- Open Access
Current evidence for spinal X-ray use in the chiropractic profession: a narrative review
Chiropractic & Manual Therapiesvolume 26, Article number: 48 (2018)
The use of routine spinal X-rays within chiropractic has a contentious history. Elements of the profession advocate for the need for routine spinal X-rays to improve patient management, whereas other chiropractors advocate using spinal X-rays only when endorsed by current imaging guidelines. This review aims to summarise the current evidence for the use of spinal X-ray in chiropractic practice, with consideration of the related risks and benefits. Current evidence supports the use of spinal X-rays only in the diagnosis of trauma and spondyloarthropathy, and in the assessment of progressive spinal structural deformities such as adolescent idiopathic scoliosis. MRI is indicated to diagnose serious pathology such as cancer or infection, and to assess the need for surgical management in radiculopathy and spinal stenosis. Strong evidence demonstrates risks of imaging such as excessive radiation exposure, overdiagnosis, subsequent low-value investigation and treatment procedures, and increased costs. In most cases the potential benefits from routine imaging, including spinal X-rays, do not outweigh the potential harms. The use of spinal X-rays should not be routinely performed in chiropractic practice, and should be guided by clinical guidelines and clinician judgement.
Chiropractic has a long association with the use of spinal X-rays in clinical practice. Early X-ray technology was incorporated within chiropractic clinical examinations from 1910, with the stated purpose to visualise the alignment of spinal vertebrae and direct appropriate treatment [1, 2]. Since that time chiropractors around the globe have gained licensure for X-ray machine ownership and use. Over the last three decades the evidence-base for the diagnosis and management of spinal pain has transitioned from a static mechanical model, as visualised by X-ray, to a patient-centred model operating within a biopsychosocial context . This transition, combined with the low diagnostic yield of clinically relevant radiographic findings , and increased awareness of associated risks has led to questioning of the routine use of imaging (including X-rays) to evaluate spinal pain [5, 6]. Current evidence-based guidelines recommend that imaging be limited predominantly to cases of suspected underlying serious pathology or trauma [7,8,9,10,11,12,13]. Controversy exists within the chiropractic profession, however, with some groups advocating for continued routine use of spinal X-rays within chiropractic clinical practice [14, 15]. The aim of this review is to summarise the current evidence for the use of spinal X-ray in chiropractic practice, with consideration of the related risks and benefits. The review is presented in four sections: 1) the current use of spinal X-ray imaging within chiropractic clinical practice; 2) the evidence for potential reasons for obtaining spinal X-rays within chiropractic; 3) the evidence of possible risks or limitations associated with the use of spinal X-rays; and 4) guidelines for the appropriate use of imaging in chiropractic clinical practice.
Search strategies and study selection
PubMed and The Index of Chiropractic Literature were searched using broad search terms such as: chiropractic, spinal X-rays, adverse events, imaging risks and benefits, X-ray radiation exposure, and back and neck pain guidelines. Reference lists from relevant review articles were also searched. Guidelines and systematic reviews were selected where possible.
Current use of spinal X-ray within chiropractic clinical practice
The proportion of patients receiving X-ray as a result of chiropractic consultation ranges from 8 to 84% [16,17,18,19,20,21,22,23,24]. Significant decrease in X-ray utilisation over time has been shown in some studies [16, 20, 25], whereas an increase in X-ray utilisation by chiropractors over time has also been identified . A recent Australian Medicare benefits schedule review taskforce concluded that spinal X-rays continued to be overused within chiropractic clinical practice . As a result, Medicare rebates for three and four-region spinal X-rays in Australia under the public health system have been withdrawn from chiropractors, while remaining for physiotherapists and osteopaths . Of additional concern, only 50% of Australian chiropractors report awareness of current radiographic guidelines for low back pain .
Reasons given for obtaining spinal X-rays by chiropractic practitioners are varied, with many not supported by evidence of benefit. These include diagnosis of pathology or trauma; determination of treatment options; detection of contraindications to care; spinal biomechanical analysis; patient reassurance; and medicolegal reasons [27,28,29,30]. Specific drivers of these varied reasons for obtaining X-rays are unknown, although some associations have been demonstrated including lack of education, ownership of X-ray facilities, and preferred chiropractic technique modalities . A number of different treatment technique modalities exist within chiropractic, some of which advocate the use of routine spinal X-rays to perform biomechanical analysis, direct appropriate treatment, and perform patient reassessment . Different chiropractic educational institutions show a similar variance in their teaching of potential reasons to obtain X-rays , and this is reflected in an association between both rates of X-ray utilisation , and unorthodox use of radiography , with the institution of chiropractic education.
