ORIGINAL ARTICLES

DIAGNOSTIC IMAGING PRACTICE GUIDELINES FOR

MUSCULOSKELETAL COMPLAINTS IN ADULTSAN
EVIDENCE-BASED APPROACH: INTRODUCTION
Andr E. Bussires, DC, a Cynthia Peterson, DC, RN, MMedEd,b and John A.M. Taylor, DCc

ABSTRACT

Purpose: Imaging technology can improve patient outcomes by allowing greater precision in diagnosing and treating
patients. However, there is evidence that overuse, underuse, and misuse of imaging services occur. The purpose of
this project was to develop evidence-based diagnostic imaging practice guidelines for musculoskeletal complaints for use
by doctors of chiropractic and other primary health care professionals.
Methods: An electronic search of the English and French language literature (phase 1) was conducted on several
databases. Cross references, and references provided by clinicians, were also used. Independent assessment of the quality
of the citations used to support recommendations in the guidelines was performed using the QUADAS, the AGREE,
and the SPREAD evaluation tools. A first draft of a diagnostic imaging practice guideline was produced, using the
European Commission's Referral Guidelines for Imaging document as a template. Results were sent to 12 chiropractic
specialists for a first external review. A modified Delphi process, including 149 international experts, was used to
generate consensus on recommendations for diagnostic imaging studies. The reliability of proposed recommendations
was further tested on field chiropractors and on a group of specialists both in chiropractic and in medicine in both Canada
and the United States. All recommendations were graded according to the strength of the evidence.
Results: The research procedure resulted in the recommendations for diagnostic imaging guidelines of adult extremity
and spine disorders supported by more than 685 primary and secondary citations. High levels of agreement among
Delphi panelists were reached for all proposed recommendations. Comments received by specialists were generally very
favorable and reflected high levels of agreement with the proposed recommendations, perceived ease of use of
guidelines, and implementation feasibility.
Conclusions: These evidence-based diagnostic imaging practice guidelines are intended to assist chiropractors and
other primary care providers in decision making on the appropriate use of diagnostic imaging for specific clinical
presentations. In all cases, the guidelines are intended to be used in conjunction with sound clinical judgment and
experience. Application of these guidelines should help avoid unnecessary radiographs, increase examination precision,
and decrease health care costs without compromising the quality of care. All guidelines are documents to be refined and
modified regularly with new information and experience. (J Manipulative Physiol Ther 2007;30:617-683)
Key Indexing Terms: Diagnostic Imaging; Radiology; Diagnostic X-Ray; Radiography; Practice Guideline;
Musculoskeletal System; Chiropractic

a
Professor, Chiropractic Department, Universit du Qubec
pproximately 150 musculoskeletal diseases and
Trois-Rivires, Trois-Rivires, Qubec, Canada G9A 5H7.
b
Professor, Canadian Memorial Chiropractic College, Toronto,
Ontario, Canada.
c
Professor of Radiology, New York Chiropractic College,
Seneca Falls, New York; Adjunct Professor, D'Youville College,
A syndromes associated with pain and loss of physical
function commonly affect children and adults in all
regions of the world. The most common conditions include
osteoporosis, arthritis, spinal disorders (including low back
Buffalo, New York.
Submit requests for reprints to: Andr E. Bussires, DC, pain [LBP]), and the consequences of severe trauma. The
Professor, Dpartement chiropratique, Universit du Qubec total cost of musculoskeletal disease in the USS in the year
Trois-Rivires, C.P. 500, Trois-Rivires, Qubec, Canada G9A 5H7 2000 has been calculated at US$254 billion. In developing
(e-mail: andre.bussieres@uqtr.ca). countries, the cost of musculoskeletal injury care is estimated
Paper submitted July 15, 2007; in revised form September 12, at US$100 billion, a figure nearly twice that of total foreign
2007; accepted October 14, 2007.
0161-4754/$32.00 aid for these nations.1,2 Diagnostic imaging is the most
Copyright 2007 by National University of Health Sciences. rapidly evolving specialty within health care.3,4 Imaging
doi:10.1016/j.jmpt.2007.10.003 technology can improve patient outcomes by allowing

617
618 Bussires et al
Diagnostic Imaging Guidelines
greater precision in diagnosing and treating patients. Despite
the advent of new and advanced techniques, conventional
radiography remains the cornerstone of diagnostic imaging
for patients presenting with regional musculoskeletal pain,
especially for acute fractures of the extremities or for
suspected neoplasia.5-7 However, evidence of overuse,
underuse, and misuse of imaging services has been
emphasized in the literature.8-13 In the US alone, more
than $500 million are spent each year on lumbar spine
radiography14 and in Ontario, Canada, the Ontario Health
Insurance Plan spends more than $16 million annually on
physician-requested imaging for LBP.15 Such costs are
unlikely to outweigh the effect of small reported increases in
patient satisfaction, especially when considering potential
risks of ionizing radiation exposure and lack of demonstrable
benefits to patients.16-18 It should be noted that this
significant rise in expenditure has recently motivated the
US Congress to reduce payments for such imaging
services.19 Several factors contributing to escalating imaging
costs have been identified: the aging population; the practice
of defensive medicine; overuse of diagnostic imaging; self-
referral abuses; duplicative studies; consumer demand; and
advanced technology. Research has shown many of these
costs could be decreased if the referring physician commu-
nity had a solid understanding of the appropriate ordering of
diagnostic imaging studies and the risks related to radiation
exposure.20
There is an urgent need throughout the health care
professions to develop practice guidelines. Brown21 sum-
marized the characteristics of quality care as (a) patient
centered, (b) scientifically based, (c) population outcomes
based, (d) refined through quality improvement and bench-
marking, (e) individualized to each patient, and (f)
compatible with system policies and resources. Government
agencies, professional accreditation agencies, and public
institutional policies are now demanding that all health
professions develop practice guidelines that may be used to
evaluate what are deemed reasonable and appropriate
indications for care. In addition, recent recommendations
of the Institute for Alternative Futures for the chiropractic
profession include accelerating research activity, striving for
high standards of practice, engaging in consumer-driven
health models, engaging integration and collaboration with
mainstream health care, achieving greater professional unity,
and meaningfully contributing to the public health agenda.22
Evidence-based diagnostic imaging practice guidelines
facilitate the implementation of such recommendations.23,24
The purposes of guidelines are to:25
1. describe appropriate care based on the best available
scientific evidence and broad consensus;
2. reduce inappropriate variation in practice;
3. provide a more rational basis for referral;
4. provide a focus for continuing education;
5. promote efficient use of resources;
Journal of Manipulative and Physiological Therapeutics
November/December 2007
6. act as focus for quality control, including audit;
7. highlight shortcomings of existing literature and
suggest appropriate future research.
These guidelines have been created to improve patient
care by detailing the appropriate information gathering and
decision-making processes involved in the diagnostic
imaging of musculoskeletal care.
The initial impetus for this project occurred in 2003 when
the Council on Chiropractic Education in Canada (CCEC)
requested a revision of the diagnostic imaging guidelines
used at the chiropractic teaching clinic of l'Universit du
Qubec Trois-Rivires (UQTR). CCEC recommended
incorporating protocols that were centered on the clinical
presentation of patients. We first identified the need for an
extensive literature review to propose recommendations on
the use of imaging studies for musculoskeletal disorders. The
review began with a search for the relative risks and benefits
of imaging, clinical indications for imaging of the spine and
extremities, knowledge of existing guidelines, and consid-
eration of potential barriers to dissemination and implemen-
tation strategies of any such guidelines. We set out to initially
answer the following 10 questions:
1. Does ionizing radiation from radiography carry a
potential risk to patients?
2. What is the frequency of conventional radiography
use?
3. What are the associated costs associated with the use of
conventional radiography?
4. What factors influence practitioners in determining the
need for radiographs in adults?
5. What is the evidence supporting the recommendations
of various national and international practice guidelines
for radiography utilization for musculoskeletal condi-
tions for adults?
6. What is the clinical usefulness of spine radiography in
biomechanical analysis, including spinal curvatures
and scoliosis, especially with respect to the effects on
spinal degeneration?
7. What are the indicators of potentially serious pathology
involving the musculoskeletal system (red flags) in
adults?
8. What is the prevalence of congenital anomalies that are
considered contra-indications for high velocity, low
amplitude manual spinal adjustment or manipulation?
Furthermore, what is the associated complication rate
of these maneuvers in patients with such anomalies?
9. What are the clinical indicators leading to optimal
investigation and management of osteoporosis?
10. What are the appropriate clinical findings indicating
radiographic evaluation of the extremities in adults?
Sensitivity, specificity, reliability, validity, predictive
values, and likelihood ratios were considered when available
Journal of Manipulative and Physiological Therapeutics
Volume 30, Number 9
and appropriate. Two hundred and fifty-seven citations were
retrieved and synthesized by the principal investigator (AB)
and presented in a French language narrative review to
UQTR clinicians in June 2003. Relevant findings were also
presented at a research conference.26
This narrative review helped identify the need for
development of diagnostic imaging guidelines for muscu-
loskeletal disorders. Although several answers to the
above 10 questions are integrated within the guidelines,
the routine use of conventional radiography and the
consequent risks of low-dose ionizing radiation exposure
remain significantly contentious and will be further
addressed in a separate article. Proponents of the routine
use of conventional radiography offer the following
justifications for that practice:27
1. To screen for and prevent rare possible complications
associated with spinal manipulative therapy;
2. For nonclinical motives, including patient preference
and satisfaction; medicolegal concerns; political influ-
ence and administrative factors;
3. For postural and biomechanical analysis of spinal
disorders both before and during the provision of
manual therapy;
4. To provide patients with a more accurate prognosis;
5. Because they consider the effects of ionizing radiation
exposure on human health to be negligible.
The proposed diagnostic imaging practice guidelines
represent a shift to a more evidence-based approach and are
supported by more than 680 primary and secondary citations.
When available, meta-analyses and systematic reviews,
randomized clinical trials (RCTs), nonrandomized studies,
cohort and case-control studies, nonexperimental studies,
and existing high-quality clinical guidelines were used
to propose recommendations for various patient presenta-
tions (specific conditions) and comments supporting
those recommendations.
The guidelines pertain only to adult patients and are
divided into 3 parts. Part I specifically addresses lower
extremity disorders; part II addresses upper extremity
disorders; and part III addresses spinal disorders. All 3
parts are condition specific (symptom-based), a feature that
should make these guidelines practical, user-friendly, and
efficacious for practitioners.28 Because accurate history and
examination are crucial initial steps in the diagnosis of any
musculoskeletal disorder, specific clinical criteria are
emphasized for most every condition. The initial triage of
patients with LBP is a constant recommendation of various
clinical guidelines and we believe it to be equally applicable
to the initial management of other regional painful
conditions.29,30 One major objective of the initial triage is
to determine the presence of clinical indicators (red flags) for
serious pathologies requiring diagnostic imaging, appro-
priate referral, or urgent surgical intervention. In the absence
Bussires et al 619
Diagnostic Imaging Guidelines
of such clinical indicators, simple decisions based on
separation into articular vs nonarticular disorders and on
the duration of the patient complaint (acute, subacute,
persistent/chronic) are favored by most recent expert
consensus statements.30,31
Clinical presentations are divided accordingly throughout
the guidelines. Recommendations for radiography (indi-
cated, not initially indicated, not routinely indicated) appear
for every clinical presentation throughout the guidelines.
Because professional self-regulation and knowledge about
the clinical usefulness of specialized diagnostic modalities
are necessary for all primary health care professionals,
recommendations for further imaging studies are therefore
discussed for each condition. 32,33 In some instances,
laboratory assessment is recommended.
Recent evidence suggests that implementation strategies
of imaging guidelines can assist in achieving a sustained
reduction in the number of radiographic examinations
obtained of the cervical spine, lumbar spine, and knees.34
Application of practical, highly sensitive, and reliable
decision rules for cervical spine, shoulder, elbow, wrist,
knee, ankle, and foot trauma has a potential to reduce the use
of radiography by a factor of 16% to 50% in emergency
departments and sports injury clinics alone.35-46 Although
the authors are uncertain of precise chiropractic utilization
rates in these cases, it is likely that utilization rates in
chiropractic parallel those in general medical practice
because a substantial portion of chiropractic patients present
with spine and extremity disorders or have a history of
cervical spine trauma.47 Although targeting a different
population (generally not as acutely injured), application of
decision rules in private practice should also help reduce the
use of radiographic studies. For example, in acute LBP in
adults, the age criterion proposed in earlier guidelines (N50
years of age) as well as the tendency to order radiographs in
patients with symptom duration of less than 4 weeks has low
specificity and substantially increased utilization.12,48 One
authority now recommends obtaining lumbar spine radio-
graphs in patients older than 65 years rather than 50 and
waiting up to 7 weeks to obtain radiographs in patients with
an untreated first episode of LBP.49
The aim in conducting an evidence review is to
facilitate the integration of the best available evidence
with clinical expertise and the values and beliefs of
patients. Although these proposed guidelines are more
restrictive and likely more cost-efficient, practitioners are
provided with the necessary information to allow for
significant flexibility in decision making. As with all
guidelines, clinical judgment and clinician experience must
be used in all cases. It must also be emphasized that
clinical practice guidelines (CPGs) are intended to assist,
not replace, clinicians in their decision-making processes.
Guidelines aid in the application of selective diagnostic
tools and therapeutic approaches for specific clinical
presentations while considering patient preference.50
620 Bussires et al
Diagnostic Imaging Guidelines
METHODS
Statement of Purpose
The purpose of this project was to develop evidence-
based diagnostic imaging practice guidelines for adult
musculoskeletal complaints for use by chiropractors and
other primary health care professionals. The guidelines aim
to describe appropriate care based on the best available
scientific evidence and broad consensus, reduce inappropri-
ate variation in practice, provide a more rational basis for
referral, provide a focus for continuing education, promote
efficient use of resources, act as a focus for quality control
(including audit), highlight shortcomings of existing litera-
ture, and suggest appropriate future research. The project
consists of 9 phases; a flow diagram demonstrating the
placement of each phase is provided in Figure 1.
Phase 1: Literature Search. The literature search focused on
the appropriate use of conventional radiography and
specialized (advanced) imaging for adult musculoskeletal
disorders of the spine and extremities. Studies conducted in
any setting were included in the review, including general
practice, accident and emergency, and hospital clinics. The
selection criteria were applied to the abstracts of the
publications retrieved by the search strategy described
below. The publications were retrieved and read if the
abstracts provided insufficient information to enable
selection. The review also considered biomechanics,
degenerative changes and spinal curvatures (and their
relationship to patient symptoms), indicators of potentially
serious pathology (red flags), as well as congenital
anomalies, trauma, scoliosis, and osteoporosis. Any study
that compared clinical examination and/or assessment of
patient history with an acceptable gold standard for the
evaluation of patients with musculoskeletal pain was
included. A review of various national and international
chiropractic and medical guidelines discussing the use of
imaging studies for musculoskeletal disorders was also
incorporated in the literature review.
Phase 1 consisted of an electronic search in English and
French language literature. Two literature updates were
conducted using a similar strategy. This included MEDLINE
(Pub Med) (1966-2003; -2005; -August 2006), the Cochrane
Register (-January 2004, 2006), the National Research
Register (-January 2004, 2006), the National Guideline
Clearinghouse (-January 2004, 2006), the internet bGoogleQ
search engine, as well as cross references and references
provided by clinicians. The search strategy also included other
databases such as EMBASE to identify relevant studies for
several of the disorders. A combination of subject headings
(MeSH headings) and keywords were searched (specific
disorders of the adult hip, knee, ankle and foot, shoulder,
elbow, wrist and hand, pain, extremity, lumbar spine, thoracic
spine, cervical spine, low back pain, thoracic pain, neck pain,
whiplash, trauma, diagnostic, radiograph, x-ray, imaging,
Journal of Manipulative and Physiological Therapeutics
November/December 2007
Fig 1. Diagram of flow of information from literature to publica-
tion. Phase 1, literature review; phase 2, independent literature
assessment; phase 3, guideline development (specific recommenda-
tions); phase 4, first external review; phase 5, consensus panel;
phase 6, public website; phase 7, second external review; phase 8,
final draft and grading of the evidence; phase 9, dissemination.
US, CT, MRI, MRA, bone scan, nuclear medicine, muscu-
loskeletal, chiropractic, and medical guideline).
Specific disorders of the extremities and spine were
subdivided into the following categories:
1. Adult hip pain: acute hip injury, strain, tendinitis or
tendinosis, piriformis syndrome, trochanteric and iliop-
soas bursitis, osteoporotic fractures, septic arthritis,
chronic pain, congenital/developmental abnormalities,
osteoarthritis (DJD or OA), inflammatory arthritis,
osteonecrosis, tumors and metastatic lesions, stress
(fatigue or insufficiency) fractures, physical examination.
2. Adult knee pain: acute knee injury, osteoarthritis (DJD
or OA), inflammatory arthritis, bursitis, tendinitis,
strain, tendinosis, anterior knee pain, internal joint
derangement, physical examination.
3. Adult ankle and foot pain: acute ankle and foot injury,
chronic ankle and tarsal pain, impingement syndromes,
peroneal tendinosis, lateral premalleolar bursitis, tarsal
tunnel syndrome, chronic foot pain, hindfoot-heel pain,
plantar fasciitis, calcaneal enthesosphyte (spur), sinus
tarsi syndrome, midfoot pain, flat foot with posterior
tibial tendon dysfunction/rupture, navicular tuberosity
pain and tenderness, complex regional pain syndrome,
forefoot pain, metatarsal bursitis, Morton's neuroma,
stress (fatigue or insufficiency) fracture, osteonecrosis
(avascular necrosis), hallux rigidus and hallux valgus,
sesamoiditis, physical examination.
4. Adult shoulder pain: localized pain, acute injury,
glenohumeral joint (trauma, instability, arthritis),
Journal of Manipulative and Physiological Therapeutics
Volume 30, Number 9
rotator cuff, adhesive capsulitis, osteoarthritis, acro-
mioclavicular joint, physical examination.
5. Adult elbow pain: acute injury, lateral and medial
epicondylitis, forearm (or wrist) pain and trauma,
physical examination.
6. Adult wrist and hand pain: acute injury/localized
trauma (wrist, hand, finger), forearm/wrist pain,
tenosynovitis, DeQuervain's disease, trigger finger,
carpal tunnel syndrome (CTS), osteoarthritis, arthro-
pathy (inflammatory, crystal, infection), rheumatoid
arthritis, physical examination.
7. Adult spinal trauma/injury: lumbar, thoracolumbar,
thoracic, cervical spine, whiplash, chest wall (thorax),
pelvis, sacrum, coccyx, coccydynia.
8. Adult lumbar spine disorders: acute, subacute, and
chronic LBP, nontraumatic, uncomplicated, sciatica,
radicular pain, stenosis (lateral, central), spondylolith-
esis, inflammatory spondyloarthropathy, fracture, neo-
plasia, infection, structural deformity, surgical fusion,
laboratory examination, cauda equina syndrome, abdom-
inal aortic (aneurysm, dissection, condition, risk factors),
complication, epidemiology, physical examination.
9. Adult thoracic spine disorders: acute, subacute,
chronic, osteoporosis (collapse, compression, fracture,
risk factors, evaluation, monitoring), scoliosis, chest
wall pain, aortic dissection, complication, epidemiol-
ogy, physical examination.
10. Adult cervical spine disorders: acute, subacute, chronic,
nontraumatic, radicular, neck and arm pain, cervical
myelopathy, radiculomyelopathy, ligament laxity, atlan-
toaxial instability, congenital anomaly, cervical artery
dissection/condition (vertebral/carotid artery, transient
ischemic attack [TIA], stroke, risk factors, past trauma),
complication, epidemiology, physical examination.
When available, systematic reviews and meta-analyses,
RCTs, nonrandomized studies, observational studies (cohort
and case-controlled studies), nonexperimental (nonanalytic)
studies, and existing high-quality clinical guidelines took
precedence over case studies, case series, or opinion for
inclusion in the study. Articles were excluded from the
recommendations if they were not available in English or
French or could not be translated, if they were published
before 1980 (except for some rare classic papers), and if they
specifically focused on thermography, electrodiagnostic
studies, intervention, nonmusculoskeletal disorders, or on
children. Details of the literature review (2003-2006) are
available upon request.
Phase 2: Independent Literature Assessment. Early phases of this
guideline project used the European Commission classifica-
tion (2001) 51 to classify grade of recommendations
(Table 1). However, several new instruments have been
proposed to evaluate scientific literature. Weaknesses
identified in the grading system initially proposed by the
Bussires et al 621
Diagnostic Imaging Guidelines
Table 1. Classification used by the European Commission (2001)51
Grade Type of evidence a
A RCTs, meta-analysis, systematic reviews; or
B Robust experimental or observational studies; or
C Other evidence where the advice relies on expert opinion and
has the endorsement of respected authorities
a
NHS Executive. Clinical Guidelines: Using Clinical Guidelines to
Improve Patient Care within the NHS (96CC0001). NHS Executive,
Leeds, 1996.
US Agency for Healthcare Research and Quality led to the
development of new tools to assess available literature.52
With the objective of independently assessing the level of
evidence of citations listed in the guidelines and considering
the recently developed assessment tools, 5 literature
reviewers (licensed practitioners, 4 with specialized training
in research methods) were invited to review the citations of
the spine and extremity imaging guidelines. A number of
citations were assessed by at least 2 evaluators to compare
the level of agreement between evaluators. In cases of
disagreement, the research team reached a decision and
classified the citation.
The methodological quality of all studies that were included
in the review was assessed by means of a methodological
quality assessment list. Participants were asked to complete an
evidence extraction table (Excel spreadsheet), provided at the
outset of the review, with a list of all citations included in the
spinal and extremity disorders guidelines. Requested informa-
tion included summaries of study design; study objective in
brief; type of analysis; methods (including population studied,
and follow-up period); study results/evidence provided; scores
for the scoring instruments (QUADAS, AGREE, and
SPREAD); significant biases.
Three methodological scoring instruments were used, as
described below.
1. The QUADAS instrument53 of the Health Technology
Assessment Diagnostic Evaluation is an evidence-based
assessment tool to evaluate the quality of primary studies
of diagnostic accuracy. The tool, derived from 3
systematic reviews, does not include a quality score.
Instead, it is structured as a list of 14 questions that should
be answered Yes, No, or unclear (Fig 2). Although
some minor modifications have been proposed,54,55
QUADAS appears useful for highlighting the strengths
and weaknesses of existing diagnostic accuracy studies.
Effects of a negative response to item 3 (quality of the
reference standard), item 5 (verification bias), items 10
and 11 (blinded interpretation of index test and reference
standard), and item 14 (withdrawals) are assumed to be
particularly important and thus are identified as critical.
Therefore, the following scoring system was used:
High quality study = all 5 critical items + at least 3
other yes items = 8 yes or more
Good quality = 1 critical item missing but N 8 yes
622 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007

