP patients were expected to be less able or sometimes even completely incapable to do their job, resulting in presenteeism, absenteeism, and potentially even unemployment. This loss of work productivity may negatively affect income and worries about present and future income may increase perceived insecurity.\u003c/p\u003e \u003cp\u003e Furthermore, patients\u0026rsquo; perceived insecurity was also argued to be reliant on the adherence to LBP guidelines by providers. Decreased adherence to guidelines by providers may cause and increase practice variation. While an expansion of available care options may seem positive for patients, it is questionable whether this is the case. Practice variation was considered to influence patients in a negative manner and contribute to patients\u0026rsquo; insecurity, because they would hear multiple \u0026ldquo;truths\u0026rdquo; of what could cause their pain and how this should be treated. However, in most cases, providers comply to the guidelines and recommend patients to avoid additional diagnostical services (such as imaging), because the cause of non-specific LBP cannot be found.\u003c/p\u003e \u003cp\u003eFinally, participants argued that increased perceived insecurity could influence and reinforce factors included in loop R1, through increasing patients\u0026rsquo; stress level and, subsequently, the severity of patients\u0026rsquo; LBP complaints, and eventually patients\u0026rsquo; insecurity itself.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLoop R2 \u0026lsquo;\u0026rsquo;Uncertainty avoidance\u0026rdquo;\u003c/b\u003e \u003c/p\u003e \u003cp\u003eLoop R2 (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e) illustrates the main rationale for patients to demand LBP imaging. Interpreted from left to right, patients\u0026rsquo; insecurity could motivate patients in three different ways towards thinking that knowing more about their LBP complaints is better (i.e., the imperative knowledge bias). First, participants argued that patients\u0026rsquo; insecurity may directly influence this imperative knowledge bias. Patients with LBP often face uncertainty about the causes and/or consequences of their condition, and tend to think that knowing more is better. Second, this desire to know more may be indirectly influenced by patients\u0026rsquo; fear and anxiety about their situation. For example, LBP patients might become immobilized by pain or attempt to restrict movements due to fear of injury or to avoid pain. Third, through the confirmation bias, patients could be inclined to try and seek more information to obtain proof that their pain is real.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAdditionally, patients\u0026rsquo; imperative knowledge bias was argued to depend on patients\u0026rsquo; expectations of receiving LBP imaging. These expectations may be the result of influences from their social network. For example, experiences shared by friends, family, and relatives receiving care in similar situations, can create a sense of entitlement and lead patients to expect similar treatment. It was also mentioned that patients\u0026rsquo; expectations could be influenced by marketing, the cultural background of patients, and their past experiences with imaging. Marketing could influence expectations, for instance, through stories in magazines of other patients that were able to determine the cause of their pain through imaging. Participants reasoned that these success stories could result in misconceptions among patients that LBP imaging would provide more information about the origin of their pain. Regarding cultural background, participants argued that patients from countries with less strict clinical guidelines and easier access to LBP imaging, may expect to receive the same treatment when seeking care in other countries. Turning to the past experiences, previous experiences with receiving imaging were thought to shape patients' expectations about similar care in the future.\u003c/p\u003e \u003cp\u003eMoreover, it was mentioned that patients\u0026rsquo; imperative knowledge bias is strongly related to the imperative action bias. More specifically, patients\u0026rsquo; tendencies to gain more information about their health status influences them to think that it is better to do something instead of nothing, and hence, demand LBP imaging. However, demand for LBP imaging is usually denied by providers, because clinical guidelines recommended evidence based care. This includes care does not focus on identifying the source of LBP, but focuses on improving daily activities, acceptance of pain (e.g. psychological help), or watchful waiting. Denial of imaging may prompt patient dissatisfaction, as they remain uncertain of the cause of their persisting pain. Conversely, it has been argued that clinicians may provide LBP imaging to increase patient satisfaction.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLoop R3 \u0026lsquo;\u0026rsquo;Dissatisfaction induced demand\u0026rsquo;\u0026rsquo;\u003c/b\u003e \u003c/p\u003e \u003cp\u003eLoop R3 (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e) illustrates how imaging demand can be reinforced. In certain cases, demand for LBP imaging may result in LBP imaging. GMB participants expected that, if this happens, most patients will remain undiagnosed, still receiving no clarity about the source of their pain. These patients would then be dissatisfied with the outcomes of imaging and, consequently, remain or become even more insecure. Patients could also immediately demand LBP imaging again, if they believe that initial imaging was conducted incorrectly.