The Rationale and Safety of Routine Imaging in Rehabilitative Spine Care: Delayed Radiographs for Patients Presenting With Spine Disorders is Debatable

Abstract

Postural alignment is a critical determinant of health status. Its degradation is associated with deformity-caused and compensation-related back pain, neurologic involvement, osteoarthritic development, as well as disability and reduced quality of life. Radiography remains the most efficient method of evaluating standard sagittal and coronal spine and pelvic metrics that are used to plan surgical and nonsurgical treatment strategies. Many current spine guidelines dissuade the use of initial screening X-rays and some chiropractic guidelines condemn repeat imaging to assess progress from treatment regimens; these are anti-scientific viewpoints that ignore alternate viewpoints and evidence. Current understanding of the relationship between different spinopelvic parameters are essential to plan biomechanically appropriate interventions that are patient-specific. There are radiographically measured parameter thresholds critically related to several spinal disorders and positive patient outcomes. Current guidelines must include a caveat for contemporary biomechanical evaluation and its consequent specific treatments and should recommend routine radiographic imaging for spine patients undergoing corrective rehabilitative interventions. The failure to radiographically diagnose spinal deformity is argued to be negligence in many cases. The prime obstacle to routine X-ray imaging lies with the presumed threat of cancer, however, this is dogma; we summarize the main evidence from recent publications why this is so.

Keywords

spine x-rays low back pain linear no-threshold radiophobia

Introduction

Many guidelines for low back and neck pain recommend delayed imaging and dissuade practitioners from taking initial radiographs of their patients.^1–4 This is particularly emphasized for patients presenting with new or acute spine pain, and some guidelines go as far as dissuading repeat imaging for assessing response to treatment (eg, ACA Choosing Wisely⁵).^5–8

A reality in spine care is that most patients have recurrent spine problems. Investigations have shown the majority of patients who have a first episode of low back pain (LBP) will go on to have more than one episode.⁹ Several studies have determined that about a third of patients experiencing an acute LBP episode progress along a trajectory towards developing chronic LBP.^10,11 Some estimates have been as high as 75% of patients being shown to suffer from their pain 1 year after a LBP episode.¹² The reality is that in clinical practice, the presenting patient is not reporting a first time incidence of LBP, but more likely a recurrent episode or exacerbation indicative of the common waxing and waning of an original back problem.¹³

Chronic back pain has direct links to spine deformity and altered alignment.^14–16 Several systematic reviews have unravelled the association and causative effects of biomechanical structural misalignments and their relationships to chronic LBP. For example, loss of lumbar lordosis and spondylolisthesis have both been shown to have direct biomechanical relationships to LBP.^14–16 Importantly, these ‘biomechanical diagnoses’ are essential to uncover via radiography, and with modern spine rehabilitation methods, these conditions and others are treatable. In fact, the spine literature has provided an abundance of evidence clearly showing the close relationship between spine deformities (ie, subluxation displacements) with pain, disability and poor health-related quality of life measures.^14–19

The spine literature has greatly advanced in the last 20 years. There are now well-established spine parameter thresholds that serve as treatment targets or structural goals of care.^20–23 Surgeons who perform spine fusions use various radiography-measured biomechanical spinal parameters, and then follow best-practice guidelines to achieve improved spine and postural displacement positions within certain thresholds in order to prevent poor post-surgical outcomes. Accordingly, non-surgical musculoskeletal health care providers (eg, chiropractors, physiotherapists, etc.) also treat various spine deformities, and importantly treat patients who, without successful treatment, may regress to the point of becoming a surgical spine patient. With the evolution in both the understanding of the interrelationships between spine and pelvis parameters and how these are related to spine function and patient health, it is imperative to perform full-spine radiography to evaluate these relationships in the planning of contemporary spine-altering treatment regimens.

Several factions of spine care specialists, including surgeons, chiropractors and physiotherapists who specialize in spine altering treatments, universally stress the necessity and encourage initial biomechanical parameter assessment via radiographic screening.^24–29 Thus, we argue that it is ethical to routinely image the spine in the initial assessment of spine patients as there are a multitude of benefits vs no risks. Herein, we outline why the traditional view of radiogenic cancer risk is outdated, dogmatic and not supported by the literature. We describe how this misinformation serves to perpetuate unnecessary fear and is a major obstacle to the universal acceptance of routine radiographic imaging in practice. Second, we outline how routine X-ray imaging of the spine leads to a multitude of benefits which include: 1. Biomechanical diagnosis (ie, by using contemporary metrics); 2. Avoiding delayed or outright missed diagnoses; 3. Making timely referrals to appropriate specialists; 4. Cost savings by avoiding unnecessary costly advanced imaging (eg, MRI); 5. Satisfying the patient.

Part I. Radiation Fear-Mongering and Cancer Risk Misinformation

Many recent chiropractic guidelines and opinion commentaries have reiterated the disuse of routine X-ray imaging for the initial assessment of LBP patients as well as the re-assessment of patients following care.^4–8 The perceived risk stems from the ionizing radiation, presumed to be associated with the potential of inducing future cancers.³⁰ There are, however, scientific flaws and logical misrepresentations associated with this traditional and long-held perception.

Recent evidence has come to light showing that the critical events leading to the eventual adoption of a linear-no-threshold (LNT) model of cancer risk assessment was attributed to poor study design and unethical scientific misconduct by Hermann Muller, the Nobel prize winning geneticist.³¹ Historical documents reveal that leading up to his famous Nobel lecture advocating for the use of the LNT model for radiation risk assessment, he was conflicted between the smooth path forward ensuring his continued funding from the Rockefeller Foundation vs his ethical obligations to the scientific community to expose possible scientific misconduct of recent studies that supported the LNT by entities involved in the granting of the funding he was receiving.³² In a series of papers, Calabrese et al prove that Muller misled the scientific community in his famous Nobel Prize lecture, that represented a monumental event leading to the world-wide adoption of the LNT radiation risk assessment model.³³

The LNT model is more of a convenience model than a scientifically accurate model of radiation exposure.^34,35 LNT theory assumes that high-dose radiation exposures and the corresponding physiological effects are related linearly; from high exposure down to zero exposure. Belief in the LNT theory assumes that all ionizing radiation is harmful (carcinogenic), and that it is also cumulative (dose additivity).³⁶ Problematically, neither assumptions are true. First, there exists no data supporting low radiation doses (<200 mrem) causes cancer. In fact, there are hundreds of studies that show the opposite.³⁷ In fact, the LNT is not supported by modern radiation biology.³⁸ Ironically, the LNT projects radiation damage down to the smallest exposure approaching the zero exposure, but the model is unrealistic as a zero-exposure environment does not exist.³⁹ All humans are constantly bombarded with radiation from many sources on a daily basis including background radiation.

Background radiation mostly comes from terrestrial and cosmic sources and no human can escape this exposure. If the LNT was an accurate model of cancer risk, then humans exposed to greater amounts of background radiation would have higher cancer and mortality rates, however, the reverse is true. David et al, for example, showed that there is a positive linear relationship between greater background radiation levels and increased life expectancy, and a negative linear relationship between greater background radiation levels and less cancer death rates, for both males and females.⁴⁰ Importantly, this study used data from 320 million people from 3139 counties in the US. They showed that life expectancy, considered the most integrative index of human health, was about 2.5 years longer for people living in higher background vs lower background radiation levels (>180 vs < 100 mrem/yr, p < .005).⁴⁰

The second assumption of the LNT, that all radiation exposure is additive is also false; in fact, if it were true, all people exposed to daily background radiation would eventually die from its accumulation and additive effects. The phenomenon of radiation hormesis is an alternate model of radiation exposure that graphically illustrates radiation exposures as having a ‘U’ shape. Low-dose radiation, but more than zero, has the most beneficial effects on physiology as opposed to both lower amounts and higher amounts. In other words, there is an optimal amount of radiation exposure that has been found to stimulate the body’s adaptive protection systems to repair any DNA damage caused.^41–43 Lobrich et al⁴⁴ determined that DNA double-strand breaks (DSBs) occurs in humans after receiving a CT scan. The DSBs were seen to be self-repaired between 5-24 hours after the scan, and importantly, the body’s innate repair mechanisms repaired more than the original damage caused by the scan. In other words, the final DNA DSB count was less than the initial count prior to the scan.⁴⁴ It is now understood that the application of low-dose radiation can have positive effects on human health and can be used in the treatment of many human ailments,⁴⁵ as well as its demonstration of increased longevity as previously discussed.⁴⁰

A final consideration for this review is that compared to the very small amounts of radiation experienced from spinal X-rays, the fact is, our own body’s metabolism produces the greatest threat to our cells every day. Our metabolism produces endogenous reactive oxygen species (ROS) and hydrogen peroxide (H2O2) from aerobic metabolism^46–48 (ie, breathing air) and incredibly, produces about 200 million times greater genetic damage than background radiation.³¹ The radiation dose from plain film spinal X-rays are approximated to be within the range of background radiation levels that fluctuate depending on geographic region. Our adaptive repair systems, however, are so efficient that 99.99999% of the oxidative damage gets repaired.³¹ Therefore, it is argued that the body’s repair mechanisms have evolved to not only repair radiation damage from minute sources, such as background radiation (or occasional X-rays), but rather to protect us from the unavoidable, endogenous damage from normal metabolism.³¹ As we have previously argued, this point alone deems radiogenic cancer risks from spinal X-rays completely irrelevant⁴⁹; why don’t restrictive imaging guidelines warn people of the cancer risks of breathing air?

