Implementing Evidence-Based Guidelines for Radiography in Acute Low Back Pain: A Pilot Study in a Chiropractic Community

H

IMPLEMENTING EVIDENCE-BASED GUIDELINES FOR

RADIOGRAPHY IN ACUTE LOW BACK PAIN:

A PILOT STUDY IN A CHIROPRACTIC COMMUNITY

Carlo Ammendolia, DC, MSc,a Sheilah Hogg-Johnson, PhD,b Victoria Pennick, RN, MHSc,c

Richard Glazier, MD, MPH,d and Claire Bombardier, MD, MScb

ABSTRACT

aCanadian MemWork & Health, T

b Institute for Woof Medicine, Toro

c Institute for WdUniversity of T

Canada.This research

Foundation for SpSubmit requests

Institute for WorkToronto, Ontarioiwh.on.ca).Paper submitted

2003.0161-4754/2004Copyright n 20doi:10.1016/j.jm

170

Objective: To evaluate the ability of a systematic educational intervention strategy to change the plain radiography

ordering behavior of chiropractors toward evidence-based practice for patients with acute low back pain (LBP).

Design: A quasi-experimental method was used comparing outcomes before and after the intervention with those of a

control community.

Setting: Two communities in southern Ontario.

Data Source: Mailed survey data on the management of acute LBP.

Outcome Measures: Plain radiography use rates for acute LBP based on responses to mailed surveys.

Results: Following the intervention, there was a 42% reduction in the self-report need for plain radiography for

uncomplicated acute LBP (P< .025) and a 50% reduction for patients with acute LBP < 1 month (P < .025) in the

intervention community. There was no significant change in the self-report need for plain radiography in the control

community (P > .05).

Conclusions: The educational intervention strategy used in this study appeared to have an effect in reducing the

perceived need for plain radiography in acute LBP. (J Manipulative Physiol Ther 2004;27:170-9)

Key Indexing Terms: Radiology; Chiropractic; Low Back Pain

INTRODUCTION

istorically, conventional radiography has been an

intregral part of chiropractic practice; yet, its

role remains controversial.1-3 This is particularly

true for the use of plain radiography for assessing patients

with back pain.4,5 National clinical guidelines on the

management of acute low back pain (LBP), including

orial Chiropractic College, and Institute fororonto, Ontario, Canada.rk & Health, and University of Toronto, Facultynto, Ontario, Canada.ork & Health, Toronto, Ontario, Canada.oronto, Faculty of Medicine, Toronto, Ontario,

was partially funded by the Chiropracticinal Research.for reprints to: Carlo Ammendolia DC, MSc,& Health 481 University Ave, Suite 800,M5G 2E9, Canada (e-mail: cammendol@

December 3, 2002; in revised form January 2,

/$30.0004 by National University of Health Sciences.pt.2003.12.021

the use of radiography, have been published in at least

11 countries since 1994.6 Recommendations on the use of

plain radiography are similar and suggest radiographs are

of limited value unless there are red flags present sugges-

tive of serious pathology, such as fracture, infection,

cancer, and inflammatory disease. Collectively, these con-

ditons are uncommon, representing less than 6% of all

causes of back pain.7,8

Despite the limited evidence for its use, studies of Ontario

and US chiropractors have demonstrated a high radiography

use rate for patients with acute low back pain, ranging from

58% to 92%.9-11

Unnecessary radiography use has implications for health

care costs and public safety. In 1991, an estimated $500

million was spent on low-back radiographs in the United

States,12 while in 1995, the Ontario Health Insurance Plan

spent over $16 million.13 Lumbar spine radiographs result in

one of the highest cumulative doses of radiation to the

reproductive organs of any radiological study.14 This expo-

sure increases the risk of cell mutation and cancer in this

highly susceptible tissue.15

In addition to their limited value, high cost, and potential

risks, a recent randomized control trial found lumbar spine

Fig 1. Questions pertaining to radiography use in survey.

Ammendolia et alJournal of Manipulative and Physiological TherapeuticsRadiography Guidelines and Acute LBPVolume 27, Number 3

171

radiographs were also associated with less favorable clin-

ical outcomes.16 Changing practice behavior is complex.

