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Radiophobia Overreaction: College of Chiropractors of British Columbia Revoke Full X-Ray Rights Based on Flawed Study and Radiation Fear-Mongering

  • Ideal Spine Health Center and CBP NonProfit, Inc. --A Spine Research Foundation in Eagle, ID

Abstract and Figures

Fears over radiation have created irrational pressures to dissuade radiography use within chiropractic. Recently, the regulatory body for chiropractors practicing in British Columbia, Canada, the College of Chiropractors of British Columbia (CCBC), contracted Pierre Côté to review the clinical use of X-rays within the chiropractic profession. A "rapid review" was performed and published quickly and included only 9 papers, the most recent dating from 2005; they concluded, "Given the inherent risks of radiation, we recommend that chiropractors do not use radiographs for the routine and repeat evaluation of the structure and function of the spine." The CCBC then launched an immediate review of the use of X-rays by chiropractors in their jurisdiction. Member and public opinion were gathered but not presented to their members. On February 4, 2021, the College announced amendments to their Professional Conduct Handbook that revoked X-ray rights for routine/repeat assessment and management of patients with spine disorders. Here, we highlight current and historical evidence that substantiates that X-rays are not a public health threat. We also point out critical and insurmountable flaws in the single paper used to support irrational and unscientific policy that discriminates against chiropractors who practice certain forms of evidence-based X-ray-guided methods.
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Original Article
An International Journal
July-September 2021:135
© The Author(s) 2021
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DOI: 10.1177/15593258211033142
Radiophobia Overreaction: College of
Chiropractors of British Columbia Revoke
Full X-Ray Rights Based on Flawed Study and
Radiation Fear-Mongering
Paul A. Oakley
, Joseph W. Betz
, Deed E. Harrison
Leonard A. Siskin
, Donald W. Hirsh
, and International
Chiropractors Association Rapid Response Research
Review Subcommittee
Fears over radiation have created irrational pressures to dissuade radiography use within chiropractic. Recently, the regulatory
body for chiropractors practicing in British Columbia, Canada, the College of Chiropractors of British Columbia (CCBC),
contracted Pierre Cˆ
e to review the clinical use of X-rays within the chiropractic profession. A rapid reviewwas performed
and published quickly and included only 9 papers, the most recent dating from 2005; they concluded, Given the inherent risks
of radiation, we recommend that chiropractors do not use radiographs for the routine and repeat evaluation of the structure
and function of the spine.The CCBC then launched an immediate review of the use of X-rays by chiropractors in their
jurisdiction. Member and public opinion were gathered but not presented to their members. On February 4, 2021, the College
announced amendments to their Professional Conduct Handbook that revoked X-ray rights for routine/repeat assessment and
management of patients with spine disorders. Here, we highlight current and historical evidence that substantiates that X-rays
are not a public health threat. We also point out critical and insurmountable aws in the single paper used to support irrational
and unscientic policy that discriminates against chiropractors who practice certain forms of evidence-based X-ray-guided
radiophobia, X-ray, radiograph, chiropractic, clinical utility, guidelines
Radiographic analysis is not only the rst choice in imaging of
the spine in all forms of clinical healthcare practice but it is the
gold standard for the examination of patients presenting with
spinal disorders.
In this context, X-rays can provide critical
and immediate information to guide treatment decisions re-
garding further imaging (e.g., MRI), referral (e.g., surgical
consult), indications for co-management (rheumatologist and
pain specialist), to rule out or conrm a denitive diagnosis,
help provide a timely diagnosis, ease the anxiety of the patient,
and satisfy the doctors liability concerns.
In the current era
of value-based healthcare,
routine initial X-ray screening is,
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons
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Private Practice, Newmarket, ON, Canada
Private Practice, Boise, ID, USA
CBP NonProt, Inc, Eagle, ID, USA
Private Practice, Green Brook, NJ, USA
Private Practice, Laurel, MD, USA
Received 20 April 2021; received revised 17 June 2021; accepted 22 June
Corresponding Author:
Paul A. Oakley, Private Practice, 11A-1100 Gorham Street, Newmarket, ON
L3Y 8Y8, Canada.
in fact, encouraged as it reduces costs associated with more
advanced imaging (i.e., CT and MRI).
Last, the evaluation of
biomechanical relationships of the spine and pelvis have direct
consequences on patient pain, disability, quality of life, and spinal
function, and patient outcomes can be altered with evidence-
based spine rehabilitation procedures utilized by many manual
therapists including doctors of chiropractic.
Within the profession of chiropractic, there has been recent
controversy over X-ray use in clinical practice. For example,
in 2017, the American Chiropractic Association (ACA) re-
leased a statement that it had joined the Choosing Wisely
initiative and listed 5 practices that were discouraged.
rst two points were associated with X-ray use: specically,
(1) to not X-ray a patient presenting with acute low back pain
within the rst 6 weeks of onset, and (2) to not X-ray a patient
to assess response to treatment. Despite the fact that the ACAs
listed items are not supported by any valid or discipline-
specic evidence,
the promoted discouragement of X-ray
use through the Choosing Wisely program has led to far-
reaching and cascading consequences including the use of this
list by insurance companies to deny reimbursement to prac-
ticing chiropractors using X-rays to diagnose and assess their
Further examples of controversy over X-ray use in chi-
ropractic include a debate between afliates of Chiropractic
Biophysics NonProt and Anderson, Kawchuk and members
of the Research Council of the World Federation of Chiro-
The scoping reviewby Jenkins et al
for X-ray
use in chiropractic that was heavily criticized,
as well as
most recently, a controversial rapid reviewon X-ray utility
in chiropractic concluding there was no evidence for routine or
repeat X-ray imaging in chiropractic practice beyond suspected
red ags(i.e., serious medical conditions including cancer,
infection, fracture, etc.).
This last review attempted to assess
the chiropractic literature from the inception of multiple da-
tabases to November 2019, but only included 9 papers in their
nal analysis and none dated from the last 15 years!
It is precisely this last article mentioned that underpins
recent events regarding the College of Chiropractors of British
Columbia (CCBC) to make sweeping policy changes to re-
strict chiropractors from taking X-rays practicing within the
jurisdiction of the Province of British Columbia (BC), Canada.
Legal adoption of this CCBC policy change would mean BC
chiropractors have lost their full X-ray rights for use for
treatment assessment and evaluation of spine disorders unless
used strictly for the purpose of examining red agsonly.
So-called red ag onlyguidelines for the chiropractic
profession have been heavily criticized as they rely virtually
exclusively on data from allopathic medical practice (pharma-
cologic practice), they ignore the plethora of spine literature
correlating spine alignment with health outcomes, they ignore
the high-quality and evolving evidence for approaches vali-
dating spine-altering methods, they ignore studies showing
high rates of bony anomalies/pathologies that may alter treat-
ment approach, and they discriminate against chiropractors that
practice alternative forms of evidence-based practice that utilize
initial and repeat spine X-rays.
This article addresses the peculiar events that have rapidly
occurred which seem to be motivated by misguided opinion
and political policy over science. First, we highlight recent
reviews substantiating diagnostic X-rays as harmless to public
health as well as historical evidence about the pseudo-science
surrounding the adoption of the linear no-threshold (LNT)
model that underpins all radiation risk assessment. We discuss
the many criticisms of BEIR VII that is proclaimed to be the
primordial LNT support document as well as low-dose ra-
diation as an effective treatment for human diseases. Next,
we discuss critical and insurmountable aws in the con-
tracted rapidreview
invalidating the CCBCs X-ray
policy changes. We point out the complete lack of trans-
parency of the CCBC and highlight the Collegesfailure to
perform its role of protecting the publicby speedily
adopting unscientic and unethical policy based on a single
awed manuscript. Finally, we discuss how radiophobia has
escalated and culminated into poor policy that neglects
consideration of the bulk of existing science.
X-Rays Are Not a Public Health Threat
The rst and foremost criterion that precludes denitive action
toward dissuading, or in this case radical policy change to
outright revoke, full X-ray rights is having belief in the
conjecture that X-rays cause cancer.Today, this notion is
understood to be false. For all intents and purposes, low-dose
radiation in the amounts given from X-rays (and CT scans)
offers no threat to public health as they have never been shown
to cause harm and in fact, have only been shown to enhance
health (aka radiation hormesis
). Here, we briey sum-
marize the main ndings from several recent studies, we show
that the traditional events and science leading to the adoption
and acceptance of the LNT model was based on pseudo-
science, we present the multiple fundamental aws which
invalidate the use of the US National Academy of Sciences
Biological Effects of Ionizing Radiation report (BEIR VII) for
use in radiation risk assessment from X-rays, and discuss low-
dose radiation as a successful treatment for human diseases.
Contemporary Reviews Show No Harm from
Low-Dose Radiation/X-rays
Schultz et al performed a quantitative assessment on the
methodologic quality of studies that had evaluated cancer risk
from low-dose sources (i.e., X-ray and gamma radiation ex-
posures less than 200 mSv) to determine the evidentiary
strength supporting or refuting a causal relationship between
low-dose radiation and cancer.
