X-ray marks the spot

I have a confession to make. Although I have practiced for more than 38 years, it was not until a little over a year ago that I truly appreciated the value of X-ray studies in my practice.

Like many of you, I have read studies published indicating little clinical benefit of radiographic studies in the diagnosis and treatment of musculoskeletal injuries and dysfunction. As a result, over the past decade or so prior to my epiphany, I drastically reduced the use of X-ray in my practice as per recommendation of the “authorities,” choosing to rely more upon chiropractic and orthopedic testing as well as the strength of a strong consultation (never bad things to do regardless).

My clinical results were certainly adequate, but I was finding that often, either the time taken to resolve the problem exceeded my expectations, or the condition recurred with greater frequency or simply failed to fully respond.

Aside from being perplexing, this was challenging my beliefs and confidence in my own abilities – both of which were unacceptable. After many years of what most would consider a successful practice, I sought out the advice of a respected coach, Dr. Keith Thomson, to help me figure out either what I was doing wrong, or more importantly, what I needed to do to be a better and more effective practitioner.

It wasn’t long into our initial conversations that I was confronted with the question: “How many of your patients do you X-ray as part of your investigative process?”

Initially, I was quite proud to report that I probably took radiographs on perhaps one in 10 of my neck and back patients, as per current recommendations on X-ray use in chiropractic practice. Thomson’s response was a simple: “Well that is a huge part of your dilemma.”

I initially scoffed at the observation, echoing back the science confirming that there is little or no benefit of static X-ray to clinical practice. This was met with a series of questions that totally changed my perspective on x-ray use in chiropractic practice, as well as the success of my outcomes going forward with my patients.

Here are some more of Thomson’s questions and my responses.

Why do many patients go to a chiropractor? They come to us in many instances because the initial response to their pain – whether rest, medical services, physiotherapy or whatever – did not work.

Do medical practitioners take X-rays for their low back and neck patients? Yes they do, but almost exclusively for purposes of ruling out pathology or developmental anomaly.

In the above cases, are the functional implications of structural changes, such as shifts in alignment, acknowledged? The answer here is, rarely. Often, minor scoliosis or alterations in lordosis are not mentioned at all.

From purely a logical perspective, could even a minor change in spinal alignment indicate a functional change resulting in pain or dysfunction? The answer here is of course a resounding, yes. Most spinal joint deterioration is considered wear-and-tear. If you look at spinal mechanics, they are not unlike a column of gears designed to function in a very prescribed and deliberate fashion. Altering the shape of the column changes the integrity of joint function and thereby stimulating degeneration over time.

Building on the above, is it a reasonable assumption, that positive findings on X-ray of either existing degeneration or alterations in structure could be a reflection of ongoing perverse biomechanical changes? Again, the response is a resounding, yes. Often, patients present with what appears to be a simple back or neck strain, acute in onset, with few, if any, positive orthopedic signs. Yet, response to treatment is slow or worse, serves to aggravate or expand the symptom complex.
This could result in a negative clinical experience for both the practitioner and the patient.

With appropriate use of X-ray, a more comprehensive picture of the patient’s biomechanical profile is often achieved. Underlying weaknesses, structural alterations or deteriorations are identified and explained. In viewing the radiographs, the patient as well as the practitioner gain deeper insight and understanding. When deterioration or structural change is evidenced, the practitioner is better equipped to create a more realistic treatment program for the patient.

Regardless of the science, it is logical to expect that a spine, which is showing structural compromise may require more comprehensive treatment beyond the reduction of the immediate symptoms.

What do you think patients feel when a practitioner presents and explains to them their X-ray studies? I will tell you with absolute certainty, that the appropriate use of X-ray in my practice has raised patient confidence. I am told repeatedly how thankful they are for the thoroughness of my investigations, how it has given them a much clearer understanding of the genesis of their discomforts. All of which serve to improve patient compliance, which translates into better clinical outcomes.  

Thomson then shares with me an actual clinical scenario: Patient X age 50 comes to me for what appears to be a simple back strain. After consult and examination, I decided not to X-ray. I saw that patient eight times. The initial response to care was positive but within a couple of months, the condition recurred. What do you think the likelihood was on this patient coming back to me for care? He did not, and this is a scenario that is far too common in practice.

Why do you think this happened? From the patient’s perspective the math is easy and pragmatic. From their experience, although the pain initially went away with care, the condition recurred. Therefore, the logical assumption is that chiropractic must not have worked. The truth is, that it was not the therapy that failed; it was me, the practitioner, for not digging deep enough to uncover the root of the problem. In this case, when the patient received X-rays at the direction of his medical doctor, underlying degenerative changes and a minor scoliosis were discovered providing the logical link between the initial problem and the recurrence.

When you fail to X-ray appropriately and miss an underlying weakness or deterioration, you neglected to assess all of the variables. Now, your credibility suffers and more importantly, the patient fails to receive the appropriate corrective care. Conversely, by getting a full clinical picture, presenting it to the patient with appropriate guidelines for care, the accountability now lies with the patient to comply. If he or she fails to do so, then it is very difficult to blame the process or the practitioner for the failure to achieve results.

The absolute correctness of this hit me like a brick.

By being more balanced in my use of X-ray, we have provided much more comprehensive care for our patients, seen clinical results improve significantly, with our compliance and patient satisfaction increasing exponentially.  

In our continued research, all indications are that X-ray should become an increasingly important component of the chiropractic corrective process. With the explosion of structural changes associated with forward head carriage, sitting work environments and continued expansion of sedentary North American lifestyle, comprehensive treatment strategies going well beyond pain management will be required to keep people functionally viable.

Radiographic imaging will, by necessity and appropriateness, become a more integral tool in the diagnosis and management of dysfunctions associated with these changes in lifestyle.

Dr. Douglas Pooley graduated from the CMCC and has practiced in St. Thomas, Ont., for the past 38 years. He has represented his profession on national and provincial boards and has lectured nationally and internationally.

Dr. Keith Thomson is both a chiropractor and naturopathic doctor. He is a former president of the College of Chiropractors of Ontario. He has been in practice in Peterborough, Ont., for almost 40 years.