Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
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 Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007
greater precision in diagnosing and treating patients. Despite 6. act as focus for quality control, including audit;
the advent of new and advanced techniques, conventional 7. highlight shortcomings of existing literature and
radiography remains the cornerstone of diagnostic imaging suggest appropriate future research.
for patients presenting with regional musculoskeletal pain,
especially for acute fractures of the extremities or for These guidelines have been created to improve patient
suspected neoplasia.5-7 However, evidence of overuse, care by detailing the appropriate information gathering and
underuse, and misuse of imaging services has been decision-making processes involved in the diagnostic
emphasized in the literature.8-13 In the US alone, more imaging of musculoskeletal care.
than $500 million are spent each year on lumbar spine The initial impetus for this project occurred in 2003 when
radiography14 and in Ontario, Canada, the Ontario Health the Council on Chiropractic Education in Canada (CCEC)
Insurance Plan spends more than $16 million annually on requested a revision of the diagnostic imaging guidelines
physician-requested imaging for LBP.15 Such costs are used at the chiropractic teaching clinic of l'Universit du
unlikely to outweigh the effect of small reported increases in Qubec Trois-Rivires (UQTR). CCEC recommended
patient satisfaction, especially when considering potential incorporating protocols that were centered on the clinical
risks of ionizing radiation exposure and lack of demonstrable presentation of patients. We first identified the need for an
benefits to patients.16-18 It should be noted that this extensive literature review to propose recommendations on
significant rise in expenditure has recently motivated the the use of imaging studies for musculoskeletal disorders. The
US Congress to reduce payments for such imaging review began with a search for the relative risks and benefits
services.19 Several factors contributing to escalating imaging of imaging, clinical indications for imaging of the spine and
costs have been identified: the aging population; the practice extremities, knowledge of existing guidelines, and consid-
of defensive medicine; overuse of diagnostic imaging; self- eration of potential barriers to dissemination and implemen-
referral abuses; duplicative studies; consumer demand; and tation strategies of any such guidelines. We set out to initially
advanced technology. Research has shown many of these answer the following 10 questions:
costs could be decreased if the referring physician commu-
nity had a solid understanding of the appropriate ordering of 1. Does ionizing radiation from radiography carry a
diagnostic imaging studies and the risks related to radiation potential risk to patients?
exposure.20 2. What is the frequency of conventional radiography
There is an urgent need throughout the health care use?
professions to develop practice guidelines. Brown21 sum- 3. What are the associated costs associated with the use of
marized the characteristics of quality care as (a) patient conventional radiography?
centered, (b) scientifically based, (c) population outcomes 4. What factors influence practitioners in determining the
based, (d) refined through quality improvement and bench- need for radiographs in adults?
marking, (e) individualized to each patient, and (f) 5. What is the evidence supporting the recommendations
compatible with system policies and resources. Government of various national and international practice guidelines
agencies, professional accreditation agencies, and public for radiography utilization for musculoskeletal condi-
institutional policies are now demanding that all health tions for adults?
professions develop practice guidelines that may be used to 6. What is the clinical usefulness of spine radiography in
evaluate what are deemed reasonable and appropriate biomechanical analysis, including spinal curvatures
indications for care. In addition, recent recommendations and scoliosis, especially with respect to the effects on
of the Institute for Alternative Futures for the chiropractic spinal degeneration?
profession include accelerating research activity, striving for 7. What are the indicators of potentially serious pathology
high standards of practice, engaging in consumer-driven involving the musculoskeletal system (red flags) in
health models, engaging integration and collaboration with adults?
mainstream health care, achieving greater professional unity, 8. What is the prevalence of congenital anomalies that are
and meaningfully contributing to the public health agenda.22 considered contra-indications for high velocity, low
Evidence-based diagnostic imaging practice guidelines amplitude manual spinal adjustment or manipulation?
facilitate the implementation of such recommendations.23,24 Furthermore, what is the associated complication rate
The purposes of guidelines are to:25 of these maneuvers in patients with such anomalies?
9. What are the clinical indicators leading to optimal
1. describe appropriate care based on the best available investigation and management of osteoporosis?
scientific evidence and broad consensus; 10. What are the appropriate clinical findings indicating
2. reduce inappropriate variation in practice; radiographic evaluation of the extremities in adults?
3. provide a more rational basis for referral;
4. provide a focus for continuing education; Sensitivity, specificity, reliability, validity, predictive
5. promote efficient use of resources; values, and likelihood ratios were considered when available
Journal of Manipulative and Physiological Therapeutics Bussires et al 619
Volume 30, Number 9 Diagnostic Imaging Guidelines
and appropriate. Two hundred and fifty-seven citations were of such clinical indicators, simple decisions based on
retrieved and synthesized by the principal investigator (AB) separation into articular vs nonarticular disorders and on
and presented in a French language narrative review to the duration of the patient complaint (acute, subacute,
UQTR clinicians in June 2003. Relevant findings were also persistent/chronic) are favored by most recent expert
presented at a research conference.26 consensus statements.30,31
This narrative review helped identify the need for Clinical presentations are divided accordingly throughout
development of diagnostic imaging guidelines for muscu- the guidelines. Recommendations for radiography (indi-
loskeletal disorders. Although several answers to the cated, not initially indicated, not routinely indicated) appear
above 10 questions are integrated within the guidelines, for every clinical presentation throughout the guidelines.
the routine use of conventional radiography and the Because professional self-regulation and knowledge about
consequent risks of low-dose ionizing radiation exposure the clinical usefulness of specialized diagnostic modalities
remain significantly contentious and will be further are necessary for all primary health care professionals,
addressed in a separate article. Proponents of the routine recommendations for further imaging studies are therefore
use of conventional radiography offer the following discussed for each condition. 32,33 In some instances,
justifications for that practice:27 laboratory assessment is recommended.
Recent evidence suggests that implementation strategies
1. To screen for and prevent rare possible complications of imaging guidelines can assist in achieving a sustained
associated with spinal manipulative therapy; reduction in the number of radiographic examinations
2. For nonclinical motives, including patient preference obtained of the cervical spine, lumbar spine, and knees.34
and satisfaction; medicolegal concerns; political influ- Application of practical, highly sensitive, and reliable
ence and administrative factors; decision rules for cervical spine, shoulder, elbow, wrist,
3. For postural and biomechanical analysis of spinal knee, ankle, and foot trauma has a potential to reduce the use
disorders both before and during the provision of of radiography by a factor of 16% to 50% in emergency
manual therapy; departments and sports injury clinics alone.35-46 Although
4. To provide patients with a more accurate prognosis; the authors are uncertain of precise chiropractic utilization
5. Because they consider the effects of ionizing radiation rates in these cases, it is likely that utilization rates in
exposure on human health to be negligible. chiropractic parallel those in general medical practice
because a substantial portion of chiropractic patients present
The proposed diagnostic imaging practice guidelines with spine and extremity disorders or have a history of
represent a shift to a more evidence-based approach and are cervical spine trauma.47 Although targeting a different
supported by more than 680 primary and secondary citations. population (generally not as acutely injured), application of
When available, meta-analyses and systematic reviews, decision rules in private practice should also help reduce the
randomized clinical trials (RCTs), nonrandomized studies, use of radiographic studies. For example, in acute LBP in
cohort and case-control studies, nonexperimental studies, adults, the age criterion proposed in earlier guidelines (N50
and existing high-quality clinical guidelines were used years of age) as well as the tendency to order radiographs in
to propose recommendations for various patient presenta- patients with symptom duration of less than 4 weeks has low
tions (specific conditions) and comments supporting specificity and substantially increased utilization.12,48 One
those recommendations. authority now recommends obtaining lumbar spine radio-
The guidelines pertain only to adult patients and are graphs in patients older than 65 years rather than 50 and
divided into 3 parts. Part I specifically addresses lower waiting up to 7 weeks to obtain radiographs in patients with
extremity disorders; part II addresses upper extremity an untreated first episode of LBP.49
disorders; and part III addresses spinal disorders. All 3 The aim in conducting an evidence review is to
parts are condition specific (symptom-based), a feature that facilitate the integration of the best available evidence
should make these guidelines practical, user-friendly, and with clinical expertise and the values and beliefs of
efficacious for practitioners.28 Because accurate history and patients. Although these proposed guidelines are more
examination are crucial initial steps in the diagnosis of any restrictive and likely more cost-efficient, practitioners are
musculoskeletal disorder, specific clinical criteria are provided with the necessary information to allow for
emphasized for most every condition. The initial triage of significant flexibility in decision making. As with all
patients with LBP is a constant recommendation of various guidelines, clinical judgment and clinician experience must
clinical guidelines and we believe it to be equally applicable be used in all cases. It must also be emphasized that
to the initial management of other regional painful clinical practice guidelines (CPGs) are intended to assist,
conditions.29,30 One major objective of the initial triage is not replace, clinicians in their decision-making processes.
to determine the presence of clinical indicators (red flags) for Guidelines aid in the application of selective diagnostic
serious pathologies requiring diagnostic imaging, appro- tools and therapeutic approaches for specific clinical
priate referral, or urgent surgical intervention. In the absence presentations while considering patient preference.50
620 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007
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.
rotator cuff, adhesive capsulitis, osteoarthritis, acro- Table 1. Classification used by the European Commission (2001)51
mioclavicular joint, physical examination. Grade Type of evidence a
5. Adult elbow pain: acute injury, lateral and medial A RCTs, meta-analysis, systematic reviews; or
epicondylitis, forearm (or wrist) pain and trauma, B Robust experimental or observational studies; or
physical examination. C Other evidence where the advice relies on expert opinion and
6. Adult wrist and hand pain: acute injury/localized has the endorsement of respected authorities
a
trauma (wrist, hand, finger), forearm/wrist pain, NHS Executive. Clinical Guidelines: Using Clinical Guidelines to
tenosynovitis, DeQuervain's disease, trigger finger, Improve Patient Care within the NHS (96CC0001). NHS Executive,
carpal tunnel syndrome (CTS), osteoarthritis, arthro- Leeds, 1996.
pathy (inflammatory, crystal, infection), rheumatoid
arthritis, physical examination. US Agency for Healthcare Research and Quality led to the
7. Adult spinal trauma/injury: lumbar, thoracolumbar, development of new tools to assess available literature.52
thoracic, cervical spine, whiplash, chest wall (thorax), With the objective of independently assessing the level of
pelvis, sacrum, coccyx, coccydynia. evidence of citations listed in the guidelines and considering
8. Adult lumbar spine disorders: acute, subacute, and the recently developed assessment tools, 5 literature
chronic LBP, nontraumatic, uncomplicated, sciatica, reviewers (licensed practitioners, 4 with specialized training
radicular pain, stenosis (lateral, central), spondylolith- in research methods) were invited to review the citations of
esis, inflammatory spondyloarthropathy, fracture, neo- the spine and extremity imaging guidelines. A number of
plasia, infection, structural deformity, surgical fusion, citations were assessed by at least 2 evaluators to compare
laboratory examination, cauda equina syndrome, abdom- the level of agreement between evaluators. In cases of
inal aortic (aneurysm, dissection, condition, risk factors), disagreement, the research team reached a decision and
complication, epidemiology, physical examination. classified the citation.
9. Adult thoracic spine disorders: acute, subacute, The methodological quality of all studies that were included
chronic, osteoporosis (collapse, compression, fracture, in the review was assessed by means of a methodological
risk factors, evaluation, monitoring), scoliosis, chest quality assessment list. Participants were asked to complete an
wall pain, aortic dissection, complication, epidemiol- evidence extraction table (Excel spreadsheet), provided at the
ogy, physical examination. outset of the review, with a list of all citations included in the
10. Adult cervical spine disorders: acute, subacute, chronic, spinal and extremity disorders guidelines. Requested informa-
nontraumatic, radicular, neck and arm pain, cervical tion included summaries of study design; study objective in
myelopathy, radiculomyelopathy, ligament laxity, atlan- brief; type of analysis; methods (including population studied,
toaxial instability, congenital anomaly, cervical artery and follow-up period); study results/evidence provided; scores
dissection/condition (vertebral/carotid artery, transient for the scoring instruments (QUADAS, AGREE, and
ischemic attack [TIA], stroke, risk factors, past trauma), SPREAD); significant biases.
complication, epidemiology, physical examination. Three methodological scoring instruments were used, as
described below.
When available, systematic reviews and meta-analyses,
RCTs, nonrandomized studies, observational studies (cohort 1. The QUADAS instrument53 of the Health Technology
and case-controlled studies), nonexperimental (nonanalytic) Assessment Diagnostic Evaluation is an evidence-based
studies, and existing high-quality clinical guidelines took assessment tool to evaluate the quality of primary studies
precedence over case studies, case series, or opinion for of diagnostic accuracy. The tool, derived from 3
inclusion in the study. Articles were excluded from the systematic reviews, does not include a quality score.
recommendations if they were not available in English or Instead, it is structured as a list of 14 questions that should
French or could not be translated, if they were published be answered Yes, No, or unclear (Fig 2). Although
before 1980 (except for some rare classic papers), and if they some minor modifications have been proposed,54,55
specifically focused on thermography, electrodiagnostic QUADAS appears useful for highlighting the strengths
studies, intervention, nonmusculoskeletal disorders, or on and weaknesses of existing diagnostic accuracy studies.
children. Details of the literature review (2003-2006) are Effects of a negative response to item 3 (quality of the
available upon request. reference standard), item 5 (verification bias), items 10
and 11 (blinded interpretation of index test and reference
Phase 2: Independent Literature Assessment. Early phases of this standard), and item 14 (withdrawals) are assumed to be
guideline project used the European Commission classifica- particularly important and thus are identified as critical.
tion (2001) 51 to classify grade of recommendations Therefore, the following scoring system was used:
(Table 1). However, several new instruments have been High quality study = all 5 critical items + at least 3
proposed to evaluate scientific literature. Weaknesses other yes items = 8 yes or more
identified in the grading system initially proposed by the 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 4. Classification based on SPREAD validated methodological Table 2. Typical effective ionized radiation dose for common
criteria57 imaging procedures
1++ High-quality meta-analyses without heterogeneity, Typical effective
systematic reviews of RCTs each with small CI, or Class dose (mSv) Examples
RCTs with very small CI and/or very small and
1+ Well-conducted meta-analyses without clinically
0 0 Ultrasound, magnetic resonance imaging
relevant heterogeneity, systematic reviews of RCTs, or
RCTs with small CI and/or small and
I b1 Radiograph: cervical and thoracic
1 Meta-analyses with clinically relevant heterogeneity,
spine, extremities, pelvis, and lungs
systematic reviews of RCTs with large CI, or RCTs with
large CI and/or or
II 1-5 Lumbar spine radiograph, bone scan,
2++ High-quality systematic reviews of case-control or
cervical spine CT
cohort studies. High-quality case-control or cohort
studies with very small CI and/or very small and
III 5-10 Chest and abdomen CT
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 Classification of the typical effective dose of ionizing radiation from
or common imaging procedures. Adapted from: European Commission.
3 Nonanalytic studies, eg, case reports, case series Radiation protection 118. Referral guidelines for imaging in conjunction
4 Expert opinion with the UK Royal College of Radiologists; Italy 2001. p 21.
(minus) Meta-analyses with clinically relevant heterogeneity;
systematic reviews of trials with large confidence assessment (phase 2) included citations retrieved during the
intervals; trials with large CIs, and/or large and/or initial literature search, the 2 literature updates, and articles
Revised grading system for recommendations in evidence-based provided by Delphi panelists and participants in the second
guidelines58 external review phase.
