Do we perform X-rays?
I get this questions ALLLLL the time! We do NOT take x-rays on patients. Here are my reasons why.
Although I was trained in how to take and interpret x-rays, they are no evidence that supports they are recommendation in chiropractic clinics or that x-rays needs to be repeated. There is little evidence that states acute low back pain patients require x-rays for care.
Research has been showing that roughly 37% of asymptomatic 20 year old’s and 96% of 80 year old’s have spinal degeneration (Brinjikii, et al, 2015). Spinal disc degeneration & loss of disc signal is present in 90% of the population that is older than 60 years of age. More than 50% of asymptomatic 30-39 year old’s who have been x-rayed have and incidentally had the finding of degeneration.
It is important to understand the prevalence of incidental (accidental) findings of degeneration in asymptomatic population. My reason for mentioning the research findings is to tell you that most of us will have some type of degeneration changes, loss of disc signal or change in spinal curve. There could be many reasons for this such as a part of the normal aging process, or the fact that most of our jobs are sedentary and change out spinal structure, or other reasons that we have not thought of, yet.
Plain x-rays of the lumbar spine are not routinely recommended for people with acute low back pain (French, et al, 2022). There has not found to be a benefit in reduction of pain, improvement in function or quality of life by taking an x-ray before treatment. Now if we have a pain that is changing or not getting better, then we need to talk about referring for imaging to determine what the cause of the pain is and the next course of action.
Currently, it is very important to advise patients to stay active. This will provide beneficial effect on pain, rate of recovery & function. The worse thing you can do is stop moving! It could be going for a walk, performing exercises for an area not affected or doing your rehab exercises to get better. There also needs to be focus on addressing psychosocial issues of managing pain. This is extremely important because often we are starting to explore the effect that a mindset or mental health can play in regards to chronic pain or the reoccurrence of pain.
Current evidence recommends against the routine use of imaging patients with low back pain however imaging rates remain high (Jenkins, et al, 2015). This is not only pertaining to chiropractic clinics but also at the hospital levels. This has been associated with poorer patient outcomes & higher health care costs not only to the patient but to the insurance companies.
I am not saying that if you chiropractor x-rays you that is a bad thing. The reason I have chosen to not x-ray is because I have to ask the question “will it give me any more valuable information?”. Most of the time unless there is trauma, changing chronic pain, or certain information on your history that would indicate an x-ray, then x-rays are not needed. Often patient’s question if I want to see what is happening in the spine or how do I know where to adjust or work on. The simple answer is no. You can not determine a spinal restriction off of an x-ray. Spinal adjustments are assessed based on the resistance at the segments (another blog post to come on this).
If an x-ray is needed, I am able to refer to a local clinic or hospital to get my patient’s seen rather quickly. I do not spend all day looking at x-rays but that is was Radiologists do. This is where I need to let them do what they are good at & I do what I am good at.
Citations:
Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27. PMID: 25430861; PMCID: PMC4464797.
French, S.D., O’Connor, D.A., Green, S.E. et al. Improving adherence to acute low back pain guideline recommendations with chiropractors and physiotherapists: the ALIGN cluster randomised controlled trial. Trials 23, 142 (2022). https://doi.org/10.1186/s13063-022-06053-x
Jenkins HJ, Hancock MJ, French SD, Maher CG, Engel RM, Magnussen JS. Effectiveness of interventions designed to reduce the use of imaging for low-back pain: a systematic review. CMAJ. 2015 Apr 7;187(6):401-408. doi: 10.1503/cmaj.141183. Epub 2015 Mar 2. PMID: 25733741; PMCID: PMC4387031.
