Chiropractors have achieved a status amongst practitioners of alternative medicine that is almost unrivalled. In the UK, they have achieved a level of mainstream acceptance, regulation and recognition that must be the envy of homeopaths and herbalists. Such is their standing that I suspect that many people would not even consider them as part of the alternative medicine scene. Chiropractors, like their close cousins the Osteopaths, are statutorily regulated in the UK, and this means that they have ‘protected title’ and other rights not afforded to lesser practices.
And yet, chiropractic remains firmly an alternative medicine. It is founded on pre-scientific views of the body (innate intelligence flows though our nerves), a discredited model of illness (subluxations) and a feeble evidence base. Chiropractors are taught that “The basic principle of chiropractic is that disturbances of the nervous system, resulting from subluxation of the bones of the spine and other parts of the body, are a primary or contributory factor in the pathological process of many common human and animal ailments.” Subluxations are suppose to block the flow of ‘innate intelligence‘ around the body. This is a mystical notion with no basis in science.
Whether or not Chiropractors believe this nonsense, taught to them under the watchful eyes of British Universities, we would be quite right to ask if Chiropractic techniques actually help people, regardless of whether the theory behind it is fantasy. Looking at the most recent review of all the evidence (Ernst and Canter, 2006), the conclusion is that “reviews were largely negative, except for back pain where spinal manipulation was considered superior to sham manipulation but not better than conventional treatments. Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.”
At best, Chiropractic looks like one more quack placebo treatment. It may help a little with lower back pain, but that is it – and probably not better than a couple of paracetamol and some moderate exercise. But chiropractors do not let science get in their way. Simon Singh, the award winning science writer, is currently being sued by the British Chiropractic Association, for daring to write in the Guardian that Chiropractors were promoting ‘bogus treatments’ when they suggest that they can cure ear infections and infant colic. Given this, it is even more remarkable that the government has conferred such legislative privilege upon the trade.
One privilege that Chiropractors have is that they fall into one of the few named professions that is legally allowed to refer patients for an X-ray. What is even more remarkable is that Chiropractors, almost uniquely, can fulfil all duties (employer, practitioner, referrer and operator) defined by law when giving medical exposures. (Dentists may do too, but the exposures involved are a lot smaller.)
Now, a basic tenet of ionising radiation protection for many years has been that all exposures should be as low as is reasonably practicable (ALARP). In the medical world, if you are to expose patients to ionising radiation, there must be some clinical benefit from that exposure that justifies the risks. The Chiropractic guidance is clear:
The principle of justification is that medical exposures shall show sufficient benefit so that the potential diagnostic and therapeutic benefit is greater than the individual detriment that the exposure might cause. The key requirement of this section is that each individual medical exposure should be justified in advance.
The UK Ionising Radiation (Medical Exposures) Regulations, IR(ME)R 2000, require that types of practice are justified and that it is “justified by its economic, social or other benefits in relation to the health detriment it may cause.” Presumable Chiropractic has been seen to fit the bill. In addition to the type of practice, the individual exposure must be justified too. This is where I struggle to see how a Chiropractor could make a sound case for ever X-raying a customer.
There are two aspects to this:
1) On what diagnostic basis will the resultant X-ray images be used?
2) How will the subsequent diagnosis inform an effective treatment plan?
Given that Chiropractic is founded on pseudoscientific notions of health and that the concept of spinal subluxations has never been empirically validated, just what are Chiropractors looking for in X-rays? And since chiropractic treatment cannot demonstrate efficacy to a reasonable standard, how will X-raying a patient lead to a therapeutic benefit? In addition, since the positive effects seen for some sort of back pain are only comparable to conventional treatment where no X-ray is required, surely there is always an alternative treatment plan that does not involve exposing the patient to the risk of ionising radiation?
Are Chiropractors misusing X-rays? The trade has come under a lot of criticism for some of its business practices. Do patients really benefit from X-rays at the Chiropractic clinic? Or are they a way of scaring patients into lengthy and ineffective treatment plans?
The Chiropractic profession is regulated in the UK by the General Chiropractic Council. There are times when the X-raying practices of their members has moved them to take action. They note in their 2007 Fitness to Practice Report that,
The Professional Conduct Committee has seen that treatment plans are exploitative when they are constructed around a diagnosis that leads patients to believe they are more seriously ill than they are, with the intention to promote undue dependence on chiropractic care. Some treatment plans, as shown by the evidence heard by the Professional Conduct Committee, were formulated without any adequate assessment or reassessment of patients’ needs. Going hand in hand with this approach was the routine X-ray of patients without justification. The images were used as sales tools further to pressurise patients to accept treatment.
