DCs should take advantage of the latest radiological technology available

The use of imaging by chiropractors has changed over the years, now including the possibility of having access to better-quality radiography with the use of digital imaging. In the case of advanced imaging, this continues to be an arena that grows continuously with the introduction of refined techniques that are able to determine more precisely the origin of patients’ symptoms and which contribute greatly to the understanding of disorders. Examples of such sensitivity have extended to the use of functional magnetic resonance imaging (MRI), and now the use of position emission tomography (PET) imaging. Knowledge of the application of these imaging techniques will continue to enhance the evaluation of patients, leading to improved chiropractic management of a wide range of disorders.—Michelle Wessely, BSc (Chiropractic), DC, DACBR, head of clinical research, Institut Franco-Europeen de Chiropratique, Ivry-Sur-Seine, France.

Many of today’s modern imaging techniques are well-suited for the evaluation of chiropractic patients. X-ray, MRI, and computed tomography (CT) can improve the effectiveness of treatment and provide us with information to formulate a good diagnosis. Yet, many chiropractors are unsure of how or when to take advantage of the benefits afforded by multiple imaging techniques. This can have a detrimental impact on the effectiveness of our diagnostic capabilities. Due to the nature of chiropractic adjustments, patient imaging techniques can be helpful in matching technique to a patient’s condition.

Of course, conventional radiology is the most commonly used and the most cost efficient. It requires no contrast medium, it is readily available, and films are easily read in our offices or by a Diplomate of the American Chiropractic Board of Radiology (DACBR). X-rays—which are dependent on the five radiographic densities: air, water, bone, fat, and metal—provide a good diagnostic tool that many have right in their offices. Because of the potential for the chiropractic treatment methods to cause harm, x-rays provide us with a way to investigate the patient’s biomechanical structure prior to applying treatment. However, plain x-ray has some limitations that hinder their diagnostic use. X-ray does not show soft tissue very clearly. It offers a low sensitivity to bone density. (A 30%–50% bone loss must be present for it to be seen on an x-ray.)

X-rays should be recommended in several situations, including, but not limited to, trauma, unexplained weight loss, night pain, inflammatory arthritis, history of malignancy, fever of an unknown origin, structural deformities, failure to respond to care, and for situations where legal issues may arise, such as personal injury or workers’ compensation cases. The use of x-rays should also be considered for patients who are older than 50 years of age or have a history of drug, alcohol, or corticosteroid use.

Digital Imaging is Another Option
While digital imaging units may be cost-prohibitive for most clinics, they are often available through hospitals and radiology clinics. Digital imaging provides improved image quality, and is easily transferable to digital media, CD, or email. Computed radiography is also available. By retrofitting newer standard x-ray units, you can have digital-quality images and the flexibility of image manipulation in the office. While these retrofits are expensive, it is likely they will become more cost-efficient in the near future, especially when one considers the savings for film and chemical supplies.

CT scanning is an advanced imaging method that translates tissue density and converts it into a computerized image. CT is excellent for visualizing osseous structures and, to some extent, soft-tissue regions. The uses of CT include trauma, certain bone tumors, and, in some cases, the effect of degenerative processes such as spinal stenosis, degenerative joint disease (DJD), and degenerative disc disease (DDD). CT is very good at measuring tissue density and therefore provides diagnostic capabilities for detecting osteopenia earlier than plain x-ray. When MRI is contraindicated, CT may be considered.

Soft tissue that is well-visualized with CT includes the chest (with disorders such as pneumonia and tumors); and in the abdomen (including disorders such as abdominal aortic aneurysms). The disadvantages of this radiology technique are high-dose exposure to x-ray, image distortion due to patient size (check with the imaging center for weight limitations), and artifacts created from metal implants.

MRI is the technique of choice when you need diagnostic information about soft tissue. MRI is a computer-generated image that is very versatile in showing the subtleties between different types of tissue. Often used for chiropractic-related conditions, MRI provides excellent images of the spine and discs and can be used to identify a multitude of spinal disorders, including DJD, DDD, recurrent disc lesions, postoperative scar-tissue formation, myelopathy or cord injury, discitis, vascular pathology, primary and secondary neoplasms, bone marrow, anomalous structures, and extremity disorders such as those about the knee, in the case of cruciate ligament pathologies.

