Table 3 Key themes identified within relevant domains

Knowledge

Knowledge of guidelines

“I think that good practices would suggest minimized interventions and maximized treatment, such as physio, lifestyle changes and really avoid things like narcotics and opioids.” [FP05]

“Active exercises were two of the most recommended treatment modalities for mechanical back pain. Diagnostic imaging was not as recommended as previously thought.” [CH13]

“Movement is something that’s important […] when you have a low back injury. Exercise is definitely something that is recommended.” [PT07]

Partial knowledge of important elements without knowing guidelines

“If you’re not responding in four weeks or whatever of care, then we can consider that [imaging]…” [FP09]

“Conservative approach, first and foremost in a six-week intervention.” [CH14]

“If they’re showing no signs of improvement over, for example, three weeks to a month [as an indicator for imaging].” [PT14]

Knowledge of good general practice in low back pain care

“I would discuss with the patient […] typically this type of pain does get better on its own over time. But there are some things that can help move that along, so remaining active is kind of the number one, staying mobile. Obviously some medication that can decrease the pain and inflammation, basic things like that.” [FP11]

“Essentially if it’s obviously the mechanical pain you gotta somehow reduce the pain and increase strength and mobility.” [CH15]

“Once you build that rapport with them you can do a little bit of hands-on to decrease their pain, to allow them to do the exercises a little bit further, to build the trust, to calm down the pain sensitivity.” [PT05]

Source of knowledge (training)

“When we become independent family doctors, we sign up for the CFPC [College of Family Physicians of Canada] thing and then there comes the magazine and I think that’s where I was first exposed to that. The CORE [Clinically Organized Relevant Exam] tool definitely came from colleagues.” [FP14]

“It’s either through the Canadian Chiropractic Association or the Ontario Chiropractic Association.” [CH16]

“I did this McKenzie course and few years ago and ….I have also looked like on-line for guidelines when I have a question.” [PT06]

Skills

Competence and ability at avoiding imaging

“I tried to understand what they’re looking for, what their expectations are, …what they’re looking for in imaging basically.” [FP12]

“If I don’t think it’s necessary I will explain that for their age, their general health condition, their description of their pain, whatever it may be…but for their circumstances I don’t feel that I would get any useful information out of x-rays and I feel that we’d be exposing them to radiation for no beneficial reason, always subject to re-visitation if treatment doesn’t go as expected.” [CH13]

“That is often one of the first things that I educate patients about, is I tell them that based on what I'm hearing from you, you don't have any red flags that would warrant the need for imaging right away.” [PT04]

Identify tricky or challenging

“I had somebody go for testing, and I find this is another thing that happens, who goes for testing, has findings, but has several other comorbidities.” [FP06]

“I think that’s the biggest challenge, that in a lot of cases people want to be better yesterday and you know they’re in some severe pain and, to manage their expectations that 'You know, you might get a little bit worse before you get better, you’re going to have to work through this.” [CH18]

“I think what's challenging is…if again, going back to a complex patient, who may be elderly and has a lot of either co-morbidities or other issues going on. Sometimes it's hard to tell… it’s hard to really understand what is the cause of the symptoms and whether they truly do need the imaging or not.” [PT13]

Beliefs about capabilities

Beliefs about capability in managing pain, or responding to patient needs

“So I would say I’m reasonably confident. And without imaging, yeah, reasonably confident.” [FP13]

“I mean, everybody’s an individual, but I’m confident in my ability to help people and if I can’t, then I send them out, you know?” [CH10]

“Clinically I am confident to let them know that they will get better. they just have to do the therapy and once they’ve done the sessions, they’re good to go.” [PT03]

Confidence in ability to decide or explain rationale for not imaging

“I think you can glean a lot from the history and the physical exam and so rule out any of the red flags. I think, yeah, it can give you a very good idea of the type of pain the patient is experiencing. And also, the ability to follow up with them.” [FP11]

“I would explain to them that I don’t want any unnecessary radiation, that I’m confident in what is going on and that we are able to help them reduce the pain or resolve it.” [CH15]

“But that's what I'm going to try to tell them’If you do want to know what you have you're going to have to talk to a doctor. I cannot order imaging but also, I don't feel it’s that necessary right now.’ So I'll try to put it in perspective and explain how I feel about it.” [PT06]

Confidence in NOT missing anything by not routinely seeking imaging

“If the history matches my understanding of common causes of low back pain, and if the patient starts to improve in response to my treatment and everything goes as expected, then that strengthens my confidence.” [FP08]

