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In Response: Thank you for the opportunity to respond to the letter by Hansen et al, who cite articles supporting the use of routine plain film lumbar radiographs and suggest clinician experience and the need to identify and correct subluxations as valid reasons for chiropractors to take radiographs. Hansen et al cite several articles on spinal radiographic analysis by Harrison DE, Troyanovich SJ, and Harrison DD, including a review of the literature on this topic, in which they conclude there is evidence supporting the use of routine radiographic spinal analysis.1.Harrison DE Harrison DD Troyanovich SJ Reliability of spinal displacement analysis on plain x-rays: a review of commonly accepted facts and fallacies with implications for chiropractic education and technique.J Manipulative Physiol Ther. 1998; 21: 252-266PubMed Google Scholar In a recent article published in this journal, Haas et al2.Haas M Taylor JAM Gillette RG Commentary. The routine use of radiographic spinal displacement analysis: a dissent.J Manipulative Physiol Ther. 1999; 22: 254-259Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar critically appraised this review by Harrison et al1.Harrison DE Harrison DD Troyanovich SJ Reliability of spinal displacement analysis on plain x-rays: a review of commonly accepted facts and fallacies with implications for chiropractic education and technique.J Manipulative Physiol Ther. 1998; 21: 252-266PubMed Google Scholar and concluded it suffers from serious methodologic deficiencies, the most important of which are omitting relevant studies, misrepresenting the evidence, and disregarding the rules of evidence. In contrast, the evidence against routine use for acute low back pain (LBP), the most common type of LBP seen in chiropractic practice,3.Hurwitz EL Coulter ID Adams AH Genovese BJ Shekelle PG Use of chiropractic services from 1985 through 1991 in the United States and Canada.Am J Public Health. 1998; 88: 771-776Crossref PubMed Scopus (156) Google Scholar is substantial and methodologically sound. This is demonstrated by the clear and consistent recommendations found in the LBP guidelines published in over a dozen countries worldwide which state the vast majority of patients with acute LBP do not need a radiography evaluation.4.Koes B van Tulder M Ostelo R Burton K Waddell G Clinical guidelines for the management of low back pain in primary care.Spine. 2001; 26: 2504-2514Crossref PubMed Scopus (543) Google Scholar We agree that the role of clinical experience is important in clinical decision making. However, it should be used in the context of, and not independent of, the best available evidence, cost, and risks and benefits to individual patients. Current evidence for routine plain film radiography for acute LBP suggests that there is not only limited benefit to patients but it is associated with potential harm and adds unnecessary costs to the health care system.5.Halpin SF Yeoman L Dundas DD Radiographic examination of the lumbar spine in a Community Hospital: an audit of current practice.BMJ. 1991; 303: 813-815Crossref PubMed Scopus (45) Google Scholar, 6.Owens JP Rutt G Keir MJ Spencer H Richardson D Richardson A et al.Survey of general practitioners' opinions on the role of radiology in patients with low back pain.Br J Gen Pract. 1990; 40: 98-101PubMed Google Scholar, 7.Hall FM Back pain and the radiologist.Radiology. 1980; 137: 861-863PubMed Google Scholar As a profession, chiropractors must develop rational explanations for the use of plain film radiology in clinical practice. In this era of increasing health care accountability, a more judicial use of spine radiography is necessary among all health care providers. The development of evidence-based, condition-specific imaging guidelines for chiropractic practice, unlike the vague and nonspecific imaging guidelines found in both the Canadian and American Chiropractic Practice Guidelines,8.Henderson D Chapman-Smith D Mior S Vernon H Clinical guidelines for chiropractic practice in Canada. Canadian Chiropractic Association, Toronto Ontario, Canada1994Google Scholar, 9.Haldeman S Chapman-Smith D Peterson DM Guidelines for chiropractic quality assurance and practice parameters. Mercy Conference Center; January 25-30. 1992Google Scholar would be a useful first step in improving the appropriate use of plain film radiography in chiropractic practice.

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