Chiropractic schools teach evidence-based X-ray use

The use of X-rays by chiropractors, especially for low-back pain, has long been controversial. Evidence-based guidelines for treating low-back pain recommend using X-rays only when there are signs — or “red flags” — of underlying serious disease. Serious disease in back pain is rare, occurring in less than five per cent of patients. Yet in Canada, X-ray use among chiropractors for patients with back pain ranges from 35 per cent to 63 per cent. This study examined whether chiropractic schools taught the use of X-rays in accordance with existing evidence-based guidelines for low-back pain.

The researchers identified and approached 33 accredited chiropractic schools globally to participate in an anonymous web-based survey. Most practising chiropractors in the world have attended one of these schools. Participants were asked about the instruction given to students on the use of X-rays for patients with low-back pain. Survey responses were compared to the evidence-based guidelines on managing acute low-back pain from the U.S. Agency for Healthcare Research and Quality.

Almost all (32/33) of the identified schools answered the survey. Consistent with the guidelines, most respondents did not:

• recommend routine X-ray before spinal manipulation (78 per cent)
• instruct students to use X-rays to assess misalignments of the spine (77 per cent)
• see a role for full spine X-rays in assessing patients with low-back pain (91 per cent).

More than nine in 10 respondents also said that they taught students to use X-rays when red flags were present in cases of acute back pain (less than three months). However, four in 10 respondents said there was a role for X-rays in evaluating patients with acute low-back pain, even without the presence of red flags.

One strength is that almost all accredited chiropractic schools that were contacted took part, and the people responding were in charge of their school’s X-ray instruction. The biggest limitation is that responses were not verified to confirm that respondents actually taught what they said they did.