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. As part of the campaign, an organization creates an evidence-based list of 5 tests and/or procedures that may be common…but often should not be part of routine care. The program encourages an evidence-based approach to patient care and shared decision-making between doctors and patients. The American Chiropractic Association (ACA) joined the Choosing Wisely® campaign recently because these are principles that ACA strongly supports.
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.
Some doctors of chiropractic may be surprised that ACA included this recommendation. 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.
As Evidence Expands, Our Practice Must Evolve
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. We would not want our child’s pediatrician to recommend a medication that was popular when he graduated from medical school 20 years ago rather than the one that was recently shown in clinical trials to be the safest and most effective. Further, 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. The onus is on those practicing chiropractic techniques that have not yet been evaluated to support research to determine if the risk of x-rays is outweighed by any additional benefit when compared to techniques such as HVLA and flexion-distraction. Choosing Wisely® recommendations are not set in stone. Rather, they are updated as new high-quality evidence becomes available.
Letting Go of “Defensive” Practice
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!
Always Weighing Benefits vs. Risks
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. For instance, one really wants to avoid putting a dynamic thrust into a transitional segment with an accessory joint. 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. For instance, Syringomyelia is a relative contraindication to spinal manipulation. Yet it is not standard practice to order an MRI on every patient to rule out this possibility. Why? Because it is simply not possible or advisable to do every test on every patient every time. 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.
Dr. Goertz is senior scientific advisor for the ACA and chairperson of association’s Committee on Quality Assurance and Accountability, which developed the Choosing Wisely® recommendations for the association.