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

Article Outline

• Abstract
• Reporting of Topics Included in the Development of the Diagnostic Imaging Practice Guidelines1
  • Focus
  • Objectives
  • Target Users/Setting
  • Target Population
  • Developers
  • Evidence Collection
  • Methods for Synthesizing Evidence
  • Recommendation Grading Criteria
  • Patient Preferences: Condition-Specific Imaging Guidelines
  • Stakeholders and Editorial Independence
    • Pre-release Review
    • Potential Conflict of Interest
    • Funding Sources/Sponsors
  • Updating/Revision
  • Potential Benefits and Harm
  • Dissemination/Implementation Considerations
  • Definitions, Patient Presentations, Recommendations, and Rationale
• Preliminary Considerations and Disclaimer
  • What is the Role of These Guidelines?
  • What These Guidelines Do and What They Do Not Do
  • What is Evidence-Based Health Care?
  • Potential Disagreements
  • Standard Patient Management Activities
  • Duration of Disorders
  • Are there Potential Risks Associated with Conventional Radiographs?
• Acknowledgment
• Appendix A. List of Abbreviations and Glossary for Lower Extremity Disorders
• Appendix B. Summary of Recommendations
• Appendix C. General Indications for Advanced Imaging in Extremity Disorders
• Appendix D. Typical Effective Ionized Radiation Dose for Common Imaging Procedures*
• Appendix E. Additional Reading Recommended on MRI
• Appendix F. Acknowledgements
• References
• Copyright

Abstract 

Purpose

The aim of this study was to develop evidence-based diagnostic imaging practice guidelines to assist chiropractors and other primary care providers in decision making for the appropriate use of diagnostic imaging of lower extremity disorders.

Methods

A comprehensive search of the English and French language literature was conducted using a combination of subject headings and keywords. The quality of the citations was assessed using the Quality of Diagnostic Accuracy Studies (QUADAS), the Appraisal of Guidelines Research and Evaluation (AGREE), and the Stroke Prevention and Educational Awareness Diffusion (SPREAD) evaluation tools. The Referral Guidelines for Imaging (Radiation Protection 118) coordinated by the European Commission served as the initial template. The first draft was sent for external review. A Delphi panel composed of international experts on the topic of musculoskeletal disorders in chiropractic radiology, clinical sciences, and research were invited to review and propose recommendations on the indications for diagnostic imaging. The guidelines were pilot tested and peer reviewed by field chiropractors, and by chiropractic and medical specialists. Recommendations were graded according to the strength of the evidence.

Results

Recommendations for diagnostic imaging guidelines of adult lower extremity disorders are provided, supported by more than 174 primary and secondary citations. Except for trauma, the overall quality of available literature is low. On average, 57 Delphi panelists completed 1 of 2 rounds, reaching more than 83% agreement on all 56 recommendations. Peer review by specialists reflected high levels of agreement, perceived ease of use of guidelines, and implementation feasibility.

Conclusions

The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be updated regularly. Dissemination and implementation strategies are discussed. Future research is needed to validate their content.

Key Indexing Terms: Practice Guideline, Guideline, Diagnostic Imaging, Radiology, Diagnostic X-ray, Radiography, Adult, Musculoskeletal System, Pain, Lower Extremity, Hip, Knee, Ankle, Foot, Trauma

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Reporting of Topics Included in the Development of the Diagnostic Imaging Practice Guidelines¹ 

An initial literature review considered 10 clinical questions pertaining to imaging of musculoskeletal conditions to evaluate the pertinence of developing diagnostic imaging guidelines. This initial review led to a research project divided into 9 phases: (1) literature search, (2) independent literature assessment, (3) guideline development specific recommendations, (4) first external review, (5) consensus panel (modified Delphi), (6) public Web site, (7) second external review, (8) final draft and grading of the recommendations, and (9) dissemination and implementation. Details of this study are published elsewhere.²

Focus 

These diagnostic imaging guidelines concern adult musculoskeletal disorders of the lower extremities where conventional radiography and specialized imaging studies are deemed useful for diagnostic purposes.

