Part one of this series discussed that our academic and clinical relationships with multiple healthcare disciplines demonstrated that documentation is one of the biggest challenges no matter the discipline. Documentation also presents a significant risk to the provider’s licenses and practices. Chiropractic is not immune to this issue, and too often, your documents place you in the “crosshairs” of the carriers. This forces you not to defend your care but the details of your records; what you document is ultimately reviewable.
This article sheds light on what clinical documents do either for you or to you. Drs. Studin, Owens, and Manoni have also witnessed a direct correlation between increased documentation compliance and increased practice income. Part of that success solution is reversing carrier denials based upon incomplete and non-compliant clinical information.
Although EMR systems can be helpful as a guide, they come with a caveat that reflects the adage “garbage in; garbage out.” The best, most robust, most costly, and most complete EMR systems cannot overcome the laziness of a doctor seeking to cut corners on an initial examination or a patient reevaluation. We were shocked that contemporary doctors do not know what evaluation and management (E&M) mean, let alone the details required for compliance. It is equally shocking that many doctors do not know the difference between a review of systems and a past medical history, and they regularly omit those elements in their documentation. These same doctors often fraudulently bill for 99203, 99204, and 99205, but they are surprised when sued by carriers.
This article will focus on two issues in depth. First, we will discuss predetermined treatment plans. Second, we’ll cover the medical necessity of ordering X-rays. Carriers have outlined explicitly within the bodies of their litigation complaints why they consider both of those issues indicators of fraudulent activity. Those indicators put you on the legal defensive. Carriers now consider them indicative of fraud based on aggregated statistics acquired over many years (yes, you are being profiled). Additionally, as you will learn from the following discussion, carriers misuse the American Chiropractic Association’s (ACA) policies when making allegations of fraud against doctors of chiropractic regarding the use of X-rays.
PREDETERMINED TREATMENT PLANS
In the most recent case reviewed, a carrier studied 138 adult cases over six years from a doctor of chiropractic’s office. They are claiming that, in every case, the patient was subject to a predetermined treatment plan. Recently, in a conversation with attorneys representing the same carrier, it was verbally confirmed that the carriers are still using the “predetermined treatment plan” argument today. The reason is that it has been persistently successful for the carriers in case outcomes.
NOTE: After each following bolded section reflecting the carrier’s litigation complaints, you will find the author’s comments.
Initial Evaluations
Patients received an initial examination wherein ABC Chiropractic identified that more than 90% of the patients had “fixation, spasm, tenderness, and inflammation” at six spinal levels (e.g., Cl, C6, T4, T9, LI, and sacrum).
Comment: When dealing with spinal assessment and diagnosis, chiropractors only treat 24 movable segments. Therefore, we are limited by those anatomical constraints. However, to list the exact same segments in 90% of cases is highly unusual. You either need to be more reflective of specific segments affected per patient or list regions treated. Other than Medicare’s required listing of segments treated, for a myriad of reasons beyond the scope of this article, consider listing spinal regions treated.
ABC Chiropractic diagnosed 100% of patients with pain/injuries in at least three out of the five spinal regions (cervical, thoracic, lumbar, sacral, or pelvic).
Comments: This is a reach for carriers because chiropractic only treats five spinal regions. However, it can “open the door” to attempt to show the same predetermined treatment plan issue from a different perspective. Remember, the carrier’s perspective is not about any specific case; it is about many over time. The real issue is in your documentation. Was every region documented with a symptom, clinical finding, and diagnosis? The lack of any of those elements in a systematized manner is problematic. As all chiropractors are trained in biomechanics (advanced training in spinal biomechanical engineering is recommended), in this case, there should be demonstrative documented pathobiomechanical lesions in three or more regions, if that is what was diagnosed. Then there are no issues.
Of those five spinal regions, ABC Chiropractic diagnosed approximately 99% of the patients with a cervical injury, 99% of the patients with a thoracic injury, and 99% of patients with a lumbar injury. ABC Chiropractic diagnosed approximately 92% of the patients needing ongoing chiropractic treatment at exactly six spinal regions of concern (e.g., Cl, C4, T2, T12, L2, L5).