The publication and distribution of clinical practice guide-

lines do not appear to be sufficient to change practice

behavior.17-21 Strategies aimed at changing the use of

radiography for LBP in primary care toward an evidence-

based approach have had mixed results.22-26 Strategies that

appear to have some success are those that use multiple

interventions, such as audit and feedback and academic

detailing, and use opinion leaders and/or peers deemed to

be educationally influential to assist in the delivery of the

interventions.27,28

The purpose of this pilot study was to test the effec-

tiveness of a multifaceted educational intervention strategy

in reducing the perceived need for radiography use for

acute LBP among chiropractors in a select community

in Ontario.

METHODS

Research Design, Setting, and ParticipantsThe study design was quasi-experimental, comparing

outcomes before and after an educational intervention with

those of a concurrent control group. Data were collected

from chiropractors using surveys. Information from non-

responders was obtained via personal communication. Two

southern Ontario communities were involved in the study; 1

received the intervention and the other acted as a control

group. The communities were preselected by researchers at

the Institute for Work & Health (IWH) based on feasibility

factors surrounding implementation of an intervention for a

larger study.29 Each community had a population of ap-

proximately 100,000 with similar total labor force, unem-

ployment rate, and average income. All chiropractors in

each community were sent a survey. The chiropractors were

identified from the directory of the College of Chiropractors

of Ontario,30 the licensing body for Ontario chiropractors

which assigns all practicing chiropractors to a particular

community based on postal codes. There were 25 eligible

chiropractors in the intervention community and 21 in the

control community.

Preintervention Phase (July 1997 to January 1998)Description of surveys. Surveys were mailed to all chiroprac-

tors in each community. A modified Dillman mailing strat-

egy was used: 2 mailings (second mailing to nonresponders),

Table 1. Summary of survey respondents and participants in intervention community

Total no. of

Survey respondents

No. of chiropractors No. of chiropractors

No. of one to one chiropractor

chiropractors Pre Post Both in focus group at workshop Visits Phone

Intervention 25 19 14 14 7 9 17 1

Control 21 13 13 13 N/A N/A N/A N/A

Table 2. Comparison of personal and practice characteristics of responders and nonresponders to preintervention surveys inboth communities

Intervention Control

Characteristics Responders (n = 19) Nonresponders (n = 6) Responders (n = 13) Nonresponders (n = 8)

Age, mean years 41.3* 43.7 37.3 46.1z

Duration in practice, mean years 14.4* 16.5 11.2 17.3z

Year of graduation, % z 1983 42 50 69 43z

Male, % 79 67 77 88

Solo practice, % 68 33 31 50

Postgraduate training, % 50* 50 38 25

Teach chiropractic trainees, % 11* 0 15 0

Canadian Chiropractic College

graduate, %

95 100 77 100z

In-office radiography use, % 74 67 50y 63

*n = 18, y n = 12, and z n = 7 due to missing data.

Table 3. Personal and practice characteristics and the proportionof respondents who indicated they would use radiography forclinical vignette 1 using pooled data from both communities

Characteristics

Proportion of

respondents (n)

Year of graduation z 1983 0.59 (10)

Male 0.61 (14)

Solo practice 0.65 (11)

Postgraduate training 0.67 (10)

Inoffice radiography use 0.67 (14)

172 Journal of Manipulative and Physiological TherapeuticsAmmendolia et alMarch/April 2004Radiography Guidelines and Acute LBP

1 postcard reminder, and 2 telephone calls.31 The survey

instrument had been used in a previous study and pretested

for reliability (kappa 0.81) and content validity.9 For this

study, the questions of interest from the survey are described

in Figure 1.

Identification and training of educationally influential chiropractors.The preintervention survey also included a question used

to assist in the identification of local chiropractors that

were considered by their peers to be educationally

influential in the community. These individuals were to

be trained to assist in the delivery of the educational

intervention.

Focus group session. A focus group was conducted in the

intervention community to gather information on the views

and beliefs of the use of radiography. This information

was used to tailor a workshop and other components of

the intervention. Seven local chiropractors in the interven-

tion community participated in the focus group session.

