Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults—An Evidence-Based Approach: Introduction

Article Outline

• Abstract
• Methods
  • Statement of Purpose
    • Phase 1: Literature Search
    • Phase 2: Independent Literature Assessment
    • Phase 3: Guideline Development: Specific Recommendations
    • Phase 4: First External Review
    • Phase 5: Expert Consensus Panel
    • Phase 6: Public Website
    • Phase 7: Second External Review
    • Phase 8: Final Draft of the Diagnostic Imaging Guidelines and Grading of Evidence
      • Grading of Evidence
    • Phase 9: Dissemination—Implementation
• Results and Discussion
  • Literature Search and Independent Literature Assessment (Phases 1-2)
    • Results of The Literature Review of Clinical Indications for Extremity and Spine Disorders
      • Citations Supporting Proposed Recommendations for Lower Extremity Disorders
      • Citations Supporting Proposed Recommendations for Upper Extremity Disorders
      • Citations Supporting Proposed Recommendations for Spinal Disorders
    • Results from the Independent Literature Assessment
  • Delphi Panel—Consensus Opinion (Phase 5)
    • Part 1: Lower Extremity Disorders (Phase 5)
      • Hip Disorders
      • Knee Disorders
      • Ankle and foot disorders
    • Part 2: Upper Extremity Disorders (Phase 5)
      • Shoulder Disorders
      • Elbow Disorders
      • Wrist and Hand Disorders
    • Part 3: Spine Disorders (Phase 5)
      • Spinal Trauma
      • Nontraumatic Lumbar Spine Disorders
      • Nontraumatic Thoracic Spine Disorders
      • Nontraumatic Cervical Spine Disorders
• Discussion—Delphi Panel: Consensus Opinion (Phase 5)
  • Delphi Panel—Consensus Opinion (Phase 5)
    • Part 1: Lower Extremity Disorders (Phase 5)
    • Part 2: Upper Extremity Disorders (Phase 5)
    • Part 3: Spine Disorders (Phase 5)
  • “Public” Consultation (Phase 6)
    • Lower Extremity Disorders
    • Spine Disorders
      • Demographic Information
      • Comprehensiveness of Proposed Recommendations
      • Perceived Ease of Use of Guidelines and Implementation Feasibility
• Discussion—Public Consultation (Phase 6)
  • Year of Graduation
  • Onsite Access to Radiography
  • Number of Radiographic Series Ordered Per Week
  • Type of Practice
  • Second External Review (Phase 7)
    • 1. Chiropractic specialties:
    • 2. Medical specialties:
    • Comprehensiveness of Proposed Recommendations
    • Perceived Ease of Use of Guidelines and Implementation Feasibility
• Discussion—Second External Review (Phase 7)
  • Phase 8: Final Draft of the Diagnostic Imaging Guidelines and Grading of Evidence
    • Grading of Evidence
  • Study Limitations
    • Dissemination-Implementation-Evaluation-Revision
  • Potential Barriers to Implementation
    • Pretest of the Initial Draft Implemented in an Outpatient Chiropractic Teaching Institution
    • Peer Review of the Guidelines: Worldwide Public Consultation (Phase 6) and External Review (Phase 7)
    • Independent Set of Imaging Guidelines in Chiropractic
  • Strategies for Effective Guidelines Dissemination, Implementation, and Monitoring
  • Monitoring of the Guidelines/Clinical Audit
  • Updating/Revision
  • Recommendations for Future Studies
• Conclusions
• Acknowledgment
• Appendix A. Supplementary data
• Appendix B. Comments Received by Participants of the “Public” Website (Phase 6) Specific Comments Pertaining to the Lower Extremity Disorders Guidelines
• Appendix C. Some Examples of Comments Provided by Participants of the Second External Review (Phase 7)
• Appendix D. Evidence Synthesis and Grading of the Evidence for Recommendations Included in the Lower Extremity Disorders, Upper Extremity Disorders, and Spine Disorders Guidelines
• References
• Copyright

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.

Key Indexing Terms: Diagnostic Imaging, Radiology, Diagnostic X-Ray, Radiography, Practice Guideline, Musculoskeletal System, Chiropractic

Approximately 150 musculoskeletal diseases and 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 pain [LBP]), and the consequences of severe trauma. The total cost of musculoskeletal disease in the USS in the year 2000 has been calculated at US$254 billion. In developing countries, the cost of musculoskeletal injury care is estimated at US$100 billion, a figure nearly twice that of total foreign aid for these nations.^1,2 Diagnostic imaging is the most rapidly evolving specialty within health care.^3,4 Imaging technology can improve patient outcomes by allowing greater precision in diagnosing and treating patients. Despite the advent of new and advanced techniques, conventional radiography remains the cornerstone of diagnostic imaging for patients presenting with regional musculoskeletal pain, especially for acute fractures of the extremities or for suspected neoplasia.⁵, ⁶, ⁷ However, evidence of overuse, underuse, and misuse of imaging services has been emphasized in the literature.⁸, ⁹, ¹⁰, ¹¹, ¹², ¹³ In the US alone, more than $500 million are spent each year on lumbar spine radiography¹⁴ and in Ontario, Canada, the Ontario Health Insurance Plan spends more than $16 million annually on physician-requested imaging for LBP.¹⁵ Such costs are unlikely to outweigh the effect of small reported increases in patient satisfaction, especially when considering potential risks of ionizing radiation exposure and lack of demonstrable benefits to patients.¹⁶, ¹⁷, ¹⁸ It should be noted that this significant rise in expenditure has recently motivated the US Congress to reduce payments for such imaging services.¹⁹ Several factors contributing to escalating imaging costs have been identified: the aging population; the practice of defensive medicine; overuse of diagnostic imaging; self-referral abuses; duplicative studies; consumer demand; and advanced technology. Research has shown many of these costs could be decreased if the referring physician community had a solid understanding of the appropriate ordering of diagnostic imaging studies and the risks related to radiation exposure.²⁰

There is an urgent need throughout the health care professions to develop practice guidelines. Brown²¹ summarized the characteristics of quality care as (a) patient centered, (b) scientifically based, (c) population outcomes based, (d) refined through quality improvement and benchmarking, (e) individualized to each patient, and (f) compatible with system policies and resources. Government agencies, professional accreditation agencies, and public institutional policies are now demanding that all health professions develop practice guidelines that may be used to evaluate what are deemed reasonable and appropriate indications for care. In addition, recent recommendations of the Institute for Alternative Futures for the chiropractic profession include accelerating research activity, striving for high standards of practice, engaging in consumer-driven health models, engaging integration and collaboration with mainstream health care, achieving greater professional unity, and meaningfully contributing to the public health agenda.²² Evidence-based diagnostic imaging practice guidelines facilitate the implementation of such recommendations.^23,24 The purposes of guidelines are to:²⁵

These guidelines have been created to improve patient care by detailing the appropriate information gathering and decision-making processes involved in the diagnostic imaging of musculoskeletal care.

The initial impetus for this project occurred in 2003 when the Council on Chiropractic Education in Canada (CCEC) requested a revision of the diagnostic imaging guidelines used at the chiropractic teaching clinic of l'Université du Québec à Trois-Rivières (UQTR). CCEC recommended incorporating protocols that were centered on the clinical presentation of patients. We first identified the need for an extensive literature review to propose recommendations on the use of imaging studies for musculoskeletal disorders. The review began with a search for the relative risks and benefits of imaging, clinical indications for imaging of the spine and extremities, knowledge of existing guidelines, and consideration of potential barriers to dissemination and implementation strategies of any such guidelines. We set out to initially answer the following 10 questions:

Sensitivity, specificity, reliability, validity, predictive values, and likelihood ratios were considered when available and appropriate. Two hundred and fifty-seven citations were retrieved and synthesized by the principal investigator (AB) and presented in a French language narrative review to UQTR clinicians in June 2003. Relevant findings were also presented at a research conference.²⁶

This narrative review helped identify the need for development of diagnostic imaging guidelines for musculoskeletal disorders. Although several answers to the above 10 questions are integrated within the guidelines, the routine use of conventional radiography and the consequent risks of low-dose ionizing radiation exposure remain significantly contentious and will be further addressed in a separate article. Proponents of the routine use of conventional radiography offer the following justifications for that practice:²⁷

The proposed diagnostic imaging practice guidelines represent a shift to a more evidence-based approach and are supported by more than 680 primary and secondary citations. When available, meta-analyses and systematic reviews, randomized clinical trials (RCTs), nonrandomized studies, cohort and case-control studies, nonexperimental studies, and existing high-quality clinical guidelines were used to propose recommendations for various patient presentations (specific conditions) and comments supporting those recommendations.

The guidelines pertain only to adult patients and are divided into 3 parts. Part I specifically addresses lower extremity disorders; part II addresses upper extremity disorders; and part III addresses spinal disorders. All 3 parts are condition specific (symptom-based), a feature that should make these guidelines practical, user-friendly, and efficacious for practitioners.²⁸ Because accurate history and examination are crucial initial steps in the diagnosis of any musculoskeletal disorder, specific clinical criteria are emphasized for most every condition. The initial triage of patients with LBP is a constant recommendation of various clinical guidelines and we believe it to be equally applicable to the initial management of other regional painful conditions.^29,30 One major objective of the initial triage is to determine the presence of clinical indicators (red flags) for serious pathologies requiring diagnostic imaging, appropriate referral, or urgent surgical intervention. In the absence of such clinical indicators, simple decisions based on separation into articular vs nonarticular disorders and on the duration of the patient complaint (acute, subacute, persistent/chronic) are favored by most recent expert consensus statements.^30,31

Clinical presentations are divided accordingly throughout the guidelines. Recommendations for radiography (indicated, not initially indicated, not routinely indicated) appear for every clinical presentation throughout the guidelines. Because professional self-regulation and knowledge about the clinical usefulness of specialized diagnostic modalities are necessary for all primary health care professionals, recommendations for further imaging studies are therefore discussed for each condition.^32,33 In some instances, laboratory assessment is recommended.

Recent evidence suggests that implementation strategies of imaging guidelines can assist in achieving a sustained reduction in the number of radiographic examinations obtained of the cervical spine, lumbar spine, and knees.³⁴ Application of practical, highly sensitive, and reliable decision rules for cervical spine, shoulder, elbow, wrist, knee, ankle, and foot trauma has a potential to reduce the use of radiography by a factor of 16% to 50% in emergency departments and sports injury clinics alone.³⁵, ³⁶, ³⁷, ³⁸, ³⁹, ⁴⁰, ⁴¹, ⁴², ⁴³, ⁴⁴, ⁴⁵, ⁴⁶ Although the authors are uncertain of precise chiropractic utilization rates in these cases, it is likely that utilization rates in chiropractic parallel those in general medical practice because a substantial portion of chiropractic patients present with spine and extremity disorders or have a history of cervical spine trauma.⁴⁷ Although targeting a different population (generally not as acutely injured), application of decision rules in private practice should also help reduce the use of radiographic studies. For example, in acute LBP in adults, the age criterion proposed in earlier guidelines (>50 years of age) as well as the tendency to order radiographs in patients with symptom duration of less than 4 weeks has low specificity and substantially increased utilization.^12,48 One authority now recommends obtaining lumbar spine radiographs in patients older than 65 years rather than 50 and waiting up to 7 weeks to obtain radiographs in patients with an untreated first episode of LBP.⁴⁹

The aim in conducting an evidence review is to facilitate the integration of the best available evidence with clinical expertise and the values and beliefs of patients. Although these proposed guidelines are more restrictive and likely more cost-efficient, practitioners are provided with the necessary information to allow for significant flexibility in decision making. As with all guidelines, clinical judgment and clinician experience must be used in all cases. It must also be emphasized that clinical practice guidelines (CPGs) are intended to assist, not replace, clinicians in their decision-making processes. Guidelines aid in the application of selective diagnostic tools and therapeutic approaches for specific clinical presentations while considering patient preference.⁵⁰

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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 inappropriate 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 literature, 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.

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• Fig 1. 

  Diagram of flow of information from literature to publication. Phase 1, literature review; phase 2, independent literature assessment; phase 3, guideline development (specific recommendations); phase 4, first external review; phase 5, consensus panel; phase 6, public website; phase 7, second external review; phase 8, final draft and grading of the evidence; phase 9, dissemination.

The literature search focused on the appropriate use of conventional radiography and specialized (advanced) imaging for adult musculoskeletal disorders of the spine and extremities. Studies conducted in any setting were included in the review, including general practice, accident and emergency, and hospital clinics. The selection criteria were applied to the abstracts of the publications retrieved by the search strategy described below. The publications were retrieved and read if the abstracts provided insufficient information to enable selection. The review also considered biomechanics, degenerative changes and spinal curvatures (and their relationship to patient symptoms), indicators of potentially serious pathology (red flags), as well as congenital anomalies, trauma, scoliosis, and osteoporosis. Any study that compared clinical examination and/or assessment of patient history with an acceptable gold standard for the evaluation of patients with musculoskeletal pain was included. A review of various national and international chiropractic and medical guidelines discussing the use of imaging studies for musculoskeletal disorders was also incorporated in the literature review.

Phase 1 consisted of an electronic search in English and French language literature. Two literature updates were conducted using a similar strategy. This included MEDLINE (Pub Med) (1966-2003; -2005; -August 2006), the Cochrane Register (-January 2004, 2006), the National Research Register (-January 2004, 2006), the National Guideline Clearinghouse (-January 2004, 2006), the internet “Google” search engine, as well as cross references and references provided by clinicians. The search strategy also included other databases such as EMBASE to identify relevant studies for several of the disorders. A combination of subject headings (MeSH headings) and keywords were searched (specific disorders of the adult hip, knee, ankle and foot, shoulder, elbow, wrist and hand, pain, extremity, lumbar spine, thoracic spine, cervical spine, low back pain, thoracic pain, neck pain, whiplash, trauma, diagnostic, radiograph, x-ray, imaging, US, CT, MRI, MRA, bone scan, nuclear medicine, musculoskeletal, chiropractic, and medical guideline).

Specific disorders of the extremities and spine were subdivided into the following categories:

When available, systematic reviews and meta-analyses, RCTs, nonrandomized studies, observational studies (cohort and case-controlled studies), nonexperimental (nonanalytic) studies, and existing high-quality clinical guidelines took precedence over case studies, case series, or opinion for inclusion in the study. Articles were excluded from the recommendations if they were not available in English or French or could not be translated, if they were published before 1980 (except for some rare classic papers), and if they specifically focused on thermography, electrodiagnostic studies, intervention, nonmusculoskeletal disorders, or on children. Details of the literature review (2003-2006) are available upon request.

Early phases of this guideline project used the European Commission classification (2001)⁵¹ to classify grade of recommendations (Table 1). However, several new instruments have been proposed to evaluate scientific literature. Weaknesses identified in the grading system initially proposed by the US Agency for Healthcare Research and Quality led to the development of new tools to assess available literature.⁵²

Table 1. Classification used by the European Commission (2001)⁵¹

With the objective of independently assessing the level of evidence of citations listed in the guidelines and considering the recently developed assessment tools, 5 literature reviewers (licensed practitioners, 4 with specialized training in research methods) were invited to review the citations of the spine and extremity imaging guidelines. A number of citations were assessed by at least 2 evaluators to compare the level of agreement between evaluators. In cases of disagreement, the research team reached a decision and classified the citation.

The methodological quality of all studies that were included in the review was assessed by means of a methodological quality assessment list. Participants were asked to complete an evidence extraction table (Excel spreadsheet), provided at the outset of the review, with a list of all citations included in the spinal and extremity disorders guidelines. Requested information included summaries of study design; study objective in brief; type of analysis; methods (including population studied, and follow-up period); study results/evidence provided; scores for the scoring instruments (QUADAS, AGREE, and SPREAD); significant biases.

Three methodological scoring instruments were used, as described below.

The main measure was the degree of quality expressed in terms of percentage within a range of 0% (minimum) to 100% (maximum) for each of the 6 domains (Fig 3).