Comment: Ninety-nine percent of patients with diagnosable issues in all three spinal regions can be a reach, but it is legally defensible from a chiropractic standpoint since the spine is a single organ system. Again, that needs to be reflected in the documentation, particularly in the patient-centered rationale for why they have those injuries. The literature clearly shows that damaged ligaments never heal but repair wounds with a “poorer grade” of tissue.1 However, it is unusual for this high number of cases to have the same levels that never changed. ABC Chiropractic must demonstrably show pathology in those regions in every case. There are mensuration tools that offer findings to conclude diagnosable pathology at those levels, but none were offered or documented based upon the complaint. 2,3
After completing the initial evaluation, ABC Chiropractic’s treatment plan recommended that approximately 96% of patients receive the exact same three treatment modalities: (1) gentle facet manipulation; (2) strengthening exercises; and (3) traction.
Comment: A baseline protocol is a reasonable approach to care based on an initial evaluation. An ophthalmologist, faced with a clinical finding of macular degeneration, would consider fluorescein angiography (FA)-guided reduced-fluence photodynamic therapy (PDT) as a treatment and accepted protocol.4 If a patient presents to the emergency room with an occlusive stroke, the protocol is a tissue plasminogenic activator (r-tPA) within four hours.5 A patient with worsening symptoms of gait abnormalities, weakness, sensory changes, and diagnosed with cervical spondylotic myelopathy with minimal symptoms without hard evidence of gait disturbance or pathologic reflexes warrants nonoperative treatment, but patients with demonstrable myelopathy and spinal cord compression are candidates for operative intervention.6 This is an accepted protocol depending upon all the factors that the physician observes and documents. As a treatment protocol to move teeth, orthodontists create a force-induced tissue strain to create alterations in vascularity.7
The previous four sample protocols are in different medical specialties, and each specialty has its protocol. Chiropractic is no different. Based on the literature, there are three recommendations for immediate care:
1. Based on the evidence, three steps are recommended—diagnosis, treatment, and reassessment that includes both idiopathic and identified causes. Dosage is based upon “best practice,” and the selection should respect the second recommendation.8
2. Based on all evidence, recommendations for initial care include multimodal care inclusive of manipulation (chiropractic spinal adjustment), mobilization, ischemic pressure, clinic and home-based exercise, supervised graded strengthening exercises, traction, patient education, low-power laser, massage, transcutaneous electrical nerve stimulation (TENS), pillows, pulsed electromagnetic therapy, or ultrasound. This is true for patients with acute or chronic pain, where the origin of the pain is known or unknown, to improve pain and some range in motion (ROM), and in dosages and methods based on the practitioner’s experience and the patient’s specific situation.9
3. Based on all the evidence, in the absence of objective findings with neck pain not due to whiplash (e.g., ROM, muscle hypertonicity), we do not recommend initiating treatment. If, after a complete examination, all findings except for pain are normal, we recommend discharge of the patient from chiropractic care and, possibly, referral, based on the practitioner’s experience.10
Having “predetermined protocols” is what we call a “standard of care” and a diagnostic or treatment regimen to follow. People smarter than us have already determined the standards of care, and it is in the public interest. Every healthcare profession has a regimen of diagnosis and care that they call “predetermined protocols.”
Absent of any clinical “red flags,”11 following a thorough clinical evaluation, almost 100% of your patients would be expected to undergo any combination of the previously mentioned treatment modalities. According to Dr. Anthony Onaroto, Dr. Frank Zolli, and Dr. James Anderson, the addition of heat or ice and strengthening exercises is initially indicated when a biomechanical lesion is demonstrated by muscle spasticity, joint restrictions, or motor unit misalignment.
According to Dr. William Owens, when teaching medical students in the classroom and clinical setting, the following parameters warrant a referral to chiropractic care:
Dr. Owens’ medical students are taught that the initial trial of care is consistent with the above authoritative bodies of work and is taught in contemporary chiropractic academia.
Your first reevaluation should be used to determine the subsequent course of care. It is always dictated by clinical evaluations and reevaluations, not the insurers’ misuse of statistics in creating deceptive litigation documentation rhetoric. It should not be utilized to alter accepted literature and academic protocols taught in chiropractic. Under no circumstance should you depart from the accepted standards of care. Departing from accepted standards of care would create a public health crisis in any healthcare discipline.
