• De Carvalho D
• Bussières A
• French SD
• Wade D
• Brade-Patten D
• O'Keefe L
• Elliott B
• Budgell K
• O'Reilly S
• To D
• Hall A

• Affiliation / Macquarie University. Faculty of Science and Engineering. Department of Chiropractic
• Affiliation / McGill University. Faculty of Medicine. School of Physical and Occupational Therapy
• Affiliation / Memorial University of Newfoundland. Faculty of Medicine. Division of Community Health and Humanities.
• Affiliation / Memorial University of Newfoundland. Faculty of Medicine. Primary Healthcare Research Unit
• Affiliation / Nipissing University. Faculty of Education and Professional Studies. School of Nursing
• Affiliation / Private Practice
• Affiliation / Université du Québec à Trois-Rivières (UQTR). Département de chiropratique
• Affiliation(G) / Australia / New South Wales / Sydney
• Affiliation(G) / Canada / Newfoundland and Labrador / Bay St. George
• Affiliation(G) / Canada / Newfoundland and Labrador / St. John's
• Affiliation(G) / Canada / Ontario / North Bay
• Affiliation(G) / Canada / Quebec / Montreal
• Affiliation(G) / Canada / Quebec / Trois-Rivières
• Back Pain / diagnostic imaging
• Chiropractors / Canada
• Guideline Adherence
• Low Back Pain
• Open Access Document
• Practice Guidelines as Topic
• Radiography / standards
• Spinal Diseases / diagnostic imaging

Background: Low back pain (LBP) rarely requires routine imaging of the lumbar spine in the primary care setting, as serious spinal pathology is rare. Despite evidence-based clinical practice guidelines recommending delaying imaging in the absence of red flags, chiropractors commonly order imaging outside of these guidelines. The purpose of this study was to survey chiropractors to determine the level of knowledge, adherence to, and beliefs about, clinical practice guidelines related to the use of lumbar radiography for LBP in Newfoundland and Labrador (NL), Canada.

Methods: A cross-sectional survey of chiropractors in NL (n = 69) was conducted between May and June 2018, including questions on demographics, awareness of radiographic guidelines, and beliefs about radiographs for LBP. We assessed behavioural simulation using clinical vignettes to determine levels of adherence to LBP guideline recommendations.

Results: The response rate was 77% (n = 53). Half of the participants stated they were aware of current radiographic guideline recommendations, and one quarter of participants indicated they did not use guidelines to inform clinical decisions. The majority of participants agreed that x-rays of the lumbar spine are useful for patients with suspected pathology, are indicated when a patient is non-responsive to 4 weeks of conservative treatment for LBP, and when there are neurological signs associated with LBP. However, a small proportion indicated that there is a role for full spine x-rays (~ 21%), x-rays to evaluate patients with acute LBP (~ 13%), and that patient expectations play a role in decision making (4%). Adherence rate to radiographic guidelines measured using clinical vignettes was 75%.

Conclusions: While many chiropractors in this sample reported being unsure of specific radiographic guidelines, the majority of respondents adhered to guideline recommendations measured using clinical vignettes. Nonetheless, a small proportion still hold beliefs about radiographs for LBP that are discordant with current radiographic guidelines. Future research should aim to determine barriers to guideline uptake in this population in order to design and evaluate tailored knowledge translation strategies to reduce unnecessary LBP imaging.

Author keywords: Diagnostic imaging - Low back pain - Guidelines - Knowledge and beliefs - Chiropractors

Author affiliations: DDC, DT: Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland & Labrador, Canada; AB: School of Physical and Occupational Therapy, McGill University, Montréal, Quebec, Canada; AB: Département chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada; SDF: Department of Chiropractic, Macquarie University, Sydney, New South Wales, Australia; DW, KB: Private Practice, St. John's, Newfoundland & Labrador, Canada; DB-P: Private Practice, Bay St. George, Newfoundland & Labrador, Canada; LO: Private Practice, Terra Nova, Newfoundland & Labrador, Canada; BE: Patient Engagement Partner, North Bay, Ontario, Canada; BE: Faculty of Education and Professional Studies - School of Nursing, Nipissing University, North Bay, Ontario, Canada; SO: Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland & Labrador, Canada

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