Objectives 

These proposed guidelines are intended to reduce unnecessary radiation exposure and the use of specialized imaging studies, increase examination precision, and decrease health care costs—all without compromising quality of care. The reasons for developing these guidelines include assisting current and future health care providers to make appropriate use of imaging studies, providing indications for the need of imaging studies according to current literature and expert consensus, and assisting in optimizing the use of limited available resources.

Target Users/Setting 

Intended users of the guidelines are chiropractors and other primary health care providers prescribing diagnostic imaging studies. The setting in which these guidelines may be used include private clinics, outpatient clinics, and hospital emergency departments.

Target Population 

The patient population eligible for guideline recommendations are adult patients presenting with musculoskeletal disorders of the lower extremities. Children and pregnant patients are excluded from these guideline recommendations.

Developers 

The proposed guidelines are developed from the results of 9 distinct phases overseen by a research team composed of the 3 investigators with postgraduate education from 3 independent teaching institutions. The guidelines were further developed and peer reviewed by more than 60 chiropractic clinicians, academics, researchers, and a group of physicians.

Evidence Collection 

Electronic searches in English and French language literature occurred, and cross-references were repeated on 3 different occasions between 2003 and 2006.

Methods for Synthesizing Evidence 

Recommendation Grading Criteria 

The evaluation tool used was designed by the Scottish Intercollegiate Guidelines Network (SIGN) and adapted by the Stroke Prevention and Educational Awareness Diffusion (SPREAD group).^5,7

Patient Preferences: Condition-Specific Imaging Guidelines 

Integral to evidence-based health care, decisions regarding the use of imaging studies should be based on the best available evidence, and the experience and judgment of the clinician, while considering patient preference. A public member reviewed all documents and provided comments and suggestions.

Stakeholders and Editorial Independence 

Before the release of the guidelines, the reliability of proposed recommendations was tested on specialists both in chiropractic and in medicine as well as on field chiropractors.

The research team involved in the development of these guidelines declares no existing or potential conflict of interest. No investigators have received, nor will receive, any personal financial benefits or derive any salary from this project.

Updating/Revision 

The literature review and the guidelines should be updated every 2 to 3 years.

Potential Benefits and Harm 

These include selection of appropriate radiologic imaging procedures for evaluation of patients with musculoskeletal disorders of the lower extremities; and decreased unnecessary ionizing radiation exposure, decreased costs, and improved accessibility.

Dissemination/Implementation Considerations 

Means of dissemination include publication; application to the National Guideline Clearinghouse; posting of the electronic document on various Web sites (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 conferences.

Definitions, Patient Presentations, Recommendations, and Rationale 

These topics are integral parts of each one of the three diagnostic imaging guidelines: lower extremity disorders, upper extremity disorders, and spine disorders. Results of the 9 phases of the research project are published elsewhere in this issue of the journal.²

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Preliminary Considerations and Disclaimer 

What is the Role of These Guidelines? 

These evidence-based diagnostic imaging practice guidelines are intended to assist primary care providers and students in decision making regarding the appropriate use of diagnostic imaging for specific clinical presentations. The guidelines are intended to be used in conjunction with sound clinical judgment and experience. For example, other special circumstances for radiographic imaging studies may include: patient unable to give a reliable history, crippling cancer phobia focused on back pain, need for immediate decision about career or athletic future or legal evaluation, history of significant radiographic abnormalities elsewhere reported to patient but no films or reliable report reasonably available, and history of finding from other study (eg, nuclear medicine or imaging of the pelvis) that requires radiograph for correlation.⁸ Application of these guidelines should help avoid unnecessary radiographs, increase examination precision, and decrease health care costs without compromising the quality of care.