There is a growing movement in healthcare to reduce low-value care, including unnecessary and wasteful tests and procedures [33,34,35], spearheaded by the Choosing Wisely™ movement . Choosing Wisely™ works with healthcare organisations and patient groups to develop campaigns to address overuse of tests that do not add value for patients and may cause harm. Reducing inappropriate imaging for low back pain is a prominent message in many Choosing Wisely™ campaigns for different healthcare providers, including the American Chiropractic Association and Chiropractic Australia [37,38,39,40]. This has been driven by inappropriate imaging that leads to patient harm, inefficiencies and waste in the healthcare system [36, 40, 41].
Evidence for potential reasons for obtaining spinal X-rays within chiropractic
Diagnosis of pathology or trauma
Spinal X-rays are well established as a diagnostic modality to aid in the confirmation of suspected serious pathology or traumatic injury, as reflected in current imaging guidelines [7,8,9,10,11,12,13]. A chiropractors’ diagnosis of underlying serious pathology (i.e. cancer, infection, spondyloarthropathy) or traumatic fracture is important as clinical management would necessitate referral to medical specialities and may contraindicate manipulative therapy.
Serious pathology and traumatic injury, however, are rare causes of spinal pain. Various studies have found the incidence of serious pathology presenting as low back pain in primary care settings to be between 0.2 and 3.1% [4, 21, 42,43,44], and fracture to be between 0.2 and 6.6% [4, 21, 42,43,44]. Therefore, while these diagnoses are important to be made when the clinical circumstances exist, routine use of X-ray imaging to diagnose these conditions is not recommended due to the rarity of these presentations in clinical practice. Furthermore, recent evidence informed consensus suggests referral for MRI and blood tests, rather than X-ray, as the preferred investigation when serious pathology such as cancer or infection is suspected .
Spinal X-ray imaging may also be used to diagnose more benign spinal findings such as degenerative arthritis, spondylolisthesis, and transitional vertebral segments. An important consideration, however, is whether these radiographic findings are clinically important, and whether there is evidence that diagnosis by X-ray leads to a change in patient management. Many of these radiographic findings, although relatively common [21, 46, 47], show either no or weak association with symptomatology [48,49,50,51,52], making their clinical relevance questionable. Furthermore, there is no high quality evidence to demonstrate that patient management should be modified based on presence of benign radiographic findings that could not be determined from patient clinical history or exam alone. Current chiropractic clinical practice guidelines do not differentiate between treatment options based on the presence or absence of these benign radiographic findings . Therefore, based on the evidence, the use of X-ray imaging to diagnose benign spinal findings will not improve patient outcomes or safety.
Determining treatment options
The use of spinal X-ray imaging may be justified where findings may result in a beneficial change to patient management. For patients presenting with conditions such as radiculopathy or spinal stenosis, imaging may be used to support the decision-making process (e.g. to determine whether conservative or surgical care is more appropriate) [7, 8, 45]. However, most cases of radiculopathy or stenosis can initially undergo a trial of conservative care [45, 53], and there is no evidence that early imaging leads to improved management beyond that informed by the clinical presentation alone . Current guidelines recommend that imaging be deferred until after a trial of care, and is only indicated in cases of progressive or widespread neurological compromise [7, 8, 45]. In these cases, X-ray is not recommended and MRI is the more valuable form of imaging for assessment [8, 45].
The use of spinal X-ray imaging has been postulated to be important to help direct appropriate chiropractic management, where specific X-ray findings would lead to a change in the type of technique modality selected. However, we could find no studies assessing the impact of routine imaging on technique modality selection resulting in improved patient outcomes. While there are many different technique modalities used within chiropractic practice, there is a lack of high quality evidence to indicate which technique modalities are superior for a given condition. Furthermore, spinal X-ray has not been found to be a useful method to determine the site of spinal manipulation . For usual medical care of non-specific back or neck pain, studies show no difference in treatment outcome when routine spinal X-rays have been used, compared to management without X-rays [56, 57]. Therefore, without any clear evidence of benefit of using spinal X-ray to direct treatment modality selection, clinician selection of modality should be made based on the clinical presentation, and the use of initial X-ray confirmation is not justified..
Screening patients for contraindications prior to care
A common reason suggested by chiropractors for spinal X-ray imaging is to screen for anomalies or serious pathology that may contraindicate treatment that were otherwise unsuspected by the clinical presentation. While some cases of serious pathology, such as cancer and infection, may not initially present with definitive symptoms, X-ray assessment at this early stage of the disease process is also likely to be negative, and is not recommended as a screening tool . The development of symptoms, which would then indicate the need for imaging referral, often reflects progression of the underlying pathology, and therefore an increased likelihood of observing related imaging findings. However, even in symptomatic patients, MRI rather than X-ray is recommended as the initial imaging modality due to the higher sensitivity of MRI for the detection of pathological changes [45, 58]. Pathological causes of back and neck pain are rare [4, 42, 44], and even fewer cases would be asymptomatic, further reducing the potential benefit of routine imaging. Furthermore, imaging referral consistent with current imaging guidelines has not been shown to have an increased risk of missing serious pathology [44, 59]. Therefore, routine imaging (including spinal X-rays) for unsuspected serious pathology is not supported by evidence.
