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

This recent article is truly remarkable:

There is a faction within the chiropractic profession passionately advocating against the routine use of X-rays in the diagnosis, treatment and management of patients with spinal disorders (aka subluxation). These activists reiterate common false statements such as “there is no evidence” for biomechanical spine assessment by X-ray, “there are no guidelines” supporting routine imaging, and also promulgate the reiterating narrative that “X-rays are dangerous.” These arguments come in the form of recycled allopathic “red flag only” medical guidelines for spine care, opinion pieces and consensus statements. Herein, we review these common arguments and present compelling data refuting such claims. It quickly becomes evident that these statements are false. They are based on cherry-picked medical references and, most importantly, expansive evidence against this narrative continues to be ignored. Factually, there is considerable evidential support for routine use of radiological imaging in chiropractic and manual therapies for 3 main purposes: 1. To assess spinopelvic biomechanical parameters; 2. To screen for relative and absolute contraindications; 3. To reassess a patient’s progress from some forms of spine altering treatments. Finally, and most importantly, we summarize why the long-held notion of carcinogenicity from X-rays is not a valid argument.

Not only is low dose radiation not detrimental, but it also protects us from cancer, according to the authors:

Exposures to low-dose radiation incites multiple and multi-hierarchical biopositive mechanisms that prevent, repair or remove damage caused mostly by endogenous reactive oxygen species (ROS) and H2O2 from aerobic metabolism. Indeed, non-radiogenic (i.e. naturally occurring) molecular damage occurs daily at rates many orders of magnitude greater than the rate of damage caused by low-dose radiation such as diagnostic X-rays. It is estimated that the endogenous genetic damage caused on a daily basis from simply breathing air is about one million times the damage initially resulting from an X-ray. We concur that “it is factually preposterous to have radiophobic cancer concerns from medical X-rays after considering the daily burden of endogenous DNA damage.”

And, of course, radiological imaging makes sense in cases of non-specific back pain due to ‘malalignment’ of the spine:

Pressures to restrict the use of “repeat” (i.e. follow-up) X-rays for assessing patient response to treatment shows a complete disregard for the evidence discussed that definitively illustrates how modern spine rehabilitation techniques and practices successfully re-align the spine and pelvis for a wide variety of presenting subluxation/deformity patterns. The continued anti-X-ray sentiment from “consensus” and opinion within chiropractic needs to stop; it is antithetical to scientific reality and to the practice of contemporary chiropractic practice. We reiterate a quote from the late Michael A. Persinger: “what is happening in recent years is that facts are being defined by consensus. If a group of people think that something is correct, therefore it’s true, and that’s contradictory to science.”

Thus, the authors feel entitled to conclude:

Routine and repeat X-rays in the nonsurgical treatment of patients with spine disorders is an evidence-based clinical practice that is warranted by those that practice spine-altering methods. The evidence supporting such practices is based on definitive evidence supporting the rationale to assess a patient’s spinopelvic parameters for biomechanical diagnosis, to screen for relative and absolute contraindications for specific spine care methods, and to re-assess the spine and postural response to treatment.

The traditional and underlying presumption of the carcinogenicity from X-rays is not a valid notion because the LNT is not valid for low-dose exposures. The ALARA radiation protection principle is obsolete, the threshold for harm is high, low-dose exposures prevent cancers by stimulating and upregulating the body’s innate adaptive protection mechanisms, the TCD concept in invalid, and aged cohort studies assumed to show cancers resulting from previous X-rays are not generalizable to the wider population because they represent populations predisposed to cancers.

Red flags, or suspected serious underlying disease is a valid consideration warranting screening imaging by all spine care providers. We contend, however, that as long as the treating physician or rehabilitation therapist is practicing evidence-based methods, proven to improve spine and postural parameters in order to provide relief for the myriad of spinal disorders, spinal X-rays are unequivocally justified. Non-surgical spine care guidelines need to account for proven and evolving non-surgical methods that are radiographically guided, patient-centered, and competently practiced by those specialty trained in such methods. This is over and above so-called “red flag only” guidelines. The efforts to universally dissuade chiropractors from routine and repeat X-ray imaging is neither scientifically justified nor ethical.

There seems to be just one problem here: the broad consensus is against almost anything these authors claim.

Oh, I almost forgot: this paper was authored and sponsored by CBP NonProfit.

“The mission of Chiropractic BioPhysics® (CBP®) Non-Profit is to provide a research based response to these changing times that is clinically, technically, and philosophically sound. By joining together, we can participate in the redefinition and updating of the chiropractic profession through state of the art spine research efforts. This journey, all of us must take as a Chiropractic health care profession to become the best we can be for the sake of the betterment of patient care. CBP Non-Profit’s efforts focus on corrective Chiropractic care through structural rehabilitation of the spine and posture. Further, CBP Non-Profit, Inc. has in its purpose to fund Chiropractic student scholarships where appropriate as well as donate needed chiropractic equipment to chiropractic colleges; always trying to support chiropractic advancement and education.”

