Chiropractors often refer their patients for full-length (three- to four-region) radiographs of the spine as part of their clinical assessment, which are frequently completed by radiographers in medical imaging practices. Overuse of spinal radiography by chiropractors has previously been reported and remains a contentious issue.

The purpose of this scoping review was to explore the issues surrounding the utilization of full-length spinal radiography by chiropractors and examine the alignment of this practice with current evidence.

A search of four databases (AMED, EMBASE, MedLine and Scopus) and a hand search of Google was conducted. Articles were screened against an inclusion/exclusion criterion for relevance. Themes and findings were extracted from eligible articles, and evidence was synthesized using a narrative approach.

In total, 25 articles were identified, five major themes were extracted, and subsequent conclusions drawn by authors were charted to identify confluent findings:

  • (1) The historical integration of FLS radiography in chiropractic,
  • (2) Clinical indications for FLS radiography in chiropractic,
  • (3) Risks associated with FLS radiography,
  • (4) Chiropractic techniques which prescribe the use of FLS radiography,
  • (5) Current trends in the utilisation of FLS radiography in chiropractic.

This review identified a paucity of literature addressing this issue and an underrepresentation of relevant perspectives from radiographers. Several issues surrounding the use of full-length spinal radiography by chiropractors were identified and examined, including barriers to the adherence to published guidelines for spinal imaging, an absence of a reporting mechanism for the utilization of spinal radiography in chiropractic and the existence of a spectrum of beliefs amongst chiropractors about the clinical utility and limitations of full-length spinal radiography.

The authors concluded that this review has identified a scarcity of literature addressing the completion of chiropractor‐referred FLS X‐rays. Our review has outlined several pressing issues that warrant further investigation including a lack of quantitative measures to assess the utilisation of FLS X‐rays by chiropractors, a lack of consensus of what constitutes appropriate clinical justification for imaging and the existence of a spectrum of beliefs amongst chiropractic authors about the clinical utility and limitations of FLS radiography. This provides radiographers with a definitive opportunity to demonstrate clinical leadership in this space and seek to begin a constructive dialogue with chiropractic referrers about the risks associated with unnecessary or unjustified spinal radiography. In doing this, diagnostic radiographers as evidence‐based health practitioners can actively contribute to the conversation surrounding the issues identified by this study and can be better positioned to advocate for the interests of the discipline and the safety of their patients.

The authors of this review make a number of further relevant points:

  • Between 2014 and 2015, approximately 130,000 three‐ to four‐region spinal X‐rays were performed in Australia. Most were requested by chiropractors.
  • In Australia, chiropractors often request FLS X‐ray examinations by radiographers.
  • A spectrum of beliefs and knowledge exists amongst chiropractic practitioners surrounding the appropriate use of FLS radiography which may not always align with the principles of evidence‐based practice.
  • The risks associated with the overutilization of diagnostic imaging are well documented. Aside from the inherent risks of unnecessary exposure to ionizing radiation, increased reliance on diagnostic imaging by any practitioner in the absence of sufficient clinical justification increases economic burdens encumbered upon the health care system. As such, FLS radiography should be used judiciously to ensure risks associated with its use are minimized, thus ensuring that it remains available to chiropractors and other practitioners where its use is clinically justified.
  • Imaging that is not clinically indicated also carries a risk of overdiagnosis that being the radiological diagnosis of disease which does not ultimately impact on a patient’s course of treatment.
  • The use of FLS radiography by chiropractors for the detection of red flags in the absence of any significant clinical indications for imaging could be considered a practice that carries a high risk of overdiagnosis.

When I first raised the issue of chiropractic overuse of imaging in 1998, I got fiercely attacked by a gang of chiros. Each time hence that I mention the subject, chiros loudly protest, and I do, of course, understand why. Imaging gives chiros the flair of being ‘cutting edge’; more importantly, in most countries, it is an easy source of additional income.

So, I do not expect that things will be different this time. Yet, I feel that, instead of constantly trying to shoot the messenger, chiropractors might be well advised to consider the message.


22 Responses to The over-use of full-length spinal radiographs by chiropractors

  • agree 100%

    • that makes me feel uncertain: I must be wrong then!

      • indeed this is the case many times 🙂

        • Well, science has been wrong before, that’s true.

          Then again, SCAM has been wrong one hundred percent of the time(*).

          *: And if you beg to differ, please come up with one good example where SCAM turned out to be right, proving science wrong.