The authors state that con-
cerns exist that medical radiation from X-rays (CT scans) will
cause thousands of malignancies, and that if this premise is
false, the fears from patients and doctors leading to X-ray
avoidance would be unfounded.
2Dose-Response: An International Journal
In their analysis, from an initial 4382 located studies be-
tween the years 19752017, 62 met all the inclusion/exclusion
criteria. From these, 25 studies were deemed to be of high-
quality, and importantly, 21/25 did not support cancer induction
by low-dose radiation (p= .0003). Thus, fears from X-rays were
determined to be unfounded; indeed, the authors stated
A clear preponderance of articles with higher quality methods
found no increased risk of cancer from low-dose radiation. The
evidence suggests that exposure to multiple CT scans and other
sources of low-dose radiation with a cumulative dose up to 100 mSv
(approximately 10 scans), and possibly as high as 200 mSv
(approximately 20 scans), does not increase cancer risk. (p. 3)
Vaiserman et al performed a recent literature review to
assess the validity of the LNT model of radiation damage, the
basis of current regulation.
They reviewed medical occu-
pational exposures including radiologists and technologists,
radiation workers, nuclear workers, nuclear weapons test
participants, radiation-based medical procedure participants
who received diagnostic imaging and low-dose radiotherapy,
environmental background radiation, residential radon ex-
posure, and nuclear powerplant accidents including exposures
given to residents exposed from the incidents at Three-Mile
Island (1979), Chernobyl (1986), and Fukushima (2011).
They also included the comprehensive reviews from the joint
report of the French Academy of Sciences and French Academy
of Medicine (2005),
BEIR VII (2006),
and the United Na-
tions Scientic Committee on Atomic Radiation (UNSCEAR)
report (2016).
In their Table 1
(adapted here as Table 1), it is shown that
virtually all standard mortality ratios from radiation exposed
occupational cohorts are less than 1.0 (i.e., same as back-
ground). The authors note that this data shows that the ra-
diation exposures had no effect whatsoever or may even be
The authors reiterate that no solid evidence
exists showing any type of harm at doses of up to 500 mSv/y
(2 mSv/d) and conclude that there is a growing body of
evidence that low-dose radiation, such as used in X-ray im-
aging including CT, actually promotes health rather than poses
risk.They also conclude that the regulatory burden should be
reduced due to high costs of LNT-inspired regulations since
the epidemiological data provide essentially no evidence for
detrimental health effects below 100 mSv.
In a recent review, Oakley and Harrison showed how the
use of the radiation protection concept ALARA(As Low As
Reasonably Achievable) results in more harm than benet
(Table 2).
Since ALARA is based on the LNT which is not
valid for low-dose exposures, the use of dose as a surrogate for
risk in radiological imaging is not appropriate and obsolete. In
fact, it was shown that the forced adherence to over-restrictive
radiological imaging avoidance campaigns (e.g., Image Gently
and Image Wisely
) results in real harms over theoretical harms.
Among the many potential harms presented,
the most damning
included an increased liability to physicians who avoid, or
have patients who refuse radiological imaging, potential missed
diagnoses due to reduced image quality by using lower dose
techniques in attempt to limit exposures, increased risks from
alternate imaging procedures (e.g., sedation for MRI), and the
propagation of continued radiophobia. It was concluded, the
ALARA principle, as used as a radiation protection principle
throughout medicine, is scientically defunct and should be
Many others have also advocated for the
abandonment of the use of ALARA in medical imaging.
In another recent review, it was summarized why the long-
held notion of X-ray carcinogenicity is not a valid argument.
It was shown the LNT is not valid for low-dose radiation
exposures (including X-rays) as the Life Span Study (LSS)
data, which is considered the main evidential support, shows a
hormetic dose-response curve (non-linear)
; the BEIR VII
has been heavily criticized for having both faulty assumptions
and analyses.
The original adoption of the LNT was based
on faulty data and dubious agenda,
and that the LNT has
evolved to become more political than scientic.
It was
argued that the ALARA concept is obsolete as it relies on the
invalid LNT model.
It was also illustrated that exposure
levels shown to be carcinogenic have thresholds that are very
high, for example, from the data presented from Doss
(700 mGy)
as well as Cuttler (1100 mGy).
This last
argument is of critical importance as it illustrates that X-ray
exposures represent an innitesimal fraction of the threshold
for potential cancer induction. Cuttler also noted that, even in
those exposed to above 1100 mGy from the atomic bomb,
only .5% developed leukemia which he noted was very
Oakley and Harrison
also argue that low-dose ionizing
radiation (LDIR) upregulates the adaptive protection systems
of the body that repair any damage done by X-rays,
that an X-ray would only equate to about one-millionth of the
endogenous damage from breathing air on a daily basis. Also,
LDIR treatments are based on the physiological response of
the body and have been used to treat a variety of human
ailments including inammatory and neurodegenerative con-
ditions, infections, and cancers.
It was argued the total
collective dose (TCD) concept is invalid for LDIR due to the
adaptive response mechanisms, as any DNA damage resulting
from each exposure event (X-ray) would be mitigated prior to
any subsequent exposure. It was also discussed that aged
cohort studies purveying radiogenic cancers from prior X-rays
are not generalizable to the wider population due to cohorts
who were imaged in their youth having increased incidence of
anomalies and other predisposing factors and, thus, increased
susceptibilities to cancers.
It has recently been pointed out that the Radiation Effects
Research Foundation (RERF) has recently been incorporating
non-radiation factors into consideration for cancer incidence
in the LSS cohort survivor data which has led to obvious
suspicions about the merit of previous studies published by
RERF that did not previously account for other such risk
Indeed, cancer is understood to be a multifactorial
Oakley et al. 3
disease process. In assessing two recent RERF studies (Sakata
et al
; Grant et al
), Pennington found the LSS cohort input
data and modeling had extensive deciencies and defects
and that a best estimate of radiation-only cancers within the
LSS cohorts large population using current cancer risk factors
for the Japanese population offers a strong indication that
A-bomb-blast LDIR could not produce such cancers.
also questioned how the RERF continues to nd and assert
that bomb-blast LDIR remains a distinguishable source of
radiogenic cancerwhen it was concluded that the LDIR
radiogenic cancer model is highly implausible if not
A recent review by Ricci and Tharmalingam investigated
the validity of LNT interpolations from high-dose atomic
bomb data to the use for risk assessment at low-dose levels.
Noting that LNT cancer risk modeling generally excludes co-
exposures to chemicals, dietary, and socio-economic cancer
risk factors, LNT radiation modeling always and incorrectly
predicts cancers as solely attributed to ionizing radiation
exposures. They point out that for the linear interpolation to be
correct, there would have to be exact similar biological
mechanisms that lead to cancer from high and low doses of
radiation; however, this cannot be correct as both biological
and epidemiological data show non-linearity and thresholds.
They also show that the use of the LNT suffers from mis-
specication errors, multiple testing, and other biases and its
use by regulatory agencies conates vague assertions of
scientic causation, by conjecturing the LNT, for adminis-
trative ease of use.
Recently, a task group was organized by the Society of
Nuclear Medicine and Molecular Imaging to assess the val-
idity of the LNT, its use in risk assessment and radiation
protection, and the risk of cancers from low-dose radiation
The task group concluded the evidence does not
support the use of LNT either for risk assessment or radiation
protection in the low-dose and dose-rate regionand that it is
Table 2. Synopsis of the Failure of the ALARA Radiation Protection
Reluctance of doctors to take X-rays
Constrains practice
Adds malpractice risks
Delayed diagnosis
Missed diagnosis
Alternate imaging has harms
Reluctance of patients from receiving X-rays
Shared decision-making leads to X-ray avoidance
Constrains medical management
Adds malpractice risks
Leads to more consultation time
Leads to more testing
Increased radiation exposures by aligning with ALARA
Repeated imaging
Missed diagnosis
Delayed medical procedures
Stiing of low-dose radiation research & treatment
Ignoring the bodys innate mechanisms
Ignoring historic evidence of efcacy
Propagation of radiophobia
Circular reasoning for continued ALARA
Never ending radiophobia narrative
Table 1. Overall Cancer Mortality in Cohorts Occupationally Exposed to Radiation (Adapted from Vaiserman
References Country n n (Reference population) SMR 95% CI Sex
UK 2,698 NA (general population) 0.63 (0.67-0.77) m
US 43,763 64,990 (Psychiatrists) 1.00 (0.93-1.07) m
Radiologic technologists
US 1,46,022 NA (general population) 0.73 (0.7-0.8) m
0.86 (0.9-0.8) f
US 45,634 64,401 (Psychiatrists) 0.92 (0.85-0.99) m
0.83 (0.58-1.18) f
Radiation workers
US 46,970 41,169 (Nonradiation workers) 0.88 (0.81-0.94) mix
*1.11 (0.76-1.56) mix
UK 1,24,743 NA (general population) 0.82 (0.79-0.85) mix
UK 1,74,541 NA (general population) 0.84 (0.82-0.86) mix
Nuclear workers
Japan 1,20,000 NA (general population) 0.98 (0.93-1.04) m
Russia NA NA (unexposed residents) 0.89 (0.78-1.01) m
0.96 (0.78-1.17) f
NA (general population) 0.97 (0.89-1.05) m
1.05 (0.97-1.13) f
*Leukemia; NA, not available; CI, condence interval.
