The Legal and Appropriate Use of X-Ray in Chiropractic
To Consider the American Chiropractic Association's “Choose Wisely” X-Ray Recommendations is a Potential Public Risk
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NOTE: After the references is visual evidence of why x-ray should not be limited in chiropractic
Let’s be very clear on who determines the appropriateness and necessity of chiropractic clinical practice including x-ray, it is the state licensure boards of Alabama, Alaska, Arizona, Arkansas, California and all the rest to the 50th state alphabetically through Wyoming. These authors are perplexed as to why a political organization, the American Chiropractic Association (ACA), has deliberately inserted itself between the practicing doctor of chiropractic and their individual state licensure boards which has quickly delivered its negative effects by limiting the diagnostic tools and reimbursement of chiropractors nationally. Additionally, instead of working towards and supporting increased access to chiropractic care they are consuming limited financial and personnel resources and those of other political organizations by pushing an agenda crafted by a distinct minority of the profession. This is despite our state licensure boards laws and regulations that already regulate the appropriate utilization of x-ray in chiropractic.
To think that this doesn’t have a far-reaching negative effect on your practice and reimbursement is Pollyannaish, as these authors predicted in their 2017 article “Should Chiropractic Follow the American Chiropractic Association/American Board of Internal Medicine’s Recommendation on X-Ray? (1), because it has already happened and will continue to happen. To further outline the gravity of the issue and lend objective evidence that the American Chiropractic Association is now cause for limitation of your services and reimbursement, ACA President R. Ray Tuck in an official ACA capacity, wrote to Blue Cross Blue Shield of Illinois the following letter on July 31, 2018:
“I write to you on behalf of the American Chiropractic Association ("ACA") in connection with the above-referenced coverage policy recently adopted by your company. We note that the coverage policy references a "Choosing Wisely" article entitled ‘Five Things Physicians and Patients Should Question and utilizes portions of the article as coverage standards.
Permit me to bring to your attention the following disclaimer appearing on the ‘Choosing Wisely’ web page:
‘Note: Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is an appropriate and necessary treatment. As each patient situation is unique, providers and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.’ (emphasis added)
Conveying information not intended or designed to be coverage standards as such, while at the same time attributing such standards to this association, conveys an unfair and false impression. This action also, in our view, constitutes a violation of the Illinois Unfair Claims Practices Act by knowingly misrepresenting relevant facts relating to coverage issues (215 ILCS 5/154.6(a)).
We, therefore, would request your company's immediate attention to this matter and the withdrawal of all coverage standards derived from the ‘Choosing Wisely’ article from the Chiropractic Services coverage policy.”
To review the American Chiropractic Association’s Choosing Wisely guidelines that were released in 2017, especially in regard to how they relate to imaging our patients in a clinical setting, they state “Do not obtain spinal imaging for patients with acute low-back pain during the six (6) weeks after onset in the absence of red flags.” (2) This controversial recommendation was adopted in conjunction with the American Board of Internal Medicine (ABIM) Foundation and Consumer Reports.
The ACA has continued to support their position by writing articles in support of their own internal decision. Christine Goertz DC, Ph.D. wrote in an article titled Choosing Wisely X-ray Recommendations Reflect Evolving Evidence, Accepted Standards: “This recommendation is not only on ACA’s Choosing Wisely® list; a similar item is also included on the lists of seven other organizations. This includes, among others, the American College of Emergency Physicians, the North American Spine Society and the American College of Physicians. It's also one of the performance measures established by the Centers for Medicare and Medicaid (CMS) under the MIPS Program. Thus, it is a widely accepted standard.” It should be noted, while the three groups that Dr. Goertz cited above, the American College of Emergency Physicians, the North American Spine Society and the American College of Physicians, are all held in high regard, we have to examine this fact at a deeper academic level. Regarding the North American Spine Society, their recommendations specifically state they “Do not recommend advanced imaging (MRI) of the spine within the first six weeks in patients with non-specific acute low back pain in the absence of red flags.” Their recommendations do not include x-ray. (3)The American College of Physicians, as an organization, represent internal medicine physicians and while we recognize they are focused on the diagnosis and management of systemic disease, they do not have advanced training in musculoskeletal or biomechanical spine diagnosis and are not trained as spine specialists.
Dr. John Edwards, a neurosurgeon from Provo, Utah wrote:
December 1, 2018
Dear Dr. Studin,
I would like to commend you for the work you have done to integrate chiropractic into higher education, medical research, and the medical community.
Over the past few years in my neurosurgical practice, I have understood more and more the value of biomechanical testing and treatment as the foundation for spinal care. I have discovered what you have known for years-biomechanical failures in the spine do not respond nearly as well to narcotics, steroids, injections, and surgery, as they do to chiropractic spinal adjusting.
