X-Rays in Chiropractic: New Research on When and Why to Use Them | Podcast Ep. 450

Foreign hello and welcome to the evidence based Chiropractor. I am your host Dr. Jeff Langmaid. On today's episode we are back with more research. A brand new study and it is a good one. It is around the age old question of X rays in chiropractic. The title is Chiropractors perceptions on the use of spinal radiographs in clinical practice. A qualitative study. This is a brand new one. I will be sure to drop a link down in the show notes if you want to check it out. But on today's episode we're going to talk about what are the key points, what are the findings, what influences our decision potentially to take X rays and many more questions will be asked. Before we get started I want to say a few words About Jane app JanApp is literally what we use within movement health. My practice and today's episode is sponsored by Jane, a clinic management software company and emr. Jane team knows that when your workday is spent providing awesome care for your patients, it can feel like there aren't enough hours in the day for your admin tasks. And that is how their software can make your life so much easier. You can get a one month grace period by using the code EBC1MO. I'll drop a link down in the show notes, connect with their team, have a conversation, see if Jane is right for you. But as I said at the top, we are talking all about research on today's episode and this is around X rays. This has been a topic that has probably been literally controversial in chiropractic since like the year after chiropractic was founded. This has been a constant source of tension between different types of chiropractors, between at some times governments and chiropractors. And sometimes it has been state associations and sometimes it has been different practice management groups, you name it. X rays have been a bone of contention. You get the point. For a really, really long time and there is a variety of reasons on why that's the case. X rays can be tied to technique. In some cases it can be tied to how somebody was educated. In other cases it can be tied to things like clinical implications. In some cases it can be tied to patient education. In other cases and some of what I just said you might be like that's the problem. And some you might be like that's why it's necessary. All can be correct and they can be correct through the perception of individual chiropractors. However, studies like this say let's step back from the individual and look at the holistic reasons. So we know that diagnostic imaging modalities such as radiography, AKA X rays, they're commonly used for the assessment of spine issues. As a matter of fact, about 1 in 4 people, 25% with a new episode of low back pain are referred for imaging. Now here's the catch. They estimate that about 1/3 of those images for low back pain may not be clinically indicated according to the current clinical practice guidelines. So about a third of images they're saying, eh, they might not exactly be clinically indicated according to the latest guidelines. So reasons why they might be concordant reasons why maybe you should take the X ray according to the guidelines are the suspicion of a serious pathology, fracture, myelopathy, malignancy, cauda equina infection, non response to a trial of conservative care surgical candidates of course, and, and suspicion of a clinically significant scoliosis. So that's according to the guidelines. Now those are not chiropractic guidelines. You can see there's nothing about technique in there. Those are clinical practice guidelines, but they're the guidelines nonetheless. So here's a really interesting fact, and this was shocking to me, that chiropractors are able to have their own X ray equipment and or refer for x rays in 43 out of 90 countries where chiropractors practice. So that's actually less than 50%. That was shocking to me. I would have guesstimated that it was 80 to 90%, but it's literally a minority. Now a majority of chiropractors are in the US and of course in the US we can take X rays, we can refer for X rays. So a majority of chiropractors out there do have the ability to take or refer for X rays. But if we look at it from a country perspective, it's a minority of countries that allow for it. And the proportion of patients, here's where things get really wild. The proportion of patients referred for imaging can vary from literally 8 to 84%. So one, obviously some of that comes down to if you can't refer for it and you don't have the equipment, you're probably gonna be less likely to utilize an X ray. And if your technique is 100% reliant on it, you're gonna be much more likely. Those are some of the factors we'll dive into here as we dig deeper into this study. But that's a really wide range. And it just goes to show that a lot of what we talked about at the beginning, education, location, technique, these things really matter in how Often X rays are taken and or referred for in a survey in the United States. Chiropractors. Speaking of US chiropractors, 87% of chiropractors in the US thought that obtaining X rays for biomechanical analysis had significant value. And 72% of chiropractors reported using X rays to determine where and how to perform their care, specifically a spinal adjustment. So again, a lot of this comes down to education and availability and technique. Ultimately, that's trifecta, in my humble opinion. But in the United