"Absent of any clinical “red flags,” following a thorough clinical evaluation, almost 100% of your patients would be expected to undergo any combination of the previously mentioned treatment modalities."
ABC Chiropractic’s initial examinations led to generic diagnoses of patients with conditions that varied little from patient to patient
Comment: Without having the benefit of seeing the diagnoses chosen, it is strongly suggested to be very specific with each patient, ensuring that you are diagnosing not only the region that is affected but also the tissue involved. Muscle is different from ligament, intervertebral disc, or nerve. Avoid using the same generic “strain sprain” or “segmental dysfunction” with every patient and no other supporting diagnoses because that creates an appearance of avoiding clinical decision making. Spine care has a narrow scope of diagnostic choices in the chiropractic arena for treating chiropractic vertebral subluxation/pathobiomechanical lesions (synonymous); however, an explanation is necessary, and it must be patient-centered.
Improper Use Of X-Rays
The carrier wrote in their complaint:
ABC Chiropractic ordered X-rays, took X-rays onsite ... Further, despite the patient population having diverse X-ray findings, the results of the X-rays did not impact the patients’ course of treatment, there was no change in diagnosis or prognosis. The change in the treatment plan (when it occurred at all) was almost always limited to a standard decrease in treatment frequency rather than an amended and individualized treatment plan based on the X-ray findings.
Comments: The carrier contends that there was no change in care, but a reduction in dosage (frequency) was ordered as a result of repeat imaging, which is actually a change in the treatment plan. However, if you leave it to the carrier to decide why you reduced the care, you are leaving yourself exposed. This is defensible with a straightforward explanation in your records. Secondly, when providing self-ordered X-rays within a doctor of chiropractic’s clinic, there must be a treatment order for those X-rays stating why they are being ordered before taking the X-ray. Your evaluation and management report is not a “de facto treatment order,” and you must treat this order just like one that is going to an outside facility that you do not own. In the clinical note, you must indicate why X-rays are being prescribed, and afterward, if the X-rays changed either your diagnosis, prognosis, or treatment plan. This includes confirmation of your original clinical conclusions.
Every current chiropractic student and practicing chiropractor has been taught spinal biomechanical engineering. Whether it is atlas left or pelvis 2 X PIEX, these are biomechanical listings and necessary for clinical correlation to physical examination findings. Fedorak, Ashworth, Marshall, and Pauli (2003) reported, “This study has shown that the visual assessment of cervical and lumbar lordosis is unreliable. This tool only has fair interrater reliability and poor interrater reliability. Visual assessment of spinal posture was previously shown to be inaccurate, and this study has demonstrated that its reliability is poor.” In contrast, the reliability of X-ray in morphology, measurements, and biomechanics has been determined accurate and reproducible in both chiropractic and medical specialty.12 Additionally, Ohara, Miyamoto, Naganawa, Matsumoto, and Shimzu (2006) reported, “Assessment of the sagittal alignment of the spine is important in both clinical and research settings ... and it is known that the alignment affects the distribution of the load on the intervertebral discs.”13
There are additional arguments that spinal pathological comorbidities are present in much of the population,14,15,16 and treating without a clear view of the health of the patient’s spine creates a public health risk. Screening for osseous pathology alone, on a routine basis, is compelling. We have witnessed too many incidental significant pathologies that changed our diagnosis, prognosis, and treatment plan. The risk of injury when adjusting our patients is simply too serious when doing so blindly. However, X-raying for pathobiomechanical analysis is not a screening process. It changes your diagnosis, prognosis, and treatment plan.
Screening in medicine is a strategy used to look for “as-yet-unrecognized conditions” or “risk markers.”22 We do not take X-rays to screen patients. Rather, X-rays are used as part of the spinal examination that cannot be achieved from a clinical evaluation. Approximately 38.4% of men and women will be diagnosed with cancer at some point during their lifetimes (based on 2013-2015 data).23 What is the risk of treating (chiropractic spinal adjustment) a patient with undiagnosed or diagnosed (metastatic) cancer, any type of arthritis, aneurysms, osteomyelitis, ankylosing spondylitis/diffused idiopathic skeletal hypertrophy (DISH), osteophytes abutting critical neurological elements, pathological stenosis, medical subluxation, anteroand posterolestheisis, or any other condition that can increase the risk of fracture or neurological damage. The risks are numerous. Perhaps these might be acceptable losses for the carriers but not treating doctors. Routine use of X-rays is a patient-centered approach, as is a segmental radiographic analysis based on patient presentation, past medical history, and physical examination findings.
