Volume 27, Issue 3 , Pages 219-220, March 2004
Article Outline
In Response:
Thank you for the opportunity to respond to the letter by Hansen et al, who cite articles supporting the use of routine plain film lumbar radiographs and suggest clinician experience and the need to identify and correct subluxations as valid reasons for chiropractors to take radiographs.
Hansen et al cite several articles on spinal radiographic analysis by Harrison DE, Troyanovich SJ, and Harrison DD, including a review of the literature on this topic, in which they conclude there is evidence supporting the use of routine radiographic spinal analysis.1 In a recent article published in this journal, Haas et al2 critically appraised this review by Harrison et al1 and concluded it suffers from serious methodologic deficiencies, the most important of which are omitting relevant studies, misrepresenting the evidence, and disregarding the rules of evidence. In contrast, the evidence against routine use for acute low back pain (LBP), the most common type of LBP seen in chiropractic practice,3 is substantial and methodologically sound. This is demonstrated by the clear and consistent recommendations found in the LBP guidelines published in over a dozen countries worldwide which state the vast majority of patients with acute LBP do not need a radiography evaluation.4
We agree that the role of clinical experience is important in clinical decision making. However, it should be used in the context of, and not independent of, the best available evidence, cost, and risks and benefits to individual patients. Current evidence for routine plain film radiography for acute LBP suggests that there is not only limited benefit to patients but it is associated with potential harm and adds unnecessary costs to the health care system.5., 6., 7.
As a profession, chiropractors must develop rational explanations for the use of plain film radiology in clinical practice. In this era of increasing health care accountability, a more judicial use of spine radiography is necessary among all health care providers. The development of evidence-based, condition-specific imaging guidelines for chiropractic practice, unlike the vague and nonspecific imaging guidelines found in both the Canadian and American Chiropractic Practice Guidelines,8., 9. would be a useful first step in improving the appropriate use of plain film radiography in chiropractic practice.
References
- . 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 Manipulative Physiol Ther. 1998;21:252–266
- . Commentary. The routine use of radiographic spinal displacement analysis: a dissent. J Manipulative Physiol Ther. 1999;22:254–259
- . Use of chiropractic services from 1985 through 1991 in the United States and Canada. Am J Public Health. 1998;88:771–776
- . Clinical guidelines for the management of low back pain in primary care. Spine. 2001;26:2504–2514
- . Radiographic examination of the lumbar spine in a Community Hospital: an audit of current practice. BMJ. 1991;303:813–815
- Survey of general practitioners' opinions on the role of radiology in patients with low back pain. Br J Gen Pract. 1990;40:98–101
- . Back pain and the radiologist. Radiology. 1980;137:861–863
- In: Henderson D, Chapman-Smith D, Mior S, Vernon H editor. Clinical guidelines for chiropractic practice in Canada. Toronto Ontario, Canada: Canadian Chiropractic Association; 1994;
- In: Haldeman S, Chapman-Smith D, Peterson DM editor. Guidelines for chiropractic quality assurance and practice parameters. Mercy Conference Center; January 25-30. 1992;
PII: S0161-4754(03)00238-0
doi:10.1016/j.jmpt.2003.12.016
© 2004 National University of Health Sciences. Published by Elsevier Inc. All rights reserved.
Volume 27, Issue 3 , Pages 219-220, March 2004