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLoop R4 \u0026ldquo;Denial induced Demand\u0026rdquo;\u003c/b\u003e \u003c/p\u003e \u003cp\u003eLoop R4 (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e) depicts how denial of LBP imaging may reinforce demand for LBP imaging. Interpreted from left to right, if providers deny or defer patients' demand for LBP imaging, patients may receive other recommended but non-preferred care, leading to dissatisfaction, rejection of recommended care, and increased demand for LBP imaging.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLoop R5 \u0026ldquo;Patient-provider relations\u0026rdquo;\u003c/b\u003e \u003c/p\u003e \u003cp\u003eLoop R5 and Loop R6 (see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e) are closely tied, and it illustrates how the interaction between healthcare providers and patients may result in increased perceived insecurity. In this section we focus on Loop R5 and its adjacent factors. We interpreted the figure starting from the left, moving downward, and then upward. When patients with LBP complaints visit their healthcare provider, they often receive care that aligns with the clinical guidelines concerning LBP. Adherence to the guidelines by providers is dependent on providers\u0026rsquo; knowledge of the guidelines, and on the severity of patients\u0026rsquo; LBP complaints. For example, patients with severe LBP complaints were expected to be more determined to receive imaging by trying to convince their healthcare provider to deviate from the recommendation in the guidelines. Loop R5 was argued to occur when providers adhere to the guidelines and deny imaging. Patients were anticipated to lose trust in their provider and experience their interaction with them as negative. This cycle was expected to continue and to reinforce itself, possibly as long as imaging is not provided.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eLoop R6 \u0026ldquo;Doubt\u0026rdquo;\u003c/b\u003e \u003c/p\u003e \u003cp\u003eLoop R6 functions as an intermediary loop, connected to loops R5 and R7 (see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e). This loop depicts how negative interactions with providers and patients\u0026rsquo; insecurity mutually influence each other. Participants stated that persistent insecurity about what causes their pain is a primary reason for patients to value interactions with care providers negatively. These patients were reasoned to remain or become even more insecure from the interactions with their care provider, reinforcing their perception of the interaction with their provider to be negative or unhelpful.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLoop R7 \u0026ldquo;Dissatisfaction escalation\u0026rsquo;\u0026rsquo;\u003c/b\u003e \u003c/p\u003e \u003cp\u003eLoop R7 illustrates how perceived insecurity and patients\u0026rsquo; dissatisfaction and rejection of evidence and care recommended by the provider mutually influence and reinforce each other (see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Participants argued that patients who feel insecure about their situation believe that identifying the cause of their pain should be part of the treatment plan before any suggestions towards recovery are made. However, during primary care consults, pain complaints of patients are often not adequately acknowledged by care providers and no diagnosis is provided, making patients feel that they have not received a solution for their problem. Thus, in this scenario, patients remain uncertain and become increasingly dissatisfied with the evidence-based recommendations of their care provider, who in their perception do not focus on identifying the source of their pain, and these factors may continue to reinforce each other.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLoop R8 \u0026lsquo;\u0026rsquo;Shopping for validation\u0026rsquo;\u0026rsquo;\u003c/b\u003e \u003c/p\u003e \u003cp\u003eLoop R8 (see Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e) provides insights into why patients shop around to receive their preferred care. Providers following medical guidelines may deny or defer LBP imaging, recommending other treatments or watchful waiting first. Patients were expected to reject recommended care and evidence of medical guidelines, believing treatment is only effective if the cause of their pain is identified. Dissatisfied, they may seek LBP imaging or non-conventional treatments, while remaining or becoming more dissatisfied, and continue to shop for answers.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eParticipants reasoned that some patients could be satisfied in the short term with shopping for non-conventional care, even when this care does not detect the cause of their pain. This was suggested to be often done after receiving no LBP imaging referral from their healthcare provider. These patients were argued to view consumption of non-conventional care as a checklist of available options, hoping one of them could help. However, these non-conventional care options will not help in the long term, resulting in dissatisfaction and continuation of shopping for preferred care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Literature-based validation\u003c/h2\u003e \u003cp\u003eWe found 34 sources that discuss the relationships in the CLD and support the findings from the GMB sessions (See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These sources include quantitative and qualitative research articles, and scoping and systematic reviews. Articles presenting findings of empirical research applied either quantitative methods (i.e., 18 of 34), qualitative methods (i.e., 5 of 34), or mixed methods (i.e., 1 of 34). Articles focusing more on the literature were either systematic reviews (i.e., 6 of 34) or other assessments of the literature (i.e., 4 of 34). These sources contained examples of evidence for 49 of the 50 relations depicted in the CLD. The single connection that could not be underpinned with literature was the connection between the factors comorbidity and perceived insecurity.