This tool has been developed to grade recommendations according to
the strength of available scientific evidence (level A to D) Phase 3: Guideline Development: Specific Recommendations. Based on
Grades of recommendation the literature review, the primary author (AB), with the
A At least one meta-analysis, systematic review or RCT
rated as 1++, and directly applicable to the target assistance of a staff chiropractic radiologist, composed the
population; or a systematic review of RCTs or a body of first draft of a diagnostic imaging practice guideline for
evidence consisting principally of studies rated as 1+, chiropractic interns and clinicians.
directly applicable to the target population and To simplify decision making about radiograph utilization,
demonstrating overall consistency of results
the proposed guidelines are based on common clinical
B A body of evidence including studies rated as 2++,
directly applicable to the target population and presentations of conditions affecting the spine, the lower, and
demonstrating overall consistency of results; or upper extremities. The Referral Guidelines for Imaging
extrapolated evidence from studies rated as 1++ or 1+ (radiation protection 118) coordinated by the European
C A body of evidence including studies rated as 2+, Commission in conjunction with the UK Royal College of
directly applicable to the target population and Radiologists (2001)51 served as a template for the present
demonstrating overall consistency of results; or
extrapolated evidence from studies rated as 2++** recommendations. For those guidelines, evidence gathering,
D Evidence level 3 or 4; or extrapolated evidence from synthesis, and grading were undertaken by a large group of
studies rated as 2+; or evidences from trials classified as radiologists across the European Union. Classification of
(minus) regardless of the level evidence levels was translated into grades of recommenda-
Good practice Recommended best practice based on the clinical tions based on the system developed by the US Department of
point experience of the guideline development group,
without research evidence
Health and Human Services, Agency for Health Care Policy
and Research (1993). As a means of comparison, typical
This tool aims to evaluate the scientific evidence according to prespecified
levels of certainty (1++ to 4).
effective ionizing radiation doses delivered to patients for
In this study, Good Practice Point also represents consensus of the Delphi common imaging procedures are reported in Table 2.
panel. CI indicates confidence intervals. For every clinical presentation throughout the guidelines,
one of 4 recommendations appears. When appropriate, the
to give a more comprehensive evaluation of the proposed recommendation is accompanied by the level of
available evidence. This tool aims to evaluate the evidence and pertinent comments. The recommendations are
scientific evidence according to prespecified levels of as follows:
certainty (1++ to 4) (Fig 4.).
(a) Radiographs indicated. This recommendation indicates
To further assist in their appraisal, the literature reviewers that radiographs are indicated. Further suggestions for
were provided with a checklist for the appraisal of specific radiographic projections are also suggested.
epidemiologic studies, literature review articles, and sys- (b) Radiographs not initially indicated. This recommen-
tematic reviews.59 It should be noted that the literature dation indicates that a trial of conservative therapy
624 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007
should be attempted first. Radiographs should be Web to Delphi panelists for consideration during the
considered, however, if patients demonstrate no evaluation of recommendations for spine disorders. Phase
significant benefit, generally after 4 weeks of therapy. 5 was overseen in its entirety by 2 Delphi process expert
(c) Radiographs not routinely indicated. This recommen- advisors (one from the USA and one from the UK).
dation indicates that radiographs do not generally Although face-to-face discussions between panelists are
provide significant information and are not likely to preferable to reach consensus, limitations of time and
alter the therapeutic intervention. prohibitive costs precluded using this strategy. As an
(d) Special investigations. This recommendation alternative, we incorporated electronic communication
indicates that further advanced imaging procedures technology. By accessing a restricted (password protected)
are recommended. website, experts were asked to independently evaluate the
proposed guidelines and to provide recommendations aimed
Phase 4: First External Review. The guidelines were then at forming a consensus opinion. Each scenario was
reviewed by several experts in the Spring of 2003, including accompanied by a binary type answer: agree-disagree. In
3 chiropractic radiologists from different academic institu- case of disagreement with a particular recommendation,
tions; 2 chiropractors specializing in epidemiology; and one panelists were instructed to provide comments and sugges-
practicing chiropractor who also possessed an MSc degree. tions supported by relevant references. Submission dead-
The guidelines, with input from the first 6 reviewers, were lines were regularly announced by e-mail and a regularly
then sent for external review to 6 additional chiropractors updated schedule served to inform panelists of completed
holding a diplomate or fellowship in either radiology or and upcoming sections. At the conclusion of each first
clinical sciences. Each reviewer independently assessed the round, results were made available to all panelists and an
guidelines and, where appropriate, made suggestions and updated version of the guideline was posted in PDF format
comments that were incorporated. on the website before the second round began. A minimum
of 75% agreement was established as necessary to reach
Phase 5: Expert Consensus Panel. Considering the overall low consensus for all recommendations. It was further decided
quality of scientific studies available on diagnostic imaging, to restrict the Delphi process to 2 rounds as the initial
a large Delphi consensus panel was invited to consider the guidelines were already based upon a careful review of the
proposed recommendations. When meaningful clinical trials literature. Two rounds were determined to be sufficient to
are unavailable, development of recommendations by achieve adequate consensus and served to minimize the
consensus opinion is considered an acceptable option.60-62 workload of participants. Consensus was judged as strong
Delphi surveys using large groups show greater within and (N85% of panel members), moderate (50%-84%), or low
between reliability.63 Phase 5 of this project involved a (33%-49%).65
modified Delphi panel composed of a group of international
experts on the topic of musculoskeletal disorders in clinical Phase 6: Public Website. Results of phase 5 were posted on a
chiropractic, chiropractic radiology, and chiropractic website accessible to chiropractors worldwide. Advance
research. Three sources of information were used to identify announcements were published in the World Federation of
experts: publication record, membership, and involvement in Chiropractic Quarterly World Report and Dynamic
relevant organizations such as the American Chiropractic Chiropractic publications informing chiropractors of the
College of Radiology, and recommendations from research- nature of the project and inviting them to access the
ers and educators in the field. In addition, chiropractic website and to offer comments and suggestions on
college presidents (all members of the Association of proposed recommendations. Professional trade organiza-
Chiropractic Colleges) were asked to provide the names of tions invited to nominate members to review the proposed
3 faculty members from their respective institutions: one diagnostic imaging guidelines included the following:
chiropractic radiologist, one clinical science specialist, and World Federation of Chiropractic, Canadian Chiropractic
one researcher. Among the several named techniques, Association (CCA), American Chiropractic Association
authoritative figures from Chiropractic Biophysics technique (ACA), International Chiropractic Association (ICA), State
(CBP) protocols and Gonstead technique64 were also invited and Provincial chiropractic associations, European and
to participate. Our research team determined that the expert Asian chiropractic associations.
group selected offers a diverse range of views and adequately Every section of the guideline was posted for considera-
represents the profession. Recognizing the existence of a tion for a period of 2 months. The objectives of phase 6
significant body of literature on conventional radiography were to:
for biomechanical analysis, results of the initial literature
review for question 6 (What is the clinical usefulness of 1. inform the profession of the work currently being done
spine radiography in biomechanical analysis, including in the field of chiropractic imaging guidelines;
spinal curvatures and scoliosis, especially with respect to 2. help determine if these guidelines appear reasonable
the effects on spinal degeneration?) were provided on the and user friendly for practitioners;
Journal of Manipulative and Physiological Therapeutics Bussires et al 625
Volume 30, Number 9 Diagnostic Imaging Guidelines
3. obtain comments and input from practitioners to Phase 8: Final Draft of the Diagnostic Imaging Guidelines and Grading
improve reliability; of Evidence. The research team considered all suggestions and
4. facilitate future implementation strategies by improv- comments received upon completion of the public website
ing ownership of the guidelines. (phase 6) and second external review (phase 7). In addition, a
member of the public with specialized training in research
Practitioners were invited to comment on their was asked to review the methodology and to consider all
perceived level of confidence and comfort with using the recommendations from the 3 recently developed adult
proposed Delphi results of the diagnostic imaging guide- musculoskeletal diagnostic imaging guidelines. As a patient
lines in their individual practices, as measured by an representative, this person was asked how, in general,
appropriateness (Likert) scale. Participants provided a proposed recommendations fit with public interest and
rating from 1 (strongly disagree) to 9 (strongly agree). patient protection.
They were also encouraged to provide comments with
pertinent rationale and references to support their disagree- Grading of Evidence. All recommendations are graded
ments with any of the recommendations. according to the strength of the evidence. The investigators
of this project formally met to assign a grade to each of the
Phase 7: Second External Review. To comprehensively involve recommendations, indicating the strength of available
all stakeholders and to guarantee editorial independence, a scientific evidence (level A to D) for spinal and extremity
second external review was initiated. To achieve these disorders. The criteria for the grades are outlined by the
goals, chiropractic specialists and 2 groups of medical SPREAD tool (Fig 4). The strength of evidence was assessed
experts on musculoskeletal disorders were invited to by evaluating consistency of the findings across studies and
provide comments and suggestions on the Delphi consensus the quality of the studies.
imaging guidelines (phase 5). Chiropractic specialists in These aspects were judged and summarized based on the
Canada were briefly introduced to the study objectives and following statements:
methodology by the principal investigator (AB) on
November 17, 2006, at a meeting organized by the Systematic reviews and meta-analyses, RCTs, prospec-
CFCRB during the Canadian National Convention. Cana- tive cohort studies, and high-quality clinical guidelines
da's chiropractic specialists formally received an invitation provide better evidence than nonrandomized studies,
to participate in the External Review (phase 7) by mail and case-controlled studies, nonanalytic studies and text-
e-mail. American chiropractic specialists were notified and books, case reports, or opinion.
invited to participate by mail and e-mail to addresses that Studies with a score greater than 2+ (SPREAD) are
were retrievable. Guidelines were made accessible on a new rated of high or good quality (QUADAS), or with more
website for a period of 10 weeks so that elected than 50% of the maximum attainable score in each
representatives of the following groups could evaluate domain (strongly recommended with AGREE) con-
recommendations on a specific data collecting form as tribute more to the conclusions than studies with
measured by an appropriateness (Likert) scale. Participants lower scores.
provided a rating from 1 (least appropriate/strongly At least 75% of the studies have to report a similar
disagree) to 9 (most appropriate/strongly agree), with a trend to conclude that the results across studies
separate option for don't know. are consistent.
Chiropractic specialties included the following: College of
Chiropractic Radiology, Canada (FCCR); American Chir- Members of the team had to reach consensus on the
opractic College of Radiology (ACCR); College of Chir- grades administered. Where the evidence is insufficient and
opractic Clinical Sciences (Canada) (FCCS); College of recommendations are based on consensus opinion alone, this
Chiropractic Sport Sciences (Canada) (FCCSS); College is indicated as a Good Practice Point. Recommendations
of Chiropractic Orthopedists (Canada) (FCCOC); College of are also accompanied by a suggestion of critical or
Chiropractic Rehabilitation Sciences (CCRS); American important (but not critical). Critical is defined as a life-
College of Chiropractic Orthopedists (ACCO); College of threatening condition or as a situation in which patients are at
Chiropractic Rehabilitation Sciences (CCRS); American risk of serious complications if they are not referred for
College of Chiropractic Council on Neurology (NOCA/ACCN). appropriate care in a timely manner.
Medical specialties included 2 groups of medical experts,
one from Canada and the other from the USA, with expertise Phase 9: Dissemination------Implementation. The complex and
in musculoskeletal disorders (neurology, neurosurgery, challenging issue of implementation and utilization of
orthopedics, physical medicine and sports medicine specia- CPGs also needs to be considered. To prevent duplication
lists, osteopathic medicine, and radiology). Names of experts and reduce costs, it has been proposed that results from the
were provided by personal contacts of panelists involved in Delphi panel be shared with American and Canadian
this project and members of the research team. chiropractic national guideline development committees
626 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007
and/or task forces. The CCA and the Canadian Federation of search. The literature updates and the inclusion of articles
Chiropractic Licensing Board (CCA/CFCRB task force submitted up to the second external review (phase 7) resulted
overseeing the development of clinical chiropractic practice in a total of 682 citations for the 3 diagnostic imaging
guidelines) were sent copies of these guidelines (phase 4) for guidelines (lower extremity disorders = 174 citations; upper
consideration in the fall of 2004. The Council for extremity disorders = 126 citations; spine disorders = 382
Chiropractic Guidelines and Practice Parameters (CCGPP) citations). Most citations originated from peer-reviewed
in the USA will also be consulted to consider the possibility biomedical journals published in the last decade.
of integrating sections of the diagnostic imaging guidelines
as they reach completion. We encourage researchers to apply Results of The Literature Review of Clinical Indications for Extremity and
the AGREE instrument or other similar instruments to Spine Disorders
evaluate the strength of the evidence as well as the validity of Citations Supporting Proposed Recommendations for Lower
the consensus document. Extremity Disorders. Eighty-five articles related to upper
Implementation of the final version of the guidelines and lower extremity disorders were included in the initial draft
will require involvement of national, provincial, and of the guideline between 2003 and 2004. Meta-analysis and
state organizations. In addition to publishing these in systematic reviews (4), clinical trials (35), existing clinical
this peer-reviewed journal, several other strategies are guidelines (15), review articles (28), and textbooks (3) were
being considered: used to propose recommendations and/or relevant comments.
A literature update was conducted in 2005 resulting in the
1. Registering with the National Guideline Clearinghouse; addition of 32 new studies. Overall, 117 articles pertaining to
2. Posting of the electronic document on various websites adult extremity disorders were included in this draft of the
such as those of the malpractice insurance carriers, extremity guidelines. Meta-analysis and systematic reviews
chiropractic colleges, and their respective outpatient (5), clinical trials (43), existing clinical guidelines (28), review
chiropractic clinics; articles (39), and textbooks (4) were used. Recommendations
3. Educational intervention strategies: and/or relevant comments were reviewed accordingly. A final
a. e-learning: literature update just before the launching of the lower
i. Internet platform (e-learning) for distance learn- extremity disorders Delphi process (phase 5) in February
ing (CE) including case-based learning objects 2006 and references provided by Delphi panelists (February-
and examination tests April 2006) for the lower extremity guideline alone resulted in
ii. Internet platform (e-learning) for chiropractic the addition of 91 new references. Meta-analyses and
colleges including case-based learning objects systematic reviews (0), clinical studies (40), existing clinical
and examination tests guidelines (2), review articles (30), and textbooks (19) were
b. Conducting community pilot studies; mainly added to clinical presentations and comments for
4. The use of referral guidelines, reinforced by request special imaging recommendations (Table 3).
checking and clinical management algorithms;
5. Promotion by national, provincial, and state organizations; Citations Supporting Proposed Recommendations for
6. Support from the World Federation of Chiropractic and Upper Extremity Disorders. Eighty-five articles related to
national chiropractic guideline development committees; adult upper and lower extremity disorders were included in
7. Presentation of results at various conferences, meet- the initial draft of the guideline between 2003 and 2004.
ings, symposia, and seminars.66-69 Meta-analysis and systematic reviews (4), clinical trials (35),
8. Plain language summary for patients. 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
RESULTS AND DISCUSSION February 2006 resulting in the addition of 32 new studies.
