Should Chiropractic Follow the
American Chiropractic Association
/ American Board of Internal Medicine’s
Recommendations on X-Ray?
By Mark Studin
William J. Owens
In reviewing the American Chiropractic Associations’ (ACA) position on x-ray and adopting the posture of the American Board of Internal Medicine’s (ABIM) initiative, “Choosing Wisely,” regarding x-ray, we must consider both the far-reaching effects of those recommendations as well as the education of the originators of the recommendations. In addition, the ACA in their 2017 published article Five Things Clinicians and Patients Should Question, they state, “The recommendations are not intended to prohibit any particular treatment in all scenarios or to dictate care decisions. They are also not intended to establish coverage decisions or exclusions” (https://www.acatoday.org/Patients-Choosing-Wisely?utm_campaign=sniply).
The ACA, a highly-regarded chiropractic political organization that has done a great deal in advancing the profession, is adopting the ABIM’s current position and regardless of the wording of the policy which, in the form of a disclaimer, is opining and setting precedent that can be used against individual practitioners or the entire profession. Granted, the underlying tone is to prevent unnecessary exposure to ionizing radiation, but at what cost to patient care?
The scientific evidence has shown, and continues to show, chiropractic as being highly effective for managing and treating non-specific or mechanical spine pain. 2-3-4-5-6-7 In this article, we are only considering acute low back pain treatment to meet the scope of the ACA/ABIM policy and are therefore excluding all other conditions treated within the lawful scope of chiropractic. Mechanical spine pain, pain of non-anatomical origin, is defined as spine pain not originating from fracture, tumor, infection or specifically co-related to an anatomical lesion such as degenerative intervertebral disc disease, intervertebral disc bulge or intervertebral disc herniation. The ACA/ABIM states in the absence of “red flags,” imaging should not be considered for at least 6 weeks of care. Some of these “red flags” are clearly present on physical examination, others may not reveal themselves without radiographic evidence.
The definition of red flags by the American Chiropractic Association (2017):
Red flags include history of cancer, fracture or suspected fracture based on clinical history, progressive neurologic symptoms and infection, as well as conditions that potentially preclude a dynamic thrust to the spine, such as osteopenia, osteoporosis, axial spondyloarthritis and tumors. (https://www.acatoday.org/Patients-Choosing-Wisely?utm_campaign=sniply)
When considering the training of internal medicine physicians, we recognize they are focused on the diagnosis and management of systemic disease. However, when considering musculoskeletal diagnosis, basic medical training for internal medicine residency is quite the opposite. Although it is understandable given the current climate of spine pain management in the United States that the American Board of Internal Medicine would take a stance on spine care, I would consider the opinion of an internal medicine board valuable, but less authoritative than a board comprised of practicing spine specialists that is trained in the diagnosis and management of mechanical spine pain with specific treatment designed to deliver high velocity-low amplitude thrusts (chiropractic spinal adjustments). Interestingly, in this specific case, we have a chiropractic political organization agreeing with a medical board that is specifically trained on the diagnosis of internal medicine disorders with little or no training on the management of acute spine pain.
In an article written by Humphreys, Sulkowski, McIntyre, Kasiban, and Patrick (2007), they stated:
In the United States, approximately 10% to 25% of all visits to primary care medical doctors are for MSK [musculoskeletal] complaints, making it one of the most common reasons for consulting a physician...Specifically, it has been estimated that less than 5% of the undergraduate and graduate medical curriculum in the United States and 2.26% in Canadian medical schools is devoted to MSK medicine. (p. 44)
It should be noted that primary care medical doctors are not spine specialists and are generally comprised of family or internal medicine physicians. Medical school is lacking in musculoskeletal education, particularly in spine. Graduate level medical education including residency and fellowship training, only provides spine specialty training in those boards that are focused on spine care, namely orthopedic surgery and neurosurgery. It should also be noted that both orthopedic and neurosurgery disciplines are focused on the anatomical lesion in the spine as a primary method of determining the medical necessity of intervention.