Anatomical anomalies in the upper cervical spine, such as agenesis of the dens and fusion of the occiput and atlas, have been postulated to be associated with increased upper cervical instability or neural compromise that may contraindicate manipulative therapy [46, 60]. These anomalies present with varied symptomatology, and can be difficult to clinically diagnose, thus X-ray screening has been suggested . However, the contraindication of manipulative therapy for patients with these anomalies is on a theoretical basis, rather than documented clinical evidence of harm . A scoping review of risks of manual treatment to the spine did not identify any reports of harm after manipulative therapy that were attributed to the presence of upper cervical anatomical anomalies . Prevalence rates of upper cervical anatomical anomalies are also low (between 2.1 to 3.7% [21, 46]). The low prevalence, combined with uncertain clinical significance suggests that the use of routine X-ray to screen for congenital anomalies in asymptomatic patients is not supported by evidence.
Spinal biomechanical analysis
Spinal biomechanical analysis, or spinography, has long been associated with chiropractic X-ray imaging. Early chiropractic practice was focused on the correction of spinal misalignment through spinal manipulation (adjustment), with spinography used to inform this process . Typically, X-ray images would be analysed to measure intersegmental rotation, tilt, or displacement and to measure spinal curvatures. Specific spinal adjustments could then be selected to correct the measured segmental or global misalignments. Additionally, post-treatment X-rays have been used as an outcome measure to assess for improvement in segmental or global spinal alignment with treatment .
The clinical significance of variations in spinal curvatures commonly found on X-ray imaging remains controversial. Although there is evidence that X-ray can be a reliable tool for assessing intersegmental or global spinal alignment, with good measures of inter-and intra-examiner reliability [63,64,65], the clinical relevance of these findings and usefulness in directing subsequent treatment selection has not been sufficiently demonstrated. In addition, alterations in X-ray spinal alignment may also reflect other factors such as variations in patient positioning during X-ray imaging, pain, or short-term muscle spasm , and as such may not be appropriate to inform ongoing patient management.
Some studies have reported an association between pain and variation in spinal curvatures [67,68,69], while others have not found significant association [70, 71] or argue that the association may be coincidental or reflective of normal variability [72, 73]. Individual study findings that associate symptomology with changes in spinal curves must be balanced by the findings from a systematic review by Christensen and Hartvigsen who found no robust evidence of association . Treatment directed by biomechanical X-ray analysis of the spine has shown some evidence for a positive effect on both spinal curves and pain [75, 76], however, findings related to pain are not consistently demonstrated . It is also unclear whether X-ray analysis of spinal posture is required or whether visual analysis would result in similar treatments being provided [78,79,80,81]. Therefore, it is unclear whether treatments using biomechanical X-ray analysis produce better outcomes, including any additional short and long-term cost and health benefits, compared to treatment without the use of X-ray analysis. As a result, there is currently insufficient evidence to recommend the use of routine spinal X-rays to analyse spinal biomechanics.
In contrast, X-ray analysis of structural spinal deformities is recommended to direct appropriate treatment in children or adolescents, where curve progression is of concern, or in adults with a progressive or acutely painful scoliosis or thoracic kyphosis . In these cases, X-ray findings may result in alternate management, such as bracing or spinal surgery, may be necessary to prevent further deformity, or may reveal potential pathological causes of acutely painful or progressive spinal curves . There is no current evidence that X-ray analysis of benign scoliotic curves in adults, or functional scoliotic curves in children or adolescents is required, or that it will improve conservative management in a significant way.
The use of imaging to reassure patients that they have no underlying pathology has been reported as a potential reason for imaging referral. Patients often expect imaging for the management of back pain , largely because they believe that it will help to diagnose their pain and direct suitable treatments . However, routine use of imaging has actually been associated with a lesser sense of wellbeing , and lower overall health status . Other strategies to reassure the patient such as education and explanation of the evidence about the use of routine imaging should be used as a first approach [8, 53, 59].
The use of imaging can be related to practitioner medicolegal concerns and the perceived risk that routine imaging reduces the risk of missing a more serious diagnosis [86, 87]. As discussed, research does not support the use of X-ray imaging as a reliable tool for the early detection of underlying serious pathology, or in screening for unsuspected anomalies. The authors are not aware of evidence where routine imaging has decreased the risk of malpractice claims made against chiropractors.
