I have long cautioned that chiropractic overuse of X-rays is a safety problem. Is this still an issue? A recent paper was aimed at finding out.
The objective of this review was to determine the diagnostic and therapeutic utility of routine or repeat radiographs (in the absence of red flags) of the cervical, thoracic or lumbar spine for the functional or structural evaluation of the spine. Investigate whether functional or structural findings on repeat radiographs are valid markers of clinically meaningful outcomes. The research objectives required that the researchers determine the validity, diagnostic accuracy and reliability of radiographs for the structural and functional evaluation of the spine.
The investigators searched MEDLINE, CINAHL, and Index to Chiropractic Literature from inception to November 25, 2019. They used rapid review methodology recommended by the World Health Organization. Eligible studies (cross-sectional, case-control, cohort, randomized controlled trials, diagnostic and reliability) were critically appraised. Studies of acceptable quality were included in our synthesis.
Twenty-three papers were critically appraised. No relevant studies assessed the clinical utility of routine or repeat radiographs (in the absence of red flags) of the cervical, thoracic or lumbar spine for the functional or structural evaluation of the spine. No studies investigated whether functional or structural findings on repeat radiographs are valid markers of clinically meaningful outcomes. Nine low risk of bias studies investigated the validity (n = 2) and reliability (n = 8) of routine or repeat radiographs. These studies provided no evidence of clinical utility.
The authors’ conclusions are clear: We found no evidence that the use of routine or repeat radiographs to assess the function or structure of the spine, in the absence of red flags, improves clinical outcomes and benefits patients. Given the inherent risks of ionizing radiation, we recommend that chiropractors do not use radiographs for the routine and repeat evaluation of the structure and function of the spine.
In the paper, the authors provided further valuable information and background:
In the United States in 2010, the rate of spine radiographs within 5 days of presenting to a chiropractor was 204 per 1000 new patients. An analysis of national trends in the United States suggests that the rate of spinal radiography by chiropractors and podiatrists increased by 14.4% between 2003 and 2015. This increase occurred despite the publication of several evidence-based clinical practice guidelines and clinical prediction rules to assist chiropractors in determining the indication for spine radiographs to assist with diagnosing a pathology. Overall, guidelines suggest that radiographs are indicated when signs and symptoms of potentially serious underlying pathology (red flags) are identified through the clinical history and physical examination. However, on its own, an isolated “red flag” may have a high false positive rate for the diagnosis of underlying spinal pathology, such as cancer. For example, the presence of a solitary “red flag” such as age over 50 years may not be sufficient to warrant taking spine radiographs. Therefore, clinicians are encouraged to combine sound clinical judgement and the assessment of red flags when ordering radiographs.
In the absence of “red flags”, the use of spinal radiographs is not recommended. Nevertheless, factions of chiropractors, including the International Chiropractic Association promote the use of routine or repeat radiographs to assess the structure and function of the spine. This practice which dates back to 1910 was initiated when no evidence was available to guide the judicious use of spine radiographs. Historically, these groups of chiropractors have argued that radiographs are helpful to measure postural abnormalities, identify vertebral misalignment or subluxation and guide treatment with spinal manipulative therapy. The belief that radiographs are useful to detect and correct spine structure and function provides the foundation for many chiropractic technique systems that are still in use today. To our knowledge, approximately 23 chiropractic techniques use spine radiography (including full spine radiography) to guide the clinical management of patients. These include the Gonstead, Chiropractic BioPhysics®, Toggle-Recoil, and National Upper Cervical Chiropractic Association (NUCCA) techniques. Proponents of these techniques claim that the use of routine and repeat radiographs is supported by scientific evidence and have published a guideline to assist clinicians with the biomechanical assessment of spinal subluxation in chiropractic clinical practice using radiography. However, these claims have not yet been evaluated for their clinical utility, the benefit a patient gains from a test or treatment. This was a particular concern for the College of Chiropractors of British Columbia (CCBC) which regulates the practice of chiropractic in the province of British Columbia, Canada. The mission of the CCBC is to protect the public by regulating British Columbia’s doctors of chiropractic to ensure safe, qualified and ethical delivery of care.
The references from these two paragraphs can be found in the original paper. One reference the authors did not include was my article of 1998 which, at the time, received plenty of angry responses from chiropractors. Here is its conclusion: DATA SUGGEST AN OVERUSE OF RADIOGRAPHY BY THE CHIROPRACTIC PROFESSION. THIS CONSTITUTES A SAFETY PROBLEM THAT DESERVES TO BE TAKEN SERIOUSLY AND REQUIRES FURTHER RESEARCH.
Twenty-two years later, do I get the impression that the chiropractic profession might not be the fastest in getting its act together?