Research has shown musculoskeletal complaints have a major impact on the healthcare system. Many patients believe that traditional medical providers are highly trained in diagnosis and management of musculoskeletal conditions and trust the referrals they provide to physical therapy as the best care path. A recent publication relating to basic competency have shown otherwise.
Humphreys et al. (2007) state:
A study by Childs et al on the physical therapists’ knowledge in managing MSK conditions found that only 21% of students working on their master’s degree in physical therapy and 25% of students working on their doctorate degree in physical therapy achieved a passing mark on the BCE [Basic Competency Examination]. (p. 45)
Humphreys et al. (2007) continued by reporting a comparative analysis:
The typical chiropractic curriculum consists of 4800 hours of education composed of courses in the biological sciences (i.e., anatomy, embryology, histology, microbiology, pathology, laboratory diagnosis, biochemistry, nutrition, and psychology), chiropractic sciences, and clinical sciences (i.e., clinical diagnosis, neurodiagnosis, orthorheumatology, radiology, and psychology). As the diagnosis, treatment, and management of MSK [musculoskeletal] disorders are the primary focus of the undergraduate curriculum as well as future clinical practice, it seems logical that chiropractic graduates should possess competence in basic MSK medicine. The objective of this study was to examine the cognitive (knowledge) competency of final-year chiropractic students in MSK medicine. (p. 45).
The following results were published in the article by Humphreys et al. (2007) relating to the Basic Competency Examination and evaluating the various professions that are on the “front line” in the diagnosis and treatment of musculoskeletal conditions. Passing grades were attained by 22% of recent medical graduates, 20.7% of medical students, residents, and staff physicians, 33% of osteopathic students, 21% of MSc [masters] level physical therapy students, and 26 % of DPT [doctors of physical therapy] level physical therapy and chiropractic student 64.7%…
This indicates, that unless a “boarded internist” goes back for advanced education in physical medicine, neurology, orthopedics or neurosurgery, his/her basic competency is between 20% and 33% (if a DO) at best and it is the guidelines of that profession’s board that are being adopted by the ACA. In addition, no profession, inclusive of the ACA, is discussing the difference between a diagnosis, prognosis or treatment plan for mechanical spine pain. The only discussion is related to anatomical origins and anatomical spinal pathology. They are only considering the “red flags” of non-mechanical spine pain (to the detriment of the patient with mechanical spine pain), which only drives triage to medical specialists and ignores clinically necessary treatment plans focusing on the mechanical sources of pain found within chiropractic clinics globally.
The ACA/ABIM guidelines are very specific to low back pain and refer to the “routine use of imaging,” which is understood to be x-ray as the article uses the term “ionizing imaging.” However, it is not clear if they are also including CAT scan imaging as well. What their suggested “evidence-based recommendations” omits is the diagnosis of spinal biomechanical pathology and the osseous pathology that is discovered because of a complete clinical evaluation inclusive of spinal biomechanics, which ultimately protects our patients with an accurate spinal diagnosis. That consideration is something that board certified internal medicine practitioners do not have to be concerned with as it is outside of their focus of treatment. Typically, internal medicine physicians have less chance of causing harm to their patients in the short-term with a prescription pad (drug abuse is a topic for a different conversation) vs. a high velocity-low amplitude thrust, the primary treatment modality for the doctor of chiropractic. In this specific case it is the specific type of “treatment” that requires a specific level of diagnosis to be safe.
In the process of concluding an accurate diagnosis, prognosis and treatment plan, an assessment of the structural and biomechanical integrity of the spine is integral to specific treatment recommendations and visual assessment often fails.
Fedorak, Ashworth, Marshall and Paull (2003) reported:
This study has shown that the visual assessment of cervical and lumbar lordosis is unreliable. This tool only has fair intrarater reliability and poor interrater reliability. Visual assessment of spinal posture was previously shown to be inaccurate, and this study has demonstrated that is reliability is poor. (p. 1858)
In contrast, the reliability of x-ray in morphology, measurements and biomechanics has been determined accurate and reproducible.10-11-12-13-14-15-16-17-18-19 In addition, Ohara, Miyamoto, Naganawa, Matsumoto and Shimzu (2006) reported, “Assessment of the sagittal alignment of the spine is important in both clinical and research settings… and it is known that the alignment affects the distribution of the load on the intervertebral discs” (p. 2585).
