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January 2007, Vol. 17, No. 1
Table of Contents
• Are You Busy Selling Chiropractic or Correcting Subluxations
• BJ's House Needs Repairs • Another Look At Cell Phones
• Chiropractic R.I.P. • Colloca and CBP Nonprofit Study Wins Best Paper Award • Help Us Locate Allen Botnick • Letters to the Editor
• Michigan Chiropractic Society Sees Evidence of Growing Need For Chiropractic • Meeting With Success • A New Look At Mirror Image Exercise • Mourning The Loss Of Tony Keller • Past Present and Future In Chiropractic • Posture Study By UQTR Researchers and CBP® Published by JCO • PostureRay™, PosturePrint™ Helping Doctors Help Patients
• The Importance of A Clinically Relevant Presentation of Findings
• It's Pauls Opinion • Research Corner • Scoliosis: SpineCor Brace
• Triano and CCGPP's Will Give You Six Visits
• Clinical Indications for Videoflouroscopy
• Western States Chiropractic College Receives NIH Grant •
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It's Paul's Opinion
RAC's Good Ol' Boys Club:
Politics Reign Supreme in RAC Review Process
by Paul A. Oakley, MSc, DC
Dr. Oakley received a Bachelors Degree in Kinesiology from Laurentian University, Sudbury, Ontario, Canada in 1998, a Master’s of Science Degree in Biomechanics from Queen’s University, Kingston, Ontario in 2000, and a DC Degree from PCC, Davenport, Iowa in 2003. He is a contributing author for two CBP® texts and has presented research projects at several biomechanics and chiropractic conferences as a student. Dr. Oakley is a CBP® Certified Fellow and is the first Chairperson for CBP®’s Case Study Committee.
Radiation Hormesis is the stimulatory or health-enhancing effects of low doses of radiation. Since medical x-ray exposures are smaller than the natural background radiation that we are exposed to yearly, there is no radiation hazard from medical x-rays. In terms of X-ray exposures, depending on the films taken and exposure parameters, to reach a beneficial effect in hormesis, we’re talking a few dozen to hundreds of medical x-rays!
For two years in a row now, CBP® researchers have had our papers on x-ray use and radiation hormesis receive unprofessional, child-like “scientific” reviews and subsequent ‘rejection’ at the ‘Research Agenda Conference’. The past few years, this Conference has been held in conjunction with the ‘Association of Chiropractic Colleges’ (RAC/ACC) — the prestigious international, annual scientific chiropractic conference held in March each year.
Just for the record, all CBP® authors of this x-ray use and radiation hormesis review have attended RAC conferences, as well as have presented at these conferences in the past. Additionally, all of us have even presented platform presentations at the RAC conference and two of the authors have been invited as panelists for the RAC conference. The most recent second rejection of our much improved and expanded upon review was especially noteworthy. Instead of the usual five reviews, it was only given two! In other words, it wasn’t even given a serious consideration upon being submitted. Undoubtedly, politics took precedence over scientific merit. Let’s take a look at what’s happening...
In Dec. 2005, for the first time, to our knowledge, we presented the first thorough review of radiation hormesis to the chiropractic profession.1 After a critical commentary by the ‘Red Flag Only’ creators (Andre Boussieres-UQTR, Cynthia Peterson-CMCC, John Taylor-NYCC) attempting debunk our review,2 we wrote a second rebuttal review precisely addressing their ‘critical’ concerns - of which no argument held valid.3 To this we received a Letter to the Editor,4 to which we responded and again enlightened the ‘Red Flag Only’ creators as to the reality of this phenomenon and the myth that all radiation is harmful!5
Why would the subgroup creating the ‘Red Flag Only’ guidelines6 be so critical of our reviews? Obviously because our reviews undermine the central rationale for the thrust for their x-ray guidelines; that is, (the myth) all radiation is harmful. There are actually several items typically used as supporting rationale to limit and control the routine use of x-ray in clinical practice.
What is the rationale to NOT take x-rays
There are only a limited number of articles containing statements that condemn the use of routine radiography and these are only expert opinion sources, without data. The typical arguments include: 1) X-rays cause cancer; 2) There is no useful biomechanical data on x-rays; 3) There is inconclusive/no evidence of x-ray line drawing/positioning reliability, repeatability or validity, 4) A normal spine does not exist, and 5) DCs only take x-rays for monetary reasons and no x-ray information is obtained for individualized patient care.
Is this rationale justified?