Although X-rays can be an effective diagnostic tool, the routine and improper use of X-rays subjects patients to unnecessary radiation exposure and fall outside the chiropractic standard of care.
Comments: This was clearly an opinion from the carrier with no scientific reference. The literature contradicts this statement. Tubiana, Feinendegen, Yang, and Kaminski (2009) reported, “Among humans, there is no evidence of a carcinogenic effect for acute irradiation at doses less than 100 mSv and for protracted irradiation at doses less than 500 mSv.” They go on to state, “There are potent defenses against the carcinogenic effects of ionizing radiation. Their efficacy is much higher for low doses and dose rates; this is incompatible with the LNT (linear no-threshold) model but is consistent with current models of carcinogenesis. The ionizing radiation effects of taking a set of lumbar X-rays are well below the minimum dosage to have a carcinogenic effect.”17 To summarize these and other authors, diagnostic X-rays have had virtually no negative adverse sequelae based upon this and the totality of other literature.
In the February 2020 ACR Appropriateness Criteria: Radiation Dose Assessment Introduction, the American College of Radiology stated, “Many of the diagnostic imaging examinations described in the ACR Appropriateness Criteria (AC) guidelines involve exposure of patients to ionizing radiation from radioactive materials or X-rays. It is important to be aware of the potential health risks associated with radiation exposure when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, relative radiation levels (RRLs) have been included for most imaging examinations. The RRLs are effective dose rankings.” (pg. 1) They continue by stating, “Adverse health outcomes for radiation doses below 100 mSv are not shown by the evidence. The American Association of Physicists in Medicine (AAPM) cautions that: Given the lack of scientific consensus about potential risks from low doses of radiation, predictions of hypothetical cancer incidence and mortality from the use of diagnostic imaging are highly speculative. The AAPM and other radiation protection organizations specifically discourage these predictions of hypothetical harm. Such predictions can lead to sensationalistic stories in the public media. This may lead some patients to fear or refuse safe and appropriate medical imaging to the detriment of the patient.”18 Hendee and O’Connor (2012) concurred when they reported, “No prospective epidemiologic study with nonirradiated control subjects has quantitatively demonstrated adverse effects of radiation at doses less than about 100 mSv.”19
"This opinion has given carriers the right to “copy and paste” a standard of care that is substandard, dangerous, and profitable."
OVERUSE OF X-RAY
The carrier specifically wrote in their complaint:
The American Chiropractic Association (ACA) guidelines state that a chiropractor should not subject a patient to X-rays unless there is a “medical necessity for the radiation exposure to the patient.” Furthermore, “There should always be clinical evidence of the need for diagnostic X-ray examinations before such are performed. Use of X-ray as a routine procedure and from patients’ self-referral is not good practice and is not condoned.
Comments: When “Choose Wisely” was adopted by a small but powerful “fringe” within the ACA, we opined that the ACA’s policy would be used against the chiropractic profession. This opinion, cited by the carrier from the ACA, is a prime and dangerous example that continues to plague our profession. Regardless of where we stand on the political spectrum, we should not lose sight that the ACA is a “trade organization” created to advance the business of chiropractic.
We do not see that the ACA has established standards of care, nor do we believe the ACA conducts academic or clinical research. Therefore, we do not view the ACA as an authoritative source for standards of care. They are instead a means of disseminating information that may come from many sources. By no means do they purport to present competing well-considered approaches to practice. More appropriately, the Chiropractic Council on Education (CCE),21, and our chiropractic colleges and universities are our sources of education, training, and standards. Unfortunately, misuse of the ACA’s adoption of the American Board of Internal Medicine’s X-ray protocol is frequently used by carriers to destroy certain chiropractors’ careers. Another sword that compels the use of your documentation as a shield.