Fig 3. AGREE items⁵⁶

Scope and purpose

• The overall objective(s) of the guideline is (are) specifically described

• The clinical question(s) covered by the guideline is (are) specifically described

• The patients to whom the guideline is meant to apply are specifically described

Stakeholder involvement

• The guideline development group includes individuals from all the relevant professional groups

• The patients' views and preferences have been sought. The target users of the guideline are clearly defined

• The guideline has been piloted among the target users

Rigor of development

• Systematic methods are used to search for the evidence

• The criteria for selecting the evidence are clearly described

• The methods used for formulating the recommendations are clearly described

• The health benefits, side effects, and risks have been considered in formulating the recommendations

• There is an explicit link between the recommendations and the supporting evidence

• The guidelines have been externally reviewed by experts prior to its publication

• A procedure for updating the guidelines is provided

Clarity and presentation

• The recommendations are specific and unambiguous

• The different options for management of the condition are clearly presented

• Key recommendations are easily identifiable

• The guideline is supported with tools for application

Applicability

• The potential organizational barriers in applying the recommendations have been discussed

• The potential cost implications of applying the recommendations have been considered

• The guideline presents key review criteria for monitoring and/or audit purposes

Editorial independence

• The guideline is editorially independent from funding body

• Conflicts of interest of guideline development members have been recorded

To further assist in their appraisal, the literature reviewers were provided with a checklist for the appraisal of epidemiologic studies, literature review articles, and systematic reviews.⁵⁹ It should be noted that the literature assessment (phase 2) included citations retrieved during the initial literature search, the 2 literature updates, and articles provided by Delphi panelists and participants in the second external review phase.

Based on the literature review, the primary author (AB), with the assistance of a staff chiropractic radiologist, composed the first draft of a diagnostic imaging practice guideline for chiropractic interns and clinicians.

To simplify decision making about radiograph utilization, the proposed guidelines are based on common clinical presentations of conditions affecting the spine, the lower, and upper extremities. The Referral Guidelines for Imaging (radiation protection 118) coordinated by the European Commission in conjunction with the UK Royal College of Radiologists (2001)⁵¹ served as a template for the present recommendations. For those guidelines, evidence gathering, synthesis, and grading were undertaken by a large group of radiologists across the European Union. Classification of evidence levels was translated into grades of recommendations based on the system developed by the US Department of Health and Human Services, Agency for Health Care Policy and Research (1993). As a means of comparison, typical effective ionizing radiation doses delivered to patients for common imaging procedures are reported in Table 2.

Table 2. Typical effective ionized radiation dose for common imaging procedures∗

For every clinical presentation throughout the guidelines, one of 4 recommendations appears. When appropriate, the proposed recommendation is accompanied by the level of evidence and pertinent comments. The recommendations are as follows:

The guidelines were then reviewed by several experts in the Spring of 2003, including 3 chiropractic radiologists from different academic institutions; 2 chiropractors specializing in epidemiology; and one practicing chiropractor who also possessed an MSc degree. The guidelines, with input from the first 6 reviewers, were then sent for external review to 6 additional chiropractors holding a diplomate or fellowship in either radiology or clinical sciences. Each reviewer independently assessed the guidelines and, where appropriate, made suggestions and comments that were incorporated.

Considering the overall low quality of scientific studies available on diagnostic imaging, a large Delphi consensus panel was invited to consider the proposed recommendations. When meaningful clinical trials are unavailable, development of recommendations by consensus opinion is considered an acceptable option.⁶⁰, ⁶¹, ⁶² Delphi surveys using large groups show greater within and between reliability.⁶³ Phase 5 of this project involved a modified Delphi panel composed of a group of international experts on the topic of musculoskeletal disorders in clinical chiropractic, chiropractic radiology, and chiropractic research. Three sources of information were used to identify experts: publication record, membership, and involvement in relevant organizations such as the American Chiropractic College of Radiology, and recommendations from researchers and educators in the field. In addition, chiropractic college presidents (all members of the Association of Chiropractic Colleges) were asked to provide the names of 3 faculty members from their respective institutions: one chiropractic radiologist, one clinical science specialist, and one researcher. Among the several named techniques, authoritative figures from Chiropractic Biophysics technique (CBP) protocols and Gonstead technique⁶⁴ were also invited to participate. Our research team determined that the expert group selected offers a diverse range of views and adequately represents the profession. Recognizing the existence of a significant body of literature on conventional radiography for biomechanical analysis, results of the initial literature review for question 6 (What is the clinical usefulness of spine radiography in biomechanical analysis, including spinal curvatures and scoliosis, especially with respect to the effects on spinal degeneration?) were provided on the Web to Delphi panelists for consideration during the evaluation of recommendations for spine disorders. Phase 5 was overseen in its entirety by 2 Delphi process expert advisors (one from the USA and one from the UK).

Although face-to-face discussions between panelists are preferable to reach consensus, limitations of time and prohibitive costs precluded using this strategy. As an alternative, we incorporated electronic communication technology. By accessing a restricted (password protected) website, experts were asked to independently evaluate the proposed guidelines and to provide recommendations aimed at forming a consensus opinion. Each scenario was accompanied by a binary type answer: agree-disagree. In case of disagreement with a particular recommendation, panelists were instructed to provide comments and suggestions supported by relevant references. Submission deadlines were regularly announced by e-mail and a regularly updated schedule served to inform panelists of completed and upcoming sections. At the conclusion of each first round, results were made available to all panelists and an updated version of the guideline was posted in PDF format on the website before the second round began. A minimum of 75% agreement was established as necessary to reach consensus for all recommendations. It was further decided to restrict the Delphi process to 2 rounds as the initial guidelines were already based upon a careful review of the literature. Two rounds were determined to be sufficient to achieve adequate consensus and served to minimize the workload of participants. Consensus was judged as strong (>85% of panel members), moderate (50%-84%), or low (33%-49%).⁶⁵

Results of phase 5 were posted on a website accessible to chiropractors worldwide. Advance announcements were published in the World Federation of Chiropractic Quarterly World Report and Dynamic Chiropractic publications informing chiropractors of the nature of the project and inviting them to access the website and to offer comments and suggestions on proposed recommendations. Professional trade organizations invited to nominate members to review the proposed diagnostic imaging guidelines included the following: World Federation of Chiropractic, Canadian Chiropractic Association (CCA), American Chiropractic Association (ACA), International Chiropractic Association (ICA), State and Provincial chiropractic associations, European and Asian chiropractic associations.

Every section of the guideline was posted for consideration for a period of 2 months. The objectives of phase 6 were to:

Practitioners were invited to comment on their perceived level of confidence and comfort with using the proposed Delphi results of the diagnostic imaging guidelines in their individual practices, as measured by an appropriateness (Likert) scale. Participants provided a rating from 1 (strongly disagree) to 9 (strongly agree). They were also encouraged to provide comments with pertinent rationale and references to support their disagreements with any of the recommendations.

To comprehensively involve all stakeholders and to guarantee editorial independence, a second external review was initiated. To achieve these goals, chiropractic specialists and 2 groups of medical experts on musculoskeletal disorders were invited to provide comments and suggestions on the Delphi consensus imaging guidelines (phase 5). Chiropractic specialists in Canada were briefly introduced to the study objectives and methodology by the principal investigator (AB) on November 17, 2006, at a meeting organized by the CFCRB during the Canadian National Convention. Canada's chiropractic specialists formally received an invitation to participate in the External Review (phase 7) by mail and e-mail. American chiropractic specialists were notified and invited to participate by mail and e-mail to addresses that were retrievable. Guidelines were made accessible on a new website for a period of 10 weeks so that elected representatives of the following groups could evaluate recommendations on a specific data collecting form as measured by an appropriateness (Likert) scale. Participants provided a rating from 1 (least appropriate/strongly disagree) to 9 (most appropriate/strongly agree), with a separate option for “don't know.”

Chiropractic specialties included the following: College of Chiropractic Radiology, Canada (FCCR); American Chiropractic College of Radiology (ACCR); College of Chiropractic Clinical Sciences (Canada) (FCCS); College of Chiropractic Sport Sciences (Canada) (FCCSS); College of Chiropractic Orthopedists (Canada) (FCCOC); College of Chiropractic Rehabilitation Sciences (CCRS); American College of Chiropractic Orthopedists (ACCO); College of Chiropractic Rehabilitation Sciences (CCRS); American College of Chiropractic Council on Neurology (NOCA/ACCN).

Medical specialties included 2 groups of medical experts, one from Canada and the other from the USA, with expertise in musculoskeletal disorders (neurology, neurosurgery, orthopedics, physical medicine and sports medicine specialists, osteopathic medicine, and radiology). Names of experts were provided by personal contacts of panelists involved in this project and members of the research team.

The research team considered all suggestions and comments received upon completion of the public website (phase 6) and second external review (phase 7). In addition, a member of the public with specialized training in research was asked to review the methodology and to consider all recommendations from the 3 recently developed adult musculoskeletal diagnostic imaging guidelines. As a patient representative, this person was asked how, in general, proposed recommendations “fit” with public interest and patient protection.

Grading of Evidence 

All recommendations are graded according to the strength of the evidence. The investigators of this project formally met to assign a grade to each of the recommendations, indicating the strength of available scientific evidence (level A to D) for spinal and extremity disorders. The criteria for the grades are outlined by the SPREAD tool (Fig 4). The strength of evidence was assessed by evaluating consistency of the findings across studies and the quality of the studies.

These aspects were judged and summarized based on the following statements:

Members of the team had to reach consensus on the grades administered. Where the evidence is insufficient and recommendations are based on consensus opinion alone, this is indicated as a “Good Practice Point.” Recommendations are also accompanied by a suggestion of “critical” or “important (but not critical).” Critical is defined as a life-threatening condition or as a situation in which patients are at risk of serious complications if they are not referred for appropriate care in a timely manner.

The complex and challenging issue of implementation and utilization of CPGs also needs to be considered. To prevent duplication and reduce costs, it has been proposed that results from the Delphi panel be shared with American and Canadian chiropractic national guideline development committees and/or task forces. The CCA and the Canadian Federation of Chiropractic Licensing Board (CCA/CFCRB task force overseeing the development of clinical chiropractic practice guidelines) were sent copies of these guidelines (phase 4) for consideration in the fall of 2004. The Council for Chiropractic Guidelines and Practice Parameters (CCGPP) in the USA will also be consulted to consider the possibility of integrating sections of the diagnostic imaging guidelines as they reach completion. We encourage researchers to apply the AGREE instrument or other similar instruments to evaluate the strength of the evidence as well as the validity of the consensus document.

Implementation of the final version of the guidelines will require involvement of national, provincial, and state organizations. In addition to publishing these in this peer-reviewed journal, several other strategies are being considered:

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Results and Discussion 

For clarity, the results, discussion, and related tables are presented in sequence. These include (A) the literature search and independent literature assessments (phases 1-2), (B) the Delphi panel–consensus opinion (phase 5), (C) the “public” consultation (phase 6), and (D) the second external review (phase 7).

Literature Search and Independent Literature Assessment (Phases 1-2) 

More than 300 original scientific citations published in peer-reviewed biomedical journals and 3 textbooks were selected by one investigator (AB) during the initial literature search. The literature updates and the inclusion of articles submitted up to the second external review (phase 7) resulted in a total of 682 citations for the 3 diagnostic imaging guidelines (lower extremity disorders = 174 citations; upper extremity disorders = 126 citations; spine disorders = 382 citations). Most citations originated from peer-reviewed biomedical journals published in the last decade.

Citations Supporting Proposed Recommendations for Lower Extremity Disorders 

Eighty-five articles related to upper and lower extremity disorders were included in the initial draft of the guideline between 2003 and 2004. Meta-analysis and systematic reviews (4), clinical trials (35), existing clinical guidelines (15), review articles (28), and textbooks (3) were used to propose recommendations and/or relevant comments. A literature update was conducted in 2005 resulting in the addition of 32 new studies. Overall, 117 articles pertaining to adult extremity disorders were included in this draft of the extremity guidelines. Meta-analysis and systematic reviews (5), clinical trials (43), existing clinical guidelines (28), review articles (39), and textbooks (4) were used. Recommendations and/or relevant comments were reviewed accordingly. A final literature update just before the launching of the lower extremity disorders Delphi process (phase 5) in February 2006 and references provided by Delphi panelists (February-April 2006) for the lower extremity guideline alone resulted in the addition of 91 new references. Meta-analyses and systematic reviews (0), clinical studies (40), existing clinical guidelines (2), review articles (30), and textbooks (19) were mainly added to clinical presentations and comments for special imaging recommendations (Table 3).

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

Citations Supporting Proposed Recommendations for Upper Extremity Disorders 

Eighty-five articles related to adult upper and lower extremity disorders were included in the initial draft of the guideline between 2003 and 2004. Meta-analysis and systematic reviews (4), clinical trials (35), existing clinical guidelines (15), review articles (28), and textbooks (3) were used to propose recommendations and/or relevant comments. A literature update was conducted in February 2006 resulting in the addition of 32 new studies. Overall, 52 citations pertaining to adult upper extremity disorders were included in this draft of the guidelines. Meta-analysis and systematic reviews (2), clinical studies (17), existing clinical guidelines (13), review articles (18), and textbooks (2) were used. A final literature update just before the launching of the upper extremity disorders Delphi process (phase 5) in August 2006 and references provided by Delphi panelists (October-November 2006) for the upper extremity guideline alone resulted in the addition of 74 new citations. Meta-analyses and systematic reviews (1), clinical studies (39), existing clinical guidelines (7), review articles (24), and textbooks (3) were mainly added to clinical presentations and comments for special imaging recommendations (Table 4). Recommendations and/or relevant comments were reviewed accordingly.

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

Citations Supporting Proposed Recommendations for Spinal Disorders 

One hundred and seventy-eight citations pertaining to adult spinal disorders were included in the initial draft of the guideline (December 2003). Meta-analyses (0), systematic reviews (6), clinical studies (92), existing clinical guidelines (9), review articles (51), textbooks (18), and commentaries or letters (2) were used to propose recommendations, relevant comments, and descriptive patient presentations. A literature update conducted in September 2005 resulted in the inclusion of 35 new citations: systematic reviews (2), clinical studies (20), existing clinical guidelines (4), review articles (3), textbooks (4), and commentaries (2). A final literature update just before the launching of the spine disorders Delphi process (phase 5) in April 2006 and references provided by Delphi panelists between April and July 2006 for the lumbar, thoracic, and cervical spine disorders resulted in the addition of 169 new citations: meta-analyses (3), systematic reviews (6), clinical studies (107), existing clinical guidelines (6), review articles (40), and textbooks (7) were mainly added to the clinical presentations and to the comments related to special imaging recommendations. Overall, a total of 382 citations were included in the lumbar, thoracic, and cervical spinal disorder guidelines (Table 5).

Table 5. Number and types of references included from first draft to Delphi results for spine disorders

The number of citations per individual category is as follows: spinal trauma (41), nontraumatic lumbar spine (128), nontraumatic thoracic spine (77), and nontraumatic cervical spine (108). The discrepancy between the total number of citations included in the spinal disorder guidelines (382 citations) and the addition of individual category citations (354) is related to references included as general background information at the beginning of some sections. These references do not specifically support proposed recommendations.

Results from the independent literature assessment (study quality and reported findings) are available in Appendix A (available at doi:10.1016/j.jmpt.2007.10.003). Except for citations found in the background information and those providing insights on the management of certain conditions, all citations were independently assessed by a team of reviewers. The majority of review articles are narrative rather than systematic. Narrative reviews generally are comprehensive and cover a wide range of issues within a given topic, but they do not necessarily state or follow stringent rules regarding the search for evidence. Because narrative reviews are prone to several biases (subjective, no explicit methods for searching literature or reporting and cannot be replicated), these study designs were rated as a 3 (level of evidence). Textbooks were also assigned a level 3 for the same reasons.

Delphi Panel—Consensus Opinion (Phase 5) 

The lower extremity, upper extremity, and spine disorders guidelines were evaluated using a modified Delphi panel composed of an international group of experts on the topic of musculoskeletal disorders in clinical chiropractic, chiropractic radiology, and chiropractic research. Of the 145 participants invited to participate in the Delphi panel, 44 were not included because they either could not be reached or they did not reply to invitations. Ten others declined to participate, and 7 eventually withdrew from the Delphi panel for personal reasons. Overall, 76 experts agreed to return a confidential agreement to participate. Only responses from those having returned a confidential agreement were included to participate in the Delphi panel.

Sixty-six panelists representing 20 chiropractic institutions actively participated in the first round. Expert panel composition (academic, clinicians, and researchers, and a mixture of those) for each category evaluated is provided in Figure 5, and the submission deadlines for each round are presented in Table 6. As each category was completed, the results were posted on the website in a PDF file accessible to all panelists. Changes were highlighted in the text for clarity.

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• Fig 5. 

  Delphi panel composition for adult lower extremity disorder guidelines.

Table 6. Delphi panel submission deadlines for the lower extremity disorders guidelines

Percentage agreement for each recommendation, including patient presentation and pertinent comments for round 1 and round 2 (where applicable) of adult hip, knee, and ankle and foot disorders, is tabulated in Tables 7 to 9.

