ACA Guidelines What You Should Know

Friday, 13 October 2017 14:59 Should Chiropractic Follow the American Chiropractic Association / American Board of Internal Medicine’s Recommendations on X-Ray? Written by US Chiropractic Directory Should Chiropractic Follow the American Chiropractic Association / American Board of Internal Medicine’s Recommendations on X-Ray? In reviewing the American Chiropractic Associations’ (ACA) position on x-ray and adopting the posture of the American Board of Internal Medicine’s (ABIM) initiative, “Choosing Wisely,” regarding x-ray, we must consider both the far-reaching effects of those recommendations as well as the education of the originators of the recommendations. In addition, the ACA in their 2017 published article Five Things Clinicians and Patients Should Question, they state, “The recommendations are not intended to prohibit any particular treatment in all scenarios or to dictate care decisions. They are also not intended to establish coverage decisions or exclusions” ( ). The ACA, a highly-regarded chiropractic political organization that has done a great deal in advancing the profession, is adopting the ABIM’s current position and regardless of the wording of the policy which, in the form of a disclaimer, is opining and setting precedent that can be used against individual practitioners or the entire profession. Granted, the underlying tone is to prevent unnecessary exposure to ionizing radiation, but at what cost to patient care? The scientific evidence has shown, and continues to show, chiropractic as being highly effective for managing and treating non- specific or mechanical spine pain. In this article, we are only considering acute low back pain treatment to meet the scope of the ACA/ABIM policy and are therefore excluding all other conditions treated within the lawful scope of chiropractic. Mechanical spine pain, pain of non-anatomical origin, is defined as spine pain not originating from fracture, tumor, infection or specifically co-related to an anatomical lesion such as degenerative intervertebral disc disease, intervertebral disc bulge or intervertebral disc herniation. The ACA/ABIM states in the absence of “red flags,” imaging should not be considered for at least 6 weeks of care. Some of these “red flags” are clearly present on physical examination, others may not reveal themselves without radiographic evidence. 2-3-4-5-6-7 Red flags include history of cancer, fracture or suspected fracture based on clinical history, progressive neurologic symptoms and infection, as well as conditions that potentially preclude a dynamic thrust to the spine, such as osteopenia, osteoporosis, axial spondyloarthritis and tumors. ( ) When considering the training of internal medicine physicians, we recognize they are focused on the diagnosis and management of systemic disease. However, when considering musculoskeletal diagnosis, basic medical training for internal medicine residency is quite the opposite. Although it is understandable given the current climate of spine pain management in the United States that the American Board of Internal Medicine would take a stance on spine care, I would consider the opinion of an internal medicine board valuable, but less authoritative than a board comprised of practicing spine specialists that is trained in the diagnosis and management of mechanical spine pain with specific treatment designed to deliver high velocity- low amplitude thrusts (chiropractic spinal adjustments). Interestingly, in this specific case, we have a chiropractic political organization agreeing with a medical board that is specifically trained on the diagnosis of internal medicine disorders with little or no training on the management of acute spine pain. In the United States, approximately 10% to 25% of all visits to primary care medical doctors are for MSK [musculoskeletal] complaints, making it one of the most common reasons for consulting a physician...Specifically, it has been estimated that less than 5% of the undergraduate and graduate medical curriculum in the United States and 2.26% in Canadian medical schools is devoted to MSK medicine. (p. 44) It should be noted that primary care medical doctors are not spine specialists and are generally comprised of family or internal medicine physicians. Medical school is lacking in musculoskeletal education, particularly in spine. Graduate level medical education including residency and fellowship training, only provides spine specialty training in those boards that are focused on spine care, namely orthopedic surgery and neurosurgery. It should also be noted that both orthopedic and neurosurgery By Mark Studin William J. Owens The definition of red flags by the American Chiropractic Association (2017): In an article written by Humphreys, Sulkowski, McIntyre, Kasiban, and Patrick (2007), they stated:

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