Part II: Neglecting Spinal X-Rays is Negligence – Advantages of Routine Imaging

Just as surgeons make better treatment choices based on biomechanical relationships between X-ray based spinal parameters, so too do spine rehabilitation practitioners. Le Huec and Roussouly, for example, state: “Spinal imbalance should be taken into consideration before initiation of any kind of treatment including conservative or surgical procedures.”²⁶

Despite many anti-imaging proponents claiming a lack of evidence to support X-ray-based non-surgical rehabilitation approaches,^5–8 there is in fact an overwhelming literature base supporting spine-altering approaches in the sagittal plane for the cervical spine,^50–65 thoracic spine^66–74 and lumbar spine,^74–81 and for the coronal plane in non-scoliotic spine deformities in the cervical spine,⁸² thoraco-lumbo-pelvic region⁸³ and for scoliotic spine deformities.^84–87 Further, one can argue that even non-spine altering approaches, such as spinal manipulative therapy (SMT), can be better planned for a specific patient with their unique spinal deviations and other X-ray diagnoses (degenerative changes, anomalies etc.) taken into consideration; occasionally these SMT methods are known to produce improvements in radiological outcomes on post intervention analysis.⁶²

The advantages of routine X-ray imaging in spine care include:

1. Biomechanical diagnosis (ie, by using X-ray metrics).

2. Avoiding delayed or outright missed diagnoses.

3. Making timely referrals to appropriate specialists.

4. Cost savings by avoiding unnecessary costly advanced imaging (eg, MRI).

5. Satisfying the patient.

Here we consider each.

Biomechanical Diagnosis (ie, by Using X-Ray Metrics)

Traditional pain diagnoses do not help to dictate successful treatment approaches. For example, ‘low back pain,’ ‘sciatica,’ or ‘radiculopathy’ diagnoses are common but do not translate into identifying cause or best treatment options. Alternatively, diagnoses such as ‘lumbar spine hypolordosis,’ ‘thoracic spine hyperkyphosis,’ or ‘cervical kyphosis’ do translate into cause and effect; that is, can direct treatment selection unique to the patient. Each of these biomechanical diagnoses can be quantified and then be targeted with patient-specific treatment to improve the respective spine displacement or deformity.

We emphasize the use of biomechanical diagnoses by presenting 5 consecutive patients from the first author’s spine clinic. Figures 1-5 illustrate how each individual can be diagnosed with specific biomechanical subluxation/displacement patterns that correlate to each respective patient’s symptoms and functional abilities, and although not presented here, each were treated with patient-specific approaches based on their unique spine patterns. After inspecting Figures 1-5, it becomes clear that patients can be quickly diagnosed biomechanically, either to have or not have particular biomechanical relationships in their neutral standing position. Clinically, this essential biomechanical information can only be efficiently attained via the mensuration of standing X-rays that range from the base of the skull down to the femur heads.²³ We reiterate here that this approach is definitively an evidence-based form of radiological based assessment and intervention.^50–87

Figure 1.

A 37-Year Old Concerned About His Posture and Hip Tightness. This Patient was Diagnosed With a Right Thoracic Lean, Right Head Translation, Increased Pelvic Tilt, Increased Sacral Base Angle, Lumbar Hyperlordosis, Thoracic Hyperkyphosis, Anterior Head Translation, and Cervical Hypolordosis. Note for Figures 1-5: Left: Stitched, Lateral Full-Spine Radiograph; Right: Stitched Anterior-Posterior Full-Spine Radiograph; Green line: Ideal Alignment; Red line: Patient Alignment

Figure 2.

A 32-Year Old Female With Chronic Back Pains (6/10). This Patient was Biomechanically Diagnosed With Scoliosis, Cervical Kyphosis, Thoracic Hypokyphosis, Increased Pelvic Tilt, Increased Sacral Base Angle and Lumbar Hyperlordosis

Figure 3.

A 46-Year Old Male With Chronic Neck and Back Problems Seeking Relief From Pain. This Patient was Biomechanically Diagnosed With Thoracic Hyperkyphosis, Posterior Thoracic Translation, Anterior Head Translation, Cervical Hypolordosis, and an Anatomical Leg Length Discrepancy

Figure 4.

An 83-Year Old Female Complained of the Inability to Straighten up was Told by Her Massage Therapist She May Have ‘Scoliosis.’ This Patient was Diagnosed With Severe Scoliosis, Severe Thoracolumbar Kyphosis, Anterior Head Translation, and a Reduced Sacral Base Angle. Note the Right Lateral-Listhesis of L4 on L5

Figure 5.

A 64-Year Old Female With Chronic Neck and Back Pains Averaging 8/10. This Patient was Diagnosed With Lumbar Scoliosis, Right Head Translation, Upper Thoracic Hyperkyphosis, Lower Thoracic Lordosis, Anterior Head Translation, and Cervical Hypolordosis

Many thresholds for biomechanical parameters exist in the literature (Table 1). For example, the surgical literature has shown post-surgical outcomes are superior when the head is corrected to less than 40 mm of forward head translation.⁹⁰ A more conservative cut-off is suggested as 25 mm,⁸⁹ whereas, ideal posture is considered to be less than 15 mm.⁸⁸ The definition of scoliosis is having a Cobb angle greater than 10°, however, 20° is considered the threshold for spinal deformity.^17,99 The standard classification of moderate severity scoliosis is in the range 20-40°, and above 40° is considered severe. A plethora of magnitude thresholds are available throughout the literature (Some shown in Table 1), it is up to the spine care specialist to discern what values are appropriate to select for ‘goals of care’ given the age, symptoms, degree of degenerative processes and other factors in the patient being treated.

Table 1.

Biomechanical X-Ray Parameter Thresholds Reported in the Literature as Treatment ‘Goals of Care.’