17 Responses to Strong support for routine use of radiological imaging in chiropractic?

  • a little out of date but nonetheless a sound rebuttal of their arguments:

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1839988/

    I don’t suppose it could have anything in the least to do with the fact that chiros make an awful lot of additional profit from taking many unnecessary X-Rays would it? No, of course not – that would be improper. But it must at least count as a conflict of interest…….

    But note among the COI statements at the end of the paper – “D.E.H. teaches spine rehabilitation methods and sells products to physicians for patient care that require radiography for biomechanical analysis.”

    “for a wide variety of presenting subluxation/deformity patterns.” – as ever blind-folded chiros in a dark room looking for a black cat that isn’t there and finding it every time!

    • You do know, when compared to MDs, that overall, DCs are more conservative in choosing to take x rays for back pain.

      • @ DC

        really? I am prepared to be persuaded. What evidence do you have for that statement and how do you define the parameters?
        I had a quick search but couldn’t immediately find any real comparisons but that may reflect my incompetence and lack of time.

        But I would certainly grant that MDs order far too many spine, in particular lower spine X-rays and even further investigations such as MRIs of this region unnecessarily. See below.

        But would your figures include MDs seeing patients in the ER? This would appear to be a particular problem as people are being seen by doctors who are perhaps not as experienced or confident with dismissing LBP without any investigation, who are in a rush, patients having higher expectations that an X_Ray will be done (and it takes much longer to explain why one isn’t necessary or useful than just to order one) and there is no continuity of care.
        This is a very different situation from that of a chiropractor – especially as they are meant to be back specialists after all.

        One of the perils of MDs over-investigating back pain is the amount of back surgery that is undertaken as a result which is undoubtedly increasing and much of which is of dubious benefit.

        It is heartening to see that there are campaigns in both camps attempting to persuade practitioners only to X-ray or further investigate when “red flags” are present or symptoms persist for longer than six weeks unabated for example.

        But during my searches I never came across a site or a paper from any MDs promoting the idea that MORE X-rays were a good idea or that they were a prerequisite for starting treatment of any kind. There were however dozens of papers and websites from chiros with this point of view.
        I accept that is not a scientific analysis but there does seem to be this strong section of the profession who are wedded to the idea that X-rays are part and parcel of the deal, and that means whole spine and repeat analyses.

        I think there are inherent problems with any system, such as that in the US, that rewards fee for item or service – because even with the most moral or altruistic outlook it is difficult not to believe that intervention for profit must have some influence. Back surgeons must believe that back surgery works better than no surgery.
        In the UK there is no such incentive on the NHS and it is easier to believe that an opinion is not influenced by such motives however unintentional.

        As mentioned, one of the authors of the paper is flogging devices that requires X-rays to be taken beforehand – so there is an inherent incentive to flog both the X-ray and the device. It is human nature to believe the sales patter when it is going to benefit one’s bottom line. Advertising works after all. Even scrupulous chiros may be persuaded. The unscrupulous ones ………

        Here are some interesting viewpoints:

        https://www1.health.gov.au/internet/main/publishing.nsf/Content/MBSR-reducing-unnecessary-spinal-x-rays

        https://link.springer.com/article/10.1186/s12998-018-0217-8

        https://www.radiologybusiness.com/topics/quality/emergency-radiologists-back-pain-imaging

        https://www.acpjournals.org/doi/10.7326/0003-4819-154-3-201102010-00008

        https://www.sciencedirect.com/science/article/pii/S2214031X18300883

        https://chiromt.biomedcentral.com/articles/10.1186/s12998-020-00323-8

        • @John Travis
          Your first reference is to the Australia.
          Interesting times for chiro’s and full spine xrays here and a timeline of events is illuminating.
          With the advent of digital radiology, medical radiologists realized that chiro’s were taking xrays so they approached the chiro’s to sent them the xrays for a medical report. The radiologists are paid for the report and NOT the actual taking of the xrays.
          The $160 for the report covers the costs of taking the xrays.
          So the radiologists told the chiro’s send us your xrays and we will pay you $100 to cover your costs for taking the xrays and we will keep $60 for the report. The good times rolled and the xrays flowed in.
          The government was slow but finally clamped down and said they would not pay for the radiologists report if the radiographers provider number on the report was a chiropractic radiographers.
          So the radiologists sent their own radiographers into the chiropractors practices to take the xrays and then paid “rent” to the chiropractors for the facilities.
          The good times continued to roll.
          The government saw the high proportion of full spinals being referred by chiropractors and warned the chiropractic profession. Did they audit the chiropractors and radiologists who were generating the bulk of the full spine xrays and place restrictions on them? Unfortunately no.
          The whole chiropractic profession had three regions taken off us and we can now only refer for two regions at a time.
          So what did the medical radiologists then do?
          Reprinted their referral pads to include a tick box “Chiropracctic xrays”.
          They now take three regions but only bill two regions to Medicare (public health).
          And the good times continue to roll.
          Frustrating as research has shown that over utilization of imaging leads to a poorer prognosis.