Assessment of distribution or load of spinal biomechanics, if left aberrant, will result in the initiation of the piezoelectric effect and Wolff’s Law remodeling the spine. This is the basis for the subluxation degeneration theory which historically many have scoffed at as it is not considered to be based on scientific principles. We have now verified it based upon the research, and it is now a current and verifiable event that must be taken into consideration when assigning prognosis to a biomechanically flawed spine.
A very recent and timely study by Scheer et al. (2016) takes the biomechanical assessment of the spine to an entirely different level. This concept was originally presented at the 2015 American Academy of Neurosurgery symposium.
Scheer et al. (2016) state:
Several recent studies have demonstrated that regional spinal alignment and pathology can affect other spinal regions. These studies highlight the importance of considering the entire spine when planning for the surgical correction of ASD [adult spinal deformity/scoliosis]. (p. 109)
Scheer et al. (2016) continue:
Furthermore, the cervical spine plays a pivotal role in influencing adjacent and global spinal alignment as compensatory changes occur to maintain horizontal gaze. (p. 109).
Scheer et al. (2016) also wrote:
There has been a shift from the regional view of the spine to a more global perspective, and recent work has found concomitant spinal deformities in patients. Specifically, there is a high prevalence of CD [cervical deformity/loss of cervical lordosis] among adult patients with thoracolumbar spinal deformity. (p. 109).
Finally, according to Scheer et al. (2016):
Concomitant cervical positive sagittal alignment [loss of cervical curve] in adult patients with thoracolumbar deformity is strongly associated with inferior outcomes and failure to reach MCID [minimal clinically important difference] at 2-year follow-up compared with patients without CD [cervical deformity]. (p. 114)
We are seeing that biomechanical assessment is a critical component of spine care and is a trending topic in spine research. These topics are not addressed in the Board of Internal Medicine’s opinions and should be considered strongly prior to any chiropractic advocacy organization taking a position that would give doctors pause when attempting to fully diagnose their patients, no matter the disclaimers.
When it comes to spinal assessment particularly with stress views, Hammouri, Haimes, Simpson, Alqaqa and Grauer (2007) reported, “A survey questionnaire study recently completed by our laboratory confirmed that 43% of practicing spine surgeons also obtain dynamic flexion-extension views in the initial evaluation of those patients” (p. 2361). They later stated, “These findings led to no change in conservative management and no decision to go to surgery based solely from the dynamic flexion-extension radiographs” (p. 2363).
Hammouri et. al. (2007) also discussed the possible cumulative effects of small doses of radiation as another reason to avoid taking flexion-extension x-rays. This has been a position held by practitioners for years despite the evidence that diagnostic ionizing radiation has been proven to be non-carcinogenic. When examining the evidence, Tubiana, Feinendegen, Yang and Karminski (2009) reported:
Several studies in patients after x-ray–based examinations…have not detected any increase in leukemia or solid tumors. The only positive studies were in girls or young women after repeated chest fluoroscopic procedures for chronic tuberculosis…or scoliosis…Among these patients, excess breast cancer was detected only for cumulative doses greater than about 0.5 Gy. No other excess cancer appeared after cumulative doses up to 1 Gy. There was also no increased cancer after cardiac catheterization…
Several studies stressed the risk of cancer after diagnostic irradiation with x-rays by using the LNT [linear no-threshold] model…However, several investigators…have questioned these estimates because of their doubtful assumptions. An overestimate of the diagnostic radiology risk may deprive patients from adequate treatment. (p. 17)
When considering rendering a diagnosis, prognosis and treatment plan, Hammouri et al. (2007) concluded that flexion-extension x-rays are not a determining factor for spinal surgery. However, chiropractic renders disparate treatment compared to surgeons and medical primary care doctors (family practice and internal medicine).
The authors of this current article recently sent a survey to the chiropractic profession and asked a simple question: Does the clinical use of x-rays change either your diagnosis, prognosis or treatment plan? The question was posed with the understanding that “screening purposes” are not considered clinically necessary and all testing and treatment orders must be consistent with a patient’s presentation and physical examination. The results demonstrated that 98.42% of those surveyed, used x-rays in their clinical practices that changed either the diagnosis, prognosis and/or the treatment plan.