4Dose-Response: An International Journal
actually refuted by published epidemiology and radiation
They found the LNT was not supported by any
evidence for use in the low-dose and dose-rate region.
Pseudo-Science led to the Adoption of the LNT Model
The assessment of all radiation risks is through application of
the LNT model. Soon after its rst adoption in 1956, all the
major regulatory agencies (e.g., NAS BEIR, National Council
on Radiation and Protection [NCRP], and International
Commission on Radiological Protection [ICRP]) used the
LNT as the foundation for risk assessment from radiation
exposures. The LNT implies that all radiation is harmful and
also cumulative; in fact, it asserts that no radiation is without
The LNT model is a simple model of linear extrapo-
lation from data at high radiation exposures down to the zero
dose. As will be explained, this model seems to be more about
politics than science.
Despite the exponential emergence
of data against the legitimacy for the use of LNT for low-dose
exposures such as from X-rays and CT scans, these agencies
continue to endorse the LNT.
Surprisingly, there have been new revelations about the
dubious origins of the LNT.
The origins of the LNT model
have recently been shown to have been surrounded by actions
of scientic fraud and misconduct.
The linearity concept
without a threshold for mutation induction by radiation ex-
posure came from Hermann J. Mullers original fruit y
experiments and the historic 1927 publication in Science.
Muller produced transgenerational phenotypical changes us-
ing very high radiation doses. He claimed they were gene
mutations, though decades later these were shown to be gene
deletions and other chromosomal rearrangements.
Thus, at
that time, the radiation research genetics eld was misdirected
for decades based on Mullers false claims of producing gene
mutations. It is also noted that his 1927 Science publication
presented no data and was not peer reviewed.
It appears he
avoided peer review to claim primacy for discovering gene
mutation that did lead him to receive the Nobel Prize for
physiology or medicine in 1946 for the discovery of the
production of mutations by means of X-ray irradiation.
Calabrese revealed historical documentation that legitimate
scientic evidence that directly opposed Mullers LNT theory
work was deliberately suppressed by the Nobel Laureate on
his way to winning the 1946 Nobel Prize.
Muller who gave
his Nobel Prize Lecture on December 12, 1946, knew of high-
quality data from a study by Casperi and Stern
using low-
dose radiation exposure that clearly showed a threshold and
refuted the low-dose linearity concept that Muller endorsed.
After Muller was asked for feedback, documented in a letter
back to Stern dated November 12, 1946 (1 month prior to his
Nobel lecture), Muller indicated he received the manuscript,
scanned through the entire document, saw its signicance,
knew that the ndings were refuting the low-dose linearity
concept, that the study was done by Caspari, whom he viewed
as a very competent person, so he couldnt challenge the
Regardless, in his Nobel lecture Muller stated that
there was no escape from the conclusion that there is no
In 1957, extending on the work from Muller, Lewis pub-
lished an important paper in Science generalizing the linear
relationship from germ cells to somatic cells applying it to
This inspired the NCRP in 1960 to adopt the LNT for
cancer risk assessment. As Calabrese explains, It was this
sequence of events that propelled the LNT cancer risk as-
sessment model into the public health arena, transforming the
elds of environmental health, food safety, radiation health, and
occupational health.
At this point, like dominos, many other
national advisory committees did copycat acceptances, and
linearity became a done deal. The tide was turned. It was a
paradigm shift within a very short time period.
To this day,
the international and national radiation advisory agencies
continue to endorse the LNT model for risk assessment.
Prior to the paradigm shift to the LNT model, there was a
threshold model for which many argue that the early radi-
ologist data
shows that the rst recommended dose limit of
0.2 R per day (approximately 70 rad or 700 mGy per year)
adopted by the ICRP in 1934 represents a safe dose limit
that should be re-adopted.
Cardarelli and Ulsh argue that
abandonment of the LNT model for low-dose radiation risk
assessment by incorporating contemporary science into the
regulatory processes could succeed to ensure that science
would underpin decision making, that the public be educated
on the lack of risks from low-dose radiation exposures, and to
harmonize government policies with the rest of the radiation
scientic community.
BEIR VII Is Continually Endorsed as Primordial LNT
Proof Despite Having Critical Flaws
LNT advocates always rely on the BEIR VII as the pinnacle of
scientic consensus or proof of legitimacy of the linearity
single hit theory that underpins all radiation risk assessment.
Here, we discuss the many criticisms of BEIR VII that in-
validate its use for risk assessment from X-rays.
Sutou recently summarized 5 main aws of the BEIR report
that relies heavily on the LSS data.
First, the dose-response
curve of leukemia is linear quadratic (i.e., non-linear), but
because there was no statistical difference between a linear
and linear-quadratic model, the BEIR committee adopted
the linear model. As Sutou states, this forced logic is
Second, the highest dose in the BEIR reports
(Figure 4) is 2 Gy, but excess relative risk (ERR) typically
shows a downward turn of exposures greater than 2 Gy since
individuals highly exposed would die prior to any cancer
development. Therefore, concealing a downturn by limiting
doses up to 2 Gyis successful in giving the impression of
Third, the BEIR committee performed a statistical
trick by combining all data points less than 100 mGy into 1
point, which again, conceals evidence of non-linearity.
Fourth, the BEIR committee assumed a zero-exposure in
Oakley et al. 5
the not-in-the-city (NIC) controls of the LSS data; however,
they were also exposed to residual radiation from black rain
occurring for a few hours, 45 minutes after the detonation
over Hiroshima.
Sutou shows that a re-analysis accounting
for the NIC exposures shows a threshold and hormetic dose
response (i.e., non-linearity). Fifth, the BEIR report ignores the
adaptive protection mechanisms acquired through the evo-
lution processes of billions of years
that innately attempt to
mitigate DNA damage.
Sutou concludes LNT based on
LSS is invalidIndeed, A-bomb survivors live longer and get
cancer less frequentlyIt is high time to admit benecial
effects of radiation hormesis and to establish a new paradigm
for LDR [low-dose radiation] regulation.
Siegel et al point to the limited literature included in the
BEIR VII report, particularly the reliance on use of in vitro
data that do not support the LNT. Importantly, they point to the
fact that in vitro data cannot be used as proof of carcinogenesis
for intact organisms.
Siegel et al shows the BEIR report
acknowledges epidemiological data linking cancer induction
from low-dose radiation exposures is lacking, but then places
major emphasis on a single study by Lloyd et al.
This study
is a collaborative effort from 6 laboratories that counted
chromosomal alterations (dicentric chromosomes) in human
lymphocytes induced in vitro resulting from radiation expo-
sures in the range of 0300 mGy. First, it is interesting that the
BEIR report omitted the zero-dose data point that showed a
value of 0.17 dicentrics per 100 cells. Importantly, Lloyd et al
found the dicentrics per 100 cells to be .11, .12, and .11 for
exposures of 3, 6, and 10 mGy.
This damage rate is less than
the zero-dose control and unequivocally demonstrates non-
linearity (hormesis).
Even at the higher exposure doses of 20, 30, and 50 mGy,
they remain relatively plateaued at 0.19, 0.24, and 0.24 di-
centrics per 100 cells. Only the 300 mGy, the highest exposure
dose in the study showed signicantly increased damage at
1.28 dicentrics per cell.
Siegel et al state Linearity at the
low doses does not exist (in this case 2-50 mGy and likely
beyond, somewhere between 50 and 300 mGy); rather, it is
forced by the high-dose extrapolation of the LNT model.
Although the BEIR report claims that a linear relationship
between low-linear energy transfer dose and chromosomal
mutation down to around 20 mGyexists,
Seigel et al points
out that the Lloyd et al data do not support this statement.
Further, and most importantly, BEIRs assertion that the link
between initiation and clinical cancer had been establishedis
unsupportableas Such studies (in vitro studies) can only
suggest mechanisms of cancer initiation; they cannot by
themselves provide evidence of clinical cancer development in
whole organisms.
Siegel et al call for the establishment of a
new BEIR VIII committee to critically reassess the validity,
and use, of LNT and its derived policies.
In another BEIR critique, Doss reminds us that the recent
updates to the LSS by Ozasa et al,
and Grant et al,
non-linearity and therefore, the main epidemiological evi-
dence quoted in the BEIR VII report no longer supports the
LNT model.
Doss also states that although many com-
monly argue that because innate repair mechanisms are less
than perfect, a threshold is not plausible (e.g., Duncan et al
however, when one considers the large amount of endogenous
DNA damage, low-dose radiation would result in upregulation
of the adaptive repair mechanisms so that overall, there would
be less DNA damage. Thus, there would in fact be a reduced
overall DNA damage and mutations as has been observed in
Doss states even though DNA repair mechanism is
imperfect, there would be reduction of overall DNA damage
after low radiation exposures.
In a detailed analysis, Calabrese and OConnor demon-
strate more critical aws in the BEIR VII report.
