Patients’ perceived needs for medical services for non-specific low back pain: A systematic scoping review

Background An improved understanding of patients’ perceived needs for medical services for low back pain (LBP) will enable healthcare providers to better align service provision with patient expectations, thus improving patient and health care system outcomes. Thus, we aimed to identify the existing literature regarding patients’ perceived needs for medical services for LBP. Methods A systematic scoping review was performed of publications identified from MEDLINE, EMBASE, CINAHL and PsycINFO (1990–2016). Descriptive data regarding each study, its design and methodology were extracted and risk of bias assessed. Aggregates of patients’ perceived needs for medical services for LBP were categorised. Results 50 studies (35 qualitative, 14 quantitative and 1 mixed-methods study) from 1829 were relevant. Four areas of perceived need emerged: (1) Patients with LBP sought healthcare from medical practitioners to obtain a diagnosis, receive management options, sickness certification and legitimation for their LBP. However, there was dissatisfaction with the cursory and superficial approach of care. (2) Patients had concerns about pharmacotherapy, with few studies reporting on patients’ preferences for medications. (3) Of the few studies which examined the patients’ perceived need of invasive therapies, these found that patients avoided injections and surgeries (4) Patients desired spinal imaging for diagnostic purposes and legitimation of symptoms. Conclusions Across many different patient populations with data obtained from a variety of study designs, common themes emerged which highlighted areas of patient dissatisfaction with the medical management of LBP, in particular, the superficial approach to care perceived by patients and concerns regarding pharmacotherapy. Patients perceive unmet needs from medical services, including the need to obtain a diagnosis, the desire for pain control and the preference for spinal imaging. These issues need to be considered in developing approaches for the management of LBP in order to improve patient outcomes.

aimed to review the existing literature regarding patients' perceived needs for medical services for LBP.

Methods
A systematic scoping review, based on the framework proposed by Arksey and O'Malley, was performed to enable a comprehensive exploration of the patients' perspective [28]. Systematic scoping reviews are aimed at mapping key concepts, identifying gaps in the evidence, and reviewing different types of evidence [29,30]. This review was conducted within a larger project examining the patients' perceived needs relating to musculoskeletal health [31]. The study methodology is similar to a previously published review examining patients' perceived needs of health services for osteoarthritis [32].

Search strategy and study selection
The literature search was performed by electronically searching relevant databases (MED-LINE, EMBASE, CINAHL and PsycINFO) between January 1990 and June 2016. This time period was chosen to include relevant studies examining the current patient perspective. The search strategy (see S1 File for full OVID Medline search strategy) was developed by one of the study investigators (MS), with input from clinician researchers (Rheumatologists, FC and AW and Physiotherapist, AB), a patient representative and an academic librarian (KL). The strategy combined both MeSH terms and text words to capture information regarding patients' perceived needs for medical services for LBP (S3 Supplementary Appendix). We have used the term "medical services" to include any service provided by medical practitioners, including general practitioners, specialist physicians and surgeons. A broad definition was used for "patient perceived needs", which referred to patients' perception of services that provided them with the capacity to benefit, including their expectations of satisfaction and preferences for medical services [33]. LBP was defined as non-specific LBP, with or without leg pain, excluding back pain from fractures, malignancy, infection and inflammatory spinal disorders.
Two reviewers, including LC and one of LC, TR and WP independently assessed the titles and abstracts of all studies identified by the initial search for relevance. Discrepancies in the inclusion of studies were reviewed by a third investigator (AW) to reach consensus. The initial screening was set to be open-ended to retain as many relevant studies as possible, with no restriction on the study methods. Studies were included if they met the following criteria: (1) included patients older than 18 years, (2) recruited patients with non-specific LBP and (3) reported on patients' perceived needs for medical services for LBP. Studies were limited to human studies in the English language and full-text articles. No restrictions were applied to the prevalence of LBP and studies concerning acute, subacute and chronic LBP were included. Those that appeared to meet inclusion criteria were retrieved and the full text was assessed for relevance (LC). The reference lists of identified studies and review articles were searched to find possible further studies for inclusion.