Fig 2. QUADAS tool Fig 3. AGREE items56

Item YesNoUnclear Scope and purpose
The overall objective(s) of the guideline is (are) specifically described
1. Was the spectrum of patients representative
The clinical question(s) covered by the guideline is (are)
of the patients who will receive the test
specifically described
in practice?
The patients to whom the guideline is meant to apply are
2. Were selection criteria clearly described?
specifically described
3. Is the reference standard likely to classify
Stakeholder involvement
the target condition correctly?
The guideline development group includes individuals from
4. Is the period between reference standard
all the relevant professional groups
and index test short enough to be reasonably
The patients' views and preferences have been sought. The target
sure that the target condition did not
users of the guideline are clearly defined
change between the two tests?
The guideline has been piloted among the target users
5. Did the whole sample or a random selection
Rigor of development
of the sample receive verification using
Systematic methods are used to search for the evidence
a reference standard of diagnosis?
The criteria for selecting the evidence are clearly described
6. Did patients receive the same reference
The methods used for formulating the recommendations are
standard regardless of the index test result?
clearly described
7. Was the reference standard independent of
The health benefits, side effects, and risks have been considered
the index test (ie, the index test did not
in formulating the recommendations
form part of the reference standard)?
There is an explicit link between the recommendations and
8. Was the execution of the index test described
the supporting evidence
in sufficient detail to permit replication of
The guidelines have been externally reviewed by experts prior to
the test?
its publication
9. Was the execution of the reference standard
A procedure for updating the guidelines is provided
described in sufficient detail to permit
Clarity and presentation
its replication?
The recommendations are specific and unambiguous
10. Were the index test results interpreted
The different options for management of the condition are
without knowledge of the results
clearly presented
of the reference standard?
Key recommendations are easily identifiable
11. Were the reference standard results
The guideline is supported with tools for application
interpreted without knowledge of the
Applicability
results of the index test?
The potential organizational barriers in applying the
12. Were the same clinical data available when
recommendations have been discussed
test results were interpreted as would be
The potential cost implications of applying the recommendations
available when the test is used in practice?
have been considered
13. Were uninterpretable/intermediate test
The guideline presents key review criteria for monitoring and/or
results reported?
audit purposes
14. Were withdrawals from the study explained?
Editorial independence
The guideline is editorially independent from funding body
Score
Conflicts of interest of guideline development members have
This tool has been developed to assess the quality of diagnostic accuracy been recorded
studies. The tool does not incorporate a quality score. Instead, it is structured
as a list of 14 questions that should each be answered yes, no, or
unclear. For explanation of items included the quality assessment tool that affected potential bias, a guideline would be
guide to scoring items, see Health Technology Assessment 2004; Vol. 8: No. considered to be of high quality if:
25. http://www.biomedcentral.com/1471-2288/3/25. This is an Open
Access article: verbatim copying and redistribution of this article are
(i) systematic methods were used to search for evidence;
permitted in all media for any purpose, provided this notice is preserved (ii) the criteria for selecting the evidence were
along with the article's original URL. clearly described;
(iii) the methods used for formulating the recommen-
dations were clearly described;
Fair quality = 2 critical items missing but N 8 yes (iv) there was an explicit link between the recommen-
Poor quality = N2 critical items missing and/or dations and the supporting evidence;
b7 yes (v) the guideline was editorially independent from the
2. The AGREE instrument56 was used to quantitatively funding body.
assess the quality of guidelines. The instrument The main measure was the degree of quality expressed
contained 23 items grouped into 6 quality domains in terms of percentage within a range of 0% (minimum)
with a 4-point Likert scale to score each item (scope to 100% (maximum) for each of the 6 domains (Fig 3).
and purpose, stakeholder involvement, rigour of 3. The SPREAD instrument,57 derived from the Scottish
development, clarity and presentation, applicability, Intercollegiate Guidelines Network,58 includes statis-
editorial independence). In keeping with the principles tical considerations on and error size suggested by
of important features of RCTs and systematic reviews the Centre for Evidence-Based Medicine methodology
Journal of Manipulative and Physiological Therapeutics
Volume 30, Number 9
Fig 4. Classification based on SPREAD validated methodological
criteria57
1++ High-quality meta-analyses without heterogeneity,
systematic reviews of RCTs each with small CI, or
RCTs with very small CI and/or very small and
1+ Well-conducted meta-analyses without clinically
relevant heterogeneity, systematic reviews of RCTs, or
RCTs with small CI and/or small and
1 Meta-analyses with clinically relevant heterogeneity,
systematic reviews of RCTs with large CI, or RCTs with
large CI and/or or
2++ High-quality systematic reviews of case-control or
cohort studies. High-quality case-control or cohort
studies with very small CI and/or very small and
2+ Well-conducted case-control or cohort studies with
small CI and/or small and
2 Case-control or cohort studies with large CI and/or large
or
3 Nonanalytic studies, eg, case reports, case series
4 Expert opinion
(minus) Meta-analyses with clinically relevant heterogeneity;
systematic reviews of trials with large confidence
intervals; trials with large CIs, and/or large and/or
Revised grading system for recommendations in evidence-based
guidelines58
This tool has been developed to grade recommendations according to
the strength of available scientific evidence (level A to D)
Grades of recommendation
A At least one meta-analysis, systematic review or RCT
rated as 1++, and directly applicable to the target
population; or a systematic review of RCTs or a body of
evidence consisting principally of studies rated as 1+,
directly applicable to the target population and
demonstrating overall consistency of results
B A body of evidence including studies rated as 2++,
directly applicable to the target population and
demonstrating overall consistency of results; or
extrapolated evidence from studies rated as 1++ or 1+
C A body of evidence including studies rated as 2+,
directly applicable to the target population and
demonstrating overall consistency of results; or
extrapolated evidence from studies rated as 2++**
D Evidence level 3 or 4; or extrapolated evidence from
studies rated as 2+; or evidences from trials classified as
(minus) regardless of the level
Good practice Recommended best practice based on the clinical
point experience of the guideline development group,
without research evidence
This tool aims to evaluate the scientific evidence according to prespecified
levels of certainty (1++ to 4).
In this study, Good Practice Point also represents consensus of the Delphi
panel. CI indicates confidence intervals.
to give a more comprehensive evaluation of the
available evidence. This tool aims to evaluate the
scientific evidence according to prespecified levels of
certainty (1++ to 4) (Fig 4.).
To further assist in their appraisal, the literature reviewers
were provided with a checklist for the appraisal of
epidemiologic studies, literature review articles, and sys-
tematic reviews.59 It should be noted that the literature
Bussires et al 623
Diagnostic Imaging Guidelines
Table 2. Typical effective ionized radiation dose for common
imaging procedures
Typical effective
Class dose (mSv) Examples
0 0 Ultrasound, magnetic resonance imaging
I b1 Radiograph: cervical and thoracic
spine, extremities, pelvis, and lungs
II 1-5 Lumbar spine radiograph, bone scan,
cervical spine CT
III 5-10 Chest and abdomen CT
Classification of the typical effective dose of ionizing radiation from
common imaging procedures. Adapted from: European Commission.
Radiation protection 118. Referral guidelines for imaging in conjunction
with the UK Royal College of Radiologists; Italy 2001. p 21.
assessment (phase 2) included citations retrieved during the
initial literature search, the 2 literature updates, and articles
provided by Delphi panelists and participants in the second
external review phase.
Phase 3: Guideline Development: Specific Recommendations. Based on
the literature review, the primary author (AB), with the
assistance of a staff chiropractic radiologist, composed the
first draft of a diagnostic imaging practice guideline for
chiropractic interns and clinicians.
To simplify decision making about radiograph utilization,
the proposed guidelines are based on common clinical
presentations of conditions affecting the spine, the lower, and
upper extremities. The Referral Guidelines for Imaging
(radiation protection 118) coordinated by the European
Commission in conjunction with the UK Royal College of
Radiologists (2001)51 served as a template for the present
recommendations. For those guidelines, evidence gathering,
synthesis, and grading were undertaken by a large group of
radiologists across the European Union. Classification of
evidence levels was translated into grades of recommenda-
tions based on the system developed by the US Department of
Health and Human Services, Agency for Health Care Policy
and Research (1993). As a means of comparison, typical
effective ionizing radiation doses delivered to patients for
common imaging procedures are reported in Table 2.
For every clinical presentation throughout the guidelines,
one of 4 recommendations appears. When appropriate, the
proposed recommendation is accompanied by the level of
evidence and pertinent comments. The recommendations are
as follows:
(a) Radiographs indicated. This recommendation indicates
that radiographs are indicated. Further suggestions for
specific radiographic projections are also suggested.
(b) Radiographs not initially indicated. This recommen-
dation indicates that a trial of conservative therapy
624 Bussires et al
Diagnostic Imaging Guidelines
should be attempted first. Radiographs should be
considered, however, if patients demonstrate no
significant benefit, generally after 4 weeks of therapy.
(c) Radiographs not routinely indicated. This recommen-
dation indicates that radiographs do not generally
provide significant information and are not likely to
alter the therapeutic intervention.
(d) Special investigations. This recommendation
indicates that further advanced imaging procedures
are recommended.
Phase 4: First External Review. The guidelines were then
reviewed by several experts in the Spring of 2003, including
3 chiropractic radiologists from different academic institu-
tions; 2 chiropractors specializing in epidemiology; and one
practicing chiropractor who also possessed an MSc degree.
The guidelines, with input from the first 6 reviewers, were
then sent for external review to 6 additional chiropractors
holding a diplomate or fellowship in either radiology or
clinical sciences. Each reviewer independently assessed the
guidelines and, where appropriate, made suggestions and
comments that were incorporated.
Phase 5: Expert Consensus Panel. Considering the overall low
quality of scientific studies available on diagnostic imaging,
a large Delphi consensus panel was invited to consider the
proposed recommendations. When meaningful clinical trials
are unavailable, development of recommendations by
consensus opinion is considered an acceptable option.60-62
Delphi surveys using large groups show greater within and
between reliability.63 Phase 5 of this project involved a
modified Delphi panel composed of a group of international
experts on the topic of musculoskeletal disorders in clinical
chiropractic, chiropractic radiology, and chiropractic
research. Three sources of information were used to identify
experts: publication record, membership, and involvement in
relevant organizations such as the American Chiropractic
College of Radiology, and recommendations from research-
ers and educators in the field. In addition, chiropractic
college presidents (all members of the Association of
Chiropractic Colleges) were asked to provide the names of
3 faculty members from their respective institutions: one
chiropractic radiologist, one clinical science specialist, and
one researcher. Among the several named techniques,
authoritative figures from Chiropractic Biophysics technique
(CBP) protocols and Gonstead technique64 were also invited
to participate. Our research team determined that the expert
group selected offers a diverse range of views and adequately
represents the profession. Recognizing the existence of a
significant body of literature on conventional radiography
for biomechanical analysis, results of the initial literature
review for question 6 (What is the clinical usefulness of
spine radiography in biomechanical analysis, including
spinal curvatures and scoliosis, especially with respect to
the effects on spinal degeneration?) were provided on the
Journal of Manipulative and Physiological Therapeutics
November/December 2007
Web to Delphi panelists for consideration during the
evaluation of recommendations for spine disorders. Phase
5 was overseen in its entirety by 2 Delphi process expert
advisors (one from the USA and one from the UK).
Although face-to-face discussions between panelists are
preferable to reach consensus, limitations of time and
prohibitive costs precluded using this strategy. As an
alternative, we incorporated electronic communication
technology. By accessing a restricted (password protected)
website, experts were asked to independently evaluate the
proposed guidelines and to provide recommendations aimed
at forming a consensus opinion. Each scenario was
accompanied by a binary type answer: agree-disagree. In
case of disagreement with a particular recommendation,
panelists were instructed to provide comments and sugges-
tions supported by relevant references. Submission dead-
lines were regularly announced by e-mail and a regularly
updated schedule served to inform panelists of completed
and upcoming sections. At the conclusion of each first
round, results were made available to all panelists and an
updated version of the guideline was posted in PDF format
on the website before the second round began. A minimum
of 75% agreement was established as necessary to reach
consensus for all recommendations. It was further decided
to restrict the Delphi process to 2 rounds as the initial
guidelines were already based upon a careful review of the
literature. Two rounds were determined to be sufficient to
achieve adequate consensus and served to minimize the
workload of participants. Consensus was judged as strong
(N85% of panel members), moderate (50%-84%), or low
(33%-49%).65
Phase 6: Public Website. Results of phase 5 were posted on a
website accessible to chiropractors worldwide. Advance
announcements were published in the World Federation of
Chiropractic Quarterly World Report and Dynamic
Chiropractic publications informing chiropractors of the
nature of the project and inviting them to access the
website and to offer comments and suggestions on
proposed recommendations. Professional trade organiza-
tions invited to nominate members to review the proposed
diagnostic imaging guidelines included the following:
World Federation of Chiropractic, Canadian Chiropractic
Association (CCA), American Chiropractic Association
(ACA), International Chiropractic Association (ICA), State
and Provincial chiropractic associations, European and
Asian chiropractic associations.
Every section of the guideline was posted for considera-
tion for a period of 2 months. The objectives of phase 6
were to:
1. inform the profession of the work currently being done
in the field of chiropractic imaging guidelines;
2. help determine if these guidelines appear reasonable
and user friendly for practitioners;
Journal of Manipulative and Physiological Therapeutics
Volume 30, Number 9
3. obtain comments and input from practitioners to
improve reliability;
4. facilitate future implementation strategies by improv-
ing ownership of the guidelines.
Practitioners were invited to comment on their
perceived level of confidence and comfort with using the
proposed Delphi results of the diagnostic imaging guide-
lines in their individual practices, as measured by an
appropriateness (Likert) scale. Participants provided a
rating from 1 (strongly disagree) to 9 (strongly agree).
They were also encouraged to provide comments with
pertinent rationale and references to support their disagree-
ments with any of the recommendations.
Phase 7: Second External Review. To comprehensively involve
all stakeholders and to guarantee editorial independence, a
second external review was initiated. To achieve these
goals, chiropractic specialists and 2 groups of medical
experts on musculoskeletal disorders were invited to
provide comments and suggestions on the Delphi consensus
imaging guidelines (phase 5). Chiropractic specialists in
Canada were briefly introduced to the study objectives and
methodology by the principal investigator (AB) on
November 17, 2006, at a meeting organized by the
CFCRB during the Canadian National Convention. Cana-
da's chiropractic specialists formally received an invitation
to participate in the External Review (phase 7) by mail and
e-mail. American chiropractic specialists were notified and
invited to participate by mail and e-mail to addresses that
were retrievable. Guidelines were made accessible on a new
website for a period of 10 weeks so that elected
representatives of the following groups could evaluate
recommendations on a specific data collecting form as
measured by an appropriateness (Likert) scale. Participants
provided a rating from 1 (least appropriate/strongly
disagree) to 9 (most appropriate/strongly agree), with a
separate option for don't know.
Chiropractic specialties included the following: College of
Chiropractic Radiology, Canada (FCCR); American Chir-
opractic College of Radiology (ACCR); College of Chir-
opractic Clinical Sciences (Canada) (FCCS); College of
Chiropractic Sport Sciences (Canada) (FCCSS); College
of Chiropractic Orthopedists (Canada) (FCCOC); College of
Chiropractic Rehabilitation Sciences (CCRS); American
College of Chiropractic Orthopedists (ACCO); College of
Chiropractic Rehabilitation Sciences (CCRS); American
College of Chiropractic Council on Neurology (NOCA/ACCN).
Medical specialties included 2 groups of medical experts,
one from Canada and the other from the USA, with expertise
in musculoskeletal disorders (neurology, neurosurgery,
orthopedics, physical medicine and sports medicine specia-
lists, osteopathic medicine, and radiology). Names of experts
were provided by personal contacts of panelists involved in
this project and members of the research team.
Bussires et al 625
Diagnostic Imaging Guidelines
Phase 8: Final Draft of the Diagnostic Imaging Guidelines and Grading
of Evidence. The research team considered all suggestions and
comments received upon completion of the public website
(phase 6) and second external review (phase 7). In addition, a
member of the public with specialized training in research
was asked to review the methodology and to consider all
recommendations from the 3 recently developed adult
musculoskeletal diagnostic imaging guidelines. As a patient
representative, this person was asked how, in general,
proposed recommendations fit with public interest and
patient protection.
Grading of Evidence. All recommendations are graded
according to the strength of the evidence. The investigators
of this project formally met to assign a grade to each of the
recommendations, indicating the strength of available
scientific evidence (level A to D) for spinal and extremity
disorders. The criteria for the grades are outlined by the
SPREAD tool (Fig 4). The strength of evidence was assessed
by evaluating consistency of the findings across studies and
the quality of the studies.
These aspects were judged and summarized based on the
following statements:
Systematic reviews and meta-analyses, RCTs, prospec-
tive cohort studies, and high-quality clinical guidelines
provide better evidence than nonrandomized studies,
case-controlled studies, nonanalytic studies and text-
books, case reports, or opinion.
Studies with a score greater than 2+ (SPREAD) are
rated of high or good quality (QUADAS), or with more
than 50% of the maximum attainable score in each
domain (strongly recommended with AGREE) con-
tribute more to the conclusions than studies with
lower scores.
At least 75% of the studies have to report a similar
trend to conclude that the results across studies
are consistent.
Members of the team had to reach consensus on the
grades administered. Where the evidence is insufficient and
recommendations are based on consensus opinion alone, this
is indicated as a Good Practice Point. Recommendations
are also accompanied by a suggestion of critical or
important (but not critical). Critical is defined as a life-
threatening condition or as a situation in which patients are at
risk of serious complications if they are not referred for
appropriate care in a timely manner.
Phase 9: Dissemination------Implementation. The complex and
challenging issue of implementation and utilization of
CPGs also needs to be considered. To prevent duplication
and reduce costs, it has been proposed that results from the
Delphi panel be shared with American and Canadian
chiropractic national guideline development committees
626 Bussires et al
Diagnostic Imaging Guidelines
and/or task forces. The CCA and the Canadian Federation of
Chiropractic Licensing Board (CCA/CFCRB task force
overseeing the development of clinical chiropractic practice
guidelines) were sent copies of these guidelines (phase 4) for
consideration in the fall of 2004. The Council for
Chiropractic Guidelines and Practice Parameters (CCGPP)
in the USA will also be consulted to consider the possibility
of integrating sections of the diagnostic imaging guidelines
as they reach completion. We encourage researchers to apply
the AGREE instrument or other similar instruments to
evaluate the strength of the evidence as well as the validity of
the consensus document.
Implementation of the final version of the guidelines
will require involvement of national, provincial, and
state organizations. In addition to publishing these in
this peer-reviewed journal, several other strategies are
being considered:
1. Registering with the National Guideline Clearinghouse;
2. Posting of the electronic document on various websites
such as those of the malpractice insurance carriers,
chiropractic colleges, and their respective outpatient
chiropractic clinics;
3. Educational intervention strategies:
a. e-learning:
i. Internet platform (e-learning) for distance learn-
ing (CE) including case-based learning objects
and examination tests
ii. Internet platform (e-learning) for chiropractic
colleges including case-based learning objects
and examination tests
b. Conducting community pilot studies;
4. The use of referral guidelines, reinforced by request
checking and clinical management algorithms;
5. Promotion by national, provincial, and state organizations;
6. Support from the World Federation of Chiropractic and
national chiropractic guideline development committees;
7. Presentation of results at various conferences, meet-
ings, symposia, and seminars.66-69
8. Plain language summary for patients.
RESULTS AND DISCUSSION
For clarity, the results, discussion, and related tables are
presented in sequence. These include (A) the literature
search and independent literature assessments (phases 1-2),
(B) the Delphi panelconsensus opinion (phase 5), (C) the
public consultation (phase 6), and (D) the second external
review (phase 7).
Literature Search and Independent Literature Assessment (Phases 1-2)
More than 300 original scientific citations published in
peer-reviewed biomedical journals and 3 textbooks were
selected by one investigator (AB) during the initial literature
Journal of Manipulative and Physiological Therapeutics
November/December 2007
search. The literature updates and the inclusion of articles
submitted up to the second external review (phase 7) resulted
in a total of 682 citations for the 3 diagnostic imaging
guidelines (lower extremity disorders = 174 citations; upper
extremity disorders = 126 citations; spine disorders = 382
citations). Most citations originated from peer-reviewed
biomedical journals published in the last decade.
Results of The Literature Review of Clinical Indications for Extremity and
Spine Disorders
Citations Supporting Proposed Recommendations for Lower
Extremity Disorders. Eighty-five articles related to upper
and lower extremity disorders were included in the initial draft
of the guideline between 2003 and 2004. Meta-analysis and
systematic reviews (4), clinical trials (35), existing clinical
guidelines (15), review articles (28), and textbooks (3) were
used to propose recommendations and/or relevant comments.
A literature update was conducted in 2005 resulting in the
addition of 32 new studies. Overall, 117 articles pertaining to
adult extremity disorders were included in this draft of the
extremity guidelines. Meta-analysis and systematic reviews
(5), clinical trials (43), existing clinical guidelines (28), review
articles (39), and textbooks (4) were used. Recommendations
and/or relevant comments were reviewed accordingly. A final
literature update just before the launching of the lower
extremity disorders Delphi process (phase 5) in February
2006 and references provided by Delphi panelists (February-
April 2006) for the lower extremity guideline alone resulted in
the addition of 91 new references. Meta-analyses and
systematic reviews (0), clinical studies (40), existing clinical
guidelines (2), review articles (30), and textbooks (19) were
mainly added to clinical presentations and comments for
special imaging recommendations (Table 3).
Citations Supporting Proposed Recommendations for
Upper Extremity Disorders. Eighty-five articles related to
adult upper and lower extremity disorders were included in
the initial draft of the guideline between 2003 and 2004.
Meta-analysis and systematic reviews (4), clinical trials (35),
existing clinical guidelines (15), review articles (28), and
textbooks (3) were used to propose recommendations and/or
relevant comments. A literature update was conducted in
February 2006 resulting in the addition of 32 new studies.
Overall, 52 citations pertaining to adult upper extremity
disorders were included in this draft of the guidelines. Meta-
analysis and systematic reviews (2), clinical studies (17),
existing clinical guidelines (13), review articles (18), and
textbooks (2) were used. A final literature update just before
the launching of the upper extremity disorders Delphi
process (phase 5) in August 2006 and references provided
by Delphi panelists (October-November 2006) for the upper
extremity guideline alone resulted in the addition of 74 new
citations. Meta-analyses and systematic reviews (1), clinical
studies (39), existing clinical guidelines (7), review articles
(24), and textbooks (3) were mainly added to clinical
Journal of Manipulative and Physiological Therapeutics Bussires et al 627
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table 3. Number and types of citations included from first draft to Delphi results for lower extremity disorders. Final count does not add up
as phase 1 to 3 (2003-2004) and literature update in 2005 included citations of the upper extremity guidelines
First draft phase 3 Literature update Final update lower
(upper and lower (upper and lower extremity (Feb 2006)
extremity combined) extremity combined) and Delphi Panel Total lower
2003 2004 2005 phase 5 (Feb-April 2006) extremity
Meta-analyses and systematic reviews (4) (5) (0) 5

Clinical studies (35) (43) (40) 88

Clinical guidelines (15) (28) (2) 19

Review articles (28) (39) (30) 44

Textbooks (3) (4) (19) 22

85 117 91 174

Table 4. Number and types of references included from first draft to Delphi results for upper extremity disorders. Final count does not add
up as phase 1 to 3 (2003-2004) included citations of the lower extremity guidelines
First draft phase 3 Final update upper
(upper and lower extremity (Aug 2006)
extremity combined) Upper extremity and Delphi Panel Total upper
2003-2004 update (Feb 2006) phase 5 (Oct-Nov 2006) extremity
Meta-analysis and systematic reviews (4) (2) (1) 3