For item (1), we have thoroughly put forth an abundance of the best scientific evidence refuting this widespread myth as applied to low-dose exposures.1,3,5 Remember, ‘hormesis’ is the stimulating or health-enhancing effects of low doses of otherwise toxic agents/stressors. In evaluating more than 20,000 toxicology articles of various stressors (including radiation), it was determined that hormesis is a “highly generalizable biological phenomenon independent of environmental stressor, biological endpoint, and experimental model system.”7 Hormesis researcher, Calabrese8 has created a database containing 5,600 hormetic dose-response relationships for 900 agents (including radiation). He has proven hormesis to be anything but ‘speculative and untestable’ as the ‘Rad Flag Only’ x-ray guidelines creators4 claim. In fact, hormesis is a ubiquitous natural phenomenon - man can either accept it, study it and use it (i.e. to treat cancer) or continue to deny and dismiss its existence as Bussieres et al.2,4 and others would have us do.9
For items (2) and (3), several hundred references were obtained for biomechanical x-ray data and efficacy of x-ray data. In fact, the ‘Practicing Chiropractors’ Committee on Radiology Protocols’ www.pccrp.org document has summarized 20 papers validating x-ray use for biomechanical purposes.10 Also, for item (3), there are at least 158 reliability studies on x-ray line drawing and at least 55 studies on x-ray positioning repeatability.
For item (4), both average and ideal normal spine models were found in top orthopedic journals.
For item (5), Techniques practiced by the majority of DCs require x-rays to determine spinal listings and locations to apply forces — take a look at the technique courses in the chiropractic colleges — Hello?! Further, spinography (subluxation assessment with x-ray) is a primary assessment procedure utilized by more than 50 percent of the profession on at least 60 percent and up to 95 percent of presenting patients.11-20 Last, in studies specifically considering the role of chiropractic interventions, spinal radiographs demonstrate 66.91 percent of patients can have significant abnormalities that would alter interventions.21-23 Up to 33 percent of spinal radiographs have relative contraindications and 14 percent have absolute contraindications to certain types of chiropractic adjustments.21
What’s the rap on the rationale for ‘Red Flag Only’ x-ray guidelines?
Rationale for ‘Red Flag Only’ x-ray guidelines has no scientific merit! As reviewed above, the most common criticisms used to support the notion for red flag only radiography guidelines, (cancer causing, no biomechanical data, and no x-ray reliability, repeatability, validity, no useful patient info gained) has no scientific merit. In fact, there is a substantial and incontrovertible quantity and quality of literature available to invalidate these common criticisms -— and prove the opposite!
Most importantly, the ‘pseudo-scientific’ radiography articles and chapters that condemn use of x-ray in routine practice written by a minority group of publishing DACBRs and academics, are used by Managed Care Organizations (MCO’s) (such a ACN and ASHN)24 to deny coverage for radiology services for patients seeking chiropractic care. Thus, we can only conclude that these radiology articles and texts are linked, in no small way, to MCO’s creating a situation where the chiropractic clinician is removed from the patient treatment decision making process such that costs can be ‘controlled’ and profits can be ‘maximized’.25
These few boisterous DACBRs and academics need to realize that the main arguments to support their agenda for creating and implementing ‘Red Flag Only’ x-ray guidelines for the chiropractic profession has more chiropractic discipline-specific evidence to the contrary. Any radiography guidelines created specifically for the chiropractic profession must include the plethora of evidence that invalidates the LNT model for estimating x-ray risks, and clinical evidence that validates the reliability and repeatability of x-ray use for biomechanical (i.e. subluxation) interpretation.
In summary, we reiterate what we recently stated in our Letter to the Editor Reply in Dec.06: “Routine spinal radiography is the standard of care in chiropractic practice. Since Bussieres et al. are attempting to change the standard to ‘Red Flag Only’ x-ray guidelines, they (not us) need to show that their new proposed ‘standard’ yields improved outcomes and safety as compared to the past and present standard of routine spinal radiography.”
Now we challenge the RAC supervisor, Dr. C. Johnson, to not allow this political exclusion of radiation Hormesis articles to continue.
References
1. Oakley PA, Harrison DD, Harrison DE, Haas JW. On “phantom risks” associated with diagnostic radiation: evidence in support of revising radiography standards and regulations in chiropractic. J Can Chiropr Assoc 2005; 49(4):264-269.
2. Bussieres AE, Ammendolia C, Peterson C, Taylor JAM. Ionizing radiation exposure - more good than harm? The preponderance of evidence does not support abandoning current standards and regulations. J Can Chiropr Assoc 2006; 50(2):103-106.
3. Oakley PA, Harrison DD, Harrison DE, Haas JW. A rebuttal to chiropractic radiologists’ view of the 50-year-old, linear-no-threshold radiation risk model. J Can Chiro Asso 2006; 50(3):172-181.
4. Bussieres AE, Ammendolia C, Peterson C, Taylor JAM. Letter to Editor [A rebuttal to chiropractic radialogists’ view of the 50-year-old, linear-no-threshold radiation risk model]. J Can Chiro Asso 2006; 50(4):285-286.