Methods used for the focus group have been published

elsewhere.32

Intervention Phase (January 1998 to June 1998)Workshop. Since educationally influential chiropractors

were not identified, the workshop was conducted by the

principal investigator (PI ) (the first author). Nine (36%)

of the chiropractors in the intervention community

attended the workshop (Table 1). The 2-hour workshop

consisted of an interactive discussion led by the PI.

Important elements included feedback to the participants

on their community’s radiography use rate based on the

results of the preintervention surveys; a comparison of the

radiography use rates of other communities and that

suggested by the current literature; an introduction to a

decision aid tool to assist in determining the need for

radiography based on the presence of ‘‘red flags’’; and an

overview on the evidence for radiography use and the

associated potential risks. All participants were given a

take-home educational package containing information

presented at the workshop, including a summary of

radiography guidelines for acute LBP, letters from prom-

inant chiropractors endorsing the guidelines, a copy of the

decision aid tool, and key peer-reviewed articles and

reviews on radiography use for acute LBP.

Academic detailing. Following the workshop, the PI con-

tacted all chiropractors in the intervention community. A

total of 17 (68%) chiropractors agreed to meet individu-

ally with the PI to review and discuss the information

Fig 2. Focus group session; reasons given for taking radiographs for acute LBP.


173

presented at the workshop. Those who did not attend

the workshop were given a copy of the take-home

educational package. Eight chiropractors who could not

or were unwilling to meet with the PI or attend the

workshop were also sent a copy of the take-home educa-

tional package.

Media campaign. A news release was produced and later

published (June 1998) by a local newspaper in the

intervention community (Appendix 1). The news release

highlighted issues surrounding the overutilization of radi-

ography, with special emphasis on the potential risks

associated with unnecessary back radiographs. The goal

of the media campaign was to educate the public. Public

media campaigns have been demonstrated to be helpful

in improving general practitioner beliefs about back

pain.33

Postintervention Phase (June 1998 to October 1998)Postintervention surveys. Following the completion of the

intervention, postintervention surveys were mailed to both

communities (June and July 1998). The surveys and

mailing strategy were similar to that used in the pre-

intervention phase. A questionnaire evaluating the com-

ponents of the intervention was also mailed (October

1998) to all chiropractors in the intervention community

(Appendix 2). A total of 11 chiropractors responded to

the questionnaire.

AnalysisSurvey data. The proportion of survey respondents who

requested a radiograph for Clinical Vignette 1 (Fig 1)

before and after the intervention was compared with that

of the control community, using McNemar’s Exact Test

for correlated proportions.34 Only data from chiropractors

who responded to both preintervention and postinterven-

tion surveys were analyzed. The same test was used to

compare a change in the proportion of survey respondents

who agreed that a radiograph was useful in the diagnostic

workup of patients with acute LBP of less than 1-month

duration. Descriptive analyses were performed on personal

and practice characteristics of both communities using

preintervention and postintervention survey data. Similar

analyses were used to compare respondents and nonres-

pondents. A bivariate comparison was performed using

pooled preintervention data from both communities for

radiography use in uncomplicated acute LBP (Clinical

Vignette 1) and characteristics thought to influence radi-

ography use using the Fisher Exact Test.34

RESULTS

Baseline CharacteristicsA total of 19 (76%) eligible chiropractors in the

intervention community and 13 (62%) in the control

community responded to the preintervention surveys.

One survey returned from an inactive chiropractor was

excluded. A comparison of personal and practice charac-

teristics and answers to questions on x-ray use by the

respondents are summarized in Table 2. The mean age of

respondent chiropractors in the control community was

37.3 years compared with 41.3 in the intervention com-

munity. There was a proportionately higher number of

solo practitioners (68% versus 31%) and in-office radiog-

raphy facilities (74% versus 50%) in the intervention

Table 4. Change in the proportion of respondents to questions onradiography use in acute LBP in preintervention surveys comparedwith postintervention in both communities

Preintervention Postintervention P value

Intervention

Total respondents* 14 14

Radiography in

clinical vignette 1

Yes 9 (64.3) 3 (21.4) < .025

Radiography useful in

ALBP < 1 month

Agree 10 (71.4) 3 (21.4) < .025

Control

Total respondents* 13 13

Radiography in

clinical vignette 1

Yes 6 (46.2) 5 (38.5) > .05

Radiography useful in

ALBP < 1 month

Agree 6 (46.2) 8 (61.5) > .05

LBP, Low back pain, ALBP, acute low back pain.