The descriptions of clinical presentations and proposed clinical diagnostic criteria, the recommendations for imaging studies, and the comments provided throughout this article are a synthesis of the vast body of literature consulted before and during the various phases of this research project. Where the literature was found to be of poor quality or absent, consensus based on expert opinion was used. Although the investigators and collaborators carefully searched for all relevant articles, it is probable that some have been missed. Furthermore, as many new important studies are published in the near future, these will be incorporated in subsequent revisions of the guidelines and recommendations may change accordingly.

What These Guidelines Do and What They Do Not Do 

These guidelines are intended to address issues faced by first-contact professionals only. These guidelines do not address all possible conditions associated with musculoskeletal disorders, only those that account for most initial visits to a practitioner.

Like other diagnostic tests, imaging studies should only be considered if (a) they yield clinically important information beyond that obtained from the history and physical examination, (b) this information can potentially alter patient management, and (c) this altered management has a reasonable probability to improve patient outcomes.⁹, ¹⁰, ¹¹

Investigators and collaborators in the development of these imaging guidelines believe that liability insurance companies, third-party payers, and courts of law should not rely solely on descriptions of patient presentations, proposed recommendations, and/or corresponding comments found throughout the documents because patient presentations are unique and the application of any guideline always requires clinical judgment and thus needs to be considered in the proper context. In addition, laws and regulations may vary between geographical regions and should be considered when applying the proposed indications for any imaging study.

What is Evidence-Based Health Care? 

Evidence based is about tools, not about rules.¹² Evidence-based health care is an approach in which clinicians and health care professionals use the current best evidence in making decisions about the care of patients. It involves continuously and systematically searching, appraising, and incorporating contemporaneous research findings into clinical practice. The overall goal is improving patient care through life-long learning.^12,13

Potential Disagreements 

There are several reasons for disagreement within a guideline development group. These include differences in interpretation of the research literature, differences in personal experience, and different perceptions of the inherent risks and benefits of a procedure.¹⁴ Divergent or competing guidelines on similar topics serve only to further confuse and frustrate practitioners.¹⁵ In addition, the continued lack of unity among chiropractors hinders growth of the profession by limiting integration and cooperation within the greater health care system. Readers of any guidelines are advised to critically evaluate the methods used as well as the content of the recommendations before adopting them for use in practice.¹⁶

Standard Patient Management Activities 

Standard patient management activities, including diagnostic assessment and follow-up, are integral components of every patient encounter.¹⁷ Initial triage of patients with musculoskeletal disorders is a constant recommendation of various clinical guidelines.¹⁸ Imaging studies are used most practically as confirmation studies once a working diagnosis is determined. The objective is to determine the presence of clinical indicators of serious pathologies (red flags) requiring diagnostic imaging, specialist referral, or urgent surgical intervention. When a practitioner recommends that a radiograph or other diagnostic imaging study be performed, and the patient refuses, the patient should be advised of the associated risks and implications and this should be recorded in the patient's records.

Duration of Disorders 

In clinical practice, musculoskeletal disorders are generally divided into categories according to the duration of the patient complaint on initial presentation. These diagnostic imaging guidelines therefore consider the following categories of clinical presentations: acute extremity disorder (<4 weeks of duration), subacute extremity disorder (4-12 weeks of duration), and persistent/chronic extremity disorder (>12 weeks of duration).

Are there Potential Risks Associated with Conventional Radiographs? 

