The Role of Digital X-ray In The Modern Spinal Expert Practice

In my 34 years as a chiropractor, and having owned 18 clinics, I have observed many “phases” in our profession. I’ve seen fads come and go, techniques or tools gain and then subside in popularity, and beliefs change relative to a multi-disciplinary approach to healthcare or staying chiropractic only.

And the approach to taking x-rays is not an exception.

Twenty years ago, it was common practice to x-ray all patients coming in the door. In fact, you had better have a good reason to not x-ray a patient. Today, however, some chiropractors are taking fewer and fewer x-rays for a myriad of reasons: mostly due to the perceived expense of an x-ray system; the false belief that it isn’t needed; or the now-outdated myth that radiation from taking plain-film x-rays is hazardous to your health.

That said, it’s interesting to note that a recent online survey I conducted of 364 North American-based chiropractors revealed the following:

• Doctors reported patients had more trust in the doctor-patient relationship when x-ray images were obtained.
• Practice efficiency improved significantly when adopting digital x-ray over plain film.
• Practices realized significantly improved patient compliance when using digital x-ray as a patient education and communication tool.

On this last point, this is something we know all too well. In fact, it’s something we as chiropractors

have always faced: our patients begin to feel better after we begin a schedule of adjustments, and as a result some fail to complete their recommended care plans. This not only has a direct impact on patient health and long-term outcomes, but on our practice profitability as well.

Show AND Tell

Many patients base their continuation of their care plan not on what we say, but rather on how they feel.  Why do so many patients take it upon themselves to determine when they should remove themselves from our care?

The answer is simple: they don’t see the whole picture. Or rather, they don’t see a picture at all. And the impetus is on us as chiropractors to give them one.

A 2016 Gallop-Palmer poll revealed how consumers view chiropractic: nearly two-thirds of all patients walking into chiropractic practices reported that they have not had any pressure placed on them from their chiropractor to receive more services than they want, nor had any unexpected costs.¹  So, it’s important to be up front when explaining the care plan and explain the value and evidence behind your reasoning for care. Digital x-rays help explain this evidence.

This begs the question:  How can we best give patients this understanding?

Studies have shown that three out of four people (read: patients) are visual learners. But what do most of us do when seeing a patient for the first time? We tell them our diagnosis and recommended care plan – instead of showing them.

We all know that patient compliance directly impacts practice profitability. It also impacts patient referrals and even practice efficiency as many simply don’t show up for their appointments without notice. Patients often don’t tell you their “why” – they simply stop showing up.

A colleague addressed the lack of patient compliance without realizing it. He had a technical issue with a film-based x-ray unit and decided to implement a retrofit unit and upgrade to digital x-ray technology.

Soon after, he was using the annotations on the patient’s digital x-ray images of their spine – and he would show the findings for such things as unlevel pelvis or reversed cervical curve or scoliosis type findings.  He would show them, not just tell them. It wasn’t until a few months later that he realized – patient compliance skyrocketed after adopting and using digital x-ray. And given that most people are visual learners, this approach makes sense.

Case In Point

Here’s an example where a patient didn’t have red flags upon presentation but does have a history of recurring back pain:

The patient presented with a significant increased lumbar lordosis, a “sway-back,” or more technically, an increased Lordotic Angle and a lumbar hyper-lordosis measurement. We didn’t know they had a hyper-lordosis until the lumbar images were obtained. It took less than 10 seconds to measure the lordosis and have the digital x-ray software calculate the biomechanical abnormalities. Studies show that if the lumbar lordosis is greater than the normal range and goes beyond 65 degrees and above ^2,3 that the person has a higher probable chance of developing LBP and degenerative changes in the facets and we know that when that happens the disc degenerative changes often follow, often leading to higher incidence of more chronic LBP. ^4-9

Knowing the status of the patient’s spine helps shape the care plan to include special abdominal and back exercises to affect the lordosis as well as positional ergonomic instructions. ^10-13 We would not have had the exact care plan recommendation development without knowing the x-ray findings of the hyper-lordosis and resultant predictive outcome towards the likelihood of DJD and potential disc pathology development. As a spine care specialist, we need to know the parameters affecting the overall state of the patient’s spinal health (hyper-lordosis being just one factor) to give a well-rounded comprehensive preventative approach to affect long term outcomes vs. only addressing the current episode of LBP that was absent of any red flags.