Clinical studies (35) (17) (39) 56

Clinical guidelines (15) (13) (7) 20

Review articles (28) (18) (24) 42

Textbooks (3) (2) (3) 5

85 52 74 126

presentations and comments for special imaging recommen-
dations (Table 4). Recommendations and/or relevant com-
ments were reviewed accordingly.
Citations Supporting Proposed Recommendations for
Spinal Disorders. One hundred and seventy-eight citations
pertaining to adult spinal disorders were included in the
initial draft of the guideline (December 2003). Meta-analyses
(0), systematic reviews (6), clinical studies (92), existing
clinical guidelines (9), review articles (51), textbooks (18),
and commentaries or letters (2) were used to propose
recommendations, relevant comments, and descriptive
patient presentations. A literature update conducted in
September 2005 resulted in the inclusion of 35 new citations:
systematic reviews (2), clinical studies (20), existing clinical
guidelines (4), review articles (3), textbooks (4), and
commentaries (2). A final literature update just before the
launching of the spine disorders Delphi process (phase 5) in
April 2006 and references provided by Delphi panelists
between April and July 2006 for the lumbar, thoracic, and
cervical spine disorders resulted in the addition of 169 new
citations: meta-analyses (3), systematic reviews (6), clinical
studies (107), existing clinical guidelines (6), review articles
(40), and textbooks (7) were mainly added to the clinical
presentations and to the comments related to special imaging
recommendations. Overall, a total of 382 citations were
included in the lumbar, thoracic, and cervical spinal disorder
guidelines (Table 5).
The number of citations per individual category is as
follows: spinal trauma (41), nontraumatic lumbar spine
(128), nontraumatic thoracic spine (77), and nontraumatic
cervical spine (108). The discrepancy between the total
number of citations included in the spinal disorder
guidelines (382 citations) and the addition of individual
category citations (354) is related to references included as
general background information at the beginning of some
sections. These references do not specifically support
proposed recommendations.
Results from the Independent Literature Assessment. Results from
the independent literature assessment (study quality and
reported findings) are available in Appendix A (available at
628 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007

Table 5. Number and types of references included from first draft to Delphi results for spine disorders
First draft phase 3 Literature update Final update spinal disorders
(all sections combined) (all sections combined) (April 2006) and Delphi Panel Total spinal disorders
Dec 2003 -Sept 2005 phase 5 (April-July 2006) (all sections combined)

Meta-analysis (0) (0) (3) 3

Systematic reviews (6) (2) (6) 14

Clinical studies (92) (20) (107) 219

Guidelines (9) (4) (6) 19

Review articles (51) (3) (40) 94

Textbooks (18) (4) (7) 29

Commentary/letter (2) (2) (0) 4

178 35 169 382

doi:10.1016/j.jmpt.2007.10.003). Except for citations found
in the background information and those providing insights
on the management of certain conditions, all citations were
independently assessed by a team of reviewers. The
majority of review articles are narrative rather than
systematic. Narrative reviews generally are comprehensive
and cover a wide range of issues within a given topic, but
they do not necessarily state or follow stringent rules
regarding the search for evidence. Because narrative
reviews are prone to several biases (subjective, no explicit
methods for searching literature or reporting and cannot be
replicated), these study designs were rated as a 3 (level of
evidence). Textbooks were also assigned a level 3 for the
same reasons.
Delphi PanelConsensus Opinion (Phase 5)
The lower extremity, upper extremity, and spine disorders
guidelines were evaluated using a modified Delphi panel
composed of an international group of experts on the topic of
musculoskeletal disorders in clinical chiropractic, chiroprac-
tic radiology, and chiropractic research. Of the 145
participants invited to participate in the Delphi panel, 44
were not included because they either could not be reached
or they did not reply to invitations. Ten others declined to
participate, and 7 eventually withdrew from the Delphi panel
for personal reasons. Overall, 76 experts agreed to return a
confidential agreement to participate. Only responses from
those having returned a confidential agreement were
included to participate in the Delphi panel.
Part 1: Lower Extremity Disorders (Phase 5). Sixty-six panelists
representing 20 chiropractic institutions actively partici-
pated in the first round. Expert panel composition
(academic, clinicians, and researchers, and a mixture of
those) for each category evaluated is provided in Figure 5,
and the submission deadlines for each round are
presented in Table 6. As each category was completed,
the results were posted on the website in a PDF file
accessible to all panelists. Changes were highlighted in
the text for clarity.
Percentage agreement for each recommendation, includ-
ing patient presentation and pertinent comments for round 1
and round 2 (where applicable) of adult hip, knee, and ankle
and foot disorders, is tabulated in Tables 7 to 9.
Hip Disorders. Sixty-six panelists completed the hip dis-
orders section. Results of round 1 were forwarded to all panelists
to consider comments, and new references were provided.
Although more than 75% agreement was reached for all
14 recommendations, 5 new recommendations were proposed
for the second round owing to the proposal of significant
changes. Forty-nine panelists returned round 2 (Table 7).
Knee Disorders. Fifty-four panelists completed the only
round necessary to reach consensus for all 9 recommenda-
tions (Table 8). Percentage agreement ranged between 83%
and 96%.
Ankle and foot disorders. For the ankle and foot
disorders section, 53 panelists completed all 26 recom-
mendations. Based on suggestions proposed in the first
round, 6 new recommendations were proposed for the
second round. Forty-eight panelists participated in round 2
(Table 9). Percentage agreement ranged between 87% and
100% for all recommendations accepted. Table 10 shows
the breakdown of panelists completing the lower extre-
mity disorders sections.
Part 2: Upper Extremity Disorders (Phase 5). Expert panel
composition (academic, clinicians, and researchers, and a
Journal of Manipulative and Physiological Therapeutics Bussires et al 629
Volume 30, Number 9 Diagnostic Imaging Guidelines

Fig 5. Delphi panel composition for adult lower extremity disorder guidelines.

Table 6. Delphi panel submission deadlines for the lower extremity and 2 (where applicable) of adult shoulder, elbow, and wrist
disorders guidelines and hand disorders, is provided in Tables 12 to 14.
Sections Round Date closed
Hip 1 February 27, 2006 Shoulder Disorders. Fifty-one panelists completed round 1
and 30 panelists completed round 2 of the shoulder disorders
Hip 2 March 6, 2006 category. The results of round 1 were forwarded to all
panelists for consideration of the comments and new
Knee 1 March 13, 2006
references provided by various panel members. Although
Ankle and foot 1 March 27, 2006 more than 80% agreement was reached for all 8 recommen-
dations in round 1, 5 new recommendations were proposed
Ankle and foot 2 April 10, 2006 for the second round as a result of input from panel members
(Table 12).

mixture of those) for each category evaluated is provided in
Figure 6, and the submission deadlines for each round are
presented in Table 11. For every category completed, final
results were posted on the website in a PDF file accessible to
all panelists. Changes were highlighted in the text for clarity.
Percentage agreement for each recommendation, includ-
ing patient presentation and pertinent comments for rounds 1
Elbow Disorders. Forty-eight panelists completed the only
round necessary to reach consensus, reaching between 92%
and 98% agreement for all 6 recommendations. A new
recommendation for forearm pain after trauma was added
before the final consultation of the upper extremity disorders
guideline. Comments received were integrated in the final
draft (Table 13).
630 Bussires et al
Diagnostic Imaging Guidelines
Table 7. Percentage agreement for recommendations of adult
lower extremity disorders guidelines hip (rounds 1 and 2)
% Agreement
Round 1
Patient presentation (n = 69)
General indications for radiographs 92
Adult patients with:
Full or limited movement and nontraumatic 91
hip pain of b4 wk's duration
1. Strain, tendinitis, or tendinosis 84
2. Piriformis syndrome 94
3. Nontraumatic trochanteric and 92
iliopsoas bursitis
4. Osteoporotic hip fractures 95
5. Septic arthritis of the hip 100
Chronic hip pain unresponsive to 4 wk 92
of conservative care or if one of the
following conditions is suspected:
1. Congenital/developmental abnormalities 84
2. Osteoarthritis (DJD) 98
3. Inflammatory arthritis 90
4. Osteonecrosis 93
5. Tumors and metastatic lesions 97
6. Stress (fatigue or insufficiency) fractures 97
Significant hip trauma 97
Wrist and Hand Disorders. Similarly, 48 panelists com-
pleted the only round necessary to reach consensus for all 11
recommendations, reaching between 89% and 100% agree-
ment on individual recommendations (Table 14). Table 15
depicts the breakdown of panelists completing the upper
extremity disorders sections.
Part 3: Spine Disorders (Phase 5). Expert panel composition for
each category evaluated is provided in Figure 7, and the
submission deadline for each round is presented in Table 16.
For every section completed, final results were posted on the
website in a PDF file accessible to all panelists. Changes
were highlighted in the text for clarity. Percentage agreement
for each recommendation, including patient presentation and
pertinent comments for round 1 and round 2 (where
applicable) of adult spine disorders, is provided in Tables
17 to 20. Sixty-one experts representing 21 chiropractic
institutions actively participated.
Spinal Trauma. Although all recommendations for the
spinal trauma category were integrated in the lumbar,
thoracic, and cervical spine sections of the guidelines, they
are conveniently presented here separately. Fifty panelists
completed round 1 and 42 panelists completed round 2 of the
spinal trauma categories (Table 17).
Round 1 included the following sections: (a) trauma to
the lumbar spine, pelvis, sacrum, and coccyx; (b) thoracic
spine and chest wall (thorax) trauma; and (c) cervical spine
Journal of Manipulative and Physiological Therapeutics
November/December 2007
Table 8. Percentage agreement for recommendations of adult
lower extremity disorders guidelinesknee (round 1)
% Agreement
Round 1
Round 2
Patient presentation (n = 59)
(n = 53)
General indications for radiographs 88
90
Adult patients with:
94 Full or limited movement and nontraumatic knee pain 93
of b4 wk's duration or if one of the following
conditions is suspected:
96
1. Osteoarthritis (OA) 92
96 2. Inflammatory arthritis 86
3. Bursitis/ tendinitis/ strain/ tendinosis 84
4. Anterior knee pain 83
5. Internal joint derangement 96
Acute knee injury but negative findings 94
98 for the OKRs
Acute knee injury and positive findings 94
for the OKRs
trauma. Results of round 1 were submitted for all panelists to
consider comments, and new references were provided.
Having reached consensus for all 3 cervical spine recom-
mendations and although 88% agreement was reached for all
recommendations of the remaining sections, panelists were
asked to evaluate 5 new recommendations owing to the
proposal of significant changes. Between 88% and 98%
agreement was reached for all recommendations of the first
round. Round 2 included the following sections: (a) trauma
to the lumbar spine, thoracolumbar spine, thoracic spine,
pelvis, sacrum, and coccyx regions; and (b) chest wall
(thorax) trauma. Fifty panelists returned both sections of the
second round. Percentage agreement ranged between 92%
and 100% on all 5 new recommendations (Table 17).
Nontraumatic Lumbar Spine Disorders. For the nontrau-
matic lumbar spine category, 50 panelists completed all 15
recommendations reaching a minimum of 82% agreement.
Nonetheless, based on suggestions received from the first
round, 3 recommendations were significantly modified and
one new recommendation was added for the second round.
Forty-two panelists then participated in round 2, reaching more
than 93% agreement on all 5 recommendations (Table 18).
Nontraumatic Thoracic Spine Disorders. For the nontrau-
matic thoracic spine disorders category, 50 panelists
completed all 6 recommendations. Based on suggestions
proposed in the first round, however, 7 new recommenda-
tions were proposed for the second round. Thirty-seven
panelists participated in round 2, reaching more than 92%
agreement for all recommendations (Table 19).
Journal of Manipulative and Physiological Therapeutics Bussires et al 631
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table 9. Percentage agreement for recommendations of adult lower Table 10. Delphi panel participant profile for the lower extremity
extremity disorders guidelinesankle and foot (rounds 1 and 2) disorders guidelines
% Agreement Hip Knee Ankle and foot
Round 1 Round 2 Round 1 Round 2 Round 1 Round 1 Round 2
Patient presentation (n = 57) (n = 48)
Academics 15 12 11 13 12
Adult patient with:
Clinicians 19 12 11 13 13
Acute ankle and foot injury but 87
negative findings on the OARs Researcher 1 1 2 1 1
Researchers/ 10 8 7 7 7
Acute ankle and foot injury and academics
positive findings on the OARs:
Ankle 94 Academics/ 15 12 13 13 12
Foot 81 96 clinicians
Acute toe injury 91 Researcher/ 6 4 5 4 3
Chronic ankle and tarsal pain 93 91 clinicians
Impingement syndromes 98
(a) Anterolateral impingement 93 Total 66 49 54 53 48
(b) Anterior impingement 96
(c) Anteromedial impingement 93
(d) Posterior impingement 94
Peroneal tendinosis 90 including clinical descriptions, proposing radiographic
Lateral premalleolar bursitis 100
Tarsal tunnel syndrome 98
views and specialized imaging studies, and adding new
Chronic foot pain 94 references, the guideline structure remained essentially
(A) Hindfoot-heel pain 92 unchanged. The end result is a condition-specific practice
A1. Plantar fasciitis and calcaneal 90 guideline, based on common clinical presentations of
enthesosphyte (spur) traumatic and nontraumatic conditions affecting the adult
A2. Sinus tarsi syndrome 94 91
(B) Midfoot pain (nontraumatic) 92 96
extremity and spine disorders. Although more than 75%
B1. Acquired flat foot with posterior 87 agreement was reached during the first round for all 124
tibial tendon dysfunction/rupture recommendations of the lower and upper extremity
B2. Navicular tuberosity pain and tenderness 92 disorders, and spine disorders guidelines, 39 recommenda-
B3.Complex regional pain syndrome 98 tions underwent a second round owing to the proposal
(C) Forefoot pain
C1. Metatarsal bursitis 92
of significant changes. Overall consensus was deemed
C2. Morton's neuroma 91 strong having reached over 85% agreement for all
C3. Stress (fatigue or insufficiency) fracture 92 89 124 recommendations.
C4. Osteonecrosis (avascular necrosis) 90
C5. Hallux rigidus and hallux valgus 88 Part 1: Lower Extremity Disorders (Phase 5). On average, 54
(1st MTP joint)
C6. Sesamoiditis 98
panelists completed the lower extremity guidelines. A
gradual decline in participation was observed after the very
first round (hip); however, participation remained relatively
constant thereafter. This decrease in participation occurred
Nontraumatic Cervical Spine Disorders. For the nontrau-
for various reasons including personal health issues, personal
matic cervical spine disorders category, 51 panelists
workload, the project's stringent schedule, changes of e-mail
completed all 10 recommendations, reaching between 88%
address, or vacations. Such a decline in participation over
and 98% agreement. Based on suggestions proposed in the
time was anticipated. It is unknown to what extent
first round, however, all but one recommendation were
ideological differences played a role in the decline of
modified and resubmitted to the Delphi panel. Forty-three
participants. The authors and consultants discussed the
panelists participated in round 2, reaching between 92%
decline at length, and we determined that it is not the actual
and 100% agreement for all recommendations (Table 20).
number of participants in the panel that is most important,
Table 21 outlines the breakdown of panelists completing the
but rather the distribution in 3 areas of expertise that had a
lumbar, thoracic, and cervical spine disorders rounds.
potential to threaten the validity of the results. Taking into
account the lowest participation of all sections evaluated (the
last round of the Ankle and Foot Disorders), the 48
DISCUSSIONDELPHI PANEL: CONSENSUS OPINION
participants (69.6% of the initial 69 participants) were
(PHASE 5) distributed as follows: 12 academics, 13 clinicians,12
Delphi PanelConsensus Opinion (Phase 5) academics and clinicians, 1 researcher, 7 researchers/
Although significant contributions were made by academics, 3 researchers/clinicians, including 11 chiropractic
panelists such as helping to clarify recommendations radiologists (DACBR). We concluded that this distribution
632 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007

Fig 6. Delphi panel composition for adult upper extremity disorder guidelines.

Table 11. Delphi panel submission deadlines for the upper Part 2: Upper Extremity Disorders (Phase 5). Seventy-six experts
extremity disorders guidelines initially agreed to return a confidential agreement, but only
Sections Round Date closed 51 of those actually contributed to this part of the study by
Shoulder Round 1 October 2, 2006 returning the first category (shoulder pain disorders) of the
upper extremity guidelines. The number of panelists
Shoulder Round 2 October 23, 2006 contributing to the first rounds of each category (shoulder,
Elbow Round 1 October 9, 2006
elbow, wrist and hand) remained stable with an average of
49 participants. A significant decrease in participation was
Wrist and hand Round 1 October 9, 2006 noted for the second round of the shoulder disorders
category. Various reasons contributing to this low participa-
Upper extremity Final consultation November 24, 2006 tion rate included personal workload, the stringent schedule
disorder guidelines
and length of the project, changes of e-mail address,
temporary absences, and vacations. Although we antici-
pated such a decline in participation over time, the returning
adequately represented the initial Delphi panel consisting of of 30 evaluation questionnaires is still considered accep-
a broad spectrum of individuals in the various areas of table as 4 of the 5 new recommendations had previously
expertise (Table 10). received more than 80% agreement on the first round, and
Journal of Manipulative and Physiological Therapeutics Bussires et al 633
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table 12. Percentage agreement for recommendations of adult Table 14. Percentage agreement for recommendations of adult
upper extremity disorders guidelinesshoulder (rounds 1 and 2) upper extremity disorders guidelineswrist and hand (round 1)
% Agreement % Agreement
Round 1
Round 1 Round 2
Patient presentation (n = 48)
Patient presentation (n = 51) (n = 30)
Adult patient with:
General indications for radiographs 100
Acute wrist trauma 94
Adult patient with:
Acute hand and finger trauma 98
Localized shoulder pain 88 100
Localized wrist and hand trauma 89
Acute shoulder trauma 92 96
Diffuse nonspecific pain in forearm or wrist 96
Glenohumeral joint trauma
Tenosynovitis of the wrist 92
Glenohumeral joint instability 92
Dequervain's disease 98
Rotator cuff disorders 80 96
Trigger finger 100
Adhesive capsulitis 89
CTS 92
Osteoarthritis 94 100
Osteoarthritis 94
Glenohumeral joint arthritis 98
Inflammatory or crystal induced arthropathy 100
Acromioclavicular joint disorders 89
Rheumatoid arthritis 96

Table 13. Percentage agreement for recommendations of adult Table 15. Delphi panel participant profile for the upper extremity
upper extremity disorders guidelineselbow (round 1) disorders guidelines
% Agreement Shoulder Elbow Wrist and hand
Round 1 Final
Patient presentation (n = 48) consultation Round 1 Round 2 Round 1 Round 1

Adult patient with localized elbow 98 Academics 13 5 11 11

pain after trauma Clinicians 15 12 16 16
Adult patients with full or limited 92
movement and nontraumatic Researcher/academics 7 3 7 7
elbow pain of b4 wk's duration Academics/clinicians 12 6 9 9
Researcher/clinicians 4 4 5 5
Chronic elbow pain in the adult 92
patient Total 51 30 48 48

Lateral epicondylitis 92
ers/clinicians, including 7 chiropractic radiologists
Medial epicondylitis 92
(DACBRs). We determined that this distribution adequately
Diffuse nonspecific pain in the 96 represented the broad spectrum of the various areas of
forearm (or wrist) expertise in the initial Delphi panel (Table 15). Although
included in the final draft of the upper extremity guideline
Forearm pain after trauma (included Xa consultation, the only recommendation that was not
before final consultation)
originally submitted to the Delphi panel was Forearm
a
This last recommendation was not specifically reviewed by the pain following trauma of the elbow category. Comments
Delphi panel but rather presented in the final' version of the guidelines.
and suggestions received by Delphi participants were
They were informed of this by e-mail and asked to comment. No negative
feedback was received. integrated in the final document.

the last recommendation (general indications for radio-
graphs) received 100% agreement. The distribution of
participants in the various areas of expertise for this second
round is as follows: 5 academics, 12 clinicians, 3
researchers/academics, 6 academics/clinicians, 4 research-
Part 3: Spine Disorders (Phase 5). Seventy-six experts initially
agreed to return a confidential agreement and 50 of those
actually contributed to this part of the study by returning the
first category (lumbar spine disorders) of the spine guide-
lines. On average, just more than 45 panelists completed the
634 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007

Fig 7. Delphi panel composition for adult spinal disorder guidelines.

Table 16. Delphi panel submission deadlines for the spine
extremity disorders guidelines
Sections Round Date closed
Lumbar spine 1 April 24, 2006
2 May 19, 2006
Cervical and thoracic spine 1 June 12, 2006
2 July 10, 2006
traumatic and nontraumatic spinal disorders categories
(Table 21). Various reasons contributing to the decline in
participation were similar to those of the other parts of the
study. Taking into account the lowest participation level of
all sections evaluated, that is, round 2 of the nontraumatic
thoracic spine disorders section, the 37 participants were
distributed as follows: 12 academics, 10 clinicians, 8
academics/clinicians, 0 researchers, 5 researchers/aca-
demics, 2 researchers/clinicians, including 12 chiropractic
radiologists (DACBRs). We determined that this adequately
represented the broad spectrum of the various areas of
expertise in the initial Delphi panel (Table 21).
Public Consultation (Phase 6)
Results of the diagnostic imaging guidelines by con-
sensus opinion (phase 5) were posted on a protected website
accessible to chiropractors worldwide. As the upper
extremity disorders guidelines were still under development,
only the lower extremity and spine disorders proposed
guidelines were made available for consultation. Advance
announcements published in various chiropractic journals
and other sources reached a potential of 60 000 chiropractors.
However, the total number of practitioners that was reached
using this strategy is unknown.
For this phase, a total of 930 chiropractors completed a
consent form on a protected website to review recommenda-
tions for imaging studies. Of those, 344 registered to
participate between August 5, 2006, and October 31, 2006.
As access to the website had not been closed at the date
Journal of Manipulative and Physiological Therapeutics Bussires et al 635
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table 17. Percentage agreement for recommendations of adult Table 18. Percentage agreement for recommendations of adult
traumatic spine disorders (rounds 1 and 2) nontraumatic lumbar spine disorders (rounds 1 and 2)
% Agreement % Agreement
Round 1 Round 2 Round 1 Round 2
Patient presentation (n = 50) (n = 42) Patient presentation (n = 50) (n = 42)
Adult patient with lumbar spine trauma 88 Adult patient with acute mechanical 88 95
LBP including sciatica
Adult patient with recent (b2 wk) 95 92
acute thoracolumbar, lumbar, Reevaluation of acute LBP for critical 85
or thoracic spine trauma exclusionary diagnoses and radiographs
are indicated in the absence of treatment
Adult patient with thoracolumbar, lumbar, 93 100 response after 4 to 7 weeks
or thoracic spine blunt trauma or acute
injuries (falls, motor-vehicle accidents, Common causes of sciatica 82
motorcycle, pedestrian, cyclists, etc)
Adult subacute and persistent LBP N/A 90
Adult patient with posttraumatic chest wall 92 97 without previous treatment
pain (thorax) : minor and major trauma
Adult with chronic LBP (N3 mo) without 88
Adult patient with pelvis, sacrum, 90 93 red flags
and coccyx trauma (including
fall with inability to bear weight) Adult with chronic LBP (N3 mo) and 98
unresponsive to 4 wk of conservative care
Coccyx trauma and coccydynia N/A 95
Reassess factors adversely affecting LBP 94
Adult patient with acute neck 93 prognostic/recovery in adults with
injury and negative CCSR recurrent/persistent LBP without red flags

Adult patient with acute neck injury Adults with complicated LBP 98
and positive CCSR ( with red flags):