The next question was when should an x-ray or any other type of imaging be considered? Clinically, if the patient has pain with limited range of motion in a spinal region upon either visual evaluation or dual inclinometry testing, the clinician should ask why is there biomechanical failure coupled with pain? In the absence of diagnosing anatomical (osseous or any other space occupying lesion) pathology, the aberrant verified biomechanics indicates failure at the connective tissue level (ligaments and tendons) and the mechanical source/rationale of the ensuing nociceptive, mechanoreceptive and proprioceptive neuro-pathological cascade. This in turn allows the practitioner to conclude an accurate diagnosis, prognosis and/or treatment plan based upon the pathological “listings” visualized. As reflected above with the 98.42% response, it is clear that when considering the biomechanical assessment of the human spine, x-ray analysis outside of simple anatomic pathology can change how a doctor of chiropractic manages and treats their patients.
The following is from a small sampling of responses we received from another survey of doctors nationwide. The instructions were to send over examples of how x-ray had changed their diagnoses, prognoses and/or treatment plans within the last 2-3 months. These responses underscored why chiropractors utilize x-ray and often need it to determine accurate mechanical diagnoses, prognoses and treatment plans prior to rendering care. Please note, the clinical protocols presented and x-ray diagnoses are all taught in CCE accredited chiropractic colleges and underscore the quality of a chiropractic education.
Male 70-year old. Presented in my office for 2nd opinion after the prior doctor of chiropractic did not take films. Focal sacral pain unchanged by position or movement. Plain lumbar/pelvic films revealed large radiolucency in sacrum. Patient referred out to MD/oncology for follow up. Diagnosis: Metastatic in nature.
Here is an example of how x-ray helped save a life. I had a patient 6 weeks ago come in with lumbar pain. The patient is 68yr old male with a history of lumbar pain but the pain recently became worse. During the history the patient relayed that they had recently been to their cardiologist for his regular checkup. I completed a thorough physical exam where the only positive findings were limited range of motion with pain in extension and left lateral flexion. I took lumbar x-rays of the patient. While reviewing the x-rays I noticed the outline of an Abdominal Aortic Aneurysm that measured 5cm on my lateral films. I immediately told the patient to go to the emergency room and sent the films with him. The patient stated he did not want to go and he just was at his cardiologist. I insisted and the patient finally listened. The patient had immediate surgery to repair the aneurysm and I received a thank you call from the cardiologist!! More important the patient thanked me for saving his life!!
Abdominal Aortic Aneurysms have a symptom of back pain. I will never touch a patient without being able to x-ray a patient. Who would have been blamed if my patient's aneurysm ruptured??
We had female patient in her thirties present to our office complaining of severe and unrelenting neck pain, with bilateral pain into her shoulders. She did not want an x-ray, however one of the other associates that I worked with convinced her to have two films, AP and lateral cervical. Those films revealed a lyric metastasis of the C5 vertebra, with almost a complete destruction of the vertebral body. Had she been adjusted without the images; the results would have been catastrophic.
54-year old male post MVA, Primary complaint = Low back pain, examination findings revealed positive orthopedic tests in the cervical and lumbar spine with diminished reflexes, upper and lower muscle strength 5/5. Cervical spine x-rays revealed a 3.28 mm anteriorlisthesis of C4 on C5, flexion view revealed an increased displacement to 8.28 mm. Extension view measured 5.48 mm.
Imaging altered treatment plan: Without the x-ray study, the unstable C4 would go undetected and as a result of the x-ray findings the patient was recommended to wear a c-spine collar and have a c-spine MRI. The MRI revealed a 4 x 10 mm left paracentral herniated disc with annular tear compressing the cord by 75% with myelomalacia. It also leaked into the right neural canal compressing the right C4 nerve root. I called my neurosurgeon and he will be in surgery tomorrow. Given the fragmentation of the cord seen on MRI, I shudder to think what would have happened if a high velocity thrust was introduced to his neck!
