MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

The over-use of X-ray diagnostics by chiropractors has long been a concern (see for instance here,and here). As there is a paucity of reliable research on this issue, this new review is more than welcome.

It aimed to summarise the current evidence for the use of spinal X-ray in chiropractic practice, with consideration of the related risks and benefits. The authors, chiropractors from Australia and Canada who did a remarkable job in avoiding the term SUBLUXATION throughout the paper, showed that the proportion of patients receiving X-ray as a result of chiropractic consultation ranges from 8 to 84%. I find this range quite staggering and in need of an explanation.

The authors also stated that current evidence supports the use of spinal X-rays only in the diagnosis of trauma and spondyloarthropathy, and in the assessment of progressive spinal structural deformities such as adolescent idiopathic scoliosis. MRI is indicated to diagnose serious pathology such as cancer or infection, and to assess the need for surgical management in radiculopathy and spinal stenosis. Strong evidence demonstrates risks of imaging such as excessive radiation exposure, over-diagnosis, subsequent low-value investigation and treatment procedures, and increased costs. In most cases the potential benefits from routine imaging, including spinal X-rays, do not outweigh the potential harms. The authors state that the use of spinal X-rays should not be routinely performed in chiropractic practice, and should be guided by clinical guidelines and clinician judgement.

The problem, however, is that many chiropractors do not abide by those guidelines. The most recent data I am aware of suggests that  only about half of them are even aware of radiographic guidelines for low back pain. The reasons given for obtaining spinal X-rays by chiropractors are varied and many are not supported by evidence of benefit. These include diagnosis of pathology or trauma; determination of treatment options; detection of contraindications to care; spinal biomechanical analysis; patient reassurance; and medicolegal reasons.

One may well ask why chiropractors over-use X-rays. The authors of the new paper provide the following explanations:

  • lack of education,
  • ownership of X-ray facilities,
  • and preferred chiropractic technique modalities (i. e. treatment techniques which advocate the use of routine spinal X-rays to perform biomechanical analysis, direct appropriate treatment, and perform patient reassessment).

Crucially, the authors state that, based on the evidence, the use of X-ray imaging to diagnose benign spinal findings will not improve patient outcomes or safety. For care of non-specific back or neck pain, studies show no difference in treatment outcome when routine spinal X-rays have been used, compared to management without X-rays.

A common reason suggested by chiropractors for spinal X-ray imaging is to screen for anomalies or serious pathology that may contraindicate treatment that were otherwise unsuspected by the clinical presentation. While some cases of serious pathology, such as cancer and infection, may not initially present with definitive symptoms, X-ray assessment at this early stage of the disease process is also likely to be negative, and is not recommended as a screening tool.

The authors concluded that the use of spinal X-rays in chiropractic has been controversial, with benefits for the use of routine spinal X-rays being proposed by some elements of the profession. However, evidence of these postulated benefits is limited or non-existent. There is strong evidence to demonstrate potential harms associated with spinal X-rays including increased ionising radiation exposure, over-diagnosis, subsequent low-value investigation and treatment procedures, and increased unnecessary costs. Therefore, in the vast majority of cases who present to chiropractors, the potential benefit from spinal X-rays does not outweigh the potential harms. Spinal X-rays should not be performed as a routine part of chiropractic practice, and the decision to perform diagnostic imaging should be informed by evidence based clinical practice guidelines and clinician judgement.

So, if you consult a chiropractor – and I don’t quite see why you should – my advice would be not to agree to an X-ray.

66 Responses to The benefits of chiropractic X-rays do not outweigh the risks

  • https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-018-2317-y

    The attached article strongly suggests that x-ray imaging is an integral diagnostic component required to determine what structural rehabilitation protocol needs to be performed to obtain a clinical result that appears to be superior to traditional manual pain management. All conflict of interests has been satisfactorily explained.

    • the authors concluded that “The addition of the denneroll cervical orthotic to a multimodal program positively affected CMCPS outcomes at long term follow up. We speculate the improved sagittal cervical posture alignment outcomes contributed to our findings.”
      NOT REMOTELY WHAT YOU CLAIM!?

      • It’s bizarre: the paper doesn’t even mention x-rays. Not once.

        • ah well, but it was a good try!

        • Ah, wait, it does. I’d only quickly skimmed the paper but it does mention radiography. Radiography was only used a) to screen for hypo-lordosis and b) to locate the optimum position for the denneroll cervical traction device they were testing – although only one of two positions was used in the intervention. There was no followup xray.

        • “As part of our University’s IRB approved protocol, each participant was only to receive initial cervical spine radiography (with no follow up spine radiography) …”

          “Initial cervical radiological assessment was important to identify the cervical curve apex to determine where a subject should properly place the apex of the denneroll in their cervical spine.”

  • I write as a former lecturer in anatomy (King’s College London) who dissected spines, clinical teacher (Cambridge University) and orthopaedic surgeon (Guy’s and Bedford Hospital) who did many operations on the spine.

    IMHO spinal imaging is only required to inform the surgeon where he/she should operate and what specific operation might be indicated – not whether to operate.
    That decision can only be made by a surgeon capable of operating.