Table 7. Percentage agreement for recommendations of adult lower extremity disorders guidelines —hip (rounds 1 and 2)

Patient presentation	% Agreement
	Round 1 (n = 69)	Round 2 (n = 53)
General indications for radiographs	92	90
Adult patients with:
Full or limited movement and nontraumatic hip pain of <4 wk's duration	91	94
1. Strain, tendinitis, or tendinosis	84	96
2. Piriformis syndrome	94
3. Nontraumatic trochanteric and iliopsoas bursitis	92	96
4. Osteoporotic hip fractures	95
5. Septic arthritis of the hip	100
Chronic hip pain unresponsive to 4 wk of conservative care or if one of the following conditions is suspected:	92
1. Congenital/developmental abnormalities	84	98
2. Osteoarthritis (DJD)	98
3. Inflammatory arthritis	90
4. Osteonecrosis	93
5. Tumors and metastatic lesions	97
6. Stress (fatigue or insufficiency) fractures	97
Significant hip trauma	97

Hip Disorders 

Sixty-six panelists completed the hip disorders section. Results of round 1 were forwarded to all panelists to consider comments, and new references were provided. Although more than 75% agreement was reached for all 14 recommendations, 5 new recommendations were proposed for the second round owing to the proposal of significant changes. Forty-nine panelists returned round 2 (Table 7).

Knee Disorders 

Fifty-four panelists completed the only round necessary to reach consensus for all 9 recommendations (Table 8). Percentage agreement ranged between 83% and 96%.

Table 8. Percentage agreement for recommendations of adult lower extremity disorders guidelines—knee (round 1)

Patient presentation	% Agreement Round 1 (n = 59)
General indications for radiographs	88
Adult patients with:
Full or limited movement and nontraumatic knee pain of <4 wk's duration or if one of the following conditions is suspected:	93
1. Osteoarthritis (OA)	92
2. Inflammatory arthritis	86
3. Bursitis/ tendinitis/ strain/ tendinosis	84
4. Anterior knee pain	83
5. Internal joint derangement	96
Acute knee injury but negative findings for the OKRs	94
Acute knee injury and positive findings for the OKRs	94

Ankle and foot disorders 

For the ankle and foot disorders section, 53 panelists completed all 26 recommendations. Based on suggestions proposed in the first round, 6 new recommendations were proposed for the second round. Forty-eight panelists participated in round 2 (Table 9). Percentage agreement ranged between 87% and 100% for all recommendations accepted. Table 10 shows the breakdown of panelists completing the lower extremity disorders sections.

Table 9. Percentage agreement for recommendations of adult lower extremity disorders guidelines—ankle and foot (rounds 1 and 2)

Patient presentation	% Agreement
	Round 1 (n = 57)	Round 2 (n = 48)
Adult patient with:
Acute ankle and foot injury but negative findings on the OARs	87
Acute ankle and foot injury and positive findings on the OARs:
Ankle	94
Foot	81	96
Acute toe injury	91
Chronic ankle and tarsal pain	93	91
Impingement syndromes		98
(a) Anterolateral impingement	93
(b) Anterior impingement	96
(c) Anteromedial impingement	93
(d) Posterior impingement	94
Peroneal tendinosis	90
Lateral premalleolar bursitis	100
Tarsal tunnel syndrome	98
Chronic foot pain	94
(A) Hindfoot-heel pain	92
A1. Plantar fasciitis and calcaneal enthesosphyte (spur)	90
A2. Sinus tarsi syndrome	94	91
(B) Midfoot pain (nontraumatic)	92	96
B1. Acquired flat foot with posterior tibial tendon dysfunction/rupture	87
B2. Navicular tuberosity pain and tenderness	92
B3.Complex regional pain syndrome	98
(C) Forefoot pain
C1. Metatarsal bursitis	92
C2. Morton's neuroma	91
C3. Stress (fatigue or insufficiency) fracture	92	89
C4. Osteonecrosis (avascular necrosis)	90
C5. Hallux rigidus and hallux valgus (1st MTP joint)	88
C6. Sesamoiditis	98

Table 10. Delphi panel participant profile for the lower extremity disorders guidelines

Expert panel composition (academic, clinicians, and researchers, and a mixture of those) for each category evaluated is provided in Figure 6, and the submission deadlines for each round are presented in Table 11. For every category completed, final results were posted on the website in a PDF file accessible to all panelists. Changes were highlighted in the text for clarity.

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• Fig 6. 

  Delphi panel composition for adult upper extremity disorder guidelines.

Table 11. Delphi panel submission deadlines for the upper extremity disorders guidelines

Percentage agreement for each recommendation, including patient presentation and pertinent comments for rounds 1 and 2 (where applicable) of adult shoulder, elbow, and wrist and hand disorders, is provided in Tables 12 to 14.

Table 12. Percentage agreement for recommendations of adult upper extremity disorders guidelines—shoulder (rounds 1 and 2)

Patient presentation	% Agreement
	Round 1 (n = 51)	Round 2 (n = 30)
General indications for radiographs		100
Adult patient with:
Localized shoulder pain	88	100
Acute shoulder trauma	92	96
Glenohumeral joint trauma
Glenohumeral joint instability	92
Rotator cuff disorders	80	96
Adhesive capsulitis	89
Osteoarthritis	94	100
Glenohumeral joint arthritis	98
Acromioclavicular joint disorders	89

Shoulder Disorders 

Fifty-one panelists completed round 1 and 30 panelists completed round 2 of the shoulder disorders category. The results of round 1 were forwarded to all panelists for consideration of the comments and new references provided by various panel members. Although more than 80% agreement was reached for all 8 recommendations in round 1, 5 new recommendations were proposed for the second round as a result of input from panel members (Table 12).

Elbow Disorders 

Forty-eight panelists completed the only round necessary to reach consensus, reaching between 92% and 98% agreement for all 6 recommendations. A new recommendation for forearm pain after trauma was added before the final consultation of the upper extremity disorders guideline. Comments received were integrated in the final draft (Table 13).

Table 13. Percentage agreement for recommendations of adult upper extremity disorders guidelines—elbow (round 1)

Patient presentation	% Agreement Round 1 (n = 48)	Final consultation
Adult patient with localized elbow pain after trauma	98
Adult patients with full or limited movement and nontraumatic elbow pain of <4 wk's duration	92
Chronic elbow pain in the adult patient	92
Lateral epicondylitis	92
Medial epicondylitis	92
Diffuse nonspecific pain in the forearm (or wrist)	96
Forearm pain after trauma (included before final consultation)		Xa

Wrist and Hand Disorders 

Similarly, 48 panelists completed the only round necessary to reach consensus for all 11 recommendations, reaching between 89% and 100% agreement on individual recommendations (Table 14). Table 15 depicts the breakdown of panelists completing the upper extremity disorders sections.

Table 14. Percentage agreement for recommendations of adult upper extremity disorders guidelines—wrist and hand (round 1)

Patient presentation	% Agreement Round 1 (n = 48)
Adult patient with:
Acute wrist trauma	94
Acute hand and finger trauma	98
Localized wrist and hand trauma	89
Diffuse nonspecific pain in forearm or wrist	96
Tenosynovitis of the wrist	92
Dequervain's disease	98
Trigger finger	100
CTS	92
Osteoarthritis	94
Inflammatory or crystal induced arthropathy	100
Rheumatoid arthritis	96

Table 15. Delphi panel participant profile for the upper extremity disorders guidelines

Expert panel composition for each category evaluated is provided in Figure 7, and the submission deadline for each round is presented in Table 16. For every section completed, final results were posted on the website in a PDF file accessible to all panelists. Changes were highlighted in the text for clarity. Percentage agreement for each recommendation, including patient presentation and pertinent comments for round 1 and round 2 (where applicable) of adult spine disorders, is provided in Tables 17 to 20. Sixty-one experts representing 21 chiropractic institutions actively participated.

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• Fig 7. 

  Delphi panel composition for adult spinal disorder guidelines.

Table 16. Delphi panel submission deadlines for the spine extremity disorders guidelines

Table 17. Percentage agreement for recommendations of adult traumatic spine disorders (rounds 1 and 2)

Patient presentation	% Agreement
	Round 1 (n = 50)	Round 2 (n = 42)
Adult patient with lumbar spine trauma	88
Adult patient with recent (<2 wk) acute thoracolumbar, lumbar, or thoracic spine trauma	95	92
Adult patient with thoracolumbar, lumbar, or thoracic spine blunt trauma or acute injuries (falls, motor-vehicle accidents, motorcycle, pedestrian, cyclists, etc)	93	100
Adult patient with posttraumatic chest wall pain (thorax) : minor and major trauma	92	97
Adult patient with pelvis, sacrum, and coccyx trauma (including fall with inability to bear weight)	90	93
Coccyx trauma and coccydynia	N/A	95
Adult patient with acute neck injury and negative CCSR	93
Adult patient with acute neck injury and positive CCSR
Part 1	98
Part 2	95

Spinal Trauma 

Although all recommendations for the spinal trauma category were integrated in the lumbar, thoracic, and cervical spine sections of the guidelines, they are conveniently presented here separately. Fifty panelists completed round 1 and 42 panelists completed round 2 of the spinal trauma categories (Table 17).

Round 1 included the following sections: (a) trauma to the lumbar spine, pelvis, sacrum, and coccyx; (b) thoracic spine and chest wall (thorax) trauma; and (c) cervical spine 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 recommendations and although 88% agreement was reached for all recommendations of the remaining sections, panelists were asked to evaluate 5 new recommendations owing to the proposal of significant changes. Between 88% and 98% agreement was reached for all recommendations of the first round. Round 2 included the following sections: (a) trauma to the lumbar spine, thoracolumbar spine, thoracic spine, pelvis, sacrum, and coccyx regions; and (b) chest wall (thorax) trauma. Fifty panelists returned both sections of the second round. Percentage agreement ranged between 92% and 100% on all 5 new recommendations (Table 17).

Nontraumatic Lumbar Spine Disorders 

For the nontraumatic lumbar spine category, 50 panelists completed all 15 recommendations reaching a minimum of 82% agreement. Nonetheless, based on suggestions received from the first round, 3 recommendations were significantly modified and one new recommendation was added for the second round. Forty-two panelists then participated in round 2, reaching more than 93% agreement on all 5 recommendations (Table 18).

Table 18. Percentage agreement for recommendations of adult nontraumatic lumbar spine disorders (rounds 1 and 2)

Patient presentation	% Agreement
	Round 1 (n = 50)	Round 2 (n = 42)
Adult patient with acute mechanical LBP including sciatica	88	95
Reevaluation of acute LBP for critical exclusionary diagnoses and radiographs are indicated in the absence of treatment response after 4 to 7 weeks	85
Common causes of sciatica	82
Adult subacute and persistent LBP without previous treatment	N/A	90
Adult with chronic LBP (>3 mo) without red flags	88
Adult with chronic LBP (>3 mo) and unresponsive to 4 wk of conservative care	98
Reassess factors adversely affecting LBP prognostic/recovery in adults with recurrent/persistent LBP without red flags	94
Adults with complicated LBP ( with red flags):	98
Presumed inflammatory spondyloarthropathy	96
Presumed fracture	98
Presumed neoplasia	98
Presumed infection	98
Progressive or painful structural deformity or surgical fusion	98
Elevated laboratory examination	92
Presumed cauda equine syndrome	90	98
Presumed abdominal aortic conditions	90	100

Nontraumatic Thoracic Spine Disorders 

For the nontraumatic thoracic spine disorders category, 50 panelists completed all 6 recommendations. Based on suggestions proposed in the first round, however, 7 new recommendations were proposed for the second round. Thirty-seven panelists participated in round 2, reaching more than 92% agreement for all recommendations (Table 19).

Table 19. Percentage agreement for recommendations of adult nontraumatic thoracic spine disorders (rounds 1 and 2)

Patient presentation	% Agreement
	Round 1 (n = 50)	Round 2 (n = 37)
Adult patient with nontraumatic thoracic pain with no red flags	96
Reevaluation of thoracic pain for critical exclusionary diagnoses and radiographs are indicated in the absence of treatment response after 4 to 6 wk	94
Pain—osteoporotic vertebral collapse	94
Adult scoliosis
Part 1	92
Part 2	94
Nonpainful and nonprogressive scoliosis in adult	N/A	92
Adult patient with nontraumatic chest wall pain
Part 1	N/A	100
Part 2	N/A	95
Adult patient with thoracic pain in the presence of red flags	98
Adults with complicated thoracic pain (with red flags)
(A) Adults patient with complicated (ie, “red flag”) thoracic pain and indicators of contraindication to SMT (relative/absolute)	N/A	97
(B) Suspected thoracic aortic dissection	N/A	100
(C) Suspected compression fracture	N/A	97
(D) Osteoporosis risk factor	N/A	95

Nontraumatic Cervical Spine Disorders 

For the nontraumatic cervical spine disorders category, 51 panelists completed all 10 recommendations, reaching between 88% and 98% agreement. Based on suggestions proposed in the first round, however, all but one recommendation were modified and resubmitted to the Delphi panel. Forty-three panelists participated in round 2, reaching between 92% and 100% agreement for all recommendations (Table 20). Table 21 outlines the breakdown of panelists completing the lumbar, thoracic, and cervical spine disorders rounds.

Table 20. Percentage agreement for recommendations of adult nontraumatic cervical spine disorders (rounds 1 and 2)

Patient presentation	% Agreement
	Round 1 (n = 51)	Round 2 (n = 43)
Adult patient with acute uncomplicateda neck pain (<4 wk's duration)	96
Adult patient with acute nontraumatic neck pain and radicular symptoms	88	95
Adult patient with subacute neck pain (4-12 wk's duration) or persistent neck pain (>12 wk) with or without arm painb and reevaluation for critical exclusionary diagnoses and radiographs indicated in the absence of treatment response after 4 wk	88	92
Adult patient with neck pain in the presence of red flag and indicators of contraindication to SMT	98	97
1. High-risk ligament laxity populations/possible atlantoaxial instability	90	97
2. Cervical myelopathy and radiculomyelopathy	91	95
3. (a) Cervical artery dissection (VAD, CAD), TIA	98	100
(b) Cervical artery dissection (VAD, CAD), TIA (risk factors)	89
(c) Cervical artery dissection (VAD, CAD), TIA (physical examination)	93
(d) Cervical artery dissection (VAD, CAD), TIA (past history of neck trauma)	91

Table 21. Delphi panel participant profile for the spinal disorder guidelines

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Discussion—Delphi Panel: Consensus Opinion (Phase 5) 

Delphi Panel—Consensus Opinion (Phase 5) 

Although significant contributions were made by panelists such as helping to clarify recommendations including clinical descriptions, proposing radiographic views and specialized imaging studies, and adding new references, the guideline structure remained essentially unchanged. The end result is a condition-specific practice guideline, based on common clinical presentations of traumatic and nontraumatic conditions affecting the adult extremity and spine disorders. Although more than 75% agreement was reached during the first round for all 124 recommendations of the lower and upper extremity disorders, and spine disorders guidelines, 39 recommendations underwent a second round owing to the proposal of significant changes. Overall consensus was deemed strong having reached over 85% agreement for all 124 recommendations.

On average, 54 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 for various reasons including personal health issues, personal workload, the project's stringent schedule, changes of e-mail address, or vacations. Such a decline in participation over time was anticipated. It is unknown to what extent ideological differences played a role in the decline of participants. The authors and consultants discussed the decline at length, and we determined that it is not the actual number of participants in the panel that is most important, but rather the distribution in 3 areas of expertise that had a 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 participants (69.6% of the initial 69 participants) were distributed as follows: 12 academics, 13 clinicians,12 academics and clinicians, 1 researcher, 7 researchers/academics, 3 researchers/clinicians, including 11 chiropractic radiologists (DACBR). We concluded that this distribution adequately represented the initial Delphi panel consisting of a broad spectrum of individuals in the various areas of expertise (Table 10).

Seventy-six experts initially agreed to return a confidential agreement, but only 51 of those actually contributed to this part of the study by returning the first category (shoulder pain disorders) of the upper extremity guidelines. The number of panelists contributing to the first rounds of each category (shoulder, elbow, wrist and hand) remained stable with an average of 49 participants. A significant decrease in participation was noted for the second round of the shoulder disorders category. Various reasons contributing to this low participation rate included personal workload, the stringent schedule and length of the project, changes of e-mail address, temporary absences, and vacations. Although we anticipated such a decline in participation over time, the returning of 30 evaluation questionnaires is still considered acceptable as 4 of the 5 new recommendations had previously received more than 80% agreement on the first round, and the last recommendation (general indications for radiographs) received 100% agreement. The distribution of participants in the various areas of expertise for this second round is as follows: 5 academics, 12 clinicians, 3 researchers/academics, 6 academics/clinicians, 4 researchers/clinicians, including 7 chiropractic radiologists (DACBRs). We determined that this distribution adequately represented the broad spectrum of the various areas of expertise in the initial Delphi panel (Table 15). Although included in the final draft of the upper extremity guideline consultation, the only recommendation that was not originally submitted to the Delphi panel was “Forearm pain following trauma of the elbow” category. Comments and suggestions received by Delphi participants were integrated in the final document.