* Includes respondents who completed both preintervention and post-intervention surveys.


community compared with the control community. With

respect to radiography use, 63% of the chiropractors in

the intervention community and 54% in the control

community requested a radiograph for the patient in

Clinical Vignette 1 (uncomplicated acute LBP of 1-week

duration). Radiography was considered useful in acute

LBP of less than 1-month duration (strongly agree or

agree) by 68% of the chiropractors in the intervention

community and 64% of the chiropractors in the control

community.

Less than 10% of chiropractors in the control community

and none in the intervention community stated they were

likely to use radiography for LBP because patients expected

them to do so.

In the bivariate analysis, none of the personal and practice

characteristics tested were found to be associated with

radiography use for uncomplicated acute LBP (Clinical

Vignette 1) when using pooled data from both communities

(Table 3).

When comparing preintervention survey respondents (n =

19) with nonrespondents (n = 6) in the intervention com-

munity, they appeared comparable in most characteristics,

except there were a proportionately higher number of solo

practitioners among respondents (68%) compared with

nonrespondents (33%). In the control community, survey

nonrespondents appeared to be older (by almost 10 years)

and have 20% more solo practitioners compared with

respondents (Table 2).

Educationally influential chiropractors could not be iden-

tified using the surveys. Very few responded to the question

regarding whom they seek for advice on the management of

low back pain. Of those who responded, no chiropractor

was mentioned more than once.

Focus Group SessionDetailed results and discussion of the focus group session

were recently published.32 Most of the chiropractors in the

focus group used plain radiography for reasons besides

ruling out pathology (Fig 2).

Change in Postintervention OutcomesPrimary outcome. There was a 64% response rate for the

postintervention surveys from the intervention community

and 62% from the control community. A total of 14 (56%)

and 13 (62%) respondents completed and returned both

preintervention and postintervention surveys from the

intervention and the control communities, respectively

(Table 4). In the intervention community, there was a

42.9% decrease in the proportion of respondents who

requested radiographs in Clinical Vignette 1 in the post-

intervention surveys compared with that in the prein-

tervention surveys. This difference was statistically

significant (P < .025). There was a 7.7% decrease in the

control community, which was not a statistically significant

change (P > .05).

Secondary outcome. There was a 50% decrease in the

proportion of respondents from the intervention commu-

nity who agreed that radiographs were useful in acute LBP

of less than 1-month duration, when compared with the

preintervention surveys. This was a statistically significant

decrease (P < .025). In the control community, there was a

15.3% increase, which was not statistically significant

(P > .05).

When comparing personal and practice characteristics of

respondents who completed and returned both preinterven-

tion and postintervention surveys in each community, the

differences noted were similar to those found in the

preintervention surveys (Table 5). When comparing

respondents with nonrespondents, the intervention com-

munity had similar characteristics. In the control commu-

nity, the same differences found in the preintervention

surveys were noted (Table 5). Characteristics among

respondents who reported high radiography use for Clin-

ical Vignette 1 at baseline and those who had a positive

response to the intervention for Clinical Vignette 1

appeared similar (Table 6).

There were 5 respondents in the intervention community

who completed the preintervention but not the postinterven-

tion surveys. Of these 5, 4 indicated they would request a

radiograph for Clinical Vignette 1 and also agreed that a

radiograph was useful in the diagnostic workup of patients

with acute LBP of less than 1-month duration. The remain-

ing respondent responded ‘‘no’’ to both questions. In the

Table 5. Comparison of personal and practice characteristics of responders and nonresponders to both preintervention andpostintervention surveys in both communities

Intervention Control

Characteristics Responders (n = 14) Non responders (n = 11) Responders (n = 13) Non responders (n = 8)

Age, mean years 44.9 41.8 37.3 46.1z

Duration in practice, mean years 17.3 15.7 11.2 17.3z

Year of graduation, % z 1983 43 45 69 43z

Male, % 86 73 77 88

Solo practice, % 57 55 31 50

Postgraduate training, % 43 64* 38 25

Teach chiropractic trainees, % 0 18* 15 0

Canadian Chiropractic College

graduate, %

100 91 77 100z

In-office radiography use, % 71 73 50y 63

*n = 10, y n = 12, z n = 7 due to missing data.