    Otherwise, the value of imaging is extremely small – if a doctor cannot make a diagnosis without imaging – go to another doctor!
    Sometimes there can be doubt (especially if cancer is a genuine concern), but not routinely.

    In the UK, chiropractors have no authority to order or conduct imaging. They refer patients in need to GPs.

    It seems that chiropractors elsewhere like to offer imaging as part of the illusion they wish to create that they are professional healthcare practitioners of repute. They wear white coats, some sport stethoscopes, many style themselves as ‘doctor’ though they have no PhD nor medical qualification.
    The offer of imaging is part of marketing (just as I wear a pin-stripe suit!).
    Imaging treats the patient’s emotional needs, and generally contributes nothing to identification of pathology.
    If pathology is genuinely suspected, the patient should be in the hands of a medical practitioner. Why not?

    And if you do consult a chiropractor (why would you? EE), ask “How many radiographs have you ordered? On how many occasions did you find any feature which informed your practice? Changed treatment you offered?”

      • An order for a radiograph is, in effect, a prescription for a radiation dose. In the UK doctors receive training regarding the nature of ionising radiation, its biological effects, background dose and how it is made up, and the dose received during various types of investigation, as well as on the legislation covering these areas, and the dose limits allowable in various situations. This knowledge is required in order to weigh up the risk of causing cancer against the potential benefit to the patient from the diagnostic information obtained.

        The risk to an individual from medical x-rays is low but not zero, and given that they comprise a large proportion of the radiation dose received by the general public, undoubtedly worldwide a significant number of cancers are cause by medical imaging. With this in mind, the general principle is that the radiation dose should be as low as reasonably achievable. It is also important to remember that certain individuals are particularly at-risk, such as unborn babies and children (who have a lifetime ahead of them for a cancer to manifest), and adolescent girls, whose developing breast tissue is expecially sensitive. It takes about 30 – 40 years for a radiation-induced cancer to appear, so the risk to older adults is negligible.

        To put some numbers in place, background radiation is typically about 3 – 5 millisieverts (mSv) per year (though in some parts of the world it is much higher due to peculiarities of geography). A chest x-ray will give about 0.1 mSv depending on the technique used and how modern the equipment is. This is about the same dose received in a single leg of a long-haul flight in a passenger jet (though this will also vary with the route and solar activity). A thoracic spine examination is about 1 mSv and a lumbar spine about 1.5 mSv. A series of radiographs to show the whole spine in different postures and from various angles could easily reach 10 – 20 mSv or more, which is comparable to the annual dose permitted in radiation workers.

        Bearing this in mind I am shocked at the idea of routinely ordering multiple spinal x-rays as a routine part of a chiropractic examination, particularly in children, and repeating these at subsequent visits.

        In case this sounds too scary, we know from the Hiroshima and Nagasaki bomb victims that a total body dose that is not quite enough to be fatal will give a risk of cancer of approximatedly 1 in 1,000 over and above the natural expected risk (which is about 1 in 2 to 1 in 3 over the course of a lifetime), so you have to x-ray quite a lot of people to cause one cancer. And the LD50 (the dose required to kill half of the people receiving it) for a single whole-body radiation dose is about 6 Sv (6000 mSv) which was established experimentally in a group of volunteers with terminal cancer.

  • Every chiropractor used to have a big banner outside screaming FREE BACK X-RAY!!!!

    Does anyone know why they stopped? Ethics or just a shift in public opinion about x-rays? Or maybe the cost outweighed the new business created?

  • Interestingly these CBPers set themselves above mere Chiroquackers since they decided whackin’ and crackin’ bones back-in wasn’t enough of a shtick. So they added stretchin’ into their overpriced hyperbolic nonsense (and loads of x-rays are necessary).
    I believe at least 2 recent studies and a few meta-analysis have reached the conclusion lordosis is inconsequential in the vast majority of us (and if it was in need of “improvement” do we really need to give a monetary reward to a quack selling a foam roll??). Cerv lordosis in asymptomatic individuals. J ortho surg res 2018.
    Twenty-year MRI study: impact of cerv alignment on disc degeneration. Clin spine surg 2018. “Alignment did not affect development of symptoms….prevalence of clinical symptoms was similar in lordotic and non-lordotic subjects”. Wow, just like a “subluxation”!
    Funny how there are many under-the-neck-rolls available for about $10.00. But they need to name specifically the Deneroll. Wonder if there could be a financial motive…? Oh, sorry… these are chiroquackers they NEVER have a financial motive.

  • There are some indications that early imaging may be warranted. I would suggest the public not follow the blanket (and potentially dangerous) advice of Ernst to not let a chiropractor take an x ray.

    See Choosing Wisely for a better information on the appropriate use of imaging.

    • Or, you could heed this blanket advice: avoid chiropractors (and other myth-based practitioners) and seek real medical assistance.

      • DC wrote: “See Choosing Wisely for a better information on the appropriate use of imaging.”