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe aim of this study was to explore and map factors that drive patients\u0026rsquo; demand for LBP imaging and their relations. Intrinsic to this problem is that for most patients the cause of the pain they experience cannot be identified, which results in insecurity about their situation and dissatisfaction with healthcare providers. Two GMB sessions were organized with patients and healthcare professionals, and a final CLD was developed providing insight in how psychological, socio-cultural, system and biomedical factors drive patients\u0026rsquo; demand for LBP imaging. Additionally, the CLD offers insight in reinforcing loops that contribute to this demand for imaging.\u003c/p\u003e \u003cp\u003eThe final CLD consists of 32 factors, 50 relations, and eight reinforcing loops concluded to drive LBP patients\u0026rsquo; demand for imaging. The factors included in the CLD correspond to factors found in the literature on drivers concerning patients\u0026rsquo; demand for LBP imaging [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e] (see also Appendix 1). In addition, the potential existence of 49 of the 50 relations depicted in the CLD were also supported by evidence from the literature (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Furthermore, many of the factors, relations and feedback loops found in this study correspond to those found in a similar study that focused on patients\u0026rsquo; demand for low-value care (see supplementary materials appendix 4). Therefore, this study provides case-specific evidence on unnecessary LBP imaging supporting generic evidence of factors contributing to patients\u0026rsquo; demand for unnecessary or potentially harmful care. These findings may point towards the existence of certain universal patterns explaining demand for low-value care that possibly are also relevant in other case-specific contexts [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough, such universal patterns may exist, particular factors and relations may be relevant in specific contexts. For example, in this study, the factors connected to the unidentifiable cause, denial and/or deferral of imaging, patients\u0026rsquo; dissatisfaction and rejection of evidence and recommended care, and the relations connected to this factor were essential for understanding patients\u0026rsquo; demand for LBP imaging. These factors and relationships may only exists or have a significant role in imaging-related contexts where patients demand unnecessary imaging, such as demand for imaging in headache disorders without alarming symptoms [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMoreover, through the CLD we understand that factors originally anticipated to reduce demand for imaging may function counterintuitively and, instead, foster demand. For instance, providers tend to adhere to medical guidelines and evidence-based care, which indicate against imaging. However, this adherence (i.e., the denial of imaging) was argued to enhance patients\u0026rsquo; feelings of insecurity and dissatisfaction with care. Imaging does not reveal the source of their pain, and may provoke patients\u0026rsquo; preference for LBP imaging and/or other non-conventional interventions. This process eventually resulted in a reinforced demand for imaging (see loops R4 and R7). On the other hand, non-compliance with guidelines may result in clinical practice variation and encourage patients to shop around for imaging or other non-conventional care, reinforcing their feelings of insecurity (see loops R3, R7-R8). Thus, it becomes conceivable that some providers are faced with a dilemma to either comply or deviate from the guideline when both options may lead to the same undesirable result. Determining which of the two scenarios will prevail in practice is a matter for empirical follow-up research.\u003c/p\u003e \u003cp\u003eNotwithstanding the insights drawn from this study, it is important to acknowledge a few limitations. First, the final CLD may not provide a complete overview of all the factors and relations that have an influence on patients\u0026rsquo; demand for LBP imaging. The CLD was primarily based on introspections of and consensus between participants in the two GMB sessions. They provided insights from their experiences as a patient or as a healthcare professional of factors and relations contributing to patients\u0026rsquo; demand for LBP imaging. Moreover, many of the factors and relations mentioned were also found in the literature. Still, it is possible that other participants\u0026thinsp;\u0026minus;\u0026thinsp;from the Netherlands but perhaps especially from countries with other healthcare systems and practices\u0026thinsp;\u0026minus;\u0026thinsp;would have mentioned other factors and relations. Furthermore, the CLD does not inform about the strength of the different relations, feedback loops, and the time needed for these relations to effectuate. Despite this, the current CLD should be seen as a basic framework that provides information about the complex system of demand for LBP imaging and can be used to formulate hypotheses about factors and relations that could be further explored or empirically tested [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Through testing and validation of these factors and relations, the current CLD can be used as a stepping-stone to better understand imaging demand by creating more accurate CLD\u0026rsquo;s and gain more insight in potentially effective leverage points for reducing the demand for imaging.