According to Dr. Terry Yochum in his September 2018 Dynamic Chiropractic article titled “X-Ray: To Be or Not to Be, That is the Question,” and in conversation with him recently, he expressed that the ACA had bypassed appropriate oversight when adopting the “Choose Wisely” program without tailoring its protocols to our profession’s needs. For example, the ACA’s current position is devoid of clinical decision making in the realm of spinal biomechanics. The results have been to enable the carriers to make claims about an X-ray that’s needed to protect our patients. This allows the carriers to distract the court’s attention from what we know is the most prudent, responsible standard of care. The question still looms—why? It is now up to the delegates and other ACA representatives to exercise their collective power and protect “practicing chiropractors” from the American Chiropractic Association. We must be able to freely practice within our lawful scope without the “will of the few” empowering predatory carriers to destroy our careers, as evidenced in this case.
Conclusion
Documentation is a critical component of clinical practice and the single thing that makes you bulletproof from predatory carriers. Carriers play the “long game” by aggregating statistics over many years and combining that with deceptive rhetoric, which has become the basis for contemporary lawsuits. Too many practicing chiropractors do not pay careful enough attention to those details. They fail to document at the standard they were taught in their academic training and are held to by licensure boards. This leaves doctors of chiropractic exposed to lawsuits that could have been avoided. To make matters worse, the American Chiropractic Association has opined on the limited use of X-rays, not considering the doctor’s clinical judgment. This opinion has given carriers the right to “copy and paste” a standard of care that is substandard, dangerous, and profitable.
According to Wikipedia, "A trade association, also known as an industry trade group, business association, sector association, or industry body, is an organization founded and funded by businesses that operate in a specific industry. An industry trade association participates in public relations activities such as advertising, education, publishing, lobbying, and political donations, but its focus is a collaboration between companies. Associations may offer other services, such as producing conferences, holding networking or charitable events, or offering classes or educational materials. Many associations are nonprofit organizations governed by bylaws and directed by officers who are also members.”20 Retrieved from: https://en.Wikipedia.orz/wiki/... association
Dr. Mark Studin is an adjunct associate professor of chiropractic at the University of Bridgeport, School of Chiropractic (UBSC). He teaches MRI spine interpretation, documentation, and triaging the injured. He also coordinates a chiropractic clinical rotation for UBSC on neuroradiology at the State University of New York at Stony Brook, School of Medicine, Department of Radiology. He is also an adjunct professor of clinical sciences at Cleveland University Kansas City and Texas Chiropractic College, teaching and coordinating postdoctoral education. Dr. Studin is a graduate medical education provider at the State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, teaching an array of courses from documentation to basic and advanced imaging.
Dr. William Owens is an adjunct professor of clinical sciences at the State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Family Medicine Department, working with medical students, clerks, and residents. He is also an adjunct professor of clinical sciences at Cleveland University Kansas City and Texas Chiropractic College. Dr. Owens is a graduate of the Royal College of Surgeons Certified Physician Educator Program. Additionally, he also coordinates and teaches fellowship training in spinal biomechanics and trauma through Cleveland University Kansas City.
Dr. Frank Zolli is the founding dean of the University of Bridgeport, College of Chiropractic, and served for 23 years. He is the former director of clinical sciences at New York Chiropractic College and was on the Board of the Association of Chiropractic Colleges for 23 years and served as its president. Currently, he is a professor of chiropractic clinical sciences at the School of Chiropractic, teaching orthopedics, ethics, and chiropractic principles.
Dr. Anthony Onorato is currently the associate director of clinical education at the University of Bridgeport, School of Chiropractic. He is supervising the attending physician for all clinical services. He is an associate professor of clinical sciences at Bridgeport and currently teaches physical diagnosis. Dr. Onorato was the associate dean of chiropractic at the University of Bridgeport, College of Chiropractic, for 20 years. He directed the entire academic program and was responsible for the initial and continued accreditation of the program by the Chiropractic Council on Education during his tenure. He also was a counselor for the Council on Chiropractic Education, the accrediting agency for all chiropractic programs recognized by the US Department of Education.
Dr. James Anderson is an adjunct clinical professor with Cleveland University, Kansas City, supporting doctoral-level students throughout their academic careers and transitioning to clinical practice. Dr. Anderson previously was the chairman of the Board of Trustees for both Cleveland University, Kansas City, and Cleveland Chiropractic College, Los Angeles.
Dr. Ronald Manoni is an adjunct assistant professor of clinical sciences at the University of Bridgeport, School of Chiropractic, teaching orthopedics, differential diagnosis, and treatment modalities.