Table 6. Comparison of personal and practice characteristicsof respondents reporting high radiography use for clinical


175

control community, there were no preintervention respond-

ents lost to follow-up.
vignette 1 at baseline with those who had a positive response tothe intervention
Characteristics

High radiography

use clinical vignette

1 (n = 12)

Positive response

to intervention

(n = 6)

Age, mean years 41.7* 43

Duration in practice,

mean years

15.9* 16.7

Year of graduation,

% z 1983

42 67

Male, % 38 83

Solo practice, % 75 67

Postgraduate training, % 58* 50

Teach chiropractic

trainees, %

11* 15

Canadian Memorial

Chiropractic College

graduate, %

92 83

In-office radiography

use, %

75 67

*n = 11 due to missing data.

DISCUSSION

The results of this study suggest a high rate of use of

plain radiography for uncomplicated acute LBP in the 2

study communities. This finding is consistent with other

studies evaluating radiography use among chiroprac-

tors.9,10,35-38 This rate is also high compared with the

radiography use rates found among primary care physicians

for acute LBP9,10,39-41 and the rate expected when using

evidence-based guidelines.39-41 Although the rate of use is

lower, there are also concerns about inappropriate and

excessive use of radiography for LBP among primary care

physicians.10,41-44

The focus group session provided some insight into the

reasons for the high rate of radiography use (Fig 2).

Qualitative methods, such as the use of focus groups, can

often be used to complement quantitative research and are

well suited to helping understand beliefs and behaviors and

how and why decisions are made.45-47 Although all partic-

ipants in the focus group agreed that radiography use was

important to rule out pathology in acute LBP, the majority

felt there were other reasons to take radiographs, many

being unique to chiropractors using spinal manipulation.

However, there is no evidence to support the majority of

these other reasons.2,32,48-51

The positive results in this pilot study, a 43% (P < .025)

and 50% (P < .025) reduction in both primary and secondary

outcomes, respectively, suggest the educational intervention

in this study was successful in changing the self-reported

need for radiography use in acute LBP.

Other studies evaluating interventions to reduce radiog-

raphy ordering behavior among primary care practitioners

have had mixed results.22-26 There are no other known

community-based studies evaluating interventions to reduce

radiography among chiropractors.

Systematic reviews on implementation of clinical guide-

lines17-19,27,28,52 suggest that moderately effective interven-

tions include audit and feedback targeted to specific

providers and delivered by peers considered to be educa-

tionally influential. The most successful strategies appear to

use reminder systems, academic detailing, and/or consist of

multiple practice and community-based interventions.

In this study, it is not possible to determine which

component(s) of the intervention had the most influence

on the positive change seen in responses. The majority of

those who responded to the evaluation of the intervention

(Appendix 2) felt that each component (in which they

took part) was either useful or very useful. The only

exception was the news release, which most respondents

felt was either not very useful or they could not tell.


However, the apparent success of intervention was likely

due to the implementation of all the components together

as a complete strategy, as opposed to incorporating them

individually.

There are several methodological limitations in this pilot

study that may impact the validity of the results. Important

limitations include the lack of randomization and the small

number of study communities and participants. The 2

communities in this pilot study were preselected and

matched, which may affect the generalizability of the

results. In addition, since the intervention was communi-

ty-based, the effectiveness of the intervention would best be

tested using the community as the unit of analysis rather

than the individual chiropractors. However, a properly

matched comparison (matching communities on key attri-

butes) would require 48 matched pairs of communities to

achieve 80% power to detect a change in radiography use

from 0.70 to 0.40 with a type 1 error rate of 5%.53

Although this would provide sufficient statistical power

and a means for appropriate randomization, a project this

size may not be feasible.

An attempt was made to compare the 2 communities

for characteristics that independently might influence

radiography use. However, qualitative comparisons rather

than statistical significance were used due to a lack of

power.