They note
that some BEIR reports have disagreed with other BEIR re-
ports, noting that lifetime excess cancer risksincreased an
order of magnitude from BEIR III to the BEIR V. This was
from the committee choosing to switch from using a linear-
quadratic risk model to a linear risk model (e.g., 42 vs 660
cancer deaths projected from an exposure of 100 mGy be-
tween the different reports). BEIR VII uses a combination of
the 2 risk models. Regarding this changing of risk model use,
Calabrese and OConnor state While the underlying scientic
data reviewed by these committees had obviously been up-
dated, there was and is nothing in the published literature
indicating that the risks from ionizing radiation are an order of
magnitude greater than previously thought.
It is known that the BEIR committee examined data from
many sources, but often data showing hormesis or threshold
were excluded. For example, environmental studies show that
residents living in unusually high background radiation ex-
posures, those near nuclear reactor plants and those exposed to
fallout from nuclear accidents (apart from increased thyroid
cancers) show no evidence of increased cancers. The BEIR
committee considered these types of studies to be of little use
due to being descriptive in natureand ecological in de-
Occupationally exposed workers involving nuclear
powerplant workers (Cardis et al
) initially showed an
increased mortality risk for all cancers except leukemia;
however, excluding invalid data involving one Canadian test
site showed no increased cancer risk but, in fact, also showed an
overall decreased risk of both all causes and cancers for nuclear
workers versus expected.
The BEIR report does acknowledge
this trend but attributes it to the healthy worker effectand
unknown differencesbetween nuclear workers and general
public and excludes the data for not being suitable.
The BEIR VII report almost completely relies on the data
from the LSS cohort, and in doing so, they create risk models
for calculating the risks of cancer. It is noted that an ERR
model and an excess absolute risk(EAR) model was used
by BEIR but resulted in great incongruence between the
two. The lifetime attributable risk(LAR) model which is
the difference in the rate of a condition between an exposed to
unexposed population is used to estimate the probability of
developing a premature cancer over a lifetime while ac-
counting for the age of exposure, latency period, and the dose
6Dose-Response: An International Journal
and dose rate effectiveness factor. It is pointed out that when
the LAR is based on ERR versus EAR, signicantly different
risk estimates arise, even differing by a factor of 10.
abrese and OConnor argue that ideally all estimates should be
identical and be within 1-2 standard deviations of each other
but the BEIR estimates are not. Further, the BEIR committee
assigned weighting factors, and it is pointed out that the
weighted mean risk coefcient factor from the included data
was 0.05/Gy
; however, the BEIR VII Committee chose a
value of ERR = 0.86/Gy, which is 17 times larger than the
weighted mean from all nine medical studies(that the report
Notably, the BEIR report
itself even states
because of the various sources of uncertainty it is important to
regard specic estimates of LAR with a healthy skepticism…”
(p. 278).
One nal critique worthy of mention by Calabrese and
was the use of the dose and dose rate effectiveness
factor (DDREF). This is a factor built into the BEIR estimation
of radiation risks that modies or reduces the dose-risk re-
lationship as estimated by the model to specically account for
the level of dose/dose rate for which the radiation dose was
exposed to a population. Importantly, the BEIR committee
assigned a value of 2 for the DDREF; however, as Calabrese
and OConnor state use of any value of the DDREF greater
than 1 essentially converts the LNT into a linear-quadratic or
biphasic model, and provides a means of modifying the linear
model without ofcially abandoning the LNT hypothesis.In
the end, Calabrese and OConnor conclude: Collectively, the
uncertainties in the derivation of the BEIR VII risk estimates,
and the intrinsic speculative nature of the risk estimates
themselves, cause predictions of cancers and cancer deaths to
be more hypothetical than real in populations exposed to
medical imaging.
Low-Dose Ionizing Radiation Is an Effective Treatment
for Human Illnesses
As mentioned, LDIR treatments have been used to treat a
variety of human ailments including inammatory and neu-
rodegenerative conditions, infections, and cancers (Table
7577,97119(114 119)
Recently, Calabrese et al have summa-
rized evidence from historical data on therapeutic efcacy sug-
gesting that LDIR treatment had an efcacy rate of 7590%.
This is based on radiation exposures estimated to be between 30
and 100 roentgen
which is much greater exposure than one
would receive from spinal X-rays (1-3 mGy) or CT scans
(10 mGy). We
reiterate radiation doses that are healthful
cannot simultaneously be harmful; it is the LNT mythology that
continues to perpetuate false notions of low-dose radiophobia
that only sties the research and acceptance of using LDI for
treating human disease(p. 5). LDIR therapy is also proving
successful in treating patients with COVID-19.
There has been a recent re-emergence of interest for
LDIR treatment for human disease as seen in recent case
reports and a pilot trial.
In fact, there is much hope for
LDIR therapy to prove effective for conditions that have no
successful treatment approach such as for Alzheimers dis-
It must be stated that although the mechanisms for the
therapeutic benets of LDIR are not fully elucidated, it is
understood that LDIR upregulates the innate adaptive pro-
tection systems (Figure 1).
Generally, any initial damage
caused by radiation exposures will be prevented, repaired and/
or removed by very efcient biological systems that results in
a net decrease in DNA damage; an increase in health benet.
Thus, knowledge of the innate adaptive protection systems
and how they can be stimulated to treat disease at radiation
doses far above those from spine X-rays should serve as
enough evidence to abandon the notion of low-dose carci-
nogenicity fears from X-rays.
As discussed, the underpinnings of all X-ray restriction
stem from the traditional notion of carcinogenesis of low-dose
radiation exposures that does not exist. Thus, if the funda-
mental carcinogenesis conjecture surrounding X-ray utiliza-
tion is eliminated, what is left to be of concern for the taking of
innocuous X-rays? Next, we overview the great deciencies of
the recent review paper contracted to C ˆ
e (Corso et al
Methodological Deciencies Invalidate the
Contracted C ˆ
e Paper
Here, we point out critical and insurmountable aws in the
single paper by Corso et al
used to support the irrational,
unscientic policy change by the CCBC that discriminates
Table 3. Human Diseases, Infections, and Conditions Successfully
Treated by Low-Dose Radiotherapy.
Non-cancerous Conditions Cancers
Alzheimers disease Breast
Arthritis Colon
Bronchial asthma Hematological
Bursitis Liver cell
Carbuncles Lung
Cervical adenitis Non-Hodgkins lymphoma
COVID-19 Ovarian
Deafness Prostate
Diabetes Type I Uterine
Diabetes Type II
Gas gangrene
Necrotizing fasciitis
Otitis media
Parkinsons disease
Rheumatoid arthritis
Sinus infection
Ulcerative colitis
Oakley et al. 7
against chiropractors that practice alternative forms of evidence-
based practice that utilize initial and repeat X-rays for the
analysis and treatment of spinal disorders outside of the ex-
clusive use for screening for red ags.
Rationale for Review
Aside from the radiation fear from X-rays as discussed, the
rationale for this review is unfounded. In the introduction,
Corso et al
cite Mizrahi et al
to argue that the rate of X-ray
use by chiropractors and podiatrists increased by 14.4%
between 2003 and 2015.
They go on to state: this occurred
despite the publication of several evidence-based clinical
practice guidelines and clinical prediction rules to assist
chiropractors in determining the indication for spine ra-
diographs to assist with diagnosing a pathology.
For this
statement, they readily show their bias by not even considering
X-ray use for biomechanical assessment and reference ve
problematically 3 of the 5 citations were
published after 2015
atime-machine oversight.
Of the 2 citations prior to 2015,
one was exclusively for
cervical spine trauma.
The only citation that supports
Corsos rationale is the 2008 Bussieres et al radiographic
though these have been criticized as being
recycled allopathic medical care guidelines (i.e., for the
practice of general medicine)
that are declared to be
modeled after the UK Royal College of Radiologists Referral
guidelines for imaging
(i.e., red ag guidelines) where one
of the stated purposes of the chiropractic guidelineis for use
in the hospital emergency room (i.e., medical practice).
Bussieres guideline has been heavily criticized for not in-
cluding chiropractic-specic X-ray uses
(e.g., screening
for anomalies and/or pathologies that alter manipulative
techniques) or for biomechanical analysis which is indeed the
universally accepted standard for investigating the integrity of
the spine structure and function throughout the spine care
Corso et al
further state To our knowledge, approximately
23 chiropractic techniques use spine radiography (including
full spine radiography) to guide the clinical management of
patients.First, this statement shows recognition that many
different chiropractic technique factions practice X-ray-guided
methods; there are at least 23 radiography-based chiropractic
techniques and this represents the great diversity within the
profession (Tab le 4
). Corso et al argue that although
proponents of the X-ray-based technique methods claim that
the use of routine and repeat radiographs is supported by
scientic evidence. these claims have not yet been evalu-
ated for their clinical utility(i.e., patient benets from X-ray
guided treatments are not known).
This main argument is
factually preposterous as there is an abundance of high-quality
randomized controlled clinical trials (RCTs), non-randomized
controlled trials (nRCTs), and a plethora of evolving evidence
(e.g., case reports, case series, and cohort studies) to the
contrary which we will discuss.