Overall, 52 citations pertaining to adult upper extremity
For clarity, the results, discussion, and related tables are
disorders were included in this draft of the guidelines. Meta-
presented in sequence. These include (A) the literature
search and independent literature assessments (phases 1-2), analysis and systematic reviews (2), clinical studies (17),
existing clinical guidelines (13), review articles (18), and
(B) the Delphi panelconsensus opinion (phase 5), (C) the
textbooks (2) were used. A final literature update just before
public consultation (phase 6), and (D) the second external
the launching of the upper extremity disorders Delphi
review (phase 7).
process (phase 5) in August 2006 and references provided
by Delphi panelists (October-November 2006) for the upper
Literature Search and Independent Literature Assessment (Phases 1-2) extremity guideline alone resulted in the addition of 74 new
More than 300 original scientific citations published in citations. Meta-analyses and systematic reviews (1), clinical
peer-reviewed biomedical journals and 3 textbooks were studies (39), existing clinical guidelines (7), review articles
selected by one investigator (AB) during the initial literature (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
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
85 52 74 126
presentations and comments for special imaging recommen- citations: meta-analyses (3), systematic reviews (6), clinical
dations (Table 4). Recommendations and/or relevant com- studies (107), existing clinical guidelines (6), review articles
ments were reviewed accordingly. (40), and textbooks (7) were mainly added to the clinical
presentations and to the comments related to special imaging
Citations Supporting Proposed Recommendations for recommendations. Overall, a total of 382 citations were
Spinal Disorders. One hundred and seventy-eight citations included in the lumbar, thoracic, and cervical spinal disorder
pertaining to adult spinal disorders were included in the guidelines (Table 5).
initial draft of the guideline (December 2003). Meta-analyses The number of citations per individual category is as
(0), systematic reviews (6), clinical studies (92), existing follows: spinal trauma (41), nontraumatic lumbar spine
clinical guidelines (9), review articles (51), textbooks (18), (128), nontraumatic thoracic spine (77), and nontraumatic
and commentaries or letters (2) were used to propose cervical spine (108). The discrepancy between the total
recommendations, relevant comments, and descriptive number of citations included in the spinal disorder
patient presentations. A literature update conducted in guidelines (382 citations) and the addition of individual
September 2005 resulted in the inclusion of 35 new citations: category citations (354) is related to references included as
systematic reviews (2), clinical studies (20), existing clinical general background information at the beginning of some
guidelines (4), review articles (3), textbooks (4), and sections. These references do not specifically support
commentaries (2). A final literature update just before the proposed recommendations.
launching of the spine disorders Delphi process (phase 5) in
April 2006 and references provided by Delphi panelists Results from the Independent Literature Assessment. Results from
between April and July 2006 for the lumbar, thoracic, and the independent literature assessment (study quality and
cervical spine disorders resulted in the addition of 169 new 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)
doi:10.1016/j.jmpt.2007.10.003). Except for citations found and the submission deadlines for each round are
in the background information and those providing insights presented in Table 6. As each category was completed,
on the management of certain conditions, all citations were the results were posted on the website in a PDF file
independently assessed by a team of reviewers. The accessible to all panelists. Changes were highlighted in
majority of review articles are narrative rather than the text for clarity.
systematic. Narrative reviews generally are comprehensive Percentage agreement for each recommendation, includ-
and cover a wide range of issues within a given topic, but ing patient presentation and pertinent comments for round 1
they do not necessarily state or follow stringent rules and round 2 (where applicable) of adult hip, knee, and ankle
regarding the search for evidence. Because narrative and foot disorders, is tabulated in Tables 7 to 9.
reviews are prone to several biases (subjective, no explicit
methods for searching literature or reporting and cannot be Hip Disorders. Sixty-six panelists completed the hip dis-
replicated), these study designs were rated as a 3 (level of orders section. Results of round 1 were forwarded to all panelists
evidence). Textbooks were also assigned a level 3 for the to consider comments, and new references were provided.
same reasons. Although more than 75% agreement was reached for all
14 recommendations, 5 new recommendations were proposed
Delphi PanelConsensus Opinion (Phase 5) for the second round owing to the proposal of significant
The lower extremity, upper extremity, and spine disorders changes. Forty-nine panelists returned round 2 (Table 7).
guidelines were evaluated using a modified Delphi panel
composed of an international group of experts on the topic of Knee Disorders. Fifty-four panelists completed the only
musculoskeletal disorders in clinical chiropractic, chiroprac- round necessary to reach consensus for all 9 recommenda-
tic radiology, and chiropractic research. Of the 145 tions (Table 8). Percentage agreement ranged between 83%
participants invited to participate in the Delphi panel, 44 and 96%.
were not included because they either could not be reached
or they did not reply to invitations. Ten others declined to Ankle and foot disorders. For the ankle and foot
participate, and 7 eventually withdrew from the Delphi panel disorders section, 53 panelists completed all 26 recom-
for personal reasons. Overall, 76 experts agreed to return a mendations. Based on suggestions proposed in the first
confidential agreement to participate. Only responses from round, 6 new recommendations were proposed for the
those having returned a confidential agreement were second round. Forty-eight panelists participated in round 2
included to participate in the Delphi panel. (Table 9). Percentage agreement ranged between 87% and
100% for all recommendations accepted. Table 10 shows
Part 1: Lower Extremity Disorders (Phase 5). Sixty-six panelists the breakdown of panelists completing the lower extre-
representing 20 chiropractic institutions actively partici- mity disorders sections.
pated in the first round. Expert panel composition
(academic, clinicians, and researchers, and a mixture of Part 2: Upper Extremity Disorders (Phase 5). Expert panel
those) for each category evaluated is provided in Figure 5, 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 Elbow Disorders. Forty-eight panelists completed the only
Figure 6, and the submission deadlines for each round are round necessary to reach consensus, reaching between 92%
presented in Table 11. For every category completed, final and 98% agreement for all 6 recommendations. A new
results were posted on the website in a PDF file accessible to recommendation for forearm pain after trauma was added
all panelists. Changes were highlighted in the text for clarity. before the final consultation of the upper extremity disorders
Percentage agreement for each recommendation, includ- guideline. Comments received were integrated in the final
ing patient presentation and pertinent comments for rounds 1 draft (Table 13).
630 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007
Table 7. Percentage agreement for recommendations of adult Table 8. Percentage agreement for recommendations of adult
lower extremity disorders guidelines hip (rounds 1 and 2) lower extremity disorders guidelinesknee (round 1)
% Agreement % Agreement
Round 1
Round 1 Round 2
Patient presentation (n = 59)
Patient presentation (n = 69) (n = 53)
General indications for radiographs 88
General indications for radiographs 92 90
Full or limited movement and nontraumatic 91 94 Full or limited movement and nontraumatic knee pain 93
hip pain of b4 wk's duration of b4 wk's duration or if one of the following
conditions is suspected:
1. Strain, tendinitis, or tendinosis 84 96
1. Osteoarthritis (OA) 92
2. Piriformis syndrome 94
3. Nontraumatic trochanteric and 92 96 2. Inflammatory arthritis 86
iliopsoas bursitis
4. Osteoporotic hip fractures 95 3. Bursitis/ tendinitis/ strain/ tendinosis 84
5. Septic arthritis of the hip 100
4. Anterior knee pain 83
Chronic hip pain unresponsive to 4 wk 92
of conservative care or if one of the 5. Internal joint derangement 96
following conditions is suspected:
Acute knee injury but negative findings 94
1. Congenital/developmental abnormalities 84 98 for the OKRs
2. Osteoarthritis (DJD) 98
3. Inflammatory arthritis 90 Acute knee injury and positive findings 94
4. Osteonecrosis 93 for the OKRs
5. Tumors and metastatic lesions 97
6. Stress (fatigue or insufficiency) fractures 97
Significant hip trauma 97 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-
Wrist and Hand Disorders. Similarly, 48 panelists com- mendations and although 88% agreement was reached for all
pleted the only round necessary to reach consensus for all 11 recommendations of the remaining sections, panelists were
recommendations, reaching between 89% and 100% agree- asked to evaluate 5 new recommendations owing to the
ment on individual recommendations (Table 14). Table 15 proposal of significant changes. Between 88% and 98%
depicts the breakdown of panelists completing the upper agreement was reached for all recommendations of the first
extremity disorders sections. round. Round 2 included the following sections: (a) trauma
to the lumbar spine, thoracolumbar spine, thoracic spine,
Part 3: Spine Disorders (Phase 5). Expert panel composition for pelvis, sacrum, and coccyx regions; and (b) chest wall
each category evaluated is provided in Figure 7, and the
(thorax) trauma. Fifty panelists returned both sections of the
submission deadline for each round is presented in Table 16.
second round. Percentage agreement ranged between 92%
For every section completed, final results were posted on the
and 100% on all 5 new recommendations (Table 17).
website in a PDF file accessible to all panelists. Changes
were highlighted in the text for clarity. Percentage agreement Nontraumatic Lumbar Spine Disorders. For the nontrau-
for each recommendation, including patient presentation and matic lumbar spine category, 50 panelists completed all 15
pertinent comments for round 1 and round 2 (where recommendations reaching a minimum of 82% agreement.
applicable) of adult spine disorders, is provided in Tables Nonetheless, based on suggestions received from the first
17 to 20. Sixty-one experts representing 21 chiropractic round, 3 recommendations were significantly modified and
institutions actively participated. one new recommendation was added for the second round.
Forty-two panelists then participated in round 2, reaching more
Spinal Trauma. Although all recommendations for the than 93% agreement on all 5 recommendations (Table 18).
spinal trauma category were integrated in the lumbar,
thoracic, and cervical spine sections of the guidelines, they Nontraumatic Thoracic Spine Disorders. For the nontrau-
are conveniently presented here separately. Fifty panelists matic thoracic spine disorders category, 50 panelists
completed round 1 and 42 panelists completed round 2 of the completed all 6 recommendations. Based on suggestions
spinal trauma categories (Table 17). proposed in the first round, however, 7 new recommenda-
Round 1 included the following sections: (a) trauma to tions were proposed for the second round. Thirty-seven
the lumbar spine, pelvis, sacrum, and coccyx; (b) thoracic panelists participated in round 2, reaching more than 92%
spine and chest wall (thorax) trauma; and (c) cervical spine 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
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- Part 3: Spine Disorders (Phase 5). Seventy-six experts initially
graphs) received 100% agreement. The distribution of agreed to return a confidential agreement and 50 of those
participants in the various areas of expertise for this second actually contributed to this part of the study by returning the
round is as follows: 5 academics, 12 clinicians, 3 first category (lumbar spine disorders) of the spine guide-
researchers/academics, 6 academics/clinicians, 4 research- 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
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):
Table 19. Percentage agreement for recommendations of adult Table 20. Percentage agreement for recommendations of adult
nontraumatic thoracic spine disorders (rounds 1 and 2) nontraumatic cervical spine disorders (rounds 1 and 2)
% Agreement % Agreement
Round 1 Round 2 Round 1 Round 2
Patient presentation (n = 50) (n = 37) Patient presentation (n = 51) (n = 43)
Adult patient with nontraumatic thoracic 96 Adult patient with acute uncomplicated a 96
pain with no red flags neck pain (b4 wk's duration)
Reevaluation of thoracic pain for critical 94 Adult patient with acute nontraumatic neck 88 95
exclusionary diagnoses and radiographs pain and radicular symptoms
are indicated in the absence of
treatment response after 4 to 6 wk Adult patient with subacute neck pain 88 92
(4-12 wk's duration) or persistent neck pain
Painosteoporotic vertebral collapse 94 (N12 wk) with or without arm pain b and
reevaluation for critical exclusionary
Adult scoliosis diagnoses and radiographs indicated in the
Part 1 92 absence of treatment response after 4 wk
Part 2 94 Adult patient with neck pain in the presence 98 97
of red flag and indicators of contraindication
Nonpainful and nonprogressive scoliosis in adult N/A 92 to SMT
1. High-risk ligament laxity populations/ 90 97
Adult patient with nontraumatic chest wall pain possible atlantoaxial instability
Part 1 N/A 100 2. Cervical myelopathy 91 95
Part 2 N/A 95 and radiculomyelopathy
3. (a) Cervical artery dissection (VAD, CAD), 98 100
Adult patient with thoracic pain in the 98 TIA
presence of red flags (b) Cervical artery dissection (VAD, CAD), 89
TIA (risk factors)
Adults with complicated thoracic pain (c) Cervical artery dissection (VAD, CAD), 93
(with red flags) TIA (physical examination)
(A) Adults patient with complicated N/A 97 (d) Cervical artery dissection (VAD, CAD), 91
(ie, red flag) thoracic pain and indicators of TIA (past history of neck trauma)
contraindication to SMT (relative/absolute) a
Uncomplicated indicates non traumatic neck pain without under-
(B) Suspected thoracic aortic dissection N/A 100 lying neurologic deficits or red flag.
(C) Suspected compression fracture N/A 97 b
The findings of The Bone and Joint Decade 2000-2010 Task Force on
(D) Osteoporosis risk factor N/A 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.
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 disagreed or strongly disagreed. Fifty respondents completed
67% of the lower extremity participants and 78% of the spine all 4 sections of the spine disorders guidelines, the majority
disorders guidelines participants having onsite access to of whom agreed with the proposed recommendations of the
radiography. The majority of respondents ordered on average spine trauma and nontraumatic thoracic spine sections (56%
less than 15 radiographic series per week, whereas a small and 54%, respectively). Half of the practitioners agreed with
minority (2-8%) ordered more than 15 radiographic series the nontraumatic lumbar spine section, whereas 52%
per week. More than 30% of participants admitted to never disagreed with the nontraumatic cervical spine recommenda-
taking radiographs of the lower limbs. Approximately half of tions (Table 23).
all participants said they occasionally referred patients for
specialized imaging of the extremities and spine (Table 22). Perceived Ease of Use of Guidelines and Implementation
Feasibility. Perceived overall ease of use of the proposed
Comprehensiveness of Proposed Recommendations. Par- diagnostic imaging lower extremity and spine disorders
ticipants were asked to rank the 2 diagnostic imaging guidelines was ranked as moderate to high (5 out of 9) by
guidelines for comprehensiveness on an appropriateness 77% and 56% of practitioners, respectively (Table 24). When
(Likert) scale from 1 (least appropriate/strongly disagree) to asked about the interest and desire for implementing the
9 (most appropriate/strongly agree), with a separate option proposed diagnostic imaging lower extremity and spine
for don't know. Of the 35 chiropractors who completed all disorders guidelines, 62% and 40% (respectively) of
3 sections of the lower extremity guidelines (hip, knee, and practitioners indicated being interested (5 out of 9),
ankle and foot), 77% agreed or strongly agreed with the whereas 35% (lower extremity disorders) and 59% (spine
proposed recommendations, whereas the remaining 23% 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
the lower extremity guidelines respondents and 38% of the tors for spinal conditions.70 Although there is a paucity of
spine disorders respondents ranked the feasibility of literature as to the types of extremity disorders seen by
implementing these guidelines into practice as good or very chiropractors, it is reasonable to assume that acute traumatic
good (5 out of 9). However, when considering the scope of injuries of the extremities would be more commonly seen in
practice in their own province, state, or country, 29% of the emergency facilities, rather than in chiropractic offices.
lower extremity guidelines respondents and 59% of the spine Results from this public consultation phase of the study
disorders guidelines respondents ranked the feasibility of must be interpreted with caution, considering the low
implementing these recommendations into practice as low or participation rate. Possible reasons for this are addressed in
very low (3 out of 9). 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
DISCUSSIONPUBLIC CONSULTATION (PHASE 6) for consulting, and type of technique used by participants.
Nonetheless, certain observations deserve consideration.
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- Year of Graduation
mately 15% of initial consultations in North American Crossed data analysis revealed that practitioners taking
chiropractic clinics are for disorders of the extremities, more spinal radiographs (either 5-15 or N15 sets of films per
whereas three quarters (76%) of patients consult chiroprac- 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 (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
Table 26. Year of graduation of participants in relation to their standard of care for taking routine radiographs for
opinion of how comprehensive are the nontraumatic cervical spine subluxation assessment and post-treatment radiographs? If
recommendations and corresponding comments not please review the PCCRP guidelines and complete the
How comprehensive are the nontraumatic survey
cervical spine recommendations and The practice of taking routine repeat radiographs to
corresponding comments (n = 49)
monitor patient progress is not commonplace in
I don't chiropractic,91 but some named technique systems advo-
1 2 3 4 5 6 7 8 9 know
cate this as an integral part of their standard of practice.92 It
Year of Before 1960 0 0 0 0 0 0 0 0 1 0 has been our observation that those advocating routine
graduation
radiography and repeat radiography are resistant to any
1970-1980 2 2 0 0 0 0 0 1 3 0
change that may challenge their uninhibited use of radio-
1981-1990 2 1 1 0 0 3 2 1 2 0 graphy. Not surprisingly, those feeling threatened or angry
may be more likely to answer surveys of this nature. It is
1991-2000 3 4 0 0 0 1 4 1 1 0 therefore possible that those having less practical experience,
possessing onsite access to radiography, who are in solo
2001-2006 6 2 3 0 0 0 1 3 0 0
practice, and who tend to obtain radiographs on most new
Overall appreciation using the following scoring system from 1 to 9:
patients as part of the technique used would tend to respond
1 = least appropriate, 9 = most appropriate.
negatively to the proposed diagnostic imaging guidelines.
