Examining Clinical Opinion and Experience Regarding Utilization of Plain Radiography of the Spine: Evidence from Surveying the Chiropractic Profession
Abstract
1. Introduction
2. Materials and Methods
2.1. Survey Distribution
2.2. Statistical Analyses
2.2.1. Procedures and Sample
2.2.2. Dependent Variable
- (1)
- I do NOT take radiographs in my clinic, I refer patients out to another facility (coded as 0);
- (2)
- I DO have an X-ray machine in my practice, but I still refer patients out to another facility for the majority of my spinal radiographs (coded as 0);
- (3)
- I have a plain film X-ray system in my practice and use it for the majority of my radiographs (coded as 1);
- (4)
- I have a DR (digital radiography) digital X-ray system in my practice and use it for the majority of my radiographs (coded as 1);
- (5)
- I have a CR (computed radiography) digital X-ray system in my practice and use it for the majority of my radiographs (coded as 1).
2.2.3. Predictors
2.3. Clinician Opinion & Experience on Chiropractic Radiography (COECR) Scale
2.4. Analytic Plan
2.5. Study 1: Predicting the Use of Plain Radiography of the Spine in Chiropractic Practice
2.6. Study 2: COECR Scale Development and Validation
Rasch Model
3. Results
3.1. Initial Results
3.2. Descriptive Statistics, Chi-Square, and Mean Differences
3.3. Study 1: Logistic Regression
- (1)
- radiographic procedures in a chiropractic office have value beyond the identification of pathology, OR = 1.54, p < 0.05
- (2)
- radiographs for biomechanical procedures have significant value, OR = 1.72, p < 0.01
- (3)
- radiographic procedures are vital to chiropractic care, OR = 5.93, p < 0.01
- (4)
- radiographic procedures aid in the measurement of clinical outcomes, OR = 2.23, p < 0.01
- (5)
- that sharing chiropractic clinical findings from radiographic studies with the patient is beneficial to their clinical outcome, OR = 1.18, p < 0.05
- (6)
- biomechanical analysis or measurements of spinal alignment are valid reasons for obtaining spinal radiograph, OR = 1.4, p < 0.05
- (7)
- and care plan modification consideration is a valid reason to obtain a spinal radiograph, OR = 1.57, p < 0.01.
3.4. Study 2: Scale Construction
3.5. Item Response Theory
3.6. Results Summary
4. Discussion
4.1. Other Findings
4.2. Strengths
4.3. Limitations
4.4. Future Research
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Appendix A
- Invitation to complete the Survey
- Chiropractic Radiology Evidence-Based Practice Survey
Appendix B
State | N | % |
AL | 352 | 0.72% |
AK | 146 | 0.29% |
AZ | 1032 | 2.07% |
AR | 478 | 0.96% |
CA | 7617 | 15.31% |
CO | 1304 | 2.62% |
CT | 716 | 1.44% |
DE | 81 | 0.16% |
DC | 30 | 0.06% |
FL | 4346 | 8.74% |
GA | 1447 | 2.90% |
HI | 63 | 0.13% |
ID | 399 | 0.80% |
IL | 2656 | 5.34% |
IN | 465 | 0.93% |
IA | 718 | 1.44% |
KS | 393 | 0.79% |
KY | 722 | 1.45% |
LA | 340 | 0.68% |
MA | 667 | 1.34% |
MD | 375 | 0.75% |
ME | 134 | 0.27% |
MI | 1823 | 3.66% |
MN | 1010 | 2.03% |
MS | 264 | 0.53% |
MO | 1107 | 2.23% |
MT | 172 | 0.35% |
NE | 610 | 1.23% |
NV | 315 | 0.63% |
NH | 188 | 0.38% |
NJ | 2455 | 4.93% |
NM | 179 | 0.36% |
NY | 3462 | 6.96% |
NC | 864 | 1.74% |
ND | 133 | 0.27% |
OH | 2153 | 4.33% |
OK | 355 | 0.71% |
OR | 654 | 1.31% |
PA | 1998 | 4.02% |
RI | 80 | 0.16% |
SC | 616 | 1.24% |
SD | 158 | 0.32% |
TN | 557 | 1.12% |
TX | 2657 | 5.34% |
UT | 519 | 1.04% |
VT | 97 | 0.19% |
VA | 601 | 1.21% |
WA | 1200 | 2.41% |
WV | 108 | 0.22% |
WI | 869 | 1.75% |
WY | 62 | 0.42% |
Total | 49,747 | 100.00% |
Appendix C
State | n | % |
