SIB #469- Revisiting Radiography- Guidelines for Chiropractors

The Study: Radiography and Clinical Decision-Making in Chiropractic

Overview: This paper is a narrative overview and synthesis of the evidence surrounding the use of radiography in chiropractic practice. The authors discuss the development of current guidelines and offer suggestions for improved interpretation of the clinical evidence in the light of differences between the practice of chiropractic and medicine.

 NOTE: The authors emphasize that this discussion applies to chiropractic radiography as it pertains to adults only.

 Key Points:  

·        Current guidelines recommend against radiographic imaging as long as there are no “red flags” (e.g. dislocation, infection, fractures, pathology or prolonged steroid use).  

·        The logic for these guidelines is two-fold, 1) that red flag conditions are fairly uncommon in patients presenting with spinal pain and  2) severe adverse reactions associated with spinal manipulation are extremely rare.  

·        Current guidelines are based on a decades old, “Linear-No-Threshold” (LNT) assumption which holds that all radiation is harmful regardless of how low the dose. 

·        The problem is that current guidelines may well restrict the diagnostic information chiropractic clinicians can gather on patients prior to manual therapy “leading to actual risks far greater than the hypothetical carcinogenic risk purportedly avoided.” 

·        This has been an area of some controversy and the validity of the LNT hypothesis has been repeatedly questioned in the scientific literature. 

·        Additionally, other guidelines (ICA and Practice Chiropractors Committee on Radiology Protocol/PCCRP) support the use of radiography for the assessment of spinal biomechanics and other health concerns relevant to the practice of chiropractic. 

·        The radiation dosages from typical spinal radiographs used in the chiropractic practice are so low they “are not statistically different from zero”.  

·        Our profession’s adherence to the red flag approach and the outdated LNT hypothesis “tends to promote radiophobia while ignoring the myriad benefits of imaging” and may well have the effect of actually increasing risk to our patients.  

·        The practice of chiropractic and the use of spinal manipulation is dramatically different than that of general medicine which may often only prescribe a medication. 

Author’s Conclusions: “Guidelines including current research that reflect a balanced risk assessment of diagnostic radiography, not based on the LNT assumption, would more appropriately inform practicing chiropractors.” 

Reviewer's Comments:  Current guidelines discourage the use of radiography  in the chiropractic practice unless there are red flags such as “degenerative changes, instabilities, soft tissue injuries, fractures and pathologies”, most of which cannot be detected without the use of radiography. Just think about that for a minute. 

One of the coauthors on this study, Roger R. Coleman DC is the Director of Research for the Gonstead  Clinical Studies Society, and has been a contributor to the Science In Brief since we started. His help has been invaluable. Kudos to the Gonstead organization for a great paper which gives us timely look at an important topic for all chiropractors.  MRP 

Reviewer:  Mark R. Payne DC 

Editor: Roger R. Coleman DC 

Reference: Mark A. Lopes, Roger R. Coleman, and Edward J. Cremata. Radiography and Clinical Decision-Making in Chiropractic.  J. Dose Response. Oct 1, 2021 

Link To Full Text: https://journals.sagepub.com/doi/pdf/10.1177/15593258211044844