Showing this objective evidence and peer-reviewed literature helps a patient see and understand.  Now that patient is more motivated to engage in back and abdominal exercises to improve the lordosis, and to continue with care to affect a positive outcome and minimize future degradation of their lumbar spine, which could become irreversible if neglected over the upcoming decade.  But you made them aware because the x-ray image allowed for a case of “seeing is believing”.

The Proof Is in The Picture

When you take patient communication to this level, it extends beyond the four walls of the practice.

Perhaps you have heard of the Significant Other Saboteur? This is the scenario whereby a patient is told their diagnosis and given a care plan. The patient then goes home to their significant other, then this “other” person torpedoes chiropractic and creates doubt in your patient sometimes leading to discontinuation of care.

But now, with digital x-ray technology brought to bear, those x-ray images, complete with biomechanical drawings and annotations (created for you by software), are brought home on the patient’s mobile phone and serve as the powerful proof needed to justify the money and time needed to complete a care plan. And as a result, they not only more often comply with their care plans and receive a good outcome, but they’re also more likely to refer you to their family, friends, and colleagues.

Now that the cost of high-quality digital x-ray technology has dropped below that of operating a film system, not to mention the speed at which x-rays can be taken, the excuses are gone to not modernize. Since digital is integrated directly into your EHR system, using x-rays to validate and help determine the diagnosis and care plan, resulting in helping your patient better understand their condition; it adds up to see how your adjustments can help them return to better health, which becomes an obvious advantage for all involved.

The Modern Practice

Consider the daily experience your patients have in the world. Surrounded by technology, their lives are infused in every way and on every level with innovation. They wake up to a personalized playlist streaming directly from the Internet – one that knows the exact type of music they want to hear – and when. They have technology on their wrists that track heart rate and exercise routine (including distance, time intervals, and location). They can tell their phones to remind them to buy spinach when they arrive at the store using geofencing technology and can place a two-way video call from their phone and speak to a colleague two thousand miles away.

And then they walk into a chiropractic practice.

Are they stepping into a time warp? Do they have the same experience as if they were back in the 1980’s? The point is this: a modern practice, complete with digital x-ray technology isn’t just a plus – it’s an expectation.

Practices that show they’re equipped with current technology and apply that technology in innovative ways inspire confidence and trust in the patient for their doctor! That first impression is critical, and if they walk into our practices feeling like they’ve just been transported back in time, they’re way less likely to engage in care, follow through with any recommended care plans, or refer to your practice.

Old film-based x-ray systems are costly to maintain, and the entire procedure is time consuming. But when viewed in the context that the most powerful way to discern the health of the spine is through digital x-ray, it’s incumbent upon us to use digital x-ray as a primary tool in our practice.

For less than $280 a month, a practice can retrofit a plain film or CR-Based system into true DR digital system.  Plus, the costs of the old x-ray chemicals are gone, which is better for the environment, the film costs are gone, the maintenance on the processor is gone, as well as the time to file and pay for x-ray folders and jackets that take up space. To go digital is to go green.

And for those of you who believe the scare tactics that some outdated academicians raise on radiation for plain radiography, the research shows that there are no harmful radiation effects from plain spinal x-rays (CT scans are a different category). Even international radiological organizations have debunked the old myth from fear-mongering radiation-phobes. ^14-19

Final Thoughts

We all know that chiropractic is a powerful way for patients to find better health without drugs or surgery. It has improved quality of life for untold millions over the decades. But it’s critical we, as a profession, modernize and claim our rightful status as the spinal-care experts of healthcare – and digital x-ray technology provides a critical tool in our ability to do just that.

Steven J Kraus, DC, FIACN, DIBCN, FASA

References:

1. Gallop-Palmer College of Chiropractic Report – Americans Perception of Chiropractic, 2016, Page 27-28.
2. J Formos Med Assoc. 1992 Mar;91(3):329-33. Lumbar lordosis: normal adults R M Lin 1, I M Jou, C Y Yu.
3. Wiltse LL, Winter RB. J Bone Joint Surg Am 1983;65(6):768–772
4. Effect of Age and Lordotic Angle on the Level of Lumbar Disc Herniation Ghassan S. Skaf,1 Chakib M. Ayoub,2 Nathalie T. Domloj,1 Massud J. Turbay,2 Cherine El-Zein,3 and Mukbil H. Hourani3 Advances in Orthopedics · January 2011
5. BMC Musculoskelet Dis Research Advances in Orthopedics Volume 2011, Article ID 950576, 6 pages doi:10.4061/2011/95057ord. 2017; 18: 330. Published online 2017 Aug 1. doi: 10.1186/s12891-017-1696-9  Characterisation of the correlation between standing lordosis and degenerative joint disease in the lower lumbar spine in women and men: a radiographic study.
6. Skaf, G.S.; Ayoub, C.M.; Domloj, N.T.; Turbay, M.J.; El-Zein, C.; Hourani, M.H. Effect of age and lordotic angle on the level of lumbar disc herniation. Adv. Orthop. 2011, 2011, 950576. [CrossRef].
7. J. Norton, S. A. Sahrmann, and L. R. Van Dillen, “Differences in measurements of lumbar curvature related to gender and low back pain,” Journal of Orthopaedic and Sports Physical Therapy, vol. 34, no. 9, pp. 524–534, 2004.
8. K. F. Taylor, J. Melrose, D. Burkhardt et al., “Spinal biomechanics and aging are major determinants of the proteoglycan metabolism of intervertebral disc cells,” Spine, vol. 25, no. 23, pp. 3014–3020, 2000.
9. Lumbosacral Angle Variations in Middle Aged Patients with Chronic Low Back Pain – A Retrospective Study, January 2021, Journal of Evidence Based Health Care and Medicine 8(04):208-212,Mukherjee, Kundu, et al.
10. González-Gálvez, N.; Gea-García, G.M.; Marcos-Pardo, P.J. Effects of exercise programs on kyphosis and lordosis angle: A systematic review and meta-analysis. PLoS ONE 2019, 14, e0216180. [CrossRef].
11. Effects of Corrective Exercises on Lumbar Lordotic Angle Correction: A Systematic Review and Meta-Analysis, April 2022, International Journal of Environmental Research and Public Health 19(8):4906 DOI:10.3390/ijerph19084906 Kelvin J. Murray,1 Michael R. Le Grande,2,3 Arantxa Ortega de Mues,4 and Michael F. Azari
12. Cho, I.; Jeon, C.; Lee, S.; Lee, D.; Hwangbo, G. Effects of lumbar stabilization exercise on functional disability and lumbar lordosis angle in patients with chronic low back pain. J. Phys. Ther. Sci. 2015, 27, 1983–1985. [CrossRef].
13. El-Hamalawy, F.A. A Newly Developed Exercise Program for Treatment of Mechanical Low Back Pain Associated with Accentuated Lumbar Lordosis. J. Am. Sci. 2011, 7, 58–70
14. Calabrese EJ. How the U.S. National Academy of Sciences misled the world community on cancer risk assessment: new findings challenge historical foundations of the linear dose response. Arch Toxicol. 2013;87(12):2063-2081.
15. Does Imaging Technology Cause Cancer? Debunking the Linear No-Threshold Model of Radiation Carcinogenesis Jeffry A. Siegel, PhD1 and James S. Welsh, MS, MD, FACRO2 Technology in Cancer Research & Treatment 2016, Vol. 15(2) 249–256
16. The Scoliosis Quandary: Are Radiation Exposures From Repeated X-Rays Harmful? Dose Response Journal2019 Apr-Jun; 17(2): 1559325819852810. PubMed central PMC6560808.
17. Nash CL, Jr, Gregg EC, Brown RH, Pillai K. Risks of exposure to X-rays in patients undergoing long-term treatment… J Bone Joint Surg Am. 1979;61(3):371–374.
18. Doss M, Little MP. Point/counterpoint: low-dose radiation is beneficial, not harmful. Med Phys. 2014;41(7):070601.
19. Radiation Risks from Medical Imaging: Busting the Myths; Epidemiologic evidence and bench research demonstrate the truth about low radiation risk to patients. Radiologists Dr. Akshay Baheti and Dr. Bhavin Jankharia;  Accessed May 2022. 

Chiropractors are becoming the modern spinal healthcare expert from using digital X-ray in their practices.

The science debunks the old myths regarding harmful radiation. Spinal x-rays are safe and now cost effective with the new low pricing in the digital arena.

Learn how patient compliance, referrals, and patient satisfaction go thru the roof. Read the full article here.