AL | 16 | 0.44% |
AK | 14 | 0.38% |
AZ | 51 | 1.40% |
AR | 16 | 0.44% |
CA | 423 | 11.62% |
CO | 89 | 2.44% |
CT | 27 | 0.74% |
DE | 3 | 0.08% |
DC | 5 | 0.14% |
FL | 198 | 5.44% |
GA | 199 | 5.47% |
HI | 8 | 0.22% |
ID | 59 | 1.62% |
IL | 159 | 4.37% |
IN | 89 | 2.44% |
IA | 77 | 2.11% |
KS | 31 | 0.85% |
KY | 13 | 0.36% |
LA | 84 | 2.30% |
MA | 41 | 1.13% |
MD | 47 | 1.29% |
ME | 8 | 0.22% |
MI | 259 | 7.11% |
MN | 73 | 2.00% |
MS | 5 | 0.14% |
MO | 38 | 1.04% |
MT | 25 | 0.69% |
NE | 26 | 0.71% |
NV | 43 | 1.18% |
NH | 13 | 0.36% |
NJ | 87 | 2.39% |
NM | 19 | 0.52% |
NY | 108 | 2.97% |
NC | 71 | 1.95% |
ND | 13 | 0.36% |
OH | 104 | 2.86% |
OK | 23 | 0.63% |
OR | 164 | 4.50% |
PA | 192 | 5.27% |
RI | 7 | 0.19% |
SC | 59 | 1.62% |
SD | 52 | 1.42% |
TN | 37 | 1.02% |
TX | 121 | 3.32% |
UT | 126 | 3.46% |
VT | 6 | 0.16% |
VA | 69 | 1.89% |
WA | 152 | 4.17% |
WV | 6 | 0.16% |
WI | 68 | 1.87% |
WY | 18 | 0.49% |
Total | 3641 | 100.00% |
Appendix D
- 41% were short comments emphasizing the need for X-rays as an integral and essential tool within their chiropractic practice.
- 37% commented on the differences between utilization in a chiropractic clinical setting versus a medical setting.
- 37% described conditions that they found on numerous occasions in which the patient had no red flags or complaints yet required alteration of care.
- 5% of the comments were related to clinicians supporting the need for this type of survey.
- 4% revolved around comments related to safety.
- Less than 1% commented on question selection.
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Q2.1: Radiographic procedures in a chiropractic office have value beyond identification of pathology. | 0 = No | 1 = Yes | |||
Q2.2: Radiographs for biomechanical analysis have significant value. | 0 = No | 1 = Yes | |||
Q2.3: I order radiographs only for red flags or pathology. | 0 = No | 1 = Yes | |||
Q2.4: Radiographic procedures are vital to the chiropractic care I provide in my clinic. | 0 = No | 1 = Yes | |||
Q2.5: I utilize radiographic procedures to aid in the measurement of clinical outcomes. | 0 = No | 1 = Yes | |||
Q3: What is your level of agreement/disagreement with the following statement: Based on the educational training and past clinical experiences, the Doctor of Chiropractic should be able to make their own clinical decision regarding the utilization of spinal radiographs on their patients? | 1 = Strongly disagree | 2 = Mostly disagree | 3 = Neutral | 4 = Mostly agree | 5 = Strongly Agree |
Q4: The foundation of an Evidence-Based Practice (EBP) is based on 3 integrated components: (1) Doctor’s Clinical Expertise, (2) Patient Preferences/Values, and (3) Best Research Evidence. When making the clinical decision to obtain spinal radiographs of your patient, should all three EBP components be equally considered? | 1 = Strongly disagree | 2 = Mostly disagree | 3 = Neutral | 4 = Mostly agree | 5 = Strongly Agree |
Q5: What is your level of agreement/disagreement with the following statement: In my clinical opinion, patient outcomes would benefit from continued research regarding appropriate utilization of spinal radiographs in the practice of chiropractic? | 1 = Strongly disagree | 2 = Mostly disagree | 3 = Neutral | 4 = Mostly agree | 5 = Strongly Agree |
Q6: What is your level of agreement/disagreement with the following statement: In the absence of published chiropractic research evidence, the doctor’s clinical experience combined with patient preferences are adequate for the appropriate recommendation of spinal radiographs in the practice of chiropractic? | 1 = Strongly disagree | 2 = Mostly disagree | 3 = Neutral | 4 = Mostly agree | 5 = Strongly Agree |