On the other hand, those who refer to imaging centers, are in
between 5 and 15 radiographic series per week, with 8% multi/interdisciplinary practice, and predominantly use
ordering more than 15 spine radiographic series per week. common diversified techniques were not as likely to
Recent surveys in North America indicate only 6% to 17% of participate because they were not as threatened and not as
chiropractic patients receive radiographs during their directly affected by the guidelines.
visit.70,85 In a practice-based study of chronic LBP in the Although there appears to be a strong sampling bias in
USA, 1 (25%) in 4 patients underwent radiography.86 the public feedback group, results of this phase of the
Overall, a decline in radiograph use has been observed project (phase 6) help in identifying potential obstacles to
since the late 1980s and early 1990s when more than half of dissemination and implementation strategies of these
the chiropractic patients in the USA were receiving radio- guidelines. Understanding what drives clinicians to order
graphs before treatment for their current episode of LBP.87 imaging studies is important. General comments gathered
An alternative explanation for the results in our study may be from participants during the study ranged from very
that our sample included chiropractors working in high enthusiastic to a strong desire never to see such guidelines
volume practices. The type of practice (solo or group implemented (Appendix B). The concerns could be
practice, and chiropractic technique used) may also influence classified into 3 general categories:
clinician's decision-making behavior.
1. The desire by some practitioners to reach clinical
decisions for their patients without outside interfer-
Type of Practice ence (ie, guidance);
The majority of participants in this study were in solo 2. Failure to consider a significant body of evidence on
practice. Solo practitioners traditionally tend to express more biomechanical analysis of the spine (postural analysis
negative attitudes regarding clinical guidelines than physi- and vertebral subluxations/spinal misalignments);
cians in nonsolo practices.88,89 In addition, certain practice 3. Failure to recognize the named techniques using pre-
management groups encourage chiropractors to take radio- post radiographs to provide spinal adjustments (a form
graphs to favor long-term patient retention. This factor, of spinal manipulative therapy).
however, was not measured in our study.
Spinal radiography is an integral component of patient It is our observation that there is a general misunder-
biomechanical spinal evaluation in some chiropractic techni- standing about the usefulness of evidence-based literature
ques. Although information relating to the type of chiropractic and practice guidelines. Practitioners should feel reassured to
technique used was not gathered in our study, e-mail know that the evidence-based approach to health care is
exchanges and invitations to review competing guidelines meant to assist, not replace, clinicians in clinical decision
on a website90 promoted by CBP may have had some impact making by summarizing available literature to be used in
on this phase of the project. Their welcoming page stated, conjunction with the clinician experience and judgment
The PCCRP guidelines are in direct competition/opposition while considering patient preference.93 Evidence-based care
to current attempts to restrict Chiropractic Radiography to and guidelines were never intended to replace the intelli-
Red Flag Only conditions or diagnosis. On this same gence of the clinician. One criticism is that guidelines are
website, one could read: Do you want to be outside the frequently misinterpreted and simply used by third-party
Journal of Manipulative and Physiological Therapeutics Bussires et al 641
Volume 30, Number 9 Diagnostic Imaging Guidelines
payers to restrict or deny reimbursement for care. Although sensitivity, specificity, positive and negative predictive
no one can predict how insurance companies and legislators values, positive and negative likelihood ratios, and diag-
may want to apply the abundance of guidelines available, we nostic odds ratios. In other words, how good is the index test
agree that the proposed diagnostic imaging guidelines should at detecting the target condition?110,111 Conventional radio-
not be used by legislators or in a medical-legal context as graphy does not appear to be clinically useful as a screening
other factors such as cost-effectiveness analysis and safety test as evidenced by the low prevalence of serious spinal
impact were not specifically analyzed and much of the pathologies such as cancer and infection, and the poor
content needs to be validated prospectively. sensitivity, predictive values, and likelihood ratios for many
Indications for radiography are vigorously debated within musculoskeletal conditions.112-121
chiropractic. Most chiropractors obtain radiographs for In addition, the answer to the above question (regarding the
clinical reasons, such as confirming a diagnosis of pathology, use of an index test for detecting a target condition) has not
but many continue to use radiography as a screening tool and been adequately provided by proponents of the routine use of
for medicolegal protection.27,94 The frequency of conven- imaging studies to justify its use in screening to determine the
tional radiograph utilization by chiropractors for LBP presence of chiropractic subluxations or to prevent serious
complaints ranged from 60% to 90% in North America,95-97 complications before spinal manipulative therapy.122,123
but many of the reasons provided by chiropractors for taking Experimental evidence regarding the very nature of the
radiographs are not supported by the literature.27,94,98 subluxation syndrome still appears to be lacking.124,125
Recent surveys, however, suggest a significant decrease in Clearly, well-designed prospective studies are needed to help
reported frequency over time,99 with, for example, 17% and answer many of these questions. Until such evidence is
6% of Arizona and Massachusetts patient visits involving available, selective use of imaging studies is advisable.
radiography, respectively.85 It is worth noting that since the
inception of Medicare 30 years ago, chiropractors had been
Second External Review (Phase 7)
mandated to obtain radiographs to be reimbursed for care.
More than 300 chiropractic specialists and 14 medical
Only after persistent legislative activity has this provision
specialists were invited to review the diagnostic imaging
finally been changed.100
guidelines by consensus opinion (phase 5).
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 1. Chiropractic specialties:. Invitations to review the proposed 3
obtain radiographs on only 1% to 25% of their patients diagnostic imaging guidelines were sent by mail (total of 275
increased from 35% in 1997 to 49% in 2003. This trend was specialists for whom addresses were available). In addition,
accompanied by consistent declines in the proportion of representatives of the following chiropractic specialty groups
chiropractors who obtain radiographs on more than 25% of agreed to forward the invitation by e-mail to respective
their patients.73 One reason for such reductions in utilization members (forwarded e-mails by the Council on Neurology
may be related to a more limited access to radiology were not confirmed):
equipment. In 2003, only 34% of full-time Canadian
chiropractors took their own radiographs, in comparison to American Chiropractic College of Radiology (ACCR)
50% in 1997. Of interest, 76% of Quebec full-time 166 members
chiropractors took their own radiographs compared to Ontario College of Chiropractic Radiology, Canada (FCCR)
(27%), British Columbia (26%), and Saskatchewan (7%).73 38 members (Many FCCR members are also ACCR
Similar utilization patterns by chiropractors were identi- members)
fied in Europe,101 but recent surveys also reveal a reduction College of Chiropractic Clinical Sciences (Canada)
in radiography utilization. In the year 2000, only 25% to (FCCS)55 members
30% of chiropractic patients were radiographed in the College of Chiropractic Sport Sciences (Canada)
United Kingdom102 and Switzerland.103 Limited access to (FCCSS)79 members
radiology facilities possibly explains why fewer radiographs College of Chiropractic Orthopedists (Canada)
are taken throughout several other European countries. (FCCOC)33 members
Chiropractors in Belgium, France, Germany, Greece, Italy, College of Chiropractic Rehabilitation Sciences
Spain, and Sweden do not have the legislation necessary to (CCRS)74 members
allow taking or ordering radiographs.104 Similarly, practi- American College of Chiropractic Council on Neurol-
tioners in the Netherlands have recently lost the right to use ogy (NOCA/ACCN)750 members (We were unable
radiographic equipment.105 to confirm that this invitation was extended to members)
Arguments against the routine use of imaging studies
have been addressed elsewhere. 9,94,106-109 Acceptable 2. Medical specialties:. Fourteen medical specialists from the
features of a proposed test that are sufficient to produce USA and Canada were invited to participate by e-mail,
useful information in a particular situation include the personal letters, and/or telephone calls [orthopedic surgeons
642 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007
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%)
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- ran from December 17, 2006, through February 9, 2007.
nists (2), physical medicine specialists (3), osteopathic Demographic information is detailed in Table 27.
clinicians in the USA (1), medical radiologists (2)]. Two There were 566 accesses to the welcoming page of
could not participate owing to personal illnesses. the diagnostic imaging review website (every reentry
As a result of these invitations, a total of 271 health care counted as 1). Once registered, participants entered a
professionals completed a consent form provided on a protected website housing the 3 PDF files and corre-
protected website (external reviewphase 7) to review sponding evaluation questionnaires: (1) lower extremity
recommendations of the diagnostic imaging guidelines. Of disorders diagnostic imaging guidelines, (2) upper extre-
those, 100 chiropractic specialists and 6 medical specialists mity disorders diagnostic imaging guidelines, and (3)
registered to participate in this phase of the project, which spine disorders diagnostic imaging guidelines. As every
Journal of Manipulative and Physiological Therapeutics Bussires et al 643
Volume 30, Number 9 Diagnostic Imaging Guidelines
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 Comprehensiveness of Proposed Recommendations. Experts were
counted as accessing the protected website. Of the 59 asked to rank the 3 diagnostic imaging guidelines for
participants who accessed the lower extremity evaluation comprehensiveness on an appropriateness (Likert) scale
questionnaires, 44 completed the evaluation questionnaire (Table 28). For the lower extremity guidelines, 44 reviewers
for the lower extremity guidelines. Of the 39 participants completed the hip and knee sections and 41 specialists
who accessed the upper extremity evaluation question- completed the ankle and foot section. Thirty-nine reviewers
naires, all completed the evaluation questionnaire for the completed all 3 sections of the upper extremity disorders
upper extremity guidelines. Of the 41 participants who (shoulder, elbow, and wrist and hand), and 33 reviewers
accessed the spine disorders evaluation questionnaires, 33 completed all 4 sections of the spine disorders sections (spine
completed the evaluation questionnaire for the spine trauma, nontraumatic cervical, thoracic and lumbar spine).
disorders guidelines. Except for one participant in the ankle and foot section of the
The majority of specialists who completed the evaluation lower extremity guidelines who strongly disagreed and 2
questionnaires were chiropractic radiologists (63.8%), fol- more reviewers who indicated I don't know in this same
lowed by sport science (16.3%), and clinical science specialists section, all experts strongly agreed (ranked at or N7 out of 9)
(10.3%). Approximately 65% of respondents graduated with the proposed recommendations of the lower extremity,
between 1981 and 2000 (Table 27, Figs 9 and 10). upper extremity, and spine disorders guidelines.
644 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007
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. results support the practice of treating professional specialty
Table 29 shows the data for the perceived overall ease of use, as an important determinant of the results in consensus
which was ranked as high or very high by most respondents for panels.126 Results of the external review phase of the project
each proposed guideline. Most specialists had a high interest revealed very high levels of agreement with all recommen-
and desire in implementing the proposed guidelines. When dations proposed in the Delphi panel (phase 5) for the lower
considering the scope of practice in their own province/state/ and upper extremity disorders and spine disorders diagnostic
country, the majority of specialists ranked the feasibility of imaging guidelines. Perceived ease of use of the guidelines
implementing these 3 guidelines into practice as high or very and implementation feasibility were generally high. Com-
high. Between 6% and 10% of respondents ranked the ments provided by reviewers pertaining to the content of the
feasibility of implementing the recommendations from the 3 guidelines were considered by the research team in the final
guidelines into practice as moderate. Finally, comments draft of the diagnostic imaging guidelines (phase 8).
received by specialists were generally very favorable and
reflected high levels of agreement with the proposed
recommendations, perceived ease of use of guidelines, and Phase 8: Final Draft of the Diagnostic Imaging Guidelines and Grading
implementation feasibility (Appendix C). of Evidence
Upon completion of the public website (phase 6) and
second external review (phase 7), all suggestions and
DISCUSSIONSECOND EXTERNAL REVIEW (PHASE 7) comments were considered by the research team and
In a recent experimental study of the influence of incorporated into the final version of the guidelines. A
individual participant characteristics on formal consensus member of the public with specialized training in research
development, the largest differences were between the was asked to review the methodology and to consider all
general practitioners and mental health professionals, both recommendations from the 3 guidelines. Comments and
in their initial ratings of the different interventions, and in suggestions from the public member were incorporated
how much they altered their ratings between rounds. The 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
available for some specific conditions, the processes used in preferred that 2 experienced evaluators assess each study
developing these particular guidelines are considered appro- and formally agree on differences. Unfortunately, most
priate. This strategy included a first narrative review, an initial studies could only be reviewed by one assessor due to a
literature search and 2 literature updates, an independent limited budget.
assessment of the literature supporting the proposed The quality of studies used to propose recommendations
recommendations, the use of the European Commission needs discussion. It has been acknowledged that many
Referral Guidelines for Imaging as the initial template,51 a studies on diagnostic validity are of poor quality.134 In the
large Delphi consensus panel, and 2 external reviews. overwhelming majority of axial pain syndromes, there is
Specific weaknesses of our strategy include (a) the initial little evidence supporting confidence in diagnostic test
literature search and data extraction (phase 1) performed by validity.135,136 The same conclusions appear also to apply
only one assessor (AB); (b) the use of only two literature to the clinical examination of some disorders of the upper
evaluators for most citations (phase 2); (c) the lack of and lower extremities.137-145 In real-life situations, knowl-
experience in assessing the quality of the literature by at least edge of the natural course of clinical conditions helps
one of the literature evaluators (phase 2); (d) the initial practitioners determine the need for clinical reevaluation
guidelines recommendations established by only 2 specialists and complementary investigations, including diagnostic
in chiropracticone in clinical sciences and one in radiology imaging studies.