Data extraction and analysis
The following data were systematically extracted by one investigator (LC) using a data extraction form specifically developed for this review: (1) primary study aim, (2) study population (patient age and gender, population source, population size and definition of LBP), (3) description of the study methods and (4) year of publication. Included studies were reviewed to identify aspects of medical services that patients had a preference for, expected, or were satisfied with using principles of meta-ethnography to synthesise qualitative data [34]. One author (LC) developed a framework of concepts and underlying themes, based on primary data in the included studies. Reciprocal translational analysis [34] was then undertaken to identify key concepts from individual studies and then translating and comparing these concepts to other studies to gradually explore and map the overarching themes. Data was extracted based on a customised data collection form. The framework of concepts and underlying themes were independently reviewed by three senior authors (FC and AW with over 15 years of clinical rheumatology consultant-level experience and a senior physiotherapist, AMB) to ensure accuracy of the extracted data and clinical meaningfulness.

Methodological quality assessment
To assess the methodological quality of the included studies, two from a panel of three (LC, TR, WP) independently assessed the methodological quality of all included studies.
Qualitative studies were assessed using the Critical Appraisal Skills Programme (CASP) tool [35]. The CASP is commonly used to assess qualitative research studies [35]. This tool has 10 questions that assists readers appraise articles based on appropriate research design (CASP questions 2-3), sampling (CASP question 4), data collection (CASP question 5), bias (CASP question 6), ethical issues (CASP question 7), data analysis (CASP question 8), research findings (CASP question 9) and the value of the research (CASP question 10). Each question is scored 'yes', 'no' or 'cannot tell' regarding the study quality and potential for bias. This is no overall score for the level of bias.
Hoy's risk of bias tool was utilised to assess the external and internal validity of quantitative studies. This tool was developed to examine study quality and risk of bias in prevalence studies. This tool is comprised of 10 questions that assess the external validity (questions 1-4) and internal validity (questions 5-10) of a study. Each question is scored either 'yes' (low risk of bias) or 'no' (high risk of bias). Thus for a study to be determined to be at a low risk of bias it was defined as scoring 8 or more "yes" answers, moderate risk of bias was defined as 6 to 7 "yes" answers and high risk of bias was defined as 5 or fewer "yes" answers [36]. Disagreements were resolved initially through consensus, with remaining conflicts reviewed by the senior author (AW).

Quality of studies
Quality assessments of the included studies are presented in the Figs 2 and 3. The overall quality of qualitative studies was poor (Fig 2), especially for CASP criteria 4 to 6, indicating potential biases with data sampling and collection. The quantitative studies were of low quality: 10 studies were at high risk of bias, 4 studies were at moderate risk of bias and only 2 studies were at low risk of bias (Fig 3). The quality scores for both qualitative and quantitative studies largely reflected potential biases with recruitment strategy and data collection. Systematic scoping review of patients' perceived needs for medical services for low back pain

Results of review
Four areas of perceived need were identified from the included studies (Tables 2-5).
The perceived need for medical practitioners (  61,85], to receive sickness certification and legitimation of their back pain [25,51,52]. Patients also considered consultation with primary care medical practitioners as an opportunity to explore alternative medicines [25,61] and to obtain referrals to specialist medical or surgical services [73]. Patients generally viewed medical practitioners to be knowledgeable about their pain [53,79] and could provide individual assessment [83]. Westmoreland found that patients perceived the strengths of the medical practitioner to include continuity of care, listening and counselling skills [40]. Six studies identified factors related to patient preferences regarding the role of medical practitioners in LBP and their satisfaction with them [24,41,49,62,63,74]. Patients described having faith in medical practitioners and a dependence on them and professions allied to medicine [49]. Fifty-one percent of patients thought that specialist referral was valuable [24]. Patients have reported reluctance by the general practitioner to refer patients to a specialist [41]. A single study by Carey found that patients who saw orthopaedic surgeons reported higher satisfaction than those who saw primary health care providers [63].
Patients expressed their reasons for consultation with a medical practitioner in 3 studies [58,59,64]. It has been reported that 98% of patients sought medical care due to difficulty with normal activity and 95% of patients wanted to find the cause of their pain [59]. Patients with greater pain and more severe functional impairment were more likely to seek medical help for their symptoms [58,64].
Eleven  60] and they felt that the medical practitioner's primary focus was on prescribing pain medications [53,68]. Also, patients were displeased with the delays in obtaining referrals to physiotherapy [45]. Patients also felt that once certain pathological causes of LBP were eliminated, medical practitioners appeared to slacken their investigations into the aetiology of pain [84].

