Authoritative Rebuttal of Flawed Rapid Review on X-Ray Used to Fan Flames of Radiophobia

By Beth Clay

Red Flag Rule Instituted by College of Chiropractic of British Columbia Should be Rescinded

August 17, 2021 (Falls Church, VA) The International Chiropractors Association (ICA) applauds publication of “Radiophobia Overreaction: College of Chiropractors of British Columbia Revoke Full X-Ray Rights Based on Flawed Study and Radiation Fear-Mongering”[1] the work of Dr. Paul A. Oakley, Dr. Joseph W. Betz, Dr. Deed E. Harrison, Dr. Leonard A. Siskin, Dr. Donald W. Hirsh, and the International Chiropractors Association Rapid Response Research Review Subcommittee.  The Oakley team conducted a thorough analysis of the flawed rapid review of the literature published by Pierre Côté, et. al. [2] which was conducted due to a contracted request of the regulatory Board, the College of Chiropractors of British Columbia, Canada (CCBC).  The regulatory body moved aggressively after receipt of the Côté review announcing in February 2021[1] restrictions on doctors of chiropractic to utilize x-ray imaging in the management of patients with spine disorders in accordance with their own training and best judgement.

The CCBC initiated the contract for the paper based on unfounded concern that patient safety was at risk through chiropractors’ use of x-ray imaging to assess their patients and ignored several evidence-based clinical practice guidelines.  The actions by the CCBC were not based in the full body of peer-reviewed published research and many experts, especially those with advanced post graduate training in upper cervical care, have expressed concern to the ICA that the draconian limitations instituted by the CCBC may put patients at risk.

The Oakley team identified numerous flaws with the Côté paper that include:

  • Inappropriate use of a rapid review;
  • Flawed study design that limited literature only to x-ray studies conducted by chiropractors;
  • Further limits due to flawed search strategy limited to cervical, thoracic, and lumbar spine;
  • Used the term ‘red flag’ but provided no definition;
  • Included only 9 papers, all older than 15 years;
  • Strong conclusion based on little and conflicting evidence; and
  • A priori bias of the authors evident within the text of the paper.

“The International Chiropractors Association has grave concerns about the actions of the CCBC to limit imaging, perpetuate unscientific radiophobia fear mongering, and most importantly put an unnecessary risk to patient safety and wellbeing.” Beth Clay, ICA Executive Director stated.  “The science is clear – X-ray technology of 2021 is far superior and safer than the technology in use in the 1930s, which was deemed safe and appropriate for use by the CCBC.  ICA calls for an immediate reversal of the draconian red flag rule implemented in February.”


1.  Oakley, P., 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: p. 1-35. URL:

2.  Corso, M., et al., The clinical utility of routine spinal radiographs by chiropractors: a rapid review of the literature. Chiropr Man Therap, 2020. 28(1): p. 33.


Stay Informed

Get the latest chiropractic news, events, and more.