States, an overwhelming majority of chiropractors thought there was significant value. So this study goes on to highlight the fact that, hey, as a chiropractor, a lot of what we do has a force component, and that's the force component is the chiropractic adjustment, spinal manipulation. And anytime there's a force input into the spine or the body, there is a potential risk, although small, for adverse events, especially with patients that have underlying pathology, such as fractures in patients that have osteoporosis, et cetera. And, you know, some chiropractors out there argue that revised guidelines are needed. And that's an interesting argument. And I'll take a little bit of a step to the side here as we dive into some of this, which is. Here's a spoiler alert. This is going to end up with more questions than answers at the end of this episode. And in my opinion, a lot of this comes down to education and technique. I think it's really unfair for somebody to have a technique that is considered to be chiropractic, that's approved by the board, that's taught in a school, and then not be able to do what's necessary to implement that technique. To me, that's a challenge. It's also a challenge the other way to take away X rays, but to allow the technique that's unfair to the individuals who are going through those techniques. Now, there's a variety of nuance to this. There's a lot of different subsets of questions. But the bottom line is, in my opinion, this is more of a technique question than an X ray question in most cases, most of the time. For example, in gonstead technique, extensive X rays are really a foundational part of how clinical decisions are made. So it's very difficult for me to envision saying to a Gonstead doctor who practices Gonstead, maybe they have for years, maybe they just started, but that is their technique. It is a great technique. It has provided tremendous amount of opportunity for a tremendous amount of People to see improvement over the course of decades and, and to take away a foundational construct of that technique just seems like that's just a tough equation for me to really rectify. Now I'm not in the policy space, in the government space and the regulation space. That's a question for somebody else. But in my opinion, this is really more of a technique question than anything else, because that is ultimately where the rubber meets the road, in my opinion, in many of these cases. So they highlighted in this study some what they called descriptive themes in respect to the aim of this study. And aim number one was to see how chiropractors determine when to order the X ray. And that's really important. There's three themes underneath that. Aim number two was how do chiropractors use X rays to inform their clinical care? Which had three themes and four sub themes developed. So let's start with aim number one, how chiropractors determine when to order radiographs. And this was kind of like a survey style. So that's ultimately, some of these answers are survey style. And theme number one under how chiropractors determine when to order radiographs was really a piece of the clinical puzzle. So will the information from the images change my management of the patient? That was really the feedback, and that is one of the justifications why some of X rays were recommended. Well, it's going to change how I go about my technique and my care. And they were cognizant of the role that a trial of conservative care plays before ordering the radiograph and the ability to deviate when necessary. And they also highlighted the fact that the duration of care differed between that trial, differed between people, which makes sense from a few visits to four to six weeks. And many of the individuals asked said, hey, they would do a trial course of care as recommended by the guidelines, and they'd only order imaging if the patient did respond favorably. Others describe their rationale for using these X rays in the assessment of more benign conditions, where specific information from that X ray would direct the most appropriate treatment for the patient. To me, this kind of ties back into that broad technique conversation. Theme number two is around the radiation risk. Anytime you're exposing somebody to X ray, obviously you want to collimate as much as you can. You want to make sure you're using the most modern equipment that decreases exposure. And there were under radiation risk, there were actually some conflicting perceptions, as they say, about the risk of radiation. Some thought the benefits would outweigh the risk and that the small dose was a minimal harm, others kind of felt the opposite way. So there was a spectrum there. And theme number three was experience and intuition. Many of those surveyed alluded to previous experience identifying with whether or not a radiograph would inform the care or provide value. And I don't think you can minimize that history, that clinical experience. As you have seen dozens and become hundreds and become thousands of patients and you see the case histories, you start to develop a real skill. And that skill and that intuition is a very important part of the clinical decision making process. So aim number two in this study was looking at how these X rays inform clinical management. And the theme number one under that was identifying where and how treatment should be applied. And again, this ties into technique very, very heavily. Some had a substantial