X-Ray Safety
There are zero negative effects of diagnostic X-rays in chiropractic offices. Radiation exposure to a patient in plain X-ray examinations of the spine involves an estimated 0.2, 1.0 and 1.5 mSv for the cervical, thoracic and lumbar regions, respectively.1 In 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.2
It would take five times those levels over a protracted time; however, neither of these circumstances occurs in chiropractic practices, as the safe use of radiation is inherent in our doctoral training regarding the number of necessary X-rays.
Health Risk to the General Public of NOT Taking X-Rays
The American Association of Physicians in Medicine reported, "Predictions of hypothetical cancer incidence and deaths in patient populations exposed to such low doses are highly speculative and should be discouraged. These predictions are harmful because they lead to sensationalistic articles in the public media that cause some patients and parents to refuse medical imaging procedures, placing them at substantial risk by not receiving the clinical benefits of the prescribed procedures."4 [Emphasis added]
The Necessity of X-Ray in Chiropractic Practice
Chiropractic delivery modes are very diversified and state-dependent. Some choose an exercise model, while others use soft-tissue work, joint mobilizations, arthrokinematic or kinesiological procedures, or high-velocity, low-amplitude thrusts (HVLAT, also known as a spinal adjustment or spinal manipulation).
The combined effects of genetic inheritance, aging and loading history can influence the strength of spinal tissues to such an extent that it is difficult to specify the likely strength of an individual's spine. The risk of injury depends on tissue weakness as much as peak loading.
For practitioners who consider every model except an HVLAT, there is little risk for the patient, as minimal forces are being utilized. However, in an HVLAT, there are measurable forces with peak amplitudes which are generally tolerated in healthy spines. However, with injured spines, this can potentially be harmful if the force is not applied in the correct direction.6
As evidence in the literature has evolved over time, the direction and magnitude of spinal biomechanical pathology (misalignments), in conjunction with connective tissue pathology, have been defined.7-8 In some instances, those biomechanical lesions can cause serious injury to the spinal cord and must be identified before treatment begins.9
Significant Public Health Risk of Waiting Six Weeks or for a "Red Flag" to X-Ray
For the chiropractic practitioner who utilizes a lawful HVLAT procedure in their practice (whose outcome is evidenced to reduce opiate use by 64%10 and realize a 313% lower disability outcome vs. physical therapy treatment),11 utilizing methods with poor reliability to determine care is not in the patient's interest and is at the core of every state board's responsibility.
Seffinger, et al., Troyanovich, et al., and Bialosky, et al., reported that palpation for position and movement faults has demonstrated poor reliability, suggesting an inability to determine a specific area requiring manual therapy accurately.12-14 The majority of palpatory tests studied, regardless of the study conditions, demonstrated low reliability and are invalid or unreliable; and thus should not be used to arrive at a diagnosis, plan treatment or assess progress.12
In contrast, the reliability of X-rays in morphology, measurements and biomechanics has been determined accurate and is reproducible in both chiropractic and medical specialties.15 The reliability of an X-ray is excellent for all parameters. It suggests that this valid and reliable information on accuracy should be used when assessing and interpreting a change in the cervical spine.16
For the HVLAT practitioner, treating for six weeks without evidence-based validity in diagnosis would be forcing the doctor to "guess" on formulating a prognosis and treatment plan and increase the risk to the patient.
A "red flag" X-ray policy (evidence of fracture, tumor or infection) is commonsense to any licensed provider. However, to apply the six-week or red-flag "gatekeeper rule" for X-rays equally to chiropractic and medicine, as suggested by academicians and a minority of influential political policymakers,17-18 for the HVLAT practitioner is ignoring the evidence and potentially putting the public at risk.