The perceived need for pharmacological management (Table 3)
Thirteen studies examined the need for medications [24,39,41,43,48,51,57,65,67,69,74,81,82]. Of these, 5 studies reported that patients preferred medications [24,43,57,74,81], and that analgesics enabled them to cope with their social life and activities of daily living [67]. Patients believed that medications would enable relaxation of muscles, reduce inflammation, provide pain relief, enable activity and prevent worsening of LBP [48]. Narcotic use was reported in 1 study to be associated with patient satisfaction [57]. However, Buchbinder found that only 20% of patients presenting to an academic Emergency Department with LBP requested analgesics, and those that did utilised strategies of mitigation, indirection and deference which suggested that they were aware of the intricacies of their requests [65]. Other studies of patients attending either rehabilitation or pain management programs found that the patients were generally dismissive of medication as a treatment [50] and felt that drugs were neither important nor appropriate in the management of LBP [39]. Furthermore, patients have described their general

Role of the doctor and strengths of medical practitioners
Borkan 1995 [84] • Subjects wanted an exact diagnosis Chenot 2007[73] • 57% of patients seeing their GP were seeking additional specialist care.
Chew 1997 [52] • Subjects recognized that their GP was unable to help but viewed the doctor as a resource through which their social and economic inactivity could be legitimated Coole 2010 [50] • Participants saw the main role of the GP was to prescribe medication, however many questioned the extent of its value Coole 2010 [51] • Many patients thought there was little to be gained by consulting their GP and saw the main role of the GP as prescribing medication and providing sickness certificates Crowe 2010 [82] • The majority of participants with chronic LBP had no regular contact with healthcare professionals, however 15 participants identified that healthcare professionals played a role in their self-management. The nominated professionals were predominantly physiotherapists or general practitioners.
Darlow 2013 [83] • Clinicians were seen as providing the most certainty, they could provide personspecific assessment and advice that participants hoped might prevent chronic LBP from developing Hoffman 2013 [81] • Most believed in a biomedical approach (with the exception of analgesics) of needing to find the problem and fix it in a timely manner

Holt 2015[38]
• The clinicians' provision of information and exclusion of serious disease were seen as helpful to patients, and helped them cope with their pain • Patients wanted a diagnosis, explanation of the cause of the pain and advice on how to manage the pain from their doctors Kawi 2012 [61] • Patients felt that the primary role of the health care professional is to prescribe medications. They also thought that doctors should offer alternative modalities, including physical therapy, chiropractic, injections or interventional procedures.
McPhillips-Tangum 1998 [60] • Nearly all participates described seeking medical care to discover the cause of their back problems • Most participants saw an increase in pain intensity or onset of pain as a signal to seek medical care Ong 2011 [43] • Patients wanted a diagnosis from their doctor Rhodes 1999[59] • 98% of participants said that difficulty with normal activities drove them to seek care and 95% sought to discover the cause of their pain • Several patients held an attitude of joint expertise in which they recognized the importance and value of GPs medical knowledge but also discussed the significance of their own expertise in assessing their problem • Patients recognized medical knowledge and were glad to draw upon such expertise for the treatment of their problems yet these patients also saw an important role for less scientific knowledge Rogers 1999[79] • 95% of participants saw the GP to discover the cause of their pain

Sanders 2015 [37]
• Patients wanted reassurance from their doctor and they believed that the absence of a formal diagnosis (confirmed on x-ray or MRI) could mask a more "serious" pathology • Patients wanted a diagnosis and management options Scheermesser 2012 [74] • Patients expect fast help, to be cured, healthy and pain free. They expected more paincentred passive treatment (eg massage, hot packs, relaxation in the pool).
(Continued ) • Patients described the GP's reluctance to refer to the specialist-they felt they had to make a strong case for their referral or the GP would 'not sign that piece of paper'-this was described as a battle and some felt guilty for putting pressure on the doctor

