Chiropractors have been shown to over-use X-rays (a worry about which I cautioned almost 20 years ago) and to refer for lumbar radiography inconsistent with the current clinical guidelines for low back pain. It is unknown whether this is due to lack of adherence with, or a lack of awareness of relevant guidelines. The aim of this study was to clarify this issue; more specifically, the authors wanted to determine Australian chiropractors’ awareness of, and reported adherence to, radiographic guidelines for low back pain.
An online survey was distributed to Australian chiropractors from July to September, 2014. Survey questions assessed demographic, chiropractic practice and radiographic usage characteristics, awareness of radiographic guidelines for low back pain and the level of agreement with current guidelines. Results were analysed with descriptive statistics and logistic regression analysis.
A total of 480 surveys were completed online. Only 49.6 % of the responders reported awareness of radiographic guidelines for low back pain. Chiropractors reported a likelihood of referring for radiographs for low back pain: in new patients (47.6 %); to confirm biomechanical pathologies (69.0 %); to perform biomechanical analysis (37.5 %); or to screen for contraindications (39.4 %). Chiropractors agreed that radiographs for low back pain could be useful for: acute low back pain (54.0 %); screening for contraindications (55.8 %); or to confirm diagnosis and direct treatment (61.3 %). Poorer adherence to current guidelines was seen, if the chiropractor referred to in-house radiographic facilities, practiced a technique other than diversified technique or was unaware or unsure of current radiographic guidelines for low back pain.
The authors of this paper concluded that only 50 % of Australian chiropractors report awareness of current radiographic guidelines for low back pain. A poorer awareness of guidelines is associated with an increase in the reported likelihood of use, and the perceived usefulness of radiographs for low back pain, in clinical situations that fall outside of current guidelines. Therefore, education strategies may help to increase guideline knowledge and compliance.
I am tempted to rephrase the last sentence: EDUCATION STRATEGIES MAY HELP TO INCREASE THE KNOWLEDGE THAT RESPONSIBLE HEALTHCARE PROFESSIONALS SHOULD WORK PRIMARILY FOR THE BENEFIT OF THEIR PATIENTS RATHER THAN FOR THE BENEFIT OF THEIR BANK ACCOUNTS.
In my view, this investigation confirms that:
- chiropractors still grossly over-use X-rays (it probably is fair to assume that the responders of this survey were relatively guideline-conform compared to non-responders; if that were true, the true figures of X-ray overuse would be even higher)
- they use X-rays for spurious reasons;
- they are ill-informed about the existing evidence;
- they have not abandoned the myth of ‘subluxation’, i. e. ‘biomechanical pathologies’.
Of course, the data are from Australia, and chiros elsewhere might claim that they are more guideline-conform than their Australian colleagues. But, in their discussion section, the authors of the present paper point out that “three previous studies have quantitatively assessed the adherence of registered chiropractors to radiographic guidelines for the management of low back pain (LBP). Two surveys performed in Canada with 26 and 32 responses respectively found that 63 and 59 % would use radiography for acute LBP without indicators of potential pathology and 68 and 66 % thought that radiography was useful in the evaluation of acute LBP.”