Why do chiropractors order so many X rays?

Aug 10 2010 Published by under [Medicine&Pharma]

People often visit primary care physicians and chiropractors for low back pain (LBP).  It is a very common problem, and one that usually resolves on its own.  Research has repeatedly shown that X rays are rarely useful in the evaluation and treatment of simple back pain.  Outside of certain "red flags" (fever, history of cancer, weight loss, and a few others), there is rarely any reason to get an X ray of someone's spine when they come to see the doctor for low  back pain.

Both anecdotal and quantitative studies have shown that chiropractors are very likely to order spine X rays. Given the inutility of these studies, and the radiation exposure, what reason could there be (aside from financial incentive) for chiropractors to order X rays?

Diagnosis of bone and joint disease

X rays can be very effective at diagnosing traumatic bone and joint injuries such fractures and dislocations.  These films can be very tricky to interpret, and nearly all doctors have their films over-read by a radiologist.  Given that chiropractic is not useful in the treatment of an acute fracture or dislocation, and that chiropractors are not qualified to read these films, this seems a poor excuse for ordering films.

X rays are not very sensitive or specific for the diagnosis of other important bone diseases such as osteoporosis, and can be very tricky when cancer is a consideration, as some bony cancer lesions show up on X rays and some do not.  X rays done and interpreted by a chiropractor or any other unqualified individual can lead to a false sense of security.

Diagnosis of "subluxation"

Subluxation is a word with two meanings.  In orthopedics, it refers to a specific kind of dislocation of a joint, one that can be clearly identified on an X ray.  In chiropractic, it refers to an often-invisible displacement of the vertebrae that can cause back pain and even systemic disease.   Subluxation in the chiropractic sense has never been shown to exist.  Vertebral subluxations in the orthopedic (i.e., real) sense are rarely clinically significant and are outside the purview of chiropractors.

X rays are a significant intervention. Anytime ionizing radiation is applied to a human being, there better be a good reason for it.  If there is no evidence that the X ray will help in a meaningful way with diagnosis or treatment, then no X ray should be done.  There is no clear reason any chiropractor should ever order an X ray.

32 responses so far

  • Pascale says:

    What is the rate of x-ray for lower back pain by ER and primary care physicians? I suspect it's pretty high, even though plain films are rarely of use. But patients feel like you have done something if you got an x-ray.

    • JJM says:

      PCPs are competent to take and read xrays, not so many chiros are. Moreover, there are chiros who xray every spine, regardless of indications. In my area there is a chiro who offers a low first-consultation rate including routine xray. Based on the picture she publishes with the ad, she is not "old school."

      Moreover there are rational xrays and there are chiro xrays. The large whole-spine images favored by many chiros are insufficient to show many pathologies.

  • Tzi says:

    Probably for the same unfortunate reason that people return home from doctor's appointments with antibiotics for viral infections. It pacifies the patient and makes them feel like something is being done, even if there's absolutely no reason to (and in fact a good reason not to).

    • zuska says:

      WHY are doctors giving out antibiotics for viral infections? Why? Does this really happen a lot or is it urban legend? None of my doctors ever would do it.

      Or by this, do you mean, give out antibiotics without first have a positive culture come back absolutely showing bacterial infection?

      How is a doctor supposed to decide when to give AB, and if they are handing them out like candy, is the doctor or the patient's fault?

      • palmd says:

        It's done all the time, but it's often less simple than that. For ex, studies show that most cases of sinusitis and acute bronchitis are not affected by the prescription of antibiotics, yet it is often done.

  • Daniel J. Andrews says:

    I saw a chiropractor when I was 18 after I injured my back. He refused to work on my back unless he could take x-rays. His reason was that he needed to see if any of my vertebrae were fused or had growths on them that would make it difficult for him (and painful for me) to 'sublax'.

    It took a few visits to him before I began to realize the whole idea behind chiro was dubious. There was no internet back then so I couldn't check things out readily, but I distrusted him enough that I quit going. Nice fella really, but I wouldn't want to see him playing doctor (oh wait....)