(phase 3); (e) in developing wide-ranging reviews and In the hierarchy of research designs for treatment, results
guidelines, it inevitably takes considerable time to review of randomized controlled trials are considered the highest
studies and formulate recommendations and publishing in a level of evidence, followed by controlled observational
peer-reviewed journal also adds to the time from literature studies with uncontrolled studies and opinion representing
search to date of publication; (f) summarizing complex issues the lowest level of evidence. It should be noted, however, that
in a review, such as this, can also be difficult; (g) a degree of this hierarchy of research designs has been questioned by
subjectivity in the grading of recommendations. recent publications 146,147 that identified nonsignificant
High-quality clinical guidelines should be developed differences in results between randomized controlled trials
within a structured and coordinated program127 using a and observational studies.148 The hierarchy of research
standardized approach 128,129 so that recommendations designs has also been challenged in the field of diagnostic
made by multidisciplinary, nationally representative groups anatomic pathology149 and rehabilitation research.150 A
are based on a systematic literature review.130 Using sound critical comparison of trials with observational studies
scientific methodology proves useful in ensuring that the suggests that one cannot replace the other, both designs
recommendations are explicitly linked to the supporting being susceptible to particular bias, such that neither provides
evidence131 and graded according to the strength of that perfect information.151 Bluhm152 suggests considering the
evidence.57 For some review topics, however, the strengths relationship between biological studies, epidemiological
of the systematic review may turn into weaknesses. The studies (population/clinical research), and systematic clinical
primary problem is that the narrow focus and prescribed observation: a network whereby different information
methods of the systematic review do not allow for provides for better interpretation of the existing literature.
comprehensive coverage. For example, the historical review These diagnostic imaging guidelines incorporated a combi-
is an irreplaceable means of tracing the development of a nation of clinical trials and observational studies as a basis for
scientific principle or clinical concept, but the narrative proposing recommendations.
thread could be lost in the strict rules of systematic Technical difficulties encountered at the onset of the
review.132 Although it is well known that narrative reviews Delphi process, public consultation, and second external
are prone to several biases,133 it is highly conceivable that review (access to the protected website, registering of
the literature search in this project, repeated at 3 different participants, and access to some of the documents) have
intervals using a similar strategy; the use of the European likely disenfranchised some volunteers who were initially
Commission of Radioprotection Guideline as a template; interested in reviewing the guidelines online. Although
the evaluation of all guideline recommendations by a large troubleshooting was promptly addressed, once we were
consensus group composed of more than 60 academics, advised, attrition of participants likely occurred in similar
researchers, and clinicians (modified Delphi process proportion among those in favor and those against the
phase 5); the inclusion of 2 external reviews (phase 4 and proposed recommendations.
phase 7) resulting in the contribution of more than 60 Chiropractors formed the majority of Delphi panelists. This
chiropractic and medical specialists scrutinizing every group in most jurisdictions and most practice situations does
section of the diagnostic imaging guidelines significantly not order or interpret advanced imaging. In addition, they have
reduced the risk of missing important articles and of limited experience in dealing with pathologies such as
misclassification, and have improved the reliability of these fractures, ligamentous instability, myelopathy, cancer, and
guidelines. Although the quality of studies was assessed by infection. It could be argued that it is not valid to suggest that
blinded, independent evaluators during phase 2, ideally it is these guidelines overall are a complete or accurate reflection of
Journal of Manipulative and Physiological Therapeutics Bussires et al 647
Volume 30, Number 9 Diagnostic Imaging Guidelines
best practice from the standpoint of the patient or the disease practice, where less complicated cases will have to be
itself. However, considering this work is an extension of the distinguished from multiple competing diagnoses.110 One
Referral Guidelines for Imaging by European Communities such example is the Canadian Cervical Spine Rule (CCSR)
(Radiation Protection) produced in conjunction with the UK used to exclude fractures tested in a large hospital setting
Royal College of Radiologists,51 we believe that these and trauma centers where disease prevalence and severity
guidelines are in agreement with current standards of care. tends to be greater. It is important to recognize that the
Many reasons may explain the low participation observed predictive value of a test will change with changes in the
in the public consultation (Phase 6): failure to receive or read prevalence of the disease.110 In addition, likelihood ratios
invitation announcements in journals; refusal to participate; tend to move away from the value of 1 when all patients
failure to have access to a computer or to the web; busy who have the target disorder have severe disease, and they
schedules; technical difficulties encountered during the tend to move toward the value of 1 when all patients who
project; and the size of the documents to be reviewed. have the target disorder have mild disease.155 A wide
Although those reasons should not significantly influence the spectrum of patients with low, moderate, and high levels of
results, lack of interest in research or for the study topic would clinical suspicion of fracture need to be included in the
suggest that nonresponse may be biased in ways directly studies to allow for generalization to community practices.
related to the purpose of the study.153 A low response rate does Additional studies may therefore be required to determine
not necessarily affect the validity of the data collected, whether these highly sensitive clinical decision rules
provided tests for nonresponse effects and corrections to the perform just as well in general practice. However, if one
original data be made if needed.154 Unfortunately, such practices in a similar setting to that presented in a particular
analysis was not conducted in this study. Of the 271 health study and the patient meets the study eligibility criteria, one
care professionals who completed the consent form to can be confident in applying the results of the study to his/
participate in the second external review (phase 7), only 105 her own patients.110
specialists (38.7%) registered. Reasons for not responding are
unknown. While a potential source of bias, the very high levels Dissemination-Implementation-Evaluation-Revision. Many reports
of agreement with all recommendations suggest that the results have indicated that current evidence-based guidelines are
would likely not be changed significantly with a higher underused by physicians and others, and that many barriers
participation rate considering that specialty groups tend to to an effective translation of recommendations extend into
exhibit homogeneous practice behaviors. day-to-day care. There is therefore a need to develop more
It could be argued that our process, however extensive, effective ways to communicate key information to both
did not include a sufficient number of chiropractic named caregivers and patients, and to promote appropriate health
technique representatives and a sufficient number of other behaviors.156 Reducing resistance to guideline implementa-
health professions dealing with musculoskeletal disorders. tion will require persuasion of practitioners so that the
Users of specific chiropractic techniques that rely on the perceived negative effects of guidelines on their practices are
routine use of radiography for the purpose of elaborating a balanced by improvements in the quality of care.157
plan of treatment should have a particular interest in imaging Because publication alone is not enough to change
guidelines development. Representatives from Gonstead practice158-160 , the complex and challenging issues of
Technique and from Chiropractic Biophysics protocol were implementation and utilization of CPGs also need to be
invited to participate on the Delphi panel (phase 5). considered. Many studies have shown that a combination of
Unfortunately, the Gonstead representative failed to return different strategies is necessary. Positive tendencies toward
most of the evaluation questionnaires and a cofounder of successful implementation include:
Chiropractic Biophysics protocols declined our invitation,
opting instead to develop other guidelines.90 With regard to 1. A commitment to implementing the guidelines;
the incorporation of other health care professions, ordering 2. Local authorities that take responsibility in the health-
of imaging studies is normally restricted to medical care community and designate this topic as high priority;
physicians and chiropractors, as well as to osteopaths in 3. A well-organized system for managing guidance
the USA, therefore excluding physical and occupational (regular report and audits of compliance);
therapy groups and Canadian osteopaths. Most medical 4. Sufficient funding;
specialists invited to participate in our study cited lack of 5. Buy-in (acceptance) by the health care providers
availability as the main reason for declining our invita- (provided that guidance is consistent with other
tion. One neurosurgeon had to stop participating due to published sources, views are properly represented,
personal illness. and guidance is mandatory).161
As the properties of a diagnostic test can change with
different disease severity, generalization of study results is Therefore, an investigation of possible barriers are an
another important issue to consider. In other words, an essential component of any guideline dissemination-imple-
imaging study may not perform as well in a community mentation strategy.162,163
648 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007
The different premises on which chiropractic guidelines Such a strategy has proven effective for managing shoulder
are established may derive from a longstanding ideological problems and informed use of ultrasound imaging in general
debate among chiropractors regarding the identity of practice.182 The use of referral guidelines, reinforced by
chiropractic.172-175 Mootz176 proposes that chiropractic request checking and clinical management algorithms,
institutions and organizations focus on an evidence-based produced total reductions in radiographic examinations
and best practiceoriented research priority, constructive ordered by general practitioners of the knee, lumbar spine,
engagement of the greater health care system, and successful and cervical spine of 77%, 78%, and 86%, respectively.183
ethical business models. It has been recommended that postgraduate teaching of
Divergent or competing guidelines on similar topics serve evidence-based practice should be moved from classrooms
only to further confuse and frustrate practitioners.177 In to the clinical practice setting to improve skills, attitudes, and
addition, the continued lack of unity among chiropractors behavior.184 Internet platform (e-learning) for continuing
hinders its growth by limiting engagement of the greater health education, including case-based learning objectives and
care system. We encourage readers of all guidelines to examinations, is yet another method of facilitating guideline
critically evaluate the methods used as well as the content implementation.185 Teaching diagnostic decision making in
of the recommendations before adopting them for use this way may also be a viable alternative to traditional
in practice.178 teaching formats in undergraduate programs.186 It is also
recommended that conferences and seminars be designed to
include several healthcare providers, thereby giving a
Strategies for Effective Guidelines Dissemination, Implementation, and comprehensive presentation on each topic.20
Monitoring
Proposed dissemination-implementation strategies
include publication, applying to National Guideline Clear- Monitoring of the Guidelines/Clinical Audit
inghouse; posting of the electronic document on various Guideline adaptation by regional care provider audit
websites (national, state, and provincial organizations; groups may serve as a tool for CPG implementation.187
malpractice insurance carriers; outpatient teaching clinics); Effective methods can be developed for monitoring guide-
educational intervention strategies (e-learning, community line use in primary care. However, there is a need to address
pilot studies); referral guidelines; reinforced by request the degree of understanding possessed by many primary
checking and clinical management algorithms; promotion healthcare professionals about the concepts and practical
by national, provincial, and state organizations; and issues of guideline-use monitoring, and of expectations of
presentation to conferences. Currently, there is a deficiency this within the healthcare system. In addition, a number of
of well-designed studies that document the effectiveness of technical issues concerned with efficient capture of clinical
practice guidelines. Their ultimate effectiveness will depend information and its evaluation must be considered.188 Audit
on both an improved evidence base and effective strategies (systematic monitoring) and feedback (less formal) are
for rapid dissemination of the recommendations. frequently used strategies to improve professional practice.
In the past, effective dissemination of new knowledge has When it is effective, the effects are generally small to
been a slow process, often taking years. This process can be moderate. The relative effectiveness of audit and feedback is
dramatically shortened through the development of networks likely to be greater when baseline adherence to recom-
of practice sites that share knowledge and experience in the mended practice is low and when feedback is delivered more
implementation of practice guidelines and the use of intensively.189 Computer reminders attempt to influence
strategies that take advantage of key groups in the behaviors of individuals. Reminders are more effective than
dissemination process.179 When used appropriately, practice feedback in modifying physician behavior related to
guidelines can provide an important adjunct to clinical medication management.190 In addition, such reminders
research by facilitating the dissemination of new clinical may seem less threatening as they are anonymous.191
findings and can provide an important platform for Social, political, and commercial factors often drive and
encouraging innovations in patient care.179 determine the use of evidence in policymaking. It is
In one instance, mailing of copies of the Royal College of recommended, however, that in-depth analyses from differ-
Radiologists' guidelines had a small effect on general ent perspectives be made before implementing evidence-
practitioners' use of radiographic investigations of uncertain based policies.192 Such analyses may include perspectives
clinical significance.180 There is currently considerable from patients, providers, society, payers, and others. One
debate surrounding the ability of professional education and concern is whether this type of evidence will lead to a policy
development to actually make a difference in the way change with significant benefit to society.193
clinicians practice.181 An educational intervention strategy as A significant limitation of any CPG is the skill of
a means of implementing evidence-based guidelines for clinicians. Decisions to proceed with further testing are
imaging may be most effective in reducing the perceived need based on information gathered by thorough and proper
for conventional radiography in a chiropractic community.97 history taking and results obtained from a well-conducted
650 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007
CONCLUSIONS ACKNOWLEDGMENT
The role of high-quality CPGs for quality management in The authors express their sincere appreciation to all
health care is well accepted. These evidence-based diag- independent literature reviewers (phase 2), Delphi panelists
nostic imaging practice guidelines are intended to assist (phase 5), and external reviewers (phases 4 and 7), whose
primary care providers, interns, and residents in decision significant contributions were essential in the completion of
making on the appropriate use of diagnostic imaging for this project. We are grateful to chiropractic college presidents
specific clinical presentations. In all cases, the guidelines are for recommending faculty members for the Delphi panel. We
intended to be used in conjunction with sound clinical appreciate the feedback received by colleagues in the field
judgment and experience. Application of these guidelines during and after the worldwide consultation on the Web
should help avoid unnecessary radiographs, increase (phase 6). We thank Jeffrey Cooley, DC, DACBR; Jonathon
examination precision, and decrease health care cost Todd Egan DC, Fellow; Michael Morgan, DC; Jason Napuli,
without compromising the quality of care. DC; and Julie O'Shaughnessy DC (Fellow candidate in
Guidelines are effective only if they are implemented in Clinical Sciences) for completing the independent literature
the delivery process. The implementation process should be review (phase 2); and Dr Andre Cardin of Universit du
supervised and evaluated so that adjustments are possible. Qubec Trois-Rivires for his significant input in the initial
Several important issues regarding dissemination/imple- draft (phase 3). We thank Carlo Ammendolia, DC, PhD; Joe
mentation strategies need to be considered. Health profes- Lemire DC, MSc; John Triano DC, PhD; and Jacques
sionals are slowly moving toward evidence-based health Duranceau, MD, for providing constructive advice. The
care and best practices and will appreciate the value of authors thank those who assisted us during all or part of the
CPGs provided teaching institutions and political leaders project, including Mark Laudadio, DC; Christian Eid, DC;
promote their use. Guidelines are living documents refined Julie Roy, DC; Nicholas Beaudoin; and Mme Valrie
and modified regularly with new information and experi- Lambert, academic and technology support, Computer
ence. Future research is needed to validate the content of the System Development Division at UQTR. Finally, we thank
proposed diagnostic imaging guidelines. In addition, Mrs Vicki Pennick, RN, BScN, MHSc, Senior Clinical
attempts to refine patient selection criteria to further reduce Research Project Manager, Managing Editor, Cochrane Back
unnecessary radiographic exposure without altering sensi- Review Group, Institute for Work & Health, for her valuable
tivity are recommended. advice and pertinent comments and suggestions as a public
representative.
Practical Applications
This project developed evidence-based diagnostic REFERENCES
imaging practice guidelines for musculoskeletal
complaints for use by chiropractors and other 1. Wool A, Pfleger B. Burden of major musculoskeletal
primary health care professionals. conditions. Bull World Health Organ 2003;81:646-56.
The guidelines describe appropriate care based on 2. WHO Scientific Group. The Burden of Musculoskeletal
Conditions at the Start of the New Millennium WHO and
the best available scientific evidence and broad Bone and Joint Decade. World Health Organ Tech Rep Ser
consensus, reduce inappropriate variation in prac- 919. Geneva; 2003 [cited June 2007]. Available from: http://
tice, provide a more rational basis for referral, www.emro.who.int/ncd/publications/musculoskeletalcondi-
provide a focus for continuing education, promote tions.pdf.
efficient use of resources, act as a focus for quality 3. Dixon A. Evidence-based diagnostic radiology. Lancet 1997;
350:509-12.
control (including audit), highlight shortcomings of 4. Ghozlan R, Vacher H. Where is imaging going in rheumatol-
existing literature, and suggest appropriate future ogy? Best Pract Res Clin Rheumatol 2000;14:617-33.
research. 5. Feldman F. Musculoskeletal radiology: then and now.
The guidelines have been created to improve patient Radiology 2000;216:309-16.
care by detailing the appropriate information 6. Remplik P, Stbler A, Merl T, Roemer F, Bohndorf K.
Diagnosis of acute fractures of the extremities: comparison of
gathering and decision-making processes involved low-field MRI and conventional radiography. Eur Radiol
in the diagnostic imaging of musculoskeletal care. 2004;14:625-30.
The guidelines are intended to be used in conjunc- 7. Sanders TG, Parsons T. Radiographic imaging of musculos-
tion with sound clinical judgment and experience. keletal neoplasia. Cancer Control 2001;8:221-31.
Application of these guidelines should help avoid 8. Owens JP, Ruth G, Keir MJH, et al. A survey of general
practitioners opinions on the role of radiology in patients with
unnecessary radiographs, increase examination low back pain. Br J Gen Pract 1990;40:98-101.
precision, and decrease health care costs without 9. Halpin SF, Yeoman L, Dundas DD. Radiographic examina-
compromising the quality of care. tion of the lumbar spine in a community hospital: an audit of
current practice. BMJ 1991;303:813-5.
652 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007
10. Ferriman A. UK rate of x-ray examination less than half the 29. Koes BW, van Tulder MW, Ostelo R, Kim Burton A, Waddell
US rate. BMJ 2001;322:384. G. Clinical guidelines for the management of low back pain in
11. Grassi W, Flippucci E, Carotti M, Slaffi F. Imaging modalities primary care: an international comparison. Spine 2001;26:
for identifying the origin of regional musculoskeletal pain. 2504-13.
Best Pract Res Clin Rheumatol 2003;17:17-32. 30. Croft P. Diagnosing regional pain: the view from primary care.
12. Ryynnen OP, Lehtovirta J, Soimakallio S, Takala J. Clin Rheumatol 1999;13:231-342.
General practitioners' willingness to request plain lumbar 31. Rossignol M, Arsenault B. Guide de pratiqueClinique des
spine radiographic examinations. Eur J Radiol 2001;37: lombalgies interdisciplinaires en premire ligne, Direction de
47-53. la Sant Publique de Montral; 2006. p. 40.