Although somewhat controversial,¹⁹, ²⁰, ²¹, ²² it is important to remember that health hazards of all forms of radiation are cumulative.²², ²³, ²⁴, ²⁵, ²⁶, ²⁷, ²⁸, ²⁹ The Biological Effects of Ionizing Radiation (BEIR VII) 2005 report released by the National Academy of Sciences adds further support to the “linear-no-threshold” model of cancer risk from ionizing radiation exposure.³⁰ In summary, this report concludes that ionizing radiation is dangerous even at low doses and that there are no safe limits. Given the potential risks associated with conventional radiography, only appropriate clinical indications can justify its use. In this regard, the need to confirm pathology, to follow the evolution of a pathology possibly affecting therapy, or to identify a clinically suspected contraindication to manipulative therapy are the best-documented reasons. The benefits of all diagnostic studies must outweigh the risks and the inherent costs to the patient.⁹, ³¹, ³², ³³, ³⁴, ³⁵, ³⁶, ³⁷, ³⁸, ³⁹

Uppercase letters enclosed by brackets in both tables and the appendices represent the grading for each recommendation according to SPREAD, while considering the level of evidence (LOE) of studies reviewed during the literature review of Phase 2. Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jmpt.2007.10.003 and in tables DI-D3 in Appendix D of Reference 2.

Table 1, Table 2, Table 3 list the patient presentations, recommendations, and comments regarding diagnostic imaging for lower extremity disorders. A list of abbreviations and glossary of terms used in the recommendations are in Appendix A. Appendix B provides a summary of the recommendations. General indications for advanced imaging in extremity disorders are presented in Appendix C. Typical effective ionized radiation dose for common imaging procedures are listed in Appendix D. Further recommended reading pertaining to magnetic resonance imaging of the lower extremity is offered in Appendix E.

Table 1. Adult hip disorders

NSAID, Nonsteroidal anti-inflammatory drug.

Table 2. Adult knee disorders

CI, Confidence interval; OKR, Ottawa Knee Rules.

Table 3. Adult ankle and foot disorders

See Bálint et al¹⁶⁵ for additional reading on ankle and foot disorders, and Bucholz and Heckman²¹² for fractures in adults.

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Acknowledgment 

The authors are appreciative of the efforts of the many people who assisted in this process, listed in Appendix F.

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Appendix A. List of Abbreviations and Glossary for Lower Extremity Disorders 

ACL: 

anterior cruciate ligament

 

AP: 

Anteroposterior

 

AS: 

ankylosing spondylitis

 

Osteonecrosis: 

avascular necrosis

 

CPPD: 

calcium pyrophosphate dihydrate crystal deposition disease

 

CNS: 

central nervous system

 

CT: 

computed tomography

 

Ddx: 

differential diagnosis

 

DJD: 

degenerative joint disease

 

Dx: 

diagnosis

 

GHQ questionnaire: 

General Health Questionnaire History

 

IAB: 

intra-articular osteocartilaginous body

 

JRA: 

juvenile rheumatoid arthritis

 

LOE: 

level of evidence

 

MC: 

most common

 

MSK: 

Musculoskeletal

 

MTP joint: 

metatarsophalangeal joint

 

MRA: 

magnetic resonance arthrography

 

MRI: 

magnetic resonance imaging

 

NM: 

nuclear medicine (bone scan)

 

OAR: 

Ottawa ankle and foot rules

 

OKR: 

Ottawa knee rules

 

PA: 

posteroanterior

 

PF: 

plantar fasciitis

 

ROM: 

range of motion

 

R/O: 

rule out

 

RA: 

rheumatoid arthritis

 

Sp: 

specificity

 

Sn: 

sensitivity

 

Tendinosis: 

degeneration of tendons and of tendon muscle attachments

 

US: 

ultrasound

 

x-ray: 

plain film radiograph

 

YOA: 

years of age

 

>: 

greater than

 

≥: 

equal or greater than

 

Ψ: 

psychology/psychiatry

 

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Appendix B. Summary of Recommendations 

Table 1. Summary of recommendations—adult hip disorders

Table 2. Summary of recommendations—adult knee disorders

Table 3. Summary of recommendations—adult ankle and foot disorders

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Appendix C. General Indications for Advanced Imaging in Extremity Disorders 

++, First choice; +, second choice (must be determined on a case-by-case basis)^a,b,c

^aAdapted with permission from Peterson C. Canadian Guidelines for Imaging (2002, unpublished data).