Spine region	X-Ray parameter	Threshold value	Symptom/outcome	Reference
Cervical
	Anterior head translation	15 mm	Pain-free normal	Harrison, 1996⁸⁸
		25 mm	Pain/disability	Ajello, 2017⁸⁹
		40 mm	Disability/QOL	Tang, 2012⁹⁰Ling, 2018²⁰
	C7 slope	<40°	Good economical balance in neck	Le Huec, 2015⁹¹
	T1 slope	20-40	Normal range	Ling, 2018²⁰
	Spino-cranial angle	83 ± 9°	Normal	Le Huec, 2015⁹¹Ling, 2018²⁰
	T1 slope – cervical lordosis	<20°	Important for good clinical outcomes	Ling, 2018²⁰
	Lordosis
	Cobb C2-C7	30-39°	3 x more likely to be asymptomatic	Aldabbas, 2025⁹²
	Cobb C2-C7	21-29°	1.5 x more likely to be asymptomatic	Aldabbas, 2025⁹²
	Cobb C2-C7	<20°	9-10 x more likely to have headaches	Aldabbas, 2025⁹²
	Cobb C2-C7	<20°	Pain	Okada, 2009⁹³
	Cobb C2-C7	<0°	Pain, neurovascular deficit	Tang, 2012⁹⁰Okada, 2009⁹³Katsuura, 2001⁹⁴
	ARA C2-C7	>34°	Pain-free	Harrison, 1996⁸⁸
	ARA C2-C7	31-40°	Clinically normal	McAviney, 2005⁹⁵
	ARA C2-C7	29-42°	Theoretical normal	Oakley, 2021⁹⁶
	ARA C2-C7	<29°	Acute pain threshold	Harrison, 2004⁹⁷
	ARA C2-C7	28°	Acute pain average	Askin, 2017⁹⁸
	ARA C2-C7	<22°	Chronic pain threshold	Harrison, 2004⁹⁷
	ARA C2-C7	<20°	2x likelihood of pain	McAviney, 2005⁹⁵
	ARA C2-C7	<20°	Chronic pain average, lordosis negatively correlated to pain duration	Askin, 2017⁹⁸
	ARA	<0°	18x likelihood of pain	McAviney, 2005⁹⁴
Thoracic	Kyphosis
	Cobb T4-T12	>60°	Spinal deformity, disability	Pellisé, 2015⁹⁹; Bess, 2016¹⁷
	Cobb T4-T12	>45°	Total pain, general self-image, general function, and activity	Petcharaporn, 2007¹⁰⁰
	Cobb T4-T12	45°	Limit of normal above this threshold it is abnormal and hyper kyphotic	Nissinen, 1995¹⁰¹
	Cobb T5-T12	33°	Limit of normal above this threshold it is abnormal and hyper kyphotic	Kolessar, 1996¹⁰²
Lumbar	Lordosis
	Cobb T12-S1	65°	Average normal	Harrison, 1998¹⁰³
	Cobb T12-S1	<57°	Chronic pain	Harrison, 1998¹⁰³
	ARA L1-L5	40°	Average normal	Harrison, 1998¹⁰³
	ARA L1-L5	<30°	Chronic pain	Harrison, 1998¹⁰³
Pelvis	Pelvic tilt	>20°	Spinal deformity	Schwab, 2012¹⁰⁴
		>25°	Spinal deformity, disability	Pellisé, 2015⁹⁹Bess, 2016¹⁷
	Pelvic incidence – lumbar lordosis	>10°	Mismatch	Schwab, 2012¹⁰⁴
Lateral full-spine	Sagittal vertical axis	>40 mm	Spinal deformity	Schwab, 2012¹⁰⁴
		>50 mm	Spinal deformity, disability	Pellisé, 2015⁹⁹Bess, 2016¹⁷
		>95 mm	Severe deformity	Schwab, 2012¹⁰⁴
AP full-spine	Scoliosis Cobb angle	>10°	Scoliosis Dx, mild magnitude
		>20°	Spinal deformity/disability/ moderate magnitude	Pellisé, 2015 ⁹⁹Bess, 2016¹⁷
		>30°	Deformity	Schwab, 2012¹⁰⁴
		>40°	Severe magnitude
		>50°	Surgical threshold
	Coronal plumbline offset	40 mm	Coronal imbalance	Glassman, 2005¹⁰⁵
		30 mm	Coronal imbalance	Lowe, 2006¹⁰⁶Berven 2007¹⁰⁷
		25 mm	Reduced vitality in degenerative scoliosis	Ploumis, 2009¹⁰⁸

It is important to note that thresholds of spinal deformity for spine surgeons are likely greater than the thresholds for treatment of non-surgical manual therapists.²⁹ Indeed, patients resorting to surgical consult and subsequent surgery frequently have endured excessive suffering as many consider surgery as a ‘last option’.²⁹ Therefore, patients presenting with spinal misalignments whom suffer from pain, disability and functional limitations should be considered for non-surgical spinal rehabilitation, as the closer the spine and posture is to ‘ideal,’ the easier it should be to correct it. Logically, treating smaller deformities, if successful, would lead to the prevention of larger deformities and potentially invasive surgeries.

Avoiding Delayed or Outright Missed Diagnoses

The first point, biomechanical diagnosis leads to the second listed benefit of avoiding missed and delayed diagnoses. A spine patient who has not been adequately screened by standing X-rays remains, at least biomechanically, undiagnosed. With appropriate mensuration, virtually all patients will have biomechanical diagnoses from their radiographs (ie, Figures 1-5). As demonstrated in Figures 1-5, it can be logically anticipated that all patients will demonstrate unique biomechanical relationships of the spine and posture based on previous injuries, habits, occupations, etc.

We have determined that in a sample of 100 consecutive chiropractic-seeking patients, full-spine radiography revealed that all patients had clinical information gained from the X-rays that aided in customizing treatment procedures.¹⁰⁹ Further, regarding the diagnosis of specific spine deformities, depending on the thresholds used, large percentages were diagnosed with various spine misalignments associated with pathologies. Only 12% of the sample had an ideal cervical lordosis (between 29-42° measured from C2-7 posterior tangents) where 64% had a cervical neck curve straighter than 22° which correlates to the average value of chronic neck pain subjects. Forty-four percent had an anterior head translation (forward head posture) of greater than 25 mm which correlates with pain and disability.⁸⁹ Forty-two percent of the sample had a thoracolumbar offset from the vertical of greater than 25 mm, and 20% had a sagittal vertical axis imbalance greater than 50 mm, constituting adult spinal deformity (ASD). Fifteen percent had a complete cervical kyphosis, associated with an 18x likelihood of experiencing neck pain.⁹⁴

Beyond diagnosis on spine patients seeking care for their ailments, studies on healthy populations also show high percentages of abnormal X-ray findings. Studies on military personal, for example, have shown that high percentages of the population have radiographically diagnosable pathologic findings. Hald et al¹¹⁰ found 97% of 11 000 ‘healthy’ air force recruits had pathologic findings on X-ray. Anderson et al calculated an average of 3.5 radiographically diagnosable anomalies, degenerative changes, and/or deviations of posture per screened person and suggested that due to this population being ‘highly selected’ the number may be much higher in a typical western society population.¹¹¹

An important logical point is that those who were previously treated without being X-rayed, and then sought out treatment from a provider who performed X-rays will have been a victim of a delayed diagnosis due to the avoidance of initial X-rays. There is an abundance of examples in the literature featuring previously ‘failed treatment’ as the examination of finally attained X-rays led to a biomechanical diagnosis, which in turn, appropriately led to a specific treatment for that specific biomechanical misalignment.^112–117 The final analysis of avoiding initial X-rays is that it leads to ‘black box treatment’²⁹ and therefore, spine misalignments that are not diagnosed will not get treated.

Making Timely Referrals to Appropriate Specialists

Urgent specialist referrals are appropriate when diagnosing certain rare medical conditions (eg, cancers, abdominal aortic aneurisms, etc.). Although anti-radiographic proponents argue that medical referrals based on diagnosing medically urgent ‘red flag’ diagnoses are rare, red flag screening tests are inherently known to have validity concerns (ie, false negative rates),¹¹⁸ increasing the chances of missing a serious diagnosis and increasing clinician liability. Henschke et al,¹¹⁹ for example, found a 1% incidence of serious pathology in 1172 consecutive patients. However, an alarming 80% of patients demonstrated ‘red flags,’ and 50% of the patients with serious pathology would have likely been missed without further imaging. Importantly, it was impossible for the physician to differentiate, during the initial consultation, which of the 80% (985/1172) of the sample having red flags actually had the more serious pathologies.¹¹⁹

Chiropractic-specific studies have shown that so-called ‘rare’ serious pathologies may not be so rare. In regard to malignancies, Beck found an incidence of up to 3.1% in a sample of 847 full-spine patient radiographs (ie, 1 in 32).¹²⁰ Importantly, the frequency of malignancies as incidental findings are increasing as cancer rates are continuing to rise,¹²¹ and cancer is a diagnosis that should not be missed.¹²² Outside of malignancies, other serious pathologies are possible and have relatively high incidence rates. In the same study by Beck et al,¹²⁰ the incidence of fracture was 6.6% (1 in 15), abdominal aortic aneurysm was 0.8% (1 in 125), and atlantoaxial instability was 0.6% (1 in 167). All of these are ‘incidental findings,’ and clinically important pathologies that render physical manual therapies as an absolute contraindication. Professional referral to an appropriate specialist would better serve the patients interest.

