When are X-Rays Necessary? Mark Studin, DC

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Hi, I’m Dr. Mark Studin. And, uh, I’d like to welcome to welcome you to ChiroSecure’s, uh, presentation today. And I’d like to thank them for having me here. And I have to be able to, uh, share this information with you. I’m very, very, very excited to do so. So before we get started, I just want to let you know that I am. I live in the apolitical world. This is not about politics. It’s not about ACA ICA WCA, no CA the CA it’s about the science. It’s about having a patient centered approach to healthcare, and it’s about providing quality health care in a safe environment where the doctor doesn’t guess. And to me, that’s the most important thing. So with that being said, let’s get right to the presentation. The question at hand today is x-rays and clinical chiropractic. Are they safe? Are they needed?

I mean, when do you use an x-ray? And there’s been a lot of controversy out there, but really the science answers the controversy and knowing what’s going on with your patients is always paramount. Now, never forget. There were three parameters that we live our life by diagnosis, prognosis and treatment plan. It starts with an accurate diagnosis. Then you prognose your patient. Can you help them? And then if you can, what’s the treatment plan. And in order to do that, there needs not be any guessing involved, none, zero zip, zilch, and yet garnish, no matter what language you put it in, there can never be guessing in what you do. But the only thing I want to share with you is when you order a test, whether it be an x-ray and MRI, no matter what it is, it has to affect your treatment plan because of, or your prognosis.

If it doesn’t affect your prognosis or treatment plan, what’s the purpose of doing it? You just don’t do it. Um, if you’re in a medical legal world to make a lawyer happy, that’s the last reason you do it, but you don’t not do it because you’ll anger and insurance company, those aren’t reasons to, or not to do something. So when you do a test, there always has to be an order. And having an order is critical. And when you order treat order, x-rays, it’s a form of treatment. So there must be a treatment order for everything you do and x-rays are no different for everything. And don’t think what we, if I didn’t treat my patients because I didn’t adjust them well, that’s absurd. If you’re rendering an opinion, you’ve treated them. Think about a surgeon. They walk in, they don’t do surgery, but yet the surgeon is treating them.

He’s managing their case and you have to be a case manager. So when you’re managing your case, it starts with a complete history examination. And if it’s clinically indicated, if it’s clinically indicated, then x-rays are important and you need an order. You need a treatment order. Think about the ho that go into an emergency room. You go into the ER, you see the triage nurse. Then you go into the doctor who evaluate you. He might order an x-ray, he’ll write it down. Then you go to the radiologist or the x-ray tech. They’ll take the x-ray. The radiologist writes a report, sends it back to the, to the ordering doctor with a report. And now that circle’s complete, just because you do x-rays in your office, doesn’t insulate you from that process. You see a patient you’re going to do a test. You’re going to do a treatment.

Anything you do, there needs to be an order and a clinical rationale. And for me, the clinical rationale for x-ray is always to determine based upon my examination, if there is either anatomical or biomechanical pathology, and that’s critical because those are the two things we’re looking for. Anatomical fracture, tumor infection, or a spinal biomechanical pathology, which we’ll get to in just a moment. Now I’m going to do a little bit of reading right now. Okay? And this is important to understand of how you’re being looked at from a, um, from a perspective of looking at an algorithm of the frequency of how order you, how much you order things, do things and change things. This is from the carrier side. And this is actually from a federal complaint, a Rico complaint against the doctor down Florida in July, 2020. Let’s do a little bit of reading.

ABC chiropractic ordered x-rays took x-rays on the site further, despite the patient population, having diverse x-ray findings, the results of the x-rays did not impact the patient’s course of treatment. There was no change in diagnosis or prognosis. The change in the treatment plan when it occurred at all was almost always to limit a stay limited to a standard decrease in treatment frequency rather than an amended an individualized treatment plan based on x-rays findings. Now here’s my comment. And by the way, this was published in the American chiropractor, this article about a year ago. So, um, you’re more than welcome to contact me. I’ll get a copy of the article to you. Um, but here’s the comment. The carrier contends, there was no change in care yet, or reduction in dosage or frequency was ordered as a result of repeat imaging, which is a change of the treatment plan.