Part 1 98 Presumed inflammatory 96

Part 2 95
initially announced, an additional 4 chiropractors registered
before January 31, 2007.
There were 2107 accesses to the welcoming page of the
diagnostic imaging public website (every reentry counted
as 1). Once registered, participants entered a protected
website housing the 2 PDF files and corresponding evalua-
tion questionnaires: (1) lower extremity disorders diagnostic
imaging guidelines, and (2) spine disorders diagnostic
imaging guidelines. A total of 559 accesses were counted
on the protected website (every reentry counted as 1).
Lower Extremity Disorders. Among the 75 registered partici-
pants who accessed the lower extremity disorders guidelines,
44 completed the demographic information, and 35 of those
completed the evaluation questionnaire (hip, knee, and ankle
and foot sections) (Fig 8).
Spine Disorders. Of the 87 participants who accessed the
spine disorders guidelines, 59 completed the demographic
information, and 50 completed the evaluation questionnaire
(spine trauma, nontraumatic cervical, nontraumatic thoracic,
and nontraumatic lumbar spine sections) (Fig 5).
Demographic Information. Forty-four practitioners from 6
countries (Australia, Canada, United States, Italy, New
spondyloarthropathy
Presumed fracture 98
Presumed neoplasia 98
Presumed infection 98
Progressive or painful structural 98
deformity or surgical fusion
Elevated laboratory examination 92
Presumed cauda equine syndrome 90 98
Presumed abdominal aortic conditions 90 100
Zealand, United Kingdom) completed the demographic
information for the lower extremity disorders guidelines
questionnaire, and 59 chiropractors from 6 countries
(Canada, United States, Italy, New Zealand, Switzerland,
and United Kingdom) completed the demographic informa-
tion for the spine disorders guidelines questionnaire. The
majority of practitioners were from Canada (47%) and the
United States (40%). Participants graduated from 17
different institutions, with a majority of those coming from
Canadian Memorial Chiropractic College or Palmer Chir-
opractic College West. Nearly 80% of practitioners grad-
uated after 1981, and 20% to 30% of respondents had
completed either a fellowship or a diplomate in a chiropractic
specialty. The majority of respondents were in full-time
practice (84% for lower extremity disorders and 86% for
spine disorders). A significant number of chiropractors
reported practicing alone (40% in the lower extremity
questionnaire, and 51% in the spine disorders questionnaire),
636 Bussires et al
Diagnostic Imaging Guidelines
Table 19. Percentage agreement for recommendations of adult
nontraumatic thoracic spine disorders (rounds 1 and 2)
% Agreement
Round 1
Patient presentation (n = 50)
Adult patient with nontraumatic thoracic 96
pain with no red flags
Reevaluation of thoracic pain for critical 94
exclusionary diagnoses and radiographs
are indicated in the absence of
treatment response after 4 to 6 wk
Painosteoporotic vertebral collapse 94
Adult scoliosis
Part 1 92
Part 2 94
Nonpainful and nonprogressive scoliosis in adult N/A
Adult patient with nontraumatic chest wall pain
Part 1 N/A
Part 2 N/A
Adult patient with thoracic pain in the 98
presence of red flags
Adults with complicated thoracic pain
(with red flags)
(A) Adults patient with complicated N/A
(ie, red flag) thoracic pain and indicators of
contraindication to SMT (relative/absolute)
(B) Suspected thoracic aortic dissection N/A
(C) Suspected compression fracture N/A
(D) Osteoporosis risk factor N/A
or in group or multidisciplinary practice (56% and 45%,
respectively). Ninety-eight percent reported that they were
legally allowed to take radiographs in their jurisdiction with
67% of the lower extremity participants and 78% of the spine
disorders guidelines participants having onsite access to
radiography. The majority of respondents ordered on average
less than 15 radiographic series per week, whereas a small
minority (2-8%) ordered more than 15 radiographic series
per week. More than 30% of participants admitted to never
taking radiographs of the lower limbs. Approximately half of
all participants said they occasionally referred patients for
specialized imaging of the extremities and spine (Table 22).
Comprehensiveness of Proposed Recommendations. Par-
ticipants were asked to rank the 2 diagnostic imaging
guidelines for comprehensiveness on an appropriateness
(Likert) scale from 1 (least appropriate/strongly disagree) to
9 (most appropriate/strongly agree), with a separate option
for don't know. Of the 35 chiropractors who completed all
3 sections of the lower extremity guidelines (hip, knee, and
ankle and foot), 77% agreed or strongly agreed with the
proposed recommendations, whereas the remaining 23%
Journal of Manipulative and Physiological Therapeutics
November/December 2007
Table 20. Percentage agreement for recommendations of adult
nontraumatic cervical spine disorders (rounds 1 and 2)
% Agreement
Round 2 Round 1 Round 2
(n = 37) Patient presentation (n = 51) (n = 43)
Adult patient with acute uncomplicated a 96
neck pain (b4 wk's duration)
Adult patient with acute nontraumatic neck 88 95
pain and radicular symptoms
Adult patient with subacute neck pain 88 92
(4-12 wk's duration) or persistent neck pain
(N12 wk) with or without arm pain b and
reevaluation for critical exclusionary
diagnoses and radiographs indicated in the
absence of treatment response after 4 wk
Adult patient with neck pain in the presence 98 97
of red flag and indicators of contraindication
92 to SMT
1. High-risk ligament laxity populations/ 90 97
possible atlantoaxial instability
100 2. Cervical myelopathy 91 95
95 and radiculomyelopathy
3. (a) Cervical artery dissection (VAD, CAD), 98 100
TIA
(b) Cervical artery dissection (VAD, CAD), 89
TIA (risk factors)
(c) Cervical artery dissection (VAD, CAD), 93
TIA (physical examination)
97 (d) Cervical artery dissection (VAD, CAD), 91
TIA (past history of neck trauma)
a
Uncomplicated indicates non traumatic neck pain without under-
100 lying neurologic deficits or red flag.
97 b
The findings of The Bone and Joint Decade 2000-2010 Task Force on
95 Neck Pain Its and Associated Disorders had not yet been published at the
time these guidelines were in press. It was agreed by a majority of Delphi
panellists to consider those findings and recommendations in future updates.
disagreed or strongly disagreed. Fifty respondents completed
all 4 sections of the spine disorders guidelines, the majority
of whom agreed with the proposed recommendations of the
spine trauma and nontraumatic thoracic spine sections (56%
and 54%, respectively). Half of the practitioners agreed with
the nontraumatic lumbar spine section, whereas 52%
disagreed with the nontraumatic cervical spine recommenda-
tions (Table 23).
Perceived Ease of Use of Guidelines and Implementation
Feasibility. Perceived overall ease of use of the proposed
diagnostic imaging lower extremity and spine disorders
guidelines was ranked as moderate to high (5 out of 9) by
77% and 56% of practitioners, respectively (Table 24). When
asked about the interest and desire for implementing the
proposed diagnostic imaging lower extremity and spine
disorders guidelines, 62% and 40% (respectively) of
practitioners indicated being interested (5 out of 9),
whereas 35% (lower extremity disorders) and 59% (spine
disorders) strongly disagreed (3 out of 9). Similarly, 65% of
Journal of Manipulative and Physiological Therapeutics Bussires et al 637
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table 21. Delphi panel participant profile for the spinal disorder guidelines
Lumbar spine Thoracic spine Cervical spine
Average number
Round 1 Round 2 Round 1 Round 2 Round 1 Round 2 of panelists
Researcher 0 0 0 0 1 1 0.33
Academics 11 11 10 12 11 12 11.6
Clinicians 15 12 16 10 15 13 13.5
Researcher/academics 7 7 7 5 7 5 6.3
Academics/clinicians 13 8 12 8 13 9 10.5
Researcher/clinicians 4 4 5 2 4 3 3.6
Total 50 42 50 37 51 43 45.5

Fig 8. Diagram Organization of public consultation (Phase 6).

the lower extremity guidelines respondents and 38% of the
spine disorders respondents ranked the feasibility of
implementing these guidelines into practice as good or very
good (5 out of 9). However, when considering the scope of
practice in their own province, state, or country, 29% of the
lower extremity guidelines respondents and 59% of the spine
disorders guidelines respondents ranked the feasibility of
implementing these recommendations into practice as low or
very low (3 out of 9).
DISCUSSIONPUBLIC CONSULTATION (PHASE 6)
Overall, chiropractors have a tendency to take fewer
radiographs of the extremities than of the spine, probably
related to the conditions typically seen in practice. Approxi-
mately 15% of initial consultations in North American
chiropractic clinics are for disorders of the extremities,
whereas three quarters (76%) of patients consult chiroprac-
tors for spinal conditions.70 Although there is a paucity of
literature as to the types of extremity disorders seen by
chiropractors, it is reasonable to assume that acute traumatic
injuries of the extremities would be more commonly seen in
emergency facilities, rather than in chiropractic offices.
Results from this public consultation phase of the study
must be interpreted with caution, considering the low
participation rate. Possible reasons for this are addressed in
a later part of this article. In addition, several factors related to
practice were not collected in our study, including the average
weekly number of patients and new patients, patients' reasons
for consulting, and type of technique used by participants.
Nonetheless, certain observations deserve consideration.
Year of Graduation
Crossed data analysis revealed that practitioners taking
more spinal radiographs (either 5-15 or N15 sets of films per
week) graduated between 1991 and 2006 (Table 25). In
638 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007

Table 22. Demographic information of registered participants Table 22 (continued)

(Phase 6) Lower extremity Spine disorders
Lower extremity Spine disorders Demographic data disorders (n = 44) (n = 59)
Demographic data disorders (n = 44) (n = 59) Year of graduation
Country 2001-2006 10 (23%) 17 (29%)
Australia 4 (9%) Postgraduate training
Canada 21 (48%) 27 (46%) Chiropractic fellowship 3 (7%) 7 (12%)
United States 16 (36%) 26 (44%) (sports, clinical
Italy 1 (2%) 1 (1.7%) sciences, radiology,
New Zealand 1 (2%) 3 (5%) rehabilitation)
Switzerland - 1 (1.7%) Diplomate/certificate 5 (11%) 10 (17%)
United Kingdom 1 (2%) 1 (1.7%) (orthopedic,
Practicing state/province neurology, nutrition,
Canada Alberta 2 (5%) Alberta 2 (3%) pediatric, geriatric,
BC 8 (19%) BC 7 (12%) etc)
Ontario 10 (24%) Manitoba 2 (3%) MSc 3 (7%) 4 (7%)
Quebec 1 (2%) Ontario 13 (22%) Other 3 (7%): BA, 6 (10%): ATC,
Other 5 (12%) Quebec 3 (5%) BEd, Doctor of CSCS, BA,
Other 4 (7%) Naturopathic Doctor of
United States California 1 (2%) Arkansas 9 (15%) Medicine Naturopathic
Connecticut 1 (2%) California 2 (3%) Medicine, JD,
Florida 2 (5%) Colorado 1 (2%) MA(Ed), MBA,
Illinois 2 (5%) Connecticut 1 (2%) QME, Radiology
Kentucky 2 (5%) Florida 4 (7%) Professional membership (National):
Missouri 1 (2%) Illinois 2 (3%) American (ACA) 9 (20%) 9 (15%)
Montana 1 (2%) Kentucky 2 (3%) British (BCC) 1 (2%) 1 (2%)
Rhode Island 1 (2%) Maryland 1(2%) Canadian (ACC) 19 (43%) 19 (32%)
Texas 2 (5%) Michigan 1 (2%) Australia (CAA) 4 (9%)
Utah 1 (2%) Missouri 1 (2%) General Council, UK 1 (2%)
Virginia 1 (2%) Montana 1 (2%) New Zealand (NZCA) 1 (2%) 3 (5%)
New Jersey 1 (2%) Italy (AIC) 1 (2%) 1 (2%)
New York 3 (5%) Swiss (SCA) 1 (2%)
South Dakota 1 (2%) None 1 (2%) 1 (2%)
Tennessee 1 (2%) Member one other 2 (4.5%): 6 (10.7%): ACA (1),
Texas 1 (2%) association CAND- BCA (1), ECU (1),
Virginia 1 (2%) Naturopathic (1), CAND-
Washington 1 (2%) ICPA (1) Naturopathic (1),
Wisconsin 1 (2%) ACC (1) , ICPA (1)
Chiropractic college attended ICA 2 (4.5%) 9 (15%)
AECC 2 (4.5%) 4 (7%) World Chiropractic 2 (4.5%) 3 (5.3%)
Canadian Memorial 14 (24%) 19 (32%) Alliance
Chiropractic College Practice
Cleveland (Kansas) 1 (2%) Full time 36 (82%) 50 (85%)
Cleveland (LA) Part time 6 (14%) 4 (7%)
Life West (CA) 1 (2%) Academicteacher 2 (5%) 3 (5%)
Life University (GA) 1 (2%) 3 (5%) No longer in practice 2 (3%)
Logon 3 (7%) 4 (7%) Type of practice
LACC 1 (2%) 2 (3%) Solo 17 (40%) 30 (51%)
MacQuarie 1 (2%) Group 14 (33%) 18 (31%)
National 1 (2%) Multi/ 10 (23%) 8 (14%)
NYCC 4 (9%) 2 (3%) Interdisciplinary
Northwestern 2 (3%) Academicteacher 2 (5%) 2 (3%)
Palmer (Davenport) 3 (7%) 5 (9%) None 1 (2%)
Palmer west 7 (16%) 12 (21%) Qualified to take radiographs in jurisdiction
Parker 1 (2%) Yes 43 (98%) 57 (98%)
Sherman 1 (2%) 1 (2%) No 1 (2%) 1 (2%)
Texas 1 (2%) 1 (2%) On site access to radiography
Unit (Victoria Australia) 1 (2%) Yes 29 (67%) 46 (78%)
Not specified 2 (5%) No 14 (33%) 13 (22%)
Year of graduation Average number radiographic series ordered per week
Before 1960 1 (2%) None 14 (32%) 2 (3%)
1970-1980 9 (20%) 10 (17%) b5 27 (61%) 20 (34%)
1981-1990 10 (23%) 15 (25%) Between 5-15 2 (5%) 32 (54%)
1991-2000 15 (34%) 16 (27%) Over 15 1 (2%) 5(8%)
Journal of Manipulative and Physiological Therapeutics Bussires et al 639
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table 22 (continued) Table 24. Percentage agreement for perceived ease of use of
Lower extremity Spine disorders
guidelines and implementation feasibility of adult lower extremity
Demographic data disorders (n = 44) (n = 59) disorders and spine disorders guidelines. Based on a scoring
system from 1 to 9 (1 = least appropriate, 9 = most appropriate)
Average number of referral for specialized imaging studies per month
None 21 (48%) 22 (37%) Question 5-7: Results
b5 22 (50%) 31 (53%) Perceived ease of use of
N5 1 (2%) 6 (10%) guidelines and implementation Lower extremity Spine disorders
feasibility disorders (n = 35) (n = 50)
Question 5: Perceived overall ease of use of the proposed guideline
Score
Table 23. Percentage agreement for recommendations of adult b5 23% 44%
lower extremity disorders and spine disorders guidelines. Based on 5 77% 56%
a scoring system from 1 to 9 (1 = least appropriate, 9 = most Question 6: Interest/desire for implementing guidelines into own practice
appropriate) Score
Question 14: Results b5 38% 60%
How comprehensive are the 5 62% 40%
recommendations and Lower extremity Spine disorders Question 7: Feasibility of implementing the proposed recommendations
corresponding comments? disorders (n = 35) (n = 50) into practice considering the scope of practice in own province/
state/country
Question 1 Hip pain Spine trauma Score
Score b5 35% 61%
b5 23% 44% 5 65% 38%
5 77% 56% No response = 1

Question 2 Knee pain Non traumatic

lumbar spine
Score
Table 25. Year of graduation of participants in relation to the
b5 23% 50% average number of spinal radiographic series ordered per week
5 77% 50% Between
None b5 5 and 15 N15
Question 3 Ankle and Non traumatic
Year of graduation Before 1960 0 1 0 0
foot pain thoracic spine
Score
1970-1980 1 4 5 0
b5 23% 46%
5 77% 54%
1981-1990 1 6 7 1
Question 4 N/A Non traumatic
1991-2000 0 4 10 2
cervical spine
Score
2001-2006 0 5 10 2
b5 52%
5 48%

majority of chiropractors no longer own their own equip-

addition, recent graduates were least likely to find the
recommendations and corresponding comments comprehen-
sive or useful and were least interested in implementing the
proposed spine disorders guidelines in their practices, even
when considering the scope of practice in their own
province, state, or country (Table 26). Although the ordering
of more tests is common behavior among many who lack
experience,71 implementation of clinical decision rules by
practitioners of all levels of clinical experience can result in a
decrease in radiography, waiting times, and costs without
altering the quality of care.72 Thus using imaging guidelines
can help reassure less experienced practitioners.
ment. Survey results from 2003 reveal that only 34% of full-
time Canadian chiropractors took their own radiographs. In
Ontario and British Columbia, Canada, where most
Canadian participants reside and practice, only 27% and
26%, respectively, of full-time chiropractors own their own
x-ray equipment.73 Ownership of ancillary services and self-
referral raise issues of potential conflicts of interest.74-80
Thus, it appears that chiropractors who own their own x-ray
equipment were far more likely to participate in this survey
as the proposed imaging guidelines could potentially have
more impact on their practice patterns and hence a negative
effect on income.

Onsite Access to Radiography Number of Radiographic Series Ordered Per Week

A large majority of participants had onsite access to It is well known that when health care professionals own
radiography (78% of respondents for the spine disorders and their own imaging equipment this results in far more frequent
67% for the extremity disorders guidelines). This very likely utilization.81-84 In our study, more than half (54%) of
skewed the results. According to one Canadian survey, the participants in the spine disorders guidelines section ordered
640 Bussires et al
Diagnostic Imaging Guidelines
Table 26. Year of graduation of participants in relation to their
opinion of how comprehensive are the nontraumatic cervical spine
recommendations and corresponding comments
How comprehensive are the nontraumatic
cervical spine recommendations and
corresponding comments (n = 49)
I don't
1 2 3 4 5 6 7 8 9 know
Year of Before 1960 0 0 0 0 0 0 0 0 1 0
graduation
1970-1980 2 2 0 0 0 0 0 1 3 0
1981-1990 2 1 1 0 0 3 2 1 2 0
1991-2000 3 4 0 0 0 1 4 1 1 0
2001-2006 6 2 3 0 0 0 1 3 0 0
Overall appreciation using the following scoring system from 1 to 9:
1 = least appropriate, 9 = most appropriate.
between 5 and 15 radiographic series per week, with 8%
ordering more than 15 spine radiographic series per week.
Recent surveys in North America indicate only 6% to 17% of
chiropractic patients receive radiographs during their
visit.70,85 In a practice-based study of chronic LBP in the
USA, 1 (25%) in 4 patients underwent radiography.86
Overall, a decline in radiograph use has been observed
since the late 1980s and early 1990s when more than half of
the chiropractic patients in the USA were receiving radio-
graphs before treatment for their current episode of LBP.87
An alternative explanation for the results in our study may be
that our sample included chiropractors working in high
volume practices. The type of practice (solo or group
practice, and chiropractic technique used) may also influence
clinician's decision-making behavior.
Type of Practice
The majority of participants in this study were in solo
practice. Solo practitioners traditionally tend to express more
negative attitudes regarding clinical guidelines than physi-
cians in nonsolo practices.88,89 In addition, certain practice
management groups encourage chiropractors to take radio-
graphs to favor long-term patient retention. This factor,
however, was not measured in our study.
Spinal radiography is an integral component of patient
biomechanical spinal evaluation in some chiropractic techni-
ques. Although information relating to the type of chiropractic
technique used was not gathered in our study, e-mail
exchanges and invitations to review competing guidelines
on a website90 promoted by CBP may have had some impact
on this phase of the project. Their welcoming page stated,
The PCCRP guidelines are in direct competition/opposition
to current attempts to restrict Chiropractic Radiography to
Red Flag Only conditions or diagnosis. On this same
website, one could read: Do you want to be outside the
Journal of Manipulative and Physiological Therapeutics
November/December 2007
standard of care for taking routine radiographs for
subluxation assessment and post-treatment radiographs? If
not please review the PCCRP guidelines and complete the
survey
The practice of taking routine repeat radiographs to
monitor patient progress is not commonplace in
chiropractic,91 but some named technique systems advo-
cate this as an integral part of their standard of practice.92 It
has been our observation that those advocating routine
radiography and repeat radiography are resistant to any
change that may challenge their uninhibited use of radio-
graphy. Not surprisingly, those feeling threatened or angry
may be more likely to answer surveys of this nature. It is
therefore possible that those having less practical experience,
possessing onsite access to radiography, who are in solo
practice, and who tend to obtain radiographs on most new
patients as part of the technique used would tend to respond
negatively to the proposed diagnostic imaging guidelines.
On the other hand, those who refer to imaging centers, are in
multi/interdisciplinary practice, and predominantly use
common diversified techniques were not as likely to
participate because they were not as threatened and not as
directly affected by the guidelines.
Although there appears to be a strong sampling bias in
the public feedback group, results of this phase of the
project (phase 6) help in identifying potential obstacles to
dissemination and implementation strategies of these
guidelines. Understanding what drives clinicians to order
imaging studies is important. General comments gathered
from participants during the study ranged from very
enthusiastic to a strong desire never to see such guidelines
implemented (Appendix B). The concerns could be
classified into 3 general categories:
1. The desire by some practitioners to reach clinical
decisions for their patients without outside interfer-
ence (ie, guidance);
2. Failure to consider a significant body of evidence on
biomechanical analysis of the spine (postural analysis
and vertebral subluxations/spinal misalignments);
3. Failure to recognize the named techniques using pre-
post radiographs to provide spinal adjustments (a form
of spinal manipulative therapy).
It is our observation that there is a general misunder-
standing about the usefulness of evidence-based literature
and practice guidelines. Practitioners should feel reassured to
know that the evidence-based approach to health care is
meant to assist, not replace, clinicians in clinical decision
making by summarizing available literature to be used in
conjunction with the clinician experience and judgment
while considering patient preference.93 Evidence-based care
and guidelines were never intended to replace the intelli-
gence of the clinician. One criticism is that guidelines are
frequently misinterpreted and simply used by third-party
Journal of Manipulative and Physiological Therapeutics
Volume 30, Number 9
payers to restrict or deny reimbursement for care. Although
no one can predict how insurance companies and legislators
may want to apply the abundance of guidelines available, we
agree that the proposed diagnostic imaging guidelines should
not be used by legislators or in a medical-legal context as
other factors such as cost-effectiveness analysis and safety
impact were not specifically analyzed and much of the
content needs to be validated prospectively.
Indications for radiography are vigorously debated within
chiropractic. Most chiropractors obtain radiographs for
clinical reasons, such as confirming a diagnosis of pathology,
but many continue to use radiography as a screening tool and
for medicolegal protection.27,94 The frequency of conven-
tional radiograph utilization by chiropractors for LBP
complaints ranged from 60% to 90% in North America,95-97
but many of the reasons provided by chiropractors for taking
radiographs are not supported by the literature.27,94,98
Recent surveys, however, suggest a significant decrease in
reported frequency over time,99 with, for example, 17% and
6% of Arizona and Massachusetts patient visits involving
radiography, respectively.85 It is worth noting that since the
inception of Medicare 30 years ago, chiropractors had been
mandated to obtain radiographs to be reimbursed for care.
Only after persistent legislative activity has this provision
finally been changed.100
The percentage of patients x-rayed by full-time Canadian
chiropractors has also decreased since 1997. According to
one Canadian survey, the proportion of chiropractors who
obtain radiographs on only 1% to 25% of their patients
increased from 35% in 1997 to 49% in 2003. This trend was
accompanied by consistent declines in the proportion of
chiropractors who obtain radiographs on more than 25% of
their patients.73 One reason for such reductions in utilization
may be related to a more limited access to radiology
equipment. In 2003, only 34% of full-time Canadian
chiropractors took their own radiographs, in comparison to
50% in 1997. Of interest, 76% of Quebec full-time
chiropractors took their own radiographs compared to Ontario
(27%), British Columbia (26%), and Saskatchewan (7%).73
Similar utilization patterns by chiropractors were identi-
fied in Europe,101 but recent surveys also reveal a reduction
in radiography utilization. In the year 2000, only 25% to
30% of chiropractic patients were radiographed in the
United Kingdom102 and Switzerland.103 Limited access to
radiology facilities possibly explains why fewer radiographs
are taken throughout several other European countries.
Chiropractors in Belgium, France, Germany, Greece, Italy,
Spain, and Sweden do not have the legislation necessary to
allow taking or ordering radiographs.104 Similarly, practi-
tioners in the Netherlands have recently lost the right to use
radiographic equipment.105
Arguments against the routine use of imaging studies
have been addressed elsewhere. 9,94,106-109 Acceptable
features of a proposed test that are sufficient to produce
useful information in a particular situation include the
Bussires et al 641
Diagnostic Imaging Guidelines
sensitivity, specificity, positive and negative predictive
values, positive and negative likelihood ratios, and diag-
nostic odds ratios. In other words, how good is the index test
at detecting the target condition?110,111 Conventional radio-
graphy does not appear to be clinically useful as a screening
test as evidenced by the low prevalence of serious spinal
pathologies such as cancer and infection, and the poor
sensitivity, predictive values, and likelihood ratios for many
musculoskeletal conditions.112-121
In addition, the answer to the above question (regarding the
use of an index test for detecting a target condition) has not
been adequately provided by proponents of the routine use of
imaging studies to justify its use in screening to determine the
presence of chiropractic subluxations or to prevent serious
complications before spinal manipulative therapy.122,123
Experimental evidence regarding the very nature of the
subluxation syndrome still appears to be lacking.124,125
Clearly, well-designed prospective studies are needed to help
answer many of these questions. Until such evidence is
available, selective use of imaging studies is advisable.
Second External Review (Phase 7)
More than 300 chiropractic specialists and 14 medical
specialists were invited to review the diagnostic imaging
guidelines by consensus opinion (phase 5).
1. Chiropractic specialties:. Invitations to review the proposed 3
diagnostic imaging guidelines were sent by mail (total of 275
specialists for whom addresses were available). In addition,
representatives of the following chiropractic specialty groups
agreed to forward the invitation by e-mail to respective
members (forwarded e-mails by the Council on Neurology
were not confirmed):
American Chiropractic College of Radiology (ACCR)
166 members
College of Chiropractic Radiology, Canada (FCCR)
38 members (Many FCCR members are also ACCR
members)
College of Chiropractic Clinical Sciences (Canada)
(FCCS)55 members
College of Chiropractic Sport Sciences (Canada)
(FCCSS)79 members
College of Chiropractic Orthopedists (Canada)
(FCCOC)33 members
College of Chiropractic Rehabilitation Sciences
(CCRS)74 members
American College of Chiropractic Council on Neurol-
ogy (NOCA/ACCN)750 members (We were unable
to confirm that this invitation was extended to members)
2. Medical specialties:. Fourteen medical specialists from the
USA and Canada were invited to participate by e-mail,
personal letters, and/or telephone calls [orthopedic surgeons
642 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007