Another consideration is that the biomechanical diagnoses obtained via radiography offers the opportunity to identify patients at risk for certain conditions based on spinal misalignments. Adolescent idiopathic scoliosis, for example, is often first noticed by the parent while coincidentally noticing asymmetries in their child’s back. Since scoliosis screening programs are frequently no longer endorsed, scoliosis is often missed. Problematically, larger curves are more difficult to treat, while smaller curves afford a better opportunity for a better outcome if diagnosed early in its development.¹²³ Other deformities such as thoracic hyperkyphosis, scoliosis, forward lean of the body (sagittal vertical axis), and ASD are associated with balance instability,¹²⁴ and patients with instability, particularly older patients, should be triaged for balance rehabilitation to prevent falls, injuries and deaths.¹²⁵

The universal proposition for the avoidance of initial X-rays (‘red flag only’ guidelines), are based on the low odds of finding serious pathology (eg, cancer, fracture, etc.). However, most chiropractic guidelines are simply a reiteration of medical physician LBP guidelines which provides guidance on the treatment of back pain mainly by pharmaceutical agents, not imparting manual forces directly onto the spine. Manual therapists, including chiropractors and physiotherapists offer fundamentally different treatments, and logically, should have unique considerations included into discipline-specific guidelines. In this section, we have argued that timely referral to appropriate specialists can be made when definitive information from radiographs are immediately available. As demonstrated, when images are not at hand, much opportunity is lost at the patient’s expense. An inconvenient reality for anti-imaging proponents is the fact that even when manual practitioners abide by X-ray restrictive guidelines, under-referring for X-rays are common.¹²⁶ In other words, when ‘red flags’ are present, many times the patient is not referred for imaging; this is very concerning. Initial routine imaging would eliminate this possibility.

Cost Savings by Avoiding Unnecessary Costly Advanced Imaging

Anti-imaging proponents argue that avoiding routine imaging helps to reduce health-care costs.^6,7 In certain cases this may be true, but only by a marginal magnitude as plain film imaging is very cost effective and readily available. More importantly, routine plain film imaging leads to a large reduction in health care expenditures as it reduces or eliminates the need for higher cost imaging (eg, MRI, CT etc.).¹²⁷ In fact, the implementation of routine initial radiological spine screening would greatly reduce healthcare costs that are associated with more advanced imaging including CT and MRI.

Further, in the larger context of patient management, routine X-ray screening provides immediate and potentially critical information to assist in the guidance for treatment decisions regarding triage for advanced imaging (eg, MRI), for referral (eg, surgical and specialist consultation), prompting indications for co-management (rheumatologist and pain specialist), for ruling out or confirming a definitive diagnosis, for easing the anxiety of the patient, satisfying liability concerns of the practitioner and third party payors, and providing a timely diagnosis.^128–130 Perhaps the latter point, providing a timely diagnosis (or non-diagnosis) culminates in the most healthcare savings as it prevents the lingering of patient diagnosis and treatment, and facilitates timely management.

Satisfying the Patient

The 3 arms of modern evidence-based medicine includes best research evidence, clinical expertise as well as patient values and preferences.¹³¹ Unfortunately, patient values and preferences are often ignored in the triage of the patient encounter.¹³² It must be pointed out, however, that patients who seek spine care expect a thorough examination that includes radiographic imaging.^133–135 The classic Deyo study, for example, determined that 73% of patients expect x-rays for the diagnosis of their spine problem.¹³⁴ Jenkins et al¹³⁵ determined about half of all patients seeking care for low back pain consider imaging necessary. Satisfying patient needs involves fulfilling their expectations. It is established that patients are already more satisfied with chiropractic care,¹³⁶ but they are particularly satisfied when their beliefs are met by receiving radiographic imaging for their spinal problems.^137–139

A frequently cited reference used to support the discouragement of routine radiography in LBP management is the Kendrick study.^137,138 Ironically, Kendrick et al determined that two-thirds of all the patient radiographs were abnormal and also that 61% of patients who were followed for 9-months remained in pain. Importantly, the back pain patients who received imaging were more satisfied with the (ineffective) care they received. The study also found that patients allocated to a preference group, where the decision to receive lumbar radiography was made by them, achieved clinically significant improved outcomes compared to those randomized to a non-radiography or to a radiography group.^137,138

Thus, it seems patients who are radiographically screened and given a certain diagnosis or non-diagnosis are more satisfied with the care they are provided, regardless of treatment effectiveness. Of course, critics would argue that reporting potential non-significant X-ray findings to a patient may lead to detrimental outcomes as the patient may cling to an image finding when it could be a coincidental and benign finding, we argue the onus is on the practitioner to realistically report X-ray results to the patient and its importance or particularly, its lack of importance as it would be unconscionable to not report radiographic findings regardless of the implications.

Discussion

Herein we described how there are no valid data to support use of LNT theory for the low-dose ionizing radiation exposures. Therefore, dose as a surrogate for risk in radiological imaging is not appropriate, and as argued previously, the use of the ‘as low as reasonably achievable ‘ (ALARA) concept in medical imaging is obsolete.¹⁴⁰ Regarding the ALARA concept, Oakley and Harrison¹⁴⁰ have described how the continued application of a false principle unnecessarily constrains healthcare professionals who attempt to deliver high-quality patient care and leads to the reluctance by doctors to order images, leads to a resistance from patients (or their parents) to receive images, leads to subquality images, leads to repeated imaging and increased radiation exposures, stifles use of low-dose radiation research and treatments (low-dose radiation therapy), and continues the endorsement of the ALARA principle. Tragically, it also propagates radiophobia; that is, the ubiquitous fear of X-rays.³⁰

The LNT model of radiation damage has been thoroughly discredited¹⁴¹ and remains the universal cancer risk model for political and economic reasons, not for safety reasons.¹⁴² We summarized how the 2 underlying features of LNT concept, linearity and additivity, are not true for the low-dose exposure region. Also, as discussed, breathing air is millions of times more harmful and we are not concerned with this. It is ironic that within literature debates between pro-imaging and anti-imaging proponents (‘red flag’ only use),^5–8 the anti-imaging adversaries cannot address legitimate validity concerns over use of the LNT and the current radiobiological evidence that fails to support LNT.^143–146

We summarized 5 clinically significant reasons supporting the use of routine imaging by spine care specialists including 1. Biomechanical diagnosis (ie, by using X-ray metrics), 2. Avoiding delayed or outright missed diagnoses, 3. Refer to appropriate specialist, 4. Cost savings by avoiding unnecessary costly advanced imaging (eg, MRI), and 5. Satisfy patient. All of these arguments individually support routine imaging; particularly as there are no radiation risks. Ultimately, we argue that the routine radiographic imaging approach has a risk-benefit profile of all benefit, no risk.

Regarding biomechanical diagnosis and X-ray cut off metrics that are reported in the scientific literature (Table 1), there is often conflicting evidence reported in the literature. For example, the 2018 systematic literature review with meta-analysis by Guo et al¹⁴⁷ reported that there is no difference in radiographically measured cervical lordotic values between patients with chronic neck pain compared to asymptomatic controls. Problematically, this highly cited publication is fraught with a disturbing scientific error. Guo et al¹⁴⁷ inappropriately cited and included the Harrison et al 1996⁸⁸ investigation as a case control of asymptomatic vs neck pain patients when in fact this manuscript did not report such data. Guo et al failed to properly identify the Harrison et al 2004⁹⁷ investigation as the correct case control to be included in their analysis even though they did include this reference in their asymptomatic data analysis. This gross oversight let to the incorrect conclusion regarding an abnormal reduced cervical lordosis as a significant predictor of neck pain. In contrast, the 2024 systematic review and meta-analysis by Kim et al¹⁴⁸ properly evaluated the 2004 Harrison et al⁹⁷ case control investigation in their analysis and found that patients with neck pain have a statistically relevant reduced cervical lordosis on X-ray. Thus, the challenge becomes which lens a clinician and/or researcher chooses to look through when making informed decisions regarding the scientific evidence supporting or refuting radiographic investigation of a patients spine. While there exists evidence to the contrary to that reported herein, the current authors argue that the prevailing literature continues to support the use of spine radiography to analyze, diagnose, and treat patient disorders.^149–151

Recently, anti-imaging proponents have published studies concluding that imaging did not result in altering the outcome in patient care.^152,153 These studies, however, are setup for imaging to fail from the start; in other words, the main flaw is that the X-rays were not used for the gain of biomechanical information to dictate a patient-specific treatment approach to exactly alter the patients abnormal alignment towards normal. Radiographic imaging does little to alter an approach consistent with gross spinal manipulation. Obviously, as opposed to the misuse of routine imaging^152,153 an approach to routine imaging applies to clinicians who offer treatments that alter spine deformities,^50–87 and it is time that current spine pain guidelines outline triage pathways that highlight the unique needs of practitioners specializing in spine and posture correcting methods.