  • PalMD, subluxation can either mean a legitimate diagnosis or a fake one where some kook tries to get you to come in three times a week for some crackin'.

  • JJM says:

    Chiropractors take xrays because they are impressive and most of us cannot interpret them so we are at their mercy of their interpretations. In the 1960s (article at http://www.quackwatch.com) they were challenged to identify their subluxations on unlabeled xray films, and they had to admit they could not. Today, some of them still do routine xrays to find their subluxations.

    Chiropractors are massagers with delusions of grandeur. It is a waste of time to try to understand anything they do.

  • mxh says:

    I agree with JJM about it being more of a ploy to say "hey, look, your spine needs adjusting." Although, another reason could be that they are saving themselves from being sued. If there is any obvious spinal pathology (i.e., cancer lesions) and the chiropractor doesn't order the x-ray and starts manipulating, they could easily cause fractures and spinal injuries (not to mention miss cancer). I'd say that, given relatively low radiation exposure plain film X-rays have (although spinal radiographs have more radiation exposure than chest X-rays), I'd rather have them waste a bit of money than cause paralysis or miss dangerous diseases in more people (of course, this is all assuming that chiropractors know how to read the X-rays they get).

  • Nathan Myers says:

    When my father broke his pelvis, various physicians ordered x-ray after x-ray of his ankle, which it turned out was not actually injured, and which he wasn't complaining about. Is it anybody's job to make sure too many x-rays aren't taken? (They refused to look at his knee for a week, which swelled up to grapefruit size, apparently because they hadn't noticed it was injured when he was wheeled in. And they stopped, abruptly, his duloxetine.)

    While we're talking about excessive irradiation, let's keep talking about excessive irradiation even after we run out of chiropractors to excoriate.

  • Shannon says:

    @Nathan

    Sounds like your father got some unnecessary diagnostics. Clearly unfortunate; mistakes and misdiagnoses are, of course, all too frequent.

    I will say, however, that I've reviewed hundreds of medical cases where quality of care was not ideal... and it's my experience that rarely is the care team an arrogant bunch of bumbling buffoons. Once in a while, yes, it's a jackass. But, mostly, well-intentioned people without enough experience, time, information, or failures of systemic checks and balances.

    Anyhoo, I digress. Your comment is a great example of recall bias - a proximal, sometimes strongly emotional experience that eclipses all our memories of our broad experience with a larger population. Anecdotes are great ways to sell things - products, theories, political candidacy, etc. But, to improve safety and reliability of our system, we've got to move away from recall bias-driven care to -alas- a cold blooded look at the data. If we were to do this in medicine, the evidence suggests that CT scans are more likely to decrease risk than plain films in current practice.

    PAL's done a nice job of describing a systematic overuse of a diagnostic test with real risk and undemonstrated value. This is what we should be chasing.

  • OleanderTea says:

    I've worked in health insurance for about twenty years and I know exactly why chiroquackers order so many x-rays.

    Many insurers (including Medicare) require X-rays "demonstrating evidence of subluxations" be taken before a single "spinal adjustment" was paid for.

    As Pal said, it's the financial incentives.

    • Mike says:

      By the way, the Medicare x-ray requirement was rescinded in 2002. Prior to that, Medicare did require chiropractors to obtain xrays, but oddly Medicare did not pay for them. There are a number of reasons for this, but there may not be enough bandwidth to get into them.

      I know of no other insurer that has ever maintained an xray requirement for any period of time for chiropractors.

  • Nathan Myers says:

    "Your comment is a great example of recall bias"

    Your comment is a great example of changing the subject. I did not present the example as indicative of a trend. If it has any valence, it comes from the small sample: why should I know of examples of excessive irradiation? Its purpose was to lead to the question, which was "Is it anybody’s job to make sure too many x-rays aren’t taken?" (Not, apparently, at that hospital.) That's not evidence of buffoonery, it's an institutional matter. If it's nobody's job, of course it doesn't get done. How many times as many unnecessary x-rays are ordered at hospitals, collectively, than at chiropractors' offices? 10? 100? 1000? Is it anybody's job to count? It's satisfying to criticize out-guild abuses, but our enthusiasm mustn't blind us to where the bulk of the problem lies.