  • I have gone up against these folks several times.

    Based upon my reading, Chiropractic BioPhysics® can, with their research, claim two things (kind of three).

    1. Patients can be repeatedly repositioned for x rays.

    2. They can change the structural alignment of the spine (up to a year or so)

    3. Their approach is better than a fragmented PT approach for a couple of conditions.

    If i recall, around 1-2% of the profession use this Technique.

  • Hormesis is widely debated and there are arguments on both sides in the radiation community.
    There is no argument that an upper limit of exposure should not b breached.

    It is preposterous to advocate unlimited X-ray exposure.

    • JimR,

      There is no upper limit to medical x-ray exposure, at least in the UK (total body irradiation is still sometimes used for treating certain sorts of malignancies to a dose that would be fatal without bone marrow or stem cell rescue). However, the principle is that all exposures have to be kept “as low as reasonably achievable”, any medical exposure needs to be justified and signed off by a doctor who has undergone radiation protection training.

      Just to put this into perspective, the maximum radiation dose that members of the general public (including non-classified radiation workers such as those involved in radiotherapy) is 15 mSv (millisieverts) per year. The average background radiation dose (from cosmic rays, radon gas and other natural sources) is about 3 mSv per year, though there are places where it is much higher, either because of altitude (the atmosphere stops most cosmic rays) or because of radioactivity in the ground. There is also radiation exposure due to human activities such as mining and burning coal (the small amount of radioactive material in coal collectively amounts to a great deal more than the total released as a result of nuclear power), and long-haul flights in a commercial airliner (the cruising altitude is 30,000 – 40,000 feet; the dose received depends on the route and on solar activity but for a single leg is generally equivalent to a bit less than a chest x-ray and occasionally much more).

      Dose limits are based on the risk of additional cancers as a result of the radiation exposure and a risk of one fatal cancer per 20,000 dose years is considered acceptable for classified radiation workers (this is much safer than other hazardous occupations such as mining). This has resulted in a limit being set of 50 mSv per year, though I think this is now out of date.

      By comparison, a chest x-ray typically gives a dose of 0.1 mSv, a single spinal x-ray of 1.5 mSv and a CT scan of the abdomen and pelvis of 10 mSv, though these doses depend on the technique used and the age and design of the equipment. Undoubtedly some cancers occur as a result of this, though the risk to the individual is very small, and since about 1 in 3 people will develop cancer anyway it is hard to detect an excess. Certain individuals (e.g. children and pregnant women) and certain tissues (e.g. developing breasts in a teenage girl) are much more sensitive to the carcinogenic effects of radiation.

      I don’t know what a typical chiropractic spinal study involves, but from what I have heard they often request whole spine x-rays (i.e. cervical, thoracic and lubosacral, which means three sites), and lateral as well as anteroposterior views. This is a minimum of 6 x-rays, and if images are requested in different postures (e.g. flexion and extension) this could double, which brings the total dose to a level comparable to the highest-dose form of CT scan and well over the permitted annual dose for non-medical exposure.

      I am not convinced that chiropractors are very good at reading x-rays, apart from being able to find the subluxations that are invisible to radiologists (who in any case use the term to refer to something different). Certainly the ones that I have dealt with have missed obvious spinal tumours.

      • Not a lot of research on this, but at least one study found that chiropractors are equivalent to their medical counterpart.

        Thus, the average chiropractor is just as good, or bad, as a PCP, at least per study criteria.

        I can hunt down the reference upon request.

  • We all know that the only way for chiropractors to “update the chiropractic profession” is for chiropractors to qualify as MDs.
    Most do not bother to do this (do any?) – and yet they wonder why the medical profession wants little to do with them.
    Sigh.

  • I’ve been blocked by Deed Harrison for questioning his faith/CBP(tm).
    I recommend reading some of Hazel Jenkins papers here:
    https://www.researchgate.net/profile/Hazel-Jenkins
    A group of Chiro PhD’s also replied to Deed Harrison(tm) in this journal in the past. See here:
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6311565/
    “Given the above, we request that the editors of Dose-Response retract the commentary in question immediately.”
    Instead the editors of the journal Dose Response published the rubbish that Edzard cites in this blog.
    Odd that Deed uses Dose Response to publish much of his tripe. Wonder if there is a connection to the journal?
    Chiropractors have also responded here:
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7346665/
    And here:
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7812732/

    The researchers are also calling out the vitalistic chiropractors here:
    https://chiromt.biomedcentral.com/articles/10.1186/s12998-021-00362-9
    And fired shots across the subluxation bow here:
    https://chiromt.biomedcentral.com/articles/10.1186/s12998-020-00342-5
    These two articles question the regulators, educators and insurers. Now that the blood is in the water hopefully it will lead to vitalistic chiropractors becoming uninsurable, unable to be registered and their colleges unable to get accreditation.
    They may need to rebrand as spinologists and go the way of Reggie Gold.

    It stands to reason that Deed would write the commentary that Edzard cites in his blog as Deed’s whole business model ™ relies upon it.

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