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Imaging and Chiropractic

Have you experienced pain or injury and had a well-meaning friend or family member ask if you’ve had a scan yet? Diagnostic imaging such as X-ray, Computed Tomography (CT scan) and Magnetic Resonance Imaging (MRI) are common knowledge within society and most people have had some interaction with these tests in some way or another. These advanced technologies are often considered as the gold standard of medical testing and may give the general population a perception that they’re not only useful, but essential for the diagnosis and management of pain and injury.

 

Diagnostic imaging can be extremely valuable in certain situations, even lifesaving! But that’s not always the case, in other situations, imaging can have negative effects on our health and wellbeing. In this insight we will explore why imaging can be useful in a chiropractic setting, and how to interpret specific findings that commonly found on imaging.

 

“Do I need a scan?”

 

First things first, when is it necessary to get a scan?

 

Diagnostic imaging can be useful in specific cases to help your practitioner decide what might be going on, and how best to help you. However, the number of cases that would benefit from immediate imaging is slim… in fact less than 1% of low back presentations would fit into this category! (1)

 

There are clear guidelines regarding when and why imaging should be used (2), here are the main reasons your chiropractor might want to order imaging:

  • You have signs or symptoms that may indicate a serious pathology (e.g. Back pain after significant trauma may indicate a fracture)
  • You’ve had a trial of conservative treatment already and it hasn’t helped
  • You have a significant spinal curvature such as scoliosis (especially in a child)

In general, imaging should only be ordered if there is a likelihood that it will change how the chiropractor will manage you. Beyond these reasons, there is limited evidence that imaging is beneficial in a chiropractic setting (3).

 

To highlight how we come to this decision in clinic, here is a case study that shows this:

 

John, a 60-year-old man comes to us with a 1-week history of severe deep low back pain. The pain came on after working in his garden. He’s never had this before. He smokes 1 pack of cigarettes a week, is not very physically active, and has felt very fatigued and run down recently. His pain is constant and isn’t relieved by ibuprofen.

 

In this situation, John has a number of red flags that make us suspicious that there could be something serious causing his back pain, such as infection or cancer. Even though the likelihood of that is still low, it’s important to rule out those things before starting treatment, in this case.

 

Now for a different example:

 

Jenny, a 40-year-old woman comes to us with a 1-week history of low back pain. The pain came on gradually after starting to run again and is worse when she bends backwards. She doesn’t smoke, has no other health conditions, but she’s unable to finish her runs due to the pain. She also reports some stiffness in her hip from a previous injury.

 

In this situation, nothing jumps out to us as potentially serious. Jenny’s issue seems very biomechanical and associated with her running. Therefore, at this point imaging is unlikely to help our management.

 

“Why not just scan everyone to be sure?”

 

Although it may seem logical to get a scan “just in case”, there are potential risks and harms associated with imaging:

  • Radiation exposure – X-ray and CT scans use varying amounts of radiation which can increase the risk of cancer over time
  • Expensive – not all types of scans are bulk billed, such as MRI, which can be a significant out of pocket expense
  • Increase chance of surgery or further testing (4)
  • Increase anxiety and fear over incidental findings

To highlight this last point, let’s use Jenny’ example again:

 

Jenny sees her GP and requests a scan because she’s concerned about her back pain. She gets an X-ray taken. The GP explains that’s there’s nothing significant on the X-ray and to see her chiropractor for care. Before she went, she read the X-ray report and does not understand what the report is saying. “Multi-level degenerative changes, loss of disc height, projecting osteophytes” makes Jenny think that the GP has missed something, because it sounds pretty serious! She googles her findings which only increases her anxiety and fear, so by the time she gets to the chiropractor, Jenny is quite distressed about her scan.

 

“My scan showed some degeneration… What does that mean?”

 

Cases like Jenny’s are common situations we see in clinic, and can be very challenging to address. Although some of these findings sound scary, they are not always relevant to your pain, this is something we call an incidental finding. Osteoarthritis or “degeneration” is a condition that happens normally as we age. It’s not just “wear and tear” but is a complex process that involves multiple factors. Most importantly it shows a poor correlation with pain, in fact 68% of 40-year-old will but degenerative findings on MRI, but have no pain! (5) This tells us that imaging findings are only 1 part of the clinical picture, and we need to consider other factors.

 

So how do we approach these situations?

 

It’s really important that you understand what your imaging findings means, and the degree to which they may impact your pain.

 

Validate – Even if there are no significant findings on your scan, that doesn’t mean your pain isn’t real, it just means there may be other factors that are contributing to your experience.

 

Reassure – As Jenny’s case shows, imaging findings can be distressing, and has the possibility to prolong and worsen our experience of pain. By explaining the findings for the patient’s specific context, we aim to provide reassurance and reduce these feelings of anxiety and fear.

 

If you’d like to learn more about imaging, here is a great resource:

https://www.nps.org.au/assets/81ab7562891245b2-5948693db67c-NPS2060_LBP_FactSheet_v7-as-accessible.pdf

 

References

  1. Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, York J, Das A, McAuley JH. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology. 2009 Oct;60(10):3072-80.
  2. Hutchins TA, Peckham M, Shah LM, Parsons MS, Agarwal V, Boulter DJ, Burns J, Cassidy RC, Davis MA, Holly LT, Hunt CH. ACR appropriateness criteria® low back pain: 2021 update. Journal of the American College of Radiology. 2021 Nov 1;18(11):S361-79.
  3. Jenkins HJ, Downie AS, Moore CS, French SD. Current evidence for spinal X-ray use in the chiropractic profession: a narrative review. Chiropractic & Manual Therapies. 2018 Dec;26(1):1-1.
  4. Jacobs JC, Jarvik JG, Chou R, Boothroyd D, Lo J, Nevedal A, Barnett PG. Observational study of the downstream consequences of inappropriate MRI of the lumbar spine. Journal of general internal medicine. 2020 Dec;35(12):3605-12
  5. Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American

 

About the Authors

chatswood chiro david mcnaughton

David McNaughton is a clinician and a researcher. He is the director and principal chiropractor at DMC Health & Wellness. He has an extensive background in the diagnosis and management of chronic pain. In addition to his clinical studies, David holds a Master’s of Research and PhD in Psychology. He regularly publishes his research in peer reviewed medical and psychology journals. David has taught both undergraduate and postgraduate studies in Chiropractic and Psychology at Macquarie University.

 

 

Isaac-Searant-DMC-ChiroIsaac completed a Bachelor of Chiropractic Science and Master of Chiropractic at Macquarie University, and is currently enrolled in a Master of Research. His research aims to understand the clinical decisions health practitioners make about diagnostic imaging. His clinical interests include spinal pain (neck and back) and sporting injuries. Regardless of the condition, his goal as a chiropractor is to work collaboratively with patients.

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