Examining Clinical Opinion and Experience Regarding Utilization of Plain Radiography of the Spine: Evidence from Surveying the Chiropractic Profession (original) (raw)
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Chiropractic & Manual Therapies
Introduction: When indicated by signs or symptoms of potentially serious underlying pathology (red flags), chiropractors can use radiographs to inform their diagnosis. In the absence of red flags, the clinical utility of routine or repeat radiographs to assess the structure and function of the spine is controversial. Objectives: To determine the diagnostic and therapeutic utility of routine or repeat radiographs (in the absence of red flags) of the cervical, thoracic or lumbar spine for the functional or structural evaluation of the spine. Investigate whether functional or structural findings on repeat radiographs are valid markers of clinically meaningful outcomes. The research objectives required that we determine the validity, diagnostic accuracy and reliability of radiographs for the structural and functional evaluation of the spine. Evidence review: We searched MEDLINE, CINAHL, and Index to Chiropractic Literature from inception to November 25, 2019. We used rapid review methodology recommended by the World Health Organization. Eligible studies (cross-sectional, case-control, cohort, randomized controlled trials, diagnostic and reliability) were critically appraised. Studies of acceptable quality were included in our synthesis. The lead author extracted data and a second reviewer independently validated the data extraction. We conducted a qualitative synthesis of the evidence. Findings: We identified 959 citations, screened 176 full text articles and critically appraised 23. No relevant studies assessed the clinical utility of routine or repeat radiographs (in the absence of red flags) of the cervical, thoracic or lumbar spine for the functional or structural evaluation of the spine. No studies investigated whether functional or structural findings on repeat radiographs are valid markers of clinically meaningful outcomes. Nine low risk of bias studies investigated the validity (n = 2) and reliability (n = 8) of routine or repeat radiographs. These studies provide no evidence of clinical utility. Conclusion: We found no evidence that the use of routine or repeat radiographs to assess the function or structure of the spine, in the absence of red flags, improves clinical outcomes and benefits patients. Given the inherent risks of ionizing radiation, we recommend that chiropractors do not use radiographs for the routine and repeat evaluation of the structure and function of the spine.
Adherence to Radiography Guidelines for Low Back Pain: A Survey of Chiropractic Schools Worldwide
Journal of Manipulative and Physiological Therapeutics, 2008
Objective: This study describes instruction provided at chiropractic schools worldwide on the use of spine radiography and compares instruction with evidence-based guidelines for low back pain. Methods: Individuals responsible for radiology instruction at accredited chiropractic schools throughout the world were contacted and invited to participate in a Web-based survey. The survey included questions on the role of conventional radiography in chiropractic practice and instruction given to students for its use in patients with acute low back pain. Results: Of the 33 chiropractic schools identified worldwide, 32 (97%) participated in the survey. Consistent with the guidelines, 25 (78%) respondents disagreed that "routine radiography should be used prior to spinal manipulative therapy," 29 (91%) disagreed that there "was a role for full spine radiography for assessing patients with low back pain," and 29 (91%) disagreed that "oblique views should be part of a standard radiographic series for low back pain." However, only 14 (44%) respondents concurred with the guidelines and disagreed with the statement that there "is a role for radiography in acute low back pain in the absence of 'red flags' for serious disease." Conclusions: This survey suggests that many aspects of radiology instruction provided by accredited chiropractic schools appear to be evidence based. However, there appears to be a disparity between some schools and existing evidence with respect to the role of radiography for patients with acute low back pain without "red flags" for serious disease. This may contribute to chiropractic overutilization of radiography for low back pain. (J Manipulative Physiol Ther 2008;31:412-418) Key Indexing Terms: Public health; Chiropractic M ore than 90 000 chiropractors practice internationally, and this number is expected to grow to 150 000 by the year 2010. 1 Most practicing chiropractors are graduates of one of approximately 30
BACKGROUND: Plain film radiography is the most common imaging technique requested by chiropractors to assist in the management of patients with musculoskeletal complaints. There is a paucity literature indicating that chiropractors’ interpretive radiographic skills are consistently able to achieve the same outcome given a particular set of radiographs. An important indication for the use of radiography in chiropractic is to exclude any possible contraindications to spinal manipulative therapy (SMT) that could cause serious injury to a patient if it is left unmodified or excluded as a treatment option. OBJECTIVES: The study aimed to investigate the inter- and intra-examiner reliability of chiropractor’s diagnosis on cervical spine radiographs. Additionally, the effect of clinical history added to the radiographs was assessed. METHODS: Inter- and intra-examiner evaluations occurred on two consecutive readings of 30 radiographs by six qualified chiropractors. No clinical history was gi...
The Journal of the Canadian Chiropractic Association, 2013
Students learn a plethora of physical examination and manual therapy procedures over the course of their chiropractic education. However, it is uncertain to what extent they continue to use these procedures in practice after graduation. The purpose of this study was to determine which diagnostic and therapeutic procedures of the spine are most commonly utilized by chiropractors practicing in Ontario. In Part 1 of this study (presented here), the demographics and practice patterns of the respondents are presented. Part 2 of this study will present the results of the utilization rates of diagnostic and therapeutic procedures used by respondents. The study consisted of a paper-based survey that was sent to 500 pseudo-randomly selected Ontario chiropractors who responded confidentially. Survey questions inquired into demographic and practice style characteristics. There were 108 respondents to the survey, giving a response rate of 22.4%. Many chiropractors self-identified themselves wit...