Seventy-six experts initially agreed to return a confidential agreement and 50 of those actually contributed to this part of the study by returning the first category (lumbar spine disorders) of the spine guidelines. On average, just more than 45 panelists completed the traumatic and nontraumatic spinal disorders categories (Table 21). Various reasons contributing to the decline in participation were similar to those of the other parts of the study. Taking into account the lowest participation level of all sections evaluated, that is, round 2 of the nontraumatic thoracic spine disorders section, the 37 participants were distributed as follows: 12 academics, 10 clinicians, 8 academics/clinicians, 0 researchers, 5 researchers/academics, 2 researchers/clinicians, including 12 chiropractic radiologists (DACBRs). We determined that this adequately represented the broad spectrum of the various areas of expertise in the initial Delphi panel (Table 21).

“Public” Consultation (Phase 6) 

Results of the diagnostic imaging guidelines by consensus opinion (phase 5) were posted on a protected website accessible to chiropractors worldwide. As the upper extremity disorders guidelines were still under development, only the lower extremity and spine disorders proposed guidelines were made available for consultation. Advance announcements published in various chiropractic journals and other sources reached a potential of 60000 chiropractors. However, the total number of practitioners that was reached using this strategy is unknown.

For this phase, a total of 930 chiropractors completed a consent form on a protected website to review recommendations for imaging studies. Of those, 344 registered to participate between August 5, 2006, and October 31, 2006. As access to the website had not been closed at the date initially announced, an additional 4 chiropractors registered before January 31, 2007.

There were 2107 accesses to the welcoming page of the diagnostic imaging “public website” (every reentry counted as 1). Once registered, participants entered a protected website housing the 2 PDF files and corresponding evaluation questionnaires: (1) lower extremity disorders diagnostic imaging guidelines, and (2) spine disorders diagnostic imaging guidelines. A total of 559 accesses were counted on the protected website (every reentry counted as 1).

Among the 75 registered participants who accessed the lower extremity disorders guidelines, 44 completed the demographic information, and 35 of those completed the evaluation questionnaire (hip, knee, and ankle and foot sections) (Fig 8).

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• Fig 8. 

  Diagram Organization of public consultation (Phase 6).

Of the 87 participants who accessed the spine disorders guidelines, 59 completed the demographic information, and 50 completed the evaluation questionnaire (spine trauma, nontraumatic cervical, nontraumatic thoracic, and nontraumatic lumbar spine sections) (Fig 5).

Demographic Information 

Forty-four practitioners from 6 countries (Australia, Canada, United States, Italy, New Zealand, United Kingdom) completed the demographic information for the lower extremity disorders guidelines questionnaire, and 59 chiropractors from 6 countries (Canada, United States, Italy, New Zealand, Switzerland, and United Kingdom) completed the demographic information for the spine disorders guidelines questionnaire. The majority of practitioners were from Canada (47%) and the United States (40%). Participants graduated from 17 different institutions, with a majority of those coming from Canadian Memorial Chiropractic College or Palmer Chiropractic College West. Nearly 80% of practitioners graduated after 1981, and 20% to 30% of respondents had completed either a fellowship or a diplomate in a chiropractic specialty. The majority of respondents were in full-time practice (84% for lower extremity disorders and 86% for spine disorders). A significant number of chiropractors reported practicing alone (40% in the lower extremity questionnaire, and 51% in the spine disorders questionnaire), or in group or multidisciplinary practice (56% and 45%, respectively). Ninety-eight percent reported that they were legally allowed to take radiographs in their jurisdiction with 67% of the lower extremity participants and 78% of the spine disorders guidelines participants having onsite access to radiography. The majority of respondents ordered on average less than 15 radiographic series per week, whereas a small minority (2-8%) ordered more than 15 radiographic series per week. More than 30% of participants admitted to never taking radiographs of the lower limbs. Approximately half of all participants said they occasionally referred patients for specialized imaging of the extremities and spine (Table 22).

Table 22. Demographic information of registered participants (Phase 6)

Demographic data	Lower extremity disorders (n = 44)	Spine disorders (n = 59)
Country
Australia	4 (9%)	–
Canada	21 (48%)	27 (46%)
United States	16 (36%)	26 (44%)
Italy	1 (2%)	1 (1.7%)
New Zealand	1 (2%)	3 (5%)
Switzerland	-	1 (1.7%)
United Kingdom	1 (2%)	1 (1.7%)
Practicing state/province
Canada	Alberta 2 (5%)	Alberta 2 (3%)
	BC 8 (19%)	BC 7 (12%)
	Ontario 10 (24%)	Manitoba 2 (3%)
	Quebec 1 (2%)	Ontario 13 (22%)
	Other 5 (12%)	Quebec 3 (5%)
		Other 4 (7%)
United States	California 1 (2%)	Arkansas 9 (15%)
	Connecticut 1 (2%)	California 2 (3%)
	Florida 2 (5%)	Colorado 1 (2%)
	Illinois 2 (5%)	Connecticut 1 (2%)
	Kentucky 2 (5%)	Florida 4 (7%)
	Missouri 1 (2%)	Illinois 2 (3%)
	Montana 1 (2%)	Kentucky 2 (3%)
	Rhode Island 1 (2%)	Maryland 1(2%)
	Texas 2 (5%)	Michigan 1 (2%)
	Utah 1 (2%)	Missouri 1 (2%)
	Virginia 1 (2%)	Montana 1 (2%)
		New Jersey 1 (2%)
		New York 3 (5%)
		South Dakota 1 (2%)
		Tennessee 1 (2%)
		Texas 1 (2%)
		Virginia 1 (2%)
		Washington 1 (2%)
		Wisconsin 1 (2%)
Chiropractic college attended
AECC	2 (4.5%)	4 (7%)
Canadian Memorial Chiropractic College	14 (24%)	19 (32%)
Cleveland (Kansas) Cleveland (LA)	–	1 (2%)
Life West (CA)	–	1 (2%)
Life University (GA)	1 (2%)	3 (5%)
Logon	3 (7%)	4 (7%)
LACC	1 (2%)	2 (3%)
MacQuarie	–	1 (2%)
National	1 (2%)	–
NYCC	4 (9%)	2 (3%)
Northwestern	–	2 (3%)
Palmer (Davenport)	3 (7%)	5 (9%)
Palmer west	7 (16%)	12 (21%)
Parker	1 (2%)	–
Sherman	1 (2%)	1 (2%)
Texas	1 (2%)	1 (2%)
Unit (Victoria Australia)	1 (2%)	–
Not specified	2 (5%)	–
Year of graduation
Before 1960	–	1 (2%)
1970-1980	9 (20%)	10 (17%)
1981-1990	10 (23%)	15 (25%)
1991-2000	15 (34%)	16 (27%)
2001-2006	10 (23%)	17 (29%)
Postgraduate training
Chiropractic fellowship (sports, clinical sciences, radiology, rehabilitation)	3 (7%)	7 (12%)
Diplomate/certificate (orthopedic, neurology, nutrition, pediatric, geriatric, etc)	5 (11%)	10 (17%)
MSc	3 (7%)	4 (7%)
Other	3 (7%): BA, BEd, Doctor of Naturopathic Medicine	6 (10%): ATC, CSCS, BA, Doctor of Naturopathic Medicine, JD, MA(Ed), MBA, QME, Radiology
Professional membership (National):
American (ACA)	9 (20%)	9 (15%)
British (BCC)	1 (2%)	1 (2%)
Canadian (ACC)	19 (43%)	19 (32%)
Australia (CAA)	4 (9%)	–
General Council, UK	–	1 (2%)
New Zealand (NZCA)	1 (2%)	3 (5%)
Italy (AIC)	1 (2%)	1 (2%)
Swiss (SCA)	–	1 (2%)
None	1 (2%)	1 (2%)
Member one other association	2 (4.5%): CAND-Naturopathic (1), ICPA (1)	6 (10.7%): ACA (1), BCA (1), ECU (1), CAND- Naturopathic (1), ACC (1) , ICPA (1)
ICA	2 (4.5%)	9 (15%)
World Chiropractic Alliance	2 (4.5%)	3 (5.3%)
Practice
• Full time	36 (82%)	50 (85%)
• Part time	6 (14%)	4 (7%)
• Academic—teacher	2 (5%)	3 (5%)
• No longer in practice	–	2 (3%)
Type of practice
• Solo	17 (40%)	30 (51%)
• Group	14 (33%)	18 (31%)
• Multi/Interdisciplinary	10 (23%)	8 (14%)
• Academic—teacher	2 (5%)	2 (3%)
• None	–	1 (2%)
Qualified to take radiographs in jurisdiction
• Yes	43 (98%)	57 (98%)
• No	1 (2%)	1 (2%)
On site access to radiography
• Yes	29 (67%)	46 (78%)
• No	14 (33%)	13 (22%)
Average number radiographic series ordered per week
• None	14 (32%)	2 (3%)
• < 5	27 (61%)	20 (34%)
• Between 5-15	2 (5%)	32 (54%)
• Over 15	1 (2%)	5(8%)
Average number of referral for specialized imaging studies per month
• None	21 (48%)	22 (37%)
<5	22 (50%)	31 (53%)
>5	1 (2%)	6 (10%)

Comprehensiveness of Proposed Recommendations 

Participants were asked to rank the 2 diagnostic imaging guidelines for comprehensiveness on an appropriateness (Likert) scale from 1 (least appropriate/strongly disagree) to 9 (most appropriate/strongly agree), with a separate option for “don't know.” Of the 35 chiropractors who completed all 3 sections of the lower extremity guidelines (hip, knee, and ankle and foot), 77% agreed or strongly agreed with the proposed recommendations, whereas the remaining 23% disagreed or strongly disagreed. Fifty respondents completed all 4 sections of the spine disorders guidelines, the majority of whom agreed with the proposed recommendations of the spine trauma and nontraumatic thoracic spine sections (56% and 54%, respectively). Half of the practitioners agreed with the nontraumatic lumbar spine section, whereas 52% disagreed with the nontraumatic cervical spine recommendations (Table 23).

Table 23. Percentage agreement for recommendations of adult lower extremity disorders and spine disorders guidelines. Based on a scoring system from 1 to 9 (1 = least appropriate, 9 = most appropriate)

Question 1–4: How comprehensive are the recommendations and corresponding comments?	Results
	Lower extremity disorders (n = 35)	Spine disorders (n = 50)
Question 1	Hip pain	Spine trauma
Score
• <5	23%	44%
• ≥5	77%	56%
Question 2	Knee pain	Non traumatic lumbar spine
Score
• <5	23%	50%
• ≥5	77%	50%
Question 3	Ankle and foot pain	Non traumatic thoracic spine
Score
• <5	23%	46%
• ≥5	77%	54%
Question 4	N/A	Non traumatic cervical spine
Score
• <5		52%
• ≥5		48%

Perceived Ease of Use of Guidelines and Implementation Feasibility 

Perceived overall ease of use of the proposed diagnostic imaging lower extremity and spine disorders guidelines was ranked as moderate to high (≥5 out of 9) by 77% and 56% of practitioners, respectively (Table 24). When asked about the interest and desire for implementing the proposed diagnostic imaging lower extremity and spine disorders guidelines, 62% and 40% (respectively) of practitioners indicated being interested (≥5 out of 9), whereas 35% (lower extremity disorders) and 59% (spine disorders) strongly disagreed (≤3 out of 9). Similarly, 65% of the lower extremity guidelines respondents and 38% of the spine disorders respondents ranked the feasibility of implementing these guidelines into practice as good or very good (≥5 out of 9). However, when considering the scope of practice in their own province, state, or country, 29% of the lower extremity guidelines respondents and 59% of the spine disorders guidelines respondents ranked the feasibility of implementing these recommendations into practice as low or very low (≤3 out of 9).

Table 24. Percentage agreement for perceived ease of use of guidelines and implementation feasibility of adult lower extremity disorders and spine disorders guidelines. Based on a scoring system from 1 to 9 (1 = least appropriate, 9 = most appropriate)

Question 5-7: Perceived ease of use of guidelines and implementation feasibility	Results
	Lower extremity disorders (n = 35)	Spine disorders (n = 50)
Question 5: Perceived overall ease of use of the proposed guideline
Score
• <5	23%	44%
• ≥5	77%	56%
Question 6: Interest/desire for implementing guidelines into own practice
Score
• <5	38%	60%
• ≥5	62%	40%
Question 7: Feasibility of implementing the proposed recommendations into practice considering the scope of practice in own province/state/country
Score
• <5	35%	61%
• ≥5	65%	38%
		No response = 1

Back to Article Outline

Discussion—Public Consultation (Phase 6) 

Overall, chiropractors have a tendency to take fewer radiographs of the extremities than of the spine, probably related to the conditions typically seen in practice. Approximately 15% of initial consultations in North American chiropractic clinics are for disorders of the extremities, whereas three quarters (76%) of patients consult chiropractors for spinal conditions.⁷⁰ Although there is a paucity of literature as to the types of extremity disorders seen by chiropractors, it is reasonable to assume that acute traumatic injuries of the extremities would be more commonly seen in emergency facilities, rather than in chiropractic offices.

Results from this public consultation phase of the study must be interpreted with caution, considering the low participation rate. Possible reasons for this are addressed in a later part of this article. In addition, several factors related to practice were not collected in our study, including the average weekly number of patients and new patients, patients' reasons for consulting, and type of technique used by participants. Nonetheless, certain observations deserve consideration.

Year of Graduation 

Crossed data analysis revealed that practitioners taking more spinal radiographs (either 5-15 or >15 sets of films per week) graduated between 1991 and 2006 (Table 25). In addition, recent graduates were least likely to find the recommendations and corresponding comments comprehensive or useful and were least interested in implementing the proposed spine disorders guidelines in their practices, even when considering the scope of practice in their own province, state, or country (Table 26). Although the ordering of more tests is common behavior among many who lack experience,⁷¹ implementation of clinical decision rules by practitioners of all levels of clinical experience can result in a decrease in radiography, waiting times, and costs without altering the quality of care.⁷² Thus using imaging guidelines can help reassure less experienced practitioners.

Table 25. Year of graduation of participants in relation to the average number of spinal radiographic series ordered per week

Table 26. Year of graduation of participants in relation to their opinion of how comprehensive are the nontraumatic cervical spine recommendations and corresponding comments

Overall appreciation using the following scoring system from 1 to 9: 1 = least appropriate, 9 = most appropriate.

Onsite Access to Radiography 

A large majority of participants had onsite access to radiography (78% of respondents for the spine disorders and 67% for the extremity disorders guidelines). This very likely skewed the results. According to one Canadian survey, the majority of chiropractors no longer own their own equipment. Survey results from 2003 reveal that only 34% of full-time Canadian chiropractors took their own radiographs. In Ontario and British Columbia, Canada, where most Canadian participants reside and practice, only 27% and 26%, respectively, of full-time chiropractors own their own x-ray equipment.⁷³ Ownership of ancillary services and self-referral raise issues of potential conflicts of interest.⁷⁴, ⁷⁵, ⁷⁶, ⁷⁷, ⁷⁸, ⁷⁹, ⁸⁰ Thus, it appears that chiropractors who own their own x-ray equipment were far more likely to participate in this survey as the proposed imaging guidelines could potentially have more impact on their practice patterns and hence a negative effect on income.

Number of Radiographic Series Ordered Per Week 

It is well known that when health care professionals own their own imaging equipment this results in far more frequent utilization.⁸¹, ⁸², ⁸³, ⁸⁴ In our study, more than half (54%) of participants in the spine disorders guidelines section ordered between 5 and 15 radiographic series per week, with 8% ordering more than 15 spine radiographic series per week. Recent surveys in North America indicate only 6% to 17% of chiropractic patients receive radiographs during their visit.^70,85 In a practice-based study of chronic LBP in the USA, 1 (25%) in 4 patients underwent radiography.⁸⁶ Overall, a decline in radiograph use has been observed since the late 1980s and early 1990s when more than half of the chiropractic patients in the USA were receiving radiographs before treatment for their current episode of LBP.⁸⁷ An alternative explanation for the results in our study may be that our sample included chiropractors working in high volume practices. The type of practice (solo or group practice, and chiropractic technique used) may also influence clinician's decision-making behavior.