          • I fail to see how taking full spine x rays is an attempt to “prove science wrong”.

          • @DC
            Mr Almog suggests that Edzard Ernst (and by extension science) has been wrong many times. And this ‘science was wrong before’ is also a popular trope among proponents of alternative modalities to support the validity of their own claims.

            What these proponents of SCAM usually fail to notice is that they have been wrong even more often – as in: virtually all of the time, and in far more egregious ways, at that.

  • In a timely manner, a rebuttal via a letter to the editor will be submitted that will provide a counter point to the authors conclusions. The LTE will expand on a manuscript published in 2018.

  • Do any of the chirps know the dosage in milliSieverts delivered by FLS films and the risk of malignant transformation per film? Have they been on courses similar to the IRMER ones required in the U.K. by any practitioner who uses or requests radiographic imaging? Do they make a written record of the justification for each film and a written report of the radiographic findings? I use radiography all the time in dental practice and I have to know and do these things.

  • There has been a significant over medicalisation of back pain for years – by many different therapists including Drs / Chiro’s/ Physio’s and others – but we have learnt and have increasingly treated pain (not just back pain) more within the bio-psycho-social model. Greg Lehman who is a chiropractor and physiotherapist and strength and conditioning coach (makes me look lazy) has done some really good work (along with many others such as Lorimore Moseley) in developing a helpful booklet to help people recover from or manage painful conditions once they have been assessed and medically cleared for serious pathology:-

    Thats not to say Imaging is unhelpful and there are guidelines for their use but they have been overused+++ particularly for non-specific spinal pain i.e back pain only with no radicular symptoms. There has been a drive in Britain to develop a more standard pathway across the country for the management of spinal pain which is comprehensive and has input from multiple professionals including chiropractors I believe:-

    Implenting such an ambitious pathway is always difficult and undoing overmedicalisation and unecessary imaging I suspect will take some time. I think you would find broad support from many health care professionals to limit x-rays which are largely unhelpful for most spinal pain unless clinically indicated.

      I was told this stuff at med school some 40 years ago

      • This reminds me of a teacher who once said “don’t throw your jeans out’ :). Likewise been in healthcare a while and seen things come and go. It takes a while but I do believe it’s sinking in. Hope over expectation maybe!

      • right…

        “Clinicians and patients can believe that diagnostic imaging is an important tool for locating the source of non-specific low back pain.”

        • I wouldn’t disagree – patients in particular in my experience (i realise not scientific) often seem to believe this and sometimes its true. However for most back pain a specific diagnosis is not possible hence the term ‘non specific’ but this doesn’t stop clinicians trying largely based on their own bias. Our understanding of back pain and pain has moved on as examplified by this excellent overview.

          It would be ridiculous though to say the bio- components of back pain are unimportant they are just not as important as we thought and some probably very unimportant.

          There are lots of reasons for imaging including clearing pathology, patients beliefs, risk of litigation and sometimes for distress reasons but x-rays for non-specific back pain are largely not recommended. My colleagues who specialise in back pain and can oder imaging (they are not doctors) rarely if ever order them for this diagnosis. There is always the risk of missing something by not imaging its a risk:benefit analysis but over imaging and medicalising non-specific back pain has been seriouly unhelpful to say the least. Hence the drive to reduce their use which is what this article was about.

          • “ However for most back pain a specific diagnosis is not possible hence the term ‘non specific’ ”

            Not really, non-specific back pain means there is not a known pathology. One can have a specific dx within nonspecific back pain. There is a move to abandon the label nonspecific back pain as it is often misinterpreted as meaning idiopathic back pain.

  • Perhaps I missed it but I didn’t read where they actually provided a percentage of how many chiropractors ordered/took full spine x rays and what percentage would be considered inappropriate and what the trend has been.

    Last I heard taking full spine x rays was not part of the clinical protocol at any USA chiropractic college.

  • Readers may recall – though really I know not why they should – fourteen Chiropractic Limericks I hitherto posted here, in an earlier thread, each beginning with the subtitle of Prof. Ernst’s then newly-published book on Chiropractic.

    The muse descended upon me again, though in a somewhat vitiated form, on reading this thread, and another little Limerick popped out. It’s not very great, but I’m too tired to think of anything better:

    Not all that it’s cracked up to be;
    Spinal x-rays irradiate thee
    The tissues inside
    Get entirely fried
    Yet your back is no better, you see?

  • Can you send me some peer reviewed articles supporting the overuse of radiographs?

  • How peremptory!

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