"But doc, don't I need an x-ray before you can see me?"

I've heard this question asked so many times by new patients, whether it be over the phone or during the initial examination. I always try to gently explain to people that we most often can begin treatment without needing radiographic imaging. Patients understand what I'm telling them and are willing to proceed with the recommended treatment I outline not because some belief that "I'm the doctor therefore I should always be trusted" but rather because I provide my patients with evidence based clinical decision making from credible research journals, state guidelines, position statements of well-known manual therapy associations, and my own clinical experience.

Recently I was shocked to learn that an article was published titled "X-Ray Imaging is Essential for Contemporary Chiropractic and Manual Therapy Spinal Rehabilitation: Radiography Increases Benefits and Reduces Risks" by Paul A. Oakley, Jerry M. Cuttler, Deed E. Harrison. In their article the authors “encourage routine use of radiography in manual spine therapy” and opine that “radiographic imaging is necessary to deliver acceptable patient care in the practice of contemporary manual therapy of the spine.” 

This belief that routine radiographic imaging (x-ray) is necessary to deliver acceptable patient care in the practice of contemporary manual therapy or that regular imaging is needed to improve the safety of manual therapy in general or spinal manipulative therapy are not true. No reputable clinical practice guideline or high-quality evidence suggest that radiological imaging is a routine requirement for effective treatment of back pain. In fact, the opposite is often the case; when imaging is performed, there is evidence that it does not improve patient outcomes but can result in undesirable and unintended effects.

I agree that timely imaging in musculoskeletal health care is indicated by many clinical practice guidelines when clinical findings indicate suspected pathology (eg, fracture), when surgery is being considered, a patient is not responding to the standard treatment of care, or when a patient is routinely suffering the same chronic, recurring problem.

This is not just my professional opinion but that of many other colleagues of mine including, The World Federation of Chiropractic Research Council.

In Health,
Dr Jared L Wilson, DC, MS

References
1.National Institute for Health and Care Excellence: Clinical Guidelines (NICE). Low back pain and sciatica in over 16s: assessment and management | Guidance and guidelines. Natl Inst Heal Care Excell; 2016. 
2.Qaseem, A, Wilt, TJ, McLean, RM, Forciea, MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514–530. doi:10.7326/M16-2367. 
3.Stochkendahl, MJ, Kjaer, P, Hartvigsen, J. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018;27(1):60–75. doi:10.1007/s00586-017-5099-2. 
4.Bussières, AE, Stewart, G, Al-Zoubi, F. Spinal manipulative therapy and other conservative treatments for low back pain: a guideline from the Canadian Chiropractic Guideline initiative. J Manipulative Physiol Ther. 2018;41(4):265–293. doi:10.1016/j.jmpt.2017.12.004. 
5.Ash, LM, Modic, MT, Obuchowski, NA, Ross, JS, Brant-Zawadzki, MN, Grooff, PN. Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol. 2008;29(6):1098–1103. doi:10.3174/ajnr.A0999. 
6.Kendrick, D, Fielding, K, Bentley, E, Miller, P, Kerslake, R, Pringle, M. The role of radiography in primary care patients with low back pain of at least 6 weeks duration: a randomised (unblinded) controlled trial. Health Technol Assess. 2001;5(30):1–69. 
7.Kerry, S, Hilton, S, Dundas, D, Rink, E, Oakeshott, P. Radiography for low back pain: a randomised controlled trial and observational study in primary care. Br J Gen Pract. 2002;52(479):469–474. 
8.Djais, N, Kalim, H. The role of lumbar spine radiography in the outcomes of patients with simple acute low back pain. APLAR J Rheumatol. Wiley/Blackwell (10.1111). 2005;8:45–50. doi:10.1111/j.1479-8077.2005.00122.x.