However, if you leave it to the carrier to decide why you reduce the care, you are leaving yourself exposed, this is the fences with a straightforward explanation and your records. Secondly, when providing self ordered x-rays within a doctor of chiropractic clinic, there must be a treatment order for those x-rays stating why they are being ordered before taking the x-ray your ENM report, your evaluation or reevaluation evaluation and management. That’s an ENM is not a defacto treatment order. And you must treat this order, just like the one that’s going to an outside facility that you do not own. In the clinical note, you must indicate both why the x-rays are being prescribed and afterwards, if and how the x-rays change your diagnosis, prognosis and treatment plan. This includes confirmation of your original clinical conclusions. And that’s really important to understand. Um, I took x-rays. The listings changed.

I took x-rays. There was no fracture, tumor infection, uh there’s you know, all these things change what you do. So what you’re going to look at and for a reason, and I spoke about this a moment ago, you need either an anatomical pathology, anatomy, fracture, tumor infection, change in tissue structure or competency, our composition, um, anything where you think might be, there is a reason. Secondly, spinal biomechanics, the pathology, abnormal osseous location, that’s spinal biomechanical, pathology, anything that’s a precursor to Wolff’s law. And Will’s law says a bone. That’s an average position. We’ll remodel that bone. In other words, it will create arthritis and Julius Wolff coined that about 1850, 1860, even before x-rays were invented in 1895. So they knew that abnormal position in vertebra, um, ankles, knees, anything aren’t. If there’s abnormal pressure, the bone is gonna remodel. Anytime you have a table, and this is related to the spine or pelvis, anytime you have routine oral motor human deviation, well that’s abnormal biomechanical pathology, pelvic deviation, abnormal biomechanic pathology.

You are diagnosing pathology, and that’s a reason for ordering x-ray. Now let’s look, this is something, every chiropractor in the world is taught spinal biomechanical pathology. We’re taught. If you look at the Chiro touches, um, a report here, um, C3 posterior on the right, see T1 posterial left than inferior. I T two it’s Antero TA does retro. These are listenings. These are, this is biomechanical pathology, and you need to understand this. So if we look at even one step further and you look at a pelvis, ASI in Alma on the right P I E X on the left, this is standard. Every single chiropractor in the nation is taught this every in the world, not just the nation, it’s just integral to our training. We are all spinal biomechanists. We’re all, we’ve all been trained in that. And we all understand it. But the question is, how do you know what’s going?

Why do you think in school, you spend so many years with x-ray x-ray posy, geology, osseous pathology and understanding all of these things. You’re not just bone lepers, okay? You’re not, you’re not just there to move a bone, you know, play the piano, go up in there. You need specific listings. You know, you need to know what the lesions are. What are the primary lesions? Is it compensation? What else is going on? Is there degeneration? There, there is a lot of issues going on that we need to know. Now let’s take me for an example. Okay, well, let’s just go before me. We’ll get to me in a moment. Um, let’s take visual assessment because they say, oh, I’m going to visualize what’s going on. And you’ll look at postural assessment. Well, let’s go to the literature, fedora and Al in 2003 reported visual assessment has shown that this study has shown that visual, visual assessment and cervical lumbar lordosis is in row unreliable.

The tool as visual assessment only has fair inter-rater reliability, important intro, random reliability, visual assessment of spinal posture was previously shown to be an accurate. And this study has demonstrated that reliability is poor, and I give you the citation on the bottom. Now let’s go to motion palpation. Now that’s a little bit different than a little dicey, but you’ve got to look at the literature as far as, um, what you consider or I would consider acceptable hold on 2017 reported. And again, the citation is on the bottom. There was a high level of inter examiner reliability, but that only reflected 54.3% agreement between two doctors in one study, half agree half. Now there was a limitation of the study because there were no x-rays to support the conclusion. Two doctors agreed, but then they turned around and said, well, we don’t have x-rays. We don’t even know if they’re right, but they only grade on 54% of the time.

