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Necessary Use of Initial X-Rays in Chiropractic: FACT SHEET

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Necessary Use of Initial X-Rays in Chiropractic



By Mark Studin DC, FASBE(c), DAAPM

Anthony Onorato DC, MBA


Reference: Studin M., Onorato A. (2023) Fact Sheet: Necessary Use of Initial X-Rays in Chiropractic, Dynamic Chiropractor, 42(03)


Public Health Risks


X-Ray Safety: There are ZERO negative effects of diagnostic X-rays in chiropractic offices. Radiation exposure to a patient in plain x-ray examinations of the spine involves an estimated 0.2, 1.0, and 1.5 mSv for the cervical, thoracic, and lumbar regions, respectively.[1] 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.[2] The American College of Radiology, in their February 2020 ACR Appropriateness Criteria, reported, "Adverse health outcomes for radiation doses below 100 mSv are not shown by the evidence."[3] In chiropractic practice, it would require 500 cervical x-rays, 100 thoracic x-rays, or 67 lumbar x-rays in a single encounter to realize an adverse effect. It would take 5 times those levels over a protracted time; however, neither of these circumstances occurs in chiropractic practices as the safe use of radiation is inherent to our doctoral training regarding the number of necessary x-rays.


General Public Health Risk of NOT Taking X-Rays: The American Association of Physicians in Medicine reported, "Predictions of hypothetical cancer incidence and deaths in patient populations exposed to such low doses are highly speculative and should be discouraged. These predictions are harmful because they lead to sensationalistic articles in the public media that cause some patients and parents to refuse medical imaging procedures, placing them at substantial risk by not receiving the clinical benefits of the prescribed procedures."[4]


The Necessity of X-Ray in Chiropractic Practice: Chiropractic delivery modes are very diversified and state-dependent. Some choose an exercise model, while others use soft tissue work, joint mobilizations, arthrokinematic or kinesiological procedures, or high velocity, low amplitude thrusts (HVLAT, also known as a spinal adjustment or spinal manipulation). The combined effects of genetic inheritance, aging, and loading history can influence the strength of spinal tissues to such an extent that it is difficult to specify the likely strength of an individual’s spine. The risk of injury depends on tissue weakness as much as peak loading.[5]For the practitioners that consider every model but an HVLAT, there is little risk for the patient as minimal forces are being utilized. However, in an HVLAT, there are measurable forces with peak amplitudes that are generally tolerated in healthy spines. However, with injured spines, this can potentially be harmful if the force is not applied in the correct direction.[6]


As evidence in the literature has evolved over time, the direction and magnitude of spinal biomechanical pathology (misalignments), in conjunction with connective tissue pathology, have been defined.[7],[8] In some instances, those biomechanical lesions can cause serious injury to the spinal cord and must be identified before treatment begins.[9]


Significant Public Health Risk of Waiting 6 Weeks or a “Red Flag” to X-Ray: For the chiropractic practitioner that utilizes a lawful HVLAT procedure in their practice, whose outcome is evidenced to reduce opiate use by 64%[10] and realize a 313% lower disability outcome vs. physical therapy treatment[11], utilizing methods with poor reliability to determine care is not in the patient’s interest and is at the core of every state board’s responsibility. Seffinger et al., Troyanovich et al., and Bialosky et al. reported that palpation for position and movement faults had demonstrated poor reliability, suggesting an inability to determine a specific area requiring manual therapy accurately.[12],[13],[14]


Given that the majority of palpatory tests studied, regardless of the study conditions, demonstrated low reliability and invalid or unreliable and should not be used to arrive at a diagnosis, plan treatment, or assess progress.12 In contrast, the reliability of X-rays in morphology, measurements, and biomechanics, has been determined accurate and reproducible in both chiropractic and medical specialty.[15] The reliability of an x-ray is excellent for all parameters. It suggests that this valid and reliable information on accuracy should be used when assessing and interpreting a change in the cervical spine.[16]


For the HVLAT practitioner, treating for 6 weeks without evidence-based validity in diagnosis would be forcing a doctor to “guess” on formulating a prognosis and treatment plan and increase the risk to the patient. A “Red Flag” x-ray policy (evidence of fracture, tumor, or infection) is commonsense to any licensed provider. However, to apply the 6-week or red-flag “gatekeeper rule” for x-rays equally to chiropractic and medicine, as suggested by academicians and a minority, but influential political policymakers[17],[18] for the HVLAT practitioner is ignoring the evidence and potentially putting the public at risk. To underscore the necessity, the American College of Radiology Appropriateness Criteria 2021 lists in Variant 6 “low back pain with or without radiculopathy,” initial imaging of radiography of the lumbar spine; “Usually Appropriate.[19]