\u003c/p\u003e \u003cp\u003eSecond, one might argue that the overlap between this study\u0026rsquo;s findings and existing literature is a result of using a topic list that was partially derived from previous studies. However, we refrained from using the topic list to steer participant input until no participant input emerged. This underscores the predominantly participant-driven nature of the data even when researchers\u0026rsquo; prompts were introduced. The topic list was primarily used as a reference to identify relevant factors and relations that could summarize the broad discussions during the sessions.\u003c/p\u003e \u003cp\u003eThe third limitation is related to the knowledge gaps of participants to identify and/or specify how some factors precisely work and are related to each other. For example, GMB participants remained uncertain of whether and why patients with different cultural backgrounds may have different expectations of LBP imaging. Although a diverse group of participants with distinct backgrounds were included in the GMB sessions, the nature of this specific relation remained unclear. Therefore, it seems worthwhile to explore this relation in more detail in a larger and diverse sample (e.g., using a survey).\u003c/p\u003e \u003cp\u003eThe fourth limitation concerns the sample size of the study. While the sample size is modest (i.e., six participants in the first sessions and 3 in the second session), it does reflect deliberate focus on participants experiencing LBP and healthcare professionals with substantial domain expertise on this topic. Therefore, our sampling strategy focused on inviting and selecting knowledgeable key actors who are involved in this issue. This strategy proved successful, as it enabled us to engage relevant disciplines and participants with varying experiences. For example, all included healthcare professionals draw on various knowledge sources, such as their basic medical training, years of experience interacting with patients seeking imaging, and literature or research as some are also researchers. Other indications proving our strategy to be successful are related to the identified factors during the sessions. We found that the factors and relationships identified in the existing sessions closely align with the results of our scoping literature study (see supplementary materials appendix 2) and the broader literature on why patients demand low-value care interventions [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], including non-specific LBP imaging. To minimize our selection or sampling bias we asked participants at the end of each session to recommend us the names of individuals or occupations that should be involved in the study. We found however that occupations or names of participants that were already involved were named again.\u003c/p\u003e \u003cp\u003eLastly, although the CLD provides insight in the variety of factors that influence demand for LBP imaging and their relations, it remains challenging to identify leverage points for interventions in this complex system, where small changes in the system are expected to result in significant reductions of demand for imaging [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Previous research using network analysis to identify such leverage points based on the structure of CLDs showed that factors that are highly connected, have the shortest path to others factors, or factors that are connected to other important factors, may seem as promising intervention points in complex systems [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Alternatively, in system dynamic modelling (SDM) approaches factors with strong measured feedback loop effects or factors with large observed effect sizes are often identified as important leverage points in complex systems. However, system dynamic modelling (SDM) typically requires empirical data or expert estimates to define the strength of the causal relations or influences between factors in the system. When such information is unavailable, we propose a sensitivity analysis or binary SDM as alternative method to identify leverage points in complex systems. By defining a standardized minimum and maximum range effect size for each factor, the changes and impact of each factor over time can be explored through computational simulations. Despite providing some insights on the potential behaviour of the factors within the system, this approach may result in oversimplified relational effects and limited insight when used to identify effective leverage points.