Inadequacies of the doctor
Borkan 1995 [84] • Physicians seen to have superficial approach and are mistrusted because of their tendency to delegitimize suffering and perceived as not taken seriously • Once certain pathological causes of LBP are eliminated, the physicians appear to slacken their investigations into the aetiology of the pain practitioners as being too "keen to dish out drugs" and patients viewed medication use as treating symptoms rather than managing the actual problem [41]. Some patients would only take medications if strictly necessary [69] and were generally resistant to taking medication regularly [82]. Patients recruited from all levels of healthcare (i.e. general practice, the community, specialist referral centres and allied health practitioners) have concerns regarding medications, which were reported in 8 studies [42,44,48,54,65,74]. Patients were apprehensive about the side-effects of medications and the potential for addiction and desensitisation [42][43][44]48]. Many patients felt trapped in a vicious cycle of increasing pain and consumption of drugs [42,74]. They were also concerned about the impact of medications on their work [51]. Furthermore, patients have reported confusion about medications and a lack of explanation by their healthcare provider [54]. Patients also expressed a reluctance to request analgesics for fear of stigmatisation, and if they did request medications, they were more likely to do so indirectly, particularly opioidbased analgesics [65].

The perceived need for interventional therapies (Table 4)
Five studies explored patients' preferences for interventional treatment for LBP [44,48,55,70,75]. A single study by Lyons assessed patients' preferences for injection therapy and found that most patients avoided injections and would "rather live with the pain" [44]. Two studies reported that patients would rather avoid surgery and viewed surgical intervention as a last resort [44,48]. Franz found that half of the patients referred to a neurosurgical clinic were willing to undergo surgery in the absence of pain if they had radiological

McIntosh 2002[46]
• Patients felt that their GPs had not provided them with an 'explicit' diagnosis and none of the patients appeared to have any conception or understanding of the problem of diagnostic uncertainty in LBP.
• Patients associate GPs' perceived lack of diagnostic certainty with assumptions that the GP is either unable to help or believes them to be malingering and is thus withholding diagnostic information and access to more specialized back pain services.
McPhillips-Tangum 1998 [60] • Several patients expressed frustration over not receiving any diagnosis Sanders 2015[37] • Clinical explanations were perceived as inadequate, and back pain was presented as a common and "normal" problem with no clear options for addressing the problem • Many GPs attitudes were perceived as dismissive and patients felt disheartened and considered themselves a burden.
• GP might be inadequately qualified in the complementary therapy and too tired or have insufficient time to provide an optimal service.

Patients' reasons for seeking medical care
Carey 1999 [64] • Patients with more severe levels of impairment were more likely to seek professional help for their symptoms Rhodes 1999[59] • 98% of participants said that difficulty with normal activities drove them to seek care and 95% sought to discover the cause of their pain Sharma 2003[58] Health status indicators associated with choice of MDs include greater pain, greater functional disability and chronic LBP. Patients who expected their care to be paid for by 3 rd parties were more likely to choose MD treatment when compared with self-pay patients https://doi.org/10.1371/journal.pone.0204885.t002 Systematic scoping review of patients' perceived needs for medical services for low back pain abnormalities, however, only 33% of patients believed surgery to be more effective than physical therapy [55]. Patients were willing to wait 2 years for the effects of conservative treatment to avoid surgery [70]. In comparison, Lacroix stated that patients felt that "there comes a moment when an operation becomes inevitable" [75]. Patients who preferred surgical intervention were more likely to be male, have higher pain scores and a longer duration of pain [55,70].