Plain x-ray of the spine is the foundation of biomechanical diagnosing and biomechanical treatment, and supplemented with MRI as needed, enables the chiropractor as a primary spinal provider to triage patient care and initiate treatment as clinically indicated.
I think it is appropriate for the American Board of Internal Medicine to limit the frequency with which their providers are ordering diagnostic spinal tests, but inappropriate to hold this same standard to chiropractors. Internists generally know little about how to diagnose and treat spinal conditions. However, as a well-trained chiropractor, you understand when to order these tests. You can interpret them. You have validated, low cost, low-risk interventions that you can implement for treatment.
I hope the biomechanically trained chiropractor will be valued, validated, and viewed as the most important primary care spinal provider in the future. In our low access, high cost, high-risk health care system, the high access, low cost, low-risk management chiropractors can provide should be embraced by the entire medical community.
Although state licensure boards have spoken loudly in their historical support of doctors of chiropractic having the right to take x-rays within their lawful scope of practice, let’s examine the list of other organizations that have no such x-ray recommendation like the ACA has adopted. These groups are arguably in a better position to provide recommendations as they relate to and represent doctors with advanced training in spinal care and diagnosis. This list includes the American Academy of Orthopedic Surgeons, the American Academy of Physical Medicine and Rehabilitation, the North American Spine Society, the American College of Radiology, the American College of Surgeons, the American Medical Society for Sports Medicine, the American Society for Clinical Pathology, and the American Society of Clinical Oncology. These organizations have far more experience when dealing with x-rays and how they relate to treating patients for spine pain particularly in the diagnosis of spinal disorders. The ACA should have consulted with these groups before providing their recommendations for the Choosing Wisely program. Instead they sided with organizations consisting of non-spine specialties while choosing to ignore those with advanced training.
Plain film radiographs are clinically indicated to both asses anatomical (space occupying lesion, fracture, tumor or infection) and biomechanical pathology directed by thorough clinical evaluation. In the absence of an anatomical source of pathology and spine pain, associated it is critical that aberrant biomechanical motion is assessed. These paradoxical biomechanical diagnoses indicate failure of the surrounding spinal ligaments and/or tendons demonstrating the mechanical source of the ensuing nociceptive, mechanoreceptive and proprioceptive neuropathological cascade. 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 intra-rater 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.” (4). In contrast, the reliability of x-ray in morphology, measurements, and biomechanics has been determined accurate and reproducible. Additionally, 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”(5)
In a recent informal survey of 400 doctors of chiropractic nationally returning 152 responses asking “Does the clinical use of x-rays changes either your diagnosis, prognosis or treatment plan?” Out of 152 respondents, 98.42% of those surveyed, used x-rays in their clinical practices that changed either the diagnosis, prognosis and/or treatment plan for their patients. X-rays, and being able to visualize the biomechanical pathology in the absence of anatomical pathology, is vital to the chiropractic physician and the outcomes of their patients.
Some organizations, such as the American Association of Neurological Surgeons, have published recommendations stating, “Do not obtain spinal imaging for patients with acute “non-specific” low-back pain during the six (6) weeks after onset in the absence of red flags.” (6) Let us examine the term non-specific low back pain and how it relates to the clinical assessment of other professions outside chiropractic. Non-specific low back pain is low back pain without a known anatomical cause, meaning without structural pathology. Simply because there is no anatomical pathology present doesn’t mean the pain is “non-specific.” Doctors of chiropractic have long known the cause of non-specific low back pain, it has gone by various names, neuro-biomechanical lesions, biomechanical lesions, subluxation, vertebral subluxation complex, and spinal fixation.
Gedin et. Al (2018) reported, “it has been estimated that the vast majority of back pain cases is of non-specific origin. (7) The concept of simply focusing on the anatomical component of spine pain patients would render chiropractic no different than any other health profession. When focusing on the “non-specific” nature of spine pain, the focus must be on the biomechanical pathological component since the anatomical correlation is missing or does not correlate. The direction of care should be to the biomechanical compensation and individual motor units of the spine with a particular focus on spinal function and balance. Previous literature has verified that the supposition that “non-specific” is synonymous with “unobjectifiable” is erroneous since definite biomechanical changes in the motor units of the spine cause alterations of spinal balance, therefore resulting in “very specific” biomechanical pathology causing pain syndromes.