Evidence of possible risks or limitations associated with the use of spinal X-rays
Radiation exposure from spinal X-rays is well recognised and quantifiable, ranging from 0.2 mSv for cervical spine X-rays, 1.5 mSv for lumbar spine X-rays, to 2.7 mSv for three-region spine X-rays . These are considered to be low levels of single exposure, comparable to less than 1 year of exposure to natural background radiation ; however, cumulative exposure also needs to be considered, with some chiropractors’ advocating repeat spinal X-rays to monitor spinal change from the care provided . The collective dose from spinal imaging is high and chiropractors’ have been shown to have a relatively high contribution to that collective dose , without corresponding high levels of demonstrated patient benefit.
Risks of harm from low levels of radiation exposure are difficult to calculate. Increased risk of cancer has been definitively associated with high-levels of radiation exposure in survivors of the atomic bombings of Hiroshima and Nagasaki . Risk from low-levels of radiation exposure has been extrapolated using the linear no-threshold model . This model assumes no safe level of radiation exposure, with a linear association between radiation exposure and risk of cancer. Epidemiological studies have associated protracted low-level radiation exposure and CT scans in childhood with increased cancer risk [91,92,93]; however, increased risk of cancer at low-levels of radiation exposure and the accuracy of the linear no-threshold model have not been definitively demonstrated.
Alternate models for the risk of low-levels of radiation have been postulated, including the linear threshold and hormetic models . The linear threshold model incorporates a threshold below which radiation exposure is not associated with increased risk of cancer . The hormetic model postulates that low levels of radiation exposure may in fact produce benefits rather than damage to tissue . Evidence for these models is inconclusive [94, 95], and uncertainty remains as to the risk associated with low-level radiation exposure. In addition, even assuming these alternate models to be accurate, there is no definitive data regarding the exact threshold of radiation exposure that would be considered either beneficial or safe. There is also no way to accurately calculate past radiation exposure from natural and additional sources to account for summative levels of radiation exposure that might increase risk. Therefore, regardless of the model of risk of low levels of radiation exposure used, it is not currently possible to define a ‘safe’ level of radiation exposure, with no additional risk.
Without definitive thresholds of safe levels of radiation exposure, it should be assumed that some level of risk is associated with the use of X-rays. This risk is considered under the precautionary principle to ‘First do no harm’ , and is recognised by practice standards and radiation protection principles advocating the ‘As Low As Reasonably Achievable’ (ALARA) principle . Whether X-rays are taken, which X-ray series are requested, and the technique used to perform the X-ray are all important considerations to ensure that radiation exposure is as low as possible .
The risk from radiation exposure should not be considered a barrier to requesting imaging where it is clinically justifiable. Even using the linear no-threshold model, lifetime risk of cancer from a single X-ray is considered to be minimal in the neck (1/1000000–1/100000) and very low in the spine (1/100000–1/10000) , and, therefore, should not be a reason to limit the use of X-ray when clinically indicated, as recommended in evidence based guidelines [7,8,9,10,11,12,13].
Spinal X-rays may lead to the detection of radiographic findings of uncertain clinical significance, leading to unnecessary diagnosis (overdiagnosis). X-ray findings, such as osteophytes, reduced disc height, spondylolisthesis, transitional segments, and other anatomical anomalies are common [21, 46,47,48, 52], but show poor correlation with clinical symptoms [48,49,50,51, 98, 99]. Brinjikji et al. found a high prevalence of disc degeneration in asymptomatic individuals, ranging from 37% of 20-year-olds to 96% of 80-year-olds . Carragee et al. found that 84% of new low back pain presentations had unchanged or improved imaging findings when compared to baseline images taken when asymptomatic , and Panagopoulos et al. found similar radiographic findings between low back pain patients and healthy controls, with similar changes to these findings seen over time . Furthermore, beneficial changes to conservative management of the patient is unlikely when these X-ray findings are present, with no robust evidence that early imaging improves clinical outcomes [56, 57, 85, 102,103,104,105,106,107].
Inconclusive X-ray findings such as suspicion of pathology may lead to more complex investigation and unnecessary worry for the patient before the diagnosis (or lack thereof) is confirmed. Wnuk et al. found that of 78% of cases of suspected cancer or infection on imaging were found to be false positive results . For patients without indicators of serious pathology, the increase in information available from X-ray confers little additional benefit to patient health, but may unnecessarily increase patient concern and thus contribute to low value care [33, 34].