        @ DC

        Here it is:

        QUOTE

        ‘Do not obtain spinal imaging for patients with acute low-back pain during the six (6) weeks after onset in the absence of red flags.’

        “What red flags, you ask? The ACA mentions ‘history of cancer, fracture or suspected fracture based on clinical history, progressive neurologic symptoms and infection, as well as conditions that potentially preclude a dynamic thrust to the spine, such as osteopenia, osteoporosis, axial spondyloarthritis and tumors’. I would argue that if you have any of these red flags, you should not be under the care of a chiropractor. There isn’t any evidence to support superiority of chiropractic care to conventional approaches for acute low-back pain anyway.”

        Ref: https://sciencebasedmedicine.org/the-american-chiropractic-association-answers-crislips-call-joins-the-choosing-wisely-campaign/

        More:

        “Choosing Wisely aims to promote conversations between clinicians and patients by helping patients choose care that is:

         Supported by evidence
         Not duplicative of other tests or procedures already received
         Free from harm
         Truly necessary

        The Choosing Wisely lists published by participating organizations aren’t meant to serve as treatment guidelines, of course. Instead, they are intended to encourage a conversation around whether or not the listed interventions are a good idea, or if they may put patients at risk of more harm than benefit. Unfortunately, in my opinion, they have largely gone unnoticed by medical providers and the general public. I am confident that the list of questionable chiropractic interventions will be similarly ignored by practitioners.

        -snip-

        All that the ACA has done is provide a list of redundant or unnecessary recommendations. And the few chiropractors who already avoid excessive spinal imaging will continue to do so, while the vast majority will compartmentalize these ‘suggestions’ and carry on as is.”

  • Good article from Hazel Jenkins.
    She has written a few articles on this topic and it is shaking things up.
    @Michael Epstein
    You have been sprouting CBP rubbish on chiropractic forums recently and been justifiably hammered. Poor articles by Deed Harrison published in McCoy press are a joke.
    I recommend you read this review of CBP co-authored by Stephen Perle and Robert Cooperstein (who I believe gave his friend John Badannes the title TEO that is used to this day) in 2006:
    “Flawed trials, flawed analysis: why CBP should avoid rating itself”
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1839992/
    Stephen recently commented that his view on CBP has not changed in the intervening years.
    @Blue Wode
    “vast majority”
    Carpet bombing with sweeping statements again Blue.
    “redundant or unnecessary recommendations”
    I think you need to take a closer look at the Choosing Wisely movement across all professions and its important impact on clinical guidelines and practice.
    “compartmentalize these ‘suggestions’ and carry on as is.”
    Interesting question Blue. How long on average does it take research and guidelines to change clinical practice in medicine?
    You will be surprised.
    @Richard Rawlins
    “And if you do consult a chiropractor (why would you? EE), ask “How many radiographs have you ordered? On how many occasions did you find any feature which informed your practice? Changed treatment you offered?”
    Good question.
    I rarely order imaging these days. Chronic pain patients frequently rock up with a pile going back years from their doctors.
    After the history and examination I then throw them in the bin so the patient gets the idea. I return them to the patient after explaining their significance and translating the radiologist reports into plain English to de-medicalise and de-catastrophise the patient.
    Last week I had a new patient who told me his doctor on viewing his imaging said “your screwed”. I felt like going and knocking the doctors teeth out. We had a long discussion on the true significance of the xrays.
    This paper sums up my views on imaging nicely:
    “Overuse, Overdose, Overdiagnosis… Overreaction?”
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097773/

    • Critical_Chiro wrote: “How long on average does it take research and guidelines to change clinical practice in medicine?”

      @ Critical_Chiro

      I don’t know, but given that chiropractic is a narrow field, I find it disingenuous of the UK chiropractor regulator, the General Chiropractic Council (GCC), to not be up to speed with the guidelines for manual therapy for low back pain and sciatica – i.e. its ‘Seeing a chiropractor for the first time’ publication continues, in item 6, to apply NICE guidelines that have been obsolete for the last two years:
      https://www.gcc-uk.org/publications/publications-for-patients-and-the-public/

      This is what the current guidelines say:
      https://complementaryandalternative.wordpress.com/2016/12/06/nice-guidelines-for-low-back-pain-and-sciatica-a-clarification/

      It’s not pleasant reading for chiropractors, is it?

      FYI, since 4th February this year, I’ve informed the GCC several times about the error but they’ve ignored me.

      • that’s scandalous!
        they have no right to ignore you

      • I wonder, what would the Venn Diagram of
        (a) People who go to Chiropractors and get needless X-rays
        (b) People who freak out about microwaves and radiation from WiFi
        look like?

      • Below is not is not the current guideline. It is just the opinion of an anonymous and ignorant blogger with an agenda of mis-information.

        This is what the current guidelines say:
        https://complementaryandalternative.wordpress.com/2016/12/06/nice-guidelines-for-low-back-pain-and-sciatica-a-clarification/

        Just your typical and normal trash by Blue. I can understand why the GCC has ignored you, Blue. It is because you are not telling the truth.

        • GibleyGibley wrote: “Below is not is not the current guideline. It is just the opinion of an anonymous and ignorant blogger with an agenda of mis-information.”