References:
1. Hauser, R. A., Dolan, E. E., Phillips, H. J., Newlin, A. C., Moore, R. E., & Woldin, B. A. (2013). Ligament injury and healing: a review of current clinical diagnostics and therapeutics. The Open RehabilitatioJournal, 6(1).
2. Ruhan Sa, William Owens Jr, Raymond Wiegand, Mark Studin, Donald Capoferri, Kenneth Bahoora, Alexander Greaux, Robbrey Rattray, Adam Hutton, John Cintineo, & Vipin Chaudhary. Intervertebral Disc Detection in X-Ray Images Using Faster R-CNN. 39th Annual International Conference of the IEEE Engineering in Medicine & Biology Society (EMBC 7 7) to be held at the International Convention Center, Jeju Island, S. Korea, from 11-15 July 2017.
3. Appanacharya, K T. J., Tatinati, A. K, Kunderu, H. K, Syed, K M., Channappayya, S. S., Acharyya, A., & Tripathi, S. (2013, July). A low cost scalable solution for digitizing analog X-rays with applications to rural healthcare. In 2013 35th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC) (pp. 74967499). IEEE.
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7. Planning, O. T. (2001). Congenitally missing maxillary lateral incisors and orthodontic treatment considerations for the single-tooth implant. J can dent assoc, 67, 25-8.
8. Canadian Chiropractic Association, Canadian Federation of Chiropractic Regulatory Boards, Clinical Practice Guidelines Development Initiative, & Guidelines Development Committee. (2005). Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash. The Journal of the Canadian Chiropractic Association, 49(3), 158.
9. Bussieres, A. E., Stewart, G., Al-Zoubi, F., Decina, P, Descarreaux, M, Hayden, J.,... & Srbely J. (2016). The treatment of neck pain-associated disorders and whiplash-associated disorders: a clinical practice guideline. Journal of manipulative and physiological therapeutics, 39(8), 523-564.
10. Ibid
11. Sizer Jr, P. S., Brismee, J. M, & Cook, C. (2007). Medical screening for red flags in the diagnosis and management of musculoskeletal spine pain. Pain Practice, 7(1), 53-71.
12. Fedorak, C„ Ashworth, N„ Marshall, J., & Pauli, H. (2003). Reliability of the visual assessment of cervical and lumbar lordosis: how good are we?. Spine, 28(16), 1857-1859.
13. Ohara, A., Miyamoto, K, Naganawa, T., Matsumoto, K, & Shimizu, K. (2006). Reliabilities of and correlations among five standard methods of assessing the sagittal alignment of the cervical spine. Spine, 31(22), 2585-2591.
14. Panjabi, M. M., Hausfeld, J. N„ & White, A. A. (1981). A biomechanical study of the ligamentous stability of the thoracic spine in man. Acta Orthopaedica Scandinctvica, 52(3), 315-326.
15. Oxland, T. R. (2016). Fundamental biomechanics of the spine: what we have learned in the past 25 years and future directions. Journal of biomechanics, 49(6), 817-832.
16. Breen, A., Mellon F., & Breen, A. (2018). Aberrant intervertebral motion in patients with treatment-resistant nonspecific low back pain: a retrospective cohort study and control comparison. European Spine Journal, 27(11), 2831-2839.
17. Tubiana, M, Feinendegen, L. E., Yang, C., & Kaminski, J. M. (2009). The linear no-threshold relationship is inconsistent with radiation biologic and experimental data. Radiology, 251(1), 13-22.
18. Wang, J. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction.
19. Hendee, W. R., & O’Connor, M. K. (2012). Radiation risks of medical imaging: separating fact from fantasy. Radiology, 264(2), 312-321.
20. https://en.Wikipedia.org/wiki/... association
21. https://www.cce-usa.org/dcp-in...
22. https ://en.Wikipedia.org/wiki/Screening (medicine)
23. https://www.cancer.gov/about-c...
24. Ammendolia, C., Taylor, J. A., Pennick, V, Cote, P, Hogg-Johnson, S., & Bombardier, C. (2008). Adherence to radiography guidelines for low back pain: a survey of chiropractic schools worldwide. Journal of manipulative and physiological therapeutics, 31(6), 412-418..