^bSantiago RC, Gimenez CR, McCarthy K. Imaging of osteomyelitis and musculoskeletal soft tissue infections: current concepts. Rheum Dis Clin North Am 2003;29(1):89-109.

^cCardinal E, Bureau NJ, Aubin B, Chhem RK. Role of ultrasound in musculoskeletal infections. Radiol Clin North Am. 2001;39(2):191-201.

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Appendix D. Typical Effective Ionized Radiation Dose for Common Imaging Procedures* 

*Classification of the typical effective dose of ionizing radiation from common imaging procedures. Adapted from European Commission. Radiation protection 118. Referral guidelines for imaging in conjunction with the UK Royal College of Radiologists; Italy 2001. p 21.

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Appendix E. Additional Reading Recommended on MRI 

• Grenier JM, Wessely MA. Hip and pelvis MRI. Part 1: A basic overview. Clin Chiropr 2006; 9:92-8.

• Grenier JM, Wessely MA. Hip and pelvis MRI. Part 2: Common pathological conditions of the pelvis and hip. Clin Chiropr 2006;9:150-159.

• Grenier JM, Green NA, Wessely MA. Knee MRI. Part I: basic overview. Clin Chiropr 2004; 7:84-9

• Grenier JM, Wessely MA. Knee MRI. Part II: MR imaging of common internal derangement affecting the knee. Clin Chiropr 2004; 7:131-40.

• Wessely MA. MR imaging of the ankle and foot—a review of normal imaging appearance with an illustration of common disorders. Clin Chiropr 2007; 10:101-11.

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Appendix F. Acknowledgements 

The authors express their sincere appreciation to all Delphi panelists (phase 5), external reviewers (phases 4 and 7), and to the quality of literature assessors (phase 2): Jeffrey Cooley, Jonathon Egan, Michael Morgan, Julie O'Shaughnessy, and Jason Napuli, whose significant contributions were essential in the completion of this project. The authors are grateful to chiropractic college presidents for recommending faculty members for the Delphi panel. The authors have appreciated the feedback received by colleagues in the field during and after the worldwide consultation on the Web (phase 6). Many thanks to Dr Andre Cardin of Université du Québec à Trois-Rivières for his significant input in the initial draft (phase 3); Drs Michelle Wessely of the Institut Franco-Europeen de Chiropratique and Julie-Marthe Grenier of Université du Québec à Trois-Rivières for their valuable editorial input; and to Drs Carlo Ammendolia, DC, PhD, Joe Lemire DC, MSc, John Triano, DC, PhD, and Jacques Duranceau, MD, for providing constructive advice. The authors are indebted to those who assisted during all or part of the project, including Drs 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, the authors would like to thank Mrs Vicki Pennick, RN, BScN, MHSc, Senior Clinical Research Project Manager, Managing Editor, Cochrane Back Review Group, Institute for Work and Health, for her valuable advice and pertinent comments and suggestions as a public representative.

The authors acknowledge all Delphi panelists who have dedicated their time to this project. The following is a list of Delphi panelists who have agreed to be acknowledged for their significant contribution to the research project.

Allan Adams, DC, MSEd

Texas, USA, Texas Chiropractic College (Academic and Researcher)

Peter Aker, DC, MSc, FCCS, FCCRS

Ontario, Canada (Clinician and Researcher)

Thomas F. Bergmann, DC

Minnesota, USA, Professor, Northwestern Health Sciences University (Academic, Clinician)

Douglas G. Brandvold, DC

British Columbia, Canada (Clinician)

Peter Bull, DC, MAppSc, FICC

Sydney, Australia, Senior Lecturer, Director of Postgraduate Studies, Macquarie University (Academic and Clinician)

Jeanmarie Burke, PhD

New York, USA, Research Director, New York Chiropractic College (Researcher and Academic)