          @GibleyGibley

          The current guideline says:

          “1.2.7 Consider manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) for managing low back pain with or without sciatica, but only as part of a treatment package including exercise, with or without psychological therapy.”

          Ref: https://www.nice.org.uk/guidance/NG59/chapter/Recommendations#non-invasive-treatments-for-low-back-pain-and-sciatica

          Where is the misinformation in the blogger’s conclusion? Here it is again:

          QUOTE

          “NICE have made it clear in their own press release that exercise is the ‘first step in managing the condition’. This something of a problem for osteopaths and chiropractors as their primary treatments are no longer first line choices and they are not well placed to offer a suitable exercise programme. Some of them may opt to continue treating patients the way the always have and not take the NICE guidelines into account. However, that is a potentially risky strategy for two reasons:

          It doesn’t seem to be in the best interest of their patients
          They risk being found in breach of their ‘Practice Standards’ which could result in formal complaints to either the General Osteopathic Council (GOsC) or General Chiropractic Council (GCC).”

          Ref: https://complementaryandalternative.wordpress.com/2016/12/06/nice-guidelines-for-low-back-pain-and-sciatica-a-clarification/

          As for the GCC ignoring me, I’m not surprised. It seems that they don’t like being given a hard time. For example, I was fobbed off by them recently regarding this raw milk related article:
          https://www.express.co.uk/life-style/life/663130/doctor-advises-stop-drinking-milk-but-is-this-safe

          After consulting a chiropractic expert witness, they informed me that the comments of the chiropractor who featured in the article were “consistent with a body of reasonable chiropractic opinion”.

          NB. Opinion, not evidence!

        • @GibleyGibley
          I am indeed an anonymous blogger and it’s therefore reasonable to check the actual guidelines yourself to ensure that what I’ve reported is accurate. They are available here: https://www.nice.org.uk/guidance/ng59 . @BlueWode is correct that the GCC are applying out of date guidelines in their own publications. There is nowhere in the current guidelines that says this “The national (NICE) guidelines for low back pain advise that after 6-9 treatments you should be feeling significantly better.” That was from the old guideline that was updated in November 2016. It is appalling that a regulator has failed to correct this important factual error in their own publications when they have been told about it several times. The regulator should be protecting the public not misleading them.

      • @Blue Wode
        In medicine, on average 10 years. Not pleasant reading is it and definitely scandalous when it comes to risky surgery.
        Nice to see you applying a much higher standard to chiropractic of 2 years.
        Time to search the literature instead of blogs for a change.
        Do a literature search on arthroscopy for knee OA. It will open your eyes.
        Your second link is to a blog. Why am I not surprised.
        Exercise makes up a large % of the chiropractic course here in Australia.
        The problem on this blog is that you think chiropractic is a single technique.
        Time to update your knowledge of chiropractic and not trust blogs or a Wikipedia page that is as outdated as the subluxation based chiropractors.

        • Critical_Chiro wrote: “In medicine, on average 10 years. Not pleasant reading is it and definitely scandalous when it comes to risky surgery. Nice to see you applying a much higher standard to chiropractic of 2 years.”

          @ Critical_Chiro

          Do you have a good citation for “an average of 10 years” for guidelines to be implemented in medicine?

          With regard to the UK General Chiropractic Council being two years out of date with the NICE guidelines for low back pain (and sciatica), they should, at the very least, be *publishing* current, factual information on their website. As they haven’t done so, the public is being misled and the GCC are failing in their duties.

        • A wife comes home and finds her husband in bed with another woman…he says “are you going to believe me, or your eyes?” Given the choice between a blog, wikipedia or an uncritical-chiroquacker I’m all in with the former.
          “There’s nothing more dangerous than a man with a religious conviction” said Neitzche.
          And especially when that religion has a lucrative financial reward.
          Why don’t you update your knowledge and go back to a real college and get a real degree?
          Perhaps one who’s ONLY use isn’t to create private-practices defrauding the gullible and worried-well.
          Cosmetology is well respected and has real, definitive outcomes….a claim chiropractic is unable to make after 120 years and the creation of 100 different denominations.

  • BW…do you agree with EE advice (as i understand it) that under no circumstances should any person, regardless of their history or clinical presentation, ever allow any chiropractor to take an x ray of them?

    • @ DC

      Until there is overarching, evidence-based standardisation within the chiropractic industry, then, yes, I agree with prof. Ernst’s advice.

      BTW, ‘my comments’ were lifted from a piece by Clay Jones MD who writes for Science Based Medicine:
      https://sciencebasedmedicine.org/author/clayjones/

      • unfortunate and potentially dangerous advice to the public. But then again, safely tucked away behind a keyboard, you won’t be named in the malpractice lawsuit.

        • this sounds like the remark of a patronising git

          • Your advice sounds like someone ignorant of the consequences.

          • Please tell us about the consequences, “DC”.
            And it would be very good of you to support your thoughts with some evidence.

          • I’m still waiting for a good evidence to tell people to never let any chiropractor to take an x ray on anybody for any reason, ever.