5. Oakley PA, Harrison DD, Harrison DE, Haas JW. Letter to Editor-Reply [A rebuttal to chiropractic radialogists’ view of the 50-year-old, linear-no-threshold radiation risk model]. J Can Chiro Asso 2006; 50(4):286-288.
6. Bussieres A, Peterson C, Taylor J, et al. Diagnostic Imaging Practice guidelines for Musculoskeletal Complaints by Consensus Opinion for Chiropractic Clinicians. Accessed July 28, 2006: www.uqtr.ca/imagingchiroguidelines.
7. Calabrese EJ, Baldwin LA. Hormesis: a generalizable and unifying hypothesis. Crit Rev Toxicol 2001; 31(4-5):353-424.
8. Calabrese EJ, Blain R. The occurrence of hormetic dose responses in the toxicological literature, the hormesis database: an overview. Toxicol Appl Pharmacol 2005; 202(3):289-301.
9. Kauffman JM. Radiation hormesis: demonstrated, deconstructed, denied, dismissed, and some implications for public policy. J Sci Expl 2003; 17(3):389-407.
10. Harrison DE, Kent C, Oakley PA, et al. Practicing Chiropractors’ Guidelines for the Utilization of Plain Film X-Ray Imaging for the Biomechanical Assessment, Characterization, and Quantification of Spinal Subluxation in Chiropractic Clinical Practice. Practicing Chiropractors’ Committee on Radiology Protocols (PCCRP) www.pccrp.org.
11. Harger BL, Taylor JAM, Haas M, Nyiendo J. Chiropractic radiologists: a survey of chiropractors’ attitudes and patterns of use. J Manip Physiol Ther 1997; 20:311-314.
12. Marchiorri DM, Hawk C, Howe J. Chiropractic radiologists: A survey of demographics, abilities, educational attitudes and practice trends. J Manipulative Physiol Ther 1998;21:392-398.
13. Hawk C, Long CR, Boulanger KT. Prevalence of non-musculoskeletal complaints in chiropractic: report from a practice-based research program. J Manipulative Physiol Ther 2001;24:157-169.
14. Walker, BF.; Buchbinder, R.; Most Commonly Used Methods of Detecting Spinal Subluxation and the Preferred Term for Its Description: A Survey of Chiropractors in Victoria, Australia. J Manipulative Physiol Ther 1997;20(9):583-9.
15. Walker BF. Most Common Methods Used in Combination to Detect Spinal Subluxation. A Survey of Chiropractors in Victoria. Australia Chiropractic and Osteopathy 1998; 7(3):109-11.
16. Bolton SP. X-Ray Dispossessed-Expedience versus Standards? Chiropractic Journal of Australia 2004; Volume 34, Number 1, March 2004.
17. Aroua A, Decka I, Robert J, Vader JP, Valley JF. Chiropractor’s use of radiography in Switzerland. J Manipulative Physiol Ther. 2003 Jan;26(1):9-16.
18. Carey TS, Garrett J. Patterns of Ordering Diagnostic Tests for Patients with Acute Low Back Pain. Am College of Physicians 1996;125 (10):807-814.
19. Cherkin CD, MacCornack FA, Berg AO. Managing low back pain. A comparison of the beliefs and behaviors of family physicians and chiropractors. West J Med 1988;149:475-480.
20. Ammendolia C, Hogg-Johnson S, Pennick V, Glazier R, Bombardier C. Implementing evidence-based guidelines for radiography in acute low back pain: A pilot study in a chiropractic community. J Manipulative Physiol Ther 2004; 27:170-179.
21. Bull PW. Relative and absolute contraindications to spinal manipulative therapy found on spinal x-rays. Proceedings of the World Federation of Chiropractic 7th Biennial Congress; Orlando, FL, May 2003, page 376.
22. Pryor M, McCoy M. Radiographic findings that may alter treatment identified on radiographs of patients receiving chiropractic care in a teaching clinic. J Chiropractic Education 2006; 20(1):93-94.
23. Beck RW, Holt KR, Fox MA, Hurtgen-Grace KL. Radiographic Anomalies That May Alter Chiropractic Intervention Strategies Found in a New Zealand Population. J Manipulative and Physiol Ther 2004; 27(9):554-559.
24. American Specialty Health Network. Clinical Practice Guideline: X-ray Guidelines: Date of Implementation March 13, 2003. http://www.ashcompanies.com/Providers/CQM/guidelines/X-RayGuidelines.pdf. Date accessed: May 13, 2006.
25. Latov N. Evidence-Based Guidelines: Not Recommended. J Amer Physicians Surgeons 2005; 10(1):18-19.
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