Q8: What level of risk do you believe is present in your chiropractic practice affecting your patients’ health, as a result of X-ray radiation from your utilization of radiography? | 1 = No risk | 2 = Very low risk | 3 = Low risk | 4 = Moderate Risk | 5 = High risk |
Q7.1: I do not take radiographs in my clinic. I refer out to another facility. | |||||
Q9: What is your level of agreement/disagreement with the following statement: In my clinical experience, sharing chiropractic clinical findings from radiographic studies with the patient is beneficial to their clinical outcome? | 1 = Strongly disagree | 2 = Mostly disagree | 3 = Neutral | 4 = Mostly agree | 5 = Strongly Agree |
Q10.1: To determine adjusting technique or vertebral levels to be adjusted. | 0 = No | 1 = Yes | |||
Q10.2: Mechanical analysis or obtaining measurements of spinal alignment. | 0 = No | 1 = Yes | |||
Q10.3: Future plan modification and considerations. | 0 = No | 1 = Yes | |||
Q10.4: Determine spinal complications such as degenerative changes, anomalies, or defects. | 0 = No | 1 = Yes | |||
Q10.5: Investigate red flags (fracture, neurologic deficits, suspected pathology). | 0 = No | 1 = Yes |
Predictor | % |
---|---|
Q2: Please select all statements that you agree with regarding spinal radiographs (multiple choices allowed). (n = 4231) | |
Q2.1: Radiographic procedures in a chiropractic office have value beyond identification of pathology. | 91.9 |
Q2.2: Radiographs for biomechanical analysis have significant value. | 86.7 |
Q2.3: I order radiographs only for red flags or pathology. | 16.5 |
Q2.4: Radiographic procedures are vital to the chiropractic care I provide in my clinic. | 82.9 |
Q2.5: I utilize radiographic procedures to aid in the measurement of clinical outcomes. | 67.4 |
Q7: Please select the one answer that best describes your use of general spinal radiography in your practice (This is not regarding advanced imaging such as CT/MRI). (n = 4138) | |
Q7.1: I do not take radiographs in my clinic. I refer out to another facility. | 24.7 |
Q7.2: I do have an X-ray machine in clinic, but I still refer patients out to another facility for the majority of my spinal radiographs. | 2.1 |
Q7.3: I have a plain film X-ray system in my practice and us it for the majority of my radiographs. | 16 |
Q7.4: I have a DR digital X-ray system in my practice and use it for the majority of my radiographs. | 47.7 |
Q7.5: I have a CR digital X-ray system in my practice and use it for the majority of my radiographs. (CR digital requires the cassette to be placed into the image processor to process images) | 9.5 |
Q10: Based on your clinical experience, which reasons are valid to obtain a spinal radiograph in the practice of chiropractic? (choose all that apply): (n = 4106) | |
Q10.1: To determine adjusting technique or vertebral levels to be adjusted. | 72.1 |
Q10.2: Mechanical analysis or obtaining measurements of spinal alignment. | 84.5 |
Q10.3: Future plan modification and considerations. | 81.9 |
Q10.4: Determine spinal complications such as degenerative changes, anomalies, or defects. | 97.1 |
Q10.5: Investigate red flags (fracture, neurologic deficits, suspected pathology). | 98.2 |
Predictor | n | Strongly Agree | Mostly Agree | Neutral | Mostly Disagree | Strongly Disagree |
---|---|---|---|---|---|---|
Q3 | 4223 | 92.9 | 5.3 | 0.7 | 0.6 | 0.5 |
Q4 | 4198 | 43.3 | 34.4 | 9.2 | 7.6 | 4.6 |
