Choosing Wisely X-ray Recommendations Reflect Evolving Evidence, Accepted Standards
Thursday, September 07, 2017 05:31 PM

By Christine Goertz, DC, PhD

The goal of the Choosing Wisely® campaign is to promote conversations between doctors and their patients about utilizing the most appropriate tests and treatments. The campaign is an initiative of the American Board of Internal Medicine Foundation and Consumer Reports. 

The first ACA Choosing Wisely® recommendation states: In the absence of red flags, do not obtain spinal imaging (X-rays) for patients with acute low-back pain during the six weeks after the onset of pain. This recommendation is not only on ACA’s Choosing Wisely® list; a similar item is also included on the lists of seven other organizations. This includes, among others, the American College of Emergency Physicians, the North American Spine Society and the American College of Physicians. It's also one of the performance measures established by the Centers for Medicare and Medicaid (CMS) under the MIPS Program. Thus, it is a widely accepted standard.

It's important to clarify that ACA's recommendation refers to imaging patients with acute low back pain, not those with chronic pain or acute pain caused by trauma sufficient to suspect pathology that may be identified by imaging, such as compression fracture.

There are many DCs who are committed to delivery of high-quality patient care that currently take or order X-rays on a majority of their patients because they believe that X-rays are a necessary component of the examination process. There are a number of reasons why this is the case. First, many of us were taught to do so in chiropractic school, with the intent to either rule out underlying pathology and/or contraindications to spinal manipulation or to deliver a chiropractic technique that is based upon X-ray findings.

Clinical practice for all health professions continues to evolve after we graduate from our educational institutions. This is the reason why continuing education is required. There is no evidence that those chiropractic techniques based primarily on X-ray findings lead to better outcomes than those techniques that do not. To be clear, there is no evidence against either. There is simply very little evidence at all. While one must always be cognizant of the fact that lack of evidence does not equate to evidence against, it is now the national standard across all health professions to take an evidence-informed approach to patient care. Choosing Wisely® recommendations are not set in stone. As new high-quality evidence becomes available they will be changed.

As with many of our colleagues in the health care professions, we have learned from experience to practice “defensive medicine.”  This perspective may be even more deeply ingrained within the chiropractic profession based on our prior experiences with bias and/or lack of understanding regarding chiropractic care. As an example, just look how long it took before Choosing Wisely® was even willing to consider a chiropractic list!

Every chiropractor in practice for more than a few weeks has run across a patient with sub-pathological findings that could potentially impact treatment decisions. We know there are contraindications that can be identified using X-rays in the absence of red flags that are identified through the history and examination process. However, X-rays do not identify all contraindications. Good clinical practice involves constant juxtapositioning between benefits and the risks of progressively more advanced and invasive diagnostic procedures as we assess each individual patient. While there may be some benefit to a limited number of patients in conducting routine X-ray examinations (similar to routine mammograms in patients under the age of 50), research has shown that for the majority, imaging tests do not ensure a speedy recovery, are expensive and involve some risk to the patient in terms of radiation and increased likelihood of receiving surgical treatment.

More frequently than not, clinical decisions need to be made with imperfect information. Fortunately, the majority of absolute contraindications to spinal manipulation are relatively rare, those that are discovered on X-rays in the absence of red flags are even more so.