The Chiropractic Council for Education, under “META-COMPETENCY 1 – ASSESSMENT & DIAGNOSIS” (D), states, “Perform and utilize diagnostic studies and consultations when appropriate, inclusive of imaging, clinical laboratory, and specialized testing procedures, to obtain objective clinical data.” Most state scope parameters are consistent with the Federal Guidelines on imaging. Currently, x-ray procedures are being taught in every CCE-accredited program, and the Doctor of Chiropractic has the right, based upon a clinical decision for their treatment path, to take x-rays. This should not change. Carriers should not use political guidelines to limit the use of initial x-rays, nor should chiropractic colleges be allowed to limit the training on X-rays. This will increase the risk to the public.



[1]Mettler FA, Huda W, Yoshizumi TT, Mahesh M (2008) Effective doses in radiology and diagnostic nuclear medicine: A catalog Radiology 248: 254-263.

[2] Tubiana, M., Feinendegen, L. E., Yang, C., & Kaminski, J. M. (2009). The linear no-threshold relationship is inconsistent with radiation biologic and experimental data. Radiology251(1), 13-22


[4] American Association of Physicists in Medicine. Position statement of the American Association of Physicists in Medicine. Radiation risks from medical imaging procedures. December 2011. http://www.aapm. org/.

[5] Adams, Michael A., and Patricia Dolan. "Spine biomechanics." Journal of biomechanics 38.10 (2005): 1972-1983.

[6] Lopes, Mark A., Roger R. Coleman, and Edward J. Cremata. "Radiography and Clinical Decision-Making in Chiropractic." Dose-Response 19.4 (2021): 15593258211044844.

[7] Steilen, D., Hauser, R., Woldin, B., & Sawyer, S. (2014). Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal, 8, 326.

[8] Lee, Derek J., and Beth A. Winkelstein. "The failure response of the human cervical facet capsular ligament during facet joint retraction." Journal of Biomechanics 45.14 (2012): 2325-2329

[9] Yang, Sun Y., et al. "A review of the diagnosis and treatment of atlantoaxial dislocations." Global spine journal 4.3 (2014): 197-210.

[10] Corcoran, Kelsey L., et al. "Association between chiropractic use and opioid receipt among patients with spinal pain: a systematic review and meta-analysis." Pain Medicine 21.2 (2020): e139-e145

[11] Blanchette, M. A., Rivard, M., Dionne, C. E., Hogg-Johnson, S., & Steenstra, I. (2017). Association between the type of first healthcare provider and the duration of financial compensation for occupational back pain. Journal of occupational rehabilitation27(3), 382-392

[12] Seffinger, Michael A., et al. "Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature." Spine 29.19 (2004): E413-E425.

[13] Troyanovich, Stephan J., Deed E. Harrison, and Donald D. Harrison. "Motion palpation: It's time to accept the evidence." Journal of Manipulative & Physiological Therapeutics 22.3 (1999): 186-191.

[14] Bialosky, Joel E., et al. "The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model." Manual therapy 14.5 (2009): 531-538.

[15] Fedorak, C., Ashworth, N., Marshall, J., & Paull, H. (2003). Reliability of the visual assessment of cervical and lumbar lordosis: how good are we? Spine28(16), 1857-1859.

[16] Marques, Catarina, et al. "Accuracy and reliability of X-ray measurements in the cervical spine." Asian spine journal 14.2 (2020): 169





Dr. Mark Studin is an Adjunct Associate Professor at the University of Bridgeport School for Chiropractic teaching advanced imaging and triaging chronic and acute patients, and an Adjunct Post-Doctoral Professor at Cleveland University-Kansas City College of Chiropractic. He is also a Clinical Instructor for the State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Office of Continuing Medical Education. Dr. Studin consults for doctors of chiropractic, medical primary care providers and specialists, and teaching hospitals nationally. He can be reached at or 631-786-4253. TAP HERE for his CV

Dr. Anthony Onorato is the associate director of clinical education at the University of Bridgeport, School of Chiropractic. He is supervising attending physician for all clinical services. He is also an associate professor of clinical sciences at Bridgeport and currently teaches physical diagnosis. Dr. Onorato was the associate dean of chiropractic at the U of B College of Chiropractic, for 20 years. He directed the entire academic program and was responsible for the initial and continued accreditation of the program by the Council on Chiropractic Education (CCE) during his tenure. He also was a counselor for the CCE.


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