Type of Practice 

The majority of participants in this study were in solo practice. Solo practitioners traditionally tend to express more negative attitudes regarding clinical guidelines than physicians in non–solo practices.^88,89 In addition, certain practice management groups encourage chiropractors to take radiographs to favor long-term patient retention. This factor, however, was not measured in our study.

Spinal radiography is an integral component of patient biomechanical spinal evaluation in some chiropractic techniques. Although information relating to the type of chiropractic technique used was not gathered in our study, e-mail exchanges and invitations to review competing guidelines on a website⁹⁰ promoted by CBP may have had some impact on this phase of the project. Their welcoming page stated, “The PCCRP guidelines are in direct competition/opposition to current attempts to restrict Chiropractic Radiography to ‘Red Flag Only’ conditions or diagnosis.” On this same website, one could read: “Do you want to be outside the ‘standard of care’ for taking ‘routine’ radiographs for subluxation assessment and post-treatment radiographs? If not please review the PCCRP guidelines and complete the survey…”

The practice of taking routine repeat radiographs to monitor patient progress is not commonplace in chiropractic,⁹¹ but some “named” technique systems advocate this as an integral part of their standard of practice.⁹² It has been our observation that those advocating routine radiography and repeat radiography are resistant to any change that may challenge their uninhibited use of radiography. Not surprisingly, those feeling threatened or angry may be more likely to answer surveys of this nature. It is therefore possible that those having less practical experience, possessing onsite access to radiography, who are in solo practice, and who tend to obtain radiographs on most new patients as part of the technique used would tend to respond negatively to the proposed diagnostic imaging guidelines. On the other hand, those who refer to imaging centers, are in multi/interdisciplinary practice, and predominantly use common diversified techniques were not as likely to participate because they were not as threatened and not as directly affected by the guidelines.

Although there appears to be a strong sampling bias in the public feedback group, results of this phase of the project (phase 6) help in identifying potential obstacles to dissemination and implementation strategies of these guidelines. Understanding what drives clinicians to order imaging studies is important. General comments gathered from participants during the study ranged from very enthusiastic to a strong desire never to see such guidelines implemented (Appendix B). The concerns could be classified into 3 general categories:

It is our observation that there is a general misunderstanding about the usefulness of evidence-based literature and practice guidelines. Practitioners should feel reassured to know that the evidence-based approach to health care is meant to assist, not replace, clinicians in clinical decision making by summarizing available literature to be used in conjunction with the clinician experience and judgment while considering patient preference.⁹³ Evidence-based care and guidelines were never intended to replace the intelligence of the clinician. One criticism is that guidelines are frequently misinterpreted and simply used by third-party payers to restrict or deny reimbursement for care. Although no one can predict how insurance companies and legislators may want to apply the abundance of guidelines available, we agree that the proposed diagnostic imaging guidelines should not be used by legislators or in a medical-legal context as other factors such as cost-effectiveness analysis and safety impact were not specifically analyzed and much of the content needs to be validated prospectively.

Indications for radiography are vigorously debated within chiropractic. Most chiropractors obtain radiographs for clinical reasons, such as confirming a diagnosis of pathology, but many continue to use radiography as a screening tool and for medicolegal protection.^27,94 The frequency of conventional radiograph utilization by chiropractors for LBP complaints ranged from 60% to 90% in North America,⁹⁵, ⁹⁶, ⁹⁷ but many of the reasons provided by chiropractors for taking radiographs are not supported by the literature.^27,94,98 Recent surveys, however, suggest a significant decrease in reported frequency over time,⁹⁹ with, for example, 17% and 6% of Arizona and Massachusetts patient visits involving radiography, respectively.⁸⁵ It is worth noting that since the inception of Medicare 30 years ago, chiropractors had been mandated to obtain radiographs to be reimbursed for care. Only after persistent legislative activity has this provision finally been changed.¹⁰⁰

The percentage of patients x-rayed by full-time Canadian chiropractors has also decreased since 1997. According to one Canadian survey, the proportion of chiropractors who obtain radiographs on only 1% to 25% of their patients increased from 35% in 1997 to 49% in 2003. This trend was accompanied by consistent declines in the proportion of chiropractors who obtain radiographs on more than 25% of their patients.⁷³ One reason for such reductions in utilization may be related to a more limited access to radiology equipment. In 2003, only 34% of full-time Canadian chiropractors took their own radiographs, in comparison to 50% in 1997. Of interest, 76% of Quebec full-time chiropractors took their own radiographs compared to Ontario (27%), British Columbia (26%), and Saskatchewan (7%).⁷³

Similar utilization patterns by chiropractors were identified in Europe,¹⁰¹ but recent surveys also reveal a reduction in radiography utilization. In the year 2000, only 25% to 30% of chiropractic patients were radiographed in the United Kingdom¹⁰² and Switzerland.¹⁰³ Limited access to radiology facilities possibly explains why fewer radiographs are taken throughout several other European countries. Chiropractors in Belgium, France, Germany, Greece, Italy, Spain, and Sweden do not have the legislation necessary to allow taking or ordering radiographs.¹⁰⁴ Similarly, practitioners in the Netherlands have recently lost the right to use radiographic equipment.¹⁰⁵

Arguments against the routine use of imaging studies have been addressed elsewhere.^9,94,106, ¹⁰⁷, ¹⁰⁸, ¹⁰⁹ Acceptable features of a proposed test that are sufficient to produce useful information in a particular situation include the sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and diagnostic odds ratios. In other words, how good is the index test at detecting the target condition?^110,111 Conventional radiography does not appear to be clinically useful as a screening test as evidenced by the low prevalence of serious spinal pathologies such as cancer and infection, and the poor sensitivity, predictive values, and likelihood ratios for many musculoskeletal conditions.¹¹², ¹¹³, ¹¹⁴, ¹¹⁵, ¹¹⁶, ¹¹⁷, ¹¹⁸, ¹¹⁹, ¹²⁰, ¹²¹

In addition, the answer to the above question (regarding the use of an index test for detecting a target condition) has not been adequately provided by proponents of the routine use of imaging studies to justify its use in screening to determine the presence of chiropractic subluxations or to prevent serious complications before spinal manipulative therapy.^122,123 Experimental evidence regarding the very nature of the subluxation syndrome still appears to be lacking.^124,125 Clearly, well-designed prospective studies are needed to help answer many of these questions. Until such evidence is available, selective use of imaging studies is advisable.

Second External Review (Phase 7) 

More than 300 chiropractic specialists and 14 medical specialists were invited to review the diagnostic imaging guidelines by consensus opinion (phase 5).

Invitations to review the proposed 3 diagnostic imaging guidelines were sent by mail (total of 275 specialists for whom addresses were available). In addition, representatives of the following chiropractic specialty groups agreed to forward the invitation by e-mail to respective members (forwarded e-mails by the Council on Neurology were not confirmed):

Fourteen medical specialists from the USA and Canada were invited to participate by e-mail, personal letters, and/or telephone calls [orthopedic surgeons (5), neurosurgeons (2), rheumatologists (1), medical internists (2), physical medicine specialists (3), osteopathic clinicians in the USA (1), medical radiologists (2)]. Two could not participate owing to personal illnesses.

As a result of these invitations, a total of 271 health care professionals completed a consent form provided on a protected website (external review—phase 7) to review recommendations of the diagnostic imaging guidelines. Of those, 100 chiropractic specialists and 6 medical specialists registered to participate in this phase of the project, which ran from December 17, 2006, through February 9, 2007. Demographic information is detailed in Table 27.

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

Country			N = 105
USA			59 (56%)
Canada			45 (43%)
UK			1 (1%)
Practicing state/province
USA	Canada	UK
Alaska (1), Arizona (1), California (5), Connecticut (2), Colorado (2), Florida (3), Georgia (2), Hawaii (1), Illinois (6), Indiana (1), Iowa (2), Kansas (1), Maryland (2), Missouri (2), MS (1), Montana (2), 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)	Alberta (4), British Columbia (8), Manitoba (2), Nova Scotia (1), Ontario (21), Quebec (9)	1
Year of graduation
Before 1970			11 (10.4%)
1970-1980			11 (10.4%)
1981-1990			29 (27.6%)
1991-2000			41 (39%)
2001-2006			11 (10.4%)
Unknown			2 (2%)
Postgraduate training			105 (100%)
Chiropractic fellowship and diplomats			100 (95%)
Radiology			59 (57%)
Sports			19 (18%)
Orthopedics			8 (7.6%)
Rehabilitation			7 (6.6%)
Clinical sciences			6 (5.7%)
Other			1 (0.95%)
Participants holding additional specialty and/or having completed a master degree			11 (10%), MSc (10), DACNB (2), rehabilitation (1), acupuncture (1)
Medical degree			6 (5.6%)
• Orthopedics			2 (1.9%)
• Rehabilitation			2 (1.9%)
• Internal medicine			1 (0.9%)
• Neurosurgery			1 (0.9%)
Practice
• Full-time			71 (67.6%)
• Part-time			18 (17%)
• Academic—teacher			13 (12%)
• No longer in practice			3 (3%)

There were 566 accesses to the welcoming page of the diagnostic imaging “review website” (every reentry counted as 1). Once registered, participants entered a protected website housing the 3 PDF files and corresponding evaluation questionnaires: (1) lower extremity disorders diagnostic imaging guidelines, (2) upper extremity disorders diagnostic imaging guidelines, and (3) spine disorders diagnostic imaging guidelines. As every reentry is counted as 1, a total of 310 individuals were counted as accessing the protected website. Of the 59 participants who accessed the lower extremity evaluation questionnaires, 44 completed the evaluation questionnaire for the lower extremity guidelines. Of the 39 participants who accessed the upper extremity evaluation questionnaires, all completed the evaluation questionnaire for the upper extremity guidelines. Of the 41 participants who accessed the spine disorders evaluation questionnaires, 33 completed the evaluation questionnaire for the spine disorders guidelines.

The majority of specialists who completed the evaluation questionnaires were chiropractic radiologists (63.8%), followed by sport science (16.3%), and clinical science specialists (10.3%). Approximately 65% of respondents graduated between 1981 and 2000 (Table 27, Fig 9, Fig 10).

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• Fig 9. 

  Speciality of reviewers having completed at least one evaluation questionnaire (Phase 7).

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• Fig 10. 

  Year of graduation of reviewers having completed at least one evaluation questionnaire (Phase 7).

Experts were asked to rank the 3 diagnostic imaging guidelines for comprehensiveness on an appropriateness (Likert) scale (Table 28). For the lower extremity guidelines, 44 reviewers completed the hip and knee sections and 41 specialists completed the ankle and foot section. Thirty-nine reviewers completed all 3 sections of the upper extremity disorders (shoulder, elbow, and wrist and hand), and 33 reviewers completed all 4 sections of the spine disorders sections (spine trauma, nontraumatic cervical, thoracic and lumbar spine). Except for one participant in the ankle and foot section of the lower extremity guidelines who strongly disagreed and 2 more reviewers who indicated “I don't know” in this same section, all experts strongly agreed (ranked at or >7 out of 9) with the proposed recommendations of the lower extremity, upper extremity, and spine disorders guidelines.

Table 28. Percentage agreement for recommendations of adult lower extremity disorders, upper extremity disorders, and spine disorders guidelines

Question 1–4: How comprehensive are the recommendations and corresponding comments?	Results
	Lower extremity disorders (n = 44)	Upper extremity disorders (n = 39)	Spine disorders (n = 33)
Question 1	Hip pain	Shoulder pain	Spine trauma
Score
• <5 (least appropriate)	–	–	–
• ≥7 (most appropriate)	100%	100%	100%
• I don't know	–	–	–
Question 2	Knee pain	Elbow pain	Nontraumatic lumbar spine
Score
• <5	–	–	–
• ≥7	100%	100%	100%
• I don't know	–	–	–
Question 3	Ankle and foot pain	Wrist and hand pain	Nontraumatic thoracic spine
Score	(n = 41)
• <5	2%	–	–
• ≥7	93%	100%	100%
• I don't know	5%	–	–
Question 4	N/A	N/A	Nontraumatic cervical spine
Score			–
• <5		–	­
• ≥7			100%
• I don't know

Instructions to participants: evaluate all sections of the Lower Extremity Guidelines (hip, knee, ankle and Foot), Upper Extremity Guidelines (shoulder, elbow, wrist and hand), and Spine Disorders Guidelines (trauma, lumbar, thoracic, and cervical spine) by indicating your overall opinion using a scoring system from 1 to 9 (1 = least appropriate, 9 = most appropriate). An additional box stating “I don't know” was also available.

Table 29 shows the data for the perceived overall ease of use, which was ranked as high or very high by most respondents for each proposed guideline. Most specialists had a high interest and desire in implementing the proposed guidelines. When considering the scope of practice in their own province/state/country, the majority of specialists ranked the feasibility of implementing these 3 guidelines into practice as high or very high. Between 6% and 10% of respondents ranked the feasibility of implementing the recommendations from the 3 guidelines into practice as moderate. Finally, comments received by specialists were generally very favorable and reflected high levels of agreement with the proposed recommendations, perceived ease of use of guidelines, and implementation feasibility (Appendix C).

Table 29. Percentage agreement for perceived “ease of use” of guidelines and implementation feasibility of adult lower extremity, upper extremity, and spine disorders guidelines

Question 5–7: Perceived ease of use of guidelines and implementation feasibility	Results
	Lower extremity disorders	Upper extremity disorders	Spine disorders
Question 5. Perceived overall ease of use of the proposed guideline	(n = 43)	(n = 39)	(n = 33)
Score
• <5	4.8%	2.6%	3%
• ≥5	95.3%	97.4%	97%
• ≥7	73%	83%	81%
• I don't know	–	–	–
Question 6. Interest/desire for implementing guidelines into own practice	(n = 41)	(n = 36)	(n = 31)
Score	–	2.7%	–
• <5	97.6%	94.4%	96.8%
• ≥5	2%	2.7%	3.2%
• I don't know
Question 7. Feasibility of implementing the proposed recommendations into practice considering the scope of practice in own province/state/country	(n = 41)	(n = 35)	(n = 31)
Score
• <5	2.4%	–	3.2%
• ≥5	92.6%	94.3%	90.3%
• I don't know	5%	5.7%	6.4%

Scoring system from 1 to 9: 1 = least appropriate, 9 = most appropriate.

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Discussion—Second External Review (Phase 7) 

In a recent experimental study of the influence of individual participant characteristics on formal consensus development, the largest differences were between the general practitioners and mental health professionals, both in their initial ratings of the different interventions, and in how much they altered their ratings between rounds. The results support the practice of treating professional specialty as an important determinant of the results in consensus panels.¹²⁶ Results of the external review phase of the project revealed very high levels of agreement with all recommendations proposed in the Delphi panel (phase 5) for the lower and upper extremity disorders and spine disorders diagnostic imaging guidelines. Perceived ease of use of the guidelines and implementation feasibility were generally high. Comments provided by reviewers pertaining to the content of the guidelines were considered by the research team in the final draft of the diagnostic imaging guidelines (phase 8).

Phase 8: Final Draft of the Diagnostic Imaging Guidelines and Grading of Evidence 

Upon completion of the public website (phase 6) and second external review (phase 7), all suggestions and comments were considered by the research team and incorporated into the final version of the guidelines. A member of the public with specialized training in research was asked to review the methodology and to consider all recommendations from the 3 guidelines. Comments and suggestions from the public member were incorporated where deemed appropriate by the research team.

The initial template used for the guidelines was from the European Commission on radioprotection (2001).⁵¹ The gradings (ie, strength of recommendations) they administered included only 3 levels, from A to C (Table 1). In comparison, grades from the European Commission were generally higher than the ones assigned to the various recommendations in these current guidelines. This is partly explained by the more stringent criteria of the SPREAD instrument, which was used for the current guidelines (Fig 4). This tool uses 2 additional grades (D and Good Practice Point) and considers the quality of meta-analysis and systematic reviews. Under the European Commission grading system, those studies would have been graded as level A. However, as already mentioned, high-quality meta-analyses, systematic reviews, and RCTs are uncommon at this time as evidenced by the fact that only a dozen were retrieved in total. In addition, the weighting system itself is subjective. “Good Practice Point” is also indicated where emergency referral is recommended. Although abundant literature is available to support the need for a rapid intervention in cases such as cauda equina syndrome and dissecting abdominal aortic aneurysms, literature regarding treatment was not specifically reviewed in these guidelines. Recommendations are also accompanied by a designation of “Critical” or “Important (but not critical).” Critical is defined as a life-threatening condition or as a situation in which the patient is at risk of serious complications if they are not referred for appropriate care in a timely manner. These specifications were added to the respective tables (Appendix D).