Role of medications and patients' preferences for medications
Amonkar 2011 [24] • Patient consider medications a slightly more useful option than doctors Buchbinder 2015 [65] • Only 20% of patients in the study requested analgesics Coole 2010 [50] • Patients were generally dismissive of medication as a treatment Crowe 2010 [82] • A few of the participants used general practitioner-prescribed analgesics to manage their pain when it was severe. Most participants were generally resistant to taking medication regularly.
Dima 2013 [48] • Patients perceive medications as relaxing muscles, reducing inflammation, enabling detachment, provides temporary relief and prevents worsening, enables activity but use as a last resort.
Hoffman 2013 [81] • Some patients expected analgesics for the management of acute LBP.
Ong 2011 [43] • The perceived effectiveness of painkillers to deal with sciatica appeared to outweigh patients' concerns about long-term consequences such as dependency.
• Strong painkillers were needed to cope with daily life Scheermesser 2012 [74] • Patients preferred passive treatments including medication, rest and did not understand why they should increase activity in the presence of pain, even though health professional seek to increase patients' activity, coping and involvement. The perceived need for imaging (Table 5) Both qualitative and quantitative studies found that patients wanted imaging of their spine to find a diagnosis of their LBP [24,69,76,77,81]. Hoffman reported that most patients expected their general practitioner to refer them for an x-ray, particularly if they felt that their pain was severe [81]. Amonkar found that more than 60% of participants thought that back x-rays were a positive investigation [24]. Many patients felt that x-rays provided reassurance as well as confirmation of their general practitioner's diagnosis [38,81]. Furthermore, imaging that showed a physical defect seemed to provide closure [66] and relief [85] for patients and patients sought diagnostic imaging as a means to legitimise their back pain [59,60,77]. Two studies examined the characteristics of patients requesting spinal imaging [56,76]. Wilson found that radiology utilisation was associated with the severity of back pain and a history of osteoporosis [56]. Jenkins reported that increased age, lower education level, non-European cultural background, history of previous spinal imaging and negative beliefs about back pain were associated with a perceived need for imaging [76].

Discussion
This review identified 50 relevant articles that explored patients' perceived needs for medical services for LBP. Four main areas of perceived need emerged, related to the need for (1) medical practitioners, (2) pharmacotherapy, (3) interventional therapies and (4) diagnostic evaluation. Patients with LBP sought healthcare from medical practitioners to obtain a diagnosis, sickness certification and to receive management options. However, patients were dissatisfied with a biomedical approach to care provided by medical practitioners. Patients saw a need for pharmacotherapy in pain management to facilitate function, however, they had concerns about medication side-effects and a fear of stigmatisation. Of the limited studies that examined the patients' perceived need for invasive therapies, they reported that patients tend to avoid these treatment modalities. Furthermore, patients had misplaced beliefs about the necessity of imaging, and desired spinal imaging for diagnostic purposes and legitimation of symptoms.

Preference for injections
Lyons 2013 [44] • Most avoided injections stating they would rather 'live with pain' Preference for operations Dima 2013[48] • Patients feel that this is the last resort, medium term solution but are concerned about the inherent risks of surgery and implications for permanent changes to the spine.
Franz 2015 [55] • 52% of patients referred to a neurosurgery clinic would be willing to undergo surgery based on reported MRI abnormalities in the absence of symptoms • 33% of patients thought that surgery is more effective than physical therapy Klojgaard 2014 [70] • Patients are willing to wait 2 years for the effects of treatment to avoid surgery Lacroix 1995[75] • "When one has constantly to take anti-inflammatory medication, there comes a moment when an operation becomes inevitable" Lyons 2013[44] • Most avoided surgery stating they would rather 'live with pain'

Characteristics of patients preferring surgery
Franz 2015 [55] • Men were more likely to believe that back surgery was more effective than physical therapy Patients perceive a need for medical practitioners to obtain a diagnosis and strategies to cope with LBP and the associated disability [89] , [25,37,38,50,51,[59][60][61]67,69,74,[79][80][81][82][83][84][85]. In particular, patients with greater pain and more severe functional limitation sought medical help [58,59,64], thus highlighting the urgent need for more comprehensive and targeted delivery of effective and tailored pain management and coping strategies. In particular, it reinforces the importance of educating patients that in more than 90% of cases LBP cannot be attributed to a pathoanatomic cause, and is thus termed 'non-specific'. Here, it is critical to reassure patients about their presentation and prognosis. [90]. The patients' utilisation of medical services for sickness certification and legitimisation of their back pain has also clearly emanated from this review [25,43,[50][51][52]60,69,79,84]. This mirrors the complexity of LBP and the widespread impact of the condition on social functioning, financial security and workplace satisfaction.
Patients have areas of dissatisfaction with the medical approach to management of LBP. They have expressed a lack of confidence in general practitioners in the management of their LBP[41,46,47], which may reflect the knowledge gap in primary care settings in LBP management [91,92]. This reinforces the need for training medical practitioners and further targeted education campaigns to upskill clinicians [93,94]. Patients were also displeased with the biomedically-focussed and cursory approach of medical practitioners in managing LBP [37,40,41,[45][46][47]51,53,60,84]. This frustration with medical practitioners may stem from the biomedical

