Chiropractic X-ray Utilization: Trends and Insights
X-rays are a valuable tool in chiropractic practice, offering diagnostic insights and supporting patient education. However, with advancements in technology and evolving clinical practice guidelines, how chiropractors use X-rays has shifted.
With the help of the ChiroUp network and our friends at FTCA, we surveyed more than 400 evidence-based chiropractors to get a clearer picture of current chiropractic X-ray utilization trends. Check out this blog for the key takeaways (and remember, this “hot topic” blog simply relays the facts; if you disagree with something, please don’t shoot the messenger).
1. X-ray Utilization Among Chiropractors
Fast fact: On average, 28% of new presentations are imaged, and 6% of all presentations are reimaged post-care.
Imaging new patient presentations
Previously published studies documented a wide range in the percentage of chiropractic patients referred for imaging, varying from 8% to 84%. (1) A June 2024 paper provided some insight into the dramatic variance:
“The wide range in reported usage may reflect differences in opinion between chiropractors regarding the appropriate use of radiographs in clinical practice. While some chiropractors primarily use radiographs to rule out serious pathology and trauma, which is in line with CPGs [Clinical Practice Guidelines], others consider such recommendations to be too restrictive. Some chiropractors suggest that radiographs are additionally necessary in the assessment of structural misalignment, to determine/guide appropriate treatment, and to identify clinically unsuspected contraindications to management.” (2)
On average, chiropractors in our survey performed imaging on approximately 28% of new musculoskeletal (MSK) patients. However, over half of respondents (51%) imaged 10% or fewer of their new cases, suggesting that while X-rays are considered a valuable diagnostic tool, they are used selectively.
How do imaging rates for PCPs compare to DCs?
Our survey average is consistent with findings from a BMJ systematic review of 20 million low back pain (LBP) cases, showing primary care providers imaged approximately one in four initial LBP presentations, highlighting relatively similar imaging rates. (3)
Repeat imaging
On average, only 6% of patients receive follow-up films at the conclusion of care, indicating that most chiropractors don’t rely on repeated imaging to assess progress unless clinically indicated. This aligns with a 2020 paper published in Chiropractic Manual Therapies regarding the use of routine and repeat X-rays. (4)
Chiropractic X-ray trends and takeaways from our survey:
Fewer than 5% of chiropractors routinely order X-rays for more than 90% of their patients.
Of the chiropractors who routinely image over 90% of new patients, 40% also conduct routine post-care imaging.
Approximately 82% of DCs re-image 5% of cases or fewer, with the vast majority indicating 0-1%.
Approximately 5% of DCs re-image more than 25% of their patients.
Approximately 1% of DCs re-image over 90% of their patients.
Check out this synopsis of indications and red flags for spinal imaging.
2. How Chiropractic X-ray Utilization Has Changed Over the Last 5 Years
Fast fact: Chiropractic X-ray rates have trended downward.
Imaging rates in prior decades were unquestionably higher. An analysis of 3810 random chiropractic practices between 1993 and 2015 showed that approximately 56% of new chiropractic patients were radiographed during that period. (5)
A 2023 Danish study of 254 chiropractic practices revealed that the proportion of patients receiving radiographs was reduced by half between 2010 and 2020. (6) This decline is likely due to the growing influence of evidence-based guidelines, which emphasize the judicious use of diagnostic imaging unless specific clinical red flags are present.
We asked our survey respondents how their utilization has changed in the past five years. Most DCs reported that their X-ray usage has either stayed the same or decreased:
43% of respondents reported no change in their utilization.
40% reported a decrease in utilization.
17% reported an increase in utilization.
3. The Role of Radiologist Over-Reads
Fast fact: Two-thirds of DCs have a radiologist overread their in-house films
Most chiropractors are well-trained in radiographic interpretation and show strong proficiency in reading films. (7-9) DCs often rely on their expertise to read X-rays. However, over two-thirds (71%) of our survey respondents reported that they always or sometimes have a radiologist review their in-house films for an added layer of confidence. The remaining 29% of DCs never seek a radiologist's input for in-house films.
4. Chiropractic X-ray Equipment: The Shift to Digital
Fast fact: 95% of in-house chiropractic imaging is digital.
Digital X-rays have become significantly more popular due to many advantages, including cleaner images, faster and simpler processing, easier storage, and integration with EHR systems. Our study confirmed that the overwhelming majority of chiropractic practices have embraced digital X-rays, with 95% of respondents using digital equipment and only 5% still using conventional films.
