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New patient consultations leave lasting impressions. Most new patients are pleasant; others are combative and difficult.  Regardless, every new encounter provides a foundation for your future relationship.  These moments build trust and loyalty if you can adequately understand the problem and clearly relay the diagnosis to the patient.  Most importantly, this newfound relationship is predicated on making the right diagnosis the first time. Only then can the patient enter into the correct treatment pathway.

Unfortunately, not all new patient presentations are straight-forward.  Some have holes in their stories, or the evaluation doesn’t match the history.  Frequently, there are additional questions that need to be answered through diagnostic tests, blood work, imaging, or record reviews. If we don’t gather all of the correct information and arrive at the right diagnosis, both you and your patient leave with an uneasy lasting impression.

Watch Dr. Steele explain new research regarding the current standard of care for diagnostic imaging.

Evidence-based chiropractors pride themselves on being efficient, effective, and following clinical practice guidelines.

Imaging is not intended to diagnose a patient; instead, it should be used to rule in or rule out differential considerations.  The use of clinical prediction rules and diagnostic clusters yield stronger diagnoses: many times with the same specificity and sensitivity of imaging.  When orthopedic tests are inconclusive, the history and mechanism of injury don’t add up, or there are red flags present, we must consider imaging to gather additional information.

A recent study by Jenkins et al. (2018) Found that imaging was inappropriately ORDERED or NOT ORDERED at alarming rates.  That’s right! In fact, physicians not only order imaging on people who don’t need it, but they don’t order imaging on the patients who do.  Let’s examine these findings and consider solutions you can make today to protect your patients, and yourself.

Finding 1:In patients referred for lumbar imaging, 34.8% were judged inappropriate by the absence of red flags for severe pathology, and 31.6% were judged inadequate by the criteria of no clinical suspicion of pathology.”

Solution 1: For a list of red flags and imaging recommendations, refer to the CONDITION REFERENCE section in ChiroUp and select your primary diagnosis. (Imaging recommendations are regularly updated and reviewed by DACBR chiropractors.)

Finding 2: “In patients presenting for care, imaging was inappropriately performed in 27.7% of cases when judged by the duration of the episode, 9.0% of cases when judged by the absence of red flags and 7.0% when judged by no clinical suspicion of pathology.

Solution 2: Patients often respond well to care and show continual improvement in their subjective and objective findings.  If a patient is not meeting treatment goals or shows frequent relapses—imaging may be necessary.  Most peer-reviewed recommendations and insurance carriers cite 4-6 weeks of care before imaging.  If your clinical suspicion is high, never shy away from digging deeper sooner with imaging or other diagnostic tests.

Finding 3: “In patients presenting for care, imaging was NOT performed where appropriately indicated in 65.6% of patients who presented with red flags, and 60.8% with clinical suspicion of severe pathology.

Solution 3: Don’t dig your head in the sand and shun imaging in every case. In this study, over 60% of people with red flags or suspicious exam findings didn’t get imaged. Considered imaging for acute low back pain when there is clinical suspicion of severe pathology or surgery is being considered to address a specific pathology. The prevalence of threatening pathologies such as an infection or tumor is estimated to be the cause of LBP in less than 1% and 10% of presentations respectively. Editing your review of systems and exam forms to ask the rights questions or perform the right tests will also help in your diagnostic process.

There is a time and place for everything especially when establishing diagnoses that serve as the foundation for your care.  Don’t fall into a rut by performing the same tests, rendering the same diagnosis, and applying the same treatments to everyone.  There is a huge difference between treating someone and applying best practice care. Our number one responsibility to the patient is to diagnose them. That requires knowing what tests to perform or not to perform.  ChiroUp subscribers enjoy exam forms, up-to-date literature reviews, expert advice videos, and patient education that confidently guides them into making the right decisions.

Access our professions most innovative knowledge transfer database today with one CLICK.


Jenkins HJ, et al. Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis The Spine Journal 2018

About the Author

Dr. Brandon Steele

Dr. Brandon Steele


Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.

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