          • I did state
            “if you consult a chiropractor – and I don’t quite see why you should – my advice would be not to agree to an X-ray.”
            this is not quite what you imply, is it?

          • X-rays of the spine, neck, or back may be performed to diagnose the cause of back or neck pain, fractures or broken bones, arthritis, spondylolisthesis (the dislocation or slipping of 1 vertebrae over the 1 below it), degeneration of the disks, tumors, abnormalities in the curvature of the spine like kyphosis or scoliosis, or congenital abnormalities. John Hopkins Medicine

            X-ray — Application of radiation to produce a film or picture of a part of the body can show the structure of the vertebrae and the outline of the joints. X-rays of the spine are obtained to search for other potential causes of pain; i.e. spinal malalignment, tumors, infections, fractures, etc. American Association of Neurological Surgeons

            Lawyer…so Mr Chiropractor, Mrs Jones presented with the symptoms/clinical signs of (pick one of the above) but you didn’t order/take an x ray. The standard of care would have been for you, at minimum, to order/take an initial x ray. Why didn’t you do it doctor?

            Chiropractor…because Edward Ernst told the public that chiropractors should never take an x ray for any reason.

            Judge…guilty.

            (That was the stupidest advice I’ve ever seen Ernst give on his blog, he should be ashamed).

          • thanks
            coming from a chiro, it must mean that, in truth, it was sound advice

          • EE wrote…”thanks coming from a chiro, it must mean that, in truth, it was sound advice.”

            What a meaningless and pathetic response.

          • if you read it again, you might realise that it was merely an attempt to make fun at your pathetic response.

          • @DC
            Chiropractors are at risk of missing most of the type of lesions you enumerate. The X-rays chiropractors take are not suitable for clinical medical/pathological diagnosis. In other words, chiropractic spine films are generally of such poor technical quality they are practically useless, except of course for impressing customers. In addition most chiro´s can´t read them properly. They probably won´t miss a large listhesis but they canþt do anything about that so why spend uselessly radiation on shitty images that have to be redone anyway?
            Their diagnostic sensitivity and specificity is abysmal. Chiro´s are trained to look at angles and alignment (clinically insignificant, mostly) and are prone to both over- and underdiagnose medical pathology so the customer has to get proper x-rays any which way if the chiro misses something or thinks she sees something that is out of her ballpark, thereby adding to the DNA fragmenting lifetime accumulated radiation dose.
            Better take proper medically useable studies right away when indicated, which is actually never with uncomplicated back pain.

            I have a recorded case, for example, where a young, perfectly healthy lady was visiting a chiropractic establishment as part of a TV health program thing. The chiro got her to volunteer, took whole body X-rays ( no gonadal shielding) and diagnosed her with scoliosis (a very minor, insignificant degree) that he pretended to treat. She walked in healthy and out with a severely exagerated chronic health condition and several milliSiewerts added to her lifetime risk of cancer for no health benefit whatsoever. And perhaps also advice for regular chiropractic “treatments” indefinitely?

            The use of ionising, DNA-damaging radiation purely for theatrical stage effect and marketing purposes is hardly justifiable, don´t you think?

    • My advice would be that under no circumstances should any person, regardless of their history or clinical presentation, ever allow any chiropractor to see and treat them. At all. Period.

  • “…under no cicumstances should any person allow any chiropractor to take an x-ray…” OR ever allow any chiropractor to lay a hand (or adjusting gun) on them. There’s the best public-health, evidenced-based guideline.

  • The author of this article is obviously not a clinician. The advice of a portal of entry practitioner to not access use of diagnostic testing within their scope of practice is irresponsible and frankly, dangerous. Perhaps it is a cultural issue as it appears most of the comments suggest the main body of this echo chamber, with the science-based medicine blog, are from the UK. Perhaps the chiropractic profession in England is not as advanced, or, the medical culture in England is not as advanced. Either one. This blog seems wholly out of date regarding the chiropractic profession.
    Current ODG guidelines regarding x-rays in the use of diagnostics are:
    Indications for imaging — Plain X-rays:
    – Thoracic spine trauma: severe trauma, pain, no neurological deficit
    – Thoracic spine trauma: with neurological deficit
    – Lumbar spine trauma (a serious bodily injury): pain, tenderness
    – Lumbar spine trauma: trauma, neurological deficit
    – Lumbar spine trauma: seat belt (chance) fracture
    – Uncomplicated low back pain, trauma, steroids, osteoporosis, over 70
    – Uncomplicated low back pain, suspicion of cancer, infection
    – Myelopathy (neurological deficit related to the spinal cord), traumatic
    – Myelopathy, painful
    – Myelopathy, sudden onset
    – Myelopathy, infectious disease patient
    – Myelopathy, oncology patient
    – Post-surgery: evaluate status of fusion

