Chiropractic X-rays

Chiropractic X-rays are safer than some other forms of radiation exposure.

How Do X-rays Work?

Wilhelm Roentgen, a physicist from Germany, invented the X-ray in 1895. They are a light ray, but they are not visible to the human eye because eyes cannot see certain wavelengths, such as the shorter ones of X-rays. These rays can pass through objects that are non-metallic, such as organs and tissues in the body. They are beneficial to medicine because they can help doctors see things inside the body without surgery. In order to get an X-ray picture, the machines “produce a very concentrated beam of electrons onto a metal film”. The beam itself can travel through air until it reaches the body’s tissues. Since the soft tissues of the body “cannot absorb the high-energy rays”, the beam just passes right through them. Bones, which are denser, “absorb the radiation”. On the X-ray film, black areas are where the X-rays have passed through (soft tissues) and white areas have absorbed X-rays (bones).¹

Risks of Radiation

Radiation exposure is a concern for people who have X-rays, but there are other ways people can get this exposure, such as frequent flyers on airplanes. Some scientists say “some frequent flyers are exposed to more radiation than nuclear power plant workers”. This “could increase the risk for certain cancers”.² Other people at risk for radiation exposure are those who use tanning beds. A tan is not a sign of health, but it does signify skin damage. The darkening of the skin indicates the skin’s self-defense of producing melanin. Over time, the skin ages and some people may develop skin cancer. Tanning beds emit UV-A and UV-B forms of radiation, both of which harm the skin. Using tanning beds before age 35 increases the risk of melanoma. In addition, the radiation exposure not only causes premature aging and leathery skin, but it also leads to immune suppression, eye damage, and can cause an allergic rash.³ As for medical and dental X-rays, practitioners should follow the ALARA principle: As Low As Reasonably Achievable. This is a “regulatory requirement for all radiation safety programs”. This means that radiation exposure is minimized and there is awareness of the hazards as well as compliance with safety procedures. The three main principles with mitigating radiation exposures are time, distance, and shielding. The time of exposure should be minimal, to reduce the radiation dose. The distance between the body and the radiation source is also important (“doubling the distance” from the radiation “will divide the…exposure by a factor of 4”). Shielding with lead also reduces exposure.⁴

Uses of Chiropractic X-rays

While some chiropractors routinely use X-rays, others do not, out of concern for radiation exposure. X-rays may become necessary, however, if patients do not respond to treatment over several weeks. They are also recommended if patients might have a broken bone, dislocated joint, or other traumatic injury, if there is infection, a tumor, or cancer, or in certain other cases. If a patient has joint disease, such as arthritis, if the patient is elderly, or if osteoporosis is suspected, an X-ray would likely be warranted to “direct treatment protocols” and “provide critical information”. X-rays can be helpful in identifying or ruling out a “vertebral fracture from osteoporosis” and to detect an instability in the spine. X-rays should not be routine for “general musculoskeletal lower back pain in someone under age 65”. They are not appropriate for “exploratory purposes” or during pregnancy. X-rays are not useful for the identification of soft tissue problems, since ligaments, muscles, tendons or areas “within the spinal disc” are not regions X-rays can show. They are only helpful in identifying joint and bone pathology. MRIs are more appropriate for soft tissue problems.⁵ Digital X-rays are available on the market now. Many of the chiropractic electronic health records software products incorporate X-ray records into the system, allowing for patient records to be maintained in one location. For example, E-Z BIS EHR provides a means of importing X-rays. A DICOM viewer allows for the display of the digital X-rays.⁶

Radiation from Chiropractic X-rays vs. Other Sources

In terms of radiation exposure, the “average person is exposed to…3.0 mSv (millisieverts) of radiation per year”. A chest X-ray is about “10 days of typical background radiation exposure”. The X-rays of the arms and legs expose the patient to a lower dose of radiation than a chest X-ray; however lower torso ones have a higher dosage. Extremities are equal to about three background radiation hours. The spine is about 6 months’ worth. The FDA feels that patients should not refuse X-rays if the risk of a doctor not knowing how to diagnose and treat a patient could exceed the risk of radiation exposure. Because chiropractic X-rays are used to detect malformation, fractures, and cancer, as well as “other contraindications to chiropractic adjustment”, it may be necessary for safety reasons to have the X-ray.⁷ When compared to other forms of radiation exposure for workers in certain fields, the annual effective dosage of medical radiation is about 0.75 mSv, but aviation is about 3.07 mSv. Nuclear power plant work exposure is equivalent to 1.87 mSv per year.⁸Body tissues all absorb radiation differently, and that is why the values for X-rays for different body parts vary. Radiation exposure is “cumulative over time” with regard to the risk of disease. If a patient is receiving X-rays from multiple medical or healthcare providers, they should keep track of their exposure. As the FDA notes, “The risk of not having a needed X-ray is greater than the small risk of radiation.” Children and pregnant women have different dosage requirements, though.⁹

ACRRT Certification and DACBR

The American Chiropractic Registry of Radiologic Technologists (ACRRT) recognizes “chiropractic paraprofessionals” who have the qualifications to “engage in radiologic technology”. These practitioners are required to receive “prerequisite education and experience” in order to complete the ACRRT exam. The Registry aims to uphold ethical and educational standards, as well as maintain a list of qualified professionals who are able to assist Doctors of Chiropractic (DCs).¹⁰ Different states have licensing requirements for X-ray technicians. As for chiropractic radiology, most states allow “plain film radiography” as part of a “chiropractor’s scope of practice”. Some are allowed to “order and even interpret advanced imaging”, provided they have the appropriate credentials and training. The main difference between chiropractic and medical radiology is “in the areas of emphasis”. Medical radiologists tend to be “generalists”, while chiropractic radiologists are “neuromusculoskeletal radiologists”. If the chiropractors themselves are unable to read or interpret the films, then they will need to use the services of a chiropractic radiologist. According to the American Chiropractic College of Radiology (ACCR), there are about “150 chiropractic radiologists” in the US. Chiropractic radiologists are examined by the American Chiropractic Board of Radiology (ACBR) and pass the certification to receive the designation called Diplomate of the ACBR (DACBR). It takes about 300-400 hours of chiropractic school training “to learn about acquitting and interpreting plain film radiography”, along with 4,000 hours of didactic and practical training “during their three- to four-year full-time residencies”. The ACBR has no affiliation with the “American Chiropractic Association Council on Diagnostic Imaging or the College of Radiology”; therefore, “there is no conflict of interest or undue influence”.¹¹