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

Gillroy R. L. Fraser ^a,b,c,d*, G. Ardine de Wit ^a,b,, Job van Exel ^c,d, Peter M. A. Sloot ^e,f, Raymond W. J. G. Ostelo ^g,h, Frenk van Harreveld ^i,j, Mattijs S. Lambooij ^c,d,i

^a Department of Health Economics and Health Services Research, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands.

^b Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.

^c Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.

^d Erasmus Centre for Health Economics Rotterdam (EsCHER), Rotterdam, The Netherlands.

^e Institute for Advanced Study, University of Amsterdam, Amsterdam, The Netherlands.

^f The complexity Science Hub, Vienna, Austria.

^g Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences Research Institute, Amsterdam, Netherlands.

^h Department of Epidemiology and Data Science, Amsterdam University Medical Centre, Vrije Universiteit, Amsterdam, Netherlands.

ⁱ Center for Prevention, Lifestyle and Health, Department Behaviour & Health, National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands.

^j Faculty of Social and Behavioral Sciences, University of Amsterdam, Amsterdam, Netherlands.

* Corresponding author. Antonie van Leeuwenhoeklaan 9, P.O. Box 13720 BA Bilthoven, The Netherlands. Telephone: +316 29660944

Email addresses: gillroy.fraser@rivm.nl (Gillroy R. L. Fraser), ardine.de.wit@rivm.nl (G. Ardine de Wit), vanexel@eshpm.eur.nl (Job van Exel), p.m.a.sloot@uva.nl (Peter M. A. Sloot), r.ostelo@vu.nl (Raymond W. J. G. Ostelo), f.vanharrveld@uva.nl (Frenk van Harreveld), mattijs.lambooij@rivm.nl (Mattijs S. Lambooij).

Orcid ID: Gillroy R. L. Fraser (0009-0003-7050-3607), G. Ardine de Wit (0000-0002-1375-7657), Job van Exel (0000-0002-4178-1777),

Peter M. A Sloot (0000-0002-3848-5395), Raymond W. J. G. Ostelo (0000-0001-7679-7210), Frenk van Harreveld (0000-0003-3717-2773), Mattijs S. Lambooij (0000-0002-1965-3568)

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.

Key words:

Low back pain

imaging

demand

low-value care

complex systems approach

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 A A ^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.

Fig. 2

– Loop R1 Non-specific low back pain and uncertainty

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.

Fig. 3

– Loop R2 Uncertainty avoidance, Loop R3 Dissatisfaction induced Demand, and Loop R4 Denial induced demand

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.

Fig. 4

– Loop R5 Patient-provider relations, R6 Doubt, and R7 Dissatisfaction escalation

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.

Fig. 5

– Loop R8 Shopping for validation

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.

List of 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.

Data Availability

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 Contribution

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. Lambooij, G. Ardine de Wit, Job van Exel, Raymond W.J.G. Ostelo, Frenk van Harreveld, Peter M.A. Sloot.

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. Lambooij, G. Ardine de Wit, Job van Exel, Raymond W.J.G. Ostelo, Frenk van Harreveld, Peter M.A. Sloot.

Acknowledgement

The 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.

Electronic Supplementary Material

Below is the link to the electronic supplementary material

Supplementary Material 1

Supplementary Material 2

Supplementary Material 3

Supplementary Material 4

Supplementary Material 5

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Figure 2 – Loop R1 Non-specific low back pain and uncertainty

Figure 3 – Loop R2 Uncertainty avoidance, Loop R3 Dissatisfaction induced Demand, and Loop R4 Denial induced demand

Figure 4 – Loop R5 Patient-provider relations, R6 Doubt, and R7 Dissatisfaction escalation

Figure 5 – Loop R8 Shopping for validation

Table 1 Participant domain table

Table 2: Examples of evidence from the literature

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
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

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) ^[24]	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) ^[22]	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) ^[5]	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) ^[44]	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) ^[45]	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) ^[46]	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) ^[47]	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) ^[52]	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) ^[49]	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) ^[50]	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) ^[51]	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) ^[53]	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) ^[54]	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) ^[55]	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) ^[22]	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) ^[66]	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) ^[20]	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) ^[4]	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) ^[65]	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) ^[67]	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) ^[34]	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) ^[24]	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) ^[56]	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) ^[57]	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) ^[54]	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) ^[23]	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) ^[24]	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) ^[58]	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) ^[34]	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) ^[34]	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) ^[24]	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) ^[59]	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) ^[34]	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) ^[22]	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) ^[22]	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) ^[26]	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) ^[24]	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) ^[24]	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) ^[24]	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) ^[24]	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) ^[24]	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) ^[34]	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) ^[34]	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) ^[23]	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) ^[34]	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) ^[25]	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) ^[22]	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) ^[60]	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) ^[24]	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) ^[25]	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) ^[24]	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) ^[24]	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) ^[61]	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) ^[62]	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) ^[63]	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) ^[22]	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) ^[64]	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) ^[24]	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.

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
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

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) ^[24]	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) ^[22]	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) ^[5]	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) ^[44]	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) ^[45]	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) ^[46]	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) ^[47]	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) ^[52]	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) ^[49]	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) ^[50]	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) ^[51]	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) ^[53]	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) ^[54]	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) ^[55]	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) ^[22]	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) ^[66]	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) ^[20]	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) ^[4]	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) ^[65]	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) ^[67]	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) ^[34]	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) ^[24]	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) ^[56]	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) ^[57]	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) ^[54]	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) ^[23]	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) ^[24]	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) ^[58]	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) ^[34]	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) ^[34]	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) ^[24]	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) ^[59]	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) ^[34]	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) ^[22]	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) ^[22]	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) ^[26]	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) ^[24]	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) ^[24]	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) ^[24]	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) ^[24]	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) ^[24]	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) ^[34]	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) ^[34]	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) ^[23]	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) ^[34]	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) ^[25]	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) ^[22]	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) ^[60]	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) ^[24]	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) ^[25]	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) ^[24]	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) ^[24]	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) ^[61]	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) ^[62]	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) ^[63]	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) ^[22]	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) ^[64]	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) ^[24]	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.

Yes