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

The over-use of X-ray diagnostics by chiropractors has been the topic of previous posts, e.g.:

The authors of this review state that many clinicians use radiological imaging in efforts to locate and diagnose the cause of their patient’s pain, relying on X-rays as a leading tool in clinical evaluation. This is fundamentally flawed because an X-ray represents a “snapshot” of the structural appearance of the spine and gives no indication of the current function of the spine. The health and well-being of any system, including the spinal motion segments, depend on the inter-relationship between structure and function. Pain, tissue damage, and injury are not always directly correlated. Due to such a high incidence of abnormalities found in asymptomatic patients, the diagnostic validity of X-rays can be questioned, especially when used in isolation of history and/or proper clinical assessment. The utility of routine X-rays is, therefore, questionable. One may posit that their application promotes overdiagnosis, and unvalidated treatment of X-ray findings (such as changes in postural curvature), which may mislead patients into believing these changes are directly responsible for their pain. A substantial amount of research has shown that there is no association between pain and reversed cervical curves. Accuracy can also be questioned, as X-ray measurements can vary based on the patient’s standing position, which research shows is influenced by an overwhelming number of factors, such as patient positioning, patient physical and morphological changes over time, doctor interreliability, stress, pain, the patient’s previous night’s sleep or physical activity, hydration, and/or emotional state. Furthermore, research has concluded that strong evidence links various potential harms with routine, repeated X-rays, such as altered treatment procedures, overdiagnosis, radiation exposure, and unnecessary costs. Over the past two decades, medical boards and health associations worldwide have made a substantial effort to communicate better “when” imaging is required, with most education around reducing radiographic imaging. In this review, we describe concerns relating to the high-frequency, routine use of spinal X-rays in the primary care setting for spine-related pain in the absence of red-flag clinical signs.

Many chiropractors over-use X-rays (not least because it is a significant source of income) and claim to be able diagnose subluxations with X-ray diagnostics. The authors of the review state are unimpressed by this habit:

Spinal X-rays can lead to the detection of radiographic findings that can be used as an overdiagnosis for the patient, even though they may be asymptomatic. These include spinal anomalies, osteophytes, reduced disc heights, low-grade spondylolisthesis, transitional segments, and spina bifida occulta. The chiropractor can use all radiographic findings as “scare tactics” or “fear-mongering” to retain a patient under a specific frequency of care, thus creating unnecessary concern for the patient. Multiple studies have concluded that radiographic findings do not always correlate with a patient’s symptomatology. Brinjikji et al. (2015) concluded that disc degeneration was present in asymptomatic individuals, ranging from 37% in 20 year olds to 96% in 80 year olds.

Many chiropractors use “phases of degeneration” as a method of communication in order for patients to adhere to excessive treatment plans. It is unnecessary and unethical to scare patients to obtain compliance with chiropractic care. These “scare tactics” can negatively influence patients’ behavior, especially those who already experience reduced levels of self-efficacy. This unnecessary use of communication can cause negative thoughts, leading to fear of avoidance of physical activity and management advice as there is a concern for further damage. In addition, the likelihood that a patient will experience chronic pain may arise due to the belief that they won’t get better until the radiographic findings are resolved.

Vertebral subluxation is a term and condition created by chiropractors that refers to misalignment of the vertebra, a bone out of place, causing pressure on the spinal nerve and interference with mental impulses. Subluxation is a legitimate medical condition; however, this completely differs from the condition used by chiropractors. Over the years, there have been numerous definitions and takes on what “vertebral subluxation” is – even though the term and concept date back to 1902, it is still commonly used in the chiropractic community. It has been described that the misalignment of the vertebra causes occlusion of where the spinal nerve travels, thus causing nerve pressure and disrupting the “mental impulse,” which is part “intelligence,” a synonym for “spirit” and part of the “mental realm,” and part neural impulse; which is part of the physical realm. Many chiropractors believe that when bones press on nerves, the corresponding organ on the other end of the nerve will suffer disease. At this point, it appears more like religion; however, it is crucial that we include this as many clinicians use this “condition” as grounds to order unnecessary radiographic imaging. Extensive medical research has shown that bones do not slip out of place, squishing nerves causing various and different pathologies – and there is certainly no way to scientifically prove the interference of a “spirit” or life force. Nonetheless, none of this is grounds for ordering an X-ray and does not qualify as any type of “red flag,” raising concern about how and when chiropractors are using radiographic imaging.

