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Radiographic Anomalies That May Alter Chiropractic Intervention Strategies Found in a New Zealand Population
RADIOGRAPHIC ANOMALIES THAT MAY ALTER CHIROPRACTIC INTERVENTION STRATEGIES FOUND IN A NEW ZEALAND POPULATION
To the Editor: Beck et al1 in their recent article fail to provide sound evidence that chiropractors need their own set of radiography guidelines, bnot medical guidelines,Q nor do they provide valid evidence to justify the use of full spine radiography in 84% of patients who present to the outpatient clinic at the New Zealand Chiropractic College. In their article, the authors found that 68% of patients presenting for chiropractic care who had full spine radiography had significant anomalies. They suggest that this finding may have implication for chiropractic treatment. However, the likelihood of detecting an anomaly on a radiograph is unimportant unless it has clinical relevance.2,3 To have clinical relevance, the anomaly should, first, provide information beyond that obtained during history taking and physical examination; secondly, its presence should significantly alter patient management; and thirdly, the alteration in management should be associated with a benefit to the patient (improved outcome). When examining the 68% of patients who were found to have anomalies (their Table 1), more than 75% of patients had anomalies that lack sufficient evidence of their clinical relevance such as transition segments, blocked vertebrae, nonunion, spina bifida occulta, mild scoliosis, and facet tropism.4 There is no convincing evidence that these anomalies are contraindications to spinal manipulative therapy.5 Furthermore, there is no evidence that their presence alters patient management or that altering management (spinal manipulative therapy) will result in improved patient outcomes. The remaining patients had clinically relevant pathologic conditions of low prevalence that are either found among high-risk groups or are incidental findings. High-risk patients can usually be identified by the presence of red flags during history taking and physical examination.6 As for the unsuspecting pathologies, these are relatively uncommon and there is no evidence to justify using full spine radiography to screen for these conditions. In conclusion, most patients in this sample had anomalies of no proven clinical relevance. Selective criteria based on the presence of clinical indicators (red flags) have been shown to be highly sensitive in ruling out most of the remaining clinically relevant conditions.6 The chiropractic profession urgently needs to critically appraise its current use of radiography. In addition to clinical relevance, the potential risks of routine spinal radiography must be considered. In the United States, approximately 5700 cancer cases a year are attributed to diagnostic x-rays.7 In the sample of Beck et al of 847 full spine radiographs, most patients are younger than 40 years. The cells in young individuals, particularly the reproductive tissues, are most susceptible to mutation from ionizing radiation. The concern
for inappropriate use of radiography by chiropractors in The Netherlands prompted the government to prohibit chiropractors from owning any further x-ray equipment.8 For the sake of patient safety, professional responsibility, and credibility within the scientific community, the chiropractic profession must take it upon itself to reduce unnecessary radiography or they may find that someone else will do it for them. Carlo Ammendolia, DC, MSc PhD candidate Institute for Work and Health 481 University Ave Toronto, Ontario, Canada M5G 2E9 0161-4754/$30.00
Copyright D 2005 by National University of Health Sciences doi:10.1016/j.jmpt.2005.04.013
REFERENCES 1. Beck RW, Holt KR, Fox MA, Hurtgen-Grace KL. Radiographic anomalies that may alter chiropractic intervention strategies found in a New Zealand population. J Manipulative Physiol Ther 2005;27:554 - 9. 2. Sackett DL, Haynes RB, Guyatt G, Tugwell P. Clinical epidemiology: a basic science for clinical medicine. 2nd ed. 7 Little Brown and Company; p. 69 - 152. 3. Sackett DL, Haynes RB, Tugwell PX, Trout KS, Stoddard GL. How to read clinical journals: II. To learn about a diagnostic test. CMAJ 1981;124:703 - 9. 4. Ammendolia C, Bombardier C, Hogg-Johnson S, Glazier R. Views on x-ray use in patients with acute low back pain among chiropractors in an Ontario community. J Manipulative Physiol Ther 2002;25:511 - 20. 5. Gatterman M. Standards of practice relative to complications of and contraindications to spinal manipulative therapy. J Can Chiropr Assoc 1991;35:232 - 6. 6. Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001; 344:363 - 70. 7. Berrington de Gonzalez A, Darby S. Risk of cancer from diagnostic x-rays: estimates for the UK and 14 other countries. Lancet 2004;363:345 - 51. 8. Imbros N, Langworthy J, Wilson F, Regelink G. Practice characteristics of chiropractors in The Netherlands. Clin Chiropr 2005;8:7 - 12.