Table 27. Demographics of all registered participants (Phase 7)

Country N = 105
USA 59 (56%)
Canada 45 (43%)
UK 1 (1%)

Practicing state/province
USA Canada UK
Alaska (1), Arizona (1), California (5), Connecticut (2), Colorado (2), Alberta (4), British Columbia (8), 1
Florida (3), Georgia (2), Hawaii (1), Illinois (6), Indiana (1), Iowa (2), Manitoba (2), Nova Scotia (1),
Kansas (1), Maryland (2), Missouri (2), MS (1), Montana (2), Ontario (21), Quebec (9)
Minnesota (1), Nevada(1), North Dakota (1), Hew Hampshire (1),
New Mexico (2), New York (6), Ohio (3), Oregon (2),
Pennsylvania (2), Texas (3), Washington (2), Other (1)

Year of graduation
Before 1970 11 (10.4%)
1970-1980 11 (10.4%)
1981-1990 29 (27.6%)
1991-2000 41 (39%)
2001-2006 11 (10.4%)
Unknown 2 (2%)

Postgraduate training 105 (100%)

Chiropractic fellowship and diplomats 100 (95%)

Radiology 59 (57%)
Sports 19 (18%)
Orthopedics 8 (7.6%)
Rehabilitation 7 (6.6%)
Clinical sciences 6 (5.7%)
Other 1 (0.95%)

Participants holding additional specialty and/or having completed a master degree 11 (10%), MSc (10),
DACNB (2),
rehabilitation (1),
acupuncture (1)
Medical degree 6 (5.6%)

Orthopedics 2 (1.9%)
Rehabilitation 2 (1.9%)
Internal medicine 1 (0.9%)
Neurosurgery 1 (0.9%)

Practice
Full-time 71 (67.6%)
Part-time 18 (17%)
Academicteacher 13 (12%)
No longer in practice 3 (3%)

(5), neurosurgeons (2), rheumatologists (1), medical inter-
nists (2), physical medicine specialists (3), osteopathic
clinicians in the USA (1), medical radiologists (2)]. Two
could not participate owing to personal illnesses.
As a result of these invitations, a total of 271 health care
professionals completed a consent form provided on a
protected website (external reviewphase 7) to review
recommendations of the diagnostic imaging guidelines. Of
those, 100 chiropractic specialists and 6 medical specialists
registered to participate in this phase of the project, which
ran from December 17, 2006, through February 9, 2007.
Demographic information is detailed in Table 27.
There were 566 accesses to the welcoming page of
the diagnostic imaging review website (every reentry
counted as 1). Once registered, participants entered a
protected website housing the 3 PDF files and corre-
sponding evaluation questionnaires: (1) lower extremity
disorders diagnostic imaging guidelines, (2) upper extre-
mity disorders diagnostic imaging guidelines, and (3)
spine disorders diagnostic imaging guidelines. As every
Journal of Manipulative and Physiological Therapeutics
Volume 30, Number 9
Fig 9. Speciality of reviewers having completed at least one evaluation questionnaire (Phase 7).
reentry is counted as 1, a total of 310 individuals were
counted as accessing the protected website. Of the 59
participants who accessed the lower extremity evaluation
questionnaires, 44 completed the evaluation questionnaire
for the lower extremity guidelines. Of the 39 participants
who accessed the upper extremity evaluation question-
naires, all completed the evaluation questionnaire for the
upper extremity guidelines. Of the 41 participants who
accessed the spine disorders evaluation questionnaires, 33
completed the evaluation questionnaire for the spine
disorders guidelines.
The majority of specialists who completed the evaluation
questionnaires were chiropractic radiologists (63.8%), fol-
lowed by sport science (16.3%), and clinical science specialists
(10.3%). Approximately 65% of respondents graduated
between 1981 and 2000 (Table 27, Figs 9 and 10).
Bussires et al 643
Diagnostic Imaging Guidelines
Comprehensiveness of Proposed Recommendations. Experts were
asked to rank the 3 diagnostic imaging guidelines for
comprehensiveness on an appropriateness (Likert) scale
(Table 28). For the lower extremity guidelines, 44 reviewers
completed the hip and knee sections and 41 specialists
completed the ankle and foot section. Thirty-nine reviewers
completed all 3 sections of the upper extremity disorders
(shoulder, elbow, and wrist and hand), and 33 reviewers
completed all 4 sections of the spine disorders sections (spine
trauma, nontraumatic cervical, thoracic and lumbar spine).
Except for one participant in the ankle and foot section of the
lower extremity guidelines who strongly disagreed and 2
more reviewers who indicated I don't know in this same
section, all experts strongly agreed (ranked at or N7 out of 9)
with the proposed recommendations of the lower extremity,
upper extremity, and spine disorders guidelines.
644 Bussires et al
Diagnostic Imaging Guidelines
Fig 10. Year of graduation of reviewers having completed at least one evaluation questionnaire (Phase 7).
Perceived Ease of Use of Guidelines and Implementation Feasibility.
Table 29 shows the data for the perceived overall ease of use,
which was ranked as high or very high by most respondents for
each proposed guideline. Most specialists had a high interest
and desire in implementing the proposed guidelines. When
considering the scope of practice in their own province/state/
country, the majority of specialists ranked the feasibility of
implementing these 3 guidelines into practice as high or very
high. Between 6% and 10% of respondents ranked the
feasibility of implementing the recommendations from the 3
guidelines into practice as moderate. Finally, comments
received by specialists were generally very favorable and
reflected high levels of agreement with the proposed
recommendations, perceived ease of use of guidelines, and
implementation feasibility (Appendix C).
DISCUSSIONSECOND EXTERNAL REVIEW (PHASE 7)
In a recent experimental study of the influence of
individual participant characteristics on formal consensus
development, the largest differences were between the
general practitioners and mental health professionals, both
in their initial ratings of the different interventions, and in
how much they altered their ratings between rounds. The
Journal of Manipulative and Physiological Therapeutics
November/December 2007
results support the practice of treating professional specialty
as an important determinant of the results in consensus
panels.126 Results of the external review phase of the project
revealed very high levels of agreement with all recommen-
dations proposed in the Delphi panel (phase 5) for the lower
and upper extremity disorders and spine disorders diagnostic
imaging guidelines. Perceived ease of use of the guidelines
and implementation feasibility were generally high. Com-
ments provided by reviewers pertaining to the content of the
guidelines were considered by the research team in the final
draft of the diagnostic imaging guidelines (phase 8).
Phase 8: Final Draft of the Diagnostic Imaging Guidelines and Grading
of Evidence
Upon completion of the public website (phase 6) and
second external review (phase 7), all suggestions and
comments were considered by the research team and
incorporated into the final version of the guidelines. A
member of the public with specialized training in research
was asked to review the methodology and to consider all
recommendations from the 3 guidelines. Comments and
suggestions from the public member were incorporated
where deemed appropriate by the research team.
Journal of Manipulative and Physiological Therapeutics Bussires et al 645
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table 28. Percentage agreement for recommendations of adult Table 29. Percentage agreement for perceived ease of use of
lower extremity disorders, upper extremity disorders, and spine guidelines and implementation feasibility of adult lower extremity,
disorders guidelines upper extremity, and spine disorders guidelines
Results Results
Question 57:
Question 14: Lower Upper Spine Perceived ease of use of Lower Upper Spine
How comprehensive are extremity extremity disorders guidelines and implementation extremity extremity disorders
the recommendations and disorders disorders (n = 33) feasibility disorders disorders
corresponding comments? (n = 44) (n = 39)
Question 5. (n = 43) (n = 39) (n = 33)
Question 1 Hip pain Shoulder Spine trauma Perceived overall ease
pain of use of the proposed guideline
Score
b5 (least appropriate) Score
7 (most appropriate) 100% 100% 100% b5 4.8% 2.6% 3%
I don't know 5 95.3% 97.4% 97%
7 73% 83% 81%
Question 2 Knee pain Elbow pain Nontraumatic I don't know
lumbar spine
Score Question 6. (n = 41) (n = 36) (n = 31)
b5 Interest/desire for
7 100% 100% 100% implementing guidelines
I don't know into own practice