13. Houben PHH, van der Weijden T, Sijbrandij J, Grol RPTM, 32. Tan AL, Wakefield R, Conaghan PC, Emery P, McGonagle D.
Winkens RA. Reasons for ordering spinal x-ray investiga- Imaging of the musculoskeletal system: magnetic resonance
tions. How they influence general practitioners' management. imaging, ultrasonography and computed tomography. Best
Can Fam Physician 2006;52:1266-7. Pract Res Clin Rheumatol 2003;17:513-28.
14. Russo R, Cook P. Diagnosis of low back pain: role of imaging 33. Bohndorf K, Kilcoyne RF. Traumatic injuries: imaging of
studies. Occupational Med: State of the Art Reviews 1998;13: peripheral musculoskeletal injuries. Eur Radiol 2002;12:
83-97. 1605-16.
15. ICES Practice Atlas. In: Braddley E, Glazier R, editors. 34. Glaves J. The use of radiological guidelines to achieve a
Institute for Clinical Evaluative Sciences in Ontario. Canadian sustained reduction in the number of radiographic examina-
Medical Association; 2004. tions of the cervical spine, lumbar spine and knees performed
16. Miller P, Kendrick D, Bentley E, Fielding K. Cost-effective- for GPs. Clin Radiol 2005;60:914-20.
ness of lumbar spine radiography in primary care patients with 35. Hoffman JR, Mower WR, Wolfson AB, Tood KH, Zucker M,
low back pain. Spine 2002;27:2291-7. for the National Emergency X-Radiography Utilization Study
17. Laupacis A, Evans W. Diagnostic imaging in Canada. Healthc Group. Validity of a set of clinical criteria to rule out injury to
Pap 2005;6:8-15. the cervical spine in patients with blunt trauma. New Engl J
18. Committee to Assess Health Risks From Exposure to Low Med 2000;343:94-9.
Levels of Ionizing Radiation, National Research Council, 36. Stiell IG, Wells G, Vandemheen KL, et al. The Canadian
Health Risks from Exposure to Low Levels of Ionizing cervical spine rule for radiography in alert and stable trauma
Radiation: BEIR VII-Phase 2 [monograph on the Internet]. patients. JAMA 2001;286:1841-8.
Washington: National Academy Press; 2006. Available from: 37. Fraenkel L, Shearer P, Mitchell P, La Valley M, Feldmen J,
http://books.nap.edu/catalog/11340.html. Felson DT. Improving the selective use of plain film
19. Iglehart JK. The new era of medical imagingprogress and radiographs in initial evaluation of shoulder pain. J Rheumatol
pitfalls. Health policy report. N Engl J Med 2006;354: 2000;27:200-4.
2822-6. 38. Hendey GW. Necessity of radiographs in the emergency
20. DiLeo R, Spinelli R. Strategies for teaching non-radiologist department management of shoulder dislocation. Ann Emerg
physicians the appropriate use of imaging studies: use of Med 2000;36:108-13.
radiology seminars. J Med Pract Manage 2006;21:362-6. 39. Docherty MA, Schwab RA, Ma OJ. Can elbow extension be
21. Brown SJ. Managing the complexity of best practice health used as a test of clinical significant injury? South Med J 2002;
care. J Nurs Care Qual 2001;15:1-8. 95:539-41.
22. Institute for Alternative Futures. The future of chiropractic 40. Cevik AA, Guna I, Masinali M, Yanturali S, Atilla R,
revisited. Alexandria, VA: The Institute for Alternative Holliman CJ. Evaluation of physical findings in acute wrist
Futures; 2005. p. 2005-15. [Monograph on the Internet] trauma in the emergency department. Ulus Tavma Derg 2003;
[cited 2007 June 16]. Available from: http://www.altfutures. 9:257-61.
com. Used with permission. 41. Mehta M, B0rautigan MW. Fractures of the carpal
23. Stein LA. Making the best use of radiological resources in navicular-efficacy of clinical findings and improved diag-
Canada. Healthc Pap 2005;6:18-23. nosis with six-view radiography. Ann Emerg Med 1990;19:
24. Vader JP, Terraz O, Perret L, Aroua A, Valley JF, Burnand B. 255-7.
Use of and irradiation from plain lumbar radiography in 42. Stiell IG, Greenberg GH, Wells GA, et al. Prospective
Switzerland. Swiss Med Wkly 2004;134:419-22. validation of a decision rule for the use of radiography in acute
25. Clinical practice guidelines. [monograph on the Internet], knee injuries. JAMA 1996;275:611-5.
Lincoln's Inn Fields, London. Open clinical knowledge 43. Emparanza JI, Aginaga JR. Validation of the Ottawa Knee
management for medical care [cited July 5th, 2007]. Rules. Ann Emerg Med 2001;38:364-8.
Available from: http://www.openclinical.org/guidelines. 44. Wynn-Thoma S, Love T, McLeod D, Vernall S, Kljakovic M,
html#purposes; 2002. Dowell A, Durham J. The Ottawa ankle rules for the use of
26. Bussires AE, Cardin A, Peterson C, Taylor J. Radiology diagnostic X-rays in after hours medical centres in New
practice guidelines for extremity disorders in the adult Zealand. N Z Med J 2002;115:U184.
Indications for x-ray taking for the chiropractic intern and 45. Papacostas E, Malliaropaulos N, Papadopoulos A, Liouliaski
clinician; 2004. ACC-RAC 2004. Las Vegas, NV; March C. Validation of the Ottawa ankle rules protocol in Greek
11-13. athletes. Study in the emergency departments of a district
27. Ammendolia C, Bombardier C, Hogg-Johnson S, Glazier R. general hospital and sport injury clinic. Br J Sports Med 2001;
Views on radiography use for patients with acute low back 35:445-7.
pain among chiropractors in an Ontario community. J 46. Tay S, Thoo F, Sitohy Y, Seow E, Wong H. The Ottawa Ankle
Manipulative Physiol Ther 2002;25:511-20. Rules in Asia: validating a clinical decision rules for
28. Dhingsa R, Finlay DB, Robinson GD, Liddicoat AJ. requesting x-rays in twisting ankle and foot injuries. J
Assessment of agreement between general practitioners and Emerg Med 1999;17:945-7.
radiologists as to whether a radiation exposure is justified. Br 47. Coulter ID, Hurwitz EL, Adams AH, Genovese BJ, Hays R,
J Radiol 2002;75:136-9. Shekelle PG. Patients using chiropractors in North America:
Journal of Manipulative and Physiological Therapeutics Bussires et al 653
Volume 30, Number 9 Diagnostic Imaging Guidelines
who are they, and why are they in chiropractic care? Spine Research., Conference; September 15-16, Chicago, Illinois;
2002;27:291-6. 2006.
48. Suarez-Almazor ME, Belseck E, Russell AS, Mackel J. Use of 68. Bussires A, Taylor J, Peterson C. Indications for Diagnostic
lumbar spine radiographs for the early diagnosis of low back Imaging in Adults. Part 3Spine Disorders: Consensus Opinion
pain. JAMA 1997;277:1782-6. Recommendations Based on Current Literature. WFC's and
49. Simmons ED, Guyer RD, Graham-Smith A, Herzog R. FCER's International Conference on Chiropractic Research,
Radiographic assessment for patients with low back pain. Conference, Vilamoura, Portugal, May 17-19; 2007.
Spine 1995;20:1839-41. 69. Bussires A, Peterson C, Taylor J. Suisse Annual Continuing
50. Hurwitz B. How does evidence based guidance influence Education Congress. Diagnostic Imaging Guidelines. Con-
determinations of medical negligence? BMJ 2004;329: ference, Davos, Switzerland, September 6-9; 2007.
1024-8. 70. Coulter ID, Shekelle PG. Chiropractic in North America: a
51. European Commission. Radiation protection 118. Referral descriptive analysis. J Manipulative Physiol Ther 2005;28:
guidelines for imaging in conjunction with the UK Royal 83-9.
College of Radiologists: Luxembourg; 2001. 71. Griffith CH, Desai NS, Wilson JF, Griffith EA, Powell KJ,
52. Hadorn DC, Baker D, Hodges JS, Hicks N. Rating the quality Rich EC. Housestaff experience, workload, and test ordering
of evidence for clinical practice guidelines. J Clin Epidemiol in a neonatal intensive care unit. Acad Med 1996;71:1106-8.
1996;49:749-54. 72. Stiell I, Wells G, Laupacis A, Brison R, Verbeek R,
53. Whiting P, Rutjies AWS, Dinnes J, Reitma JB, Bossuyt PMM, Vandemheen K, Naylor CD. Multicentre trial to introduce
Kleijnen JK. Development of validation of methods for the Ottawa ankle rules for use of radiography in acute ankle
assessing the quality of diagnostic accuracy studies. Chap 9. injuries. Multicentre Ankle Rule Study Group. BMJ 1995;
Health Technol Assess 2004;8:59-65. 311:594-7.
54. Hollingworth W, Medina LS, Lenkinski RE, Shibata DK, 73. Stowe S. A comprehensive inventory of practical information
Bernal B, Zukowski D, Comstock B, Jarvik JG. Interrater about Canada's licensed chiropractors. Canadian Chiropractic
reliability in assessing quality of diagnostic accuracy studies Resources Databank (CCRD) Summary Report. June; 2004.
using the QUADAS toll. A preliminary assessment. Acad p. 29-30.
Radiol 2006;13:803-10. 74. Wagner M. Ownership issues blurring the future of imaging
55. Whiting PF, Weswood ME, Rutjes AW, Reitsma JB, Bossuyt centers. Mod Healthc 1992;22:24-6.
PN, Kleijnen J. Evaluation of QUADAS, a tool for the quality 75. Mitchell JM, Sass TR. Physician ownership of ancillary
assessment of diagnostic accuracy studies. BMC Med Res services: indirect demand inducement or quality assurance? J
Methodol 2006;6:9. Health Econ 1995;14:263-89.
56. The Agree Collaboration. Development and validation of an 76. Conflicts of interest. Physician ownership of medical facil-
international appraisal instrument for assessing the quality of ities. Council on Ethical and Judicial Affairs, American
clinical practice guidelines: the AGREE project. Qual Saf Medical Association. JAMA 1992;267:2366-9.
Health Care 2003;12:18-23. 77. Morreim EH. Physician investment and self-referral: philoso-
57. Ricci S, Celani MG, Righetti E. Development of clinical phical analysis of a contentious debate. J Med Philos 1990;15:
guidelines: methodological and practical issues. Neurol Sci 425-48.
2006;27(Suppl 3):S228-30. 78. Miller JN. Scanning for dollars. Joint ventures in imaging.
58. Harbour R, Miller J, for the SIGN grading review group. A MGMA Connex 2003;3:52-5.
new system for grading recommendations in evidence based 79. Imaging. Hospitals 1990;64:24-33 (abstract).
guidelines. BMJ 2001;323:334-6. 80. Litt AW, Ryan DR, Batista D, Perry KN, Lewis RS, Sunshine
59. Haneline MT. Evidence-based chiropractic practice. Sudbury, JH. Relative procedure intensity with self-referral and
Mass: Jones and Bartlett Publishers; 2007. radiologist referral: extremity radiography. Radiology 2005;
60. Cassidy CM. Unravelling the ball of strings: reality, 235:142-7.
paradigms, and the study of alternative medicine. J Mind 81. Hillman BJ, Joseph CA, Mabry MR, Sunshine JH, Kennedy
Body Health 1994;10:5-31. SD, Noether M. Frequency and costs of diagnostic imaging in
61. Hearnshaws HM, Harker RM, Cheater FM, Baker RH, office practicea comparison of self-referring and radiolo-
Grimshaw GM. Expert consensus on desirable characteristics gist-referring physicians. N Engl J Med 1990;323:1604-8.
of review criteria for improvement of health care quality. Qual 82. Levin DC, Merrill C. Sosman Lecture. The practice of
Health Care 2001;10:173-8. radiology by nonradiologists: cost, quality, and utilization
62. Brown MJ. Prevalence of pathology seen on lumbar x-rays in issues. Am J Roentgenol 1994;162:513-8.
patients over the age of 50 years. Br J Chiropr 2001;5:23-30. 83. Levin DC, Edmiston RB, Ricci JA, Beam LM, Rosetti GF,
63. Raine R, Sanderson C, Black N. Developing clinical guide- Harford RJ. Self-referral in private offices for imaging studies
lines: a challenge to current methods. BMJ 2005;331:631-3. performed in Pennsylvania Blue Shield subscribers during
64. Plaugher G, Lopes MA. Textbook of clinical chiropractic. A 1991. Radiology 1993;189:371-5.
specific biomechanical approach. Maryland: Williams & 84. Sunshine JH, Bansal S, Evens RG. Radiology performed by
Wilkins; 1993. nonradiologists in the United States: who does what? Am J
65. Guzman J, et al. Key factors in back disability prevention: a Roentgenol 1993;161:419-29.
consensus panel on their impact and modifiability. Spine 85. Mootz RD, Cherkin DC, Odegard CE, Eisenberg DM, Barassi
2007;32:807-15. JP, Deyo RA. Characteristic of chiropractic practitioners,
66. Bussires A, Cardin A. Radiology practice guidelines for patients, and encounters in Massachusetts and Arizona. J
adult spinal disorders and pediatric musculoskeletal com- Manipulative Physiol Therapeutics 2005;28:645-53.
plaints. Indications for X-ray taking for the chiropractic intern 86. Nyiendo J, Haas M, Goodwin P. Patient characteristics,
and clinician. J Chiropr Ed 2004;18:3-4. practice activities, and one-month outcomes for chronic,
67. Bussires A, Peterson C, Taylor J. Diagnostic imaging recurrent low-back pain treated by chiropractors and family
practice guidelines for musculoskeletal complaints: Adult medicine physicians: a practice-based feasibility study. J
Lower Extremity FCER's Conference on Chiropractic Manipulative Physiol Ther 2000;23:239-45.
654 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007
87. Hurwitz EL, Coulter ID, Adams AH, Genovese BJ, Shekelle 107. Espeland A, Albrektsen G, Larsen JL. Plain radiography of
PG. Use of chiropractic services from 1985 through 1991 in the lumbosacral spine. An audit of referrals from general
the United States and Canada. Am J Public Health 1998;88: practitioners. Acta Radiol 1999;40:52-9.
771-6. 108. Eccles M, Steen N, Grimshaw J, Thomas L, McNamee P,
88. James PA, Cowan TM, Graham RP, Majeroni BA. Family Soutter J, Wilsdon J, Matowe L, Needham G, Gilbert F. Effect
physicians' attitudes about and use of clinical practice of audit and feedback, and reminder messages on primary-
guidelines. J Fam Pract 1997;45:341-7. care radiology referrals: a randomised trial. Lancet 2001;357:
89. Wolfe RM, Sharp LK, Wang RM. Family physicians' 1406-9.
opinions and attitudes to three clinical practice guidelines. J 109. Liang M, Kattz JN, Frymoyer JW. Plain film radiographs in
Am Board Fam Pract 2004;17:150-7. evaluating the spine. In: Frymoyer JW, editor. The Adult
90. Harrison DE, editor, PCCRP: Practicing Chiropractors' Spine. New York: Raven Press; 1991. p. 699-718.
Committee on Radiology Protocols for Biomechanical 110. Bhandari M, Montori V, Swiontkowski MF, Guyatt HH.
Assessment of Spinal Subluxation in Chiropractic Clinical User's guide to the surgical literature: how to use an article
Practice [monograph on the Internet], Evanston [cited 2007 about a diagnostic test. Current concept review. J Bone Joint
March 17th]. Available from: http://www.pccrp.org/ Surg 2003;85-A:1133-40.