Overdiagnosis may create unwarranted concern for the patient [108, 109] and a misguided belief in a pathoanatomical cause to their pain . Patients may believe that their pain will not improve until the imaging findings have resolved, which may increase the risk of developing chronic pain [53, 99, 103]. Overdiagnosis may also contribute to fear-avoidance behaviours, where patients are less likely to follow management advice (e.g. maintaining exercise and physical activity) for fear of further damage [8, 53]. Early imaging of the low back has been associated with resultant increased disability [103, 105], a lesser sense of well-being , and lower health status .
Early use of spinal X-rays may lead to false negative results (type II error), due to inability to detect early pathological change, or the use of imaging modalities with poor diagnostic utility based on convenience. This may lead to false reassurance of absence of pathology, and may delay the use of appropriate imaging when the disease is sufficiently progressed to demonstrate imaging findings. Although X-ray is often used to screen for pathology, it does not have high sensitivity for early detection of pathology [58, 110]. For example, there needs to be a minimum of between 30 to 50% loss in bone mass before pathology is often detectible on X-ray , and overlapping anatomy may also obscure pathological changes to further limit radiographic diagnosis. Poor radiographic technique or reporting errors may also lead to false negative results .
Inappropriate use of spinal X-rays and other imaging techniques may lead to waste in the form of unnecessary invasive diagnostic procedures and subsequent treatment, increased waiting time for people who are in need of more appropriate imaging, excessive costs and poor utilisation of human resources [103, 113,114,115,116,117].
The use of spinal X-ray when not indicated leads to increased financial cost to the health care system, the patient, and the population. Financial costs are related to that of the spinal X-ray itself, and downstream costs due to increased healthcare utilisation, poorer patient outcome, poorer productivity, or increased disease burden [53, 99, 118, 119]. Early imaging has been associated with a greater use of medical care and associated costs . Webster et al. found that early imaging was associated with an increase in use of medical services, with costs between $7643 to $13,816 higher per episode than the group without imaging . The authors hypothesised that this increase in costs may have been the result of treatment or investigation of clinically insignificant radiographic findings found on the initial imaging . Similarly, Jarvik et al. found that total costs were between 27 to 30% higher in early imaging groups compared to no imaging groups . Depending on the healthcare system, patients may not have substantial out of pocket expenses when referred for imaging, however, the expense to the public health system is high, and reflected in increased indirect costs to the population.
Guidelines for the appropriate use of imaging
Most cases of acute spinal pain improve within the first 4 weeks [120,121,122], with imaging discouraged within this time period to allow for natural recovery [8, 53]. The decision to use imaging to manage patients with back and neck pain is a balance between the consideration of potential risks and benefits for each patient. To facilitate this process, guidelines for the chiropractic profession [7, 10], and for primary medical care [8, 9, 11,12,13] have been produced to help guide clinicians in the decision-making process. These guidelines have been based on the available evidence and therefore recommend that diagnostic imaging is used only when there is clinical suspicion of serious pathology or when imaging findings are likely to lead to a beneficial change in management, improvement in patient outcome, or decrease in patient harm. Failure of a patient to respond to care over a four to 6 week time period may indicate the need for imaging; however, imaging should still only be undertaken when there is a suspected serious pathological cause of the patient’s pain, or it is anticipated that a significant change in management will result [7, 8]. A summary of current imaging guidelines is presented in Table 1.
Alternate X-ray guidelines for the chiropractic profession have also been proposed . These guidelines have not been considered in the summary provided in Table 1 because: 1) they make the initial assumption that spinal X-rays are required for a chiropractor to provide optimal management of the patient; 2) all available high quality evidence and peer-reviewed imaging guidelines do not support the routine use of spinal imaging for spinal conditions; 3) to the best of our knowledge, the guidelines in question have not been published in a peer-reviewed journal; and 4) the guidelines do not adequately consider the well-established evidence for the potential risks of spinal X-rays, as presented in this and other review papers [8, 45, 53].
Determining which patients have sufficient clinical suspicion of serious pathology to warrant imaging can be challenging. Specific signs and symptoms associated with pathology (“red flags”) have been used in the past to help guide the selection of patients requiring imaging, however, the diagnostic accuracy of most red flags is poor [124,125,126]. For example, the probability of finding a spinal malignancy or spinal fracture is only modestly higher even when multiple red flags are present . In addition, up to 80% of patients presenting to primary care have at least one red flag , limiting their usefulness in selecting specific patients for imaging. Indeed, the use of a single red flag to guide imaging has been associated with increased referral [127, 128]. As presented in Table 1, more recent guidelines [9, 45] base the decision to refer for imaging on the clinical suspicion of the referring practitioner, and provide a list of alerting clinical features that may indicate increased likelihood of serious underlying pathology. When there is lower clinical suspicion of serious underlying pathology, a strategy of watchful waiting is recommended, where a trial of appropriate conservative management is initiated and patient symptoms are monitored for progression or lack of resolution which may indicate the need for imaging .