Conclusion

Current understanding of the relationship between different spinopelvic parameters are essential to plan biomechanically appropriate interventions that are patient-specific. There are radiographically measured parameter thresholds critically related to several spinal disorders and positive patient outcomes. Current guidelines must include a caveat for contemporary biomechanical evaluation and its consequent specific treatments and should recommend routine radiographic imaging for spine patients undergoing corrective rehabilitative interventions. The failure to radiographically diagnose spinal deformity is argued to be negligence in many cases. The prime obstacle to routine X-ray imaging lies with the presumed threat of cancer, however, this is dogma.

Footnotes

Acknowledgement

We acknowledge the patients who consented to the presentation of their X-rays as used in Figures 1-.

ORCID iD

Paul A. Oakley

Author Contributions

PAO created the first draft of the manuscript; all authors reviewed, edited and consented to the publication of the final version.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by funds from CBP NonProfit, Inc.

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: P.A.O. is a compensated consultant for Chiropractic BioPhysics, NonProfit, Inc J.W.H. is a compensated researcher for CBP Non-Profit, Inc D.E.H. is the CEO of Chiropractic BioPhysics® (CBP®) and provides post-graduate education to healthcare providers and physicians. Spine rehabilitation devices are distributed through his company. D.E.H. is the president of CBP Non-Profit, Inc, a not-for-profit spine research foundation.

References

Foster

Anema

Cherkin

, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391(10137):2368-2383.

Koes

Van Tulder

Lin

Macedo

McAuley

Maher

. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010;19:2075-2094.

Taylor

Bussières

. Diagnostic imaging for spinal disorders in the elderly: a narrative review. Chiropr Man Ther. 2012;20(1):16.

Bussières

Taylor

Peterson

. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders. J Manip Physiol Ther. 2008;31(1):33-88.

American Chiropractic Association . Five things physicians and patients should question. 2017. https://www.choosingwisely.org/societies/american-chiropractic-association/. Accessed 25 January 2021.

Williams

Gichard

Johnson

Louis

. An investigation into the chiropractic practice and communication of routine, repetitive radiographic imaging for the location of postural misalignments. J Clin Imaging Sci. 2024;14:28.

Corso

Cancelliere

Mior

Kumar

Smith

Côté

. The clinical utility of routine spinal radiographs by chiropractors: a rapid review of the literature. Chiropr Man Ther. 2020;28(1):33.

Jenkins

Downie

Moore

French

. Current evidence for spinal X-ray use in the chiropractic profession: a narrative review. Chiropr Man Ther. 2018;26:48.

Gatchel

Bevers

Licciardone

Brotto

. Transitioning from acute to chronic pain: an examination of different trajectories of low-back pain. Healthcare. 2018;6(2):48.

10.

Burke

Fillipo

George

, et al. Transition from acute to chronic low back pain in a community-based cohort. J Pain. 2024;26:104704.

11.

Stevans

Delitto

Khoja

, et al. Risk factors associated with transition from acute to chronic low back pain in US patients seeking primary care. JAMA Netw Open. 2021;4(2):e2037371.

12.

Croft

Macfarlane

Papageorgiou

Thomas

Silman

. Outcome of low back pain in general practice: a prospective study. BMJ. 1998;316(7141):1356-1359.

13.

Kääriä

Luukkonen

Riihimäki

Kirjonen

Leino-Arjas

. Persistence of low back pain reporting among a cohort of employees in a metal corporation: a study with 5-10-and 28-year follow-ups. Pain. 2006;120(1-2):131-137.

14.

Sadler

Spink

De Jonge

Chuter

. Restriction in lateral bending range of motion, lumbar lordosis, and hamstring flexibility predicts the development of low back pain: a systematic review of prospective cohort studies. BMC Muscoskelet Disord. 2017;18(1):179.

15.

Chun

Lim

Kim

Hwang

Chung

. The relationships between low back pain and lumbar lordosis: a systematic review and meta-analysis. Spine J. 2017;17(8):1180-1191.

16.

Raastad

Reiman

Coeytaux

Ledbetter

Goode

. The association between lumbar spine radiographic features and low back pain: a systematic review and meta-analysis. Semin Arthritis Rheum. 2015;44(5):571-585.

17.

Bess

Line

, et al. The health impact of symptomatic adult spinal deformity: comparison of deformity types to United States population norms and chronic diseases. Spine. 2016;41(3):224-233.

18.

Waldrop

Cheng

Devin

McGirt

Fehlings

Berven

. The burden of spinal disorders in the elderly. Neurosurgery. 2015;77(Suppl 4):S46-50.

19.

Hijikata

Kamitani

Sekiguchi

, et al. Association of kyphotic posture with loss of independence and mortality in a community-based prospective cohort study: the Locomotive Syndrome and Health Outcomes in Aizu Cohort Study (LOHAS). BMJ Open. 2022;12(3):e052421.

20.

Ling

Chevillotte

Leglise

Thompson

Bouthors

Le Huec

. Which parameters are relevant in sagittal balance analysis of the cervical spine? A literature review. Eur Spine J. 2018;27(Suppl 1):8-15.

21.

Patwardhan

Khayatzadeh

Havey

, et al. Cervical sagittal balance: a biomechanical perspective can help clinical practice. Eur Spine J. 2018;27(suppl 1):25-38.

22.

Celestre

Dimar

Glassman

. Spinopelvic parameters: lumbar lordosis, pelvic incidence, pelvic tilt, and sacral slope: what does a spine surgeon need to know to plan a lumbar deformity correction? Neurosurg Clin N Am. 2018;29(3):323-329.

23.

Bess

Protopsaltis

Lafage

, et al. Clinical and radiographic evaluation of adult spinal deformity. Clin Spine Surg. 2016;29(1):6-16.

24.

Lin

. Correlations and age-related changes of cervical sagittal parameters in adults without symptoms of cervical spinal disease. Spine. 2020;45(23):E1542-E1548.

25.

Diebo

Varghese

Lafage

Schwab

Lafage

. Sagittal alignment of the spine: what do you need to know? Clin Neurol Neurosurg. 2015;139:295-301.

26.

Le Huec

Roussouly

. Sagittal spino-pelvic balance is a crucial analysis for normal and degenerative spine. Eur Spine J. 2011;20(Suppl 5):556-557.

27.

Oakley

Ehsani

Harrison

. Repeat radiography in monitoring structural changes in the treatment of spinal disorders in chiropractic and manual medicine practice: evidence and safety. Dose Response. 2019;17(4):1559325819891043.

28.

Oakley

Cuttler

Harrison

. X-ray imaging is essential for contemporary chiropractic and manual therapy spinal rehabilitation: radiography increases benefits and reduces risks. Dose Response. 2018;16(2):1559325818781437.

29.

Oakley

Harrison

. Radiophobic Fear-Mongering, misappropriation of medical references and dismissing relevant data forms the false stance for advocating against the use of routine and repeat radiography in chiropractic and manual therapy. Dose Response. 2021;19(1):1559325820984626.

30.

Oakley

Harrison

. X-Ray hesitancy: patients' radiophobic concerns over medical X-rays. Dose Response. 2020;18(3):1559325820959542.

31.

Calabrese

. Cancer risk assessment, its wretched history and what it means for public health. J Occup Environ Hyg. 2024;21(4):220-238.

32.

Calabrese

Giordano

. Muller letter reveals scientific scandal that discredits evidence used to support LNT. Chem Biol Interact. 2023;27:110787.

33.

Calabrese

. Confirmation that Hermann Muller was dishonest in his Nobel Prize lecture. Arch Toxicol. 2023;97(11):2999-3003.

34.

Calabrese

. On the origins of the linear no-threshold (LNT) dogma by means of untruths, artful dodges and blind faith. Environ Res. 2015;142(5):432-442.

35.

Calabrese

. From muller to mechanism: how LNT became the default model for cancer risk assessment. Environ Pollut. 2018;241(1):289-302.

36.

Doss

. Linear No-Threshold model VS. Radiation hormesis. Dose Response. 2013;11(4):480-497.

37.

Calabrese

Blain

. The hormesis database: the occurrence of hormetic dose responses in the toxicological literature. Regul Toxicol Pharmacol. 2011;61(1):73-81.

38.