In several recent publications, evidence-based X-ray-guided
treatment by chiropractors and other manual therapists have
been summarized.
It needs to be noted
that the evidence-base for the manual therapy sciences in
general is lacking,
and that chiropractors use a broad and
diverse range of patient treatments, whether specically
studied by chiropractors or other healthcare specialties (This is
important to note as we discuss later, the Corso paper inclusion
criteria only included studies where treatment was exclusively
Figure 1. The adaptive response systems very efciently prevent, repair, or remove virtually all DNA alterations.
8Dose-Response: An International Journal
done by chiropractorswhich automatically excluded 100s of
otherwise eligible studies). In brief, for spine radiographic
assessment and outcomes, there exists the highest quality
evidence (RCTs) for methods shown to decrease forward
head posture,
increase cervical lordosis,
decrease thoracic hyperkyphosis,
increase lumbar
and decrease/stabilize scoliosis
It is noted that although some of the
RCTs assessing thoracic hyperkyphosis used surface con-
tour instead of imaging, imaging is the most appropriate
method to assess the exact type or cause of kyphosis
(fracture, postural, senile, congenital, Scheuermanns, etc.)
as well as the segmental location of any deformity. Fur-
thermore, regarding these spine displacements with RCT
evidence, chiropractors are intimately trained in the eval-
uation of these, are intimately trained in these specic
treatment protocols and interventions used, and chiro-
practors are legally licensed in the clinical application of
these protocols and practices.
There are also multiple non-randomized clinical control
trials (nRCTs) and hundreds of case reports/series showing
X-ray-guided chiropractic treatment leads to positive patient
Several recent case reports/series document the
improvement in several different spine displacement patterns
(i.e., spinal deformities/subluxation patterns
only precisely diagnosed and quantied by radiography
including reduction of anterior whole-spine sagittal
reduction of cervical pseudo-scoliosis,
reduction of lumbar pseudo-scoliosis,
improving thoracic
hypokyphosis (straight back syndrome),
reduction of
thoracolumbar kyphosis,
correcting lumbar kyphosis (at
back syndrome),
reduction of lumbar hyperlordosis and
pelvic tilt,
reduction of cervical spondylolisthesis,
and reduction of lumbar spondylolisthesis.
As illustrated, even prior to critically debunking the Corso
review, it can be seen that the rationale for inquiry is based on
misplaced bias. There is an underlying assumption that X-ray-
guided chiropractic techniques and practices are not evi-
dence-basedmethods and that the chiropractors who do
utilize radiography outside of allopathic red aguse are
practicing negligence and are a public health threat. As will be
illustrated, this is farthest from reality.
Selection of Rapid Review
The contracted review (Corso et al
) was initially registered
with the PROSPERO (International prospective register of
systematic reviews) on November 12, 2019, and the start
datewas listed as November 4, 2019.
In its ling under the
section Type and method of review,it was listed as a
systematic review(SR). The completed manuscript was
submitted to the journal Chiropractic & Manual Therapies on
March 31, 2020, accepted on May 24, 2020, and published
online on July 9, 2020.
According to the PROSPERO website, planned prospec-
tive reviews may be considered prospective until the point of
data extraction from included studies. This means that most
of the work on the Corso manuscript occurred over the course
of less than 5 months. Considering the average SR takes 6
months to 2 years for completion,
this project was per-
formed remarkably quick. Also noted is that despite being
registered as an SR,the nal published review was actually
arapid review(RR). According to Tricco et al, a RR is a
form of knowledge synthesis in which components of the
systematic review process are simplied or omitted to produce
information in a timely manner.
For such an established
aspect of clinical practice (taking X-rays), it is questioned why
a RR was performed and not a standard SR (which was of-
cially registered but not actually performed). What was the
urgency to evaluate a common practice that has existed for
decades and specically been practiced without public health
concern for 87 years in BC, Canada?
As mentioned pre-
viously, at least 23 chiropractic technique systems and many
other rehabilitation practices are X-ray-guided.
In a review of RR methods, 50 different methodological
approaches were identied.
In other words, RRs are ab-
struse as there is no consensus to their make-up. Interestingly,
the main unifying theme of RRs is that they are performed
with signicant and purposeful methodological shortcutsas
compared to the standard SR.
In actuality, a RR allows
the investigator to introduce bias by electing which pro-
cedures to eliminate in order to expediate the process. The
methods naturally become vulnerable to vast criticism for
being shottyor suspectdepending on the intent of the
study. Because no universal denition for RR methodology
(i.e., remains underdeveloped), many experts ques-
tion their validity.
Table 4. X-ray based Chiropractic Technique Systems.
Upper Cervical Techniques Full Spine Techniques
Advanced Orthogonal Aragona Spinal Biomechanics
Atlas Orthogonality Chiropractic BioPhysics
Applied Upper Cervical Biomechanics Gonstead
Blair Logan Basic
Duff Method Palmer-Gonstead
Grostic Pettibon
Kale Pierce-Stillwagon
Knee Chest Upper Cervical Specic Spinal Stressology
Sutter Specic Atlas Correction
Upper Cervical Orthogonal
Toggle Recoil (Hole-in-One)
Abbreviations: NUCCA, National Upper Cervical Chiropractic Association;
SONAR, Spinal Orthopedic Neurological Advancement and Research.
Oakley et al. 9
As we will show with the Corso study,
the inferences from
this RR are as what all RRs are understood to be; that is, their
scope is limited.
In fact, RRs should be read with a cautious
interpretation of ndings as there are gaps in transparency and
knowledge about the trustworthiness of rapid reviews.
Indeed, RRs have been found to be incongruent with stan-
dard SRs.
We question what time-sensitive demand could
have made the authors choose a RR on the utilization of X-ray
by chiropractors in British Columbia, Canada, that again, we
note, has been competently practiced without prior public
health concern for 87 years?
Inappropriate Referencing of WHO Guidelines
Corso et al cite the World Health Organizations overview of
RR uses.
According to this report, Policy-makers require
valid evidence to support time-sensitive decisions regarding
the coverage, quality, efciency and equity of health systems
and that There is also a need for capacity strengthening in
low- and middle-income countries in the eld of evidence
synthesis and rapid reviews more specically.Thus, it seems
the purpose of a RR as described by the WHO appears to be in
situations where a time-sensitivematter is at hand and/or
when decisions need to be made by low- and middle-income
countries (where a proper systematic review of the literature
may not be feasible) for which Canada is denitively not.
The WHO document is also specically designed for a
newdiagnostic test, but X-rays are the gold standard for
evaluation of spinal disorders and have been used for this
purpose for over 100 years! According to the WHO report, a
SR would be a standard necessary to properly assess
healthcare policy; therefore, as stated in the WHO report:
generally accepted standards for study selection, data ab-
straction, and quality assessment for systematic reviewsis to
use two or more reviewers, working independently, to screen
and select studies.The lead author (Corso) was responsible to
identify and screen all eligible articles.
The authors validated
the quality of screening by this single author by randomly
screening only ten percent of all eligible articles by a second
investigator. The decision to use only one reviewer (Corso)
introduced potential bias in the study design and goes against
the recommendations made by the WHO.
Eliminating Valid Studies If Not Performed by
One of the most condemning aws of the Corso et al review is
the inclusion criteria being studies of patients presenting to
chiropractors who received spinal radiographs of the cervical,
thoracic or lumbar spine region, in the absence of red ags.
Knowing that literature of the manual therapy sciences is
and that in particular, chiropractic specic literature
is limited,
setting this inclusion criteria to be strictly studies
done by chiropractorsautomatically excludes hundreds if
not thousands of otherwise relevant studies where the
interventions are part of a practicing chiropractors legally
licensed armamentarium!
An illustration of the tragic aw of strictly requiring
chiropractic patientsinvolves the exclusion of multiple
recent RCTs from the Chiropractic BioPhysics (CBP) and
related groups,
which, of course, represents the
highest level of scientic evidence. Several high-quality RCTs
show that X-ray-guided structural rehabilitation procedures
(which were invented by and are routinely practiced by a
signicant faction of chiropractors) denitively leads to im-
provement of spine alignment as measured from X-rays and
most importantly, superior long-term patient outcomes
(Figures 2-5).
The inclusion of even
one of these RCTs would have reversed the conclusion of the
review; in fact, these RCTs alone refute their ndings of no
clinical utility of X-rays as the RCT is level 1 evidence versus
the Corso et al
rapid review (i.e., decient review) which we
believe, should be considered level 5 evidence equivalent to
expert opinion.
Missed and Excluded Reliability Studies
Of the 8 total studies included in their review pertaining to
the reliability of X-rays, 6 of the 8 were from the CBP
chiropractic group.
Surprisingly, Corso et al missed 8
other papers on reliability/repeatability of X-ray mensu-
ration procedures also published by the CBP authors.