They speak of a few cases:
This year the Professional Conduct Committee heard evidence in one case that also demonstrated a blatant disregard for patients’ safety and wellbeing. Amongst other things, patients, including a child, were exposed to ionising radiation for no other reason than to use X-rays to pressurise patients to sign up to long contracts of care. The individual concerned showed no insight, understanding or remorse for what he had done and was removed from the Register.
During another Professional Conduct Committee hearing, a respondent chiropractor admitted that he had routinely X-rayed nine out of 10 adult patients. Upon considering an audit of nine patient records, the Professional Conduct Committee was of the view that there was no justification for those patients to have been exposed to ionising radiation.
Given that it is difficult to see how any Chiropractic X-ray can be justified, is this just the tip of the iceberg? How widespread is X-raying in Chiropractic clinics and how often are X-rays used? Fortunately, we can look to GCC surveys to answer that question.
In 2004, their members were asked about their X-ray usage.
Table 33. & 34. X-rays
Chiropractors were asked:
a) For what percentage of your patients is an x-ray justified?
b) Do you take x-rays of your patients?
c) Do you refer patients direct for imaging?
d) Do you refer patients for imaging via GPs?
e) Do you interpret the x-rays?
Table 33. a) X-ray justified?
Number of Range chiropractors
0% 9 1% 1-20% 525 61% 21-40% 99 12% 41-60% 51 6% 61-80% 47 6% 81-100% 34 4% Didn’t specify 89 10%
Table 34. b, c, d, e) X-rays
B C D E Yes 294 (34.43%) 499 (58.43%) 568 (66.51%) 593 (69.44%) No 542 (63.47%) 306 (35.83%) 246 (28.81%) 241 (28.22%) Didn’t specify 18 (2.1%) 49 (5.74%) 40 (4.68%) 20 (2.34%)
Clearly, the majority of Chiropractors are X-raying fairly regularly and some are performing it routinely. There are undoubtedly practitioners out there that believe wholeheartedly in the concepts of subluxations and use X-rays to try to find their mysterious problems. One comment in the Survey noted this ‘fundamentalist’ approach to their art,
A point raised by 6 respondents and made more loosely by several others was that chiropractic is at odds with medicine (basic approach to health) and being closely linked with the NHS will cause the profession to become mere spinal technicians. It was also said that the general population is moving away from the allopathic model of healthcare towards a more vitalistic and holistic model focussed on the pursuit of true health and wellness and in their opinion the chiropractic profession was best placed to lead this ‘wellness revolution’. It was therefore felt that it was in this direction that the GCC should focus its attention to avoid being just another drugless management of back pain.
Why do we not see more prosecutions? That is a tricky question to answer. At the root of the problem is understanding who actually would initiate an investigation and see through prosecutions. When we look at other X-raying healthcare providers we would see the Healthcare Professions Council who might oversee X-ray usage. Chiropractors are special cases and sit outside this regime of regulation and sit under their own regulator, the GCC. It could be argued that this creates a conflict of interest in that serious investigations into widespread misuse of X-rays within Chiropractic could serious damage the reputation of the profession and the businesses of their members.
Ionising Radiation Regulation is complex and it is unlikely that any other authority could step in to address the question. Trading Standards do not have the specialists. The Health and Safety Executive may well be more geared up to ensure the more industrial side of radiation protection is enforced, such as the compliance with controlled areas for exposure. The situation gets even worse when you look at the significant number of ‘spinal manipulators’ who have chosen not to be regulated by not calling themselves Chiropractors. Osteomyologists, according to the Times, are sometimes “illegal chiropractors” and some still carry out X-ray procedures to help with their sales patter. There appear to be no agencies that can be expected to oversee the illegal use of X-rays in this situation.
What should a potential patient do? Well, first of all – do not go to Chiropractors. It is unlikely you will get meaningful benefit from the visits and a few people will get hurt by them. Your back is liekly to get better anyway, and your doctor may be able to advise you on exercise and pain killers. If you do go, walk away if you are offered X-rays and find a chiropractor who believes they do not need to X-ray you. They may well be a little more reliable.
Chiropractor’s Use of X-rays E Ernst The British Journal of Radiology, 71 (1998), 249-251
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