Question 3 Ankle and Wrist and Nontraumatic Score 2.7%

foot pain hand pain thoracic spine b5 97.6% 94.4% 96.8%
Score (n = 41) 5 2% 2.7% 3.2%
b5 2% I don't know
7 93% 100% 100%
I don't know 5% Question 7. (n = 41) (n = 35) (n = 31)
Feasibility of implementing the
Question 4 N/A N/A Nontraumatic proposed recommendations into
cervical spine practice considering the scope
Score of practice in own province/
b5 state/country
7 100%
I don't know Score
Instructions to participants: evaluate all sections of the Lower Extremity b5 2.4% 3.2%
Guidelines (hip, knee, ankle and Foot), Upper Extremity Guidelines 5 92.6% 94.3% 90.3%
(shoulder, elbow, wrist and hand), and Spine Disorders Guidelines (trauma, I don't know 5% 5.7% 6.4%
lumbar, thoracic, and cervical spine) by indicating your overall opinion Scoring system from 1 to 9: 1 = least appropriate, 9 = most appropriate.
using a scoring system from 1 to 9 (1 = least appropriate, 9 = most
appropriate). An additional box stating I don't know was also available. Although abundant literature is available to support the need
for a rapid intervention in cases such as cauda equina syndrome
Grading of Evidence. The initial template used for the and dissecting abdominal aortic aneurysms, literature regard-
guidelines was from the European Commission on radio- ing treatment was not specifically reviewed in these guidelines.
protection (2001).51 The gradings (ie, strength of recommen- Recommendations are also accompanied by a designation of
dations) they administered included only 3 levels, from A to C Critical or Important (but not critical). Critical is defined as
(Table 1). In comparison, grades from the European Commis- a life-threatening condition or as a situation in which the
sion were generally higher than the ones assigned to the patient is at risk of serious complications if they are not referred
various recommendations in these current guidelines. This is for appropriate care in a timely manner. These specifications
partly explained by the more stringent criteria of the SPREAD were added to the respective tables (Appendix D).
instrument, which was used for the current guidelines (Fig 4).
This tool uses 2 additional grades (D and Good Practice Point)
and considers the quality of meta-analysis and systematic Study Limitations
reviews. Under the European Commission grading system, This study has several limitations. First to consider was
those studies would have been graded as level A. However, as the strategy used to develop guidelines recommendations.
already mentioned, high-quality meta-analyses, systematic Realizing that the first objective of this project was to respond
reviews, and RCTs are uncommon at this time as evidenced by to a concern raised by an accrediting agency to review an
the fact that only a dozen were retrieved in total. In addition, the institution's diagnostic imaging guidelines, while consider-
weighting system itself is subjective. Good Practice Point is ing the significant costs and time associated with CPG
also indicated where emergency referral is recommended. development, and until meaningful clinical trials become
646 Bussires et al
Diagnostic Imaging Guidelines
available for some specific conditions, the processes used in
developing these particular guidelines are considered appro-
priate. This strategy included a first narrative review, an initial
literature search and 2 literature updates, an independent
assessment of the literature supporting the proposed
recommendations, the use of the European Commission
Referral Guidelines for Imaging as the initial template,51 a
large Delphi consensus panel, and 2 external reviews.
Specific weaknesses of our strategy include (a) the initial
literature search and data extraction (phase 1) performed by
only one assessor (AB); (b) the use of only two literature
evaluators for most citations (phase 2); (c) the lack of
experience in assessing the quality of the literature by at least
one of the literature evaluators (phase 2); (d) the initial
guidelines recommendations established by only 2 specialists
in chiropracticone in clinical sciences and one in radiology
(phase 3); (e) in developing wide-ranging reviews and
guidelines, it inevitably takes considerable time to review
studies and formulate recommendations and publishing in a
peer-reviewed journal also adds to the time from literature
search to date of publication; (f) summarizing complex issues
in a review, such as this, can also be difficult; (g) a degree of
subjectivity in the grading of recommendations.
High-quality clinical guidelines should be developed
within a structured and coordinated program127 using a
standardized approach 128,129 so that recommendations
made by multidisciplinary, nationally representative groups
are based on a systematic literature review.130 Using sound
scientific methodology proves useful in ensuring that the
recommendations are explicitly linked to the supporting
evidence131 and graded according to the strength of that
evidence.57 For some review topics, however, the strengths
of the systematic review may turn into weaknesses. The
primary problem is that the narrow focus and prescribed
methods of the systematic review do not allow for
comprehensive coverage. For example, the historical review
is an irreplaceable means of tracing the development of a
scientific principle or clinical concept, but the narrative
thread could be lost in the strict rules of systematic
review.132 Although it is well known that narrative reviews
are prone to several biases,133 it is highly conceivable that
the literature search in this project, repeated at 3 different
intervals using a similar strategy; the use of the European
Commission of Radioprotection Guideline as a template;
the evaluation of all guideline recommendations by a large
consensus group composed of more than 60 academics,
researchers, and clinicians (modified Delphi process
phase 5); the inclusion of 2 external reviews (phase 4 and
phase 7) resulting in the contribution of more than 60
chiropractic and medical specialists scrutinizing every
section of the diagnostic imaging guidelines significantly
reduced the risk of missing important articles and of
misclassification, and have improved the reliability of these
guidelines. Although the quality of studies was assessed by
blinded, independent evaluators during phase 2, ideally it is
Journal of Manipulative and Physiological Therapeutics
November/December 2007
preferred that 2 experienced evaluators assess each study
and formally agree on differences. Unfortunately, most
studies could only be reviewed by one assessor due to a
limited budget.
The quality of studies used to propose recommendations
needs discussion. It has been acknowledged that many
studies on diagnostic validity are of poor quality.134 In the
overwhelming majority of axial pain syndromes, there is
little evidence supporting confidence in diagnostic test
validity.135,136 The same conclusions appear also to apply
to the clinical examination of some disorders of the upper
and lower extremities.137-145 In real-life situations, knowl-
edge of the natural course of clinical conditions helps
practitioners determine the need for clinical reevaluation
and complementary investigations, including diagnostic
imaging studies.
In the hierarchy of research designs for treatment, results
of randomized controlled trials are considered the highest
level of evidence, followed by controlled observational
studies with uncontrolled studies and opinion representing
the lowest level of evidence. It should be noted, however, that
this hierarchy of research designs has been questioned by
recent publications 146,147 that identified nonsignificant
differences in results between randomized controlled trials
and observational studies.148 The hierarchy of research
designs has also been challenged in the field of diagnostic
anatomic pathology149 and rehabilitation research.150 A
critical comparison of trials with observational studies
suggests that one cannot replace the other, both designs
being susceptible to particular bias, such that neither provides
perfect information.151 Bluhm152 suggests considering the
relationship between biological studies, epidemiological
studies (population/clinical research), and systematic clinical
observation: a network whereby different information
provides for better interpretation of the existing literature.
These diagnostic imaging guidelines incorporated a combi-
nation of clinical trials and observational studies as a basis for
proposing recommendations.
Technical difficulties encountered at the onset of the
Delphi process, public consultation, and second external
review (access to the protected website, registering of
participants, and access to some of the documents) have
likely disenfranchised some volunteers who were initially
interested in reviewing the guidelines online. Although
troubleshooting was promptly addressed, once we were
advised, attrition of participants likely occurred in similar
proportion among those in favor and those against the
proposed recommendations.
Chiropractors formed the majority of Delphi panelists. This
group in most jurisdictions and most practice situations does
not order or interpret advanced imaging. In addition, they have
limited experience in dealing with pathologies such as
fractures, ligamentous instability, myelopathy, cancer, and
infection. It could be argued that it is not valid to suggest that
these guidelines overall are a complete or accurate reflection of
Journal of Manipulative and Physiological Therapeutics
Volume 30, Number 9
best practice from the standpoint of the patient or the disease
itself. However, considering this work is an extension of the
Referral Guidelines for Imaging by European Communities
(Radiation Protection) produced in conjunction with the UK
Royal College of Radiologists,51 we believe that these
guidelines are in agreement with current standards of care.
Many reasons may explain the low participation observed
in the public consultation (Phase 6): failure to receive or read
invitation announcements in journals; refusal to participate;
failure to have access to a computer or to the web; busy
schedules; technical difficulties encountered during the
project; and the size of the documents to be reviewed.
Although those reasons should not significantly influence the
results, lack of interest in research or for the study topic would
suggest that nonresponse may be biased in ways directly
related to the purpose of the study.153 A low response rate does
not necessarily affect the validity of the data collected,
provided tests for nonresponse effects and corrections to the
original data be made if needed.154 Unfortunately, such
analysis was not conducted in this study. Of the 271 health
care professionals who completed the consent form to
participate in the second external review (phase 7), only 105
specialists (38.7%) registered. Reasons for not responding are
unknown. While a potential source of bias, the very high levels
of agreement with all recommendations suggest that the results
would likely not be changed significantly with a higher
participation rate considering that specialty groups tend to
exhibit homogeneous practice behaviors.
It could be argued that our process, however extensive,
did not include a sufficient number of chiropractic named
technique representatives and a sufficient number of other
health professions dealing with musculoskeletal disorders.
Users of specific chiropractic techniques that rely on the
routine use of radiography for the purpose of elaborating a
plan of treatment should have a particular interest in imaging
guidelines development. Representatives from Gonstead
Technique and from Chiropractic Biophysics protocol were
invited to participate on the Delphi panel (phase 5).
Unfortunately, the Gonstead representative failed to return
most of the evaluation questionnaires and a cofounder of
Chiropractic Biophysics protocols declined our invitation,
opting instead to develop other guidelines.90 With regard to
the incorporation of other health care professions, ordering
of imaging studies is normally restricted to medical
physicians and chiropractors, as well as to osteopaths in
the USA, therefore excluding physical and occupational
therapy groups and Canadian osteopaths. Most medical
specialists invited to participate in our study cited lack of
availability as the main reason for declining our invita-
tion. One neurosurgeon had to stop participating due to
personal illness.
As the properties of a diagnostic test can change with
different disease severity, generalization of study results is
another important issue to consider. In other words, an
imaging study may not perform as well in a community
Bussires et al 647
Diagnostic Imaging Guidelines
practice, where less complicated cases will have to be
distinguished from multiple competing diagnoses.110 One
such example is the Canadian Cervical Spine Rule (CCSR)
used to exclude fractures tested in a large hospital setting
and trauma centers where disease prevalence and severity
tends to be greater. It is important to recognize that the
predictive value of a test will change with changes in the
prevalence of the disease.110 In addition, likelihood ratios
tend to move away from the value of 1 when all patients
who have the target disorder have severe disease, and they
tend to move toward the value of 1 when all patients who
have the target disorder have mild disease.155 A wide
spectrum of patients with low, moderate, and high levels of
clinical suspicion of fracture need to be included in the
studies to allow for generalization to community practices.
Additional studies may therefore be required to determine
whether these highly sensitive clinical decision rules
perform just as well in general practice. However, if one
practices in a similar setting to that presented in a particular
study and the patient meets the study eligibility criteria, one
can be confident in applying the results of the study to his/
her own patients.110
Dissemination-Implementation-Evaluation-Revision. Many reports
have indicated that current evidence-based guidelines are
underused by physicians and others, and that many barriers
to an effective translation of recommendations extend into
day-to-day care. There is therefore a need to develop more
effective ways to communicate key information to both
caregivers and patients, and to promote appropriate health
behaviors.156 Reducing resistance to guideline implementa-
tion will require persuasion of practitioners so that the
perceived negative effects of guidelines on their practices are
balanced by improvements in the quality of care.157
Because publication alone is not enough to change
practice158-160 , the complex and challenging issues of
implementation and utilization of CPGs also need to be
considered. Many studies have shown that a combination of
different strategies is necessary. Positive tendencies toward
successful implementation include:
1. A commitment to implementing the guidelines;
2. Local authorities that take responsibility in the health-
care community and designate this topic as high priority;
3. A well-organized system for managing guidance
(regular report and audits of compliance);
4. Sufficient funding;
5. Buy-in (acceptance) by the health care providers
(provided that guidance is consistent with other
published sources, views are properly represented,
and guidance is mandatory).161
Therefore, an investigation of possible barriers are an
essential component of any guideline dissemination-imple-
mentation strategy.162,163
648 Bussires et al
Diagnostic Imaging Guidelines
Potential Barriers to Implementation
Pretest of the Initial Draft Implemented in an Outpatient Chiropractic
Teaching Institution. The initial draft of the diagnostic imaging
guidelines (phase 3) was implemented into the outpatient
teaching chiropractic clinic at UQTR in July 2003 after formal
presentations to UQTR interns and clinicians. Implementation
strategies of the initial draft included frequent reminders to
clinicians (letters) from the clinic directors. In addition, for
each new patient examined in the clinic, interns discussed with
the supervising clinician whether radiographs should be
ordered. If deemed appropriate, the intern and clinician were
required to complete an order form based on the design of the
proposed imaging guidelines. Reasons for ordering films, as
well as pertinent clinical indicators and specific views, had to
be specified. Adherence to the new spine disorders guidelines
was evaluated retrospectively between February 2004 and
February 2005. The overall level of agreement between
clinical decision making and the new diagnostic imaging
guidelines was moderate (71.7%; = 0.432; CI, 0.298-0.550).
Reasons for disagreement included not ordering radiographs
when recommended by the guidelines; ordering radiographs of
the main complaint despite not being recommended by the
guidelines; ordering radiographs of asymptomatic anatomical
regions other than the main presenting complaints (eg, past
history of neck trauma). None of the incidental findings
identified on the radiographs represented an absolute contra-
indication to chiropractic care. Although the aim of this project
was to measure adherence to the proposed recommendations
for spine disorders and did not specifically address the
implementation strategies, it is worth noting that the
percentage of new patients that had radiographs ordered
decreased from a mean of 88% before implementing the new
guidelines to 57.4% and 49.1% during academic years 2003 to
2004 and 2004 to 2005, respectively. This decrease may be
partially related to changes in the radiography fee schedule
during that same period.
Peer Review of the Guidelines: Worldwide Public Consultation (Phase 6)
and External Review (Phase 7). As discussed earlier, other
potential barriers to successful implementation of practice
guidelines may include chiropractors' attitudes toward
chiropractic ideology and scope of practice.164 These
potential barriers were indirectly addressed in our study
when dealing with issues involving stakeholders and
editorial independence. A worldwide consultation invited
doctors of chiropractic to access an imaging guideline
website and to provide comments and suggestions (phase
6). Professional associations and organizations were invited
to nominate members to review these proposed recommen-
dations. Simultaneously, the expert consensus guidelines
were forwarded to specialists in chiropractic and medicine
who were invited to independently evaluate the proposed
imaging guidelines (phase 7). The research team considered
all comments received in drafting the final version of the
Journal of Manipulative and Physiological Therapeutics
November/December 2007
guidelines. Details of phases 6 and 7 are presented
elsewhere in this paper.
A minority of participants who responded to the
public consultation phase favored the routine use of
conventional radiography offering the following justifica-
tions for this practice:
1. To screen for and prevent rare possible complications
associated with spinal manipulative therapy;
2. For nonclinical motives, including patient preference
and satisfaction, medicolegal concerns, political influ-
ence, and administrative factors;
3. For postural and biomechanical analysis of spinal
disorders before and during the provision of spinal
manipulative therapy;
4. Because the adverse effects of ionizing radiation
exposure on human health are considered, by some,
to be negligible.
Current guidelines do not consider these reasons adequate
justification for the routine exposure of patients. Never-
theless, each of these points is a potential barrier to
implementation by practitioners.
Independent Set of Imaging Guidelines in Chiropractic. Disagreement
within a guideline development group may include differ-
ences in interpretation of the research literature, differences
in personal experience, and different perceptions of the
inherent risks and benefits of a procedure.63 After declining
an invitation to participate in our study, an ICA board
member and principal founder of CBP, a chiropractic
technique organization, elected to develop an independent
set of imaging guidelines: Practicing Chiropractors' Com-
mittee on Radiology Protocols for Biomechanical Assess-
ment of Spinal Subluxation in Chiropractic Clinical Practice
(PCCRP).90
It is well documented that the composition of the working
group and group dynamics can influence the outcome of
discussions and lead to variation among the recommenda-
tions of different groups.165 A similar pattern has been
observed within the chiropractic profession in the past with
the development of alternative sets of guidelines. In response
to the Guidelines for Chiropractic Quality Assurance and
Practice Parameters (Mercy)166 and the Clinical Guidelines
for Chiropractic Practice in Canada (Glenerin)167 modeled
after the Mercy guidelines, alternative guidelines soon
followed including the Vertebral Subluxation in Chiroprac-
tic Practice (CCP)168 and the Recommended Clinical
Protocols and Guidelines for the Practice of Chiropractic
(ICA).169 Independent assessment of 3 of these chiropractic
guidelines concluded that neither the CCP nor the ICA
alternatives were suitable for utilization in chiropractic
practice, whereas the Mercy guidelines were recommended
for application in chiropractic practice, with the provision
that new scientific data should be considered.170,171
Journal of Manipulative and Physiological Therapeutics
Volume 30, Number 9
The different premises on which chiropractic guidelines
are established may derive from a longstanding ideological
debate among chiropractors regarding the identity of
chiropractic.172-175 Mootz176 proposes that chiropractic
institutions and organizations focus on an evidence-based
and best practiceoriented research priority, constructive
engagement of the greater health care system, and successful
ethical business models.
Divergent or competing guidelines on similar topics serve
only to further confuse and frustrate practitioners.177 In
addition, the continued lack of unity among chiropractors
hinders its growth by limiting engagement of the greater health
care system. We encourage readers of all guidelines to
critically evaluate the methods used as well as the content
of the recommendations before adopting them for use
in practice.178
Strategies for Effective Guidelines Dissemination, Implementation, and
Monitoring
Proposed dissemination-implementation strategies
include publication, applying to National Guideline Clear-
inghouse; posting of the electronic document on various
websites (national, state, and provincial organizations;
malpractice insurance carriers; outpatient teaching clinics);
educational intervention strategies (e-learning, community
pilot studies); referral guidelines; reinforced by request
checking and clinical management algorithms; promotion
by national, provincial, and state organizations; and
presentation to conferences. Currently, there is a deficiency
of well-designed studies that document the effectiveness of
practice guidelines. Their ultimate effectiveness will depend
on both an improved evidence base and effective strategies
for rapid dissemination of the recommendations.
In the past, effective dissemination of new knowledge has
been a slow process, often taking years. This process can be
dramatically shortened through the development of networks
of practice sites that share knowledge and experience in the
implementation of practice guidelines and the use of
strategies that take advantage of key groups in the
dissemination process.179 When used appropriately, practice
guidelines can provide an important adjunct to clinical
research by facilitating the dissemination of new clinical
findings and can provide an important platform for
encouraging innovations in patient care.179
In one instance, mailing of copies of the Royal College of
Radiologists' guidelines had a small effect on general
practitioners' use of radiographic investigations of uncertain
clinical significance.180 There is currently considerable
debate surrounding the ability of professional education and
development to actually make a difference in the way
clinicians practice.181 An educational intervention strategy as
a means of implementing evidence-based guidelines for
imaging may be most effective in reducing the perceived need
for conventional radiography in a chiropractic community.97
Bussires et al 649
Diagnostic Imaging Guidelines
Such a strategy has proven effective for managing shoulder
problems and informed use of ultrasound imaging in general
practice.182 The use of referral guidelines, reinforced by
request checking and clinical management algorithms,
produced total reductions in radiographic examinations
ordered by general practitioners of the knee, lumbar spine,
and cervical spine of 77%, 78%, and 86%, respectively.183
It has been recommended that postgraduate teaching of
evidence-based practice should be moved from classrooms
to the clinical practice setting to improve skills, attitudes, and
behavior.184 Internet platform (e-learning) for continuing
education, including case-based learning objectives and
examinations, is yet another method of facilitating guideline
implementation.185 Teaching diagnostic decision making in
this way may also be a viable alternative to traditional
teaching formats in undergraduate programs.186 It is also
recommended that conferences and seminars be designed to
include several healthcare providers, thereby giving a
comprehensive presentation on each topic.20
Monitoring of the Guidelines/Clinical Audit
Guideline adaptation by regional care provider audit
groups may serve as a tool for CPG implementation.187
Effective methods can be developed for monitoring guide-
line use in primary care. However, there is a need to address
the degree of understanding possessed by many primary
healthcare professionals about the concepts and practical
issues of guideline-use monitoring, and of expectations of
this within the healthcare system. In addition, a number of
technical issues concerned with efficient capture of clinical
information and its evaluation must be considered.188 Audit
(systematic monitoring) and feedback (less formal) are
frequently used strategies to improve professional practice.
When it is effective, the effects are generally small to
moderate. The relative effectiveness of audit and feedback is
likely to be greater when baseline adherence to recom-
mended practice is low and when feedback is delivered more
intensively.189 Computer reminders attempt to influence
behaviors of individuals. Reminders are more effective than
feedback in modifying physician behavior related to
medication management.190 In addition, such reminders
may seem less threatening as they are anonymous.191
Social, political, and commercial factors often drive and
determine the use of evidence in policymaking. It is
recommended, however, that in-depth analyses from differ-
ent perspectives be made before implementing evidence-
based policies.192 Such analyses may include perspectives
from patients, providers, society, payers, and others. One
concern is whether this type of evidence will lead to a policy
change with significant benefit to society.193
A significant limitation of any CPG is the skill of
clinicians. Decisions to proceed with further testing are
based on information gathered by thorough and proper
history taking and results obtained from a well-conducted
650 Bussires et al
Diagnostic Imaging Guidelines
physical examination. Lack of standardization of these
procedures is a concern, however, both intraprofessionally
and interprofessionally. For more in-depth discussions on the
subject of history and physical examination, recent reviews
and textbooks are available.137,194-198 There are some
indications that structured data collection and explicit
questioning may help inexperienced physicians make more
accurate judgments about the need for radiography.199 Such
data collection forms should be developed for health care
professionals, interns, and residents.
Updating/Revision
Guidelines are living documents refined regularly with
new information and experience, a process that can be
challenging given the rapid evolution of technology and
practice in the field. The guideline development group
believes that the literature review and the guidelines should
be periodically updated every 2 to 3 years to determine
whether the guidelines should be reconsidered in light of
new research evidence. In addition, the research group
should convene when major new research evidence is
published in the interim.63
Using current recommended methodology 127-131 to
develop a scientifically robust guideline represents a
major academic endeavor. With more than 125 patient
presentations and 240 recommendations, including conventional
radiography and specialized imaging in the 3 diagnostic
imaging guidelines, such expenditure of time and human
and financial resources is prohibitive. Clearly, such a
strategy will require support form national and international
organizations. Nonetheless, improving on the quality of the
process is important and the following strategies should
be considered:
The inclusion of methodologists throughout the revi-
sion process;
The completion, where possible, of systematic reviews
of selected conditions;
The development of the electronic search in collabora-
tion with an experienced librarian;
The refining of the search strategy by systematically
including other databases such as Medion, OSTMED,
EMBASE, CINAHL, US National Library of Medicine,
and the Database of Reviews of Effectiveness (DARE)
to identify relevant studies;
The inclusion of experts from other fields in the
guideline development team;
The inclusion of a large number of experienced
literature reviewers from several health care
professions;
The hiring of additional support staff and a project
manager;
The inclusion of experts from other fields to provide a
large multidisciplinary external review team.
Journal of Manipulative and Physiological Therapeutics
November/December 2007
Recommendations for Future Studies
These proposed guidelines are intended to reduce
unnecessary radiation exposure, increase examination pre-
cision, and decrease health care costsall without compro-
mising quality of care. However, the potential of guidelines
for resolving clinical questions should not be overstated.
Further research is recommended in the following 2 areas:
1. Prospective validation of the content of the diagnostic
imaging guidelines to ensure that similar results are
replicated in a different population of patients or in a
different health care setting.
2. Assessment of the impact of the diagnostic imaging
guidelines implementation on practice patterns, out-
come of care, and costs. This is the ultimate step as
guidelines are useful only to the extent that they can
improve clinically relevant outcomes, increase
patient satisfaction, and decrease costs once imple-
mented into clinical practices. The extent to which
patient concordance with the guideline recommenda-
tions is taken into account in the assessment of
clinician conformance with guideline recommenda-
tions is important, as are the costs and benefits to
patient care of guideline-use monitoring. In addition,
it is crucial to consider the most efficient methods
of developing valid and reliable policy- and
evidence-based review criteria; whether such review
criteria are more useful than guidelines in improving
quality of care; and what additional benefits to
patient care can be offered by monitoring patient-
centered health outcomes in addition to process and
cost of care.187
Prospective studies on the prognostic value of symp-
toms, signs, and diagnostic labels remain a research
priority in the field of regional musculoskeletal pain. In
addition, derivation of practical, highly sensitive, and
reliable clinical decision rules or clinical prediction rules
for the selective use of diagnostic imaging similar to those
for knee, ankle and foot, and cervical spine trauma would
prove useful.183,200 These rules use clinical findings
(history, physical examination, and tests results) to make
a diagnosis or predict an outcome. Well-developed clinical
decision rules result in less radiography, less time spent in
the emergency department, and do not decrease patient
satisfaction or result in misdiagnosis.200 Clinical prediction
rules may be thought of as the combination of relevant
clinical findings to calculate the numeric probability of the
presence of a specific disorder or likelihood of an
outcome. They act as adjuncts to the evaluation process.201
Clinical rules require prospective validation as well as
impact analysis.202,203
Reporting of topics included in the development of the
diagnostic imaging practice guidelines are provided in a
standard format for each of the guidelines.204
Journal of Manipulative and Physiological Therapeutics
Volume 30, Number 9
CONCLUSIONS
The role of high-quality CPGs for quality management in
health care is well accepted. These evidence-based diag-
nostic imaging practice guidelines are intended to assist
primary care providers, interns, and residents in decision
making on the appropriate use of diagnostic imaging for
specific clinical presentations. In all cases, the guidelines are
intended to be used in conjunction with sound clinical
judgment and experience. Application of these guidelines
should help avoid unnecessary radiographs, increase
examination precision, and decrease health care cost
without compromising the quality of care.
Guidelines are effective only if they are implemented in
the delivery process. The implementation process should be
supervised and evaluated so that adjustments are possible.
Several important issues regarding dissemination/imple-
mentation strategies need to be considered. Health profes-
sionals are slowly moving toward evidence-based health
care and best practices and will appreciate the value of
CPGs provided teaching institutions and political leaders
promote their use. Guidelines are living documents refined
and modified regularly with new information and experi-
ence. Future research is needed to validate the content of the
proposed diagnostic imaging guidelines. In addition,
attempts to refine patient selection criteria to further reduce
unnecessary radiographic exposure without altering sensi-
tivity are recommended.
Practical Applications
This project developed evidence-based diagnostic
imaging practice guidelines for musculoskeletal
complaints for use by chiropractors and other
primary health care professionals.
The guidelines describe appropriate care based on
the best available scientific evidence and broad
consensus, reduce inappropriate variation in prac-
tice, provide a more rational basis for referral,
provide a focus for continuing education, promote
efficient use of resources, act as a focus for quality
control (including audit), highlight shortcomings of
existing literature, and suggest appropriate future
research.
The guidelines have been created to improve patient
care by detailing the appropriate information
gathering and decision-making processes involved
in the diagnostic imaging of musculoskeletal care.
The guidelines are intended to be used in conjunc-
tion with sound clinical judgment and experience.
Application of these guidelines should help avoid
unnecessary radiographs, increase examination
precision, and decrease health care costs without
compromising the quality of care.
Bussires et al 651
Diagnostic Imaging Guidelines
ACKNOWLEDGMENT
The authors express their sincere appreciation to all
independent literature reviewers (phase 2), Delphi panelists
(phase 5), and external reviewers (phases 4 and 7), whose
significant contributions were essential in the completion of
this project. We are grateful to chiropractic college presidents
for recommending faculty members for the Delphi panel. We
appreciate the feedback received by colleagues in the field
during and after the worldwide consultation on the Web
(phase 6). We thank Jeffrey Cooley, DC, DACBR; Jonathon
Todd Egan DC, Fellow; Michael Morgan, DC; Jason Napuli,
DC; and Julie O'Shaughnessy DC (Fellow candidate in
Clinical Sciences) for completing the independent literature
review (phase 2); and Dr Andre Cardin of Universit du
Qubec Trois-Rivires for his significant input in the initial
draft (phase 3). We thank Carlo Ammendolia, DC, PhD; Joe
Lemire DC, MSc; John Triano DC, PhD; and Jacques
Duranceau, MD, for providing constructive advice. The
authors thank those who assisted us during all or part of the
project, including Mark Laudadio, DC; Christian Eid, DC;
Julie Roy, DC; Nicholas Beaudoin; and Mme Valrie
Lambert, academic and technology support, Computer
System Development Division at UQTR. Finally, we thank
Mrs Vicki Pennick, RN, BScN, MHSc, Senior Clinical
Research Project Manager, Managing Editor, Cochrane Back
Review Group, Institute for Work & Health, for her valuable
advice and pertinent comments and suggestions as a public
representative.
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on guideline standardization. Ann Intern Med 2003;139:
493-8.
Journal of Manipulative and Physiological Therapeutics
Volume 30, Number 9
APPENDIX A. SUPPLEMENTARY DATA
Supplementary data associated with this article can
be found, in the online version, at doi:10.1016/j.jmpt.
2007.10.003.
APPENDIX B. COMMENTS RECEIVED BY PARTICIPANTS OF
THE PUBLIC WEBSITE (PHASE 6) SPECIFIC COMMENTS
PERTAINING TO THE LOWER EXTREMITY DISORDERS
GUIDELINES
Positive comments
Great work overall.
Excellent, keep it coming.
Usually treatment failure will lead to advanced imaging studies. An
exhaustive work, the participants are to be congratulated!
Excellent.
Very helpfulI think it will also be helpful to use with the medical
profession.
This was a great review of lots of things I don't see too often. The
chart format is easy to read and will be a great resource.
Not terribly exciting reading; however, good review of what every
practicing D.C. should have learned in school or continuing ed.
Negative comments
I understand your objectives with this study, but, my practice and in
my mind, chiropractic in general is not about pain.
Chiropractors diagnose and treat subluxations. X-rays identify the
underlying biomechanical cause of symptoms. Determination should
be with the clinician based on benefits of x-ray exceeding the risk.
Chiropractic is a unique health care solution. These guidelines would
be good for a medical doctor but not a chiropractor.
You can't legislate clinical decision making because patients don't
fall into neat categories. Your attempt to do so is ignorant at best and
pernicious at worst.
Neutral comments
Best practices are a much better alternative to guidelines.
Given that I practice in a more rural setting access to and/or the ability
to refer patients for US, CT or MRI evaluations is limited by the low
number of facilities in our area and their extensive use by allopathic
practitioners.
I always try to send pt's back to their MD for films as we do not have
x-ray capabilities. Because someone else is sometimes the gate keeper
it makes it difficult to follow the guidelines exactly.
The medical profession in Italy is going through a similar exercise.
Best practices are better than guidelines.
More diagrams please.
Be careful, not to let this survey become too restrictive as other
guidelines have. Academicians and researchersdifferent arena than
DC's in the office.
Comments Pertaining to the Spine Disorders Guidelines
Positive comments
Fantasticabout time, good research!!
Interesting traumatic guidelines.
Love itgreat detail and research.
I really liked the summary of recommendations.
Bussires et al 657
Diagnostic Imaging Guidelines
Jennifer Jamison would be proud of you!
My interdisciplinary colleagues will love this as well, psychiatrist,
neuro, ortho, etc
Biomechanical x-ray analysis, including chiropractic spinal analysis for
subluxation and alignment/postural correction, not properly included.
(n = 30)
Chiropractic spinal analysis for subluxation not properly included.
Guidelines fail to acknowledge the special interventive procedures
(adjustments) employed by most D.C.'s
Lacking in research for biomechanical x-ray analysis and how this
analysis does alter patient management and outcomes greatly.
Reasons for taking x-ray are very limited and narrow scope
The guideline fails to address the use of spinography for
subluxation assessment. As such, the proposed guideline is of
very limited value.
There is no reference to alignment/postural correction. To reference a
few papers to rule out work such as CBP and Pettibon is absurd.
These regulations do not take into consideration the upper cervical
specific practitioner who needs x-rays to get a listing. In shortthese
guidelines are NOT APPROPRIATE for Chiropractors.
This document needs to improve regarding the use of films for
biomechanical evaluation. Ref 24 has been soundly refuted by Harrison
et al, JCCA,2006,50(3) yet this document fails to include it. Bias?
I do not like that these guidelines will not give me the choice to X-ray
for biomechanical analysis as I deem necessary. X-rays are as
important to direct Tx/rehab as they are for pathology.
In dealing with spinal trauma there is a great need to document the
patient's injuries and not to base on a guideline rather than a thinking
doctor is just wrong.
Please withdraw and revise these guidelines to more appropriately
match the 90% of subluxation based chiropractors practicing in North
America.
Our state scope of practice provides that subluxation may be the sole
basis for chiropractic care. These guidelines fail to address the use of
spinography for subluxation assessment.
None of these guidelines are applicable to the practicing chiropractic
community.
Please withdraw and revise these guidelines to include Subluxation/
Biomechanical basis for radiography in the chiropractic practice
The info I get from x-rays is invaluable. Consult Dr. Burns at Palmer
or Dr. Cox with Gonstead Seminar. Don't limit me because some
don't understand how to use x-ray.
These guidelines are not appropriate for Chiropractors.
This document does NOT reflect my scope of practice.
There is no allowance for wellness and prevention and spinal
hygiene.
Implementing these guidelines into my practice would severely limit
my ability to help people in my community. I don't see or understand
how these could possibly help anyone.
Research based chiropractic guidelines for radiology is necessary. I
am concerned about being overly restricted with non-SMT based
guidelines for x-ray. I want to SEE what I am manually adjusting.
Regional anomaly, 1 level severe DDD, need for a short leg heel lift,
etc, can be assessed best with x-ray and may not directly associate
with trauma, disease and pain based x-ray guidelines.
Chiropractors diagnose and treat subluxations. X-rays are necessary
in a chiropractic practice. Determination should be with the clinician
based on benefits of x-ray exceeding the risk.
As a chiropractor it is traditional & very important to take x-rays for not
only pathology but for biomechanical evaluation. This type of x-ray is
both reproducible & valid.
Too superficial of a review of the literature. Ignores medical
guidelines and biomechanical analysis.
(continued on next page)
658 Bussires et al
Diagnostic Imaging Guidelines
Such guidelines have no clinical application as x-ray is a logical and
well supported piece of any health care provider's office.
This document has nothing to do with what Chiropractic is. I am fully
& whole-heartedly against it!
I look for degeneration, alignment, listings, curvature, etc. Example, it's
very difficult to determine a Base post from an L5 subluxation without
a radiograph
While I appreciate the intent on making these guidelines EB,
there are other factors to consider beyond patient safety (ie, red
flags). Anyone in practice longer than five years (and as noted by
you) has hopefully figured out that radiographic studies usually
don't correlate to symptoms of any sort, so the use of X-ray for
pain treatment (other than ruling out critical or potentially critical
phenomenon) is pretty much useless. However, there are other
rationales to the use of this type of analysis. The first would be
postural analysis. It concerns me that you appear to have
determined that the single study by Cooperstein et al (which
challenges the body of work by CBP) is comprehensive enough to
exclude all forms of postural analysis as a rationale for utilization of
X-ray. There are numerous other technique systems (ie, NUCCA,
AO, Gonstead) utilizing both global and focal postural distortions
as part of their analytic pre-post protocol, and would suggest
perhaps considering investigating the data these groups have
accumulated on the application of X-ray in clinical use. Another
area of practical radiographic application is with regards to choice
of technique. Higher levels of joint degeneration may indicate
avoidance of vigorous manipulative approaches (diversified,
Gonstead, Crane) in favour of a more tonal nature (Toggle, TRT,
Network), not for safety, but for patient comfort and compliance to
a prescribed schedule of beneficial chiropractic care.
Structural/corrective x-rays don't fit these g-lines nor should they. We
shouldn't limit patient x-rays for structural/corrective practices. We
don't see dentists x-raying for dx only.
For diagnosis, ruling in-out, pathologies, guidelines are appropriate;
evaluating mobility and cpnts of Vertebral Dysfunction Complexes,
some X-ray studies may be required despite lack of red flags
I feel this document has been put together without considering the
current chiropractic profession. Where are the surveys to show how
chiropractors currently use x-rays?
Fails to consider x-rays as a screening tool and practitioners experience
in clinical decision making (n = 14)
It also needs to be noted that many pathologies may not have red
flag signs such as an abdominal aneurysm and could be detected on a
routine x-ray.
DDD as well as congenital disorders (spondylolithesis) can be
asymptomatic but are important in determining care. According to
these guidelines, no x-rays would be taken if asymptomatic.
Nontraumatic and uncomplicated cases may still have underlying
problems which would otherwise be overlooked, failure to utilize
simple x-ray studies does not protect the patient.
Structural/corrective x-rays don't fit these g-lines, nor should
they. The dental profession x-rays for screening/correction. We
shouldn't limit our profession from x-rays that help patient's
structure/health.
This document failed to consider the large amount of evidence for
subluxation/biomechanical based radiographs. Please see http://www.
pccrp.org
To think that X-rays should only be taken in instances of pain is
ridiculous. How many pathologies were found bk we took
radiographs of asymptomatic ptsmany certainly in my 25 high
vol practice.
Guideline criteria are entirely based on crisis management.
Deciphering contributing/predictive factors for appropriate health
promotion interventions received no consideration in this study.
Journal of Manipulative and Physiological Therapeutics
November/December 2007
It is the doctor who must decide when or when not to take x-rays,
liability for mistakes falls on that doctor. The type of treatments and
techniques provided may require follow studies
All too often I see cases where failure to use x-rays by others
practitioners has not been in the best interest of the patient.
X-rays are integral evaluation of many pt's condition. Upon
physicians evaluation, a non-trauma or trauma patient may require
them. Not all pts can be categorized so strictly. Final decision should
be left to the clinician.
Clinical decision making should be left up to the clinician and not
a set of guidelines. Everyone has studied indications and
contraindications to treatment in their undergraduate education.
They only work for the insurance industry and they open the
doctor up to malpractice lawsuits because no jury will take a
defence such as well the guidelines indicated that I did not need
x-rays.
Respect that our undergraduate training and experience should guide
our practices, not a reasonably rigid academic grounded guideline!
Chiropractors of the 50-70's had a better understanding of spinal
anatomy, anomalies etc than the present grads.
These are MD guidelines (n = 7)
These guidelines are for MD management.
These are MD guidelines. What about Gonstead and Upper Cervical
Spine doctors. If you don't need films don't take them. I don't tell you
how to practice. Radiation Hormoesis.
These recommendations would work if I were a M.D. If you want to
be a M.D. go to med school. Let the rest of us practice
CHIROPRACTIC.
Good trauma review. We need further acceptance of how films
impact pt. care. Films can be great objective outcomes for care and
yield relevant info on case management and prognosis.
I think these are bogus guidelines that will adversely affect my
practice and my patient's health. This is a poor review of
literature!
The study as is should be given to the ER department of some
hospital not our new graduatesIt seems the purpose is not to make
them think but to be scared.
I didn't feel the chiropractic profession's current use of x-rays was
considered or thoroughly researched. This would be a lovely
document for those specialising in spinal pathologies.
Negative comments (n = 4)
Not wise.
I wonder what the motive is to have such limiting guidelines are? The
pccrp guidelines are a much more appropriate set of guidelines. These
are a waste of time and should be burned.
I will tell as many DC's as possible as to how dangerous these
guidelines are to patients. I urge you to adopt the PCCRP guidelines
and throw yours away as soon as possible.
These guidelines are a waste of time and those who agree with them
are in the wrong profession, misguided and un-informed. wake up!
Suggestions for improving guidelines formatting and content (n = 6)
The formatting poor. This reference: Nhttp://www.pnlg.it/LG/014/
014-01.php Italian guidelines for disc and the European LBP
guidelines http://www.backpaineurope.org have superseded the
RCGP refs you give.
These guidelines should not be implemented in the current format.
An algorithm may be more appropriate.
The ROM of motion numbers are wrong in the Canadian
guidelines, this according to the American Medical Associations;
Guidelines to the Evaluation of Permanent Impairment, 5th edition.
Chapter 15.
Multiple post traumatic lesions are missed with plain film, CT, MRI,
Journal of Manipulative and Physiological Therapeutics
Volume 30, Number 9
etc. Videofluoroscopy studies are quite valuable in the evaluation of
the post trauma C-Spine patient.
The LNT model does not use any conclusive supporting data
according to the National Council on Radiation Protection and
Measurements February 1997.
Neutral comments (n = 5)
Impressive work, but until agreement occurs between the
DACBRs and subluxation influenced DCs, it's just another
pissing match. While interesting from the sidelines, both sides
need to come together.
Biggest problem I have is my location and the ability to refer
patients for specialty services. MDs in this area are not very
cooperative.
While I am a big fan of guidelines one can get hand cuffed by them
as well when clinical reasoning is outside the normand outside
forces love to use this against the treating DC for either not doing
enough investigation, or doing too much.
The technological advances in imaging have removed chiropractors
from the loop. Small practices are unable to afford to keep up. This
often leads to loss of control of patient since referral is necessary and
the M.D. takes control. These guidelines are likely to be implemented
only if provincial changes are made which allow direct referral to
imaging centers from chiropractors.
Given that competing radiography guidelines are being created by the
pccrp (http://www.pccrp.org) one wonders which guidelines to adopt
since both claim to be evidence based.
APPENDIX C. SOME EXAMPLES OF COMMENTS PROVIDED BY
PARTICIPANTS OF THE SECOND EXTERNAL REVIEW (PHASE 7)
Extremity Disorders Guidelines (Lower and Upper)
Positive comments
Clear and straightforward. There should be no controversy.
Comments section is very useful.
I found the comments to be fairly comprehensive regarding the role
of imaging modalities for the conditions listed.
Excellent review of the signs and symptoms, recommendations for
imaging are clear.
Excellent guidelines in keeping with current responsible literature.
Provides a concise, to the point review of most conditions
As I refer to the local hospital for X-rays, I use similar guidelines
already to determine the need for x-rays; these are more specific and
will be used. Good work!
Excellent review of all the things to consider before you perform an
adjustment
The recommendations do not vary in any significant way from
normal clinical judgement which is exercised on a daily basis. It is
being implemented based on sound clinical decision making.
There are chiropractic practitioners who will not follow these
guidelines because of their failure to appreciate their value.
Excellent decision rules; very applicable to clinical practice.
Negative comments
Not once did I see mention of a chiropracticly correctable lesion
(whatever term you prefer).
Chiropractic Subluxation should be part of any differential diagnosis.
I think the document is overly comprehensive with respect to the
descriptions of the conditions. It adds unnecessary bulk to the
document which may impede its usefulness as a quick reference.
Bussires et al 659
Diagnostic Imaging Guidelines
Simple joint dysfunction that is addressed daily in chiropractic offices
is blatantly missing.
Neutral comments
I would recommend a flow chart format for ease of use.
An algorithm might be helpful for each anatomic area or disorder.
Many doctors will order x-rays prior to 4 weeks of failed care if for
only medico legal aspects and also patient expectation of good care.
The fear of failing to diagnose drives such action.
The biggest impediment will be managing patients that require
imaging studies as these services have been politically removed from
the chiropractic scope of practice.
Spine Disorders Guidelines
Positive comments
Excellent synopsis of DDX and x-ray decision making
I've given 8's simply because I am trying to read this while being
very tired and I am nervous I might have missed something.
Otherwise, I feel it is a very thorough document.
The pertinent clinical information is very useful, as are the suggestions
of when to x-ray and not. This is the same for all guidelines.
A very useful and necessary tool for all practitioners
Summary of recommendations is a MUST (glad to see it was
included) as the document itself is very long and may not have been
readily used by the clinician because of its length.
All three (spine, upper & lower extremity) are great documents and
the authors are to be commended for this work. My one concern is the
perhaps mis-use of this document by 3rd party payers.
These guidelines are necessary because medical legal suits
against chiropractors are often made because x- rays were not
taken at the start of care. It will support not taking them with
this document.
An excellent document. Thank you for all of the intense work you've
put into this.
Excellent review and reference material for the practitioner.
Great Job!
These decision rules should be implemented as standard teaching
material in ALL chiropractic colleges. These rules demonstrate a level
of responsibility that other recent guidelines cannot approach.
These guidelines would provide a very quick yet thorough resource
for busy practitioners.
Negative comments
Four weeks is entirely too long to treat a patient with radiating pain
without MRI. Malpractice risk escalates due to SMT being blamed for
causing or increasing the size of a HNP if not originally imaged.
Conservative Chiropractic treatment requires active manipulation of
the affected area.
I think that the prognostic information obtained by films has been
minimized by only looking at the film findings from a diagnostic
perspective and are therefore too stringent.
Neutral comments
When I tried a quick access approach to the guideline after a full
perusal I found the recommendations too broad although better in the
summary.
It may just require further familiarization with the format.
MRI has a long wait and must be obtained through an MD.
My opinion (without reference) is that some chiropractors will
want to x-ray all patients, regardless of any Guidelines put forth
to them.
660 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007