    Those exact same guidelines regarding chiropractic/manipulation:
    ODG Chiropractic Guidelines:
    Therapeutic care –
    Mild: up to 6 visits over 2 weeks
    Severe*: Trial of 6 visits over 2 weeks
    Severe: With evidence of objective functional improvement, total of up to 18 visits over 6-8 weeks, if acute (not chronic)
    Elective/maintenance care – Not medically necessary
    Recurrences/flare-ups – Need to re-evaluate treatment success, if RTW achieved then 1-2 visits every 4-6 months when there is evidence of significant functional limitations on exam that are likely to respond to repeat chiropractic care
    * Severe may include severe sprains/strains (Grade II-III) and/or non-progressive radiculopathy (the ODG Chiropractic Guidelines are the same for sprains and disc disorders) (Hannafin, 2004)

    Thus, chiropractic care is a completely valid course of treatment for nonemergency spinal/low back pain issues.
    If a person presents to a chiropractor with such low back pain, yet, the chiropractor perceives something else such as a fracture or even cancer before manipulation is performed as a treatment, you’re saying they should not order x-rays?
    X-rays are x-rays. If they are ordered by a chiropractor, what is the difference if an objective issue is found and can be sent to the proper scope of practice? Say, an oncologist, or an orthopedists? And, if those issues suspected are indeed not seen on x-rays, then continue the course of conservative management with a chiropractor thus saving healthcare costs?

    Regardless of your opinion, chiropractors are a portal of entry into healthcare, at least here in America. The benefits of x-rays as a diagnostic tool, when properly used according to guidelines, are not only as a benefit to a patient’s overall healthcare, it also decreases the cost of that healthcare, increases efficiency, and keeps the patient from being exposed to radiation from multiple providers.

    I’m flabbergasted at the ignorance of the writers of this blog. No matter what the credentials of the author may be or have been, they are wholly ignorant and irresponsible in modern healthcare. I would suggest removal of this blog from the site for fear of potential legal action should this affect any future patient care.

    • it might affect patient care – but only to the better.
      thanks for the legal threat; it makes you MOST CREDIBLE!

    • Multi-Disciplinary DC said:

      I would suggest removal of this blog from the site for fear of potential legal action should this affect any future patient care.

      Awww… bless…

      The last time chiros here tried to sue someone for what they said about chiro quackery, it didn’t work out that well for the chiros. Do you know anything about it? I suspect not.

      But you do know that England is not the UK, don’t you? Oh. You don’t…

      And odd you should link to a website that requires a password to access… Is your page on xrayx for LBP a secret?

      • Mr Edzard, are you continuing to suggest that substandard care by well renown peer reviewed guidelines and accepted across medical and legal industries is appropriate? Alan Hennes- You obviously are not a doctor of any sort and do not read nor keep up to date with current guidlines. ODG is industry standard. https://www.mcg.com/odg/odg-solutions/treatment-guidelines/

        But thank you. You both have exposed this blog as nothing more than a semi-medico tabloid that is most appropriately viewed while straining a bowel movement in a public subway bathroom. Good day!

        • 1) you cannot even get my name right
          2) I never suggested that “substandard care by well renown peer reviewed guidelines and accepted across medical and legal industries is appropriate”
          3) thank you for discrediting yourself even further by stating ” this blog is nothing more than a semi-medico tabloid that is most appropriately viewed while straining a bowel movement in a public subway bathroom”
          ISN’T IT JUST MIRACULOUS HOW CHIROS REGULARLY MANAGE TO DISCREDIT THEMSELVES AND THEIR PROFESSION SO THOROUGHLY?

        • Multi-Disciplinary DC said:

          Mr Edzard

          Prof or Dr Ernst… Please try to be civil.

          You obviously are not a doctor of any sort and do not read nor keep up to date with current guidlines. ODG is industry standard.

          Bizarre. But nice try to deflect attention from your failure to provide a link that works – your failure is not my fault. But it looks like the website you linked to was closed some time ago – are you sure you’re up to date?

          You both have exposed this blog as nothing more than a semi-medico tabloid that is most appropriately viewed while straining a bowel movement in a public subway bathroom.

          Please try to be civ… Oh, probably not much point in asking a second time.

    • Under what circumstance would a chiro not do an x-ray?

  • Bjorn, it seems you disagree with those organizations. Your choice I guess.

    there are studies looking at comparing reading x rays between professions. what do those studies tell us Bjorn?

    as far as quality of x rays taken by chiropractors, i haven’t seen any research on that topic. Please share.

    as far as sensitivity, specificity…it varies by lesion.

    • @DC wrote

      Bjorn, it seems you disagree with those organizations…

      Not at all DC. I agree fully with them. It is you who seem not competent to understand their messages.
      You seem to be copying parts of statements from John Hopkins Medicine and the American Association of Neurological Surgeons to use as arguments for chiropractors radiating customer so as not to miss important things like fractures and cancer.
      These medical institutions are certainly not, in their statements about the importance of radiological diagnostics, referring to the kind of diagnostic imaging standard in chiropractic parlours. They are talking about real, clinical, professional X-ray examinations, which are far, far more advanced in any respect.