Further, although they included a chiropractic clinical out-
come study by Plaugher, et al
on the Gonstead analysis
system, they missed a reliability study on same system for
the pelvis by the same author
as well as they missed the
Surprisingly, a 1997 study published in Spine by Cˆ
et al, the co-author contracted to perform the manuscript in
question, found, Measuring the magnitude of the sagittal
curve from C2 to C7 had excellent interexaminer agree-
ment, with an intraclass correlation coefcient of 0.96 (95%
condence interval, 0.88-0.98) and an interexaminer error
of 8.3 degrees.
Oddly, this study was not included by
Corso et al.
Additionally, we found 12 other articles that included
analysis of reliability of X-ray mensuration procedures,
published by chiropractors and missed by Corso et al.
This makes 23 missed papers, that should have been included
according to their own inclusion criteria that limited papers to
being published by chiropractors. This is very concerning
considering these are more papers than they included in their
We believe these citations alone would have altered
their ndings regarding reliability/validity of X-ray mensu-
ration analysis.
Many more studies (we reference >130 here) were ex-
cluded merely because the reliability study was published by
non-chiropractors, although the mensuration analyses are
taught in chiropractic school and used by chiropractors on a
10 Dose-Response: An International Journal
daily basis (e.g., Cobb method for scoliosis analysis), and
published in chiropractic radiography guidelines.
Missed and Excluded Clinical Outcome Studies
Only 9 total papers were included in their rapid review; 7 of
these papers were investigations on CBP chiropractic technique
Additionally, it is unbelievable that the
most recent of these included papers was published in 2005
and no studies were included in the evaluation of X-ray utility
for the entire chiropractic profession from the last 15 years!
An inquiry to the CBP NonProt website lists over 150 papers
published since 2005.
This includes spinal modeling studies,
the sum of which has been described in recent publications.
Figure 2. Data from 2 RCTs demonstrates patients receiving lumbar extension traction as well as conventional treatments have lordosis
improvements that are sustained for 6 months after stopping treatment versus the lumbar curve in comparative groups (controls) remain
unaffected by conventoinal treatments (weighted averages from 2 RCTs
). *Indicates a signicant group difference as specied in each of
the 2 trials; brackets represent weighted standard deviation.
Figure 3. Data from 2 RCTs demonstrate patients achieving lumbar lordosis improvement (via extension traction) as well as conventional
treatments have pain reductions that are sustained for 6 months after stopping treatment versus comparative groups (controls not achieving
lordosis improvement) who show a regression (increase) of pain intensity toward baseline after stopping treatment (weighted averages from
2 RCTs
). *Indicates a signicant group difference as specied in each of the 2 trials; brackets represent weighted standard deviation.
Oakley et al. 11
The CBP research group has modeled the normal human spine
where the cervical curve is a portion of a circle and the thoracic
and lumbar spinal curves are portions of ellipses that meet at the
thoracolumbar junction at their straightest sections. Importantly,
the Harrison normal spinal model has been validated in multiple
ways. Simple analysis of alignment data on samples of the
normal, asymptomatic population has been done.
Comparison studies between normal samples to symp-
tomatic samples,
as well as between normal sam-
ples to theoretical ideal models have been done.
Two studies even showed that pain patients and asymp-
tomatic persons can be successfully identied by discriminant
statistical analysis based on spine alignment parameters; that
is, the presence of cervical or lumbar hypolordosis
which is consistent with systematic literature reviews and
meta-analysis ndings from the current literature.
These modeling papers
are important for the profes-
sion and add great weight to the clinical utility of radiography
use in chiropractic and the manual therapies.
Regarding CBP literature, there were also 4 clinical trials
done by chiropractorsalso missed by Corso.
Most importantly, and as mentioned, there were 7 RCTs also
not included (excluded by strict inclusion criteria) by
The results of these trials
demonstrate that patients who receive spine traction methods
(invented by chiropractors) based on radiographic measure-
ments (Posterior tangent method invented by Don Harrison,
DC) as a part of spine rehabilitation programs show statisti-
cally better long-term improvement in pain, disability, and
other functional outcomes as well as spinal kinematics and
other physiological measures at long-term follow-up with
improvement in radiographically measured spine alignment.
The RCTs met all the inclusion criteria of the authors, except
that the care was provided at a physiotherapy department by
physiotherapists despite the fact that many of the trials were
co-designed and co-authored by a chiropractor.
Non-surgical management of spinal deformities (e.g.,
scoliosis and thoracic hyperkyhosis) are also within the
scope of practice of Doctors of Chiropractic. Three studies
were missed by Corso et al that were conducted by chiro-
practors in chiropractic settings and published in chiro-
practicjournals for treatment of scoliosis.
The bulk of
research on the conservative approach to the management of
Figure 4. Data from 5 RCTs demonstrates patients receiving
cervical extension traction as well as conventional treatments have
lordosis improvements that are sustained for 1 year after stopping
treatment versus the cervical curve of comparative groups (controls)
remain unaffected by conventional treatments (weighted averages
from 5 RCTs
). *Indicates a signicant group
difference as specied in each of the 5 trials; brackets represent
weighted standard deviation.
Figure 5. Data from 5 RCTs demonstrate patients achieving cervical lordosis improvement (via extension traction) as well as conventional
treatments have pain reductions that are sustained for 1 year after stopping treatment versus comparative groups (controls not achieving
lordosis improvement) who show a regression (increase) of pain intensity toward baseline after stopping treatment (weighted averages from
5 RCTs
). *Indicates a signicant group difference as specied in each of the 5 trials; brackets represent weighted standard
12 Dose-Response: An International Journal
scoliosis/hyperkyphosis has been performed by and pub-
lished from other disciplines (Physical Medicine and Re-
habilitation, Physical Therapy and Physiotherapy).
These studies report on treatment methods commonly used
in chiropractic practice, including exercises and the pro-
vision of thoracolumbosacral orthoses (TLSOs). Results
across these disciplines show that scoliosis specicexer-
cises with and without bracing is effective in the management
of scoliosis,
as well as the sagittal spine defor-
mity of thoracic hyperkyphosis.
Failure to Include Upper Cervical, Full-Spine, Pelvis,
and Leg Length Inequality
Chiropractors have utilized unique X-ray views of the joints of
the spine and pelvis for over 100 years, including upper
cervical specic views, full-spine views, pelvic views, and
views specic for evaluation of leg length inequality (LLI)
(e.g., femoral head view or modied Risser-Ferguson view).
All these chiropractic specic views and their analyses are
presented in the ICA X-ray guidelines.
Importantly, the
Corso et al review did not consider these unique X-ray
views or their treatment by chiropractors as their search
strategy only included the terms cervical,”“thoracic,and
It is widely known that many specialty chiropractic tech-
niques utilize upper cervical X-ray views including Atlas
Orthogonality (AO), Blair, Grostic, NUCCA, Kale, Toggle
recoil, and others (Table 4). Dedicated upper cervical chiro-
practic X-ray views are unique to chiropractic are not typically
performed within allopathic medicine, and these include the
anterior-posterior (AP) open mouth, nasium, vertex, base
posterior, and Blair protracto views.
Regarding these
views, there are both reliability studies
clinical outcome studies.
Again, these studies should
have been included by Corso et al.
Regarding full spine X-ray analysis, many technique systems
in chiropractic utilize the AP or posterior-anterior (PA) full
spine radiographic view routinely such as Gonstead technique.
This is also the standard radiographic view throughout all
healthcare for the analysis of scoliosis. Regarding the lateral
full-spine radiograph, it is well known that the full spine view
is the standard for biomechanical assessment
and much information can be gained such as:
·A global view of the sagittal balance of C1, T1, T12,
and S1;
·An evaluation of forward/backward head translation;
·An evaluation of forward/backward ribcage posture;
·An evaluation of sagittal posture (from the postural
examination) and spinal coupling on the radiograph;
·An evaluation of cervical lordosis;
·An evaluation of thoracic kyphosis;
·An evaluation of lumbar lordosis;
·An evaluation of pelvic tilt;
·An evaluation of pelvic morphology;
·An evaluation of any retro- or spondylolisthesis;
·An evaluation of spinal degeneration (vertebrae, discs,
and spinal ligaments);
·Spinal canal dimensions; and
·A number of other anomalies, fractures, and instabilities.
The pelvic X-ray view is a popular view for some chiro-
practic approaches including the Gonstead system.
pelvic and sacral listings (i.e., thrust vector trajectories) can be
determined as well as insight into pelvic anomalies and pa-
thologies that may alter treatment approaches. Radio-
graphic screening for suspected LLI is also a common practice
by chiropractors. An LLI can induce full-spine postural
and be implicated in the pathogenesis of
spinal disorders.
Again, there are reliability studies
on radiographically measuring LLI
and outcome studies on use of shoe lifts for treatment of
These should have been consid-
ered by Corso et al.
Failure to Include Studies on Anomalies/Pathologies
that Alter Manipulative Treatment
As discussed previously, chiropractic treatment is unique and
often involves imparting high-velocity, low-amplitude forces
into the body of patients. As has been studied, albeit not
enough, every study done in chiropractic on assessing the
prevalence of bony anomalies and pathologies that may alter
the adjusting and treatment approach within chiropractic has
found alarmingly high rates (Table 5).
In other studies, it was determined that in a population of
almost 11,000 so-called healthyair force recruits, 97%
had pathological ndings.
