Before chiropractors treat neck pain, back pain or joint pain, they can take X-rays to check the spinal alignment and bone health and to look for ligament damage or anything that could be causing the pain.
How often do you order X-rays for your new chiropractic patients? Are there any instances where you would not order an X-ray?
Dr. Luke Stringer: Great question. This is a question that I commonly discuss with our patients. It all depends on the type of chiropractic you are, essentially. The beauty of chiropractic is everyone goes through school, studies the same curriculum, takes the same board exam, gets the same license, but thereafter, you can practice however you like. Some chiropractors want to focus more on the sports, some want to focus on pain management, some are more holistic.
However, the way we practice is corrective care. What is causing the pain and dysfunction and what do we need to do to fix that pain and dysfunction? We practice a technique called chiropractic biophysics, which is the most researched form of chiropractic. It’s all based on science and data. Dr. Deed Harrison and his team are leading the field in the world for neuromusculoskeletal pain.
We use X-rays because to see is to know. And if we’re going to work with the spine and the nervous system on a patient, I want to see exactly what’s going on within that spine. For us, typically, 95% of the time we are going to take an X-ray because we want to see exactly what that spine looks like. We do that because they’re before us. If we have a reduction in the curve or any shifts, we want to know about it because how we prescribe treatment involves spinal traction. We can objectively change the shape of that patient’s spine, which, research supplements, improves objective outcomes long-term. Also, there might be a growth, or a tumor or an infection within the spine the patient doesn’t know about it, and we can catch on X-rays.
It’s also going to make sure that we’re being really super diligent in evaluating the health of the spine on a neuro and a physiological level. And also, how are we going to adjust that spine? For example, I had a patient who came in on Monday. Younger, active, pain level was really low, hasn’t been going on for a massive amount of time. We shot some X-rays and his spine was massively shifted, inch to the left, inch forward, and reverse in his curve. His main concern was headaches and the atlas bone, which is the top bone in your neck, was actually poking up into his skull. I need to know that. If I’m going to adjust that bone, I want to make sure that I’m adjusting it appropriately.
So, for us, that’s why we take X-rays. However, my good friend up the street, he’s more of a sports chiropractor. He is joint and soft tissue based. He’s not going to shoot X-rays until he feels that he needs them, based on people failing treatment. It all kind of depends on how you practice. But for me, if I am going to be receiving treatment from a chiropractor, and I’m going to have a chiropractor adjusting my spine, which chiropractic is, then I want to know what my spine looks like to obviously develop a plan that’s going to work best for that spine, if that’s adjustments, traction, physical therapy, soft tissue, or all in between. It’s like building a house. You don’t build a house without blueprints. Otherwise, you’re guessing. Same with working with the spine.
Are chiropractors trained to read X-rays or do they rely on a radiologist?
Dr. Luke Stringer: Absolutely. Chiropractors take a massive amount of radiology curriculum and board examinations ranging from how to take them to how to review them and then going through all the pathology within the spine. Then there are medical doctors where their scope of practice is radiology. Actually, chiropractors can do a crossover where they’re called a DACBR where they’re actually clinically trained like radiologists to read images, MRI, CTs, X-rays, et cetera.
How we do it in the practice is we do it both ways. We take X-rays, we evaluate them on our own, but we also refer them out to radiologists to get a second set of eyes on them. I do that to be super thorough, not all chiropractors do that. Some do, some don’t, but chiropractors within their scope of practicing license are able to take X-rays and read them comprehensively in the state of Illinois. It might vary in a couple of different states, but in our state, you can absolutely do that.
If a new patient was suffering from back pain, what type of X-ray would you order? And what do you look for in the X-ray?
Dr. Luke Stringer: Great question. So back pain, I’m going to interpret it as low back pain. It’s the number one cause of disability in America, right? More time from work or more money spent on low back pain than anything else. So obviously it’s something that we treat a lot of.
Before we take an X-ray, people don’t just come in and get an X-ray, we’re going to do a detailed consult, a really detailed examination. There’s going to be both orthopedic and neurological and functional. That exam will then dictate X-rays if we need them. And if we want to take them, for us, again, we take X-rays.
