Imaging use for low back pain by Ontario primary care clinicians: protocol for a mixed methods study – the Back ON study

Abstract

BackgroundAt any one time, one in every five Canadians has low back pain (LBP), and LBP is one of the most common health problems in primary care. Guidelines recommend that imaging not be routinely performed in patients presenting with LBP without signs or symptoms indicating a potential pathological cause. Yet imaging rates remain high for many patients who present without such indications. Inappropriate imaging can lead to inappropriate treatments, results in worse health outcomes and causes harm from unnecessary radiation. There is a need to understand the extent of, and factors contributing to, inappropriate imaging for LBP, and to develop effective strategies that target modifiable barriers and facilitators. The primary study objectives are to determine: 1) The rate of, and factors associated with, inappropriate lumbar spine imaging (x-ray, CT scan and MRI) for people with non-specific LBP presenting to primary care clinicians in Ontario; 2) The barriers and facilitators to reduce inappropriate imaging for LBP in primary care settings.MethodsThe project will comprise an inception cohort study and a concurrent qualitative study. For the cohort study, we will recruit 175 primary care clinicians (50 each from physiotherapy and chiropractic; 75 from family medicine), and 3750 patients with a new episode of LBP who present to these clinicians. Clinicians will collect data in the clinic, and each participant will be tracked for 12 months using Ontario health administrative and self-reported data to measure diagnostic imaging use and other health outcomes. We will assess characteristics of the clinicians, patients and encounters to identify variables associated with inappropriate imaging. In the qualitative study we will conduct in-depth interviews with primary care clinicians and patients.DiscussionThis will be the first Canadian study to accurately document the extent of the overuse of imaging for LBP, and the first worldwide to include data from the main healthcare professions offering primary care for people with LBP. This study will provide robust information about rates of inappropriate imaging for LBP, along with factors associated with, and an understanding of, potential reasons for inappropriate imaging.Electronic supplementary materialThe online version of this article (10.1186/s12891-019-2427-1) contains supplementary material, which is available to authorized users.

An investigation into chiropractic intern adherence to radiographic guidelines in clinical decisions with a descriptive comparison to clinical practitioners

“…8 Inappropriate diagnostic imaging contributes to the increasing costs of spinal health care and may expose patients to unnecessary radiation, depending on the diagnostic imaging procedure performed. 9,10 It has been reported that diagnostic imaging (on initial evaluation) does not usually provide a benefit to patients with LBP, and most clinical practice guidelines (CPGs) do not First Published Online January 23 2023 recommend it unless there are red flags. 6,11 A meta-analysis revealed that there was no difference in short-or long-term outcome measures reported between patients who received immediate lumbar imaging and usual care and patients who did not receive immediate imaging for LBP.…”

Ultrasound findings are not associated with tendon pain in recreational athletes with chronic Achilles tendinopathy

“…This non-linear correlation and contradictory relationship between imaging findings and the clinical presentation are not unique to tendinopathy though; it has also been observed in other heterogeneous musculoskeletal disorders such as low back pain. 38 We further acknowledge the potential weaknesses of the current pain assessment tools used in teasing out the true nature of chronic pain.…”

Adherence to spinal imaging guidelines and utilization of lumbar spine diagnostic imaging for low back pain at a Canadian Chiropractic College: a historical clinical cohort study

“…Low back pain (LBP) is a major cause of global disease burden, with a lifetime prevalence estimated to be 80% in developed countries [1,2]. Most LBP is non-specific and uncomplicated [1,[3][4][5]; however, pathology causing LBP, such as infection, malignancy, cauda equina syndrome and fracture account for less than 5% of cases in a primary care setting [1,4,[6][7][8][9][10]. Evidence based guidelines recommend imaging a patient with LBP only if an underlying serious pathology is suspected, or if findings on the image could potentially result in a change in patient management [6,7,11,12].…”