Panjabi in 1992, who had led the laboratory-based research into biomechanical spine pain, presented a detailed work explaining how the biomechanical systems within the human spine react to the external environment, how it can become dysfunctional and cause pain. He stated “Presented here is the conceptual basis for the assertion that the spinal stabilizing system consists of three subsystems, the vertebrae, discs, and ligaments constitute the passive subsystem, all muscles and tendons surrounding the spinal column that can apply forces to the spinal column constitute the active subsystem and finally, the nerves and central nervous system comprise the neural subsystem, which determines the requirements for spinal stability by monitoring the various transducer signals [of the nervous system] and directs the active subsystem to provide the needed stability.” He goes on to state, “A dysfunction of a component of any one of the subsystems may lead to one or more of the following three possibilities, an immediate response from other subsystems to successfully compensate, a long-term adaptation response of one or more subsystems or an injury to one or more components of any subsystem.” (8)
Panjabi continues, “It is conceptualized that the first response results in normal function, the second results in normal function but with an altered spinal stabilizing system, and the third leads to overall system dysfunction, producing, for example, low back pain. In situations where additional loads or complex postures are anticipated, the neural control unit may alter the muscle recruitment strategy, with the temporary goal of enhancing the spine stability beyond the normal requirements.” (8) Panjabi’s laboratory is where the idea of biomechanical compensation was conceptualized and proven.
Panjabi’s evidence summarized in the above work is the basis for the underlying mechanics of spine pain that does NOT correlate well to anatomical findings. Anatomical findings are fracture, tumor or infection and allopathy has labeled anything else inaccurately “non-specific.” This concept and approach to spine care continue to maintain a dogmatic perspective in both clinical decision making, provider reimbursement and all too often, the literature, despite compelling evidence to the contrary.
A recent study by Scheer et al. (2016) reports a biomechanical assessment of the spine as critical to spine care including spine surgery. This concept was originally presented at the 2015 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves. The authors state “The cervical spine plays a pivotal role in influencing adjacent and global spinal alignment as compensatory changes occur to maintain horizontal gaze. Concomitant cervical positive sagittal alignment (loss of cervical lordosis) in adult patients with a thoracolumbar deformity is strongly associated with inferior outcomes and failure to reach minimal clinically important difference at 2-year follow-up compared with patients without cervical deformity.” (9) Here we see additional evidence that spinal biomechanical modeling has an effect even in the presence of severe anatomical pathology requiring surgical intervention. In this case, it was even in an adjacent spinal region to the surgical site!
The scientific literature and certainly the surgical community is showing that thorough biomechanical assessment of the patient is a critical component to spine care, particularly in the complex spine pain patient. Without x-rays, the doctor is simply guessing.
One of the primary caveats stated in the ACA’s Choosing Wisely suggestions to not take spinal x-rays is the patient’s exposure to ionizing radiation. Patients routinely ask us about the radiation effects of x-rays, therefore it is imperative that we look at the facts, not the deceptive rhetoric that is so often quoted. According to a recent article from April 2018 by Harvard Health Publishing at Harvard Medical School titled Radiation Risk from Medical Imaging, they state that the average effective dose of a lumbar x-ray is 1.5 mSv. (10) According to the Radiological Society of North America in an article published April 2009 titled The Linear No-Threshold Relationship Is Inconsistent with Radiation Biologic and Experimental Data, they state “Among humans, there is no evidence of a carcinogenic effect for acute irradiation at doses less than 100 mSv and for protracted irradiation at doses less than 500 mSv.” They go on to state “There are potent defenses against the carcinogenic effects of ionizing radiation. Their efficacy is much higher for low doses and dose rates; this is incompatible with the LNT (linear no-threshold) model but is consistent with current models of carcinogenesis.” (11) As one can clearly see, the ionizing radiation effects of taking a set of lumbar x-rays is well below the minimum dosage to have a carcinogenic effect.
The following is a sampling of responses received by the Academy of Chiropractic, these responses were received from an informal survey of doctors of chiropractic nationwide. The instructions were to send over x-rays demonstrating ONLY ANATOMICAL PATHOLOGY and a brief history taken in their offices, many of which showed significant anatomical pathology in the absence of “red flags.” These responses underscore why the options for doctors of chiropractic should not be limited by politics, but instead should be driven by clinical assessment and scientific data. This myopic vision will create a public health risk and is integral in creating an accurate diagnosis, prognosis and treatment plan for our patients particularly in those patients with spine pain not specific to an anatomical lesion. As responsible doctors of chiropractic, we and the profession urge the American Chiropractic Association not to amend it's policy on Choose Wisely, but to rescind its x-ray “suggestions” in any and all formats. Furthermore, terminate all efforts in recommending anything other than each doctor follow their scope of practice in their respective states regarding the utilization of x-ray in clinical practice and the care of their patients. The chiropractic profession needs a strong political advocate and the American Chiropractic Association has historically been a major component in successfully filiing that need, however we need a powerful voice to unite us and not create further division within our profession or waste our valuable and limited resources.