A continuing question to be addressed is the appropriate rate of X-ray utilisation within the chiropractic profession, and whether this should be different to other primary healthcare professions managing spinal pain. This is an important topic for future research and cannot be answered completely from the current peer-reviewed literature. Serious pathology as the cause of LBP is rare, estimated at less than 5% of presentations . As the diagnosis of serious pathology remains the main indicator for X-ray imaging, utilisation rates should also be low. At present appropriate utilisation rates cannot be precisely identified due to the unknown sensitivity and specificity of tests to indicate when imaging may be indicated. To date there is no evidence that X-rays should be used in different clinical scenarios for the chiropractic profession when compared to other primary healthcare professions such as medicine, physiotherapy, and osteopathy, and clinical guidelines across the different professions contain similar recommendations [7, 8, 10, 11]. Therefore, it is likely that X-ray utilisation rates across all primary care professions managing spinal pain should be similar.
Clinical guidelines are designed to complement, rather than replace, clinician decision-making. They are designed to provide a summary of the available evidence to indicate when it is likely that the benefits of referring for imaging outweigh the possible risks. While not all patient presentations will fit the guidelines specifically, and clinical judgement should always be used in the decision-making process, clinical judgement should be informed by the recommendations within clinical practice guidelines.
The use of spinal X-rays in chiropractic has been controversial, with benefits for the use of routine spinal X-rays being proposed by some elements of the profession. However, evidence of these postulated benefits is limited or non-existent. There is strong evidence to demonstrate potential harms associated with spinal X-rays including increased ionising radiation exposure, overdiagnosis, subsequent low-value investigation and treatment procedures, and increased unnecessary costs. Therefore, in the vast majority of cases who present to chiropractors, the potential benefit from spinal X-rays does not outweigh the potential harms. Spinal X-rays should not be performed as a routine part of chiropractic practice, and the decision to perform diagnostic imaging should be informed by evidence based clinical practice guidelines and clinician judgement.
Bolton SP. X-ray dispossessed-expedience versus standards? Chiropractic Journal of Australia. 2004;34(1):23–9.
Young KJ. Evaluation of publicly available documents to trace chiropractic technique systems that advocate radiography for subluxation analysis: a proposed genealogy. J Chiropr Humanit. 2014;21(1):1–24.
Pincus T, Kent P, Bronfort G, Loisel P, Pransky G, Hartvigsen J. Twenty-five years with the biopsychosocial model of low back pain—is it time to celebrate? A report from the twelfth international forum for primary care research on low back pain. Spine. 2013;38(24):2118–23.
Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis & Rheumatism. 2009;60(10):3072–80.
Schultz G, Phillips R, Cooley J, Hall T, Hoyt T, Gendreau D, et al. Diagnostic imaging of the spine in chiropractic practice: recommendations for utilization. Chiropractic Journal of Australia. 1992;22(4):141–52.
French SD, Walker BF, Cameron M, Pollard HP, Vitiello AL, Reggars JW, et al. Risk management for chiropractors and osteopaths: imaging guidelines for conditions commonly seen in practice. Australasian. Chiropractic & Osteopathy. 2003;11(2):41–8.
Bussieres A, Taylor J, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults - an evidenced-based approach - part 3: spinal disorders. J. Manip. Physiol. Ther. 2008;31:33–88.
Chou R, Qaseem A, Owens D, Shekelle P. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154:181–9.
NICE. National Institute for Health and Care Excellence. Non-specific low back pain and sciatica: management. NICE guideline NG59. 2016.
Bussières AE, Stewart G, Al-Zoubi F, Decina P, Descarreaux M, Haskett D, et al. Spinal manipulative therapy and other conservative treatments for low back pain: a guideline from the Canadian chiropractic guideline initiative. J Manip Physiol Ther. 2018;41(4):265–93.
Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018;27:60.
Childs JD, Cleland JA, Elliott JM, Teyhen DS, Wainner RS, Whitman JM, et al. Neck pain: clinical practice guidelines linked to the international classification of functioning, disability, and health from the Orthopaedic section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38(9):A1–A34.
Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841–8.
Oakley PA, Harrison DE. Radiophobia: 7 reasons why radiography used in spine and posture rehabilitation should not be feared or avoided. Dose-Response. 2018;16(2):1559325818781445.
Oakley PA, Cuttler JM, Harrison DE. X-ray imaging is essential for contemporary chiropractic and manual therapy spinal rehabilitation: radiography increases benefits and reduces risks. Dose-Response. 2018;16(2):1559325818781437.
Bussières AE, Sales AE, Ramsay T, Hilles SM, Grimshaw JM. Impact of imaging guidelines on x-ray use among American provider network chiropractors: interrupted time series analysis. Spine J. 2014;14(8):1501–9.