To underscore the necessity, the American College of Radiology Appropriateness Criteria (2021) lists in Variant 6, "low back pain with or without radiculopathy," initial imaging of radiography of the lumbar spine; "Usually Appropriate."19 [Emphasis added]
The Council on Chiropractic Education (CCE), under "META-COMPETENCY 1 – ASSESSMENT & DIAGNOSIS" (D), states, "Perform and utilize diagnostic studies and consultations when appropriate, inclusive of imaging, clinical laboratory, and specialized testing procedures, to obtain objective clinical data."
Most state scope parameters are consistent with federal guidelines on imaging. Currently, X-ray procedures are being taught in every CCE-accredited program, and the doctor of chiropractic has the right, based upon a clinical decision for their treatment path, to take X-rays.
This should not change. Carriers should not use political guidelines to limit the use of initial X-rays, nor should chiropractic colleges be allowed to limit the training on X-rays. Doing so will increase the risk to the public.
References
- Mettler FA, Huda W, Yoshizumi TT, Mahesh M. Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology, 2008;248:254-263.
- Tubiana M, Feinendegen LE, Yang, Kaminski JM. The linear no-threshold relationship is inconsistent with radiation biologic and experimental data. Radiology, 2009;251(1):13-22.
- American College of Radiology Appropriateness Criteria: www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf.
- Adams MA, Dolan P. Spine biomechanics. J Biomech, 2005;38(10):1972-1983.
- Lopes MA, Coleman RR, Cremata EJ. Radiography and clinical decision-making in chiropractic. Dose Response, 2021 Oct 13;19(4):15593258211044844.
- Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. Open Orthopaed J, 2014;8:326.
- Lee DJ, Winkelstein BA. The failure response of the human cervical facet capsular ligament during facet joint retraction. J Biomech, 2012;45(14):2325-2329.
- Yang SY, et al. A review of the diagnosis and treatment of atlantoaxial dislocations. Global Spine J, 2014;4(3):197-210.
- Corcoran KL, et al. Association between chiropractic use and opioid receipt among patients with spinal pain: a systematic review and meta-analysis. Pain Med, 2020;21(2):e139-e145.
- Blanchette MA, Rivard M, Dionne CE, et al. Association between the type of first healthcare provider and the duration of financial compensation for occupational back pain. J Occup Rehab, 2017;27(3):382-392.
- Bialosky JE, et al. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual Ther, 2009; 14(5):531-538.
- Fedora C, Ashworth N, Marshall J, Paull H. Reliability of the visual assessment of cervical and lumbar lordosis: how good are we? Spine, 2003;28(16):1857-1859.
- Marques C, et al. Accuracy and reliability of X-ray measurements in the cervical spine. Asian Spine J, 2020;14(2):169.
- "Five Things Physicians and Patients Should Question." American Chiropractic Association, Aug. 15, 2017. www.choosingwisely.org/societies/american-chiropractic-association/.
- Rao VM, Levin DC. "The Choosing Wisely Initiative of the American Board of Internal Medicine Foundation: What Will Its Impact Be on Radiology Practice?" Am J Roentenol, Feb 2014;202(2):358-61. www.ajronline.org/doi/10.2214/AJR.13.11123?mobileUi=0.
- ACR Appropriateness Criteria: Low Back Pain. https://acsearch.acr.org/docs/69483/Narrative/.
Dr. Mark Studin is an adjunct associate professor at the University of Bridgeport School for Chiropractic, teaching advanced imaging and triaging chronic and acute patients; and an adjunct postdoctoral professor at Cleveland University-Kansas City College of Chiropractic. He is also a clinical instructor for the State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Office of Continuing Medical Education. Dr. Studin consults for doctors of chiropractic, medical primary care providers and specialists, and teaching hospitals nationally. He can be reached at
or 631-786-4253.
Dr. Anthony Onorato is the associate director of clinical education at the University of Bridgeport, School of Chiropractic. He is supervising attending physician for all clinical services. He is also an associate professor of clinical sciences at Bridgeport and currently teaches physical diagnosis. Dr. Onorato was the associate dean of chiropractic at the U of B 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 Council on Chiropractic Education (CCE) during his tenure. He also was a counselor for the CCE.