Study Limitations 

This study has several limitations. First to consider was the strategy used to develop guidelines recommendations. Realizing that the first objective of this project was to respond to a concern raised by an accrediting agency to review an institution's diagnostic imaging guidelines, while considering the significant costs and time associated with CPG development, and until meaningful clinical trials become available for some specific conditions, the processes used in developing these particular guidelines are considered appropriate. This strategy included a first narrative review, an initial literature search and 2 literature updates, an independent assessment of the literature supporting the proposed recommendations, the use of the European Commission Referral Guidelines for Imaging as the initial template,⁵¹ a large Delphi consensus panel, and 2 external reviews.

Specific weaknesses of our strategy include (a) the initial literature search and data extraction (phase 1) performed by only one assessor (AB); (b) the use of only two literature evaluators for most citations (phase 2); (c) the lack of experience in assessing the quality of the literature by at least one of the literature evaluators (phase 2); (d) the initial guidelines recommendations established by only 2 specialists in chiropractic—one in clinical sciences and one in radiology (phase 3); (e) in developing wide-ranging reviews and guidelines, it inevitably takes considerable time to review studies and formulate recommendations and publishing in a peer-reviewed journal also adds to the time from literature search to date of publication; (f) summarizing complex issues in a review, such as this, can also be difficult; (g) a degree of subjectivity in the grading of recommendations.

High-quality clinical guidelines should be developed within a structured and coordinated program¹²⁷ using a standardized approach^128,129 so that recommendations made by multidisciplinary, nationally representative groups are based on a systematic literature review.¹³⁰ Using sound scientific methodology proves useful in ensuring that the recommendations are explicitly linked to the supporting evidence¹³¹ and graded according to the strength of that evidence.⁵⁷ For some review topics, however, the strengths of the systematic review may turn into weaknesses. The primary problem is that the narrow focus and prescribed methods of the systematic review do not allow for comprehensive coverage. For example, the historical review is an irreplaceable means of tracing the development of a scientific principle or clinical concept, but the narrative thread could be lost in the strict rules of systematic review.¹³² Although it is well known that narrative reviews are prone to several biases,¹³³ it is highly conceivable that the literature search in this project, repeated at 3 different intervals using a similar strategy; the use of the European Commission of Radioprotection Guideline as a template; the evaluation of all guideline recommendations by a large consensus group composed of more than 60 academics, researchers, and clinicians (modified Delphi process—phase 5); the inclusion of 2 external reviews (phase 4 and phase 7) resulting in the contribution of more than 60 chiropractic and medical specialists scrutinizing every section of the diagnostic imaging guidelines significantly reduced the risk of missing important articles and of misclassification, and have improved the reliability of these guidelines. Although the quality of studies was assessed by blinded, independent evaluators during phase 2, ideally it is preferred that 2 experienced evaluators assess each study and formally agree on differences. Unfortunately, most studies could only be reviewed by one assessor due to a limited budget.

The quality of studies used to propose recommendations needs discussion. It has been acknowledged that many studies on diagnostic validity are of poor quality.¹³⁴ In the overwhelming majority of axial pain syndromes, there is little evidence supporting confidence in diagnostic test validity.^135,136 The same conclusions appear also to apply to the clinical examination of some disorders of the upper and lower extremities.¹³⁷, ¹³⁸, ¹³⁹, ¹⁴⁰, ¹⁴¹, ¹⁴², ¹⁴³, ¹⁴⁴, ¹⁴⁵ In real-life situations, knowledge of the natural course of clinical conditions helps practitioners determine the need for clinical reevaluation and complementary investigations, including diagnostic imaging studies.

In the hierarchy of research designs for treatment, results of randomized controlled trials are considered the highest level of evidence, followed by controlled observational studies with uncontrolled studies and opinion representing the lowest level of evidence. It should be noted, however, that this hierarchy of research designs has been questioned by recent publications^146,147 that identified nonsignificant differences in results between randomized controlled trials and observational studies.¹⁴⁸ The hierarchy of research designs has also been challenged in the field of diagnostic anatomic pathology¹⁴⁹ and rehabilitation research.¹⁵⁰ A critical comparison of trials with observational studies suggests that one cannot replace the other, both designs being susceptible to particular bias, such that neither provides perfect information.¹⁵¹ Bluhm¹⁵² suggests considering the relationship between biological studies, epidemiological studies (population/clinical research), and systematic clinical observation: a network whereby different information provides for better interpretation of the existing literature. These diagnostic imaging guidelines incorporated a combination of clinical trials and observational studies as a basis for proposing recommendations.

Technical difficulties encountered at the onset of the Delphi process, “public” consultation, and second external review (access to the protected website, registering of participants, and access to some of the documents) have likely disenfranchised some volunteers who were initially interested in reviewing the guidelines online. Although troubleshooting was promptly addressed, once we were advised, attrition of participants likely occurred in similar proportion among those in favor and those against the proposed recommendations.

Chiropractors formed the majority of Delphi panelists. This group in most jurisdictions and most practice situations does not order or interpret advanced imaging. In addition, they have limited experience in dealing with pathologies such as fractures, ligamentous instability, myelopathy, cancer, and infection. It could be argued that it is not valid to suggest that these guidelines overall are a complete or accurate reflection of best practice from the standpoint of the patient or the disease itself. However, considering this work is an extension of the Referral Guidelines for Imaging by European Communities (Radiation Protection) produced in conjunction with the UK Royal College of Radiologists,⁵¹ we believe that these guidelines are in agreement with current standards of care.

Many reasons may explain the low participation observed in the “public” consultation (Phase 6): failure to receive or read invitation announcements in journals; refusal to participate; failure to have access to a computer or to the web; busy schedules; technical difficulties encountered during the project; and the size of the documents to be reviewed. Although those reasons should not significantly influence the results, lack of interest in research or for the study topic would suggest that nonresponse may be biased in ways directly related to the purpose of the study.¹⁵³ A low response rate does not necessarily affect the validity of the data collected, provided tests for nonresponse effects and corrections to the original data be made if needed.¹⁵⁴ Unfortunately, such analysis was not conducted in this study. Of the 271 health care professionals who completed the consent form to participate in the second external review (phase 7), only 105 specialists (38.7%) registered. Reasons for not responding are unknown. While a potential source of bias, the very high levels of agreement with all recommendations suggest that the results would likely not be changed significantly with a higher participation rate considering that specialty groups tend to exhibit homogeneous practice behaviors.

It could be argued that our process, however extensive, did not include a sufficient number of chiropractic named technique representatives and a sufficient number of other health professions dealing with musculoskeletal disorders. Users of specific chiropractic techniques that rely on the routine use of radiography for the purpose of elaborating a plan of treatment should have a particular interest in imaging guidelines development. Representatives from Gonstead Technique and from Chiropractic Biophysics protocol were invited to participate on the Delphi panel (phase 5). Unfortunately, the Gonstead representative failed to return most of the evaluation questionnaires and a cofounder of Chiropractic Biophysics protocols declined our invitation, opting instead to develop other guidelines.⁹⁰ With regard to the incorporation of other health care professions, ordering of imaging studies is normally restricted to medical physicians and chiropractors, as well as to osteopaths in the USA, therefore excluding physical and occupational therapy groups and Canadian osteopaths. Most medical specialists invited to participate in our study cited lack of availability as the main reason for declining our invitation. One neurosurgeon had to stop participating due to personal illness.

As the properties of a diagnostic test can change with different disease severity, generalization of study results is another important issue to consider. In other words, an imaging study may not perform as well in a community practice, where less complicated cases will have to be distinguished from multiple competing diagnoses.¹¹⁰ One such example is the Canadian Cervical Spine Rule (CCSR) used to exclude fractures tested in a large hospital setting and trauma centers where disease prevalence and severity tends to be greater. It is important to recognize that the predictive value of a test will change with changes in the prevalence of the disease.¹¹⁰ In addition, likelihood ratios tend to move away from the value of 1 when all patients who have the target disorder have severe disease, and they tend to move toward the value of 1 when all patients who have the target disorder have mild disease.¹⁵⁵ A wide spectrum of patients with low, moderate, and high levels of clinical suspicion of fracture need to be included in the studies to allow for generalization to community practices. Additional studies may therefore be required to determine whether these highly sensitive clinical decision rules perform just as well in general practice. However, if one practices in a similar setting to that presented in a particular study and the patient meets the study eligibility criteria, one can be confident in applying the results of the study to his/her own patients.¹¹⁰

Many reports have indicated that current evidence-based guidelines are underused by physicians and others, and that many barriers to an effective translation of recommendations extend into day-to-day care. There is therefore a need to develop more effective ways to communicate key information to both caregivers and patients, and to promote appropriate health behaviors.¹⁵⁶ Reducing resistance to guideline implementation will require persuasion of practitioners so that the perceived negative effects of guidelines on their practices are balanced by improvements in the quality of care.¹⁵⁷

Because publication alone is not enough to change practice¹⁵⁸, ¹⁵⁹, ¹⁶⁰, the complex and challenging issues of implementation and utilization of CPGs also need to be considered. Many studies have shown that a combination of different strategies is necessary. Positive tendencies toward successful implementation include:

Therefore, an investigation of possible barriers are an essential component of any guideline dissemination-implementation strategy.^162,163

Potential Barriers to Implementation 

The initial draft of the diagnostic imaging guidelines (phase 3) was implemented into the outpatient teaching chiropractic clinic at UQTR in July 2003 after formal presentations to UQTR interns and clinicians. Implementation strategies of the initial draft included frequent reminders to clinicians (letters) from the clinic directors. In addition, for each new patient examined in the clinic, interns discussed with the supervising clinician whether radiographs should be ordered. If deemed appropriate, the intern and clinician were required to complete an order form based on the design of the proposed imaging guidelines. Reasons for ordering films, as well as pertinent clinical indicators and specific views, had to be specified. Adherence to the new spine disorders guidelines was evaluated retrospectively between February 2004 and February 2005. The overall level of agreement between clinical decision making and the new diagnostic imaging guidelines was moderate (71.7%; κ = 0.432; CI, 0.298-0.550). Reasons for disagreement included not ordering radiographs when recommended by the guidelines; ordering radiographs of the main complaint despite not being recommended by the guidelines; ordering radiographs of asymptomatic anatomical regions other than the main presenting complaints (eg, past history of neck trauma). None of the incidental findings identified on the radiographs represented an absolute contraindication to chiropractic care. Although the aim of this project was to measure adherence to the proposed recommendations for spine disorders and did not specifically address the implementation strategies, it is worth noting that the percentage of new patients that had radiographs ordered decreased from a mean of 88% before implementing the new guidelines to 57.4% and 49.1% during academic years 2003 to 2004 and 2004 to 2005, respectively. This decrease may be partially related to changes in the radiography fee schedule during that same period.

As discussed earlier, other potential barriers to successful implementation of practice guidelines may include chiropractors' attitudes toward chiropractic ideology and scope of practice.¹⁶⁴ These potential barriers were indirectly addressed in our study when dealing with issues involving stakeholders and editorial independence. A worldwide consultation invited doctors of chiropractic to access an imaging guideline website and to provide comments and suggestions (phase 6). Professional associations and organizations were invited to nominate members to review these proposed recommendations. Simultaneously, the expert consensus guidelines were forwarded to specialists in chiropractic and medicine who were invited to independently evaluate the proposed imaging guidelines (phase 7). The research team considered all comments received in drafting the final version of the guidelines. Details of phases 6 and 7 are presented elsewhere in this paper.

A minority of participants who responded to the public consultation phase favored the routine use of conventional radiography offering the following justifications for this practice:

Current guidelines do not consider these reasons adequate justification for the routine exposure of patients. Nevertheless, each of these points is a potential barrier to implementation by practitioners.

Disagreement within a guideline development group may include differences in interpretation of the research literature, differences in personal experience, and different perceptions of the inherent risks and benefits of a procedure.⁶³ After declining an invitation to participate in our study, an ICA board member and principal founder of CBP, a chiropractic technique organization, elected to develop an independent set of imaging guidelines: Practicing Chiropractors' Committee on Radiology Protocols for Biomechanical Assessment of Spinal Subluxation in Chiropractic Clinical Practice (PCCRP).⁹⁰

It is well documented that the composition of the working group and group dynamics can influence the outcome of discussions and lead to variation among the recommendations of different groups.¹⁶⁵ A similar pattern has been observed within the chiropractic profession in the past with the development of alternative sets of guidelines. In response to the Guidelines for Chiropractic Quality Assurance and Practice Parameters (Mercy)¹⁶⁶ and the Clinical Guidelines for Chiropractic Practice in Canada (Glenerin)¹⁶⁷ modeled after the Mercy guidelines, alternative guidelines soon followed including the Vertebral Subluxation in Chiropractic Practice (CCP)¹⁶⁸ and the Recommended Clinical Protocols and Guidelines for the Practice of Chiropractic (ICA).¹⁶⁹ Independent assessment of 3 of these chiropractic guidelines concluded that neither the CCP nor the ICA alternatives were suitable for utilization in chiropractic practice, whereas the Mercy guidelines were recommended for application in chiropractic practice, with the provision that new scientific data should be considered.^170,171

The different premises on which chiropractic guidelines are established may derive from a longstanding ideological debate among chiropractors regarding the identity of chiropractic.¹⁷², ¹⁷³, ¹⁷⁴, ¹⁷⁵ Mootz¹⁷⁶ proposes that chiropractic institutions and organizations focus on an evidence-based and best practice–oriented research priority, constructive engagement of the greater health care system, and successful ethical business models.

Divergent or competing guidelines on similar topics serve only to further confuse and frustrate practitioners.¹⁷⁷ In addition, the continued lack of unity among chiropractors hinders its growth by limiting engagement of the greater health care system. We encourage readers of all guidelines to critically evaluate the methods used as well as the content of the recommendations before adopting them for use in practice.¹⁷⁸

Strategies for Effective Guidelines Dissemination, Implementation, and Monitoring 

Proposed dissemination-implementation strategies include publication, applying to National Guideline Clearinghouse; posting of the electronic document on various websites (national, state, and provincial organizations; malpractice insurance carriers; outpatient teaching clinics); educational intervention strategies (e-learning, community pilot studies); referral guidelines; reinforced by request checking and clinical management algorithms; promotion by national, provincial, and state organizations; and presentation to conferences. Currently, there is a deficiency of well-designed studies that document the effectiveness of practice guidelines. Their ultimate effectiveness will depend on both an improved evidence base and effective strategies for rapid dissemination of the recommendations.

In the past, effective dissemination of new knowledge has been a slow process, often taking years. This process can be dramatically shortened through the development of networks of practice sites that share knowledge and experience in the implementation of practice guidelines and the use of strategies that take advantage of key groups in the dissemination process.¹⁷⁹ When used appropriately, practice guidelines can provide an important adjunct to clinical research by facilitating the dissemination of new clinical findings and can provide an important platform for encouraging innovations in patient care.¹⁷⁹

In one instance, mailing of copies of the Royal College of Radiologists' guidelines had a small effect on general practitioners' use of radiographic investigations of uncertain clinical significance.¹⁸⁰ There is currently considerable debate surrounding the ability of professional education and development to actually make a difference in the way clinicians practice.¹⁸¹ An educational intervention strategy as a means of implementing evidence-based guidelines for imaging may be most effective in reducing the perceived need for conventional radiography in a chiropractic community.⁹⁷ Such a strategy has proven effective for managing shoulder problems and informed use of ultrasound imaging in general practice.¹⁸² The use of referral guidelines, reinforced by request checking and clinical management algorithms, produced total reductions in radiographic examinations ordered by general practitioners of the knee, lumbar spine, and cervical spine of 77%, 78%, and 86%, respectively.¹⁸³

It has been recommended that postgraduate teaching of evidence-based practice should be moved from classrooms to the clinical practice setting to improve skills, attitudes, and behavior.¹⁸⁴ Internet platform (e-learning) for continuing education, including case-based learning objectives and examinations, is yet another method of facilitating guideline implementation.¹⁸⁵ Teaching diagnostic decision making in this way may also be a viable alternative to traditional teaching formats in undergraduate programs.¹⁸⁶ It is also recommended that conferences and seminars be designed to include several healthcare providers, thereby giving a comprehensive presentation on each topic.²⁰

Monitoring of the Guidelines/Clinical Audit 

Guideline adaptation by regional care provider audit groups may serve as a tool for CPG implementation.¹⁸⁷ Effective methods can be developed for monitoring guideline use in primary care. However, there is a need to address the degree of understanding possessed by many primary healthcare professionals about the concepts and practical issues of guideline-use monitoring, and of expectations of this within the healthcare system. In addition, a number of technical issues concerned with efficient capture of clinical information and its evaluation must be considered.¹⁸⁸ Audit (systematic monitoring) and feedback (less formal) are frequently used strategies to improve professional practice. When it is effective, the effects are generally small to moderate. The relative effectiveness of audit and feedback is likely to be greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively.¹⁸⁹ Computer reminders attempt to influence behaviors of individuals. Reminders are more effective than feedback in modifying physician behavior related to medication management.¹⁹⁰ In addition, such reminders may seem less threatening as they are “anonymous.”¹⁹¹ Social, political, and commercial factors often drive and determine the use of evidence in policymaking. It is recommended, however, that in-depth analyses from different perspectives be made before implementing evidence-based policies.¹⁹² Such analyses may include perspectives from patients, providers, society, payers, and others. One concern is whether this type of evidence will lead to a policy change with significant benefit to society.¹⁹³

A significant limitation of any CPG is the skill of clinicians. Decisions to proceed with further testing are based on information gathered by thorough and proper history taking and results obtained from a well-conducted physical examination. Lack of standardization of these procedures is a concern, however, both intraprofessionally and interprofessionally. For more in-depth discussions on the subject of history and physical examination, recent reviews and textbooks are available.^137,194, ¹⁹⁵, ¹⁹⁶, ¹⁹⁷, ¹⁹⁸ There are some indications that structured data collection and explicit questioning may help inexperienced physicians make more accurate judgments about the need for radiography.¹⁹⁹ Such data collection forms should be developed for health care professionals, interns, and residents.