APPENDIX D. EVIDENCE SYNTHESIS AND GRADING OF THE EVIDENCE FOR RECOMMENDATIONS INCLUDED IN THE LOWER
EXTREMITY DISORDERS, UPPER EXTREMITY DISORDERS, AND SPINE DISORDERS GUIDELINES
Independent Literature Assessment and Strength of Recommendations for the Adult Lower Extremity Disorders Guidelinesa

Table D1. Adult Hip Disorders

LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading

Adult patients with full or limited movement and Radiographs not initially indicated 40 Not recommended C Important
nontraumatic hip pain of b4 wk's duration 41 3 (but not critical)
42 3
43 Strongly recommended
General indications for radiographs include If radiographs are indicated and 43 Strongly recommended B Important
44 Recommended (but not critical)
47 3
6 Recommended
45 3
46 2+
97 Strongly recommended

Special investigations 43 Strongly recommended C Important

47 3 (but not critical)
Specific clinical diagnoses:
1. Strain, tendinitis, or tendinosis Radiographs indicated in suspected 48 3 D Important
osseous avulsion fracture 49 3 (but not critical)
50 3
51 3
52 3
53 3

Special investigations 54 3 D Important

55 3 (but not critical)
2. Piriformis syndrome Radiographs not initially indicated 57 -2 D Important
58 3 (but not critical)
59 3
60 3
61 3

Special investigations 59 3 D
3. Nontraumatic trochanteric and iliopsoas bursitis Radiographs not initially indicated (C) 62 3 D Important
63 3 (but not critical)

Special investigations 64 3 D Important

(but not critical)
4. Osteoporotic hip fractures
Radiographs indicated Urgent 27 3 C Critical
orthopedic referral necessary 28 3
29 Recommended
30 3

Special investigations 31 Strongly recommended D Critical

(see thoracic spine)
5. Septic arthritis of the hip Radiographs indicated 42 3 D Critical
Emergency referral 43 Strongly recommended

Special investigations 41 3 D Critical

43 Strongly recommended
71 3
Journal of Manipulative and Physiological Therapeutics Bussires et al 661
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table D1 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading
Consider obtaining radiographs in adult patients Radiographs indicated and additional 72 Strongly recommended D Important
with chronic hip pain unresponsive to 4 wk views and special investigations 73 3 (but not critical)
of conservative care or if one of the following 74 3
conditions is suspected 75 3
76 3
77 Fair quality
Specific Clinical Diagnoses:
1. Congenital/developmental abnormalities Radiographs indicated and additional 45 3 D Important
views 49 3 (but not critical)
64 3
78 3
79 3
80 Fair quality

Special investigations 79 3 D Important

80 Fair quality (but not critical)
81 3
82 Fair quality
2. Osteoarthritis (DJD) Radiographs indicated 44 Recommended B Important
53 3 (but not critical)
84 -2
85 -2
86 Good quality
87 2+
88 1+
89 2+
90 2+
3. Inflammatory arthritis Radiographs indicated 73 3 D Important
(seronegative and 91 3 (but not critical)
seropositive) 92 3
93 3
109 3

Special investigations 75 3 D Important

78 3 (but not critical)
80 Fair quality
93 3
94 3
95 3
96 3
4. Osteonecrosis (avascular necrosis) Radiographs indicated. 43 Strongly recommended B Important
Orthopedic referral recommended 47 3 (but not critical)
76 3
97 Strongly recommended

Special investigations 43 Strongly recommended B Important

97 Strongly recommended (but not critical)
5. Tumors and metastatic lesions Radiographs indicated. 43 Not recommended D Critical
Orthopedic referral essential 47 3
and special investigations 60 3
76 3
6. Stress (fatigue or insufficiency) fractures Radiographs indicated. 65 3 D Important
Orthopedic referral recommended 98 3 (but not critical)

Special investigations 98 3 D Important

(but not critical)
(continued on next page)
662 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007

Table D1 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading
Patient presentation
Adult patients with significant hip trauma Radiographs indicated and special 100 Strongly recommended C Important
investigations 101 3 (but not critical)
a
Reference numbers (Ref #) correspond to those of the Lower Extremity Disorders Guidelines.

Table D2. Adult Knee Disorders

LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading
Adult patients with nontraumatic knee pain Radiographs not initially indicated 43 Strongly recommended C Important
of b4 wk's duration 103 3 (but not critical)
General indications for knee When radiographs are indicated or 43 Strongly recommended C Important
radiographs include unless otherwise specified 44 Recommended (but not critical)
104 2+

Special investigations 43 Strongly recommended C Important

103 3 (but not critical)
105 3
106 3
107 2+
Specific clinical diagnoses:
1. Osteoarthritis (OA) Radiographs indicated if unrelieved 107 2+ B Important
by 4 wk of conservative care and 108 Recommended (but not critical)
Additional views and special 109 3
investigations 110 High quality
111 3
112 High quality
113 3
114 -2
115 -1
116 -2
117 3
2. Inflammatory arthritis Radiographs indicated 43 Strongly recommended D Important
(seronegative and seropositive) 91 3 (but not critical)
93 3
109 3

Special investigations 43 Strongly recommended C Important

73 3 (but not critical)
74 3
75 3
118 -2
119 -2
3. Bursitis/tendinitis/strain/tendinosis Radiographs not routinely indicated unless 120 3 D Important
(but not critical)

Special investigations 120 3 D Important

121 3 (but not critical)
122 3
123 3
4. Anterior knee pain Radiographs indicated if unrelieved 124 Good quality C Important
by 4 wk of conservative care & 125 2+ (but not critical)
additional views
Special 44 3 C Important
investigations 122 3 (but not critical)
Journal of Manipulative and Physiological Therapeutics Bussires et al 663
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table D2 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading
125 2+
126 Good quality
127 3
128 High quality
5. Internal joint derangement Radiographs indicated if unrelieved by 4 wk 43 Strongly recommended B Important
of conservative care & additional views 110 Good quality (but not critical)
129 -1

Special investigations 43 Strongly recommended C Important

103 3 (but not critical)
130 Fair quality
132 3
Adult with acute knee injury but negative Radiographs not routinely indicated (A) 6 Recommended B Important
findings for the Ottawa Knee Rules (OKR) 133 2++ (but not critical)
indicates that a fracture is very unlikely 134 2+
135 2++
136 1+
137 2++
Adult with acute knee injury and positive Radiographs indicated in the presence 6 Recommended A Critical
findings for the OKRs of one or more of the OKR criteria: 133 2++
(A): and additional views 134 2+
135 2++
136 1+
137 2++
138 2+
139 1+
142 Strong recommended

Special investigations 6 Recommended C Critical

125 2+
132 3
133 2+
134 2+

Table D3. Adult Ankle and Foot Disorders

LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading
Adult with acute ankle and foot injury Radiographs not routinely 6 Recommended B Important
but negative findings on the Ottawa indicated (A) 57 -2 (but not critical)
Ankle Rules (OAR) 141 Fair quality
142 -1
143 2+
144 3
145 Good quality
146 Recommended
147 Recommended
148 Good quality
149 Good quality
150 3

Adult with acute ankle and foot injury Ankle radiographs indicated 6 Recommended B critical
and positive findings on the OARs 43 Strongly recommended
141 Fair quality
(continued on next page)
664 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007

Table D3 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading
(a) Ankle (positive OAR) 142 -1
143 2+
144 3
145 Good quality
146 Recommended
147 Recommended
148 Good quality
149 Good quality
150 3

Additional views 151 3 D Important

152 Fair quality (but not critical)
153 3

(b) Foot (positive OAR) Foot radiographs indicated: 43 Strongly recommended B critical
(A) and additional view 6 Recommended
141 Fair quality
143 1
143 2+
144 3
145 Good quality
146 Recommended
147 Recommended
148 Good quality
149 Good quality
154 3
155 3
156 3
157 3

(a) and (b) Ankle and foot Special investigations 158 3 D Important
(but not critical)
Adult with acute toe injury Radiographs indicated GPP Important
(but not critical)

Adult with chronic ankle and Radiographs indicated 159 Unsure D Important
tarsal pain and additional view 160 2 (but not critical)
161 3
162 2
163 3
164 3

Special investigations 158 3 D Important

161 3 (but not critical)

Specific clinical diagnoses:

Impingement syndromes Radiographs indicated 160 2 D Important
Anterolateral, anterior, 165 3 (but not critical)
anteromedial and posterior 166 Fair quality

Special investigations 128 2 D Important

129 3 (but not critical)
130 3
133 Fair quality
134 3
135 3
136 3
Journal of Manipulative and Physiological Therapeutics Bussires et al 665
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table D3 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading
Peroneal tendinosis Radiographs not routinely 141 3 D Important
indicated (but not critical)

Special investigations 137 3 D Important

138 3 (but not critical)
139 Poor quality
140 Poor quality
141 3
Lateral premalleolar bursitis Radiographs not GPP
routinely indicated.
Special investigations
Tarsal tunnel syndrome Radiographs not routinely indicated 58 3 D Important
176 3 (but not critical)

Special investigations 175 3 D Important

176 3 (but not critical)
177 3
178 3
179 3
Adult with chronic foot pain Radiographs generally indicated 181 Recommended C Important
and additional views 182 Strongly recommended (but not critical)
183 3
184 3

Special investigations 181 Recommended D Important

182 Strongly recommended (but not critical)
(A) Hindfoot-heel pain Radiographs indicated and 43 Strongly recommended C Important
additional views 161 3 (but not critical)
182 Strongly recommended
185 3

Special investigations 43 Strongly recommended D Important

103 3 (but not critical)

Specific clinical diagnoses:

A1. Plantar fasciitis and calcaneal Radiographs not routinely indicated 43 Strongly recommended B Important
enthesosphyte (spur) except in young athlete 182 Strongly recommended (but not critical)
186 2

Special investigations 43 Strongly recommended D Important

189 3 (but not critical)
190 3
191 3
192 3
A2. Sinus tarsi syndrome Radiographs not initially indicated 195 3 D Important
194 3 (but not critical)

Special investigations 195 3 D Important

(but not critical)

(B) Midfoot pain (nontraumatic) Radiographs indicated if unrelieved by 161 3 D Important

4 wk of conservative care (but not critical)
or in suspected inflammatory
arthritis and additional
views:
(continued on next page)
666 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007

Table D3 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading

Special investigations if radiography is GPP

Specific clinical diagnoses:
B1. Acquired flat foot with posterior
tibial tendon dysfunction/rupture
positive or if unrelieved by 4 wk of
conservative care
Radiographs indicated if unrelieved by 196 3 D Important
4 wk of conservative care or in suspected 197 3 (but not critical)
inflammatory arthritis: additional views 198 3
199 3

Special investigations 200 3 D Important

(but not critical)
B2. Navicular tuberosity pain Radiographs indicated if unrelieved 182 Strongly recommended C Important
and tenderness by 4 wk of conservative care (but not critical)

Special investigations GPP

B3. Complex regional pain syndrome Radiographs indicated 186 -2 D Important
(but not critical)

Special investigations 200 3 D Important

(but not critical)

Specific clinical diagnoses:

(C) Forefoot pain Radiographs not routinely indicated 43 Strongly recommended B Important
unless unresponsive to 4 wk of 182 Strongly recommended (but not critical)
conservative care or if inflammatory 201 3
or infectious etiology suspected

Special investigations 184 3 D Important

C1. Metatarsal bursitis
201 3 (but not critical)
Radiographs not routinely indicated GPP
unless unresponsive to 4 wk of
conservative care: or if inflammatory
or infectious etiology suspected

Special investigations 201 3 GPP

C2. Morton's neuroma Radiographs indicated 182 Strongly recommended C Important
(but not critical)

Special investigations 58 3 D Important

201 3 (but not critical)
202 3
C3. Stress (fatigue or insufficiency) Radiographs indicated 43 Strongly recommended D Important
fracture 203 3 (but not critical)
198 3

Special investigations 43 Strongly recommended C Important

205 3 (but not critical)
C4. Osteonecrosis (avascular necrosis) Radiographs indicated: (B) 6 Recommended D Important
(but not critical)

Special investigations: (B) 182 Strongly recommended C Important

(but not critical)
C5. Hallux rigidus and hallux valgus Radiographs not routinely indicated 43 Strongly recommended D Important
(1st MTP joint) unless unresponsive to 4 wk of 165 3 (but not critical)
conservative care (B) and 206 3
Journal of Manipulative and Physiological Therapeutics Bussires et al 667
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table D3 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading
additional view 207 3
208 3
209 Not recommended
210 3
C6. Sesamoiditis Radiographs not routinely indicated 165 3 D Important
Painful inflammatory condition caused by unless unresponsive to 4 weeks of 211 3 (but not critical)
repetitive injury. Reactive tendinitis, conservative care & Additional view 212 3
synovitis or bursitis common.