91. Christensen MG. Job analysis of chiropractic. Chap 10 111. Grimes DA, Schulz KF. Uses and abuses of screening tests.
Professional functions and treatment procedures. A Project Lancet 2002;359:881-4.
Report, Survey Analysis Summary of the Practice of 112. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain
Chiropractic Within United States. Greeley, Colorado: with emphasis on imaging. Ann Int Med 2002;137:586-97.
National Board of Chiropractic Examiners; 2005. p. 124-5. 113. Lurie JD. What diagnostic tests are useful for low back pain?
92. Oakley PA, Harrison DD, Harrison DE, Hass JW. Evidence- Best Pract Res Clin Rheumatol 2005;19:557-75.
based protocol for structural rehabilitation of the spine and 114. Guidelines for the initial evaluation of the adult with acute
posture review of clinical biometrics of posture (CBP) musculoskeletal symptoms. American College of Rheumatol-
publications. J Can Chiropr Ass 2005;49:270-96. ogy Ad Hoc Committee on Clinical Guidelines. Arthritis
93. Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical Rheum 1996;39:1-8.
epidemiology: a basic science for clinical medicine. 2nd ed. 115. Abdu WA, Provencher ML. Primary bone and metastatic
Boston: Little Brown and Company; 1991. tumors of the cervical spine. Spine 1998;23:2767-77.
94. Harger BL, Taylor JA, Haas M, Nyiendo J. Chiropractic 116. Shukla D, Mongia S, Devi BI, Chandramouli BA, Das BS.
radiologists: a survey of chiropractors' attitudes and patterns Management of craniovertebral junction tuberculosis. Surg
of use. J Manipulative Physiol Ther 1997;20:311-4. Neurol 2005;63:101-6.
95. Carey TS, Garrett J. Patterns of ordering diagnostic tests for 117. Sasaki K, Nabeshima Y, Ozaki A, Mori H, Fujii H, Sumi M,
patients with acute low back pain. Carolina Back Pain Project. Doita M. Septic arthritis of the atlantoaxial joint: case report. J
Ann Intern Med 1996;125:807-14. Spinal Disord Tech 2006;19:612-5.
96. Cherkin CD, MacCornack FA, Berg AO. Managing low 118. Reiter MF, Boden S. Inflammatory disorders of the cervical
back paina comparison of the beliefs and behaviours of spine. Spine 1998;23:2755-66.
family physicians and chiropractors. West J Med 1988;149: 119. Rowe LJ, Yochum TR. Normal skeletal anatomy and
475-80. radiographic positioning. In: Yochum TR, Rowe LJ, editors.
97. Ammendolia C, Bombardier C, Johnson Hogg-S, Glazier R. Essentials of skeletal radiology. 3rd ed. Philadelphia:
Implementing evidence-based guidelines for radiography in Lippincott Williams & Wilkins; 2005. p. 11.
acute low back pain: a pilot study in a chiropractic community. 120. Rogers LF. The congenital malformation syndromes: osteo-
J Manipulative Physiol Ther 2004;27:171-9. chondrodysplasias, dysostoses, and chromosomal disorders. In:
98. Schultz G, Bassano J. Is radiography appropriate for detecting Juhl JH, Crummy AB, editors. Essentials of radiologic imaging.
subluxations? Top Clin Chiro 1997:41-8. 5th ed. Philadelphia: Lippincott Company; 1987 p. 314.
99. Jackson P. Summary of the 2000 ACA professional survey on 121. Taybi H. Handbook of syndromes and metabolic disorders.
chiropractic practice. J Am Chiropr Ass 2001:27-30. Radiologic and clinical manifestations. St. Louis: Mosby;
100. Medicare program; revisions to payment policies under the 1999. pp. 875.
physician fee schedule for calendar year 2000. Health Care 122. Haldeman S. Author's reply to Oppenheim et al. (JS
Financing Administration (HCFA), HHS. Final rule with Oppenheim, DE Spitzer, DH Segal) Nonvascular complica-
comment period. Fed Regist. 1999;64:59380-590 [PMID: tions following spinal manipulation. Spine J 2006;6:474.
11010693]. 123. Ammendolia C. Radiographic anomalies that may alter
101. Pederson P, Kleberg P, Walker K. Survey of chiropractic chiropractic intervention strategies found in a New Zealand
practice in Europe. Eur J Chiro pr 1994;42:3-28. population. Letter to the editor. J Manipulative Physiol Ther
102. Wilson FJH. A survey of chiropractors in United Kingdom. 2005;28:375.
Eur J Chiropr 2003;50:185-98. 124. Keating JC, Charlton KH, Grod JP, Perle SM, Sikorski D,
103. Aroua A, Decka I, Robert J, Vader JP, Valley JF. Chiroprac- Winterstein JF. Subluxation: dogma or science? Chiropr
tor's use of radiography in Switzerland. J Manipulative Osteopat 2005;13:17.
Physiol Therapeutics 2003;26:9-16. 125. Nelson CF, Lawrence DJ, Triano JJ, Bronfort G, Perle SM,
104. Pfeifle C. European survey of chiropractic. Backspace 1998;3: Metz RD, Hegetschweiler K, LaBrot T. Chiropractic as
10-1. spine care: a model for the profession. Chiropr Osteopat
105. Imbro N, Langworthy J, Wilson F, Regelink G. Practice 2005;13:9.
characteristics of chiropractors in The Netherlands. Clin Chiro 126. Carpenter J, Hutchings A, Raine R, Sanderson C. An
2005;8:7-12. experimental study of the influence of individual participant
106. Suarez-Almazor ME, Belseck E, Russell AS, Mackel JV. Use characteristics on formal consensus development. Int J
of lumbar radiographs for the early diagnosis of low back Technol Assess Health Care 2007;23:108-15.
pain. Proposed guidelines would increase utilization. JAMA 127. Burgers JS, Cluzeau FA, Hanna SE, Hunt C, Grol R.
1997;277:1782-6. Characteristics of high-quality guidelines: evaluation of 86
Journal of Manipulative and Physiological Therapeutics Bussires et al 655
Volume 30, Number 9 Diagnostic Imaging Guidelines
clinical guidelines developed in ten European countries and 148. Brighton B, Bhandari M, Tornetta P, Felson DT. Methodolo-
Canada. Int J Technol Assess Health Care 2003;19:148-57. gical issues in the design of orthopaedic studies. Hierarchy of
128. Cluzeau FA, Littlejohn P, Grinshaw JM, Feder G, Moron SE. evidence: from case reports to randomized controlled trials.
Development and application of a generic methodology to Clin Orthop Relat Res 2003;413:19-24.
assess the quality of clinical guidelines. Int J Qual Health Care 149. Foucar E, Whick MR. An observational examination of the
1999;11:21-8. literature in diagnostic anatomic pathology. Semin Diagn
129. AGREE Instrument. Appraisal of Guidelines for Research & Pathol 2005;22:126-38.
Evaluation. London: MThe AGREE Collaboration; 2001 150. Horn SD, DeJong G, Ryser DK, Veazie PJ, Teraoka J. Another
[monograph on the Internet]. Available from: http://www. look at the observational studies in rehabilitation research:
agreecollaboration.org. going beyond the holy grail of the randomized controlled
130. Papadopoulos C. The development of Canadian Clinical trials. Arch Phys Med Rehabil 2005;86(12 suppl 2):S8-S15.
Practice Guidelines: a literature review and synthesis of 151. Sorensen HT, Lash TL, Rothman KJ. Beyond randomized
findings. Discussion paper prepared for the CCA/AFCRB controlled trials: a critical comparison of trials with non-
Task Force on Chiropractic Clinical Practice Guidelines. randomized studies. Hepathology 2006;44:1075-82.
Report June 15; 2002. p. 34. 152. Bluhm R. From hierarchy to network. A richer view for
131. Ct P, Hayden J. Clinical practice guidelines: the dangerous evidence-based medicine. Perspect Biol Med 2005;48.4:
pitfall of avoiding methodological rigor. J Can Chiropr Assoc 535-47.
2001;45:154-5. 153. Barclay S, Todd C, Finlay I, Grande G, Wyatt P. Not another
132. Collins JA, Fauser BCJM. Balancing the strengths of questionnaire! Maximizing the response rate, predicting non-
systematic and narrative reviews. Hum Reprod Update 2005; response and assessing non-response bias in postal ques-
11:103-4. tionnaire studies of GPs. Fam Pract 2002;19:105-11.
133. Schmidt LM, Gotzsche PC. Of mites and men: reference bias 154. Templeton L, Deehan A, Taylor C, Drummond C, Strang J.
in narrative review articlesa systematic review. J Fam Pract Surveying general practitioners: does a low response rate
2005;54:334-8. matter? Br J Gen Pract 1997;47:91-4.
134. Whiting P, Rutjes AW, Reitsma JB, Glas AS, Bossuyt PM, 155. Jaeschke R, Guyatt G, Sackett DL. Users' guides to the
Kleijnen J. Sources of variation and bias in studies of medical literature: III. How to use an article about a diagnostic
diagnostic accuracy: a systematic review. Ann Intern Med test: A. Are the results of the study valid? Evidence-Based
2004;140:189-202. Medicine Working Group. JAMA 1994;271:389-91.
135. Carragee EJ, Haldeman S, Hurwitz E. The pyrite standard: the 156. Boulet L, Becker A, Bowie D, McIvor A, Hernandez P,
Midas touch in the diagnosis of axial pain syndromes. Spine J Rouleau M, et al. Implementing Practice Guidelines: a
2007;7:27-31. workshop on guidelines dissemination and implementation
136. Nachemson A, Vingard E. Assessment of patients with neck with a focus on asthma and COPD. Can Respir J 2006;13
and back pain: A best-evidence synthesis, chap 9. In: (Suppl A):5-47.
Nachemson A, Jonsson E, editors. Neck and back pain 157. Bartell J, Smith M. US physicians' perceptions of the effect of
The scientific evidence of causes, diagnosis and treatment. practice guidelines and ability to provide high-quality care. J
Philadelphia: Lippincott Williams & Wilkins; 2000. Health Serv Res Policy 2005;10:69-76.
137. Fouquet B. Clinical examination as a tool for identifying the 158. Mootz RD. When evidence and practice collide. J Manip-
origin of regional musculoskeletal pain. Best Pract Res Clin ulative Physiol Ther 2005;28:551-3.
Rheumatol 2003;17:1-15. 159. Graham ID, Stiell IG, Laupaces A, et al. Awareness and use of
138. Zaker J, Gursche A. Hip pain. Best Pract Res Clin the Ottawa ankle and foot rules in 5 countries: Can publication
Rheumatol 2003;17:71-85. alone be enough to changes practice? Ann Emerg Med 2001;
139. Scholten RO, Daville WL, Opstelten W, et al. The accuracy of 37:259-66.
physical tests for assessing meniscal lesions of the knee: a 160. Hollingworth W, Todd CJ, King H, Males T, Dixon AK, Karia
meta-analysis. J Fam Pract 2001;50:938-44. KR, Kinmonth AL. Primary care referrals for lumbar spine
140. Jackson JL, O'Malley PG, Kroenke K. Evaluation of radiography: diagnostic yield and clinical guidelines. Br J Gen
acute knee pain in primary care. Ann Intern Med 2003;139: Pract 2002;52:475-80.
575-88. 161. Sheldon TA, Cullum N, Dawson D, Lankshear A, Lowson K,
141. Blint G, Korda J, Hangody L, Blint P. Foot and ankle. Best Watt I, et al. What's the evidence that NICE guidance has been
Pract Res Clin Rheumatol 2003;17:87-111. implemented? Results from a national evaluation using time
142. Dinnes J, Loveman E, McIntyre L, Waugh N. The effective- series analysis, audit of patients' notes, and interviews. BMJ
ness of diagnostic tests for the assessment of shoulder pain 2004;329:999.
due to soft tissue disorders: a systematic review. Health 162. Natsch S, van der Meer JW. The role of clinical guidelines,
Technol Assess 2003;7:178. policies and stewardship. J Hosp Infect 2003;53:172-6.
143. Brox JI. Shoulder pain. Best Pract Res Clin Rheumatol 2003; 163. Gabbay J, le May A. Evidence based guidelines or
17:33-56. collectively constructed mindlines? Ethnographic studies
144. Palmer KT. Pain in the forearm, wrist and hand. Best Pract Res of knowledge management in primary care. BMJ 2004;329:
Clin Rheumatol 2003;17:113-35. 1-5.
145. Szabo RM, Slater RR, Farver TB, Stanton DB, Sharman WK. 164. Biggs L, Hay D, Mirerau D. Canadian chiropractors' attitudes
The value of diagnosis testing in carpal tunnel syndrome. towards chiropractic philosophy and scope of practice:
J Hand Surg [Am] 1999;24:704-14. implications for the implementation of clinical practice
146. Benson K, Hartz AJ. A comparison of observational studies guidelines. J Can Chirop Assoc 1997;41:145-54.
and randomized, controlled trials. N Eng J Med 2000;342: 165. Burgers JS. Guideline quality and guideline content: are they
1878-86. related? Clin Chem 2006;52:3-4.
147. Concato J, Shah N, Horwitz RI. Randomized controlled trials, 166. Haldeman S, Chapman-Smith D, Petersen DM. Guidelines for
observational studies, and the hierarchy of research designs. chiropractic quality assurance and practice parameters.
N Engl J Med 2000;342:1887-94. Gaithersburg: Aspen Publishers; 1993.
656 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Guidelines November/December 2007
167. Henderson D, Chapman-Smith D, Miors S, Vernon H. tionevidence- and case-based knowledge translation via the
Clinical guidelines for chiropractic practice in Canada. J Internet. Methods Inf Med 2006;45:389-96.
Can Chiropr Assoc suppl 1994:38. 186. Jamison JR. Teaching diagnostic decision making: student
168. Council on Chiropractice Practice. Vertebral subluxation in evaluation of a diagnostic unit. J Manipulative Physiol Ther
chiropractic practice. Clinical practice guideline; no 1. 2006;29:315.e1-e9.
Chandler (AZ): The Council; 1998. ISBN: 0-9666598-0-5. 187. Ollenschlager G, Thomeczek C, Thalau F, Heymans L, Thole
169. Recommended clinical protocols and guidelines for the H, Trapp H, Sanger S, Lelgemann M. Clinical practice
practice of chiropractic. Arlington (VA): International Chir- guidelines in Germany, 1994 to 2004. From guideline
opractic Association; 2000. p. 218. methodology towards guideline implementation. Z Arztl
170. Cates JR, Young DN, Guerriero DJ, Jahn WT, Armine JP, Fortbild Qualitatssich 2005;99:7-13 Article in German.
Korbett AB, et al. Evaluating the quality of clinical practice 188. Hutchinson A, McIntosh A, Cox S, Gilbert C. Towards
guidelines. J Manipulative Physiol Ther 2001;24:170-6. efficient guidelines: how to monitor guideline use in primary
171. Cates JR, Young DN, Guerriero DJ, Jahn WT, Armine JP, care. Health Technol Assess 2003;7:iii, 1-97.
Korbett AB, et al. An independent assessment of chiropractic 189. Jamtvedt G, Young JM, Kristoffersen DT, O'Brien MA,
practice guidelines. J Manipulative Physiol Ther 2003;26: Oxman AD. Audit and feedback: effects on professional
282-6. practice and health care outcomes. Cochrane Database Syst
172. Carey PF, Clum G, Dixon P. Final Report of the Identity Rev. 2006 Apr 19;(2):CD000259. Update of: Cochrane
Consultation Task Force [monograph on the Internet]. Database Syst Rev 2003;(3):CD000259.
Toronto: World Federation of Chiropractic; 2005. Available 190. Bennett JW, Glasziou PP. Computerised reminders and
from: http://www.wfc.org/website/WFC/website.nsf/Web- feedback in medication management: a systematic review of
Page/IdentityConsultation. randomised controlled trials. Med J Aust 2003;178:217-22.