    Refusing to look at my father's knee for a week is entirely another matter.

  • Rowan says:

    A number of years ago I had a co-worker who was going to a chiropractor on a very regular basis for back pain. It was sad that for close to eight months she was treated with back cracking and massages for the spinal cancer which was missed and ultimately killed her.

    When she finally went to an orthopedist and then the oncologist she was stunned that the chiropractor didn't realise she had cancer because "he had taken xrays of my back." He was evidently taking them fairly regularly too in order to check progress in treatment.

  • Nathan Myers says:

    I suppose, from the timing, that it's unlikely the x-rays actually caused her cancer.

  • PalMD says:

    Seems very unlikely.

  • Adam says:

    I don't think Rowan's blaming the radiation exposure, rather that it was a lesion that the oncologist thinks shoild have been easily visible on a spinal film and caught by the chiropractor.

  • Mike says:

    Hi,

    I was a practicing chiropractor for 20 years.

    I bought a brand new xray unit when I opened my own practice, and sold it seven years later in virtually new condition, and I averaged about 25 new patients per month, the vast majority being discharged within a six (6) visit treatment course. 29% of patients who presented never received a manipulation, but were either referred to ortho, PT or massage, or simply told to sleep on their back or side rather than their stomach, stop sleeping on a heating pad (one of the worst things one should do for back pain), take a few Motrin and a big dose of suck it up. My motto in the office was "its only back pain", and patient's responded well by improving quickly (I like to think I had something to do with improving upon the natural history of the largely self limiting conditions with which they presented, but who knows?).

    No matter what anyone says, chiropractic x-ray technique or obtainment rationale is predominantly about money. An alarmingly high percentage of xrays obtained (and repeated again and again) in chiropractic offices are poorly exposed, and often without proper patient shielding. If you have never seen a ten year old patient's full spine AP/LAT xray, you don't know what your missing.

    Digital motion xray is a big joke as well. If you have any doubt, try to get a look at some of the reports that are generated by the practitioner (often a radiologist who either owns the unit or is hired by the chiropractor or company). I have read hundreds in my current capacity as consultant, and have yet to see a "normal" interpretation. Often, these units are placed in mobile vans and travel from chiropractic office to office, setting up in the driveway or parking area. Patients step inside and get zapped. Absolutely worthless, unless you are trying to make up more cool or scary reasons to keep people coming back for more cracks.

  • HennaHonu says:

    What about scoliosis? Can't x-rays be used to find scoliosis?

    • palmd says:

      Of course. That just happens to be quite irrelevant to what chiropractors do.

      • HennaHonu says:

        Where would one go to get scoliosis treated or properly diagnosed, then?

        • palmd says:

          It would depend. Most children (in the US) are screened by their pediatrician and/or in the schools. Most scoliosis requires no specific treatment.

          Orthopedic surgeons are the specialist who most commonly treat disorders of the spine (sometimes neurosurgeons, but not usually for scoliosis)

  • zuska says:

    Pal, is there anything that a chiropractor does that you would consider to be legitimate and/or helpful? I am asking quite seriously, as someone who has family members who have gone to and/or are contemplating chiropractic care.

  • palmd says:

    There is some evidence that for low back pain it is as good as "usual care" (meaning handing the pt a book on back care and giving them NSAIDs). Chiro neck manipulation is a cause of strokes from vertebral artery dissection.

  • James P. Hilton,Ph.D, EMT-P. says:

    Good article.

    Now why don't you do one on the gross overuse of x-rays by dentists, and your own profession (medical doctors) for that matter?

    It is a well known fact that the overuse of x-rays and far more dangerous CT scans has quadrupled since the 1980's. It is also an incontrovertible fact, well documented in the medical literature that ionizing radiation in ANY DOSE induces genetic mutations, which sooner or later contribute to cancer. Even the FDA's official website advises you avoid them "no matter how small the dose."