Special investigations GPP

Independent Literature Assessment and Strength of Recommendations for the Adult Upper Extremity Disorders
Guidelines
NB. Reference numbers (Ref #) correspond to those of the Upper Extremity Disorders Guidelines

Table D4. Adult shoulder disorders

LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading
Adult patients with full or limited Radiographs not initially indicated 40 Strongly recommended B Important
movement and nontraumatic 41 Strongly recommended (but not critical)
shoulder pain of b4 wk's duration 42 2+
43 High quality
44 3
45 2+
48 3

General indications for radiographs include If radiographs are indicated and 40 Strongly recommended C Important
additional views 41 Strongly recommended (but not critical)
44 3
49 3
51 3
50 3

Special investigations: 6 Recommended B Important

40 Strongly recommended (but not critical)
41 Strongly recommended
43 Good quality
44 3
49 3
50 3
52 2++
53 Good quality
54 2+
55 3
56 Strongly recommended
57 3
Glenohumeral joint disorders
Specific clinical diagnoses:
1. Rotator cuff disorders (tendinopathy) Radiographs not initially indicated 40 Strongly recommended D Important
44 3 (but not critical)D
50 3
52 2++
58 3
(continued on next page)
668 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007

Table D4 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading
59 3
60 Poor quality
61 3
62 3
63 3
64 -2
65 2+

If radiographs are 44 3 D Important

indicated and additional view 50 3 (but not critical)
52 2++
58 3
59 3
60 Fair quality
61 3
62 3
63 3
64 -2
65 2+

Special investigations 6 Recommended C Important

40 Strongly recommended (but not critical)D
50 3
52 2++
64 -2
66 Poor quality
67 Fair quality
68 3
69 2+
70 3
71 Recommended
2. Adhesive capsulitis (frozen shoulder) Radiographs not routinely indicated 59 3 D Important
72 Poor quality (but not critical)

Special investigations 59 3 D Important

73 3 (but not critical)
74 Fair quality
75 3
3. Osteoarthritis (DJD) Radiographs indicated if 59 3 D Important
and additional view 76 -2 (but not critical)
77 3
4. Glenohumeral joint Radiographs indicated and 40 Strongly recommended D Important
inflammatory arthritis additional view 78 3 (but not critical)

Special investigations
5. Glenohumeral instability Radiographs indicated 40 Strongly recommended D Important
51 3 (but not critical)
52 2++
54 2+
62 3
79 3
80 Fair quality
81 3
82 Fair quality
83 -2
Journal of Manipulative and Physiological Therapeutics Bussires et al 669
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table D4 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading

Special investigations 6 Recommended C Important

40 Strongly recommended (but not critical)
84 3
87 3
Adult patients with significant Radiographs indicated and 40 Strongly recommended B critical
shoulder/glenohumeral joint trauma additional view
44 3
43 Good quality
51 3
86 High quality
87 2

Special investigations 40 Strongly recommended D Important

49 3 (but not critical)
88 Not recommended
Acromioclavicular joint Radiographs not initially indicated 40 Strongly recommended C Important
(AC joint) disorders in nontraumatic origin 44 3 (but not critical)
64 -2
89 3

If radiographs indicated 44 3 D Important

57 3 (but not critical)
64 -2
89 3
90 +2
91 +2

Special investigations 90 2+ D Important

92 3 (but not critical)
93 3

Table D5. Adult Elbow Disorders

LOE: QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading
Adult patients with full or limited Radiographs not initially indicated 47 -2 C Important
movement and nontraumatic elbow 94 3 (but not critical)
pain of b4 wk's duration 95 Strongly recommended

General indications for radiographs include: Indicated before other imaging 40 Strongly recommended B Important
studies & additional views 41 Strongly recommended (but not critical)
95 Strongly recommended
96 3
97 Recommended

Special investigations 95 Strongly recommended C Important

96 3 (but not critical)

Chronic elbow pain in the adult patient Radiographs indicated and 95 Strongly recommended C Important
additional views 97 Recommended (but not critical)

Special investigations 95 Strongly recommended C Important

(but not critical)

Specific clinical diagnoses:

Lateral epicondylitis (tennis elbow) Radiographs not initially indicated 95 Strongly recommended C Important
97 Recommended (but not critical)
(continued on next page)
670 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007

Table D5 (continued)
(continued)
LOE: QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading
98 Fair quality
Special investigations not indicated 94 3 D Important
95 Strongly recommended (but not critical)
99 3

Medial epicondylitis (Golfers' elbow) Radiographs not initially indicated 94 3 D Important

100 3 (but not critical)
101 3

Special investigations not indicated 95 Strongly recommended C Important

(but not critical)

Patient presentation
Adult patients with localized elbow pain Radiographs indicated and 6 Recommended C Important
after trauma additional views 40 Strongly recommended (but not critical)
57 3
102 Good quality
103 3
104 3

Special investigations GPP

Diffuse nonspecific pain in the forearm Radiographs not initially indicated 100 3 D Important
(or wrist) (but not critical)
Forearm pain after trauma Radiographs indicated 100 3 D Important
103 3 (but not critical)
104 3

Table D6. Adult Wrist and Hand Disorders

LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading
Adult patients with nontraumatic localized Radiographs not initially indicated 47 -2 D Important
wrist and hand pain symptoms 108 3 (but not critical)

General and specific indications for If radiographs are indicated and 40 Strongly recommended C Important
radiographs include additional views 41 Strongly recommended (but not critical)
49 3
100 3
104 3
106 Strongly recommended
107 3
109 Unsure
112 Fair quality

Special investigations 100 3 D Important

104 3 (but not critical)
106 Strongly recommended
110 3
111 3
113 Fair quality
114 3
Journal of Manipulative and Physiological Therapeutics Bussires et al 671
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table D6 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading
Specific clinical diagnoses:
1. Tendinopathy of the wrist Radiographs not initially indicated 94 3 D Important
115 3 (but not critical)

If radiographs are indicated 94 3 D Important

115 3 (but not critical)
116 3
117 2++
2. De Quervain's tenosynovitis (stenosing Radiographs not initially indicated 94 3 D Important
tenosynovitis or tenovaginitis) 100 3 (but not critical)
117 2++

Special investigations 104 3

3. CTS Radiographs not initially indicated 100 3 C Important
117 2++ (but not critical)
118 -2
119 3
120 High quality
121 Good quality

Special investigations 57 3 D Important

114 3 (but not critical)
123 3
124 3
4. Osteoarthritis Radiographs not initially indicated 100 3 D Important
125 3 (but not critical)
5. Inflammatory or crystal induced Radiographs indicated 40 Strongly recommended D Important
arthropathy 100 3 (but not critical)
126 3
127 3

Special investigations 40 Strongly recommended C Important

106 Strongly recommended (but not critical)
128 3
129 3
6. Rheumatoid arthritis Radiographs indicated 40 Strongly recommended C Important
100 3 (but not critical)
130 Strongly recommended
131 Recommended
132 3
133 3

Special investigations 40 Strongly recommended C Important

127 3 (but not critical)
134 3
135 3
136 3
137 High quality
138 3
143 3
7. Osteonecrosis (avascular necrosis/AVN) Radiographs indicated 104 3 C Important
144 Strongly recommended (but not critical)

Special investigations 114 3 D Important

(but not critical)
(continued on next page)
672 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007

Table D6 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading
8. Complex regional pain syndrome Radiographs indicated 144 Strongly recommended D Important
145 Unsure (but not critical)

Special investigations 145 Unsure D Important

(but not critical)
9. Suspected triangular fibrocartilage Radiographs indicated 104 3 D Important
complex* lesion (articular disc) (but not critical)

Special investigations 114 3 D Important

(but not critical)
10. Trigger finger (stenosing tenosynovitis) Radiographs not initially indicated 94 3 D Important
100 3 (but not critical)
146 3
Acute wrist trauma in the adult patient Radiographs indicated 40 Strongly recommended C Important
57 3 (but not critical)
71 Recommended
104 3
147 Unsure
148 3
149 3
150 3
151 Good quality
154 3
155 3
156 3
Additional views: 157 Unsure D Important
(a) Scaphoid fracture 158 3 (but not critical)
(b) Suspected lunate instability 159 3

Special investigations 6 Recommended C Important

40 Strongly recommended (but not critical)
149 3
160 Good quality
161 3
Acute hand and finger trauma Radiographs indicated 104 3 D Important
in the adult patient 162 3 (but not critical)
163 3

Additional views GPP

Special investigations 164 3 D Important

(but not critical)

Independent Literature Assessment and Strength of Recommendations for the Adult Spinal Disorders Guidelines
NB. Reference numbers (Ref #) correspond to those of the Spine Disorders Guidelines

Table D7. Thoracolumbar, Lumbar, and Thoracic Spine Trauma

LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grade
Adult patient with recent (b2 wk) acute Radiographs not routinely indicated 6 Recommended C Important
thoracolumbar, lumbar, or thoracic 41 -2 (but not critical)
spine trauma 43 +2
44 +2
42 Strongly recommended
Journal of Manipulative and Physiological Therapeutics Bussires et al 673
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table D7 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grade
Adult patient with thoracolumbar, lumbar, Radiographs indicated 45 2++ B Critical
or thoracic spine blunt trauma or acute 46 2+
injuries (falls, motor-vehicle accidents, 47 3
motorcycle, pedestrian, cyclists, etc) 48 Good quality
49 Not Recommended
50 4
51 3
52 2
53 2

Special investigations 42 Strongly recommended C Critical

48 Good quality
54 3
55 2+
56 3
Adult patient with post-traumatic
chest wall pain
Minor trauma Radiographs not routinely indicated 6 Recommended D Important
(but not critical)
Major trauma Radiographs indicated 6 Recommended GPP
& additional views

Special investigations 57 3 GPP Critical

245 2++
Adult patient with pelvis and sacrum Radiographs indicated and 6 Recommended D Critical
trauma (including falls with inability additional views 58 3
to bear weight) 59 3

Special investigations 6 Recommended D Critical

58 3
Coccyx trauma and coccydynia Radiographs not routinely 6 Recommended C Important
indicated and additional views 60 3 (but not critical)
61 3
62 3
63 Strongly recommended
64 2

Table D8. Cervical Spine Trauma

LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grade
Adult patient with acute neck injury and Radiographs not routinely indicated 65 2+ B Important
negative CCSR (Canadian Cervical Spine 66 High quality (but not critical)
Rule for Radiography in Alert and Stable 67 Fair quality
Trauma Patients) 68 High quality
69 3
71 3
72 3
73 3
74 Unsure
75 3
76 3
77 3
78 3
(continued on next page)
674 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007

Table D8 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grade
79 3
80 3
81 3
82 1
Adult patient with acute neck injury and Radiographs indicated 65 2+ B critical
positive CCSR (Canadian Cervical Spine 66 High quality
Rule for Radiography in Alert and 67 Fair quality
Stable Trauma Patients) 68 High quality
73 3
84 2+
85 2+
86 2+
87 2+
88 2++
89 3
93 3

Additional views 96 3 GPP

97 Poor quality
98 Fair quality

Special investigations 6 Recommended C critical

47 4
54 4
90 2+
91 3
92 2+
94 3
95 Poor quality
96 3
97 Poor quality
98 Fair quality

Table D9. Nontraumatic Lumbar Spine Disorders

LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grade
General background information
Adult patient with acute uncomplicated* Radiographs not initially indicated 42 Strongly recommended B Important
LBP (b4 wk's duration) 43 2+ (but not critical)
44 2+
101 Unsure
102 2+
103 Recommended
104 2+
105 Good quality
106 1
107 1
108 Strongly recommended
109 1
110 3
111 Strongly recommended
112 Recommended
113 1
Journal of Manipulative and Physiological Therapeutics Bussires et al 675
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table D9 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grade
114 2
115 2
116 2
117 3
118 2
119 2+
120 3
121 2
122 4
125 2
126 2
126 3
127 3
128 2
130 3
131 2
132 2
133 3
134 High quality
135 2++
136 2+
137 3
139 3
140 4
141 2
142 2
143 2
144 2
145 2
146 3
147 1
148 Unsure
149 1

Special investigations not indicated 42 Strongly recommended B Important

99 2+ (but not critical)
Adult patient with uncomplicated subacute Radiographs not initially indicated 42 Strongly recommended B Important
(4-12 wk's duration) or persistent LBP 43 2+ (but not critical)
(N12 wk's duration) AND no previous 44 2+
treatment trial 63 Strongly recommended
101 Unsure
113 1
121 2
150 2+
151 2+
152 2++
153 2+
154 1
155 3
156 3
157 1
158 2+
159 2
160 3
161 1
162 3
163 3
(continued on next page)
676 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007

Table D9 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grade
Adult patient with nontraumatic acute Radiographs not initially indicated 63 Strongly recommended B Important
LBP (b4 wk's duration) AND sciatica 101 Unsure (but not critical)
(no red flags) 157 1
158 2+
159 2
160 3
161 1
162 3
163 3

Specific clinical diagnoses:

Common causes of sciatica
(A) Suspected lumbar disc herniation: Radiographs not initially indicated 6 Recommended B Important
unless patient aged N50 or has 63 Strongly recommended (but not critical)
progressive neurologic deficits 44 2+
99 2+
157 1
163 3
164 2++
165 2+
166 2+
167 2+
168 3
169 3
170 2
(B) Suspected degenerative Radiographs indicated if patient GPP Important
spondylolithesis/lateral stenosis aged N50 or has progressive (but not critical)
neurologic deficits
(C) Suspected lumbar degenerative Radiographs indicated if patient 44 2+ C Important
spinal stenosis aged N50 or has progressive 99 2+ (but not critical)
neurologic deficits 182 2+
183 3
Suspected causes of sciatica: Special investigations not 44 2+ C Important
(A) Lumbar disc herniation initially indicated 99 2+ (but not critical)
(B) Degenerative spondylolithesis/lateral stenosis 101 Unsure
(C) Lumbar degenerative spinal stenosis 134 High quality
135 2++
166 2+
181 2
184 2+
185 Recommended
188 Good quality
189 2
Adult patient reevaluation in the absence Radiographs indicated and additional 42 Strongly recommended B Important
of expected treatment response or views not routinely indicated 43 2+ (but not critical)
worsening after 4 to 6 wk 44 2+
99 2+
101 Unsure
108 Strongly recommended
109 1
189 2
191 Unsure
192 2
193 2+
195 3
196 2
197 2+
Journal of Manipulative and Physiological Therapeutics Bussires et al 677
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table D9 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grade
198 2

Special investigations 44 2+ C Important

188 Good quality (but not critical)
199 3
200 Good quality
201 3
Adults with complicated (ie, red flag) LBP Radiographs indicated & 42 Strongly recommended B Critical
and indicators of contraindication to SMT special investigations 6 Recommended
(relative/absolute) :
Patient aged b20 and N50, particularly with 43 2+
Signs and symptoms (S&S) suggesting 44 2+
systemic disease 63 Strongly recommended
Absence of expected treatment response 99 2+
or worsening after 4-6 wk 112 Recommended
Significant activity restriction N4 wk 116 2+
Nonmechanical pain (unrelenting pain at 167 2+
rest, constant or progressive S&S) 185 Recommended
Suspected inflammatory 197 2+
spondyloarthropathies 47 3
Suspected compression fracture 203 3
Suspected neoplasia 205 3
Suspected infection 206 2+
Suspected failed surgical fusion 207 3
Progressive or painful structural deformity 208 Good quality
Elevated laboratory examination and 209 3
positive S&S 210 2
211 2
212 3
213 2
214 3
215 3

Additional views 212 3 C Important

213 2 (but not critical)

Suspected cauda equine syndrome EMERGENCY REFERRAL

WITHOUT IMAGING
If clinical findings are equivocal, 44 2+ B Critical
medical referral and specialized 99 2+
imaging recommended 112 Recommended
149 1
161 1
167 2+
182 2+
215 3
216 2
217 High quality
218 2
219 3
220 3
221 3
222 3
223 3

Suspected abdominal aortic aneurysm Referral for specialized investigations 42 Strongly recommended B Critical
224 3
225 3
226 3
(continued on next page)
678 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007

Table D9 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grade
227 3
228 3
229 3
230 Strongly recommended
231 2
232 2++
233 1
234 3
235 3
236 Unsure
237 Good quality
238 2
239 Recommended
240 Poor quality

Truncal symptoms attributed to presence or Emergency referral without imaging 224 3 GPP
worsening of aortic aneurysms including Evaluation of acute aortic 225 3
dissection/ rupture/occlusion or traumatic conditions including 226 3
aortic injury dissection/rupture/occlusion 229 3
or traumatic aortic injury 241 2
242 2
243 3

Table D10. Nontraumatic Thoracic Spine Disorders

LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grade
Adult patient with uncomplicated* Radiographs not routinely indicated 6 Recommended B Important
acute (b4 weeks duration) 38 Strongly recommended (but not critical)
thoracic spine pain 42 Strongly recommended
AND 63 Strongly recommended
Adult patient with uncomplicated* Special investigations not indicated 6 Recommended B Derived from
subacute (4-12 wk's duration) or 38 Strongly recommended the lumbar spine
persistent (N12 wk's duration) thoracic 42 Strongly recommended
spine pain and no previous treatment trial 63 Strongly recommended
Adult patient: reevaluation in the absence Radiographs indicated and 6 Recommended B Important
of expected treatment response or additional views and 38 Strongly recommended (but not critical)
worsening after 4 wk 42 Strongly recommended derived from
the lumbar spine

Special investigations indicated D

Adult patient with nontraumatic chest EMERGENCY REFERRAL 244 3 GPP critical
wall pain WITHOUT IMAGING in
life-threatening conditions

History and physical exam first need to Special investigations 245 2++ C critical
rule out life-threatening conditions
including pathologies of the heart,
lungs, and large vessels
Musculoskeletal chest wall pain Radiographs not routinely indicated 63 Strongly recommended D Important
244 3 (but not critical)
246 3
247 3
248 3
Journal of Manipulative and Physiological Therapeutics Bussires et al 679
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table D10 (continued)

(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grade
Adult patient with complicated (ie, red flag) Radiographs indicated (B) & 6 Recommended B Critical
thoracic pain and indicators of additional views 38 Strongly recommended Derived from
contraindication to SMT 42 Strongly recommended the lumbar spine
(relative/absolute): 44 2+
Patient aged b20 and N50, particularly 63 Strongly recommended
with S&S suggesting systemic disease** 111 Strongly recommended
No response to care after 4 wk 114 2
Significant activity restriction N4 wk 116 2
Nonmechanical pain (unrelenting pain at 167 2
rest, constant or progressive S&S) 185 Recommended
Persistent localized pain (N4 wk) 197 2+
Progressive or painful structural 203 3
deformity: scoliosis, kyphoscoliosis 208 Good quality
Symptoms associated with neurologic 209 3
signs in the lower extremities 210 2
Nonmechanical pain (unrelenting pain 211 2
at rest, constant or progressive S&S) 226 3
Suspected inflammatory spondyloarthropathy 249 3
Suspected neoplasia 250 3
Suspected infection 251 Good quality
Suspect failed surgical fusion 252 3
Elevated laboratory examination 253 2+
and positive S&S 275 3
In recent significant trauma (any age) 276 2
277 2+
254 Recommended
278 3
279 3
280 3

Special investigations 6 Good quality B Critical

38 Strongly recommended Derived from
42 Strongly recommended the lumbar spine
209 3
215 3
253 3
281 3
284 Good quality

Suspected acute thoracic aortic aneurysms Emergency referral without imaging 249 3 GPP critical
dissection/ rupture/occlusion or traumatic 250 3
aortic injury:

Suspected compression fracture Radiographs indicated: AP, 63 Strongly recommended B Critical

lateral thoracic 251 Good quality
252 3
253 3
276 2
277 2+
254 Recommended
278 3
279 3
280 3

Additional views 275 2+ D Critical

Special investigations 63 Strongly recommended D Critical

281 3

Suspected osteoporosis Radiographs are unreliable for 42 High quality B Important

assessment of bone mass changes 206 2+ (but not critical)
(continued on next page)
680 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007

Table D10 (continued)

(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grade
Osteoporosis predisposing risk factors and before at least a 30%-50% loss 229 3
osteoporosis clinical decision rules: 239 Recommended
& special investigations 252 3
253 3
254 Recommended
255 3
256 3
257 Recommended
258 3
259 2+
260 2+
261 2
262 2
263 3
264 1+
265 3
266 3
267 3
268 3
269 3
270 High quality
271 3
272 2
273 3
284 Good quality
289 High quality
Adult patient with nonpainful and Radiographs not routinely indicated 290 2 C Important
nonprogressive scoliosis 291 2+ (but not critical)
292 3
Adult patient with painful or Radiographs indicated, additional 23 Strongly recommended B Important
progressive scoliosis views, follow-up evaluation, repeat 229 3 (critical)
radiographs, and special 292 3
investigations 293 3
295 Fair quality
296 3
297 2
298 2
299 3
300 2++
301 3
302 2
303 3
304 2
305 2

Table D11. Nontraumatic Cervical Spine Disorders

LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grade
General background information
Adult patient with acute uncomplicated * Radiographs not routinely indicated 38 Strongly recommended C Important
neck pain (b4 wk's duration) 42 Strongly recommended (but not critical)
63 Strongly recommended
128 2
155 3
Journal of Manipulative and Physiological Therapeutics Bussires et al 681
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table D11 (continued)

(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grade
318 Unsure
319 3
320 Fair quality
321 Fair quality
322 Good quality
323 Fair quality

Special investigations not indicated 38 Strongly recommended C Important

42 Strongly recommended (but not critical)

Adult patient with nontraumatic neck pain Radiographs indicated and 38 Strongly recommended D/Consensus
AND radicular symptoms additional views 42 Strongly recommended Conflicting
229 3 evidence
(A) Suspected acute cervical disc herniation: 307 3
(B) Suspected acute cervical spondylotic 318 Unsure
radicular syndrome/lateral canal stenosis 324 Poor quality
Common S&S of acute cervicobrachial 325 Fair quality
syndrome (A and B) 326 Poor quality
327 Good quality
328 Fair quality
329 2
330 3
331 3
332 Good quality
333 2++
334 3
335 3
336 2++
337 3
338 Fair quality
339 2
340 2
341 3

Special investigations if failed 38 Strongly recommended C Important

conservative management 42 Strongly recommended (but not critical)
63 Strongly recommended

1. Adult patient with uncomplicated Radiographs indicated and 6 Recommended C Important

subacute neck pain (4-12 wk's duration) additional views 38 Strongly recommended (but not critical)
with or without arm pain* 42 Strongly recommended
2. Adult patient with persistent neck pain 63 Strongly recommended
(N 12 weeks) with or without arm pain 86 2+
3. Adult patient reevaluation in the absence 87 2+
of expected treatment response or 88 3+
worsening after 4 wk 202 3
229 3
318 Unsure
319 3
320 Fair quality
332 Good quality
342 2
343 2
344 3
345 3
346 3
347 2+
348 3
349 3
(continued on next page)
682 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007

Table D11 (continued)

(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grade
Special investigations 38 Strongly recommended B Important
42 Strongly recommended (but not critical)
63 Strongly recommended
350 2+
351 3
352 3
Adult patient with complicated (ie, red flag) Radiographs indicated and 6 Recommended B critical
neck pain and indicators of additional views 38 Strongly recommended (derived from
contraindication to SMT 42 Strongly recommended the lumbar spine)
Patient aged b20 and N50, particularly 63 Strongly recommended
with S&S suggesting systemic disease** 155 3
No response to care after 4 wk 203 3
Significant activity restriction N4 wk 211 2
Nonmechanical pain (unrelenting pain 308 3
at rest, constant or progressive S&S) 318 Unsure
Neck rigidity in the sagittal plain in the 348 3
absence of trauma (discitis, infection, 349 3
tumor, meningitis, etc) 353 3
Dysphasia 354 3
Impaired consciousness 355 3
Central nervous system S&S 356 3
(cranial nerves, pathologic reflexes,
long tract signs)
High-risk ligament laxity populations/ Special investigations 6 Recommended B critical
suspected atlantoaxial instability 38 Strongly recommended
(see details below) 42 Strongly recommended
Arm or leg pain with neck movements 63 Strongly recommended
Suspected cervical myelopathy and
radiculomyelopathy (see details bellow)
Sudden onset of acute and unusual neck
pain and/or headache (typically occipital)
with or without neurologic symptoms,
suspected cervical artery dissection
(VAD, CAD), TIA (vertebrobasilar
ischemia, carotid artery ischemia), stroke
(see details bellow)
Hx of severe trauma (see trauma section)

In addition, also consider general red flags

(usually applied to LBP) which may
apply to the cervical spine
Suspected neoplasia: c
Suspected infection (discitis,
osteomyelitis, tuberculosis)
Suspect failed surgical fusion
Progressive or painful structural deformity
Elevated laboratory examination and
positive S&S

1. Suspected atlantoaxial instability: Radiographs indicated and 6 Recommended B critical

63 Strongly recommended
229 3
325 Fair quality
348 3
357 3
358 3
359 3
360 3
361 3
362 3
Journal of Manipulative and Physiological Therapeutics Bussires et al 683
Volume 30, Number 9 Diagnostic Imaging Guidelines

Table D11 (continued)

(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grade
363 3
364 3
365 3
366 Poor quality
367 3
368 3
370 3

Additional views 6 Recommended D critical

Special investigations 63 Strongly recommended C critical

318 Unsure
371 3
372 3
2. Suspected cervical compressive Radiographs indicated, additional 63 Strongly recommended C critical
myelopathy and radiculomyelopathy views, and special investigations 318 Unsure
and cervical spondylitic myelopathy 334 3
373 3
374 3
375 3
376 1
383 3
386 3
3. Suspected cervical artery dissection EMERGENCY REFERRAL 308 3 GPP critical
(VAD, CAD), TIA, vertebrobasilar WITHOUT IMAGING 318 Unsure
ischemia, carotid artery ischemia, stroke 354 3
387 3
382 3
390 2++
391 2
292 2
393 2
394 3
395 3
397 3
400 4
402 3
388 3

Special investigations 245 2++ C critical

409 3
318 Unsure
354 3
403 2
404 3
405 3
406 3
407 3
408 3
409 3
414 2+
415 3
416 2
417 3
418 3
419 3
420 3
421 3
422 3
* Findings of The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders were not published at the time of
publication of these guidelines. Recommendations 1. and 2. are expected to be changed to Not initially indicated' in a future update.