“Again, there's got to be very specific indications to do so [seek imaging]. I'm pretty confident in my assessment skills to identify whatever I need to.” [CH14]

“I can achieve a full recovery, with a high level of confidence, without any images. I can palpate, I can see, I can analyze. No, I don't feel like images will change the way I treat.” [PT11]

Beliefs about consequences

Perception that imaging findings will be incidental

“It's unnecessary, doesn't change management, back pain is going to get better in 85% of patients after six weeks. An MRI, has cost, but again, it doesn't change anything. It just shows them that they have a degenerative disc disease and a disc bulge, which is clinically not even relevant.” [FP13]

“I would say that [imaging is] limited, again unless we are trying to rule out something of higher priority.” [CH17]

“Again, in light of the fact that the image is most of the time not reflective of why they’re having their issue.” [PT13]

Perception about patient physical, psychological or financial harm

“It's really not in their best interests and in fact more harmful than helpful. Even MRI which isn't radiation, and isn't inherently a harmful test, it often finds things that are abnormal but are really irrelevant but raise questions. [It shows] nothing that's actually going to help them live longer or function better. But it actually may add morbidity because of these false diagnoses.” [FP09]

[answering a question about patient harm] “Obviously the exposure to x-rays, or the radiation… I think it's not necessary. I think similarly, with MRI and a patient's seeing a bulging disc and then all of a sudden ‘Oh, my goodness, I have a bulging disc.’ And it's not even clinically significant. But now in their head, they have this idea that they have this problem and that changes their behavior whether it's at work or at home, it just involves everything.” [CH12]

“I prefer that patients don’t get imaging because I think there’s some new research on patients’ identifying themselves or victimizing themselves with the pathology that’s written down on an MRI (laughs) or an x-ray, right? As soon as they see that they’ve got arthritis then they kind of believe… they victimize themselves and that can be worse.” [PT01]

Perception of system pressures or consequences

“It's just the cost to the system which takes away money from other things. Why are we doing a test if it’s not going to change our management, not going to [lead to] benefit?” [FP09]

“And it's a waste of resources on an already hard-pressed health care system.” [CH10]

“I always feel for the health care system, because they’re wasting money. Hundreds and hundreds of millions of dollars are wasted on imaging.” [PT02]

Value (consequence) of using imaging to guide treatment

[Imaging is] “helpful for ruling things out. Like if someone thinks there's something there and you're trying to sort of encourage them to think there isn't.” [FP07]

“Without images I don’t know what’s actually within the structure inside the body, what the spinal structure is actually. Is there previous damage, is there a congenital anomaly, is there arthritis that has caused or exacerbates what brought the patient to me on that particular day?” [CH13]

“It doesn’t explain exactly; it’s opposite. Imaging for me is just to rule out other serious pathology, not to confirm, not to tell me what I need to do.” [PT12]

Perceptions that patients will seek imaging from other providers

“I mean that’s never been an issue, but I do find if there’s someone who really wants a lot of testing, they will not stay with a doctor who doesn’t do a lot of testing. They will find someone who does the testing.” [FP07]

“There is pressure to accommodate your client. But if it’s really not in their best interest then ‘Sorry, I just don’t feel this is in your best interest’ and, very often, I said ‘Listen this is what I expect to find on your x-ray.’ I already know this in my head. Sometimes they will go to the GP [general practitioner], get the x-ray, take and get the x-ray report, bring it in and say ‘Oh, what do you know, it’s exactly what you told me.’” [CH08]

“They will depend mostly on the images and they will go to the doctor. Because they have more trust in the doctors, more than a physio.” [PT10]

Belief about consequence on patient practitioner relationship

“Some patients, you know maybe if they're very, very insistent or stubborn and want this [imaging] no matter what. That [insistence] can definitely affect the relationship because it's they're not interested in your judgement or your opinions.” [FP11]

“But I think that would be the scenario [an adverse effect on the relationship], is that someone has the circumstance in which your judgement was questioned and then if it indeed turned out to be that there was something of relevance [revealed by imaging], right?” [CH17]

“If I sense that they’re not on my side I’m more than happy to say, ‘Well, talk to your doctor and let them know you’re getting better, but you’re still scared or something like that. See what they can do for you.’” [PT05]

Social influences

Influence of patient

“Sometimes people are looking for some reassurance too. I don’t really like to do that, but in certain cases if that makes somebody sleep better at night and prevents them from coming back a gazillion times because they’re concerned that there may be something more to it.” [FP06]

