With the fast influx of emerging imaging modalities, it would be easy to lose sight of the real benefits of interpreting a regular radiograph in the chiropractic office in aiding in the diagnosis of the broad spectrum of disorders that present to chiropractors.

However, with the development of digital imaging, improvement in the way in which images can be taken, viewed, transferred, and stored has allowed for the interest in imaging technology to penetrate even the humble radiograph. The detail and quality that is afforded by digital imaging is impressive, allowing the chiropractor to extract important information from the films that would otherwise be difficult to appreciate, aiding the accurate diagnosis and therefore management of the wide range of clinical conditions presenting to the chiropractor. Features that are included with such technology allow the chiropractor to zoom in on a particular area of concern, or to change the contrast to aid the detection of pathology, a tool that is certainly not possible with the conventional radiograph systems. Further imaging systems are continuously being developed to respond to the increasing demand for detailed information regarding the patient.

—Michelle A Wessely, BSc (Chiropractic), DC, DACBR, head of radiology, head of clinical research, Institut Franco-Europeen de Chiropratique, Ivry-Sur-Seine, France.

Continuing technological advances allow chiropractors access to better-quality radiography with the use of digital imaging. Digital imaging allows the chiropractor to use computer enhancement to bring out all of the diagnostic information in the radiograph.

To find out more about the latest in digital imaging and diagnostics, Chiropractic Products interviewed four experts on the topic. Frederick R. Fischer is vice president of ALLPRO Imaging Inc, Melville, NY. Roger Titone is president/CEO of Titronics Research & Development Inc in Tiffin, Iowa. Jim Combest is director of marketing for Myotronics-Noromed Inc, Tukwila, Wash. Kent S. Greenawalt is president and CEO of Foot Levelers Inc, Roanoke, Va.

What new technologies are available to achieve the most accurate diagnostics and imaging for patients?

Fischer: All digital imaging technologies: CCD camera, auto fed and manual fed computed radiography (CR), and direct radiography (DR) produce accurate images. A manual fed CR system costs $35,000; a DR plate system starts at $100,000. Only the doctor can determine if DR is worth an additional $65,000.

Expose less than 25 x-rays per day, and a manual fed CR system may be your best choice. Simply remove the phosphor plate from the cassette and insert it into the scanner. This takes a little time, but it allows the chiropractor to enter the 21st century of digital imaging at an affordable price.

Titone: The quality (number of pixels) of the C-500 full body thermal imaging software increases as the technology of infrared cameras advances, giving sharper and more detailed body images. Titronics is developing a very advanced 3-dimensional, real-time, range-of-motion system that does not require repositioning the patient during the test (less than 30 seconds for all axes).

Titronics is now offering an advanced balance scale system for analyzing posture and patient training to improve stability.  Stability analysis and patterns of the patient’s center of gravity and center of pressure are displayed.

Combest: Most are a result of advances in digital technology. For example, computerized ROM testing has eliminated the need for the examiner to determine ROM by pushing a button to record end point. With the ability to analyze dynamic ROM patterns, ROM has become a true diagnostic test in addition to providing objective documentation. Also, advances in SEMG technology provide the ability to measure up to eight individual muscle groups and to utilize spectral frequency analysis to determine if a muscle is truly at rest or is “quiet” due to fatigue. These advances allow the DC to evaluate pathology as well as functionality.

Greenawalt: Image processing is more standardized, which maintains consistency and eliminates some of the human error component. Post x-rays, for comparative purposes, are a common occurrence in some doctor’s offices. A digital system simplifies image storage and retrieval, which allows for quick and easy comparisons. Accompanying software applications can also allow for easier and more accurate measurement and assessment of curves, angles, lines of stress, and instability.

How can diagnostics and digital imaging help a chiropractor with insurance reimbursement?

Fischer: In some medical modalities, some insurance companies will not reimburse for x-rays unless they are taken digitally. Others allow e-mail submissions with digital images to go to the front of the reimbursement line. It may be only a matter of time until all insurance companies adopt similar policies.

Titone: Insurance billing is not an area in which I am knowledgeable. We do have doctors that can share their experiences with our customers that have questions.

I understand that the rules are constantly changing. I view the equipment that a doctor requires to do his job as the tools of the trade. Almost every mechanic I know has more invested in shop equipment than any chiropractor, and you never hear them complain. If using instrumentation leads you to the right listing, resulting in a greater percentage of your patients (especially chronic cases requiring upper-cervical adjusting) returning to optimal health, how do you put a price on it, or why would you care whether a particular insurance company chooses to ignore its value?