Journal of Manipulative and Physiological Therapeutics, 2002
Background: Recent studies suggest that chiropractors continue to widely use radiography for assessing patients with acute low back pain. This practice is contrary to growing evidence that suggests only a small percentage of patients with acute low back pain require radiographic evaluation. Objectives: To assess quantitatively and qualitatively the views of chiropractors in a selected community in Ontario on the use of radiography for evaluating patients with acute low back pain. Study Design: Mailed surveys and focus group interview. Method: Surveys were mailed to all chiropractors (N ϭ 26) in a selected community in Ontario, followed by a focus group session with local chiropractors (n ϭ 7). Surveys requested information on personal and practice characteristics and the management of low back pain, including the use of radiography. The focus group, led by a facilitator, discussed issues surrounding practice guidelines and radiography use. Results: There was a 76% response rate to the mailed surveys. Of those who responded, 63% stated they would use radiography on patients with uncomplicated acute low back pain lasting 1 week; 68% stated that radiographs were useful in the diagnostic evaluation of patients with acute low back pain lasting less than 1 month. Most reasons given for use of radiography in this patient population are not supported by existing evidence.
Journal of Chiropractic Medicine, 2006
Objective: To determine if there is a greater yield of pathological findings identified on MRI scans of patients referred by chiropractors as compared to those referred by allopathic providers. Methods: MRI reports authored by medical radiologists from two independent MRI centers in the Denver metropolitan area were analyzed retrospectively for pathological data related to the spinal regions studied. A pathological report data sheet was used to record pathological findings in 22 different categories. A total of 150 reports from each provider group were reviewed. Results: Of the 22 pathological conditions studied, a statistically significant difference between doctor of chiropractic and medical doctor referrers was identified in 4 categories: central spinal canal stenosis, lateral stenosis, facet arthrosis, and negative report. The most common primary diagnoses given for MRI referral were low back pain/sciatica, neck pain, and extremity pain. Seventy-four percent of the reports evaluated were performed on patients referred with a diagnosis of pain. In 3 of the 22 categories (14%), the medical doctors had a statistically higher pathological yield than the chiropractors. However, in 4 of the 22 categories (18%), the chiropractors had a statistically higher pathological yield. In 18 of the 22 categories (82%), there was no statistical difference between the two provider groups. Conclusion: The data presented in this study suggests chiropractic and medical providers are compeer at ordering MRI for suspected pathological findings.
Radiograph utilization and demographics in a chiropractic college teaching clinic
Journal of Chiropractic Medicine, 2012
The purpose of this study is to present radiograph utilization at a chiropractic college teaching clinic, the associated patient demographics, and the utilization rates by body region. Methods: Data for outpatient services over a 3-year period were extracted from a college clinic administrative software program. Radiographic data were matched with patient demographic information providing the age, sex, and financial class for all patients. Results: The overall radiograph utilization rate was 8%, with the highest frequency occurring in the spine in the order of lumbar, cervical, and then thoracic regions. Spinal radiographs made up 66% of the total radiographs taken. The utilization rate increased as the age of the patients increased. The average patient age was 46, and 48% were female. Conclusion: The radiograph utilization rate at this teaching clinic was lower than previous studies. This study provides new information regarding overall and regional radiography rates and associated patient demographics from an American chiropractic college.
Chiropractic & Manual Therapies, 2021
Background Low back pain (LBP) rarely requires routine imaging of the lumbar spine in the primary care setting, as serious spinal pathology is rare. Despite evidence-based clinical practice guidelines recommending delaying imaging in the absence of red flags, chiropractors commonly order imaging outside of these guidelines. The purpose of this study was to survey chiropractors to determine the level of knowledge, adherence to, and beliefs about, clinical practice guidelines related to the use of lumbar radiography for LBP in Newfoundland and Labrador (NL), Canada. Methods A cross-sectional survey of chiropractors in NL (n = 69) was conducted between May and June 2018, including questions on demographics, awareness of radiographic guidelines, and beliefs about radiographs for LBP. We assessed behavioural simulation using clinical vignettes to determine levels of adherence to LBP guideline recommendations. Results The response rate was 77% (n = 53). Half of the participants stated the...
Chiropractic & Manual Therapies
Background Diagnostic imaging is useful for assessing low back pain (LBP) when a clinician suspects a specific underlying pathology. Evidence-based imaging guidelines assist clinicians in appropriately determining the need for imaging when assessing LBP. A previous study reported high adherence to three clinical guidelines, with utilization rate of 12.3% in imaging of LBP patients attending a chiropractic teaching clinic. A new imaging guideline for spinal disorders has been published and used in teaching. Thus, the aims of our study were to assess the adherence to the new guideline and X-ray utilization in new episodes of LBP. Methods We conducted a historical clinical cohort study using patient electronic health record audits at seven teaching clinics over a period of 20 months. Records of patients who were at least 18 years of age, presented with a new onset of LBP, and consented to data collection were included. Abstracted data included patient demographics, the number and type ...