For the past year, I have been asked by many practicing chiropractors, college presidents, faculty and others what my opinion is on the "Choosing Wisely" guidelines the American Chiropractic Association (ACA) recently adopted for its members. The specific guideline I am referring to reads, "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."
Many doctors have related the negative impact these guidelines have had on their ability to provide appropriate care to their patients. In fact, I so commonly field questions from attendees at seminars, conferences and other professional events I attend, that I feel compelled to share a few thoughts on the topic with a broader audience within the profession through this publication.
A Flawed Process
My first concern with this guideline is in regard to the process followed by the ACA to produce its "Choosing Wisely" criteria. For years, the ACA Council on Diagnostic Imaging and the American Chiropractic College of Radiology have been recognized by the ACA as the de facto authorities for the chiropractic profession on issues related to diagnostic imaging.
As an active member of the ACA's own Council on Diagnostic Imaging (CDI) and the CDI's subordinate organization of the American Chiropractic College of Radiology (ACCR), I am perplexed that the ACA didn't engage our group of content experts on the "Choosing Wisely" project. In my opinion, this is a significant oversight by the ACA.
Excluding Clinical Judgment
The ACA's "Choosing Wisely" statements on radiology also exclude practitioner clinical judgment. As written, the first statement disallows the competent and well-trained practicing chiropractor from using his or her clinical acumen and experience to determine when an X-ray will be necessary to give the patient the appropriate diagnosis and/or treatment needed.
To deny practicing chiropractors their rights and responsibilities to exercise clinical judgment based on rational clinical practice creates a public health hazard and a potential medical liability. The guidelines poorly adapt to the needs of a profession that relies heavily on both the biomechanical analysis of the spine for treatment planning and the application of physical forces in treatment delivery.
I believe these key factors have been neglected in developing the guidelines and are, in large part, why they are not being widely embraced by the profession.
Ignoring the Importance of Biomechanical Considerations
The guidelines have not given appropriate attention to the importance of the biomechanical information that can be gleaned from weight-bearing spinal radiographs. Biomechanical information impacts how practitioners specifically treat their patients.
A short-leg syndrome or increased lumbar lordosis with an increase in the Ferguson's sacral base angle, which may translate into a lumbar facet syndrome, may be important to the clinical context of care. The presence of clinically silent congenital anomalies and structural changes such as scoliosis, spondylolisthesis, os odontoideum, blocked vertebra or transitional segments at the lumbosacral junction, with or without an accessory joint articulation, certainly impact which form of treatment would be appropriate or not appropriate for the patient.
The ACA's first "Choosing Wisely" statement does not allow for biomechanical considerations.
Ironically, the importance of structural defects seems to be recognized in related content on the ACA's website, at the same time it is categorically dismissed by the ACA's "Choosing Wisely" document.
For example, in an article titled "'Choosing Wisely'" X-Ray Recommendations Reflect Evolving Evidence, and Accepted Standards," under the subheading, "always weighing benefits versus risks," the author states: "One really wants to avoid putting a dynamic thrust into a transitional segment with an accessory joint." I agree with the author acknowledging that the presence of a transitional segment with accessory joints is important, yet it does not meet the "red flags" threshold adopted within the "Choosing Wisely"statements. Without appropriate radiographic images, this variant would go undetected.
Moving Forward: Two Suggestions
I encourage the ACA to create a task force to revisit this guideline with these two suggestions in mind:
First, make every effort to ensure that the insights of those within our profession with expertise in diagnostic imaging are taken into consideration. To this end, I would respectfully request the ACA involve the profession's content experts, such as inviting one or more diplomates of the American Chiropractic Board of Radiology to serve on a task force.
Second, I suggest the guideline take into consideration the particular needs of the chiropractor as a spinal manipulator, who may need more information than his or her allopathic counterparts, to determine the safety and potential efficacy of applying mechanical force to the musculoskeletal system as part of his or her treatment regime. I believe a revision would be in the overall best interests of practicing doctors of chiropractic, the patients they serve, and the ACA.
I hope my opinion is received in the same constructive spirit in which it is rendered. I am a longtime member and supporter of the ACA.
Editor's Note: Other perspectives on the ACA's "Choosing Wisely" X-ray guideline from the ICA, Palmer College and Sherman College appear in our December 2017, April 2018 and June 2018 issues, respectively.
Dr. Terry R. Yochum is a second-generation chiropractor and a cum laude graduate of the National College of Chiropractic, where he subsequently completed his radiology residency. He is a diplomate of the American Chiropractic Board of Radiology and served as its vice president and president for seven years (1983-1990). An adjunct Professor of Radiology at the Southern California University of Health Sciences and member of the Department of Radiology at the University of Colorado School of Medicine, Dr. Yochum is the co-author of Essentials of Skeletal Radiology – the required textbook in radiology at all 50 chiropractic colleges and used in more than 100 medical schools around the world.