Do chiropractors recommend back radiographs too frequently?

In brief

  • Compared to trainees, practising chiropractors used radiography more often for a number of reasons: attendance at seminars or courses encouraging radiography use, financial pressures or fear of malpractice.
  • Following treatment guidelines closely may reduce the unnecessary use of radiography.

Why was this study done?

Currently, radiography is recommended only for low-back pain patients showing signs of serious underlying disease. Recent research suggests that chiropractors request radiographs more often than other health-care practitioners, and they may exceed the recommendations from treatment guidelines. This study looked at how well chiropractic trainees follow three radiography guidelines for low-back pain. The researchers wanted to see if the gap between the guidelines and practice began during undergraduate training.

How was the study done?

The study involved 448 patients with low-back pain at six teaching clinics of the Canadian Memorial Chiropractic College. At their first visit, patients completed a questionnaire about their low-back pain and possible signs of serious disease. Chiropractic trainees answered questionnaires later in the treatment process on patient health, signs of serious disease and recommendations for radiography. Finally, the actual clinical care for these patients was measured against three radiography guidelines: (i) the Agency for Healthcare Policy and Research (AHCPR) (now known as the Agency for Healthcare Research and Quality), (ii) modified AHCPR and (iii) the Simmons guidelines.

What did the researchers find?

Researchers focused on patients with no “red flags” signalling more serious disease. These patients should not receive radiography. They found that chiropractic trainees did not recommend radiography for most of those patients (between 89 per cent and 95 per cent). In total, radiography was recommended for 12 per cent of all patients. This rate is lower than in past studies of Ontario chiropractors. Overall, between 45 and 70 per cent of patients had at least one red flag. However, the presence of red flags alone may not mean a patient needs radiography.

What are some strengths and weaknesses of the study?

There was a high participation rate among patients and chiropractors in the clinics, with 89 per cent participating. However, the trainees’ recommendations may have been influenced by the presence of researchers in the clinics.

Publication Information

Title: 

Do chiropractors adhere to guidelines for back radiographs? A study of chiropractic teaching clinics in Canada.

Author(s): 

Ammendolia C, Côté P, Hogg-Johnson S, Bombardier C

Journal: 

Spine, 2007: vol. 32, no. 22, pp. 2509-2514