Updating/Revision 

Guidelines are living documents refined regularly with new information and experience, a process that can be challenging given the rapid evolution of technology and practice in the field. The guideline development group believes that the literature review and the guidelines should be periodically updated every 2 to 3 years to determine whether the guidelines should be reconsidered in light of new research evidence. In addition, the research group should convene when major new research evidence is published in the interim.⁶³

Using current recommended methodology¹²⁷, ¹²⁸, ¹²⁹, ¹³⁰, ¹³¹ to develop a scientifically robust guideline represents a major academic endeavor. With more than 125 patient presentations and 240 recommendations, including conventional radiography and specialized imaging in the 3 diagnostic imaging guidelines, such expenditure of time and human and financial resources is prohibitive. Clearly, such a strategy will require support form national and international organizations. Nonetheless, improving on the quality of the process is important and the following strategies should be considered:

Recommendations for Future Studies 

These proposed guidelines are intended to reduce unnecessary radiation exposure, increase examination precision, and decrease health care costs—all without compromising quality of care. However, the potential of guidelines for resolving clinical questions should not be overstated. Further research is recommended in the following 2 areas:

Prospective studies on the prognostic value of symptoms, signs, and diagnostic labels remain a research priority in the field of regional musculoskeletal pain. In addition, derivation of practical, highly sensitive, and reliable clinical decision rules or clinical prediction rules for the selective use of diagnostic imaging similar to those for knee, ankle and foot, and cervical spine trauma would prove useful.^183,200 These rules use clinical findings (history, physical examination, and tests results) to make a diagnosis or predict an outcome. Well-developed clinical decision rules result in less radiography, less time spent in the emergency department, and do not decrease patient satisfaction or result in misdiagnosis.²⁰⁰ Clinical prediction rules may be thought of as the combination of relevant clinical findings to calculate the numeric probability of the presence of a specific disorder or likelihood of an outcome. They act as adjuncts to the evaluation process.²⁰¹ Clinical rules require prospective validation as well as impact analysis.^202,203

Reporting of topics included in the development of the diagnostic imaging practice guidelines are provided in a standard format for each of the guidelines.²⁰⁴

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Conclusions 

The role of high-quality CPGs for quality management in health care is well accepted. These evidence-based diagnostic imaging practice guidelines are intended to assist primary care providers, interns, and residents in decision making on the appropriate use of diagnostic imaging for specific clinical presentations. In all cases, the guidelines are intended to be used in conjunction with sound clinical judgment and experience. Application of these guidelines should help avoid unnecessary radiographs, increase examination precision, and decrease health care cost without compromising the quality of care.

Guidelines are effective only if they are implemented in the delivery process. The implementation process should be supervised and evaluated so that adjustments are possible. Several important issues regarding dissemination/implementation strategies need to be considered. Health professionals are slowly moving toward evidence-based health care and best practices and will appreciate the value of CPGs provided teaching institutions and political leaders promote their use. Guidelines are living documents refined and modified regularly with new information and experience. Future research is needed to validate the content of the proposed diagnostic imaging guidelines. In addition, attempts to refine patient selection criteria to further reduce unnecessary radiographic exposure without altering sensitivity are recommended.

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Acknowledgment 

The authors express their sincere appreciation to all independent literature reviewers (phase 2), Delphi panelists (phase 5), and external reviewers (phases 4 and 7), whose significant contributions were essential in the completion of this project. We are grateful to chiropractic college presidents for recommending faculty members for the Delphi panel. We appreciate the feedback received by colleagues in the field during and after the worldwide consultation on the Web (phase 6). We thank Jeffrey Cooley, DC, DACBR; Jonathon Todd Egan DC, Fellow; Michael Morgan, DC; Jason Napuli, DC; and Julie O'Shaughnessy DC (Fellow candidate in Clinical Sciences) for completing the independent literature review (phase 2); and Dr Andre Cardin of Université du Québec à Trois-Rivières for his significant input in the initial draft (phase 3). We thank Carlo Ammendolia, DC, PhD; Joe Lemire DC, MSc; John Triano DC, PhD; and Jacques Duranceau, MD, for providing constructive advice. The authors thank those who assisted us during all or part of the project, including Mark Laudadio, DC; Christian Eid, DC; Julie Roy, DC; Nicholas Beaudoin; and Mme Valérie Lambert, academic and technology support, Computer System Development Division at UQTR. Finally, we thank Mrs Vicki Pennick, RN, BScN, MHSc, Senior Clinical Research Project Manager, Managing Editor, Cochrane Back Review Group, Institute for Work & Health, for her valuable advice and pertinent comments and suggestions as a public representative.

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Appendix A. Supplementary data 

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Appendix B. Comments Received by Participants of the “Public” Website (Phase 6) Specific Comments Pertaining to the Lower Extremity Disorders Guidelines 

Positive comments

• Great work overall.

• Excellent, keep it coming.

• Usually treatment failure will lead to advanced imaging studies. An exhaustive work, the participants are to be congratulated!

• Excellent.

• Very helpful—I think it will also be helpful to use with the medical profession.

• This was a great review of lots of things I don't see too often. The chart format is easy to read and will be a great resource.

• Not terribly exciting reading; however, good review of what every practicing D.C. should have learned in school or continuing ed.

Negative comments

• I understand your objectives with this study, but, my practice and in my mind, chiropractic in general is not about pain.

• Chiropractors diagnose and treat subluxations. X-rays identify the underlying biomechanical cause of symptoms. Determination should be with the clinician based on benefits of x-ray exceeding the risk.

• Chiropractic is a unique health care solution. These guidelines would be good for a medical doctor but not a chiropractor.

• You can't legislate clinical decision making because patients don't fall into neat categories. Your attempt to do so is ignorant at best and pernicious at worst.

Neutral comments

• Best practices are a much better alternative to guidelines.

• Given that I practice in a more rural setting access to and/or the ability to refer patients for US, CT or MRI evaluations is limited by the low number of facilities in our area and their extensive use by allopathic practitioners.

• I always try to send pt's back to their MD for films as we do not have x-ray capabilities. Because someone else is sometimes the gate keeper—it makes it difficult to follow the guidelines exactly.

• The medical profession in Italy is going through a similar exercise.

• Best practices are better than guidelines.

• More diagrams please.

• Be careful, not to let this survey become too restrictive as other guidelines have. Academicians and researchers—different arena than DC's in the office.

Comments Pertaining to the Spine Disorders Guidelines

Positive comments

• Fantastic—about time, good research!!

• Interesting traumatic guidelines.

• Love it—great detail and research.

• I really liked the summary of recommendations.

• Jennifer Jamison would be proud of you!

• My interdisciplinary colleagues will love this as well, psychiatrist, neuro, ortho, etc

Biomechanical x-ray analysis, including chiropractic spinal analysis for subluxation and alignment/postural correction, not properly included. (n = 30)

• Chiropractic spinal analysis for subluxation not properly included.

• Guidelines fail to acknowledge the special interventive procedures (adjustments) employed by most D.C.'s

• Lacking in research for biomechanical x-ray analysis and how this analysis does alter patient management and outcomes greatly.

• Reasons for taking x-ray are very limited and narrow scope

• The guideline fails to address the use of spinography for subluxation assessment. As such, the proposed guideline is of very limited value.

• There is no reference to alignment/postural correction. To reference a few papers to rule out work such as CBP and Pettibon is absurd.

• These regulations do not take into consideration the upper cervical specific practitioner who needs x-rays to get a listing. In short—these guidelines are NOT APPROPRIATE for Chiropractors.

• This document needs to improve regarding the use of films for biomechanical evaluation. Ref 24 has been soundly refuted by Harrison et al, JCCA,2006,50(3) yet this document fails to include it. Bias?

• I do not like that these guidelines will not give me the choice to X-ray for biomechanical analysis as I deem necessary. X-rays are as important to direct Tx/rehab as they are for pathology.

• In dealing with spinal trauma there is a great need to document the patient's injuries and not to base on a guideline rather than a thinking doctor is just wrong.

• Please withdraw and revise these “guidelines” to more appropriately match the 90% of subluxation based chiropractors practicing in North America.

• Our state scope of practice provides that subluxation may be the sole basis for chiropractic care. These guidelines fail to address the use of spinography for subluxation assessment.

• None of these guidelines are applicable to the practicing chiropractic community.

• Please withdraw and revise these guidelines to include Subluxation/Biomechanical basis for radiography in the chiropractic practice

• The info I get from x-rays is invaluable. Consult Dr. Burns at Palmer or Dr. Cox with Gonstead Seminar. Don't limit me because some don't understand how to use x-ray.

• These guidelines are not appropriate for Chiropractors.

• This document does NOT reflect my scope of practice.

• There is no allowance for wellness and prevention and spinal hygiene.

• Implementing these guidelines into my practice would severely limit my ability to help people in my community. I don't see or understand how these could possibly help anyone.

• Research based chiropractic guidelines for radiology is necessary. I am concerned about being overly restricted with “non-SMT” based guidelines for x-ray. I want to SEE what I am manually adjusting. Regional anomaly, 1 level severe DDD, need for a “short leg” heel lift, etc, can be assessed best with x-ray and may not directly associate with trauma, disease and pain based x-ray guidelines.

• Chiropractors diagnose and treat subluxations. X-rays are necessary in a chiropractic practice. Determination should be with the clinician based on benefits of x-ray exceeding the risk.

As a chiropractor it is traditional & very important to take x-rays for not only pathology but for biomechanical evaluation. This type of x-ray is both reproducible & valid.

• Too superficial of a review of the literature. Ignores medical guidelines and biomechanical analysis.

• Such guidelines have no clinical application as x-ray is a logical and well supported piece of any health care provider's office.

• This document has nothing to do with what Chiropractic is. I am fully & whole-heartedly against it!

I look for degeneration, alignment, listings, curvature, etc. Example, it's very difficult to determine a Base post from an L5 subluxation without a radiograph

• While I appreciate the intent on making these guidelines “EB”, there are other factors to consider beyond patient safety (ie, red flags). Anyone in practice longer than five years (and as noted by you) has hopefully figured out that radiographic studies usually don't correlate to symptoms of any sort, so the use of X-ray for pain treatment (other than ruling out critical or potentially critical phenomenon) is pretty much useless. However, there are other rationales to the use of this type of analysis. The first would be postural analysis. It concerns me that you appear to have determined that the single study by Cooperstein et al (which challenges the body of work by CBP) is comprehensive enough to exclude all forms of postural analysis as a rationale for utilization of X-ray. There are numerous other technique systems (ie, NUCCA, AO, Gonstead) utilizing both global and focal postural distortions as part of their analytic pre-post protocol, and would suggest perhaps considering investigating the data these groups have accumulated on the application of X-ray in clinical use. Another area of practical radiographic application is with regards to choice of technique. Higher levels of joint degeneration may indicate avoidance of vigorous manipulative approaches (diversified, Gonstead, Crane) in favour of a more tonal nature (Toggle, TRT, Network), not for safety, but for patient comfort and compliance to a prescribed schedule of beneficial chiropractic care.

• Structural/corrective x-rays don't fit these g-lines nor should they. We shouldn't limit patient x-rays for structural/corrective practices. We don't see dentists x-raying for dx only.

• For diagnosis, ruling in-out, pathologies, guidelines are appropriate; evaluating mobility and cpnts of Vertebral Dysfunction Complexes, some X-ray studies may be required despite lack of red flags

• I feel this document has been put together without considering the current chiropractic profession. Where are the surveys to show how chiropractors currently use x-rays?

Fails to consider x-rays as a screening tool and practitioners experience in clinical decision making (n = 14)

• It also needs to be noted that many pathologies may not have “red flag” signs such as an abdominal aneurysm and could be detected on a routine x-ray.

• DDD as well as congenital disorders (spondylolithesis) can be asymptomatic but are important in determining care. According to these guidelines, no x-rays would be taken if asymptomatic.

• Nontraumatic and uncomplicated cases may still have underlying problems which would otherwise be overlooked, failure to utilize simple x-ray studies does not protect the patient.

• Structural/corrective x-rays don't fit these g-lines, nor should they. The dental profession x-rays for screening/correction. We shouldn't limit our profession from x-rays that help patient's structure/health.

• This document failed to consider the large amount of evidence for subluxation/biomechanical based radiographs. Please see http://www.pccrp.org

• To think that X-rays should only be taken in instances of pain is ridiculous. How many pathologies were found bk we took radiographs of asymptomatic pts—many certainly in my 25 high vol practice.

• Guideline criteria are entirely based on crisis management. Deciphering contributing/predictive factors for appropriate health promotion interventions received no consideration in this study.

• It is the doctor who must decide when or when not to take x-rays, liability for mistakes falls on that doctor. The type of treatments and techniques provided may require follow studies

• All too often I see cases where failure to use x-rays by others practitioners has not been in the best interest of the patient.

• X-rays are integral evaluation of many pt's condition. Upon physicians evaluation, a non-trauma or trauma patient may require them. Not all pts can be categorized so strictly. Final decision should be left to the clinician.

• Clinical decision making should be left up to the clinician and not a set of guidelines. Everyone has studied indications and contraindications to treatment in their undergraduate education.

• They only work for the insurance industry and they open the doctor up to malpractice lawsuits because no jury will take a defence such as “well the guidelines indicated that I did not need x-rays”.

• Respect that our undergraduate training and experience should guide our practices, not a reasonably rigid academic grounded guideline!

• Chiropractors of the 50-70's had a better understanding of spinal anatomy, anomalies etc than the present grads.

These are MD guidelines (n = 7)

• These guidelines are for MD management.

• These are MD guidelines. What about Gonstead and Upper Cervical Spine doctors. If you don't need films don't take them. I don't tell you how to practice. Radiation Hormoesis.

• These recommendations would work if I were a M.D. If you want to be a M.D. go to med school. Let the rest of us practice CHIROPRACTIC.

• Good trauma review. We need further acceptance of how films impact pt. care. Films can be great objective outcomes for care and yield relevant info on case management and prognosis.

• I think these are bogus guidelines that will adversely affect my practice and my patient's health. This is a poor review of literature!

• The study as is should be given to the ER department of some hospital not our new graduates—It seems the purpose is not to make them think but to be scared.

• I didn't feel the chiropractic profession's current use of x-rays was considered or thoroughly researched. This would be a lovely document for those specialising in spinal pathologies.

Negative comments (n = 4)

˙Not wise.

• I wonder what the motive is to have such limiting guidelines are? The pccrp guidelines are a much more appropriate set of guidelines. These are a waste of time and should be burned.

• I will tell as many DC's as possible as to how dangerous these guidelines are to patients. I urge you to adopt the PCCRP guidelines and throw yours away as soon as possible.

• These guidelines are a waste of time and those who agree with them are in the wrong profession, misguided and un-informed. wake up!

Suggestions for improving guidelines formatting and content (n = 6)

• The formatting poor. This reference: >http://www.pnlg.it/LG/014/014-01.php Italian guidelines for disc and the European LBP guidelines http://www.backpaineurope.org have superseded the RCGP refs you give.

• These guidelines should not be implemented in the current format.

• An algorithm may be more appropriate.