“‘According to the x-rays that we did before you don’t have anything really significant. You should continue the physical therapy.’ And then he came back two or three times, was persistent. I did order an MRI.” [FP04]

“But if the patient says ‘I would, I do not feel mentally, emotionally at ease until or unless we do an x-ray to see if I have a fracture’ or whatever it might be, then sometimes just to give them the peace of mind.” [CH06]

"Sometimes you have to accept that the patient mentally needs that result." [PT05]

Perceptions of patients wanting imaging done

“People want to have a label, they want a name, they want a diagnosis with a whole bunch of words. Being told that they have a normal blood work, blood pressure, echo., x-ray, that is not reassuring for a select group of anxious patients.” [FP14]

“Honestly, there’s just some people that just need that reassurance by being able to see it. Right? It’s just that they need physical proof.” [CH16]

“It’s like they feel they need to get an image to see what’s damaged, to find out what’s going on.” [PT09]

Perceptions of other providers

“Some of them I find order imaging a little more readily. I think they trained in a different era than I did. So I think their education went a little differently.” [FP03]

“I think that they would be consistent with the way that I do things. I have some peers who are very close by, we think alike and treat people the same way. I know that there’s other chiropractors in proximity to me who routinely x-ray every patient.” [CH07]

“All of them have been really great mentors to me and they’ve really helped shape the way that I approach imaging and low back pain for sure. I can say that they do feel similarly.” [PT04]

Behavioural regulation

Alternate behaviours (managing without imaging)

“So, I say, ‘We're going to treat it like a sprain.' I talk about Advil, Tylenol. Of course, Advil only if there aren't any other medical contra-indications, because it can be risky in older people, not in people with anticoagulants; Tylenol is much easier to use. I'll talk about other really conservative things like heat, Voltaren, self-massage. And I love a good trigger point ball example (chuckles). I keep some tennis balls and lacrosse balls in my clinic so I can show people. And then of course I talk about things like physio and, if I think that there's a lot of muscle tension for whatever reason, [then] a real massage.” [FP14]

“With patients their key thing is ‘get me out of pain’, so that’s my first and ultimate goal is to reduce the pain with my modalities and physical or manual therapies and some education on things they can do at home to reduce the pain. And then we move on with flexibility, movement and strength.” [CH12]

“I try to reassure them that if it is acute or sub-acute; acute is like four weeks and sub-acute is anything between four and 12 weeks and then twelve weeks more is chronic. If it's acute or sub-acute I'd reassure them that it's gonna get better on its own regardless of any treatment. They just need to learn how to self-manage themselves. So, I educate them on that. But on top of that, if they're really, really in pain and they need some advice, I give them some stretches.” [PT10]

Negotiation strategies

“I can tell them ‘OK, this is what I think it is, this is the plan. If your pain isn't improving in the next 2 weeks, for example, I want you to get in touch again. Book another appointment for follow-up.’ If I had no options for follow-up at all, maybe I would be a little more liberal with maybe ordering tests right off the bat. But often if you can give it a bit of time it helps with confirming the diagnosis.” [FP11]

“I would say ‘Let's go over a few treatments before even considering imaging. You don't want any unnecessary radiation in your body. I've seen a lot of good results with manual therapy, chiropractic care, with treating low back pain without any imaging. We'll go through a few weeks or a couple months of treatment. If you're still not getting any better, if pain's getting worse, then we'll order some imaging.’” [CH15]

“So, I say ‘Try eight weeks. If in eight weeks there’s no change, I will gladly write a letter saying that we’ve tried physio, these are the things we’ve tried, and [refer] back to the doctor for further analysis.” [PT08]

Principle, theory or approach used for low back pain patients

“I have lots of great tools [that support] decision-making. I usually use something very similar to the CORE back tool, or what Dr. Hamilton Hall used to talk about in his back pain approach.” [FP14]

“Specifically, for low back pain I'm usually using Kemp's test if I'm suspecting that might be from the facet joints. Then I'm using a straight leg raise, a Valsalva maneuver and a slump to try to rule in or out discogenic pain, and then I'll move on typically to rule in or out the hips and the SI joint. So, I’ll screen the hips using just a scour or a FABER test.” [CH05]

“I follow a mostly McKenzie approach, so I most often start my assessment with McKenzie forms, asking questions like what their aggravating factors are, what the relieving factors are, what their occupation is, if they're like sitting a lot, trying to determine if it is mechanical in nature.” [PT07]