Preference for imaging
Amonkar 2011 [24] • >60% of participants thought that back x-rays were a positive investigation Hoffman 2013 [81] • Most patients expected their GP to refer them for an X-ray particularly patients who felt that their pain was severe. Patients reported that the usefulness of x-ray outweigh the potential risks Jenkins 2016 [76] • 54% of participants agreed or strongly agreed that radiological investigations are necessary to get the best medical care for low back pain • 48% of respondents agreed or strongly agreed that everyone with low back pain should have spine imaging Schers 2001[69] • Expectations on radiographic films varied. The patients who thought about radiographic film expected their GP to give in to their demands.

Role of imaging
Allegretti 2010 [66] • Imaging that showed a physical defect seemed to provide closure for patients while a lack of definitive scan discouraged others paradigm used by many healthcare providers, which does not adequately consider the important psychological and social drivers to a pain experience nor address the patients' need for holistic care [95]. Importantly, reliance on a biomedical approach to diagnosis and care in low back pain presentations is now considered overly reductionist and discordant with contemporary pain science. There is emerging evidence supporting the implementation of tailored therapy, addressing not only the physical aspects but also psychological factors in healthcare delivery for people with chronic LBP: this has been shown to improve health outcomes [96,97]. Despite a body of evidence supporting the biopsychosocial paradigm, practitioners encounter challenges in executing this approach to care [91,98]. In recent years, musculoskeletal Models of Care have been introduced [99][100][101]. These provide evidence-informed strategies for the delivery of patient-centred healthcare, including multidisciplinary pain management clinics, community-based education groups for patients, self-management group and individual programs for patients and carers, and education programs for primary care physicians. These interventions have been shown to improve health outcomes in terms of service delivery, patient satisfaction and health costs [96]. Further research is required to improve their implementation, assess cost effectiveness and promote the long-term sustainability of these approaches to care. There is a wide spectrum of patient perceived need for pharmacotherapy in the management of LBP. Their needs are in line with current recommendations, with due consideration of potential side effects which require careful monitoring [102][103][104][105]. This review found conflicting beliefs regarding pharmacotherapy amongst patients, with some expecting medications for LBP management [24,43,48,50,57,67,74,81], whereas others were concerned about medication side-effects and the potential for addiction and desensitisation [42][43][44]48,50,54,65,74]. There is a critical need to rationalise the utilisation of prescription medication for LBP [106] with the recent epidemic of prescription drug misuse, particularly in developed countries [107,108]. The excessive use of opioids is problematic as there is little evidence to support the use of opiates for longer than 12 weeks, there are significant risks of addiction and death [107,109], and substantial costs [110]. This highlights the need for more effective training of medical practitioners in pain management and counselling patients regarding the use of prescription analgesics. Additionally, widespread patient education programs informing patients about the potential risks of pharmacotherapy, particularly opioids, should be provided and may have positive behavioural consequences that can lower the risk of addiction and abuse related to prescription medications [111].
Although some patients perceive a need for invasive interventions to manage LBP, there is limited or inconclusive evidence to support its use [112,113]. In addition to rising costs of pharmacotherapy for LBP, the costs of interventional therapies such as epidural and facet joint injections, as well as spinal surgery have also risen substantially [7]. Despite the widespread use of interventional modalities, this review identified only five studies [44,48,55,70,75] that described patients' perceived needs for these therapies. These found that patients wanted to avoid interventional therapies such as injections and surgery[44, 48,70]. Patients who preferred invasive interventions were more likely to be male, have higher pain levels and a longer duration of symptoms [55,70]. The relationship between their preferences and understanding of the risks and benefits of these procedures was not reported. These studies mainly recruited patients from hospitals, general practices or chiropractic clinics, thus representing a population of patients that have actively sought care for the management of their LBP, and potentially may have more disabling or persistent pain and are self-selected for a biomedically-oriented belief system about the aetiology of their pain. Health system interventions may need to be introduced to limit access to these therapies that lack evidence of effectiveness. Patient education and pain multidisciplinary management programs which embrace a biopsychosocial approach to care may also be used to better equip patients with more appropriate coping strategies for pain and address the patients' perceived needs for interventional therapies in community-based populations [114].