Scott

Tharmalingam

. The LNT model for cancer induction is not supported by radiobiological data. Chem Biol Interact. 2019;301:34-53.

39.

Scott

. Vanishing by design of cancer risk uncertainty for low radiation doses is misleading and unscientific. Dose Response. 2022;20(1):15593258221078387.

40.

David

Wolfson

Fraifeld

. Background radiation impacts human longevity and cancer mortality: reconsidering the linear no-threshold paradigm. Biogerontology. 2021;22(2):189-195.

41.

Feinendegen

Loken

Booz

Mühlensiepen

Sondhaus

Bond

. Cellular mechanisms of protection and repair induced by radiation exposure and their consequences for cell system responses. Stem Cell. 1995;13(Suppl 1):7-20.

42.

Pollycove

Feinendegen

. Radiation-induced versus endogenous DNA damage: possible effect of inducible protective responses in mitigating endogenous damage. Hum Exp Toxicol. 2003;22:290-306.

43.

Feinendegen

Pollycove

Neumann

. Hormesis by low dose radiation effects: low-Dose cancer risk modeling must recognize up-regulation of protection. In: Baum

, ed. Therapeutic Nuclear Medicine. Heidelberg: Springer; 2014.

44.

Löbrich

Rief

Kühne

, et al. In vivo formation and repair of DNA double-strand breaks after computed tomography examinations. Proc Natl Acad Sci USA. 2005;102:8984-8989.

45.

Cuttler

. Application of low doses of ionizing radiation in medical therapies. Dose Response. 2020;18(1):1559325819895739.

46.

Sies

Berndt

Jones

. Oxidative stress. Ann Rev Biochem. 2017;86(7):715-748.

47.

Sies

Feinendegen

. Radiation hormesis: the link to nanomolar hydrogen peroxide. Antioxid Redox Signal. 2017;27(9):596-598.

48.

Billen

. Spontaneous DNA damage and its significance for the “negligible dose” controversy in radiation protection. Radiat Res. 1990;124(2):242-245.

49.

Oakley

Harrison

. Radiophobia: 7 reasons why radiography used in spine and posture rehabilitation should not be feared or avoided. Dose Response. 2018;16(2):1559325818781445.

50.

Moustafa

. Does improvement towards a normal cervical configuration aid in the management of fibromyalgia. A randomized controlled trial. Bull Fac Ph Th Cairo Univ. 2013;18(2):29-41.

51.

Moustafa

Diab

Taha

Harrison

. Addition of a sagittal cervical posture corrective orthotic device to a multimodal rehabilitation program improves Short- and long-term outcomes in patients with discogenic cervical radiculopathy. Arch Phys Med Rehabil. 2016;97:2034-2044.

52.

Moustafa

Diab

Harrison

. The effect of normalizing the sagittal cervical configuration on dizziness, neck pain, and cervicocephalic kinesthetic sensibility: a 1-year randomized controlled study. Eur J Phys Rehabil Med. 2017;53:57-71.

53.

Moustafa

Diab

AAM

Hegazy

Harrison

. Does rehabilitation of cervical lordosis influence sagittal cervical spine flexion extension kinematics in cervical spondylotic radiculopathy subjects? J Back Musculoskelet Rehabil. 2017;30:937-941.

54.

Moustafa

Diab

Hegazy

Harrison

. Does improvement towards a normal cervical sagittal configuration aid in the management of cervical myofascial pain syndrome: a 1-year randomized controlled trial. BMC Muscoskelet Disord. 2018;19(1):396.

55.

Mageed

SMIA

Abutaleb

EEM

Soliman

AME

Labib

. Impact of cervical lordosis rehabilitation on disability and pain in non-specific neck pain. J Medical Sciences. 2018;18(1):20-26.

56.

Moustafa

Youssef

ASA

Ahbouch

Harrison

. Demonstration of autonomic nervous function and cervical sensorimotor control after cervical lordosis rehabilitation: a randomized controlled trial. J Athl Train. 2021;56(4):427-436.

57.

Moustafa

Diab

Shousha

Harrison

. Does restoration of sagittal cervical alignment improve cervicogenic headache pain and disability: a 2-year pilot randomized controlled trial. Heliyon. 2021;7(3):e06467.

58.

Moustafa

Diab

Hegazy

Harrison

. Demonstration of central conduction time and neuroplastic changes after cervical lordosis rehabilitation in asymptomatic subjects: a randomized, placebo-controlled trial. Sci Rep. 2021;11(1):15379.

59.

Moustafa

Diab

Harrison

. The efficacy of cervical lordosis rehabilitation for nerve root function and pain in cervical spondylotic radiculopathy: a randomized trial with 2-Year Follow-Up. J Clin Med. 2022;11:6515.

60.

Moustafa

Diab

AAM

Harrison

. Does improvement towards a normal cervical sagittal configuration aid in the management of Lumbosacral radiculopathy: a randomized controlled trial. J Clin Med. 2022;11:5768.

61.

Suwaidi

ASA

Moustafa

Kim

Oakley

Harrison

. A comparison of two forward head posture corrective approaches in elderly with chronic non-specific neck pain: a randomized controlled study. J Clin Med. 2023;12:542.

62.

Parera-Turull

Garolera

Navarro

J-B

, et al. The effects of cervical manipulation compared with a conventional physiotherapy program for patients with acute whiplash injury: a randomized controlled trial. Healthcare. 2025;13(7):710.

63.

Moustafa

Ozsahin

Mustapha

Oakley

Harrison

. Utilizing machine learning to predict post-treatment outcomes in chronic non-specific neck pain patients undergoing cervical extension traction. Sci Rep. 2024;14:11781.

64.

Oakley

Ehsani

Moustafa

Harrison

. Restoring cervical lordosis by cervical extension traction methods in the treatment of cervical spine disorders: a systematic review of controlled trials. J Phys Ther Sci. 2021;33(10):784-794.

65.

Oakley

Kallan

Harrison

. Structural rehabilitation of the cervical lordosis and forward head posture: a selective review of Chiropractic BioPhysics^® case reports. J Phys Ther Sci. 2022;34(11):759-771.

66.

Oakley

Harrison

. Reducing thoracic hyperkyphosis subluxation deformity: a systematic review of chiropractic BioPhysics® methods employed in its structural improvement. J Contemp Chiropr. 2018;1(1):59-66.

67.

González-Gálvez

Gea-García

Marcos-Pardo

. Effects of exercise programs on kyphosis and lordosis angle: a systematic review and meta-analysis. PLoS One. 2019;14(4):e0216180.

68.

Bezalel

Carmeli

Levi

Kalichman

. The effect of schroth therapy on thoracic kyphotic curve and quality of life in Scheuermann's patients: a randomized controlled trial. Asian Spine J. 2019;13(3):490-499.

69.

Bezalel

Kalichman

. Improvement of clinical and radiographical presentation of Scheuermann disease after Schroth therapy treatment. J Bodyw Mov Ther. 2015;19(2):232-237.

70.

Etemadifar

Mahdinezhad

. Evaluation of changes in kyphosis angle, apex and quality of life of patients with Scheuermann kyphosis using Kyphologic brace. Int J Physiol Pathophysiol Pharmacol. 2022;14(3):187-192.

71.

Katzman

Vittinghoff

Lin

, et al. Targeted spine strengthening exercise and posture training program to reduce hyperkyphosis in older adults: results from the study of hyperkyphosis, exercise, and function (SHEAF) randomized controlled trial. Osteoporos Int. 2017;28(10):2831-2841.

72.

Katzman

Vittinghoff

Kado

, et al. Study of hyperkyphosis, exercise and function (SHEAF) protocol of a randomized controlled trial of multimodal spine-strengthening exercise in older adults with hyperkyphosis. Phys Ther. 2016;96(3):371-381.

73.

Tsekoura

Katsoulaki

Kastrinis

, et al. The effects of exercise in older adults with hyperkyphotic posture. Adv Exp Med Biol. 2023;1425:501-506.

74.

Ponzano

Tibert

Bansal

Katzman

Giangregorio

. Exercise for improving age-related hyperkyphosis: a systematic review and meta-analysis with GRADE assessment. Arch Osteoporos. 2021;16(1):140.

75.

Diab

Moustafa

. Lumbar lordosis rehabilitation for pain and lumbar segmental motion in chronic mechanical low back pain: a randomized trial. J Manip Physiol Ther. 2012;35(4):246-253.