Another study determined that
the average number of radiographic anomalies, degenerative
changes, and deviations of posture was 3.5 per screened
This latter study was performed on healthy air force
candidates, and the authors stated Since the population is
highly selected, the gures we present may be minimum
numbers in a western industrialized society.
These types of studies are of critical importance for chi-
ropractors and the implications of how different radiographic
anomalies and pathologies play into how they alter spine
manipulative approaches is an understudied area. Anecdotally,
these types of radiographic ndings are important and have
implications to patient care and outcomes.
Failure to Dene Red Flags
Despite the fact that Corso et al
mentioned the word red
ags18 times throughout their review, they failed to specify
the precise denition of the term in their paper. This is a critical
aw. For example, all spine guidelines, even red agchi-
ropractic guidelines (e.g., Bussieres et al
and Jenkins
et al
), allow for the routine and repeat use of X-rays in the
Oakley et al. 13
diagnosis and monitoring of scoliosis of the spine. Scoliosis is
not considered to be a traditional red agper se. So, if Corso
et al
do not consider scoliosis to be considered in their
interpretation of a red agthen this just adds to the in-
validation of the scope and ndings of their review as scoliosis
assessment and treatment is a major emphasis in the education
of chiropractors and is commonly managed by chiropractors.
Eliminating Valid Studies Based on Bias
In the Corso paper,
all clinical trials that were located and
included in their risk of bias scoring were thrown out due to
risk of bias.In fact, no clinical trials were considered in their
formal assessment of X-ray utility. Several of the trials we
argue were of sufcient quality. For example, the Harrison
nRCT (2002)
documenting X-ray-guided improvement in
lumbar curve and pain levels after spinal manipulative therapy
and extension traction methods as compared to no changes in
spine alignment or pain level in a control group was con-
sidered by Corso et al
to be at high risk of bias, although in a
recent systematic review this same trial was scored a low risk
of bias
and the results of this initial nRCT were later found
to be consistent with the results of RCTs on the topic.
Another Harrison nRCT (2003)
was scored similarly to
the previous trial and considered as having a high risk of bias
(their Table 1). As mentioned, Corso et al missed 4 other CBP
trials done by chiropractorsthat should have been included
in their analysis.
Importantly, if one of these trials
were included in Corso et alsnal assessment, it would have
reversed their conclusions. Corso et al mention that they in-
cluded a quality control stepin the critical appraisal of
studies; the lead author presented a summary of appraised
papers to 4 co-authors who validatedthe outcome of the
appraisals. Indeed, the nal internal validity rating of the
papers was determined through discussion(p. 4).
It seems despite using a risk of bias scoring system, the
actual allocation of uncertainty remained up to the assessor
and we argue was conveniently extra critical, particularly
when the study was performed by those who hold a pre-
existing bias against X-ray use in practice, as we will discuss.
Conclusions Dees Impairment Rating Guidelines
According to the American Medical Association (AMA),
repeatX-rays are required to be taken at maximal medical
improvement(MMI) to determine intersegmental vertebral
instability for impairment ratings.
According to the fth edition of the AMA Guidelines to
the Evaluation of Permanent Impairment, Chapter 15, The
there are 2 methods to determine permanent im-
pairment of the spine: (1) Diagnosis-Related Estimate (DRE)
and (2) Range of Motion (ROM). The DRE method is the
primary method used to evaluate individuals with an injury
(p. 374).
The guideline references White and Panjabi
to make the statement Motion of the individual
spine segments cannot be determined by a physical exami-
nation but is evaluated with exion extension roentgeno-
Impairment is rated only when the patient has
reached MMI as dened as the date from which further
recovery or deterioration is not anticipated, although over time
there may be some expected change(p. 19).
According to the sixth edition of the AMA Guidelines to
the Evaluation of Permanent Impairment (AMA Guides)
Chapter 17, The Spine and Pelvis, uses Diagnosis Based
Impairment (DBI) regional grids.
As is the case with the
fth edition,
impairment ratings are only to be made when
Table 5. Incidence of Anomalies, Pathologies and Postural Changes That Could Alter Treatment, and Relative and Absolute
Contraindications to Provide Chiropractic Treatment.
Author Region n Age Avg (SD) Sex Cohort/Setting
Contraindications Serious
PathologiesRelative Absolute
Jenkins Cervical 2814 n/r n/r Macquarie
Thoracic 695 n/r n/r Chiro Clinic 0.7%
Lumbar 1052 n/r n/r 18.3%
Young Lumbar 262 >/<50 mix Chiro Radiologist 94% 44%
Pryor Cervical 413 n/r n/r Chiro College 91%
Thoracic 403 n/r n/r Clinic 70%
Lumbar 402 n/r n/r 79%
Beck Full spine 847 33 (12) mix New Zealand Chiro 68.1% 6% 0.6-6.6%
College Clinic
Bull Full spine 1698 36 n/r Macquarie University 33% 14% 66%
Chiro Clinic
14 Dose-Response: An International Journal
the patient has reached MMI. Four of the ve dening var-
iables dictating the Class in which the severity is determined
for impairment ratings, including alteration of motion seg-
ment integrity(AOMSI) require radiographic investigation,
again at MMI.
Healthcare providers including chiropractors, therefore,
cannot perform an impairment rating in accordance with the
AMA Guides
without repeat X-rays performed after
treatment methods have been exhausted. Assuming initial
X-rays were obtained on an injured patient, these repeat
X-rays are required in the determination of most cases of
permanent impairment of the spine, and the CCBCs new
policy runs counter to the long-established AMA Guides.
Co-Authors Hold Anti-Imaging Bias
It seems ironic that a review that concludes there is no
evidenceof X-ray utility in the entire chiropractic liter-
ature when, as we have indicated this is completely contrary
to hundreds of missed studies, is made by at least 2 authors
who have known biases against routine X-ray use. C ˆ
e has
vocalized anti-imaging sentiment at scientic conferences
attended by some of the present authors (e.g., verbal exchange
during platform presentation question and answer session
and Corso has expressed anti-imaging bias on social media
outlets (Figure 6). Notably, a critical validity concern of RRs is
author bias,and notably, Corso was the sole researcher
responsible for the article review using their version of RR
Strong Conclusions Based on Little/Conicting Evidence
Corso et al
stated that No relevant studies assessed the
clinical utility of routine or repeat radiographs (in the absence
of red ags) of the cervical, thoracic, and lumbar spine for the
functional or structural evaluation of the spine. No studies
investigated whether functional or structural ndings on re-
peat radiographs are valid markers of clinically meaningful
Despite these claimed ndings, the authors draw
the conclusion we found no evidence that use of routine or
repeat radiographsimproves clinical outcomes and benets
patients.and therefore recommend chiropractors do not use
This is not a scientic statement. A basic tenant of
evidence synthesis is that one cannot make conclusive
statements when the evidence is limited (which in this case is
not, just ignored) or when the evidence is inconclusive (which
again in this case is not, just ignored). The Corso et al
ndings are opinion and at odds with scientic reality.
It has already been mentioned that many have questioned
the validity of RRs since the methods involve shortcuts,and
we pointed out that it would be easy for an investigator to
adjust the methods to suit an agenda. It is questionable that
based on only 9 papers, the authors could draw such a strong
conclusion, especially concerning that only two papers ad-
dressed the validity of X-ray use, and one of these papers
clearly support X-ray use. The McAviney et al
paper showed
powerful results in conict with Corsos conclusions. Within the
Corso paper,
they did mention McAviney et al
found that
patients having a neck curve less than 20° had twice the odds of
having cervicogenic symptoms. Importantly, McAviney et al
also determined that patients having a straightened or reversal
of the normal neck curve had 18 times the odds of having
cervicogenic symptoms. This latter nding within the included
McAviney et al
paper was not mentioned by Corso et al.
Thus, 50% of the included validity evidence (1 of 2 papers)
showed X-rays to be very useful in the assessment of sub-acute
and chronic neck pain patients. Conspicuously, Corso et al stated
that these studies provide no evidence of clinical utility.
The volume of literature is much larger than the 9 articles
included in the Corso et al analysis.
It is our contention
that the exclusion of at least the 64 missing studies meeting
their own inclusion/exclusion criteria that we mention
well as about 180 studies we also referenced that
were excluded based on not performed by a chiroprac-
would have un-
doubtedly led to the scientically accurate conclusion that
routine and repeat X-rays are very much an evidence-based
practice for chiropractors who specialize and practice various
X-ray-guided approaches to spine care.
It is noted that the journal in which they selected to publish
their RR has also published many papers with dissenting views
of the chiropractic profession in which reviews/commentaries
are known for overreaching and generalized conclusions,
and also for which the long-time chief editor has anti-imaging
Regarding the Corso et al
manuscript, several
authors of the present paper submitted letters-to-the-editor
Figure 6. Tweet by the primary author years before conducting
review on X-ray utility in chiropractic shows strong bias against X-
ray use in practice.