So to me, half being right, I mean, let’s face it. If you went to a surgeon and the surgeon said, gee, mark. You know, I think that, um, I, I know exactly where that tumor, that brain tumor is, you know, the lesion. Um, and it’s sitting somewhere maybe in the cerebellum, maybe somewhere on the ponds, but you know what? 54% of the time I get it right, I’m ready to carve your brain up. You know what you’re going to say, you’re going to tell them to put it with the sun. Don’t shine. You’re going to run out and go, oh, that guy’s an idiot. And that would be correct. I mean, it’s absurd to think that 54.3% is acceptable as a high level of inter examiner reliability. When in fact there was no image to conclude it. So from my perspective, motion, palpation is not very reliable.

Now let’s take me. This was well that’s x-rays that they get to me. And I keep, I keep trying to jump it to me. Let’s look at x-rays in contrast, the reliability of x-ray morphology measured with biomechanics and have been determined, accurate, and reproducible in both chiropractic and medical specialties. Uh, additionally O’Hara at Al reported, the assessment of sagittal alignment of the spine is important in clinical and research settings. And it is known that the alignment affects the distribution of load on the discs that goes back to Wolff’s law folks. Okay. And the site had been two citations are on the bottom, but the issue is x-rays, you know, it, I know it and everyone knows it is accurate. It is the only way to come up with an accurate biomechanical assessment of where you’re going to adjust your patient. And if you like to use the word manipulate, I don’t because PTs, um, osteopaths manipulate chiropractors, roll that to just, it’s not a philosophical issue.

It’s just the statement, which is factual. But when I adjust my patient, I like to know where now we’re going to get to my patient. Now, this was my patient. Last week I did motion palpation. I first I visually inspected. Then I did motion palpation and it revealed, um, the motion palpation revealed, uh, spineless left. But the correct vector of the spinalis was much further right than left. So in other words, the vector was right to left. I thought I had to go left to right. I had a backwards and I didn’t know the comorbidity. As you can see in this image, a fusion, I had it backwards. I thought they were responding to stuff when I moved them, I’m spineless. Right. And I apologize because when I moved them, they didn’t move too well. And the spinalis was right there. And I said, my God, you know what?

I could break up that fixation. Thank God. And by the way, I would have hurt that patient. And I’m in the game over 40 years. And I’m they really good at palpating. I am really good at motion palpation, but I would have got it wrong. Should I not an x-ray this, by the way, I don’t have to take the x-rays. I can refer afferents right. But you know what? I did know. I had no clue. I would have heard this patient. Now, if you take another case that I had, by the way, every single week, and I work with doctors in 49 different states, I get multiple costs. Oh, more, thank God. I took an x-ray thank God. I took her neck. I grabbed it, took an MRI. Um, this was two weeks ago in Georgia, a Genesis of the posterior cervical arch. That, how crazy is that?

But I’ve had three, three doctors report to me this, uh, this past year. This is a third, a 38 year experienced doctor who performed motion, palpation and fad model restrictions at feet C5, six and seven. But he always x-rays his patients because he’s looking for biomechanical changes for biomechanical pathology. This was a disaster waiting to happen. Should it be adjusted that patient’s Atlas and axis a and by the way, I know ChiroSecure is sponsoring today. And just to let you know, they never tell me what to talk about. They never give me an agenda. I do whatever I want. As long as it’s, um, uh, honest, good for the profession, uh, educational and litter. And evidence-based in the literature. In other words, I’m not making stuff up because everything I’m sharing with you is evidence-based in the literature. But thinking about happy, a malpractice carrier is because when you x-ray, you’re not guessing, and you’re not hurting people.

It’s saving them a ton of money. But think about you. If you hurt someone, forget the money. That’s not yours. You’re going to lose years of sleep, depositions, trials, guilt. I mean, think about that for what purpose. So we’re going to get to that purpose in a minute. But when you want to go to advanced spinal biomechanical engineering studies, there is a very specific tool out there called SIM Virta. Um, and what it does is on the left, you could see those bar graphs would show you the level of pathology. The green bar of what individual vertebra are, are accurately positioned biomechanically. And then on the right slide up top, you see that bar graph, it tells you with standard deviations, how much each vertebra has, has moved. So you can look at patterns and you are not guessing you can determine from this where’s the primary lesion.