• The ROM of motion numbers are wrong in the Canadian guidelines, this according to the American Medical Associations; Guidelines to the Evaluation of Permanent Impairment, 5th edition. Chapter 15.

• Multiple post traumatic lesions are missed with plain film, CT, MRI, etc. Videofluoroscopy studies are quite valuable in the evaluation of the post trauma C-Spine patient.

• The LNT model does not use any conclusive supporting data according to the National Council on Radiation Protection and Measurements February 1997.

Neutral comments (n = 5)

• Impressive work, but until agreement occurs between the DACBRs and subluxation influenced DCs, it's just another pissing match. While interesting from the sidelines, both sides need to come together.

• Biggest problem I have is my location and the ability to refer patients for specialty services. MDs in this area are not very cooperative.

• While I am a big fan of “guidelines” one can get hand cuffed by them as well when clinical reasoning is outside the norm—and outside forces love to use this against the treating DC for either not doing enough investigation, or doing too much.

• The technological advances in imaging have removed chiropractors from the loop. Small practices are unable to afford to keep up. This often leads to loss of control of patient since referral is necessary and the M.D. takes control. These guidelines are likely to be implemented only if provincial changes are made which allow direct referral to imaging centers from chiropractors.

• Given that competing radiography guidelines are being created by the pccrp (http://www.pccrp.org) one wonders which guidelines to adopt since both claim to be evidence based.

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Appendix C. Some Examples of Comments Provided by Participants of the Second External Review (Phase 7) 

Extremity Disorders Guidelines (Lower and Upper)

Positive comments

• Clear and straightforward. There should be no controversy.

• Comments section is very useful.

• I found the comments to be fairly comprehensive regarding the role of imaging modalities for the conditions listed.

• Excellent review of the signs and symptoms, recommendations for imaging are clear.

• Excellent guidelines in keeping with current responsible literature.

• Provides a concise, to the point review of most conditions

• As I refer to the local hospital for X-rays, I use similar guidelines already to determine the need for x-rays; these are more specific and will be used. Good work!

• Excellent review of all the things to consider before you perform an adjustment

• The recommendations do not vary in any significant way from normal clinical judgement which is exercised on a daily basis. It is being implemented based on sound clinical decision making.

• There are chiropractic practitioners who will not follow these guidelines because of their failure to appreciate their value.

• Excellent decision rules; very applicable to clinical practice.

Negative comments

• Not once did I see mention of a “chiropracticly” correctable lesion (whatever term you prefer).

• Chiropractic Subluxation should be part of any differential diagnosis.

• I think the document is overly comprehensive with respect to the descriptions of the conditions. It adds unnecessary bulk to the document which may impede its usefulness as a quick reference.

• Simple joint dysfunction that is addressed daily in chiropractic offices is blatantly missing.

Neutral comments

• I would recommend a flow chart format for ease of use.

• An algorithm might be helpful for each anatomic area or disorder.

• Many doctors will order x-rays prior to 4 weeks of failed care if for only medico legal aspects and also patient expectation of good care. The fear of failing to diagnose drives such action.

• The biggest impediment will be managing patients that require imaging studies as these services have been politically removed from the chiropractic scope of practice.

Spine Disorders Guidelines

Positive comments

• Excellent synopsis of DDX and x-ray decision making

• I've given 8's simply because I am trying to read this while being very tired and I am nervous I might have missed something. Otherwise, I feel it is a very thorough document.

• The pertinent clinical information is very useful, as are the suggestions of when to x-ray and not. This is the same for all guidelines.

• A very useful and necessary tool for all practitioners

• Summary of recommendations is a MUST (glad to see it was included) as the document itself is very long and may not have been readily used by the clinician because of its length.

• All three (spine, upper & lower extremity) are great documents and the authors are to be commended for this work. My one concern is the perhaps “mis-use” of this document by 3rd party payers.

• These guidelines are necessary because medical legal suits against chiropractors are often made because x- rays were not taken at the start of care. It will support not taking them with this document.

• An excellent document. Thank you for all of the intense work you've put into this.

• Excellent review and reference material for the practitioner.

• Great Job!

• These decision rules should be implemented as standard teaching material in ALL chiropractic colleges. These rules demonstrate a level of responsibility that other recent guidelines cannot approach.

• These guidelines would provide a very quick yet thorough resource for busy practitioners.

Negative comments

• Four weeks is entirely too long to treat a patient with radiating pain without MRI. Malpractice risk escalates due to SMT being blamed for causing or increasing the size of a HNP if not originally imaged. Conservative Chiropractic treatment requires active manipulation of the affected area.

• I think that the prognostic information obtained by films has been minimized by only looking at the film findings from a diagnostic perspective and are therefore too stringent.

Neutral comments

• When I tried a quick access approach to the guideline after a full perusal I found the recommendations too broad although better in the summary.

• It may just require further familiarization with the format.

• MRI has a long wait and must be obtained through an MD.

• My opinion (without reference) is that some chiropractors will want to x-ray all patients, regardless of any Guidelines put forth to them.

Back to Article Outline

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 Guidelines^a

Table D1. Adult Hip Disorders

Patient presentation	Recommendations	Ref #	LOE: QUADAS/AGREE/SPREAD	Grading
Adult patients with full or limited movement and nontraumatic hip pain of <4 wk's duration	Radiographs not initially indicated	• 40	• Not recommended	C Important (but not critical)
		• 41	• 3
		• 42	• 3
		• 43	• Strongly recommended
General indications for radiographs include	If radiographs are indicated and	• 43	• Strongly recommended	B Important (but not critical)
		• 44	• Recommended
		• 47	• 3
		• 6	• Recommended
		• 45	• 3
		• 46	• 2+
		• 97	• Strongly recommended
	Special investigations	• 43	• Strongly recommended	C Important (but not critical)
		• 47	• 3
Specific clinical diagnoses:
1. Strain, tendinitis, or tendinosis	Radiographs indicated in suspected osseous avulsion fracture	• 48	• 3	D Important (but not critical)
		• 49	• 3
		• 50	• 3
		• 51	• 3
		• 52	• 3
		• 53	• 3
	Special investigations	• 54	• 3	D Important (but not critical)
		• 55	• 3
2. Piriformis syndrome	Radiographs not initially indicated	• 57	• -2	D Important (but not critical)
		• 58	• 3
		• 59	• 3
		• 60	• 3
		• 61	• 3
	Special investigations	• 59	• 3	D
3. Nontraumatic trochanteric and iliopsoas bursitis	Radiographs not initially indicated (C)	• 62	• 3	D Important (but not critical)
		• 63	• 3
	Special investigations	• 64	• 3	D Important (but not critical)
4. Osteoporotic hip fractures
	Radiographs indicated Urgent orthopedic referral necessary	• 27	• 3	C Critical
		• 28	• 3
		• 29	• Recommended
		• 30	• 3
	Special investigations (see thoracic spine)	• 31	• Strongly recommended	D Critical
5. Septic arthritis of the hip	Radiographs indicated	• 42	• 3	D Critical
	Emergency referral	• 43	• Strongly recommended
	Special investigations	• 41	• 3	D Critical
		• 43	• Strongly recommended
		• 71	• 3
Consider obtaining radiographs in adult patients with chronic hip pain unresponsive to 4 wk of conservative care or if one of the following conditions is suspected	Radiographs indicated and additional views and special investigations	• 72	• Strongly recommended	D Important (but not critical)
		• 73	• 3
		• 74	• 3
		• 75	• 3
		• 76	• 3
		• 77	• Fair quality
Specific Clinical Diagnoses:
1. Congenital/developmental abnormalities	Radiographs indicated and additional views	• 45	• 3	D Important (but not critical)
		• 49	• 3
		• 64	• 3
		• 78	• 3
		• 79	• 3
		• 80	• Fair quality
	Special investigations	• 79	• 3	D Important (but not critical)
		• 80	• Fair quality
		• 81	• 3
		• 82	• Fair quality
2. Osteoarthritis (DJD)	Radiographs indicated	• 44	• Recommended	B Important (but not critical)
		• 53	• 3
		• 84	• -2
		• 85	• -2
		• 86	• Good quality
		• 87	• 2+
		• 88	• 1+
		• 89	• 2+
		• 90	• 2+
3. Inflammatory arthritis (seronegative and seropositive)	Radiographs indicated	• 73	• 3	D Important (but not critical)
		• 91	• 3
		• 92	• 3
		• 93	• 3
		• 109	• 3
	Special investigations	• 75	• 3	D Important (but not critical)
		• 78	• 3
		• 80	• Fair quality
		• 93	• 3
		• 94	• 3
		• 95	• 3
		• 96	• 3
4. Osteonecrosis (avascular necrosis)	Radiographs indicated. Orthopedic referral recommended	• 43	• Strongly recommended	B Important (but not critical)
		• 47	• 3
		• 76	• 3
		• 97	• Strongly recommended
	Special investigations	• 43	• Strongly recommended	B Important (but not critical)
		• 97	• Strongly recommended
5. Tumors and metastatic lesions	Radiographs indicated. Orthopedic referral essential and special investigations	• 43	• Not recommended	D Critical
		• 47	• 3
		• 60	• 3
		• 76	• 3
6. Stress (fatigue or insufficiency) fractures	Radiographs indicated. Orthopedic referral recommended	• 65	• 3	D Important (but not critical)
		• 98	• 3
	Special investigations	• 98	• 3	D Important (but not critical)
Patient presentation
Adult patients with significant hip trauma	Radiographs indicated and special investigations	• 100	• Strongly recommended	C Important (but not critical)
		• 101	• 3

Table D2. Adult Knee Disorders

Table D3. Adult Ankle and Foot Disorders

Patient presentation	Recommendations	Ref #	LOE: QUADAS/AGREE/SPREAD	Grading
Adult with acute ankle and foot injury but negative findings on the Ottawa Ankle Rules (OAR)	Radiographs not routinely indicated (A)	• 6	• Recommended	B Important (but not critical)
		• 57	• -2
		• 141	• Fair quality
		• 142	• -1
		• 143	• 2+
		• 144	• 3
		• 145	• Good quality
		• 146	• Recommended
		• 147	• Recommended
		• 148	• Good quality
		• 149	• Good quality
		• 150	• 3
Adult with acute ankle and foot injury and positive findings on the OARs	Ankle radiographs indicated	• 6	• Recommended	B critical
		• 43	• Strongly recommended
		• 141	• Fair quality
(a) Ankle (positive OAR)		• 142	• -1
		• 143	• 2+
		• 144	• 3
		• 145	• Good quality
		• 146	• Recommended
		• 147	• Recommended
		• 148	• Good quality
		• 149	• Good quality
		• 150	• 3
	Additional views	• 151	• 3	D Important (but not critical)
		• 152	• Fair quality
		• 153	• 3
(b) Foot (positive OAR)	Foot radiographs indicated: (A) and additional view	• 43	• Strongly recommended	B critical
		• 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 tarsal pain	Radiographs indicated and additional view	• 159	• Unsure	D Important (but not critical)
		• 160	• −2
		• 161	• 3
		• 162	• −2
		• 163	• 3
		• 164	• 3
	Special investigations	• 158	• 3	D Important (but not critical)
		• 161	• 3
Specific clinical diagnoses:
Impingement syndromes	Radiographs indicated	• 160	• −2	D Important (but not critical)
Anterolateral, anterior, anteromedial and posterior		• 165	• 3
		• 166	• Fair quality
	Special investigations	• 128	• −2	D Important (but not critical)
		• 129	• 3
		• 130	• 3
		• 133	• Fair quality
		• 134	• 3
		• 135	• 3
		• 136	• 3
Peroneal tendinosis	Radiographs not routinely indicated	• 141	• 3	D Important (but not critical)
	Special investigations	• 137	• 3	D Important (but not critical)
		• 138	• 3
		• 139	• Poor quality
		• 140	• Poor quality
		• 141	• 3
Lateral premalleolar bursitis	Radiographs not routinely indicated. Special investigations			GPP
Tarsal tunnel syndrome	Radiographs not routinely indicated	• 58	• 3	D Important (but not critical)
		• 176	• 3
	Special investigations	• 175	• 3	D Important (but not critical)
		• 176	• 3
		• 177	• 3
		• 178	• 3
		• 179	• 3
Adult with chronic foot pain	Radiographs generally indicated and additional views	• 181	• Recommended	C Important (but not critical)
		• 182	• Strongly recommended
		• 183	• 3
		• 184	• 3
	Special investigations	• 181	• Recommended	D Important (but not critical)
		• 182	• Strongly recommended
(A) Hindfoot-heel pain	Radiographs indicated and additional views	• 43	• Strongly recommended	C Important (but not critical)
		• 161	• 3
		• 182	• Strongly recommended
		• 185	• 3
	Special investigations	• 43	• Strongly recommended	D Important (but not critical)
		• 103	• 3
Specific clinical diagnoses:
A1. Plantar fasciitis and calcaneal enthesosphyte (spur)	Radiographs not routinely indicated except in young athlete	• 43	• Strongly recommended	B Important (but not critical)
		• 182	• Strongly recommended
		• 186	• −2
	Special investigations	• 43	• Strongly recommended	D Important (but not critical)
		• 189	• 3
		• 190	• 3
		• 191	• 3
		• 192	• 3
A2. Sinus tarsi syndrome	Radiographs not initially indicated	• 195	• 3	D Important (but not critical)
		• 194	• 3
	Special investigations	• 195	• 3	D Important (but not critical)
(B) Midfoot pain (nontraumatic)	Radiographs indicated if unrelieved by 4 wk of conservative care or in suspected inflammatory arthritis and additional views:	• 161	• 3	D Important (but not critical)
	Special investigations if radiography is positive or if unrelieved by 4 wk of conservative care			GPP
Specific clinical diagnoses:
B1. Acquired flat foot with posterior tibial tendon dysfunction/rupture	Radiographs indicated if unrelieved by 4 wk of conservative care or in suspected inflammatory arthritis: additional views	• 196	• 3	D Important (but not critical)
		• 197	• 3
		• 198	• 3
		• 199	• 3
	Special investigations	• 200	• 3	D Important (but not critical)
B2. Navicular tuberosity pain and tenderness	Radiographs indicated if unrelieved by 4 wk of conservative care	• 182	• Strongly recommended	C Important (but not critical)
	Special investigations			GPP
B3. Complex regional pain syndrome	Radiographs indicated	• 186	• -2	D Important (but not critical)
	Special investigations	• 200	• 3	D Important (but not critical)
Specific clinical diagnoses:
(C) Forefoot pain	Radiographs not routinely indicated unless unresponsive to 4 wk of conservative care or if inflammatory or infectious etiology suspected	• 43	• Strongly recommended	B Important (but not critical)
		• 182	• Strongly recommended
		• 201	• 3
	Special investigations	• 184	• 3	D Important (but not critical)
		• 201	• 3
C1. Metatarsal bursitis	Radiographs not routinely indicated unless unresponsive to 4 wk of conservative care: or if inflammatory or infectious etiology suspected			GPP
	Special investigations	• 201	• 3	GPP
C2. Morton's neuroma	Radiographs indicated	• 182	• Strongly recommended	C Important (but not critical)
	Special investigations	• 58	• 3	D Important (but not critical)
		• 201	• 3
		• 202	• 3
C3. Stress (fatigue or insufficiency) fracture	Radiographs indicated	• 43	Strongly recommended	D Important (but not critical)
		• 203	• 3
		• 198	• 3
	Special investigations	• 43	• Strongly recommended	C Important (but not critical)
		• 205	• 3
C4. Osteonecrosis (avascular necrosis)	Radiographs indicated: (B)	• 6	• Recommended	D Important (but not critical)
	Special investigations: (B)	• 182	• Strongly recommended	C Important (but not critical)
C5. Hallux rigidus and hallux valgus (1st MTP joint)	Radiographs not routinely indicated unless unresponsive to 4 wk of conservative care (B) and additional view	• 43	• Strongly recommended	D Important (but not critical)
		• 165	• 3
		• 206	• 3
		• 207	• 3
		• 208	• 3
		• 209	• Not recommended
		• 210	• 3
C6. Sesamoiditis	Radiographs not routinely indicated unless unresponsive to 4 weeks of conservative care & Additional view	• 165	• 3	D Important (but not critical)
Painful inflammatory condition caused by repetitive injury. Reactive tendinitis, synovitis or bursitis common.		• 211	• 3
		• 212	• 3
	Special investigations			GPP

Independent Literature Assessment and Strength of Recommendations for the Adult Upper Extremity Disorders Guidelines

NB. Reference numbers (Ref #) correspond to those of the Upper Extremity Disorders Guidelines

Table D4. Adult shoulder disorders

Table D5. Adult Elbow Disorders