The authors conclude that the importance of medical imaging cannot be overstated. Medical professionals, on the other hand, must adhere to ethical and responsible standards. These guidelines may be ambiguous in some situations, professions, and countries, resulting in many gray areas of practice. As discussed in this review, the ongoing justification many use to justify the excessive, repetitive, and ongoing use of X-rays for reasons that research does not support is highly concerning. This article highlights potential unvalidated practices within the chiropractic field relating to poor utility imaging.

 

29 Responses to Chiropractors’ profitable over-use of X-ray diagnostics: “scare tactics” and “fear-mongering”

  • Chiros will use anything to try to find the non-existent chiro subluxation. Unfortunately, for them, it will never be found.

    Sadly, for the few rational among us, this delusional will infect the feeble-minded and will continue.

  • There is also the question of radiation safety for patients and compliance with existing medical exposure regulations by chiropractors.
    In 2022, CQC carried out inspections to services run by chiropractors using radiography registered with the General Chiropractic Council (https://www.cqc.org.uk/publications/irmer-annual-report/2021-2022/themed-inspection-programmes/chiropractic-inspections). Their summary stated ‘In general, compliance with IR(ME)R was poor. The first 2 inspections resulted in Improvement Notices. These required the employers to appoint a medical physics expert and/or to adopt diagnostic reference levels.’. I am not aware of any further activity or response from the GCC.
    In my view, all chiropractors and clinics must be subject to the Health and Social Care Act 2008 and require registration with CQC.

    • True
      There is an urgent need for strict guidlines and regulation

    • We dentists have to record written justification of each radiograph we take and do a written report on it in the patient’s records. We have to be compliant with IR(ME)R, do regular courses to stay updated (with full records kept), have all equipment registered with PHE, have said equipment tested and serviced annually and have an named radiation protection supervisor appointed, all of which has to be recorded in a Radiation Protection file.

      How the CQC would look upon the bonecrackers’ spurious justifications for taking radiographs would be interesting.

  • The author doesn’t do a very good job presenting the actual problem. Just saying “factions” and “many” is pretty vague.

  • I know a lot of people who got better after an X-Ray of their spine!

    😀

    • In my 22 years of practice I have not taken one x ray (but I have referred out). I have never owned an operational x ray machine. I have never charged extra for an x ray (the hospital bills insurance/patient). Approximately 10% of my patients get imaging after seeing me. And I still have a lot of people who get better. Go figure.

      • And I still have a lot of people who get better. Go figure.

        That’s one of the things that controlled trials control for.

      • ‘DC’: I have never owned an operational x ray machine.

        However, owning a non-operational X‑ray machine can serve as a useful theatrical prop:

        John Badanes: Do YOU have an x-ray machine in your office?

        ‘DC’: Yes and no. A x ray machine came with the practice I bought but I have never used it.

        Chiropractic neck manipulations can damage your eyes
        Published Wednesday 29 August 2018

        • sorry Pete, it was dismantled a few years back and sold for scrap metal. The prior owner disconnected it years prior as it was costly too much to maintain it.

      • Do you refer your patients who need imaging to a board certified Chiropractic Radiologist? Why or why not?

        Chiropractic radiologists are also concerned with imaging technology including image production, demonstration of normal and abnormal anatomy, and the interaction of energy and matter. Advancement in the technological facets of radiology is so rapid that only qualified radiologists can reasonably be expected to maintain the high level of proficiency required to supervise and interpret these procedures. The practice of radiology continuously involves the application of this technology to patient imaging and treatment. It is now well recognized that chiropractic radiology includes, but is not limited to, plain film radiography, fluoroscopy, tomography, ultrasonography, radioisotope imaging, computed tomography, digital radiography, and magnetic resonance imaging. Individual practices may vary by intent, licensure, and scope of practice laws.

        https://www.acbr.org

        • I have a local medical radiologist do the reads. It’s handy and he does a good job.