\u003c/p\u003e \u003cp\u003eDespite these limitations, the findings of this study provide valuable recommendations for policymakers and healthcare providers to reduce demand for imaging by LBP patients from a complex systems approach. Policymakers could focus on tackling patients\u0026rsquo; expectations to receive imaging, or dissatisfaction of (not) receiving imaging, and rejection of recommended care through education and continued use of awareness campaigns. There is already some evidence that campaigns focusing on explaining common misconceptions that LBP patients have about imaging, and how this may lead to cascades of low-value care, can be successful [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Furthermore, policymakers could enforce adherence to LBP guidelines through implementation of financial incentives that limit provision of inappropriate imaging, steer patients away from initially demanding this, and reduce shopping around for other harmful or unnecessary care substitutes. Based on the CLD, providers should focus on developing effective communication strategies to tackle patients\u0026rsquo; insecurity, dissatisfaction, avoid preference for imaging, and convince patients of recommended evidence-based care options. Furthermore, these strategies should focus on building a solid patient-provider relationship where patients may argue but eventually follow the recommendations, authority and experience of their provider [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e].\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eTo conclude, this study shows that patients\u0026rsquo; demand for LBP imaging primarily originates from a combination of chronic or acute pain, of which the cause in most cases cannot be identified. This results in insecurity about their situation, dissatisfaction with healthcare providers and rejection of evidence-based care. These factors interact with psychological, social, system and biomedical factors, potentially reinforcing demand for LBP imaging through various feedback loops. As evidence about causal relations within this complex system is still missing, targeting factors and relations associated with these feedback loops appear to be the most promising leverage points for policy makers and healthcare providers to intervene in the system and reduce demand for LBP imaging. Although it may be challenging to implement these changes in the short term, a collective and consistent approach could shift expectations of appropriate care among LBP patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eLBP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Low back pain\u003c/p\u003e\n\u003cp\u003eGP(s) General practitioner(s)\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eCT-scans\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Computed Tomography scans\u003c/p\u003e\n\u003cp\u003eMRI(s)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(multiple) Magnetic Resonance Imaging (scans)\u003c/p\u003e\n\u003cp\u003eGMB\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Group Model Building\u003c/p\u003e\n\u003cp\u003eCLD(s)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Causal loop diagram(s)\u003c/p\u003e\n\u003cp\u003ePAIN \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Pain Alliance In the Netherlands\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Centre for Clinical Expertise (CCE) at the National Institute for Public Health and the Environment (RIVM) in the Netherlands exempted this research from further review by a medical ethics committee. The current study does not fulfill the specific conditions as stated in article one of the Dutch law for Medical Research Involving Human Subjects (WMO) or with the EU Clinical Trial Directive (2001/20/EC). Informed consent was obtained prior to participation, including consent for audio recording of the sessions. All participants were informed about the study\u0026rsquo;s purpose and procedures, their right to withdraw from the study at any time and the fact that data would be anonymized by removing personal or identifiable information. Informed consent was obtained prior to participation, including consent for audio recording of the sessions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten and oral consent from the participants concerning the purpose (including intent for publication) of the study was obtained prior to the start of each GMB session.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003cbr\u003e\u003c/strong\u003eThe analysis of the GMB sessions has not been made publicly available and currently exists only in Dutch, limiting its accessibility to non-Dutch-speaking audiences. However, it can be made available upon request. Besides this all data generated or analysed during this study are included in this published article and its supplementary information files.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the National Institute for Public Health and the Environment, grant number S/080001 Demand.\u003cbr\u003e\u003cstrong\u003e\u003cbr\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: Gillroy R.L. Fraser, Mattijs S. Lambooij, G. Ardine de Wit, Peter M.A. Sloot, Raymond W.J.G. Ostelo.\u003cbr\u003eData curation: Gillroy R.L. Fraser.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eFormal analysis: Gillroy R.L. Fraser, Mattijs S. Lambooij, G. Ardine de Wit, Job van Exel.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eFunding acquisition: G. Ardine de Wit.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eInvestigation: Gillroy R.L. Fraser, Mattijs S. Lambooij, G. Ardine de Wit, Peter M.A. Sloot.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eMethodology: Gillroy R.L. Fraser, Mattijs S. Lambooij, G. Ardine de Wit, Peter M.A. Sloot.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eResources: Gillroy R.L. Fraser, Mattijs S. Lambooij, G. Ardine de Wit, Peter M.A. Sloot.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eVisualization: Gillroy R. L. Fraser.