ACA’s Choosing Wisely recommendations are consistent with X-ray guidance in today’s classroom and trusted texts.
William* came to my office because he had hip and low back pain that had recently made even walking through the house an arduous task. He said that since the pain started a week ago just getting into his car’s front seat was a dramatic production. Despite it all, this octogenarian was in good spirits and making jokes at his own expense—one of those people who enjoyed making everyone laugh in the reception room.
He gave straight answers while taking a medical history and was cooperative as I took vitals and ran through the orthopedic and neurologic examination. He was managing his diabetes with a well-regarded primary care physician, he had no history of osteopenia or fracture, no progressive neurologic symptoms, and we could reproduce his pain with provocative tests. It looked like helping him overcome the pain that was interfering with his life was going to be pretty straightforward.
Next, I sent him to get X-rays.
In the past year, many chiropractors have discussed indications for radiographic examination with renewed interest. In particular, they have questioned the X-ray recommendations of the Choosing Wisely initiative, a project of the American Board of Internal Medicine that seeks to promote more effective use of healthcare resources. Choosing Wisely features recommendations from 90 healthcare professional societies. ACA released its own set of recommendations in 2017, which included the following:
“ACA recommends clinicians do not obtain spinal imaging for patients with acute low-back pain during the six weeks after onset in the absence of red flags.”
In addition, a second X-ray recommendation cautions clinicians not to use films as a measure of patient progress, along with three other recommendations that were generally well received. (See the complete list of ACA recommendations.)
Many chiropractic curricula include an imaging class every semester, which means that radiology is part of every chiropractor’s DNA and some chiropractors’ very identity. So, seeing their own red flags, some doctors went straight on the defensive. Many other doctors, however, passed over the recommendations without concern. For these chiropractors, the concepts summarized in Choosing Wisely were fully familiar, from texts and lectures covered in school. A chiropractic radiology curriculum covers a lot more territory and subtlety than a bulleted quick-reference table of recommendations, but the messages were consistent.
In school, modern students learn a wide breadth of basic pathology radiology, as well as basic biomechanical measures. They learn how to identify pathology such as tumors, infections, and metabolic diseases that indicate necessity for additional referral. They learn how to identify findings such as spondylolisthesis or block vertebra, which can at times alter a patient’s response to care. Chiropractors also learn to use history and examination to make reliable predictions regarding which patients might benefit from imaging, and how to develop their judgement of when to use these evaluation tools.
The Choosing Wisely recommendations are hardly revolutionary, and well in line with current radiology education. In my own final radiology classes, professors emphasized that what we learned was only the foundation of what we would need in practice, and a mere fraction of what our peers would learn should they choose to become chiropractic radiologists. The recommendations in Choosing Wisely are shorthand for what we already know. They serve to remind us of a few well established best practices, and can help optimize delivery of care when considered alongside sound clinician reasoning and patients’ preferences and goals.
To dig into specifics, some of the red flags mentioned in Choosing Wisely are right there every semester in the class notes of a thousand future chiropractors. “Red flag” indicators for early imaging in low back pain can include falls or trauma, suggestion of infection or tumor, and even age over 55. Our standard in radiology textbooks, the venerated Yochum + Rowe1, addresses re-examination by stating, “Other than scoliosis, there are few postural alterations that indicate a need to repeat a radiographic examination to evaluate therapeutic progress,” unless the clinical situation changes.
The Choosing Wisely recommendations are hardly revolutionary, and well in line with current radiology education. In my own final radiology classes, professors emphasized that what we learned was only the foundation of what we would need in practice, and a mere fraction of what our peers would learn should they choose to become chiropractic radiologists. The recommendations in Choosing Wisely are shorthand for what we already know. They serve to remind us of a few well established best practices, and can help optimize delivery of care when considered alongside sound clinician reasoning and patients’ preferences and goals.
William came back to me later in the day, and I reviewed his images as well as the radiologist’s report. Considering the patient, the images were as expected for a patient of his age and health status. No pathology showed up, and the treatment did not change due to findings. However, I recognized that his age and conditions left the possibility for several contraindications or co-morbidities, and I wanted to narrow the field of considerations. In this case my reasoning was generic (the patient was aging, with some co-morbidities) but I knew I could identify this reasoning if my patient wisely asked. His age alone qualified as a red flag, as the incidence of significant pathologies rises as we age. I used my clinical judgement in ordering imaging, based on modern chiropractic education, and well in line with the Choosing Wisely recommendations.
Dr. McCann practices in New Hampshire, where he represents his district as ACA alternate delegate. He also works as a member of the NextGenACA community and on various task forces, as well as in state association leadership. He was awarded New York Chiropractic College’s BJ Palmer Award for communications for his writing about chiropractic education while a student.
*Please note: The patient’s name has been changed to protect his privacy.
Reference
- Yochum T and Rowe L, Essentials of Skeletal Radiology, “Normal Skeletal Anatomy and Radiographic Positioning,” LWW 2004. pg. 11.
