Effect of diagnostic labelling on management intentions for non-specific low back pain: a randomised scenario-based experiment

Key points

1. 01'Arthritis', 'degeneration', and 'disc bulge' consistently raised patients' desire for scans, surgery, and a second opinion compared to simpler labels
2. 02'Episode of back pain' produced the lowest perceived need for imaging; 'non-specific LBP' produced the lowest perceived need for surgery
3. 03'Lumbar sprain' produced the most optimistic recovery expectations of all six labels
4. 04Effects were largest in people who currently had LBP and had previously sought care, the group most at risk of poor outcomes
5. 05No meaningful differences were found between any of the six labels for beliefs about whether physical activity or work would harm the back

How it was conducted

Design

Six-arm parallel-group superiority randomized experiment conducted online

Participants

1375 adults from Australia, Canada, and Ireland; mean age 41.7 years (SD 18.4); 54.4% female; three subgroups: no history of LBP, current LBP with history of seeking care, current LBP with no history of seeking care

Intervention

Each participant read an identical clinical scenario then was randomized to receive one of six diagnostic labels: disc bulge, degeneration, arthritis, lumbar sprain, non-specific LBP, or episode of back pain; all groups also received the same guideline-recommended reassurance from the clinician

Primary outcome

Perceived need for lumbar imaging rated on an 11-point Likert scale (0 = definitely not, 10 = definitely do)

Secondary outcomes

Willingness to undergo surgery, need for a second opinion, perceived seriousness, recovery expectations, and beliefs about physical activity and work (all on Likert scales)

Analysis

ANCOVA with Bonferroni correction; significance threshold p < 0.0033; 99.67% confidence intervals reported

What they found

• Need for imaging (0-10): episode of back pain 4.2 (SD 2.9), lumbar sprain 4.2 (SD 2.9), non-specific LBP 4.4 (SD 3.0) vs arthritis 6.0 (SD 2.9), degeneration 5.7 (SD 3.2), disc bulge 5.7 (SD 3.1)
• In participants with current LBP and history of seeking care, imaging scores were: disc bulge 6.3 (SD 2.8), degeneration 6.6 (SD 2.6), arthritis 6.5 (SD 2.7) vs lumbar sprain 4.8 (SD 3.1), non-specific LBP 5.0 (SD 2.9), episode of back pain 4.2 (SD 2.8)
• Willingness to undergo surgery (0-10): non-specific LBP 3.4 (SD 2.8), lumbar sprain 3.6 (SD 2.9), episode of back pain 3.7 (SD 2.9) vs degeneration 4.6 (SD 3.0), disc bulge 4.3 (SD 2.9), arthritis 4.2 (SD 2.9)
• Need for second opinion (0-10): lumbar sprain 3.6 (SD 2.9), episode of back pain 4.6 (SD 3.0), non-specific LBP 4.6 (SD 3.1) vs arthritis 5.7 (SD 3.0), degeneration 5.6 (SD 3.0), disc bulge 5.1 (SD 2.9)
• Perceived seriousness (0-10): non-specific LBP 4.1 (SD 2.5), lumbar sprain 4.2 (SD 2.6), episode of back pain 4.5 (SD 2.7) vs degeneration 6.6 (SD 2.3), arthritis 6.3 (SD 2.4), disc bulge 5.9 (SD 2.4)
• Recovery expectations (0-10): lumbar sprain 6.6 (SD 2.4), episode of back pain 6.0 (SD 2.6), non-specific LBP 5.7 (SD 2.7) vs arthritis 4.4 (SD 2.5), degeneration 4.7 (SD 2.5), disc bulge 5.5 (SD 2.4)
• For work beliefs, degeneration (3.5, SD 1.7) scored higher than disc bulge (2.9, SD 1.6), arthritis (2.9, SD 1.5), episode of back pain (2.9, SD 1.7), lumbar sprain (2.8, SD 1.7), and non-specific LBP (2.6, SD 1.6) on the item 'I should not do my normal work'; otherwise no significant differences in work or physical activity beliefs across labels
• Arthritis vs disc bulge for second opinion: mean difference 0.6 (99.67% CI: 0.1 to 1.2)

Limitations

• Scenario-based design means responses may not match real-world clinical encounters
• Outcomes were measured at a single time point immediately after label assignment; management preferences may shift with reflection over time
• Online recruitment may oversample technologically engaged individuals, though participants varied in age and education
• The study was not prospectively registered, though a formal protocol existed and outcomes were reported as planned

Why it matters

For patients

The words your clinician uses to describe your back pain can influence whether you feel you need scans or surgery, so asking for plain-language explanations rather than structural diagnoses may help you avoid unnecessary investigations.

For clinicians

Choosing labels such as 'episode of back pain' or 'non-specific LBP' instead of 'degeneration', 'arthritis', or 'disc bulge' can meaningfully reduce patients' perceived need for imaging and surgery, even when identical reassurance is provided alongside every label.

For readers

This is the first randomized experiment showing that diagnostic label choice alone, independent of clinical advice, shifts patients' treatment intentions for low back pain, with the greatest effect in the highest-risk subgroup.