Evaluation of a hybrid asynchronous-synchronous delivery model for family intervention in psychosis: the psychosis REACH program.

Chronic low back pain (CLBP) remains the leading cause of years lived with disability worldwide and is among the most common reasons for seeking healthcare. Recommended treatment emphasises reassurance, education, lifestyle modifications, and increased physical activity, while discouraging overuse of imaging, opioids, and surgery. Who will benefit from lumbar spine surgery remains unknown: research indicates that neither the duration of pre-operative conservative treatment nor pre-surgical pain intensity is associated with post-operative outcomes in spinal surgery patients. This raises questions about the criteria used to determine surgical candidacy in people with CLBP. In some cases, non-radicular spinal conditions (e.g. stenosis) may still warrant surgical assessment. In the UK, guidelines recommend against offering spinal fusion and do not support clinicians routinely offering imaging in people with CLBP, without red flags or radicular symptoms, unless the results are expected to change management. A recent series of papers in the Lancet described imaging and surgery for CLBP as costly and harmful, based on the evidence that most CLBP is unrelated to specific identifiable spinal abnormalities. In clinical practice, MRI findings frequently indicate nerve involvement in individuals without leg pain or radicular symptoms, underscoring the limited specificity of imaging for clinical decision-making. A recent, large population-based cohort study examining the relationship between MRI findings and LBP concluded that, over time, most MRI findings were not associated with future LBP severity, regardless of the presence or absence of baseline pain, suggesting limited prognostic value of these findings when imaging is obtained routinely. Participants with CLBP in this study may have a primary pain syndrome or a structural cause, without radiculopathy or red flags. A recent international survey of spine surgeons suggested that 36% prioritise ordering an MRI as the first step for people with CLBP without red flags, surpassing those who opted for conservative treatments. A study of 405,965 people with CLBP indicated that early MRI use was associated with excess surgery, greater opioid use, worse outcomes, and higher healthcare costs. These findings raise concerns about the extent to which MRI findings, rather than clinical symptoms and function, influence clinical decision-making across specialist settings. As consultations for CLBP occur not only in surgical clinics but also in chronic pain and musculoskeletal services, understanding how imaging and patient expectations influence clinical decision-making across these contexts is essential.