Does radiographic imaging for spinal pain in patients receiving chiropractic care change patient outcomes? A pilot randomised controlled trial.

The short version

This pilot randomised trial with 20 patients and 11 chiropractors explored whether it is practical to run a large study asking a simple question: does taking spinal x-rays change outcomes for people receiving chiropractic care for back or neck pain? In medical settings, trials have found routine imaging does not improve non-specific low back pain, yet chiropractors use x-rays at widely varying rates (8% to 84%), partly to screen for reasons spinal manipulation might be unsuitable. No randomised trial had tested imaging where manipulation is also part of care, so the authors first tested whether such a trial could work. Chiropractors in Sydney, Australia, invited adults with a new episode of spinal pain, where the chiropractor was unsure whether an x-ray was needed. A computer randomly assigned each consenting patient to get spinal radiographs or not, and everything else, including manipulation, was decided between chiropractor and patient. Pain, disability (Roland Morris Disability Questionnaire for the back, Neck Disability Index), satisfaction and side effects were collected at 2, 6 and 12 weeks, and chiropractors were interviewed about the experience. Recruitment was the main difficulty: 135 patients were screened, 33 (24%) were eligible and 20 took part, short of the 50 planned. Three of 10 patients assigned to imaging did not get it, and 2 of 10 assigned to no imaging did, always after a clinical change. Follow-up fell from 90% of patients at 2 weeks to 75% at 12 weeks. Pain and disability fell in both groups, but differences between groups were small and the trial was too small to compare them. Mild, short-lived side effects such as muscle soreness affected 4 of 20 participants (1 imaging, 3 no imaging). The authors judged that most criteria for a larger trial were met but recruitment and cross-over would need strategies, since COVID-19, time pressure and discomfort explaining diagnostic uncertainty to patients limited enrolment. Limitations include a self-selected group of chiropractors, probably non-consecutive recruitment and mostly young, low-disability participants.

Key findings

• This small pilot study tested whether it is practical to run a bigger trial on whether spinal x-rays change outcomes for people seeing a chiropractor for back or neck pain.
• Twenty patients and 11 chiropractors in Sydney, Australia took part; half of the patients were randomly assigned to get x-rays and half were not.
• Finding enough patients was hard: only 20 of the 50 planned patients joined, and 3 of 10 assigned to x-rays and 2 of 10 assigned to none ended up in the other group.
• Pain and disability scores fell in both groups, and mild side effects such as muscle soreness affected 4 of 20 people, but the study was too small to compare the groups.
• The authors concluded a large trial looks feasible if recruitment and group cross-over are better managed.

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