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eSupervision: Mattijs S. Lambooij, G. Ardine de Wit, Job van Exel, Raymond W.J.G. Ostelo, Frenk van Harreveld, Peter M.A. Sloot. \u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eWriting - original draft preparation: Gillroy R.L. Fraser. \u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eWriting - review \u0026amp; editing: Gillroy R.L. Fraser, Mattijs S. Lambooij, G. Ardine de Wit, Job van Exel, Raymond W.J.G. Ostelo, Frenk van Harreveld, Peter M.A. Sloot.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to sincerely thank the participants of the group model building sessions for their valuable contributions and consent to participate in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAhmed M, Bux M, Kumar M, Kumar A, Hussain G, Ahmed N. Undiagnosed anxiety and depression in patients presenting for evaluation of chronic low back pain. RMJ. 2022;47(3):661\u0026ndash;661.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndersen DF, Richardson GP. Scripts for group model building. 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Recent clinical practice guidelines for the management of low back pain: a global comparison. BMC Musculoskelet Disord. 2024;25(1):344.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZimney KJ, Puentedura E, Kolber MJ, Louw A. The correlation of trust as part of the therapeutic alliance in physical therapy and their relation to outcomes for patients with chronic low back pain. Physiother Theory Pract. 2025;41(3):473\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\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":"Low back pain, imaging, demand, low-value care, complex systems approach","lastPublishedDoi":"10.21203/rs.3.rs-8393306/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8393306/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eLow back pain (LBP) is a worldwide problem and people with LPB complaints often demand imaging to find a cause for their pain. However, in 90%-95% of cases, imaging cannot reliably identify the cause for LBP or provide relief to patients. Therefore, most clinical guidelines advise against imaging. Moreover, offering imaging in such cases may result in cascades of unnecessary and potentially harmful follow-up care for patients. In the literature, a multitude of factors have been related to patients' persistent demand for imaging, but little is known about how these factors interact and together shape demand for imaging. This study aims to map all these factors and their relations to contribute to a more comprehensive understanding of demand for imaging among patients with LBP.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eGroup model building (GMB) sessions with LBP patients and professionals from the Netherlands were organized. Participants discussed factors and relations resulting in patients\u0026rsquo; demand for LPB imaging. For each GMB session, a causal loop diagram (CLD) was created to visualize the factors and relations driving this demand. These CLDs were subsequently combined into one final CLD.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePerceived insecurity stemming from the unknown origin of patients\u0026rsquo; experienced pain is intrinsic to LBP imaging demand. Repeated failure to identify the cause of LBP was argued to increase dissatisfaction with care, leading to dismissal of evidence-based care recommendations, enhancing consumeristic behaviour, and increasing feelings of insecurity.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWhen patients demand LBP imaging, both granting and denying imaging can leave them uncertain and unsatisfied, as the cause of their pain often remains unknown. To reduce unnecessary demand for LBP imaging, future research should focus on addressing patients\u0026rsquo; concerns, insecurity and dissatisfaction, providing clear information or education, and building a solid patient-provider relationship.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003eClinical trial number not applicable.\u003c/p\u003e","manuscriptTitle":"Mechanisms contributing to patients’ demand for low back pain imaging: a complex systems approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-25 10:24:21","doi":"10.21203/rs.3.rs-8393306/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-12T18:12:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-01T11:10:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-31T02:06:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44967284516561158495609148759400374122","date":"2026-01-27T15:24:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"188799971777697163300849438808844550507","date":"2026-01-22T21:32:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"221073091086621874766912652420293144343","date":"2026-01-22T01:14:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-21T15:42:26+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-24T12:37:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-22T11:11:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-22T11:09:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-12-18T08:46:49+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":"49b916a1-f5e4-47b6-80f2-e989d0f07192","owner":[],"postedDate":"January 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-26T23:08:03+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-25 10:24:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8393306","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8393306","identity":"rs-8393306","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}