    Don't get me wrong here. If I'm in a car accident and can't feeling my toes and thus am facing a lifetime in a wheel chair, please do take x-rays!

    However, why can't I get a simple back adjustment by ANY chiropractor in any state or even have my teeth cleaned by ANY dentist these days without first submitting my body to a proven beyond dispute cancer causing radiograph?

    Can you say KA-CHING!!!

  • JJM says:

    @James P. Hilton,Ph.D, EMT-P. says: August 23, 2010 at 7:28 pm writes "Good article.

    Now why don’t you do one on the gross overuse of x-rays by dentists, and your own profession (medical doctors) for that matter?"

    Maybe because the article is about chiros? Particularly, that they are incompetent obtaining and interpreting said films.

  • palmd says:

    Physicians may in fact over-utilize radiographs, but any use by a chiro is ridiculous

  • Zeno says:

    The severely flawed NICE guidelines on low back pain that many UK chiros cite as endorsement for their treatment states:

    Do not offer X-ray of the lumbar spine for the management of non-specific low back pain.

    Chiros are more than happy to shout about the guideline's (supposed) endorsement of chiro for LBP, but I do wonder if they adhere to this categoric proscription of x-rays?

  • Sam B. says:

    I've been a chiropractor for 33 years now. I had an x-ray unit in my offices for only about 4-5 of my years in practice. Most of the time I order films from local hospitals or radiology offices. Most of the time, a report would be included in the envelope. The films are quite helpful in a chiropractic context. Besides ruling out those pathologies that do show up on plain films, they are helpful in determining any contraindications to spinal manipulation. The films show the patient's spinal history to some degree and are very helpful in guiding a plan of care that is corrective in nature as well as for just symptomatic relief. When global postural abnormalities are identified on an x-ray, early enough, the early intervention with chiropractic care can be most helpful in reducing the likely degenerative changes associated with those distortions.
    Like dentists, I have always liked the idea of early intervention and "hygiene"... instead of waiting until pathology or symptoms set in the way we are taught in an medical/allopathic approach.
    I should add that had my best friend's neck not been x-ray'd by his chiropractor after a minor bicycle accident he would, no doubt, have been neurologically injured, if not paralyzed, simply from that nights sleep in his bed. The ER he went to did not take any x-rays.
    As far as liability issues are concerned, I imagine that there are some x-rays, medical as well as chiropractic, motivated by a 'better safe than sorry" attitude.... especially in this litigious society. But, when a patient comes to me with chronic pain, has been to other medical specialties having received only more drugs Rxs, and has tried other modalities without relief, I feel ethically and professionally obligated to do as thorough an assessment as I can for them. As with most of my colleagues , I get amazingly good results for my patients with chiropractic procedures and protocols, and x-rays have been an integral part of the analysis process. I don't order them capriciously, I don't make any money from them. Even the doctors I know who have their own machines in office, don't see them as a profit center. Although it has been a while since I have had one in my office, reimbursements are not very good and are getting worse.
    When I read the various comments in this string, I must say that the opinions don't seem to be based on considered inquiry or conversation with chiropractors.... rather, a kind of thinly veiled prejudice. ... not very becoming for learned folks in the healing professions. I might be wrong about that, but why not directly ask several chiropractors about their use of x-rays; gather as much data as possible, then form an opinion, if one is needed.... just a suggestion. I am certainly open to such conversations, so please feel free to write.

  • Catherine says:

    This is all very interesting.... I have been seeing a chirpractor since I was born.

    My mother was told I needed to be in a cast for the first few years of my life - she refused to do so - so she went down the chiropractic route.

    I now live with perfectly healthy hips !

    I can physically feel when theres a subluxation in my own neck. You can feel it jut right out ! and it hurts like buggery to touch.

    Sure, there are kooks out there, but without Chiro, I would be screwed. The docs did nothing but put me on pain killers after my car accident - I went to the Chiro, and huzzah, no need for pain killers.