Looking for an EHR solution? Learn more about ChiroUp’s Revolutionary EHR.
*Our findings contrast a 2023 study of approximately 4,300 worldwide chiropractic practices that found approximately 22% still utilized conventional plain film radiography. (10)
5. Who Takes In-House Chiropractic X-rays?
Fast fact: Over two-thirds (68%) of DCs take their own films.
State-specific licensure and scope-of-practice laws govern who can perform in-house chiropractic X-rays. In some areas, anyone with minimal training can take a film, while in others, films can only legally be performed by a licensed and qualified professional like a DC, X-ray tech, or limited licensed X-ray tech.
Our survey showed that in most practices, chiropractors themselves are the ones taking X-rays:
68% of chiropractors take their own in-house X-rays.
20% employ a trained and licensed technician to perform the imaging.
12% rely on chiropractic assistants (CAs) to take the X-rays.
This data aligns with findings from the NBCE Practice Analysis of Chiropractic 2020, which revealed similar practitioner roles in taking X-rays. (5)
6. Patient Education and X-ray Review
Fast fact: 57% of DCs use X-rays as part of their patient education.
Our survey found that 57% of chiropractors routinely review X-rays with patients during the report of findings, while 43% opt not to.
Not surprisingly, our survey showed a distinct relationship between imaging rates and the use of imaging as a patient education tool.
95% of the highest quadrant of x-ray utilizers routinely incorporate xrays findings in their patient education (i.e., report of findings)
23% of the lowest quadrant routinely use those X-rays as an educational tool.
Chiropractic X-rays can be a powerful tool for patient education. Prior papers revealed that many clinicians believe sharing clinical findings with patients improves their understanding of their condition and makes the condition “real.” (2,11) One recent study of 4300 random DCs found that 93% felt that sharing clinical findings from spinal imaging studies is beneficial to clinical outcomes. (10) However, caution may be necessary. Some papers suggest that improper communication of X-ray results can have a nocebo effect, where patients might experience increased anxiety or concern based on misunderstood findings. (12)
ChiroUp subscribers can use this infographic to explain how “abnormal” imaging findings do not necessarily cause symptoms. Search “Imaging” in the Forms Library to download now.
7. X-ray Ownership
Fast Fact: The majority of DCs (59%) refer out for imaging.
Chiropractors are split when it comes to owning X-ray equipment:
59% send their patients to outside facilities for imaging.
41% of practices own and use their own X-ray machines.
Not surprisingly, our survey found that those with in-house equipment tend to have higher utilization rates.
A declining trend for ownership?
The use of in-office radiography appears to be declining. Our current finding of 41% is noticeably lower than a 2020 NBCE analysis, which reported that 47% of chiropractors performed radiographs in their offices. (5) This figure has dropped even more significantly since a 1997 survey, where 74% of DCs conducted in-office imaging. (13)
8. In-Office Imaging vs. Referring Out: What Drives Chiropractors' Decisions?
Chiropractors weigh several factors when deciding whether to invest in in-office imaging or refer patients out. While in-office imaging offers convenience and control, referring patients out can make sense for practices with lower utilization or specific logistical challenges. Here are the top survey responses driving decisions to image in vs out, along with the percentage of DCs in that group who selected that answer.
Top Reasons Why Chiropractors Choose In-Office Imaging:
Convenience for patients (94%)
Faster diagnosis (81%)
Improved compliance with the order (48%)
Control over the imaging technique (38%)
Revenue generation (34%)
Comments from our survey respondents:
“As a chiropractor, X ray is not a revenue generator considering the machine & upkeep, but it’s convenient.“
It lets me retain the ability to do my own computerized biomechanical analysis”
Top Reasons Why Chiropractors Choose to Refer Out for Imaging:
Low utilization does not justify owning equipment (72%)
Cost or hassle of owning X-ray equipment (72%)
Low reimbursement does not justify owning equipment (38%)
Lack of available space (35%)
Regulatory restrictions (15%)
Radiologist over-reads (*)
*Although our survey did not collect statistics on this factor, the most frequent write-in response was a preference for having radiologists interpret their films.
Comments from our survey respondents:
“Achieving an ROI would mean I would need to X-ray more patients than what is clinically appropriate.”
