Clinicians Versus IMEs and Academicians:

A Debate About X-ray Usage and Normal Position in JMPT

 

by Deed E. Harrison, DC

  About four years ago, my father and I grew tired of inaccurate statements made by IMEs to cut our claims. Several of these statements have been perpetuated for three decades by DACBRs and Academicians at our chiropractic colleges. In 1996-97, we wrote a review of 8 items (with approximately 20 references per item) to show that the literature contradicts what our chiropractic radiologists and academicians had been writing and teaching about:

      1. Normal spinal position does not exist,

      2. Variations in x-ray positioning simulate subluxation or correction,

      3. Posture and biomechanical analysis are not repeatable phenomena,

      4. Slight head nodding/flexion creates kyphosis in the cervical spine,

      5. Acute muscle spasms cause cervical and lumbar kyphosis or hypo-lordosis,

      6. Normal anatomic variants cause the spine to appear to be subluxated,

      7. X-rays should not be taken for biomechanical or postural screening and post x-rays are not warranted, and

      8. Radiographic line drawing for measuring spinal displacements is not reliable.

      After review and acceptance at JMPT, this paper was published in May 1998 (JMPT has a 9-12 months delay in acceptance/publication).

      Some DACBRs and academicians (3 authors and 5 consultants) took exception to our May 1998 JMPT published review and wrote a rebuttal that appeared in the May 1999 issue of JMPT. These authors got very personal in their approach to rebuttal. They included CBP®¨ technique and the Harrison spinal model, while still claiming correctness of their opinions on “no normal spine,” “no normal posture,” x-ray usage, x-ray positioning repeatability, and x-ray line drawing reliability.

      Of course, my father and I did not accept their opinions in this May 1999 rebuttal, which was minimally referenced. They accused us of “twisting the evidence,” “selective literature review,” and “misrepresenting references.” We believed that this is what they were doing because we had presented 160 references in our 1998 review compared to only 40 in theirs.

      We decided to counter-rebuttal their May 1999 JMPT article. With the aid of Stacy Harmon, DC, MD, we wrote a more exhaustive review (267 references) of normal posture, normal spinal models, x-ray positioning, x-ray line drawing reliability, uniformity and clinical significance of sagittal spinal curves across gender and nationalities, and CBP®¨ technique. This paper was just published in JMPT in December 2000. We suggest that you get a copy of this article to help you with IME rebuttals dealing with these topics.

      Now you should ask yourself, “Why did we put so much effort into this debate?” The answer is protocols of care that have and still are being used to limit chiropractic practice. While most of these DACBRs and academicians do not have private practices, what they write is used by State Boards, national chiropractic care guidelines, State Workers Comp guidelines, and insurance companies. If the only thing printed is their opinions on the previously mentioned topics, then care guidelines are skewed towards their opinions, which actually are not supported by much of the recent literature.

      For examples: 1) Many insurance companies no longer will reimburse for Chiropractic x-rays but they will for the exact same x-rays taken by hospitals or Orthopedic surgeons, 2) If they pay for the 1st set of x-rays, some insurance companies will not pay for follow-up or post x-rays but they will pay for multiple post surgical follow-up x-rays, 3) Some insurance companies will not pay for x-rays of children, 4) Many state boards have ruled against chiropractic x-rays of children and the need for post treatment x-rays to verify spinal correction, and 5) Most insurance companies refuse to pay for maintenance care for the spine but they will pay for other types of maintenance or prevention such as Dentistry (this one is illogical if one considers the fact that they make false teeth, but not false spines).

      We sincerely hope that these two reviews will spark future changes in chiropractic practice acts and aid in documentation of Chiropractic examination procedure including x-ray and postural analysis.