Reducing Low-Value Imaging for Low Back Pain: Systematic Review With Meta-analysis

Daniel L. Belavy, Scott D. Tagliaferri, Paul Buntine, Tobias Saueressig, Claire Samanna, Thomas McGuckian, Clint T. Miller, Patrick J. Owen

Research output: Contribution to journalArticleResearchpeer-review

2 Citations (Scopus)


OBJECTIVE: To examine the effectiveness of implementing interventions to improve guideline-recommended imaging referrals in low back pain. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: We searched MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature, Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials from inception to June 14, 2021, as well as Google Scholar and reference lists of relevant systematic reviews published in the last 10 years. We conducted forward and backward citation tracking. STUDY SELECTION CRITERIA: Randomized controlled or clinical trials in adults with low back pain to improve imaging referrals. DATA SYNTHESIS: Bias was assessed using the Cochrane Risk of Bias 2 tool. Data were synthesized using narrative synthesis and random-effects meta-analysis (Hartung-Knapp-Sidik-Jonkman method). We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: Of the 2719 identified records, 8 trials were included, with 6 studies eligible for meta-analysis (participants: N = 170 460). All trials incorporated clinician education; 4 included audit and/or feedback components. Comparators were no-intervention control and passive dissemination of guidelines. Five trials were rated as low risk of bias, and 2 trials were rated as having some concerns. There was low-certainty evidence that implementing interventions to improve guideline-recommended imaging referrals had no effect (odds ratio [95% confidence interval]: 0.87 [0.72, 1.05]; I2 = 0%; studies: n = 6). The main finding was robust to sensitivity analyses. CONCLUSION: We found low-certainty evidence that interventions to reduce imaging referrals or use in low back pain had no effect. Education interventions are unlikely to be effective. Organizational- and policy-level interventions are more likely to be effective. J Orthop Sports Phys Ther 2022;52(4):175-191. Epub 05 Feb 2022. doi:10.2519/jospt.2022.10731.

Original languageEnglish
Pages (from-to)175-191
Number of pages17
JournalJournal of Orthopaedic and Sports Physical Therapy
Issue number4
Publication statusPublished - 1 Apr 2022


  • implementation science
  • back pain
  • chronic pain
  • controlled before-after studies
  • CT scan
  • diagnostic imaging
  • interrupted time series analysis
  • low back pain
  • magnetic resonance
  • meta-analysis
  • radicular pain
  • radiography
  • randomized controlled trial
  • sciatica
  • systematic review
  • x-ray

Cite this