Volume 27, Issue 3 , Pages 218-219, March 2004
Views on Radiography Use for Patients with Acute Low Back Pain among Chiropractors in an Ontario Community
Article Outline
To the Editor:
Thank you for allowing a number of the members of the Grant-Adams County Chiropractic Society the opportunity to write a letter regarding the article, “Views on Radiography Use for Patients With Acute Low Back Pain Among Chiropractors in an Ontario Community” by Ammendolia et al.1 The Grant-Adams County Chiropractic Society is a small group, consisting of 9 members, which holds 10 evening discussions per year to discuss selected articles from the scientific literature relating to the practice of chiropractic. A recent discussion centered on Dr Ammendolia's article. Two of the primary points of this article appear to be that doctors of chiropractic are utilizing radiographs more often than is appropriate and for reasons that are not in keeping with current scientific evidence. We would like to respectfully disagree on 3 lines of reasoning.
The Literature
The article indicates that there is high usage of radiography in treating cases of low back pain and “this practice is contrary to growing evidence that suggests only a small percentage of patients with acute low back pain require radiographic evaluation.”1 We feel that there is evidence in the literature to counter that opinion.
Troyanovich et al2 note that radiography is “the only reliable method in the chiropractic office setting to accurately assess overall lordosis, individual intersegmental contributions to lordosis, certain aspects of pelvic mechanical integrity, and global anterior or posterior translational displacements of thoracolumbopelvic posture…” with references to other articles by Troyanovich and Harrision.2., 3., 4. They also state that “…lordosis and other biomechanical considerations have been shown to correlate with various types of low back pain syndromes.”5., 6.
While we have brought forth only a small number of references, it should be enough to make clear that not all the scientific literature is in agreement with Dr Ammendolia.
Experience
The experience of the authors of this letter ranges from almost 6 to over 36 years of practice. We all utilize radiography in our practices to varying degrees. Some of us do endeavor to change spinal alignment and our comparative radiographs confirm that we are consistently successful in making spinal changes. As it is impossible to ascertain the sagittal shape or the intersegmental alignment of the lumbar spine without radiography, we feel that without radiography it would be impossible to obtain appropriate alignment changes, as we would not know where we were starting and would not know where we had ended. In effect, we would not know what we wanted to accomplish or if we had accomplished the mechanical changes that we sought. We admit that this is clinical experience and may not be easily supported in the literature, but we suggest that a lack of reporting of a fact does not make the fact less true. We do suggest that the asymmetrical loading that would be produced by abnormal alignment is a subject that has received scientific discussion and that returning abnormally aligned spines to normal alignment is a cornerstone of chiropractic thought.
Subluxation
Dr Ammendolia has discussed the dangers and costs associated with radiography. We fully agree that these should be considered in the clinical decision process. In addition, we would like to note the dangers and costs of subluxation. We have observed that there seem to be 2 camps in regard to the word subluxation, those that place great importance on the word and those who hold it to be of little importance. We do not wish to enter into an argument as to the definition of the word. We do wish to point out that we have extensive clinical experience with what we call subluxations. We have seen them damage lives in multiple ways. Those who do not realize that the suffering caused by subluxations can rip apart the social fabric are certainly not long-time clinicians. We do understand that this article is focused on acute low back pain and that the authors have rightfully pointed out that most acute lower back pain is short lived and may accuse us, with some justification, of being slightly melodramatic in our last point. However, we would note that today's uncorrected subluxation may very well be tomorrow's chronic problem, regardless of the outcome of the acute pain, and that avoiding the creation of chronic problems should be of serious concern to all clinicians.
Perhaps the often-used quote from Wyatt7 should be applied to this question, “Will the treatment or the prognosis for the patient change if this study is performed?” For those of us who answer yes, we must give appropriate consideration to the taking of the indicated radiographs.
The purpose of this letter has not been to attack the authors or to enter into some of the lengthy and unpleasant debates that have taken place in the past in this journal.
Our intent was to register the thoughts of a group of clinicians (only 1 of our members has been published in this journal) who are greatly interested in the scientific literature relating to the practice of chiropractic. We hope this letter serves that purpose and encourages other clinicians to indulge in the study of the scientific literature and to register their opinions when appropriate. We would like to close with 1 final thought. It is the clinician, not the scientist, who delivers care to the multitude of patients. The views and experiences of these clinicians should be taken into consideration, as should the views of scientific authors. Both groups join together to make the whole and each group is dependent on the other. Thank you again for allowing us to express our views.
References
- . Views on radiography use for patients with acute low back pain among chiropractors in an Ontario Community. J Manipulative Physiol Ther. 2002;25:511–520
- . Low back pain and the lumbar intervertebral disk: clinical considerations for the doctor of chiropractic. J Manipulative Physiol Ther. 1999;22:96–104
- . Intra and interexaminer reliability of the chiropractic biophysics lateral lumbar radiographic mensuration procedure. J Manipulative Physiol Ther. 1995;18:519–524
- . Reliability of spinal displacement analysis on plain x-rays: a review of commonly accepted facts and fallacies with implications for chiropractic education and technique. J Manipluative Physiol Ther. 1998;21:252–266
- . Radiographic analysis of sagittal plane alignment and balance in standing volunteers and patients with low back pain matched for age, sex and size. Spine. 1994;19:1611–1618
- . Elliptical modeling of the sagittal lumbar lordosis and segmental rotation angles as a method to discriminate between normal and low back pain subjects. J Spinal Disord. 1998;11:430–439
- . Handbook of clinical chiropractic. Gaithersburg (MD): Aspen Publishers; 1992;
PII: S0161-4754(03)00237-9
doi:10.1016/j.jmpt.2003.12.015
© 2004 National University of Health Sciences. Published by Elsevier Inc. All rights reserved.
Volume 27, Issue 3 , Pages 218-219, March 2004
