Chiropractors' inter- and intra-examiner reliability of cervical spine radiographic analysis and its impact on clinical management

Abstract

BACKGROUND: Plain film radiography is the most common imaging technique requested by chiropractors to assist in the management of patients with musculoskeletal complaints. There is a paucity literature indicating that chiropractors’ interpretive radiographic skills are consistently able to achieve the same outcome given a particular set of radiographs. An important indication for the use of radiography in chiropractic is to exclude any possible contraindications to spinal manipulative therapy (SMT) that could cause serious injury to a patient if it is left unmodified or excluded as a treatment option. OBJECTIVES: The study aimed to investigate the inter- and intra-examiner reliability of chiropractor’s diagnosis on cervical spine radiographs. Additionally, the effect of clinical history added to the radiographs was assessed. METHODS: Inter- and intra-examiner evaluations occurred on two consecutive readings of 30 radiographs by six qualified chiropractors. No clinical history was given during Round One, but was available during Round Two. RESULTS: The inter-observer agreement for categorisation and management went from “poor agreement” in Round One (Κ=0.1962 and Κ=0.1996 respectively) to “fair agreement” (Κ= 0.2041 and Κ=0.2036 respectively) beyond that expected by chance in Round Two. Identification remained “fair agreement” beyond that expected by chance over both rounds (Κ=0.3113 and Κ=0.2159). Sensitivity at Round One was 94.4% and the specificity was 61.1%. At Round Two the sensitivity had decreased to 93.8% and the specificity had decreased to 50%. There was no significant difference between the accuracy of the Round One and Round Two results for categorisation (p=0.243) and management (p=0.220), but there was a clinical difference for identification (p=0.014). iii CONCLUSION: Differences in the result were small indicating clinical relevance with regards to inter-examiner reliability was fair in most instances. Although clinical history did not influence categorisation or management, it did improve accuracy of identification of pathology. Chiropractors successfully identified between 93.8% and 94.4% of abnormal radiographic findings demonstrating that chiropractors use of radiographs as a diagnostic tool when looking for contraindications to spinal manipulative therapy was sensitive. This demonstrates that its use as a diagnostic tool for contraindications to spinal manipulative therapy (SMT) is sensitive.