173. Nelson CF, Lawrence DJ, Triano JJ, Bronfort G, Perle SM, 191. Winkens R, Dinat GJ. Evidence base diagnostic research.
Metz RD, Hegetschweiler K, LaBrot T. Chiropractic as spine Rational, cost effective use of investigations in clinical
care: a model for the profession. Chiropr Osteopat 2005;13:9. practice. BMJ 2002;324:783-5.
174. Meeker WC, Haldeman S. Chiropractic: a profession at the 192. Wong PK. Evidence-based practice to evidence-based policy:
crossroads of mainstream and alternative medicine. Ann do we really impact on patient care? Value Health 2005;8:
Intern Med 2002;136:216-27. 451-2.
175. Homola S. Chiropractic: history and overview of theories and 193. Neumann PJ. Evidence-based and value based formulary
methods. Clin Orthop Relat Res 2006;444:236-42. guidelines. Health Aff 2004;23:124-34.
176. Mootz RD. Chiropractic's current state: impact for the future. 194. Woolf AD. History and physical examination. Best Pract Res
J Manipulative Physiol Ther 2007;30:1-3. Clin Rheumatol 2003;17:381-402.
177. Broughton R, Rathbone B. What makes a good clinical 195. Physical diagnosis-locomotor system: a teaching guide. In:
guideline?; 2001 [Serial on the internet] [cited 2007 Jul 9]; 1 Goldeman D, editor. Patient Care Canada. Toronto, Ontario:
(11): [about 8 p.]. Available from: http://www.evidence- Healthcare and Financial Publishing, Rogers Media; 2003
based-medicine.co.uk. p. 171.
178. Watine J, Friedberg B, Nagy E, Onody R, Oosterhuis W, 196. Crawford CM, Caputo LA, Littlejohn GO. Clinical assess-
Bunting PS, Charet JC, Horvath AR. Conflict between ment in rheumatic diseaseback to basics. Top Clin Chiro
guideline methodologic quality and recommendation validity: 2000;7:1-12.
a potential problem for practitioners. Clin Chem 2006;52: 197. Souza TA. Differential diagnosis and management for the
65-72. chiropractorprotocols and algorithms. 2nd ed. Maryland:
179. Bergman DA. Evidence-based guidelines and critical path- Aspen Publication; 2001. p. 1055.
ways for quality improvement. Pediatrics 1999;103(1 Suppl E): 198. Magee DJ. Orthopedic Physical Assessment. 4th ed. Phila-
225-32. delphia: Saunders; 2002. p. 1020.
180. Matowe L, Ramsay CR, Grimshaw JM, Gilbert FJ, Macleod 199. Glas AS, Pijnenburg BA, et al. Comparison of diagnostic
MJ, Needham G. Effects of mailed dissemination of the Royal decision rules and structured data collection in assessment of
College of Radiologists' guidelines on general practitioner acute ankle injury. CMAJ 2002;166:727-33.
referrals for radiography: a time series analysis. Clin Radiol 200. Blackmore CC. Clinical prediction rules in trauma imaging:
2002;57:575-8. Who, how, and why? Radiology 2005;235:371-4.
181. Bolton JE. Chiropractors' attitudes to, and perceptions of, the 201. Beattie P, Nelson R. Clinical prediction rules: what are
impact of continuing professional education on clinical they and what do they tell us? Aust J Physiother 2006;52:
practice. Med Educ 2002;36:317-24. 157-83.
182. Broadhurst NA, Barton CA, Yelland LN, Martin DK, Beilby 202. Childs JD, Cleland JA. Development and application of
JJ. Managing shoulder pain in general practice. The value of clinical prediction rules to improve decision making in
academic detailing. Aust Fam Physician 2006;35:751-2. physical therapy practice. Phys Ther 2006;86:122-31.
183. Perry JJ, Stiell IG. Impact of clinical decision rules on clinical 203. Reilly BM, Evans AT. Translating research into practice:
care of traumatic injuries to the foot and ankle, knee, cervical Impact of using prediction rules to make decisions. Ann Intern
spine, and head. Injury 2006;37:1157-65 Epub 2006 Oct 31. Med 2006;144:201-9.
184. Coomarasamy A, Khan KS. What is the evidence that 204. Shiffman RN, Shekelle P, Overhage JM, Slutsky J,
postgraduate teaching in evidence based medicine changes Grimshaw J, Deshpande AM. Standardized reporting of
anything? A systematic review. BMJ 2004;329:1-5. clinical practice guidelines: a proposal from the conference
185. Vollmar HC, Schurer-Maly CC, Frahne J, Lelgemann M, on guideline standardization. Ann Intern Med 2003;139:
Butzlaff M. An e-learning platform for guideline implementa- 493-8.
Journal of Manipulative and Physiological Therapeutics Bussires et al 657
Volume 30, Number 9 Diagnostic Imaging Guidelines
Such guidelines have no clinical application as x-ray is a logical and It is the doctor who must decide when or when not to take x-rays,
well supported piece of any health care provider's office. liability for mistakes falls on that doctor. The type of treatments and
This document has nothing to do with what Chiropractic is. I am fully techniques provided may require follow studies
& whole-heartedly against it! All too often I see cases where failure to use x-rays by others
I look for degeneration, alignment, listings, curvature, etc. Example, it's practitioners has not been in the best interest of the patient.
very difficult to determine a Base post from an L5 subluxation without X-rays are integral evaluation of many pt's condition. Upon
a radiograph physicians evaluation, a non-trauma or trauma patient may require
While I appreciate the intent on making these guidelines EB, them. Not all pts can be categorized so strictly. Final decision should
there are other factors to consider beyond patient safety (ie, red be left to the clinician.
flags). Anyone in practice longer than five years (and as noted by Clinical decision making should be left up to the clinician and not
you) has hopefully figured out that radiographic studies usually a set of guidelines. Everyone has studied indications and
don't correlate to symptoms of any sort, so the use of X-ray for contraindications to treatment in their undergraduate education.
pain treatment (other than ruling out critical or potentially critical They only work for the insurance industry and they open the
phenomenon) is pretty much useless. However, there are other doctor up to malpractice lawsuits because no jury will take a
rationales to the use of this type of analysis. The first would be defence such as well the guidelines indicated that I did not need
postural analysis. It concerns me that you appear to have x-rays.
determined that the single study by Cooperstein et al (which Respect that our undergraduate training and experience should guide
challenges the body of work by CBP) is comprehensive enough to our practices, not a reasonably rigid academic grounded guideline!
exclude all forms of postural analysis as a rationale for utilization of Chiropractors of the 50-70's had a better understanding of spinal
X-ray. There are numerous other technique systems (ie, NUCCA, anatomy, anomalies etc than the present grads.
AO, Gonstead) utilizing both global and focal postural distortions
as part of their analytic pre-post protocol, and would suggest These are MD guidelines (n = 7)
perhaps considering investigating the data these groups have These guidelines are for MD management.
accumulated on the application of X-ray in clinical use. Another These are MD guidelines. What about Gonstead and Upper Cervical
area of practical radiographic application is with regards to choice Spine doctors. If you don't need films don't take them. I don't tell you
of technique. Higher levels of joint degeneration may indicate how to practice. Radiation Hormoesis.
avoidance of vigorous manipulative approaches (diversified, These recommendations would work if I were a M.D. If you want to
Gonstead, Crane) in favour of a more tonal nature (Toggle, TRT, be a M.D. go to med school. Let the rest of us practice
Network), not for safety, but for patient comfort and compliance to CHIROPRACTIC.
a prescribed schedule of beneficial chiropractic care. Good trauma review. We need further acceptance of how films
Structural/corrective x-rays don't fit these g-lines nor should they. We impact pt. care. Films can be great objective outcomes for care and
shouldn't limit patient x-rays for structural/corrective practices. We yield relevant info on case management and prognosis.
don't see dentists x-raying for dx only. I think these are bogus guidelines that will adversely affect my
For diagnosis, ruling in-out, pathologies, guidelines are appropriate; practice and my patient's health. This is a poor review of
evaluating mobility and cpnts of Vertebral Dysfunction Complexes, literature!
some X-ray studies may be required despite lack of red flags The study as is should be given to the ER department of some
I feel this document has been put together without considering the hospital not our new graduatesIt seems the purpose is not to make
current chiropractic profession. Where are the surveys to show how them think but to be scared.
chiropractors currently use x-rays? I didn't feel the chiropractic profession's current use of x-rays was
considered or thoroughly researched. This would be a lovely
Fails to consider x-rays as a screening tool and practitioners experience document for those specialising in spinal pathologies.
in clinical decision making (n = 14)
It also needs to be noted that many pathologies may not have red Negative comments (n = 4)
flag signs such as an abdominal aneurysm and could be detected on a Not wise.
routine x-ray. I wonder what the motive is to have such limiting guidelines are? The
DDD as well as congenital disorders (spondylolithesis) can be pccrp guidelines are a much more appropriate set of guidelines. These
asymptomatic but are important in determining care. According to are a waste of time and should be burned.
these guidelines, no x-rays would be taken if asymptomatic. I will tell as many DC's as possible as to how dangerous these
Nontraumatic and uncomplicated cases may still have underlying guidelines are to patients. I urge you to adopt the PCCRP guidelines
problems which would otherwise be overlooked, failure to utilize and throw yours away as soon as possible.
simple x-ray studies does not protect the patient. These guidelines are a waste of time and those who agree with them
Structural/corrective x-rays don't fit these g-lines, nor should are in the wrong profession, misguided and un-informed. wake up!
they. The dental profession x-rays for screening/correction. We
shouldn't limit our profession from x-rays that help patient's Suggestions for improving guidelines formatting and content (n = 6)
structure/health. The formatting poor. This reference: Nhttp://www.pnlg.it/LG/014/
This document failed to consider the large amount of evidence for 014-01.php Italian guidelines for disc and the European LBP
subluxation/biomechanical based radiographs. Please see http://www. guidelines http://www.backpaineurope.org have superseded the
pccrp.org RCGP refs you give.
To think that X-rays should only be taken in instances of pain is These guidelines should not be implemented in the current format.
ridiculous. How many pathologies were found bk we took An algorithm may be more appropriate.
radiographs of asymptomatic ptsmany certainly in my 25 high The ROM of motion numbers are wrong in the Canadian
vol practice. guidelines, this according to the American Medical Associations;
Guideline criteria are entirely based on crisis management. Guidelines to the Evaluation of Permanent Impairment, 5th edition.
Deciphering contributing/predictive factors for appropriate health Chapter 15.
promotion interventions received no consideration in this study. Multiple post traumatic lesions are missed with plain film, CT, MRI,
Journal of Manipulative and Physiological Therapeutics Bussires et al 659
Volume 30, Number 9 Diagnostic Imaging Guidelines
etc. Videofluoroscopy studies are quite valuable in the evaluation of Simple joint dysfunction that is addressed daily in chiropractic offices
the post trauma C-Spine patient. is blatantly missing.
The LNT model does not use any conclusive supporting data
according to the National Council on Radiation Protection and Neutral comments
Measurements February 1997. I would recommend a flow chart format for ease of use.
An algorithm might be helpful for each anatomic area or disorder.
Neutral comments (n = 5) Many doctors will order x-rays prior to 4 weeks of failed care if for
Impressive work, but until agreement occurs between the only medico legal aspects and also patient expectation of good care.
DACBRs and subluxation influenced DCs, it's just another The fear of failing to diagnose drives such action.
pissing match. While interesting from the sidelines, both sides The biggest impediment will be managing patients that require
need to come together. imaging studies as these services have been politically removed from
Biggest problem I have is my location and the ability to refer the chiropractic scope of practice.
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 Spine Disorders Guidelines
enough investigation, or doing too much.
Positive comments
The technological advances in imaging have removed chiropractors
Excellent synopsis of DDX and x-ray decision making
from the loop. Small practices are unable to afford to keep up. This
I've given 8's simply because I am trying to read this while being
often leads to loss of control of patient since referral is necessary and
very tired and I am nervous I might have missed something.
the M.D. takes control. These guidelines are likely to be implemented
Otherwise, I feel it is a very thorough document.
only if provincial changes are made which allow direct referral to
The pertinent clinical information is very useful, as are the suggestions
imaging centers from chiropractors.
of when to x-ray and not. This is the same for all guidelines.
Given that competing radiography guidelines are being created by the
A very useful and necessary tool for all practitioners
pccrp (http://www.pccrp.org) one wonders which guidelines to adopt
Summary of recommendations is a MUST (glad to see it was
since both claim to be evidence based.
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
APPENDIX C. SOME EXAMPLES OF COMMENTS PROVIDED BY perhaps mis-use of this document by 3rd party payers.
These guidelines are necessary because medical legal suits
PARTICIPANTS OF THE SECOND EXTERNAL REVIEW (PHASE 7) against chiropractors are often made because x- rays were not
taken at the start of care. It will support not taking them with
Extremity Disorders Guidelines (Lower and Upper) this document.
An excellent document. Thank you for all of the intense work you've
Positive comments put into this.
Clear and straightforward. There should be no controversy. Excellent review and reference material for the practitioner.
Comments section is very useful. Great Job!
I found the comments to be fairly comprehensive regarding the role These decision rules should be implemented as standard teaching
of imaging modalities for the conditions listed. material in ALL chiropractic colleges. These rules demonstrate a level
Excellent review of the signs and symptoms, recommendations for of responsibility that other recent guidelines cannot approach.
imaging are clear. These guidelines would provide a very quick yet thorough resource
Excellent guidelines in keeping with current responsible literature. for busy practitioners.
Provides a concise, to the point review of most conditions
As I refer to the local hospital for X-rays, I use similar guidelines Negative comments
already to determine the need for x-rays; these are more specific and Four weeks is entirely too long to treat a patient with radiating pain
will be used. Good work! without MRI. Malpractice risk escalates due to SMT being blamed for
Excellent review of all the things to consider before you perform an causing or increasing the size of a HNP if not originally imaged.
adjustment Conservative Chiropractic treatment requires active manipulation of
The recommendations do not vary in any significant way from the affected area.
normal clinical judgement which is exercised on a daily basis. It is I think that the prognostic information obtained by films has been
being implemented based on sound clinical decision making. minimized by only looking at the film findings from a diagnostic
There are chiropractic practitioners who will not follow these perspective and are therefore too stringent.
guidelines because of their failure to appreciate their value.
Excellent decision rules; very applicable to clinical practice. Neutral comments
When I tried a quick access approach to the guideline after a full
Negative comments perusal I found the recommendations too broad although better in the
Not once did I see mention of a chiropracticly correctable lesion summary.
(whatever term you prefer). It may just require further familiarization with the format.
Chiropractic Subluxation should be part of any differential diagnosis. MRI has a long wait and must be obtained through an MD.
I think the document is overly comprehensive with respect to the My opinion (without reference) is that some chiropractors will
descriptions of the conditions. It adds unnecessary bulk to the want to x-ray all patients, regardless of any Guidelines put forth
document which may impede its usefulness as a quick reference. 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
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 59 3 D
3. Nontraumatic trochanteric and iliopsoas bursitis Radiographs not initially indicated (C) 62 3 D Important
63 3 (but not critical)
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
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 (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
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
(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
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)
Table D3 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grading
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.
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
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
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+
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
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
Chronic elbow pain in the adult patient Radiographs indicated and 95 Strongly recommended C Important
additional views 97 Recommended (but not critical)
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
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
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
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)
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)
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 (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
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
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
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
Table D9 (continued)
(continued)
LOE:
QUADAS/
Patient presentation Recommendations Ref # AGREE/SPREAD Grade
198 2
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
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
Suspected acute thoracic aortic aneurysms Emergency referral without imaging 249 3 GPP critical
dissection/ rupture/occlusion or traumatic 250 3
aortic injury:
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