          • It is interesting that you use a medical radiologist. I’d think sending your patients to a Chiropractic Radiologist would be more aligned with what you do: https://liachiro.com/why-does-my-radiology-report-say-normal-but-my-chiropractor-says-theres-a-problem-qa-1/

            In light of the above article, do you follow the diagnosis of your medical radiologist or do make your own diagnosis that may be different from that of medical radiologist’s?

            In the past, I remember you mentioning that you primarily deal with MSK issues. Yet you only send 10% of your patients to a radiologist. With the other 90% of your patients, how do you make your diagnosis without looking at imaging, bearing in mind that most of them are coming to you with MSK problems?

          • History and clinical tests

          • History and clinical tests

            Flying blind then…

            You didn’t answer my first question. Here it is again..

            In light of the above article, do you follow the diagnosis of your medical radiologist or do make your own diagnosis that may be different from that of medical radiologist’s

          • I’ve never disagreed with his interpretation of imaging.

          • As usual, Mr Thompson answers questions that were not asked.

            The question was not:

            Do you always agree with your radiologist’s “interpretation of imaging” [sic]?

            Because, obviously, Mr Thompson is not qualified to either agree or disagree with a medical radiologist’s “interpretation of imaging”.

            The question was:

            In light of the above article,

            do you follow the diagnosis of your medical radiologist

            OR

            do you make your own diagnosis that may be different from that of your medical radiologist?

          • Pete, I know you need help, so:

            Talker: do you follow the diagnosis of your medical radiologist

            Me: yes, but since 3-5% of x ray reports contain errors, I don’t blindly “follow” any radiologists.

          • I don’t blindly “follow” any radiologists.

            Red herring. Nobody claimed, implied or expected that you blindly follow your medical radiologist.

    • Going a bit off-topic:

      Since there is much mention of the 80th anniversary of the D-Day Normandy landings, I might mention that my late father was in the Royal Engineers, and was wounded there (“Bullet wounds, skull and brain” as his military pension note succinctly says).

      He underwent some two years of various treatments which he later wrote down on a sheet of writing paper that I’ve got. On 12th March 1946 he had something called “Deep X-Ray Treatment”. I found a 1947 BMJ article about this – it seems it was thought to speed up tissue recovery.

      He also records spending almost 4 months in a Plaster Jacket – a treatment that is shown in the moving docu-drama “The Best of Men”, about Ludwig Guttman. 4 months!

  • Today, just a day after this chiropractic post appeared, I attended a health fair – one of those expos that has homeopaths, acupuncturists, chiropractors & other questionable sorts mixed in with legitimate healthcare providers. The average attendee, of course, has no way of distinguishing between mainstream health professionals & quacks so everyone assumes that all exhibitors are on the up-and-up.

    One chiro booth offered several specialties, including child abuse – er, um, I should say pediatrics. They cite 10 reasons for subjecting kids to their services:

    1. To promote proper development and growth of a child’s body.
    2. To encourage adequate neural plasticity through the proper brain and nerve development.
    3. To help strengthen a child’s immune system – leading to fewer colds, coughs, earaches, sick days, and general illnesses.
    4. To help resolve breastfeeding issues, ear infections, colic, reflux, constipation, and many more.
    5. To aid in better concentration and capacity to learn.
    6. To promote proper brain and nerve communication throughout the entire body.
    7. To improve the child’s posture, the overall structure of the body, and balance throughout the body.
    8. To support digestive strength and aid in digestive issues.
    9. To reduce sleep issues and other issues with sleep disturbances and bedwetting.
    10 To allow the child’s Nervous System to function at its optimal potential so they stay healthy and that organs and other systems function at a greater level.

    Classic chiroquackery, anyone???

  • As no LTE is accepted by this journal, Chris Colloca, Paul Oakley, Joe Betz, Jason Haas and Deed Harrison are currently writing a detailed “counter’ Narrative Review. They are confident to get it published sometime soon and somewhere appropriate, so an opposing published viewpoint will be tagged to this article.

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