Why I Am Worried About PT's Ordering X-rays

As you may have heard, recently physical therapists in Wisconsin have been allowed to order x-rays. One of the rights that separates chiros and MD's from physical therapists is the ability to order imaging. A significant component of our doctoral education is built upon understanding imaging, so the APTA and subsidies in each state have been working on getting physical therapists the right to order x-rays. While this is a significant step forward in public perception and autonomy as a profession, I have some very strong concerns.

If you pay attention to much of the pain science research, you likely are aware of the large number of studies that reveal the lack of correlation between imaging findings and pain. If you take 1000 health people (without pain) off the street and take an x-ray of their lumbar spines, anywhere between 30-70% of them would have spinal stenosis, osteophytes, herniated discs, etc. Simply put we cannot link pathoanatomical findings with pain.

So what does this have to do with our ability to order x-rays? Well, one of the things that sets us as physical therapists apart from other health care practitioners is the fact that we base our diagnoses off impairments, not tissue health (or at least that's how it should be). We find weak glutes, we try and strengthen them. We find a stiff lumbar spine, we try and mobilize/manipulate it. The point is the impairments guide our treatment, not the x-ray findings. What I am concerned about, is that with the ability to order x-rays, PT's will suddenly start ordering x-rays on every other patient. Low back pain? X-rays. Knee pain? X-rays. It is inevitable that degenerative conditions will be found on the imaging and likely will be blamed for the patient's pain. In my opinion, this is next to medical malpractice. Some of the most difficult patients to treat are the ones that have their imaging findings memorized and are afraid of "crunching down on a nerve." We must be careful so as not to create these thought viruses in our patients.

Now, I absolutely still support physical therapists gaining the right to order x-rays. With our training in being able to screen patients for fractures, infection, cancer, and more, I think it can help to streamline the health care process and save money for our patients. But we must avoid ordering x-rays for every musculoskeletal injury that walks in the door. Remember, the imaging should not guide our treatment, unless managing the condition is outside our scope of practice i.e. a fracture, infection, etc. Congratulations Wisconsin PT's! Show the rest of the country that we won't abuse the power of ordering x-rays and potentially harming our patients!

-Chris

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