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evidence based practice

Should I Get An X-ray?

images-6Diagnostic imaging – whether it be X-rays, CT or MRI can significantly improve patient care and give us information that can aid in recovery. When it comes to X-rays, there is some evidence that misuse of the service occurs, whether it be overuse or under-use. It is for this reason that the Chiropractic College of Radiologists (Canada) created evidence-based Diagnostic Imaging Guidelines to be used by chiropractors and other health care professionals.

With respect to the low back and mid-back, the guidelines state that diagnostic imaging is required in the following circumstances:

  • Mid-back or low back blunt trauma or acute injuries.
  • High-risk screening criteria for spinal injuries such as mid-line tenderness of the spine with palpation, altered consciousness or neurological problems.
  • Major trauma including pelvic trauma accompanied by inability to bear weight.
  • When spinal stenosis (narrowing of the canal the spinal cord or nerves run through) or other degenerative problems are suspected.
  • Lack of improvement with treatment, or worsening of the condition.
  • Presence of red flags – suspected underlying disease, infection or cancer, etc.

With respect to the neck, the guidelines state that diagnostic imaging is required under the following circumstances:

  • Acute neck trauma in someone who is older than 65, reports a dangerous mechanism of injury OR has numbness/tingling/weakness in their arms.
  • Non-traumatic neck pain WITH pain/numbness/tingling or weakness in arms.
  • Lack of improvement with treatment, or worsening of the condition.
  • Presence of red flags – suspected underlying disease, infection, cancer, instability of the neck, etc.

It should be noted that these guidelines do not recommend taking an X-ray of every patient who walks though the door. A large number of people have simple mechanical spine pain for which further imaging is not needed, thereby sparing the patient radiation exposure and the health care system more expense. However, there are some cases (as listed above) where it is prudent to get further investigation before proceeding with treatment. Your chiropractor is trained to be able to recognize when you warrant further diagnostic imaging.

A full copy of the diagnostic imaging guidelines for the spine can be found below.

Diagnostic Imaging Guidelines

Dr. Debbie Wright is a practicing Vancouver Chiropractor.

The Evidence Supports Chiropractic Care

Myth #3: There is no evidence to support that chiropractic works.

I don’t even know where to start with this one. The fact is that there is are so many studies done on spinal manipulation that a Medline search would be overwhelming. Instead of going through the many systematic reviews and meta-analyses that exist, I think the evidence is well summed up by an review exploring international low back pain guidelines. The review can be accessed here.

Over the last 10 years, 12 countries have done critical reviews of the scientific literature concerning low back pain. The international consensus is that the balance of the evidence shows that chiropractic spinal manipulation is effective in managing low back pain, and therefore is included in the recommendations. Here is a summary of their findings:

Clinical practice guidelines for the treatment of acute lower back pain

  • Reassurance of the favourable natural history
  • Advice to stay active
  • Discourage bed rest
  • Acetaminophen, p.r.n.
  • Chiropractic spinal manipulative therapy
  • Advice against passive physiotherapy modalities, prolonged bed rest or specific back exercises.

Essentially the investigators found that following these treatment guidelines (including chiropractic spinal manipulation) led to better outcomes than usual medical care. It is important to note that the guidelines don’t recommend chiropractic as a stand alone treatment, but as one component of a continuum of care.

One of the authors of the study then went on to launch the 2-part C.H.I.R.O study (Chiropractic Hospital-Based Interventions Research Outcome study). The first part pitted chiropractic care (along with the above guideline recommendations) versus usual medical care. The people who received chiropractic care showed better functional and quality of life improvements. The results of this study have been presented at Canadian Spine Society Meeting, the International Society for the Study of the Lumbar Spine, and the North American Spine Society and will be published in an upcoming edition of Spine. A summary of the results can be found here.

In the opinion of this Comox Valley Chiropractor, we are so far past establishing that there is evidence supporting chiropractic care. We are now heading in the direction of trying to establish how to best use this tool in the management of patients, or whether certain subsets of patients will respond more favourably. In the past 5 years, Chiropractic Research Chairs have been established at many universities across Canada in order to further chiropractic research.

Dr. Debbie Wright is a practicing Comox Valley Chiropractor.