76.

Moustafa

Diab

. Extension traction treatment for patients with discogenic lumbosacral radiculopathy: a randomized controlled trial. Clin Rehabil. 2013;27(1):51-62.

77.

Diab

Moustafa

. The efficacy of lumbar extension traction for sagittal alignment in mechanical low back pain: a randomized trial. J Back Musculoskelet Rehabil. 2013;26(2):213-220.

78.

Azzm

Moustafa

Ahmed

AMA

El-Sayysd

. Efficacy of Denneroll traction on restoring normal sagittal configuration of lumbar spine in chronic mechanical low back pain. Bulletin of Faculty of Physical Therapy. 2013;15(1):5-14.

79.

Dimitrijević

Šćepanović

Milankov

Drid

. Effects of corrective exercises on lumbar lordotic angle correction: a systematic review and meta-analysis. Int J Environ Res Public Health. 2022;19(8):4906.

80.

Oakley

Ehsani

Moustafa

Harrison

. Restoring lumbar lordosis: a systematic review of controlled trials utilizing Chiropractic Bio Physics^® (CBP^®) non-surgical approach to increasing lumbar lordosis in the treatment of low back disorders. J Phys Ther Sci. 2020;32(9):601-610.

81.

Oakley

Kallan

Harrison

. Structural rehabilitation of the lumbar lordosis: a selective review of CBP® case reports. J Contemporary Chiropr. 2022;5(1):206-211.

82.

Oakley

Harrison

. A review of CBP® methods applied to reduce lateral head translation postures. J Contemporary Chiropr. 2022;5(1):19-24.

83.

Oakley

Harrison

. A systematic review of CBP® methods applied to reduce lateral thoracic translation (pseudo-scoliosis) postures. J Contemporary Chiropr. 2022;5:13-18.

84.

Lee

Wang

Mohamad

, et al. A comparison between Boston brace and European braces in the treatment of adolescent idiopathic scoliosis (AIS) patients: a systematic review based on the standardised Scoliosis Research Society (SRS) inclusion criteria for brace treatment. Eur Spine J. 2024;33(2):630-645.

85.

Chen

Zhou

, et al. The superiority of schroth exercise combined brace treatment for mild-to-moderate adolescent idiopathic scoliosis: a systematic review and network meta-analysis. World Neurosurg. 2024;186:184-196.e9.

86.

McAviney

Mee

Fazalbhoy

Du Plessis

Brown

. A systematic literature review of spinal brace/orthosis treatment for adults with scoliosis between 1967 and 2018: clinical outcomes and harms data. BMC Muscoskelet Disord. 2020;21(1):87.

87.

Negrini

Minozzi

Bettany-Saltikov

, et al. Braces for idiopathic scoliosis in adolescents. Cochrane Database Syst Rev. 2015;2015(6):CD006850.

88.

Harrison

Janik

Troyanovich

Holland

. Comparisons of lordotic cervical spine curvatures to a theoretical ideal model of the static sagittal cervical spine. Spine. 1996;21(6):667-675.

89.

Ajello

Marengo

Pilloni

, et al. Is it possible to evaluate the ideal cervical alignment for each patient needing surgery? An easy rule to determine the appropriate cervical lordosis in preoperative planning. World Neurosurg. 2017;97:471-478.

90.

Tang

Scheer

Smith

, et al. ISSG. The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery. Neurosurgery. 2012;71(3):662-669.

91.

Le Huec

Demezon

Aunoble

. Sagittal parameters of global cervical balance using EOS imaging: normative values from a prospective cohort of asymptomatic volunteers. Eur Spine J. 2015;24(1):63-71.

92.

Aldabbas

Alshana

. Cervical Cobb angle, sleep quality and psychological factors in patients with chronic neck pain with and without cervicogenic headache. Eur J Physiother. 2025;1–7.

93.

Okada

Matsumoto

Ichihara

, et al. Does the sagittal alignment of the cervical spine have an impact on disk degeneration? Minimum 10-year follow-up of asymptomatic volunteers. Eur Spine J. 2009;18:1644-1651.

94.

Katsuura

Hukuda

Saruhashi

Mori

. Kyphotic malalignment after anterior cervical fusion is one of the factors promoting the degenerative process in adjacent intervertebral levels. Eur Spine J. 2001;10:320-324.

95.

McAviney

Schulz

Bock

Harrison

Holland

. Determining the relationship between cervical lordosis and neck complaints. J Manip Physiol Ther. 2005;28(3):187-193.

96.

Oakley

Sanchez

Harrison

. Medical radiologists may not consider the cervical lordosis in radiology reports: a comparison of subjective qualitative assessment versus objective quantitative mensuration in 100 consecutive patients at one medical imaging center. J Contemporary Chiro. 2021;(4):17-25.

97.

Harrison

Janik

, et al. Modeling of the sagittal cervical spine as a method to discriminate hypo-lordosis: results of elliptical and circular modeling in 72 asymptomatic subjects, 52 acute neck pain subjects, and 70 chronic neck pain subjects. Spine. 2004;29:2485-2492.

98.

Aşkin

Bayram

Demirdal

ÜS

, et al. The evaluation of cervical spinal angle in patients with acute and chronic neck pain. Turk J Med Sci. 2017;47(3):806-811.

99.

Pellisé

Vila-Casademunt

Ferrer

, et al. Impact on health related quality of life of adult spinal deformity (ASD) compared with other chronic conditions. Eur Spine J. 2015;24(1):3-11.

100.

Petcharaporn

Pawelek

Bastrom

Lonner

Newton

. The relationship between thoracic hyperkyphosis and the Scoliosis research society outcomes instrument. Spine. 2007;32(20):2226-2231.

101.

Nissinen

Heliövaara

Seitsamo

Poussa

. Left handedness and risk of thoracic hyperkyphosis in prepubertal schoolchildren. Int J Epidemiol. 1995;24(6):1178-1181.

102.

Kolessar

Stollsteimer

Betz

. The value of the measurement from T5 to T12 as a screening tool in detecting abnormal kyphosis. J Spinal Disord. 1996;9(3):220-222.

103.

Harrison

Cailliet

Janik

Troyanovich

Harrison

Holland

. Elliptical modeling of the sagittal lumbar lordosis and segmental rotation angles as a method to discriminate between normal and low back pain subjects. J Spinal Disord. 1998;11(5):430-439.

104.

Schwab

Ungar

Blondel

, et al. Scoliosis Research Society-Schwab adult spinal deformity classification: a validation study. Spine. 2012;37:1077-1082.

105.

Glassman

Berven

Bridwell

Horton

Dimar

. Correlation of radiographic parameters and clinical symptoms in adult scoliosis. Spine. 2005;30:682-688.

106.

Lowe

Berven

Schwab

Bridwell

. The SRS classification for adult spinal deformity: building on the King/Moe and Lenke classification systems. Spine. 2006;31:S119-125.

107.

Berven

Lowe

. The Scoliosis Research Society classification for adult spinal deformity. Neurosurg Clin N Am. 2007;18:207-213.

108.

Ploumis

Liu

Mehbod

Transfeldt

Winter

. A correlation of radiographic and functional measurements in adult degenerative scoliosis. Spine. 2009;34:1581-1584.

109.

Oakley

Kallan

Haas

Harrison

. Radiographic metrics on 100 consecutive patients: patient comparison to evidence-based alignment thresholds supports need to radiographically screen all new patients. Preparation.

110.

Hald

Danz

Schwab

Burmeister

Bahren

. [Radiographically demonstrable spinal changes in asymptomatic young men]. Röfo. 1995;163(1):4-8.

111.

Andersen

Wagstaff

Sverdrup

. Spinal X-ray screening of high performance fighter pilots. Aviat Space Environ Med. 1991;62(12):1171-1173.

112.

Fortner

Oakley

Harrison

. Cervical extension traction as part of a multimodal rehabilitation program relieves whiplash-associated disorders in a patient having failed previous chiropractic treatment: a CBP^® case report. J Phys Ther Sci. 2018;30(2):266-270.

113.

Jaeger

Oakley

Moore

Ruggeroli

Harrison

. Resolution of temporomandibular joint dysfunction (TMJD) by correcting a lateral head translation posture following previous failed traditional chiropractic therapy: a CBP^® case report. J Phys Ther Sci. 2018;30(1):103-107.

114.