A patient presented with mild to moderate low back pain. Images revealed a secondary spondylolesthesis and contraindicated in a lumbar side posture. This has happened many times before and once again, prevented me from hurting my patient.
I had a patient that presented with low back pain. The lumbar film showed a 66mm aneurysm. I immediately sent him to the hospital where he was admitted and went into emergency surgery for repair. This could have ended very badly without those x-rays.
36-year old female with acute neck pain, insidious, limited cervical ROM, positive cervical tests, pain worse at night, pain described as "deep, boring, nauseating". AP and lateral cervical x-rays taken in my office revealed complete absence of C5 vertebral body. I immediately referred patient to the local ER with films in hand.
Parents brought their 10-year old son for a second opinion to evaluate a mass on the side of his neck. Their pediatrician had sent them home and told them to check back in 3 days if it didn't resolve. I took AP and lateral cervical films. Both showed the mass but particularly concerning was the AP showed the laryngeal shadow deviated laterally from the pressure of the mass. I told them not to wait 3 days but to go directly to the local emergency department. The local hospital immediately put him in an ambulance and sent him to the children's hospital in Miami. Pediatricians at the children's hospital told the parents the next day, he wouldn't have survived the night had they not taken him to the E.D. on my recommendation, based on the x-ray findings.
I had a 22-year old male present to my office complaining of bilateral low back pain and occasional mild numbness and tingling in his left leg for about 4 years following an injury at wrestling practice when he was 17 years old. Even though the complaints were moderate and his injury was 4 years old, I decided to take lumbar x-rays including oblique views. The x-rays revealed bilateral L3 and L4 pars fractures. I then took lumbar flexion/extension views which revealed a 5mm anterior translation of L4 on L5. His MRI evaluation was unremarkable and without these x-rays there would have seemed to be no contraindication to diversified adjustments including side posture. Had I not taken these x-rays, I would likely have delivered a high velocity thrust into an unstable region of the patient’s spine, potentially injuring him further. Instead, I sent him for an immediate surgical consultation.
Several days ago, a 30-year old female patient presented with a primary complaint of low back pain, neck stiffness and previous diagnosis of ocular migraines by her Neurologist. Radiographs of her Cervical and Lumbar spine were taken to evaluate her spine. A fracture of the vertebral body of C5 was found at the posterior and inferior aspect with an increase in spacing noted at the fracture site on flexion view.
I had a 15-year-old girl present to my office with severe neck pain. She stated that she had no injuries or trauma that she was aware of. She just "woke up with it". The examination revealed that she was not able to turn her head at all -literally zero range of motion in any direction. Something didn't seem right and I decided to take an x-ray. Her X-ray revealed a burst fracture of C1. It turns out that her mother who signed all the consent forms and dropped her off at my office gave her strict instructions not to tell me about the minor fender bender she was in the day before. Also, the daughter explained later that she had landed on the top of her head during volleyball about a year before. After the volleyball accident she had presented to the emergency room but they decided not to take an x-ray and told her she was fine. I sent her to the emergency room. They took an x-ray and sent her home saying there was no fracture. Later the radiologist called her back insisting she return to the hospital immediately. They confirmed the fracture. I think it is quite safe to assume what would've happened if I tried to adjust her.
I had a patient who was having pain in the mid thoracic region between the spine and the scapula. The patient had been to another chiropractor who did not take x-rays, and who did not get good clinical results. I examined and x-rayed the patient. I saw an abnormal mass in the lung field. I sent the patient to a local radiology center and ordered a plain film chest x-ray, the radiologist confirmed a mass in the right lung.
Based upon the literature, radiation is not cumulative and has rendered no evidence of long term effects. Therefore, the doctor of chiropractic must weigh the risk of treating blindly in the presence of clear biomechanical markers. Treating blindly is often done at the expense of our patients and the malpractice carriers, especially in a scenario where little risk exists. Our concern is the adoption of recommendations or guidelines that are deficient in the published and clinical evidence at hand. There also needs to be a larger clinical and academic conversation interprofessionally, to educate organizations like the ABIM and others who access spine patients, where together we can collaboratively, across professional boundaries, devise care paths to better serve society.