Where’s the secondary lesion. There’s no guessing involved when you’re dealing with carriers and they say, well, did it change your treatment plan in the x-ray? Well, sure it did. I’m looking right here. And there’s a blueprint on the right side of that screen, which gives me my primary lesion. And when I re x-ray the patient, and we’ll talk about that in a minute. And the, and the barge and the grass change. Now, I’m going to change where I adjust because the primary leases have changed as the body is compensated or moving back towards homeostasis. That’s what you want to go for. And if you have that also tough case, well, you know what, maybe you’re adjusting compensation and you’re not adjusting that primary lesion that my friends is critical because don’t muck with compensation, adjust the primary lesion and allow the body to compensate for itself.

So the first thing I do is I screen for me personally, when I’m evaluating for a patient, I’m not screening for pathology, unless there’s a red flag of which I’m screening for pathology. In other words, if I think there’s a fracture, tumor infection, instant x-ray, don’t even think I don’t even, I might even go right to MRI, not an issue, but I’m a screening for bio mechanics. My, the, the, the added bonus is looking for pathology and is so much more pathology than you can imagine. That’s being fat. Let me read. This is also one of the responses in that lawsuit. Um, when they said they weren’t doctor was using an only for screening issues, screening and medicine is a strategy used to look for as yet unrecognized condition or risk markers. We do not take x-rays to screen patients rather x-rays are used as a part of a spinal examination that cannot be achieved from a clinical evaluation.

So I’m not using a screening. That’s a part of my clinical evaluation. Okay. Now, approximately 38.4% of men and women will be diagnosed with cancer at some point in time in their lifetime. And that’s based upon 2013 to 2015 data. And I do have that census report. I didn’t, oh, it’s on the bottom. Okay. What is the risk of treating a, with a chiropractic spinal adjustment, a patient with undiagnosed or diagnosed with metastatic cancer or various types of arthritis? Arthritities aneurysms, osteomyelitis, ankylosing spondylitis, diffused, idiopathic, skeletal, hypertrophy, dish osteophytes, a budding critical neurological elements, pathological stenosis, medical subluxation, Andra, postural listhesis, and any other condition that can increase the risk of fracture or neurological damage. The risks are numerous. Perhaps these might be acceptable losses for the carriers, but not treating doctors routine use of x-ray is a patient centered approach and is a segmental radiographic analysis based on patient presentation, past medical history and physical examination findings folks, I promise you not one patient is walking in your office that says, I feel great.

Take x-rays they’re walking with pain or a problem. And you have to figure out where that lesion is because you don’t know. And I have a real hard rule and here is it’s very easy, stop guessing and start knowing it’s very simple. Stop guessing and start knowing imaging changes your whole PR diagnosis, prognosis and treatment plan, imaging changes. And it’s very, very important to understand, but what you have to do is let the science give you the answer. You got to find out the, should you x-ray, should you not? Are you going to take a political organizations, um, word for it? Are you going to take my opinion for it? Whether x-rays are safe or not? I would hope not. Okay. You have to look at the scientific method, which starts with observation, the question hypothesis, experimentation, conclusion, and then results. And with that, let’s look at radiation safety with spinal x-rays and radiation safety is critical.

I don’t want to radiate the patient. Um, that radiation is cumulative. They’re going to get cancer. They’re going to get this. They’re going to get that. Well, let’s look at the let’s look at the science, okay. It’s not who could Huff and puff the loudest and not 15 people on a board, in an organization who makes a decision for the entire profession. We’re going to let science rule the day, according to two Biana Al among the humans. And this is 2009. There is no evidence of carcinogenic effect for acute irradiation at doses, less than a hundred milliseconds. That’s for an individual x-ray. And for protracted radiation doses at less than 500 serves the American college of radiology in the February, 2020 appropriate vice appropriateness criteria reported adverse health, adverse health outcomes for radiation doses below a hundred milliseconds are not shown by the evidence. In other words, there is no adverse effect that a millimeter, um, is how much radiation is absorbed.