Previous studies have suggested that solo practice,

radiography machine ownership, and less experienced

providers were associated with higher radiography

use.10,54 At baseline, chiropractors in the intervention

community were more experienced, had a higher number

of solo practitioners and ownership of radiography

machines, and took more radiographs compared with the

control community (Table 2). Similar differences were

noted among chiropractors who responded to both prein-

tervention and postintervention surveys (Table 5). These

trends suggested a bias in favor of higher radiography use

in the intervention community and appear to add support to

the results in this study.

Another potential study limitation was the use of self-

reported surveys as the sole data source. Data from the

surveys were not verified by objective means and may

not have reflected actual practice patterns. Recall bias,

misinterpretation of questions, wanting to please the PI,

or the nonspecific effect of being involved in the study

(the Hawthorne effect)55 may all have influenced the

responses, which may not have been a reflection of their

actual practice patterns. However, the use of clinical

vignettes have been demonstrated to be an effective and

useful tool for evaluating practice behavior and elicit-

ing practitioner attitudes and beliefs.56,57 Moreover, the

rate of radiography use estimated from the survey re-

sponses appeared consistent with those of other studies,

which further adds confidence to the validity of the pre-

intervention survey results.

Since the results of the primary and secondary outcomes

in this study were based on data from survey respondents, it

is not certain if there was a change in the perceived need for

radiographs among nonrespondents following the interven-

tion. However, in the intervention community, respondent

and nonrespondent characteristics appear comparable in

both preintervention and postintervention surveys. This

may help support the generalizibility of the results to the

intervention community as a whole.

CONCLUSION

The results of this pilot study suggest the multifaceted

intervention strategy used was successful in reducing the

self-reported need for radiology use in uncomplicated acute

LBP by chiropractors in a select community in Ontario.

Notwithstanding the limitations in this study, the positive

results suggest the need for further study. A large-scale,

randomized controlled trial, although desirable, would re-

quire an enormous effort and would likely not be feasible.

Well-conducted, small trials measuring actual practice out-

comes may be the more realistic alternative.

REFERENCES

1. Phillips RB. Plain film radiology in chiropractic. J Manipula-tive Physiol Ther 1992;15:47-50.

2. Mootz RD, Hoffman LE, Hansen DT. Optimizing clinical useof radiography and minimizing radiation exposure in chiro-practic practice. Top Clin Chiropr 1997;4:34-44.

3. Ernst E. Chiropractor’s use of x-rays. BMJ 1998;71:248-51.4. Phillips RB, Frymoyer JW, MacPherson BV, Newburg AH.

Low back pain: a radiographic enigma. J Manipulative PhysiolTher 1986;9:183-7.

5. Phillips RB, Howe JW, Bustin G, Mick TJ, Rosenfeld I, MillsT. Stress x-rays and the low back pain patient. J ManipulativePhysiol Ther 1986;9:1127-33.

6. Koes B, van Tulder M, Ostelo R, Burton K, Waddell G. Clin-ical guidelines for the management of low back pain in pri-mary care. Spine 2001;26:2504-14.

7. Deyo RA, Weinstein JN. Low back pain. N Engl J Med2001;344:363-70.

8. Liang M, Komaroff AL. Roentgograms in primary care in lowback pain: a cost effectiveness analysis. Arch Intern Med1982;142:1100-12.

9. Aker P, Bombardier C, Jansz G, Bressler H. Chiropractic man-agement of low back pain: a survey of Ontario chiropractors.Presented at the Second International Forum for Primary CareResearch on Low Back Pain; May 30-31, 1997; The Hague,The Netherlands.

10. Carey TS, Garrett J. North Carolina back pain project. Patternsof ordering diagnostic tests for patients with acute low backpain. Am Coll Physicians 1996;125:807-13.

11. Cherkin CD, MacCornack FA, Berg AO. Managing lowback pain–a comparison of the beliefs and behaviours offamily physicians and chiropractors. West J Med 1988;149:475-80.

12. Russo R, Cook P. Diagnosis of low back pain: role of imagingstudies. Occup Med 1998;13:83-96.


177

13. Anderson G. Presentation of OHIP data on lumbar spineimaging. Institute for Work & Health; March 19, 1996;Toronto, Canada.

14. Maravilla KR, Cohen WA, Wessbecher FW. Imaging studiesin the assessment of low back pain. Neurosurg Clin N Am1991;2:817-22.