Haggard

Oakley

Harrison

. Reduction of progressive thoracolumbar adolescent idiopathic scoliosis by chiropractic biophysics^® (CBP^®) mirror image^® methods following failed traditional chiropractic treatment: a case report. J Phys Ther Sci. 2017;29(11):2062-2067.

115.

Oakley

Harrison

. Lumbar extension traction alleviates symptoms and facilitates healing of disc herniation/sequestration in 6-weeks, following failed treatment from three previous chiropractors: a CBP^® case report with an 8 year follow-up. J Phys Ther Sci. 2017;29(11):2051-2057.

116.

Ferrantelli

Harrison

Stewart

. Conservative treatment of a patient with previously unresponsive whiplash-associated disorders using clinical biomechanics of posture rehabilitation methods. J Manip Physiol Ther. 2005;28(3):e1-8. doi:10.1016/j.jmpt.2005.02.006

117.

Paulk

Bennett

Harrison

. Management of a chronic lumbar disk herniation with CBP methods following failed chiropractic manipulative intervention. J Manip Physiol Ther. 2004;27(9):579.

118.

Henschke

Maher

Refshauge

. A systematic review identifies five “red flags” to screen for vertebral fracture in patients with low back pain. J Clin Epidemiol. 2008;61(2):110-118.

119.

Henschke

Maher

Refshauge

, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum. 2009;60(10):3072-3080.

120.

Beck

Holt

Fox

Hurtgen-Grace

. Radiographic anomalies that may alter chiropractic intervention strategies found in a New Zealand population. J Manip Physiol Ther. 2004;27:554-559.

121.

Global Burden of Disease Cancer Collaboration Fitzmaurice

Allen

, et al. Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 32 cancer groups, 1990 to 2015: a systematic analysis for the global burden of disease study. JAMA Oncol. 2017;3:524-548.

122.

Underwood

. Diagnosing acute nonspecific low back pain: time to lower the red flags? Arthritis Rheum. 2009;60(10):2855-2857.

123.

Oakley

. Is early treatment for mild adolescent idiopathic scoliosis superior over the traditional ‘watch & wait’ approach? A case report with long-term follow-up. J Phys Ther Sci. 2018;30(5):680-684.

124.

Oakley

Power

Gage

Mochizuki

. Balance control in adult spinal deformity: a systematic review of the literature. Rev.

125.

James

Lucchesi

Bisignano

, et al. The global burden of falls: global, regional and national estimates of morbidity and mortality from the global burden of disease study 2017. Inj Prev. 2020;26(Supp 1):i3-i11.

126.

Jenkins

Downie

Maher

Moloney

Magnussen

Hancock

. Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis. Spine J. 2018;18(12):2266-2277.

127.

Kim

Dong

Brener

Coyte

Rampersaud

. Cost-effectiveness analysis of a reduction in diagnostic imaging in degenerative spinal disorders. Healthc Policy. 2011;7:e105-e121.

128.

Esslemont

. X rays for back pain. Br J Gen Pract. 2002;52(483):853-854.

129.

Oakley

Harrison

. Radiogenic cancer risks from chiropractic x-rays are zero: 10 reasons to take routine radiographs in clinical practice. Ann Vert Sublux Res. 2018;48-56.

130.

Oakley

Betz

Harrison

Siskin

Hirsh

International Chiropractors Association Rapid Response Research Review Subcommittee . Radiophobia overreaction: college of chiropractors of British Columbia revoke full X-Ray rights based on flawed study and radiation fear-mongering. Dose Response. 2021;19(3):15593258211033142.

131.

Sackett

Rosenberg

Gray

JAM

Haynes

Richardson

. Evidence-based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71-72.

132.

Schlegl

Ducournau

Ruof

. Different weights of the evidence-based medicine triad in regulatory, health technology assessment, and clinical decision making. Pharm Med (Lond). 2017;31(4):213-216.

133.

Sherman

. Chiropractic x-ray rationale. J Can Chiropr Assoc. 1986;30:33-35.

134.

Deyo

Diehl

Rosenthal

. Reducing roentgenography use. Can patient expectations be altered? Arch Intern Med. 1987;147:141-145.

135.

Jenkins

Hancock

Maher

French

Magnussen

. Understanding patient beliefs regarding the use of imaging in the management of low back pain. Eur J Pain. 2016;20(4):573-580.

136.

Baldwin

Cote

Frank

Johnson

. Cost- effectiveness studies of medical and chiropractic care for occupational low back pain: a critical review of the literature. Spine J. 2001;1:138-147.

137.

Kendrick

Fielding

Bentley

Kerslake

Miller

Pringle

. Radiography of the lumbar spine in primary care patients with low back pain: randomized controlled trial. BMJ. 2001;322:400-405.

138.

Kendrick

Fielding

Bentley

Miller

Kerslake

Pringle

. The role of radiography in primary care patients with low back pain of at least 6 weeks duration: a randomized (unblinded) controlled trial. Health Technol Assess. 2001;5:1-69.

139.

Rockey

Tompkins

Wood

Wolcott

. The usefulness of x-ray examinations in the evaluation of patients with back pain. J Fam Pract. 1978;7:455-465.

140.

Oakley

Harrison

. Death of the ALARA radiation protection principle as used in the medical sector. Dose Response. 2020;18(2):1559325820921641.

141.

Marcus

. Destroying the linear no-threshold basis for radiation regulation: a commentary. Dose Response. 2016;14(4):1559325816673491.

142.

Cuttler

. The LNT issue is about politics and economics, not safety. Dose Response. 2020;18(3):1559325820949066.

143.

Côté

Mior

Corso

Cancelliere

Kumar

Smith

. Ad Hominem Criticisms: an Old Trick to Discredit Inconvenient Research. A Response to Oakley et al. And the International Chiropractors Association Rapid Response Research Review Subcommittee. Dose Response. 2021;19(4):15593258211058339.

144.

Oakley

Betz

Harrison

Siskin

Hirsh

International Chiropractors Associat ion Rapid Response Research Review Subcommittee . Smoke Screen to Distract From Flawed Science: a Response to Côté et al. Over Criticisms to Their Deficient ‘Rapid Review’ on Chiropractic X-Ray Utility. Dose Response. 2021;19(4):15593258211058341.

145.

Kawchuk

Goertz

Axén

, et al. Letter to the editor re: Oakley PA, cuttler JM, Harrison DE. X-Ray imaging is essential for contemporary chiropractic and manual therapy spinal rehabilitation: radiography increases benefits and reduces risks. Dose response. 2018 Jun 19;16(2). Dose Response. 2018;16(4):1559325818811521.

146.

Oakley

Cuttler

Harrison

. Response to Letters From Anderson and Kawchuk et al: x-ray Imaging Is Essential for Contemporary Chiropractic and Manual Therapy Spinal Rehabilitation: radiography Increases Benefits and Reduces Risks. Dose Response. 2018;16(4):1559325818809584.

147.

Guo

Diao

, et al. Cervical lordosis in asymptomatic individuals: a meta-analysis. J Orthop Surg Res. 2018;13(1):147.

148.

Kim

K-H.

Park

S-A.

C-S.

Kim

J-L

. The relationship between cervical lordosis and neck pain: a systematic review and meta-analysis. Edelweiss Appl Sci Technol. 2024;8(5):1666-1675.

149.

Yen

Lin

Chen

, et al. Sagittal alignment to predict efficiency in pulsed radiofrequency for cervical facet joint pain. Sci Rep. 2024;14(1):28563.

150.

Cao

Sun

, et al. Preoperative cervical cobb angle is a risk factor for postoperative axial neck pain after anterior cervical discectomy and fusion with zero-profile interbody. Orthop Surg. 2022;14(12):3225-3232.

151.

Liang

Wang

Chen

, et al. Optimal cut-off points of sagittal spinopelvic parameters as a morphological parameter to predict efficiency in nerve block and pulsed radiofrequency for Lumbar Facet joint pain: a retrospective Study. J Pain Res. 2021;14:1949-1957.

152.

Maiers

Albertson

Major

Mendenhall

Petrie

. The association between individual radiographic findings and improvement after chiropractic spinal manipulation and home exercise among older adults with back-related disability: a secondary analysis. Chiropr Man Ther. 2025;33(1):2.

153.

Jenkins

Kongsted

French

, et al. What are the effects of diagnostic imaging on clinical outcomes in patients with low back pain presenting for chiropractic care: a matched observational study. Chiropr Man Ther. 2021;29(1):46.