“I don’t want the responsibility of reading and reporting. I would prefer a second set of eyes on my films”
Who did we survey: Chiropractic Practice Arrangements
We distributed our survey to the ChiroUp network of providers and gathered additional responses from FTCA followers, with over 400 practices participating. The results represent a cross-section of the chiropractic profession, with participants reporting the following practice settings:
45% operate solo practices
32% work in group practices
21% are part of multidisciplinary practices
3% work in hospital or medical healthcare settings
Conclusion: The Evolving Role of X-rays in Chiropractic Care
X-rays remain an important tool in chiropractic care, but their usage is becoming more selective as chiropractors align with current evidence-based guidelines. The shift toward digital X-rays, outside facilities and the integration of radiologist over-reads are shaping how practitioners leverage imaging in their practices.
As the chiropractic field continues to evolve, X-rays will likely remain a vital tool—especially for those focusing on biomechanical analysis and patient education. Chiropractors should continue to balance the benefits of X-rays with the risks associated with unnecessary imaging. By doing so, they can optimize care for their patients while staying aligned with best practices.
This blog was crafted with insights and feedback from our incredible ChiroUp network of over 3,000 chiropractors. Together, we’re advancing evidence-based care and elevating the chiropractic profession. Want to be part of the movement?
-
1. Jenkins HJ, Downie AS, Maher CG, Moloney NA, Magnussen JS, Hancock MJ. Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis. The Spine Journal. 2018 Dec 1;18(12):2266-77. Link
2. Searant I, Brown BT, Jenkins HJ. Chiropractors’ perceptions on the use of spinal radiographs in clinical practice: a qualitative study. Chiropractic & Manual Therapies. 2024 Dec;32(1):1-2. Link
3. Downie A, Hancock M, Jenkins H, Buchbinder R, Harris I, Underwood M, Goergen S, Maher CG. How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years. British journal of sports medicine. 2020 Jun 1;54(11):642-51. Link
4. Corso M, Cancelliere C, Mior S, Kumar V, Smith A, Côté P. The clinical utility of routine spinal radiographs by chiropractors: a rapid review of the literature. Chiropractic & Manual Therapies. 2020 Dec;28:1-5. Link
5. NBCE Survey Analysis. Practice Analysis of Chiropractic 2020. p. 80. Accessed Sept 30, 2024. Link
6. Reibke PS, Godskesen H, Jensen RK, French SD, Bussières A, Christensen HW, Jensen TS. The effect of clinical guidelines on the utilisation of radiographs in chiropractic clinics in Denmark-an interrupted time series analysis. Chiropractic & manual therapies. 2023 Nov 22;31(1):47. Link
7. de Zoete A, Assendelft WJ, Algra PR, Oberman WR, Vanderschueren GM, Bezemer PD. Reliability and validity of lumbosacral spine radiograph reading by chiropractors, chiropractic radiologists, and medical radiologists. Spine. 2002 Sep 1;27(17):1926-33. Link .
8. Taylor JA, Clopton P, Bosch E, Miller KA, Marcelis S. Interpretation of Abnormal Lumbosacra Spine Radiographs: A Test Comparing Students, Clinicians, Radiology Residents, and Radiologists in Medicine and Chiropractic. Spine. 1995 May 15;20(10):1147-53. Link
9. Assendelft WJ, Bouter LM, Knipschild PG, Wilmink JT. Reliability of lumbar spine radiograph reading by chiropractors. Spine. 1997 Jun 1;22(11):1235-41. Link
10. Arnone PA, Kraus SJ, Farmen D, Lightstone DF, Jaeger J, Theodossis C. Examining clinical opinion and experience regarding utilization of plain radiography of the spine: evidence from surveying the Chiropractic Profession. Journal of Clinical Medicine. 2023 Mar 10;12(6):2169. Link
11. Sharma S, Traeger AC, Reed B, Hamilton M, O’Connor DA, Hoffmann TC, Bonner C, Buchbinder R, Maher CG. Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis. BMJ open. 2020 Aug 1;10(8):e037820. Link
12. Ogliari L, Formica A, Bettelli L. ‘More harm than good’–A qualitative study exploring the attitudes and beliefs of a group of Italian osteopaths about spinal imaging in the management of patients with chronic low back pain. International Journal of Osteopathic Medicine. 2023 Dec 1;50:100680. Link
13. Harger BL, Taylor JA, Haas M, Nyiendo J. Chiropractic radiologists: a survey of chiropractors' attitudes and patterns of use. Journal of manipulative and physiological therapeutics. 1997 Jun 1;20(5):311-4. Link