15. Owens JP, Rutt G, Keir MJ, Spencer H, Richardson D,Richardson A, et al. Survey of general practitioners’ opinionson the role of radiology in patients with low back pain. Br JGen Pract 1990;40:98-101.

16. Kendrick D, Fielding K, Bentley E, Miller P, Kerslake R,Pringle M. The role of radiography in primary care patientswith low back pain of at least 6 weeks duration: a rando-mised (unblinded) controlled trial. Health Technol Assess2001;5:1-69.

17. Davis D, Taylor-Vaisey A. Translating guidelines into practice.Can Med Assoc J 1997;157:408-16.

18. Lomas J. Teaching old (and not so old) docs new tricks: ef-fective ways to implement research findings. CHEPAworkingpaper series no. 93-4. Hamilton, Ontario, Canada: McMasterUniversity; 1993.

19. Lomas J, Haynes RB. A taxonomy and critical review oftested strategies for the application of clinical practice recom-mendations: from ‘‘official’’ to ‘‘individual’’ clinical policy.Am J Prev Med 1988;4(Suppl 4):72-94.

20. Haynes RB. Some problems in applying evidence in clinicalpractice. Ann N Y Acad Sci 1993;703:210-25.

21. The Lancet editorial. Lancet 1998;351:997.22. Oakeshott P, Kerry SM, Williams JE. Randomized controlled

trial of the effect of the Royal College of Radiologists’ guide-lines on general practitioners’ referrals for radiographic exam-ination. Br J Gen Pract 1994;44:197-200.

23. Freeborn DK, Shye D, Mullooly JP, Eraker S, Romeo J.Primary care physicians’ use of lumbar spine imaging tests.J Gen Intern Med 1997;12:619-25.

24. Cherkin D, Deyo RA, Berg AO, Bergman JJ, Lishner DM.Evaluation of a physician education intervention to improveprimary care for low-back pain I: impact on physicians. Spine1991;16:1168-72.

25. Kerry S, Oakeshott P, Dundas D, Williams J. Influnce of postaldistribution of The Royal College of Radiologists’ guidelines,together with feedback n radiological referral rates, on x-rayreferrals from general practice: a randomised controlled trial.Fam Pract 2000;17:46-52.

26. Eccles M, Steen N, Grimshaw J, Thomas L, McNamee P,Soutter J, et al. Effect of audit and feedback, and remindermessages on primary care radiology referrals: a randomizedtrial. Lancet 2001;357:1406-9.

27. Jamtvedt G, Young JM, Kristoffersen DT, Thomson O’BrienMA, Oxman AD. Audit and feedback: effects on the profe-ssional practice and health care outcomes (Cochrane Re-view). In: The Cochrane Library, issue 1. Chichester, UK:John Wiley & Sons; 2004.

28. Thomson O’Brien MA, Oxman AD, Davis DA, Haynes RB,Freemantle N, Harvey EL. Educational outreach visits: effectson professional practice or patient outcomes (Cochrane Re-view). In: The Cochrane Library, issue 1. Chichester, UK: JohnWiley & Sons; 2004.

29. Guzman J. Development and initial evaluation of an evidence-based in-office decision aid to improve the assessment andtreatment of patients with acute low back pain in primary carepractice: the Peterborough back rules template [master of sci-ence thesis]. Toronto: University of Toronto; 1999.

30. College of Chiropractors of Ontario. Directory 1996. Ontario,Toronto, Ontario: College of Chiropractors of Ontario; 1996.

31. Dillman A, Christenson J, Carpenter E, Brooks R. Increasingmail questionnaires response: a four state comparison. AmSociol Rev 1974;39:744-56.

32. Ammendolia C, Bombardier C, Hogg-Johnson S, Glazier R.Views on x-ray use in patients with acute low back painamong chiropractors in an Ontario community. J ManipulativePhysiol Ther 2002;25:511-20.

33. Buchbinder R, Jolley D, Wyatt M. Population based interven-tion to change back pain beliefs and disability: three partevaluation. BMJ 2001;322:516-20.