Q5 | 4188 | 60.9 | 21.4 | 11.0 | 4.4 | 2.3 |
Q6 | 4156 | 56.6 | 27.5 | 7.1 | 5.7 | 3.1 |
Q8 (No Risk-High Risk) | 4138 | 0.2 | 1.1 | 10.1 | 61.2 | 27.4 |
Q9 | 4111 | 79.1 | 13.9 | 3.8 | 2.2 | 0.9 |
No Radiograph | Radiograph | |||||
---|---|---|---|---|---|---|
Predictor | % | n | % | n | χ² | |
Country | 106.34 ** | |||||
US | 24.4% | 842 | 75.6% | 2603 | ||
Canada | 30.8% | 137 | 69.2% | 308 | ||
Outside US and Canada | 58.7% | 105 | 41.3% | 74 | ||
Q 2.1 | 442.97 ** | |||||
No | 76.4% | 246 | 23.6% | 76 | ||
Yes | 22.4% | 838 | 77.6% | 2909 | ||
Q 2.2 | 450.15 ** | |||||
No | 64.3% | 343 | 35.4% | 188 | ||
Yes | 20.9% | 741 | 79.1% | 2797 | ||
Q 2.3 | 603.52 ** | |||||
No | 19.1% | 649 | 80.9% | 2751 | ||
Yes | 65.0% | 435 | 35.0% | 234 | ||
Q 2.4 | 950.1 ** | |||||
No | 73.9% | 510 | 26.1% | 180 | ||
Yes | 17.0% | 574 | 83.0% | 2805 | ||
Q 2.5 | 564.44 ** | |||||
No | 50.5% | 663 | 49.5% | 650 | ||
Yes | 15.3% | 421 | 84.7% | 2335 | ||
Q 10.1 | 407.49 ** | |||||
No | 49.1% | 558 | 50.9% | 578 | ||
Yes | 17.9% | 526 | 82.1% | 2407 | ||
Q 10.2 | 551.13 ** | |||||
No | 64.5% | 409 | 35.5% | 225 | ||
Yes | 19.7% | 657 | 80.3% | 2760 | ||
Q 10.3 | 174.09 ** | |||||
No | 46.0% | 341 | 54.0% | 400 | ||
Yes | 22.3% | 743 | 77.7% | 2585 | ||
Q 10.4 | 153.05 ** | |||||
No | 75.0% | 93 | 25.0% | 31 | ||
Yes | 25.1% | 991 | 74.9% | 2954 | ||
Q 10.5 | 0.95 | |||||
No | 31.3% | 26 | 68.7% | 57 | ||
Yes | 26.5% | 1058 | 73.5% | 2928 |
Predictor | n | Mean | SD |
---|---|---|---|
Q3 | 4069 | 4.9 | 0.44 |
Q4 | 4069 | 4.07 | 1.12 |
Q5 | 4069 | 4.35 | 0.98 |
Q6 | 4069 | 4.3 | 1.02 |
Q8 | 4069 | 1.85 | 0.65 |
Q9 | 4069 | 4.68 | 0.73 |
Item | Loadings | Standard Error |
---|---|---|
Q 2.1 | 0.95 ** | 0.01 |
Q 2.2 | 0.95 ** | 0.01 |
Q 2.3 | 0.71 ** | 0.02 |
Q 2.4 | 0.87 ** | 0.01 |
Q 2.5 | 0.82 ** | 0.01 |
Q 10.1 | 0.88 ** | 0.01 |
Q 10.2 | 0.95 ** | 0.01 |
Q 10.3 | 0.84 ** | 0.01 |
Q 10.4 | 0.97 ** | 0.01 |
Q 10.5 | 0.87 ** | 0.01 |
Item | χ² | df | Difficulty | Outfit MSQ | Infit MSQ |
---|---|---|---|---|---|
Q 2.1 | 1111.56 | 4110 | −1.92 | 0.27 | 0.69 |
Q 2.2 | 1409.32 | 4110 | −1.51 | 0.34 | 0.69 |
Q 2.3 | 51,793.5 | 4110 | 1.39 | 12.60 | 1.32 |
Q 2.4 | 2074.18 | 4110 | −1.27 | 0.51 | 0.82 |
Q 2.5 | 2657.84 | 4110 | −0.55 | 0.65 | 0.76 |
Q 10.1 | 2027.26 | 4110 | −0.66 | 0.49 | 0.66 |
Q 10.2 | 1210.89 | 4110 | −1.22 | 0.30 | 0.52 |
Q 10.3 | 1983.27 | 4110 | −1.09 | 0.48 | 0.75 |
Q 10.4 | 773.515 | 4110 | −2.15 | 0.19 | 0.65 |
Q 10.5 | 1707.58 | 4110 | −2.28 | 0.42 | 0.86 |
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Arnone, P.A.; Kraus, S.J.; Farmen, D.; Lightstone, D.F.; Jaeger, J.; Theodossis, C. Examining Clinical Opinion and Experience Regarding Utilization of Plain Radiography of the Spine: Evidence from Surveying the Chiropractic Profession. J. Clin. Med. 2023, 12, 2169. https://doi.org/10.3390/jcm12062169
Arnone PA, Kraus SJ, Farmen D, Lightstone DF, Jaeger J, Theodossis C. Examining Clinical Opinion and Experience Regarding Utilization of Plain Radiography of the Spine: Evidence from Surveying the Chiropractic Profession. Journal of Clinical Medicine. 2023; 12(6):2169. https://doi.org/10.3390/jcm12062169
Chicago/Turabian StyleArnone, Philip A., Steven J. Kraus, Derek Farmen, Douglas F. Lightstone, Jason Jaeger, and Christine Theodossis. 2023. "Examining Clinical Opinion and Experience Regarding Utilization of Plain Radiography of the Spine: Evidence from Surveying the Chiropractic Profession" Journal of Clinical Medicine 12, no. 6: 2169. https://doi.org/10.3390/jcm12062169