A typical series for your lower back is going to be what we call A to B from the front to the back. You’re going to get all the pelvic, the sacral and low back anatomy in there. And then what we call a lateral film where we take it from the side.
Now, if we’ve had a big trauma, been involved in a car accident, we might take what we call a flexion film and an extension film, where we bend to one way and we bend to the other, or we bend forwards, or we bend backwards. We do that to look for ligament damage because joints will shift and move on the X-ray. There are many different kinds of films, you can take specific films for specific conditions. But typically for us, it’s going to be the standard front to back, side and then movement film if we see any big kind of trauma or any pathology on there.
When we’re looking at them, what are we looking for? We’re looking for good joint alignment, good spine alignment, good bone health, good disc health. Have we got occlusion within the nerve canal? Do we have any pathology in there or any infection or do we have any soft tissue damage? So, all these things kind of play a role into putting together the puzzle of figuring out what’s going on for that patient and then the best type of treatment for them. It’s a great, great tool. And it’s an objective tool to figure out the best course of treatment for that patient.
For joint pain in the knee or shoulder, what type of X-ray would you need, and would it reveal the source of the pain?
Dr. Luke Stringer: Great question. So, for me, our extremity films, knee, shoulders, I take less of than the spine. And if you came in to see me, Liz, and you hadn’t had a big trauma, you were an age demographic, kind of that young professional, and you’re active, I would focus more on my exam and my functional exam with the knees and the shoulders. I’m going to ask you to go through range of motion. I’m going to perform an orthopedic test. Watch those structures move, where are you weak? Where are we deficient? I’m going to perform a neurological exam. Are the nerves in the spine and near the shoulder doing their job? And I’m going to functionally evaluate that shoulder, watch it move and have that joint loaded.
From that exam we may shoot a film in the shoulder or the knee, but again, it is objective, it’s nice to know because what do we look for? First of all, we look for alignment in your knee. We’ve got what we call a valgus deformity. That means where your knee starts kind of shifting inwards. That can increase tension in the joint, that can lead to degenerative changes. Do we have rotation in the knee? For the shoulder, same thing when we have that forward head posture, we discussed on our previous podcast, do the shoulders round in, does that shoulder blade wing out? Do we have impingement in the shoulders? Do we have degeneration? So, an X-ray is just a great way to evaluate what’s going on, but the X-ray in the joint, the knee shots for me is a little bit more clinically based, based on trauma, age and chronicity of the pain. So similar to the spine, we’re looking for alignment, bone health, joint health, any pathology, and it’s a really, really effective way to just get a baseline on the joint. Cause if we’ve got chips, degeneration, inflammation, edema, we catch a baker’s cyst, patients need to know that, and they need to be advised and/or referred out based on our findings.
Is there a type of X-ray that would help a chiropractor diagnose and treat neck pain?
Dr. Luke Stringer: Absolutely. We’ve always got to shoot neck films. There’s so much anatomy, vascular anatomy, soft tissue that we want to evaluate in the neck, but similar to our low back, first of all, consult, history, exam. And then from that exam, you would then decide if we’re going to take an X-ray. And typically, for an X-ray, we take it from the front, from the side, but again, if we’ve had a big trauma, we’ll do a flexion extension film, ie, we’re going to look down and we’re going to look up to check for ligament damage.
If we’re going to treat the neck, I really like to see the picture at a minimum from the front and from the side, because that’s going to play a big role in how we adjust the spine and that’s going to play a big role in the type of treatment that spine receives. Also, if patients come in, they’ve got high blood pressure, they’re on statins, cholesterol medication, you’ve got diabetes. You need to look at what’s going on in that neck. Do we see any calcification? Do we have any swelling in the arteries? Because if they do, they absolutely need to know about it, be referred out and/or you need to modify how you treat that patient based on that pathology. Getting an X-ray of the neck is critical for creating an effective treatment protocol for neck pain.
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