NOTE: Below the references is visual evidence of why x-ray should not be limited in chiropractic
NOTE: The following does not comment or reflect biomechanical pathology or the negative sequela of having it go undiagnosed. That is a topic for a separate article.
The following is a sampling of responses we received from a survey of doctors nationwide 3 days prior to this publishing of this article. The instructions were to send over x-rays for ONLY ANATOMICAL PATHOLGY and a brief history taken in their office within the last 3 months. These responses underscore why the utilization for chiropractors should not be limited as it will create a public health risk and is integral in creating an accurate diagnosis, prognosis and treatment plan for our patients. As responsible doctors of chiropractic we and the profession urge the American Chiropractic Association to terminate all efforts in recommending anything other than each doctor follow their scope of practice in their respective states regarding the utilization of x-ray in clinical practice.
Abdominal Aortic Aneurysm
17 year old male with chronic mid back pain from high school wrestling. Found a compression fracture.
Burst Fracture - Metastatic Cancer
Patient presented upper lumbar pain, adamant that he was cancer free, no problems whatsoever, had been cleared by PCP and oncologist in past, just "needed an adjustment" and was actually rather angry that I would not perform adjustment or treat the day of his exam.
C2 Dens Fracture
This patient is a 25-year-old female with a history of a roll-over accident 10 years ago and recurrent neck pain. During history she said "I think they said something about a neck fracture".
Lumbar Transverse Process Fracture
This patient was referred by an ENT/Facial Plastic Surgeon for evaluation of TMJ/Neck pain. The patient had the mass surgically removed.
Patient was experiencing lower extremity radicular pain. Saw a PT 6 times and a DC 6 times with no relief. Then came to me. I found the Spondylolisthesis. He is doing great without any symptoms now.
L5 Metastatic Cancer
Onset of low back pain and sciatica. X-ray revealed enlargement of L5 spinous process. Patient was reluctant to get MRI. And then I had to fight with insurance carrier to get it authorized. But the x-rays revealed a problem. MRI confirmed metastatic lesion L5-S1 and posterior elements of L5.
Anterior Cervical Discectomy and Fusion
Patient came in complaining of neck pain. Never once stated a prior neck surgery in either the paperwork or when asking about past surgeries.
Congenital Fused Vertebra
C2 Dens Instability
54 year old male delivery driver, acute on chronic onset of low back pain constant 7/10 and neck pain intermittent 5/10 for years. Seen by numerous chiropractors and medical doctors for 30+ years, taking medication for psoriasis. Patient stated that he did not need x-rays just an adjustment and he would be on his way. After x-rays I told the patient go to Kaiser and see a neurosurgeon, I refused to treat and showed him the instability. He protested and said "you are just a f_ _ _ing chiropractor and I have seen many medical doctors over the years and no one has told me anything like I might need surgery. I called him later that day and he did go to Kaiser hospital and was seen immediately a spine specialist.
Thoracic Compression Fracture
56 year old male lifting heavy coffee table 1 week prior, mid back pain acute. No insurance, did not want to spend the money on x-rays. No significant health history.
Lumbar Anterolisthesis of L3
Spinal Fusion from T1-L3
I was asked by an attorney to review a case of a 16 year old female with persistent headaches and neck pain with bilateral paresthesia in her left and right hands. He said he doesn't think she has much of a case. She was involved in a side collision with a pickup truck with a plow in a 30 mph zone. She was evaluated with CT of head and X-rays of neck and back and released by Children's hospital the same day. She has undergone a year of physical therapy for cervicalgia and neurologist for post traumatic headaches. She has 6 degrees of active extension with pain and 48 degrees of active flexion with pain. So I asked for the hospital records including copies of diagnostic imaging for my review. The cervical spine imaging report stated: "unremarkable cervical radiograph without evidence of acute osseous abnormalities." Well I have attached the lateral view for you, which I must strongly disagree with and contacted the radiologist regarding. He asked me at first why I was reviewing the films. I stole your line and said "real doctor's read their own films, would you want a surgeon doing surgery on you without looking at the films." The reply was "good point." He also agreed to write the addendum. I then advised the attorney of my findings and the text message said, "HOLY S!@#! WOW that makes so much sense."
17 year old female presented with lower back pain after baton twirling practice. No trauma. Spondylolysis of L4 most visible on the right posterior oblique.
Note multiple pathologic compression fractures and lysis of right ischial tuberosity. Turned out to be multiple myeloma, Stage 4. L3 is post vertebroplasty.
68 year old male with severe low back and right leg pain. Radiographs exhibit dextrocurvature, severe degeneration and a grade1-2 spondylolisthesis.
AC Joint Separation
Fractured Styloid and Radius