RESPONSE TO THE LETTER TO THE EDITOR In Response: We would like to thank the writer for his insightful comments. We would like to address the pertinent remarks in this letter. Firstly, it was never our purpose to provide sound evidence that chiropractors need their own set of radiography guidelines. We hope that through analysis of this type of data, we can supply some evidence for the myriad of controversial questions surrounding the issue. We 375
To the Editor: Beck et al1 in their recent article fail to provide sound evidence that chiropractors need their own set of radiography guidelines, bnot medical guidelines,Q nor do they provide valid evidence to justify the use of full spine radiography in 84% of patients who present to the outpatient clinic at the New Zealand Chiropractic College. In their article, the authors found that 68% of patients presenting for chiropractic care who had full spine radiography had significant anomalies. They suggest that this finding may have implication for chiropractic treatment. However, the likelihood of detecting an anomaly on a radiograph is unimportant unless it has clinical relevance.2,3 To have clinical relevance, the anomaly should, first, provide information beyond that obtained during history taking and physical examination; secondly, its presence should significantly alter patient management; and thirdly, the alteration in management should be associated with a benefit to the patient (improved outcome). When examining the 68% of patients who were found to have anomalies (their Table 1), more than 75% of patients had anomalies that lack sufficient evidence of their clinical relevance such as transition segments, blocked vertebrae, nonunion, spina bifida occulta, mild scoliosis, and facet tropism.4 There is no convincing evidence that these anomalies are contraindications to spinal manipulative therapy.5 Furthermore, there is no evidence that their presence alters patient management or that altering management (spinal manipulative therapy) will result in improved patient outcomes. The remaining patients had clinically relevant pathologic conditions of low prevalence that are either found among high-risk groups or are incidental findings. High-risk patients can usually be identified by the presence of red flags during history taking and physical examination.6 As for the unsuspecting pathologies, these are relatively uncommon and there is no evidence to justify using full spine radiography to screen for these conditions. In conclusion, most patients in this sample had anomalies of no proven clinical relevance. Selective criteria based on the presence of clinical indicators (red flags) have been shown to be highly sensitive in ruling out most of the remaining clinically relevant conditions.6 The chiropractic profession urgently needs to critically appraise its current use of radiography. In addition to clinical relevance, the potential risks of routine spinal radiography must be considered. In the United States, approximately 5700 cancer cases a year are attributed to diagnostic x-rays.7 In the sample of Beck et al of 847 full spine radiographs, most patients are younger than 40 years. The cells in young individuals, particularly the reproductive tissues, are most susceptible to mutation from ionizing radiation. The concern
for inappropriate use of radiography by chiropractors in The Netherlands prompted the government to prohibit chiropractors from owning any further x-ray equipment.8 For the sake of patient safety, professional responsibility, and credibility within the scientific community, the chiropractic profession must take it upon itself to reduce unnecessary radiography or they may find that someone else will do it for them. Carlo Ammendolia, DC, MSc PhD candidate Institute for Work and Health 481 University Ave Toronto, Ontario, Canada M5G 2E9 0161-4754/$30.00
Copyright D 2005 by National University of Health Sciences doi:10.1016/j.jmpt.2005.04.013
REFERENCES 1. Beck RW, Holt KR, Fox MA, Hurtgen-Grace KL. Radiographic anomalies that may alter chiropractic intervention strategies found in a New Zealand population. J Manipulative Physiol Ther 2005;27:554 - 9. 2. Sackett DL, Haynes RB, Guyatt G, Tugwell P. Clinical epidemiology: a basic science for clinical medicine. 2nd ed. 7 Little Brown and Company; p. 69 - 152. 3. Sackett DL, Haynes RB, Tugwell PX, Trout KS, Stoddard GL. How to read clinical journals: II. To learn about a diagnostic test. CMAJ 1981;124:703 - 9. 4. Ammendolia C, Bombardier C, Hogg-Johnson S, Glazier R. Views on x-ray use in patients with acute low back pain among chiropractors in an Ontario community. J Manipulative Physiol Ther 2002;25:511 - 20. 5. Gatterman M. Standards of practice relative to complications of and contraindications to spinal manipulative therapy. J Can Chiropr Assoc 1991;35:232 - 6. 6. Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001; 344:363 - 70. 7. Berrington de Gonzalez A, Darby S. Risk of cancer from diagnostic x-rays: estimates for the UK and 14 other countries. Lancet 2004;363:345 - 51. 8. Imbros N, Langworthy J, Wilson F, Regelink G. Practice characteristics of chiropractors in The Netherlands. Clin Chiropr 2005;8:7 - 12.
RESPONSE TO THE LETTER TO THE EDITOR In Response: We would like to thank the writer for his insightful comments. We would like to address the pertinent remarks in this letter. Firstly, it was never our purpose to provide sound evidence that chiropractors need their own set of radiography guidelines. We hope that through analysis of this type of data, we can supply some evidence for the myriad of controversial questions surrounding the issue. We 375