      My evaluation of the quality of imaging and their interpretation by chiro’s is professional one, based on gathered material including promotional and marketing material, case evidence (please spare us the “only anecdotes” gambit here), reading of other’s professional evaluations, and interviews with radiologists and Emergency physicians who see cases of botched diagnosis or overdiagnosis. I have no reason to exaggerate my opinion in this matter, I would be glad if I found that chiro’s were doing something useful and beneficial for their clients.

      I did seek the help of a chiropractor many years ago as I have described before. The first clue that something was seriously amiss in his professional performance was the abysmal standard of radiological examination and evaluation. At that time I was rather desperate for help so I did look beyond this and gave it a chance for many more weeks and months. I realised at last that there was nothing happening in the way of benefit (other than his finances were benefiting from the frequent visits and manipulations) and the claims and theatrical manipulations were more or less made up. I listened to another chiro in this parlour lecture about all kinds of effects the correction of subluxations could have, on anything from Alzheimers to Zoster. I found this anatomically implausible and physiologically improbable but I still gave it some more months as I recall. The experience kindled my interest in pseudomedical practices and I studied everything available about chiropractic. You may guess how I felt when I found out about the risk of cervical artery dissection and recalled that the man insisted on cracking my neck every visit even if I had never felt any problem from there. He claimed it was preventive!!!

      Right now I am gathering more real world data and evidence on the question of chiropractic use of radiology and its quality and benefit.
      The result so far is that I find no justification for the use of radiology in chiropractic parlours.
      You talk about ruling out lesions after trauma, suspected cancer, evaluation of osteoporosis etc., chiropractic radiology is not at all of sufficient technical quality and reliability. They may think they have (as evidenced by your carrying on about it) the required education and training for an acceptable diagnostic standard but this is absolutely not the case.
      I would be much more concerned, as a chiropractor, of being bashed in court because of missing important findings on a substandard X-ray and not referring to a real radiology service in the case of trauma or cancer-suspicion or similar. I have such a case in front of me.

      • oh, so we are sharing stories now. Let’s see:

        When I was in college clinic I had to get permission to x ray cadavers to receive enough credits because I refused to x ray patients just for credit.

        My senior research/residency project was x ray analysis of pelvic morphometric asymmetry to investigate certain chiropractic x ray analysis systems (100 pelves).

        I have not personally taken a x ray of a patient my whole professional life.

        I send approximately 10% of my patients to a local medical center for imaging, which uses a medical radiologist to read the imaging.

        I refer my medicare clients to their MD if I think imaging is necessary. I have only had one MD refuse to take a requested x ray. MDs around here know if I send a patient out for imaging there is a damn good reason.

        I have had numerous debates with chiropractors over proper and improper use of x rays. Most that disagree with me have either blocked or just resort to ad hom.

        Are x rays overused and improperly used in chiropractic, and other health professions? Sure.

        But for Ernst to advise that if a patient comes to a chiropractor, and they have a valid clinical indication to order a x ray, for that patient to refuse that imaging order is, well, it is just asinine advice.

        A much better approach, as I mentioned in my first comment, is for a patient to use Choose Wisely as a guide to ask questions/have a discussion as to why a x ray is being ordered.

        • “for Ernst to advise that if a patient comes to a chiropractor, and they have a valid clinical indication to order a x ray, for that patient to refuse that imaging order is, well, it is just asinine advice.”
          did I really do that?

        • “A much better approach, as I mentioned in my first comment, is for a patient to use Choose Wisely as a guide to ask questions/have a discussion as to why a x ray is being ordered., as I mentioned in my first comment, is for a patient to use Choose Wisely as a guide to ask questions/have a discussion as to why a x ray is being ordered.”
          A much better approach, as I mentioned in my first comment, is for a patient to not consult a chiro in the first place.

      • When I was a junior house officer at I was taught by my consultant that any referral to another specialist should include a specific question to answer, even if the referral was in the form of a blood test or a radiology request (i.e. an x-ray or some kind of scan). Indeed, I have often found it helpful to discuss a puzzling case with my radiologist colleagues and allow them to suggest which investigations are most likely to be helpful, and certainly to let them decide which protocols should be used in conducting the examinations (there are many ways to take a chest x-ray depending on the suspected diagnosis, let alone all the variables in MRI scans). As a consultant I came to realise that individual radiologists had particular strengths and weaknesses, and they were most helpful in their own areas of expertise.

        In case it sounds as though I am stating the obvious, I have encoutered too many situations where obvious tumours were missed, because nobody was looking for them, or because the images were reported by a non-oncology radiologist. Nowadays (or at least until I retired) when I read an x-ray report, the first thing I look at is the name of the radiologist. If it is someone I know, then I also know how to interpret their nuances of language, and indeed whether they are the right person to be looking at those images at all. If it is someone I don’t know then I will read the report but not necessarily accept it.

        Electronic imaging systems such as PACS mean that the scans, x-rays or whatever are now always available in the clinic on a computer screen, and therefore I feel that I have an obligation to look at them myself and form my own opinion (I am good at reading oncology scans, hopeless at anything else, but better than those who never look at the pictures).

        I feel that GPs are at a great disadvantage as they have to rely on reports from an unknown radiologist.