34. Rosner B. Fundamentals of biostatistics. 4th ed: Belmont(CA): Wadsworth Publishing Company; 1995. p. 379.

35. Plamindon RL. Summary of 1994 ACA statistical study. LatAm Chiropr Assoc 1995;32:57-63.

36. Hurwitz EL, Coulter ID, Adams AH, Genovese BJ, ShekellePG. Use of chiropractic services from 1985 through 1991 inthe United States and Canada. Am J Public Health 1998;88:771-6.

37. Petersen P. A survey of chiropractic practice in Europe. Eur JChiropr 1994;42:3-28.

38. Assendelft WJJ, Pfeifle ChE, Bouter LM. Chiropractic in theNetherlands: a survey of Dutch chiropractors. J ManipulativePhysiol Ther 1995;18:129-39.

39. Frazier LM, Carey TS, Lyles MF, Khayrallah MA, McGaghieWC. Selective criteria may increase lumbosacral spine roent-genogram use in acute low-back pain. Arch Intern Med1989;149:47-50.

40. Schroth WS, Schectman JM, Elinsky EG, Panagides JC. Uti-lization of medical services for the treatment of acute low backpain. Conformance with clinical guidelines. J Intern Med1992;17:486-91.

41. Suarez-Almazor ME, Belseck E, Russell AS, Mackel JV. Useof lumbar radiographs for the early diagnosis of low backpain. Proposed guidelines would increase utilization. JAMA1997;227:1782-6.

42. Deyo RA. Early diagnostic evaluation of low back pain. J GenIntern Med 1986;1:328-38.

43. Ferriman A. Early x-rays for low back pain confers little ben-efit. BMJ 2000;321:1489.

44. Espeland A, Baerheim A, Albrektsen G, Korsbrekke K, LarsenJ. Patients’ views on the importance and usefulness of plainradiography for low back pain. Spine 2001;26:1356-63.

45. Kingry MJ, Tiedje LB, Friedman LL. Focus groups: a researchtechnique for nursing. Nurs Res 1990;39:124-5.

46. Quandt SA, Arcury TA. Qualitative methods in arthritis re-search: overview and data collection. Am J Rheumatol 1997;10:273-81.

47. Pope C, Mays N. Reaching the parts other methods cannotreach: an introduction to qualitative methods in health andhealth services research. Br Med J 1995;311:42-45.

48. Taylor JAM, Resnick D. Imaging decisions in the manage-ment of low back pain. In: Advances in chiropractic. Vol. 1St. Louis: Mosby; 1994. p. 1-20.

49. van Tulder MW, Assendelft WJJ, Koes BW, Bouter LM. Spinalradiographic findings and non-specific low back pain: a sys-tematic review of observational studies. Spine 1997;22: 427-34.

50. Gatterman M. Standards of practice relative to complicationsof and contraindications to spinal manipulative therapy. J CanChiropr Assoc 1991;35:232-6.

51. Bigos SJ, Bowyer OR, Braen GR, Brown K, Deyo R,Haldeman S, et al. Acute low back problems in adults. Rock-ville (MD): Agency for Health Care Policy and Research,Public Health Service, US Department of Health and HumanServices; 1994. Clinical practice guideline no. 14.

52. Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD,


Thomson MA. Closing the gap between research and practice:an overview of systematic reviews of interventions to promotethe implementation of research findings. BMJ 1998;317:465-8.

53. Green SB, Corle DK, Gail MH, Mark SC, Pee D. Interplaybetween design and analysis for behavioral intervention trialswith community as the unit of randomization. Am J Epidemiol1995;142:587-93.

54. Childs AW, Hunter ED. Non-medical factors influencing useof diagnostic x-ray by physicians. Med Care 1972;X:323-35.

APPENDIX 1.News release sent to local newspapers

55. Parson HM. What happened at Hawthorne? Science 1974;193:922-932.

56. Jones TV, Gerrity MS, Earp J. Written case simulations: dothey predict physicians’ behaviour? J Epidemiol 1990;43:805-15.

57. Langley GR, Trichler DL, Llewellyn-Thomas HA, Till JE.Use of written cases to study factors associated with re-gional variations in referral rates. J Clin Epidemiol 1991;44:391-402.

APPENDIX 2.

Evaluation of the components of the intervention


179

Documents

Implementing Evidence-Based Guidelines for Radiography in Acute Low Back Pain: A Pilot Study in a Chiropractic Community