amount of their clinical care that was tied into that X ray, some had none. And a lot of that came down to technique. And underneath that was the theme around safety, of the application of force, being able to choose the right area to deliver the adjustment in the best manner possible to deliver the best result. And in theme number two is the confidence to predict, so to speak, prognosis and patient expectations. So really looking at a patient's ability to get well, so to speak, or improve through structural and biomechanical lenses were important to some of the individuals surveyed here. And that the X ray actually was part of a bigger clinical picture to help give the patient a real understanding. Now this also splits off into slightly different than what I will say is patient education with nothing else. I say patient education with the good X ray, bad X ray, you're a bad X ray, let's get you to a good X ray. Whether or not that happens is up for debate one way or the other. But understanding a bigger clinical picture is different than sheer patient education. And there is a continuum there and there's a nuance there. But this was really the facts, the feedback I should say, that the researchers got when asking people. Now, an interesting point of this study, and this is kind of the aha moment here, this was not US based chiropractors. So this study was actually in the South Pacific, in Australia. And Australian chiropractors that were responding to this. So there also might be full disclosure. This survey might look very different if done in the us. It might look very different if done in the uk. It might look very different if performed in Canada. I don't know the answer to that because those haven't been done. But this study was from chiropractors in Australia. So many of the chiropractors did say, hey, we are adhering to the best of our ability to those clinical practice guidelines and this has been highlighted in previous research and I think that's an important component. So the big conclusion that they got again was less of an answer and more of a here's what's out there, which is that the chiropractor surveyed in this study had decision making around spinal X rays, that that's pretty diverse and it's influenced by a number of different factors, personal, clinical, external factors, and that the reason for ordering X rays revolved a lot around clinical management and how that management might be influenced by the results on those X rays. Now, the frequency or intention to order those X rays was influenced by perception of radiation risk as well as experience and intuition. So all important things to keep in mind. I'm sure this is a conversation that'll continue to be had by chiropractors for many years to come. But I thought that this was a really interesting study that got open and honest feedback from a variety of docs about how they perceive X ray's importance in their practice. And I'm excited to see this study. Hopefully will go to the uk, hopefully it'll go to the us, hopefully it'll go to Canada because I think there'll be some very, very interesting bits of feedback from docs in different locations throughout the world. Because as I said at the top, I think that's a primary factor. Education, location and technique. Three primary factors involved in X rays and the percentage ordered, so to speak. So I loved this study. I'll drop a link again down in the show. Notes before we wrap up. Few words about neck care. Objective assessments of the cervical spine. Neck care is awesome. The technology is fantastic. Easy to remember neckcare.com if you are interested in reliable assessments and exercises for proprioception, range of motion, sensory motor integration. It's the best tool out there, bar none. I'll drop a link down below neckcare.com check out what they have going on and if you have been paying attention to me online, you probably know we recently made a massive upgrade to Patient Pilot with the inclusion of Patient Navigator. Patient Navigator literally shows you your patients who are most likely to reactivate into your practice. Nothing like it out there. Lead scores your inactive patients puts them in a lead score algorithm and shows you on a smart patient recall list who's most likely to come back in. Yes, with Patient Patient Pilot you still have access to campaign autopilot, sending awesome information each and every week. Some of your patients will click in those emails, automatically reactivate many more will open, engage, we lead, score them, get them over to Patient Navigator. So Patient Pilot is the number one patient reactivation software in chiropractic. And if you are interested in generating more patient reactivations this year, head over to smartchiropractor.com right now we actually have 50% off your first month and 25% off every single subsequent month all locked in for you. There's never been a better time to get started as we're getting into Q2, Q3 of this year. Patient reactivations, if they are on your list, and they should be, you're going to want to head over to smartchiropractor.com, get started month to month. We want to show you what is up. This tool is awesome and quite frankly I worked on this for over eight months with our team in development. So a lot of time, effort and energy to bring the best tools possible out to you. I hope you have a fantastic week of practice and I will talk to you soon.

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