So nothing below a hundred millimeters, an individual lumbar x-ray is one. Look at the look on the right 1.2 mil, the serves 1.2, cervical and thoracic or less 1.2. There is never been a study ever anything. And by the way, if you’re over a hundred millimeters, one in 100,000 patients that cancer over a hundred Mosers and radiation is not cumulative, that’s the science. So, you know, when, when, when you, when you look at all this stuff and you look at the fear and the dogma, you know, the sky is falling, chicken little was out there, yelling, run, run, run, run the sky. Let’s look at radiation, fear and dogma versus truth. I just gave you a good part of the truth. Based upon science, let’s read adverse health outcomes, radiation doses below a hundred millimeters. This is even a third reference are not shown by the evidence, the American association of physicists and medicine.

Now the American board of internal medicine that that’s, that’s internal medical doctors who failed on musculoskeletal medicine in a, in a study done at Harvard. I think it was 87% fail in a basic competency test of musculoskeletal care, or putting an opinion out of that. X-ray but here you have the American association of physician of physicists in medicine. These are the one who studied this issue, caution that given the lack of scientific consensus about potential health risks from low doses of radiation, predictions of cancer incidents and mortality from the use of diagnosis, imaging are highly speculative, the AAPM and other radiation protective organization, specifically discourage these predictions of hypothetical art. Such predictions can lead to sensationalistic stories in the public media. This may, this may lead some patients to fear or a fuse safe and appropriate medical imaging to the detriment of the patient. According to the head, the O’Connor no prospective epidemiological study with non-radiating control.

Subject has quantitatively demonstrated adverse effects of radiation at doses, less than about a hundred millimeters. It goes on and on and on and on and on the sky. Isn’t falling folks. You’re not going to kill your patients. Um, there is a few research articles that say that low dose radiation actually prevents cancer. Well, let’s look at it this way, and I don’t have the literature behind this. This is pure opinion. I have to qualify that what helps people take vitamin D to prevent cancer? Okay. Where does vitamin D come from the sun, which causes cancer? Well, let me rephrase that, which causes radiation in, in, in w which emits, but you know, everything at appropriate doses and that’s the key, but the key here in our offices, chiropractic offices around the country, your x-ray, your x-ray is not going to cause cancer. That’s just the bottom line.

The literature is very, very clear. Here is a student rule. Number one, if you don’t know, you don’t guess, and I’ve got a few hard rules that I’ve come up in my 40 some years in the center industry. But if you don’t know, you don’t guess stop laying a patient down and playing the piano up and down up, and that just whatever moves we’re going to get moving. No, find out where the primary lesion is. And you know what don’t guess, take an x-ray come up with a listing. You were trained how to do that. Folks, you were trained, have it come up with those listings. And it’s really important for you to be very specific about your patient. Now, what I like to do in the last two minutes, um, that I have right now, before I say, thank you so much. And by the way, the speaker next week is going to be Sam Collins from HJ Ross, Sam, from my perspective is arguably one of the most knowledgeable people on coding that I’ve ever worked with in my career.

He’s just wonderful, but also, um, you know, and, and Colson, you have questions just, and he’s great. You have a question we’ll always take your phone call, always answer it. But I’d like to talk about, um, very briefly, uh, in, in the last minute I have, because it affects everyone. And it was a recent ruling that came down in Georgia. And it said that a chiropractor was not allowed to opine on MRI because it wasn’t in his chiropractic credential, regardless of what are the courses he’s done. And that seems to be the, um, mantra of the carriers and the latest trend. So folks, I want to share with you, your continuing education is valuable. It’s extremely valuable. So choose carefully what you are doing, what courses you’re taking. Does it meet your needs? Is it taught by people in academia, uh, with incredible credentials, because they’re looking at the credentials of the people teaching you also really carefully think out CE that you’re going to do. And does it support the needs of your career? And that’s critically important. Um, I could go on forever, but perhaps that’ll be a topic for another conversation, but in the meantime, I’d like to, again, thank ChiroSecure. We look forward to Sam next week and I look forward to being able to present to you again. Thank you. Have a wonderful day.