        I don’t know anything about the use of x-rays by chiropractors, but if they are taking the images themselves they are not going to be optimised for diagnosing anything other than the subluxations and misalignments that they are so fond of finding, and if they are referring the patient for x-rays through a third party (such as a medical doctor in the UK) then they will be even further removed from any relevant dialogue.

        As a student at Westminster Medical School, I remember the wise words of our Dean, Dr Joe Gleeson, who was a radiologist (spoken with a soft Irish accent):

        You see what you look for.
        You look for what you know.
        And you know f**k all.

        • This study showed that pooling independent ratings increases the diagnostic accuracy in lumbosacral spine image interpretation: increasing the number of independent ratings increased both sensitivity and specificity. These results were found in both studies, each one using a different imaging technique (i.e., radiographs and MR images respectively). Our results corroborate earlier findings in different domains of medical diagnostics which have shown an increased diagnostic accuracy when pooling independent diagnostic decisions in radiology [24,25], dermatology [23,38] positive bone scan predictions [26] and emergency medicine [27]. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0194128

      • Björn…”They may think they have (as evidenced by your carrying on about it) the required education and training for an acceptable diagnostic standard but this is absolutely not the case.”

        Interesting:

        https://insights.ovid.com/pubmed?pmid=12221360

        CONCLUSIONS:
        Small differences with little clinical relevance were found. All the professional groups could adequately detect contraindications to chiropractic treatment on radiographs. For this indication, there is no reason to restrict interpretation of radiographs to medical radiologists. Good professional relationships between the professions are recommended to facilitate interprofessional consultation in case of doubt by the chiropractors.

        https://www.researchgate.net/publication/15559811_Interpretation_of_Abnormal_Lumbosacral_Spine_Radiographs

        that the test results of chiropractic radiologists, chiropractic radiology residents, and chiropractic students was significantly higher than that of the corresponding medical categories (general medical radiologists, medical radiology residents, and medical students, respectively); that no significant difference in test results was identified between chiropractic radiologists and skeletal radiologists or between chiropractic and medical clinicians; and that the length of time in practice for clinicians and radiologists was not a significant factor in the test results.

        • @DC

          Now, read my lips please…
          I am not talking about the handful (not more than a few hundred in the US, if I recall correctly) of “chiropractic radiologists”, chiropractors who have taken special interest and training in radiology, I am referring to chiropractors at large in MY part of the world.
          Please note also, that the images used for comparing the diagnostic prowess of the subject groups in the study you refer to (your link is not correctly pointing to the paper ) were selected to contain easily detectable lesions, which even ordinary chiropractors would not miss among the normal plates!
          A sixth grader would probably do as well in selecting the abnormal plates.

          Page 1927:
          A chiropractic
          and medical expert in spinal radiology, neither of whom participated
          in the subsequent film interpretation, checked all the
          “abnormal” radiographs to confirm that the abnormality was
          detectable, and that the quality was sufficient. They also
          checked a random sample of the “normal” radiographs. They
          considered all the “normal” radiographs to be of sufficient to
          good diagnostic quality. If they judged the presence of the presumed
          abnormality to be debatable, the radiograph was excluded.
          Four radiographs were excluded: one because of poor
          quality and three because the diagnosis was not confirmed by
          the chiropractic and medical experts.

          They bloody well tested if the plates were of diagnostic quality, which is not the case in most chiropractic parlours. And they tested beforehand if the lesions were easy to detect. The study subjects had normal plates to compare with as well.

          • Bjorn: “I am referring to chiropractors at large in MY part of the world.”

            OK. I am unware of any research on this specific topic in your region.

          • I am aware of only two studies on this X ray comparison. the one you read and the other which required a diagnosis. Chiropractors faired fairly evenly with their MD counterparts in both studies. Thus; available evidence, at least from the USA, seems to put us about on the same level as MDs/radiologists when he comes reading x rays, at least for the those 21 conditions.

            Of course if you have valid evidence that shows otherwise I will take a look at it.

          • @DC

            I am not a doctor. I am a lay person whose most useful tools are common sense (which is about all it takes to see the nonsense you are selling) and critical thinking.

            When I read your statement that the evidence “seems to put us about on the same level as MDs/radiologists when he comes reading x rays,” I laughed out loud.

            I’m just saying.

          • Ron. That’s what the research paper revealed. Based upon education/training there isn’t much of a difference on identifying those pathology on an x ray. But the paper also showed that its best to have a specialist do the read….be in within or outside ones profession.

  • @DC
    I forgot to mention that your second ref. confirms my point:

    . Furthermore, the study reinforces the need for radiologic specialists to reduce missed diagnoses, misdiagnoses, and medicolegal complications.

    MD´s often have to interpret X-rays pending specialist evaluation but they do not pretend to be radiologists. All plates are required to be double checked by real specialists who sometimes have them re-taken due to quality issues. I am unaware that such quality assurance is more than a rare exception in chiropractic practice. MD´s are reluctant to take unnecessary X-ray studies e.g. in cases of acute, uncomplicated lower back pain. X-ray is mainly a marketing tool in chiropractic practice.

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