Combest: Diagnostics and digital imaging are a powerful combination. Digital imaging allows for the documentation of the anatomical, while diagnostics document the functionality. Diagnostics are especially critical in cases of soft-tissue damage, which may not show up on imaging tests. In those cases, documentation of function may be the only method of providing the proof needed for reimbursement. The other powerful way to combine digital imaging and diagnostics is to use them in tandem over the course of treatment to document the initial diagnosis (need for care), to document treatment success during care, and finally to document maximum medical improvement.

Greenawalt: Insurance companies require documentation of the need for services. Digital imaging and supporting reports allow for the standardization and consistency that they are seeking, which can expedite claims processing.

How can a chiropractor’s concerns about the cost of going to digital imaging be addressed?

Fischer: The cost of x-ray film, chemistry, processor maintenance, etc is about $4 per film. There is no “per image” cost associated with digital imaging. Use that savings to amortize the cost of the digital system. Consider a manual CR system if cost is the major consideration.

Even if there is no net savings, doctors will purchase digital systems because of the intangibles. No messy processor, chemistry, darkroom, x-ray files, or film duplication. Digital images are stored on computer. Burn patient images on a CD. Share images with colleagues over the Internet. Not to mention the “wow factor” with your patients.

Titone: Digital x-ray saves time, space, film, chemistry, and disposal costs. Paraspinal digital thermal imaging is very inexpensive (less than $4,000) and provides an objective real-time measure of neurological function in a matter of seconds. Full-body digital thermal imaging is an excellent diagnostic tool at under $30,000 (especially for breast cancer screening). Knowing that the thermal imaging of the breast may show the formation of a tumor up to 6 years before a mammogram, how do you put a value on that information?

Greenawalt: It is natural to be concerned with costs when investigating new technology, but it is also important to evaluate it from the perspective of costs versus benefits. From your business standpoint, will digital imaging truly enhance your practice? How? Can you justify the expense as a means to offer better care to your patients, as a way to improve patient communication, or as a point of differentiation in the market? Basically ask yourself if the benefits outweigh the costs of implementation.

How well would digital imaging work for  a chiropractor who is not computer literate, and what type of support and training is offered?

Fischer: Digital imaging is as simple as sending e-mail. Programs are intuitive so that the software is useable with a minimum of training. Since there are many different digital systems and ways of purchasing them it is important that the doctor is certain that his/her particular needs will be met. Make sure before you sign on the dotted line that you will receive the initial training and follow-up that you need. In particular, is your post installation support entirely over the phone or are you able to request a real person to come to your office for retraining?

Titone: I can only address the thermography software. Titronics offers both instructional DVDs and phone training on the C-3000 paraspinal software. The full body camera software is very user-friendly, but training is required for taking the views correctly for a board-certified “reader” to make diagnostic decisions.  Usually an 8 to 12 hour weekend seminar is sufficient.

Greenawalt: There are many digital imaging software systems on the market. Most function by way of icon driven toolbars that resemble simple Microsoft Windows applications. Even someone with limited computer experience can easily learn the programs. Training and support are always provided along with the systems.

How does digital imaging help a chiropractor in terms of patient education? 

Fischer: Many of the same tools that a doctor would use to enhance the image can be used to help the patient understand the treatment plan. Also, colorization works well since each radiographic density is shown as a color rather than as a shade of gray. This makes x-rays easier for the patient to understand. Don’t underestimate the value of burning a patient CD. It adds a hi-tech dimension to your practice and further involves the patient in accepting the treatment plan.

Titone: “A picture is worth a thousand words” has never been more true than in the area of digital imaging and patient education.  There is no better way to show a patient abnormal physiology or structure than with accurate imaging instrumentation, be it X-ray, thermal, MRI, etc.

Greenawalt: Patient education is a function of two primary components, one is the message and two is the presentation. Even if you had the greatest digital imaging system with 42-inch plasma screens instead of view boxes, the effectiveness could be lacking if the message is not refined. This technology does not stand alone. It can simply be a more efficient and cost-effective way to address this component of your practice. However, there is definitely something to the technological component of digital imaging that can enhance the credibility of the doctor in the mind of the patient.