A disadvantage of using MRI is the relatively long exam time (30 minutes to 1 hour is common). This can be difficult if the patient is in a lot of pain and cannot remain still for the study; however, it is possible to adapt the sequence selection in such cases. Many patients also have difficulty with the claustrophobic potential of the machine; with the development of open units, however, it is possible to diminish this sensation. Currently, kinematic MRI is not universally available; this is important to consider, for example, when reviewing an MRI of the lumbar spine, which is most commonly performed with the patient supine. One must also consider patient size, as MRI—even open units—has weight limitations. Due to the size of the magnet, which can be powerful enough to pick up an automobile, metal implants may be a contraindication to MRI.

How to Use These Tools
Most of these tests can be ordered directly from the local hospital and can be performed on an outpatient basis. However, institutions like these may require the doctor to be on-staff or have some type of staff privileges with the hospital. It has become commonplace for hospitals to accept chiropractors in some capacity as a staff physician, whether as an ancillary provider or actually in an on-site capacity. Check with the hospital’s administration office to see how to go about gaining these privileges. Even consider setting an appointment and visiting with the hospital’s administrator to discuss the need to use the facilities. An American Chiropractic Association booklet titled Doctors of Chiropractic: Part of the Hospital System can help you with introductions. It offers advice on the steps to follow when trying to gain access to services with the hospital. This is a great education tool for you and the hospital.

A drawback to using the local hospital is its function. Due to the nature of their care, emergency patients will take diagnostic precedence over an out-patient service, and therefore it can cause delays in getting your imaging completed. However, the equipment is usually extremely reliable and top-quality. It is often available at hours that may be more conducive to a patient’s schedule.

Another source for these types of tests is an outpatient diagnostics imaging center. These clinics usually offer state-of-the-art diagnostic equipment in a patient-friendly environment. They are smaller than hospitals, and therefore provide easier access. Also, because they typically do not see urgent-care patients, they often are able to stay more on time with their scheduling. My experience has been that you can even get a patient in for a study the same day, if necessary.

Ordering diagnostic studies from an imaging center is really quite simple. Just call the center and ask if you need to be a registered doctor or clinic with them prior to placing your orders. This may be a short questionnaire that requests some basic information such as your name and your clinic’s name, your license information, and your address.

Once you are established with the center, ordering a test is very simple. The imaging center often will provide you with clinical order forms that you complete and fax to them to request a study. If you are unsure of what to order, many times you can consult by phone with a radiologist at the center, who can guide you as to what study may be best suited for that particular case.

I urge you to develop a relationship with the diagnostic center and the radiologists on staff. This will help establish a line of communication with them and will improve the diagnostic capacity of the studies you order. When the radiologist has a better understanding of what you are looking for with a particular case, or information that you need to have in a report, you are more likely to get the results you desire. Also, radiologists read for different types of doctors and, therefore, terminology can become confusing and transposed. For example, in the medical definition, subluxation is used in different ways and is often not understood in the same mode and complexity as chiropractors use the term. Some simple education with the radiologist can provide you with the use of terminology in reports that help to support your diagnostic capacity.

The education of today’s DCs compels us to be diagnostically proficient. Patients are increasingly seeking out our expertise to uncover the cause of their condition, rather than just treat the symptoms. As such, the radiological technology available for diagnostic imaging is perfectly suited for the chiropractic clinic. These studies provide insights into biomechanical information about patient health like no other. Chiropractors benefit as much or more from diagnostic radiology studies due to the biomechanical insights provided by these techniques. So why not take advantage of them? We benefit, and our patients benefit. It’s a winning scenario for us all.

Michael Perusich, DC, is in private practice as the clinic director of Perusich Chiropractic Rehab Center and The BackBone of Health Companies in Sedalia, Mo. Perusich is a team teacher for Integrity Management and has worked closely with many athletic organizations, including the World’s Greatest Athlete Chiropractic Decathlon Club and the Missouri Minutemen Arena Football team. He is also the vice president of the ACA Council on Chiropractic Pediatrics and is a member of the American Academy of Pain Management.