David Byfield, BSc Hons, DC, MPhil, FCC, FRSM, FBCA

Wales, UK, Divisional Head—Chiropractic,

Head of the Welsh Institute of Chiropractic Faculty of Health, Sport and Science

University of Glamorgan (Academic and Clinician)

Jeffrey Cooley, DC, DACBR

Perth, West Australia, Senior Lecturer, Murdoch University (Academic)

Vince DeBono, DC

Illinois, USA, Dean of Clinics, National University of Health Sciences (Academic, Clinician)

Martin Descarreaux, DC PhD

Quebec, Canada, Université du Québec à Trois-Rivières (Researcher, Academic and Clinician)

Renee DeVries, DC, DACBR

Minnesota, USA, Associate Professor and Consulting Radiologist, Northwestern Health Sciences University (Academic)

Shawn Dill, DC

California, USA, Professor, Life College Chiropractic West (Academic and Clinician)

Paul Dougherty, DC, FACO

New York, USA, New York Chiropractic College (Academic)

Dennis Enix, DC, MBAc

Missouri, USA, Associate Professor of Research, Logan College of Chiropractic (Researcher and Clinician)

Ronald C. Evans, DC, FACO, FICC

Iowa, USA, Senior Orthopedist, Senior Trustee, Foundation for Chiropractic Education and Research, Senior Member, Chiropractic Healthcare Benefits Advisory Committee, Health Affairs, Department of Defense (Researcher and Clinician)

Roni Evans, DC, MSc

Minnesota, USA, Dean of Research, North Western Health Sciences University (Researcher)

Simon Forster, DC DACBO

Texas, USA (Clinician)

Edward Fritsch, DC

Texas, USA, Texas Chiropractic College (Academic and Clinician)

Bryan Gatterman, DC, DACBR

California, USA, Life West Chiropractic College (Academic and Clinician)

Claude Gauthier, DC

Quebec, Canada (Clinician)

Guy Gosselin, DC, FCC (UK)

London, UK (Clinician)

Kristin L. Grace, DC DACBR

Hastings, New Zealand, Senior Lecturer, New Zealand Chiropractic College (Academic and clinician)

Gary Greenstein, DC

Connecticut, USA, University of Bridgeport (Academic)

Julie-Marthe Grenier, DC, DACBR

Quebec, Canada, Université du Québec à Trois-Rivières (Academic, Research)

Rocco Guerriero, C. BSc, DC, FCCSS(C), FCCRS(C), FCC(C)

Ontario, Canada, Canadian Memorial Chiropractic College (Academic and Clinician)

Mitchell Haas, DC, MA

Oregon, USA, Dean of Research, Western States Chiropractic College (Academic and Researcher)

Michael W. Hall, DC, DABCN

Texas, USA, Associate Professor, Parker College of Chiropractic (Academic and Clinician)

Jan Hartvigsen, DC, PhD

Odense, Denmark, Dean of Research, University of Southern Denmark (Academic and Researcher)

Shawn Henderson, DC, FCCRS(C), FCCO(C)

Ontario, Canada (Clinician)

William Hsu, DC, DACBR

Ontario, Canada, Associate Professor, Canadian Memorial Chiropractic College (Academic)

Eric Jackson, DC FCCRS

Ontario, Canada (Clinician)

Amanda Kimpton, BAppSc(Chiro), PhD

Victoria, Australia, RMIT University (Academic and Clinician)

Dana J. Lawrence, DC, FICC

Iowa, USA, Associate Professor

Palmer Chiropractic College (Academic and Researcher)

Douglas Lawson, BA, DC

Alberta, Canada (Researcher and Clinician)

Kathleen Linaker, DC, DACBR, Assistant

Georgia, USA, Professor, Director Clinic Radiology, Life University College of Chiropractic (Academic, Clinician)

Tracey Littrell, DC, DACBR

Iowa, USA, Associate Professor, Diagnosis and Radiology, Palmer-Davenport Chiropractic College (Academic)