Bussières AE, Sales AE, Ramsay T, Hilles S, Grimshaw JM. Practice patterns in spine radiograph utilization among doctors of chiropractic enrolled in a provider network offering complementary Care in the United States. J Manip Physiol Ther. 2013;36(3):127–42.
Ammendolia C, Côté P, Hogg-Johnson S, Bombardier C. Do chiropractors adhere to guidelines for back radiographs?: a study of chiropractic teaching clinics in Canada. Spine. 2007;32(22):2509–14.
Aroua A. Chiropractor's use of radiography in Switzerland. J Manip Physiol Ther. 2003;26(1):9–16.
Sorensen LP, Stochkendahl MJ, Hartvigsen J, Nilsson NG. Chiropractic patients in Denmark 2002: an expanded description and comparison with 1999 survey. J. Manip. Physiol. Ther. 2006;29(6):419–24.
Beck RW, Holt KR, Fox MA, Hurtgen-Grace KL. Radiographic anomalies that may alter chiropractic intervention strategies found in a New Zealand population. J. Manip. Physiol. Ther. 2004;27(9):554–9.
Lew M, Snow GJ. Radiograph utilization and demographics in a chiropractic college teaching clinic. J Chiropr Med. 2012;11(4):242–8.
Mizrahi DJ, Parker L, Zoga AM, Levin DC. National Trends in the utilization of skeletal radiography from 2003 to 2015. J Am Coll Radiol. 2018;15(10):1408–14.
Kindermann SL, Hou Q, Miller RM. Impact of chiropractic services at an on-site health center. J Occup Environ Med. 2014;56(9):990–2.
Ammendolia C, Cote P, Hogg-Johnson S, Bombardier C. Utilization and costs of lumbar and full spine radiography by Ontario chiropractors from 1994 to 2001. Spine J. 2009;9:556–63.
Australian Government Department of Health. Medicare benefits schedule review taskforce - first report from the diagnostic imaging clinical committee - low back pain 2016. http://www.health.gov.au/internet/main/publishing.nsf/content/E1FEC9FFE18698C0CA25801800184170/$File/MBS%20Report%20-%20Low%20Back%20Pain.pdf. Accessed 2 Sept 2016.
Jenkins HJ. Awareness of radiographic guidelines for low back pain: a survey of Australian chiropractors. Chiropr Man Therap. 2016;24(1):39.
Bussieres AE, Patey AM, Francis JJ, Sales AE, Grimshaw JM, Brouwers M, et al. Identifying factors likely to influence compliance with diagnostic imaging guideline recommendations for spine disorders among chiropractors in North America: a focus group study using the theoretical domains framework. Implement Sci. 2012;7:82.
Ammendolia C, Bombardier C, Hogg-Johnson S, Glazier R. Views on radiography use for patients with acute low back pain among chiropractors in an Ontario community. J. Manip. Physiol. Ther. 2002;25(8):511–20.
Harger BL, Taylor J, Haas M, Nyiendo J. Chiropractic radiologists: a survey of chiropractors' attitudes and patterns of use. J Manip Physiol Ther. 1997;20(5):311–4.
Ammendolia C, Taylor J, Pennick V, Cote P, Hogg-Johnson S, Bombardier C. Adherence to radiography guidelines for low back pain: a survey of chiropractic schools worldwide. J. Manip. Physiol. Ther. 2008;31(6):412–8.
Puhl AA, Reinhart CJ, Doan JB, McGregor M, Injeyan HS. Relationship between chiropractic teaching institutions and practice characteristics among Canadian doctors of chiropractic: a random sample survey. J Manip Physiol Ther. 2014;37(9):709–18.
Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, et al. Evidence for overuse of medical services around the world. Lancet. 2017;390(10090):156–68.
Buchbinder R, van Tulder M, Öberg B, Costa LM, Woolf A, Schoene M, et al. Low back pain: a call for action. Lancet. 2018;391(10137):2384–8.
Schwartz AL, Zaslavsky AM, Landon BE, Chernew ME, McWilliams JM. Low-value service use in provider organizations. Health Serv Res. 2018;53(1):87–119.
Levinson W, Kallewaard M, Bhatia RS, Wolfson D, Shortt S, Kerr EA. ‘Choosing wisely’: a growing international campaign. BMJ Qual Saf. 2015;24(2):167–74.
Choosing wisely. Clinician lists. 2018. Recommendations for low back pain. http://www.choosingwisely.org/clinician-lists/#keyword=low_back_pain. Accessed 12 Jan 2018.
Choosing wisely. American Chiropractic Association recommendations. 2018. http://www.choosingwisely.org/societies/american-chiropractic-association/. Accessed 26 Jul 2018.