Oakley et al. 15
(LTE) to point out many critical aws; however, surprisingly,
these letters were peer reviewedand nally rejected
noteworthy that some of the current authors who have
published multiple previous LTEs
had never previously
experienced a journal formally peer reviewingan LTE. In the
end, the Corso review is pseudo-science and should have failed
peer review.
CCBC Rapidly Reviews and Changes the
1934 Policy (Figures 7-9)
Chiropractors in BC have had full and unrestricted use of
radiography rights since they were established in 1934.
The Corso et al paper
was published online on July 9, 2020,
and the CCBC announced to its members that it was re-
viewing the policy of full X-ray rights one week later on July
15, 2020 (Figure 7). After collecting member and public
feedback as of September 8, 2020, it was stated that A
summary of comments will be posted after the consultation
period.(Figure 7)
As of July, 2021, 6 months after the CCBC instituted
radical policy change discriminating against chiropractors
who utilize X-rays for reasons other than diagnosing serious
medical pathology (i.e., red ags), there has been no dis-
closure of the comments from its members and the public.
On a September 25, 2020, updatethe CCBC did ac-
knowledge that they had received over 1000 responses to the
proposed changes including themes related to
·Ensuring that any policy changes more clearly include
the clinical judgment of the chiropractor;
·A request that the College further dene red agsthat
a chiropractor may use in determining the need for
radiography and what factors are necessary in leading to
determining the need for radiographs;
o Factors such as a thorough history and examination
leading to a determination of the necessity of further
testing and/or radiographs.
·Clarifying the literature/studies that were considered by
the independent researchers, and why other studies were
not included in the rapid review; and
·Providing more information about and safety concerns
regarding the use of radiography.
As shown, the issues raised in these themed responses are
important and to this day have not been addressed. The entire
timeline from when the CCBC rst informed its members that
it was reviewing a well-established and important policy of
full radiography rights to revoking these full rights to parallel
medical practice red aguse was over a period of only
6 months (Figures 7-9).
It is suspect when a governing College makes such rapid
and radical policy change to a practice that had been in place
for 87 years (1934). Particularly concerning is that the CCBC
have not posted the member/public comments, they contracted
to an individual with known anti-radiology bias and im-
plemented the draft amendments(Figure 8) citing radical
restrictions 1 month after the publication of the awed review
Figure 7. Message from CCBC to its members (August 11, 2020). This notice signied the board was collecting member and public feedback
to anticipated amendments(red agonly X-ray use) between the dates August 11, 2020, to September 8, 2020. This message also
indicated the research to support this effort was the Corso et al
rapid review.
16 Dose-Response: An International Journal
that were unchanged (Figure 9) after apparent consideration of
over 1000 member/public feedback letters of concern, ad-
mittedly most being critical to the proposed policy change.
As mentioned, reliability studies are important, and the 8
included studies showed good reliability that provide legiti-
macy for X-ray use in practice. The validity studies are of
utmost importance to address the clinical utility of X-ray use in
practice, and regarding these, we question how such a radical
and discriminatory policy change could occur so quickly after
87 years and also hinge on only 2 validity papers when one
(McAviney et al
) clearly supports X-ray use.
This new CCBC policy, that restricts full X-ray use
including for analysis of biomechanical parameters as well
as screening for anomalies and pathologies that may alter
treatment approach, is clearly neither evidence-based nor
ethical. In fact, the new policy may be a threat to public
health as spine care patients will unknowingly be limited to
subpar clinical investigation (no X-ray for biomechanical
assessment) and management (no biomechanical outcome
goalsi.e., scoliosis, etc.). Undoubtedly, this may have dire
and cascading consequences to countless patients and their
clinical outcomes.
Figure 8. Original draft amendmentsto the Professional Conduct Handbook Part 15 (X-ray use) proposed by CCBC (August 11, 2020).
This is the rst time X-rays were proposed to be restricted to red agonly use since chiropractors were licenced to utilize radiography in
British Columbia, Canada, in 1934. This draft amendment was created prior to member/public feedback.
Figure 9. Final approved amendmentsinstituted by CCBC (February 4, 2021). The new policy strictly revokes X-ray use except for
purpose of examining suspected red agconditions. In the announcement on their website, they state The application of radiography is
not without risk and therefore, must be carefully considered.
Oakley et al. 17
The many criticisms of the Corso et al
rapid review illustrate
how awed methodology results in awed conclusions. It is
suspect that the CCBC contracted an individual to conduct a
systematic review on a well-entrenched aspect of chiropractic
clinical practice that ended up as an incredibly limited and fatally
awed, rapidreview with sweeping and generalized conclu-
sions condemning routine/repeat X-ray use. In fact, the con-
clusion of the Corso et al
paper is based on only two validity
papers. One of the two validity papers very clearly powerfully
supports X-ray utility in clinical practice. It is concerning that the
authors of the contracted Cˆ
e paper concluded there is no
evidencefor X-ray use in chiropractic (outside of red ag
screening) when literally dozens of chiropractic-specic
178,181,209-232,373-380,383-387,390-40 1,413-424,429,430,432
and 100s of
other papers were clearly missed.
The Corso et al
statement We found no evidence that the
use of routine or repeat radiographs to assess the function or
structure of the spineimproves clinical outcomes and
benets patientsis factually false, it is antithetical to scientic
reality, and it is based on a fatally awed review that was
written by biased researchers who hold anti-imaging ideology.
It is ironic that Corso et al
attempted to assess the clinical
utilityof X-ray use in chiropractic when there is no un-
equivocal answer to the meaning of clinical utility; in fact,
Clinical utility will always be in the eyes of the beholder,
and the answer will therefore be different depending on the
interests and goals of the stakeholder.
Lesko et al
mind us that the evidence of clinical utility will be judged
differently by equally qualied peers to the usefulness of the
diagnostic (in this case X-rays) as applied to patients to their
real-world clinical practice settings.
It is irresponsible that the CCBC, a formal regulatory body
made a fundamental policy change so rapidly, basing its
decision on a single awed review, all while acknowledging
over 1000 feedback responses were mostly critical of the
change. The member and public feedback were obviously not
considered as the draft for the policy change released prior to
the open feedback period (Figure 8) did not change following
public/member feedback (Figure 9); in fact, it was more
strictly specied. To this day, the CCBC has not released the
content of the 1000+ feedback responses.
Perhaps the most tragic outcome to the policy change that
discriminates against chiropractors who practice evidence-
based, X-ray-guided methods is the fact it actually discrim-
inates against the healthcare consumer (ie, patient) by not
allowing them to make health choices based on education
provided within a risk-to-benet ratio by clinicians. In fact, it
is known that certain spinal disorders can predispose affected
patients to future undesirable outcomes, including greater
injury rates,
greater injury severity (e.g., during motor
vehicle collisions
), development of future pain and
disability (e.g., having lumbar hypolordosis
), having
lingering pain and disability after a sustained injury (e.g.,
nonrecovery after whiplash
) and even early mortality (ie,
from thoracic hyperkyphosis
). Most of these spine
deformities have established or evolving evidence for their
non-surgical treatment and reduction. It is an honest and
ethical practice to screen and inform appropriate patients of
the pathognomonic consequences of certain spinal conditions.
As discussed, it is a well-framed and evidence-based
practice to routinely assess a patients spine and pelvis for
biomechanical assessment that is linked to procedural treat-
ment approaches and patient outcomes. In a recent synopsis of
the clinical utility of X-rays in chiropractic and the manual
it was determined X-rays are uniquely required by
chiropractors and manual therapists specializing in spine-
altering techniques and practices for three main purposes:
1. To assess spinopelvic biomechanical parameters;
2. To screen for relative and absolute contraindications to
spine care;
3. To re-assess a patients progress to some types of spine
rehabilitative treatments.
We would add an obvious fourth reason; that is, to rule out
red agsor serious medical conditions (i.e., malignancy,
infection, and fracture) unrelated to spine care that would
warrant immediate referral. The recent restriction of X-ray
rights by the CCBC increases the liability to the doctor who, in
many instances, is now handcuffedand forced to treat
patients blindly.
Discrimination against the consumer of spine care will
subject them to limited (in many cases inadequate) clinical
investigation and therefore limit management options (e.g.,
restrict spine-altering options including specic vectored
spine adjustments, spine corrective traction, spine corrective
bracing, and spine correcting exercises). Patient care plan-
ning requires the consideration of patient goals, needs, and
values. Indeed, when clinical opinion varies, lawmakers and
policy makers must weigh consumer values and desires into
policy decisions taking into account therapeutic risks, and in
the case of diagnostic ionizing radiation, the risks are shown
to be negligible. Full evidence-based practice (EBP), in fact,
consists of three separate arms: (1) clinical evidence, (2)
practitioner experience, and (3) patient preferences.
To no t
consider practitioner experience or patient preference is to
not follow true EBP. The CCBCs new policy change to
restrict full radiography use directly opposes modern EBP
principles 2 and 3 and is clearly based on only a pre-select
dropof the actual ocean of scientic evidence available on
the topic.
Radiation exposures from X-rays used in the assessment and
monitoring of patients receiving particular forms of chiro-
practic and manual therapy treatments are not a public health
threat. These low-dose radiation exposures have not been
18 Dose-Response: An International Journal