Stephan Mayer, BSc, DC

California, USA, Chair of Diagnostic Sciences and Associate Academic Dean, Cleveland Chiropractic College (Academic)

Peter W. McCarthy, BSc (Jt Hons), PhD FBCA

Wales, UK, University of Glamorgan (Researcher and Academic)

Ian D. McLean, DC, DACBR

Iowa, USA, Professor, Clinical Radiologist Professor, Director of Clinical Radiology and Chiropractic Residencies, Palmer-Davenport Chiropractic College (Academic and Clinician)

Michael Mestan, DC, DACBR

New York, USA, Head of Department of Chiropractic Clinical Sciences, New York Chiropractic College (Academic)

Timothy J. Mick, DC, DACBR, FICC

Minnesota, USA, Associate Professor

Director—Radiological Consultation Services, Northwestern Health Sciences University (Academic)

Silvano Mior, DC, FCCS

Ontario, Canada, Canadian Memorial Chiropractic College (Researcher and Clinician)

Tom Molyneux, DipAppsc (H Biology), DipAppSc(Chiro), BAppSc(Chiro), DACBR, FACCR, GradDipTertEd

Victoria, Australia, RMIT University (Academic)

William E. Morgan, DC

Maryland, USA, Adjunct professor, New York College of Chiropractic, National University of Health Sciences (Clinician)

Elli Morton, DC

British Columbia, Canada (Clinician)

Greg Norton, DC, FACO, FIACN

Iowa, USA (Clinician)

Sandra O'Connor, DC, DACBR, FCCR

Ontario, Canada (Clinician)

Rosemary Pace, RN, DipAppSc(MedRad), MEd (ICT), MBus, GradDipEd, GradDipBus

Victoria, Australia, RMIT University (Academic and Researcher)

Joseph Pfeifer, DC

New York, USA, New York Chiropractic College (Academic)

John Pikula, FCCR(C), FCCS(C), FCCO(C)

Ontario, Canada (Clinician)

Brock Potter, DC

British Columbia, Canada (Clinician)

Tania C. Pringle, BPE, BA, DC, DACBR, FCCR(C)

Ontario, Canada, Assistant Professor, Canadian Memorial Chiropractic College (Academic)

Serge Roux, DC, DABCO

Quebec, Canada (Clinician)

Peter Scordilis, DC

New Jersey, USA (Clinician)

Thomas A Souza, DC, DACBSP

California, USA, Dean of Academic Affairs, Palmer Chiropractic College West (Academic and Clinician)

John Stites, DC, DACBR

Iowa, USA, Palmer Chiropractic College (Academic)

Rand Swenson, DC, MD, PhD

New Hampshire, USA, Associate Professor of Anatomy and of Medicine, Chairman, Department of Anatomy, Dartmouth Medical School (Academic, Clinician)

John Sweaney, AM, DC

New South Wales, Australia, Chiropractic Education Consultant (Clinician)

Cliff Tao, DC, DACBR

California, USA (Clinician)

Jeffrey Thompson, DC, DACBR

Texas, USA (Clinician and Researcher)

Jann Thulien, DC, DACBR

Ontario, Canada (Clinician)

Michelle A. Wessely, BSc, DC, DACBR

Paris, France, Professor, Head of Radiology and Clinical Research, Institut Franco‑Europeen de Chiropratique (Academic and Clinician)

Michael Whitehead, BS, DC, DACBR

Missouri, USA, Chair of Diagnostic Sciences, Cleveland Chiropractic College (Academic and Clinician)

Kenneth J. Young, DC, DACBR, FCC(UK)

Wales, UK, Senior lecturer in radiology, University of Glamorgan (Academic and Clinician)

Delphi Process Advisors

Meridel I Gatterman, MA, DC, MEd,

Colorado, USA, Chiropractic Educational Consultant

Peter Miller, BSc, MSc, FCC (Orth)

Bournemouth, UK, Anglo‑European College of Chiropractic

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