Finally, many studies found that patients with LBP wanted imaging of their spine [24,69,76,77,81], despite the evidence-based recommendations to limit the use of radiological imaging [6][7][8][9][10]115], which is inappropriately overused [8]. Patients reported a preference for imaging to find a diagnosis, and some requested imaging to legitimise their back pain [24,38,59,60,66,[76][77][78]81]. Patients' preference for imaging suggests the need for additional public education about the inability to link the experience of pain with a structural pathology in the majority of cases [8,116] and appropriate utilisation of radiology and management of LBP. Public education campaigns have been used to reduce unnecessary radiology imaging [117], which may decrease the enormous economic burden of LBP. Addressing patients' expectations and perceived needs of radiology utilisation may improve the provider-patient relationship, thus, improving health outcomes.
The results of this review need to be interpreted in light of a number of limitations. First, the included studies were heterogeneous in their study aims, study populations, participant sources, study design and methodology, thus the results of this study need to be interpreted in the context of heterogeneity in source data used. A further limitation of the design of the review is that potentially important differences between studies (e.g. population groups, healthcare settings) may be hidden by virtue of the analysis and reporting method used. Moreover, study populations were predominantly female. Participants were recruited mainly from hospital settings or general practices, rather than from the community. Additionally, many studies were from developed, English-speaking countries. These limitations restrict the generalizability of the results. Furthermore, few studies examined the possible effects of demographic variables such as age, gender, ethnicity, socioeconomic status, other co-morbidities and education on the perceived needs of medical services for LBP. Future studies examining specific subgroups defined by key characterising variables would be informative. Many of the included studies were susceptible to bias and had methodological limitations. However, as this was a scoping review, the main concern relates to a failure to capture populations that were not included and the breadth of perceived needs. Another limitation of this review is that there were no studies that specifically examined patients with acute LBP. Patients with acute LBP may have different perceived needs compared to those with chronic LBP, however, these were not differentiated in the primary papers we retrieved for this review. Therefore, the results from this review cannot be extrapolated to those with acute presentations of LBP. Future studies examining patients' perceived need for medical services for acute LBP are warranted. Despite these limitations, this review incorporates qualitative and quantitative studies and encompassed four complementary databases to capture the breadth of the topic, and found consistent themes regardless of differences in study populations and methodologies. The data from studies was collated to provide an inclusive and in-depth description of the patient perspective of the medical management of LBP.
Patient expectations inform their use of and satisfaction with healthcare, particularly with conditions driven by symptoms, such as LBP. This review has highlighted the patients' perceived needs and perceptions of the medical management of LBP and outlined gaps in our current knowledge, as well as areas of mismatch between patients' perceived needs and evidencebased practice. The National Institute of Health and Care Excellence (NICE) guidelines for LBP acknowledge the importance of "tak(ing) into account the person's expectations and preferences" in the implementation of evidence-based practice [118]. Moving forward, when formulating clinical practice recommendations, clinicians and guideline panels should collaborate with patient groups, to ensure incorporation of the patient perspective [119]. This may be achieved through a combination of consumer-centred Models of Care, public community education campaigns and enhancing clinicians' communication skills to convey the appropriate messages. A coordinated educational campaign is required to bring medical management and patient expectations in line with evidence-based practice to optimize patient and health service outcomes.