Chiropractic Australia. Chiropractic Australia's choosing wisely submission. 2018. https://chiropracticaustralia.org.au/about-chiropractic/choosing-wisely/. Accessed 8 Aug 2018.
Rosenberg A, Agiro A, Gottlieb M, Barron J, Brady P, Liu Y, et al. Early trends among seven recommendations from the choosing wisely campaign. JAMA Intern Med. 2015;175(12):1913–20.
Gidwani R, Sinnott P, Avoundjian T, Lo J, Asch S, Barnett P. Inappropriate ordering of lumbar spine magnetic resonance imaging: are providers choosing wisely? Am J Manag Care. 2016;22(2):e68.
Wnuk NM, Alkasab TK, Rosenthal DI. Magnetic resonance imaging of the lumbar spine: determining clinical impact and potential harm from overuse. Spine J. 2018;18(9):1653–8.
de Schepper EIT, Koes BW, Veldhuizen EFH, Oei EHG, Bierma-Zeinstra SMA, Luijsterburg PAJ. Prevalence of spinal pathology in patients presenting for lumbar MRI as referred from general practice. Fam Pract. 2015;33(1):51–56.
Ferrari R. Imaging studies in patients with spinal pain practice audit evaluation of choosing wisely Canada recommendations. Can Fam Physician. 2016;62(3):e129–e37.
Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017;389(10070):736–47.
Jenkins H, Zheng X, Bull P. Prevalence of congenital anomalies contraindicating spinal manipulative therapy within a chiropractic patient population. Chiropractic Journal of Australia. 2010;40(2):69.
Vining RD, Potocki E, McLean I, Seidman M, Morgenthal AP, Boysen J, et al. Prevalence of radiographic findings in individuals with chronic low back pain screened for a randomized controlled trial: secondary analysis and clinical implications. J. Manip. Physiol. Ther. 2014;37(9):678–87.
van Tulder M, Assendelft W, Koes B, Bouter L. Spinal radiographic findings and nonspecific low Back pain: a systematic review of observational studies. Spine. 1997;22(4):427–34.
Andrade NS, Ashton CM, Wray NP, Brown C, Bartanusz V. Systematic review of observational studies reveals no association between low back pain and lumbar spondylolysis with or without isthmic spondylolisthesis. Eur Spine J. 2015;24(6):1289–95.
Rudy IS, Poulos A, Owen L, Batters A, Kieliszek K, Willox J, et al. The correlation of radiographic findings and patient symptomatology in cervical degenerative joint disease: a cross-sectional study. Chiropr Man Therap. 2015;23(1):1.
Kovacs FM, Arana E, Royuela A, Estremera A, Amengual G, Asenjo B, et al. Disc degeneration and chronic low back pain: an association which becomes nonsignificant when endplate changes and disc contour are taken into account. Neuroradiology. 2014;56(1):25–33.
Brinjikji W, Luetmer P, Comstock B, Bresnahan BW, Chen L, Deyo R, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. Am J Neuroradiol. 2015;36(4):811–6.
Chou R, Deyo RA, Jarvik JG. Appropriate use of lumbar imaging for evaluation of low back pain. Radiol Clin N Am. 2012;50(4):569–85.
Gillan MG, Gilbert FJ, Andrew JE, Grant AM, Wardlaw D, Valentine NW, et al. Influence of imaging on clinical decision making in the treatment of lower back pain. Radiology. 2001;220(2):393–9.
Triano JJ, Budgell B, Bagnulo A, Roffey B, Bergmann T, Cooperstein R, et al. Review of methods used by chiropractors to determine the site for applying manipulation. Chiropr Man Therap. 2013;21(1):36.
Djais N, Kalim H. The role of lumbar spine radiography in the outcomes of patients with simple acute low back pain. APLAR J Rheumatol. 2005;8(1):45–50.
Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. Br Med J. 2001;322(7283):400–5.
Rosenthal DI. Radiologic diagnosis of bone metastases. Cancer. 1997;80(S8):1595–607.
Deyo RA, Diehl AK, Rosenthal M. Reducing roentgenography use. Can patient expectations be altered? Arch Intern Med. 1987;147(1):141–5.
World Health Organisation. WHO guidelines on basic training and safety in chiropractic. Geneva: World Health Organisation; 2005.
Gatterman MI. Standards of practice relative to complications of and contraindications to spinal manipulative therapy. J. Can Chiropr. Assoc. 1991;35(4):232.
Swait G, Finch R. What are the risks of manual treatment of the spine? A scoping review for clinicians. Chiropr Man Therap. 2017;25(1):37.
Harrison DE, Harrison DD, Cailliet R, Troyanovich SJ, Janik TJ, Holland B. Cobb method or Harrison posterior tangent method: which to choose for lateral cervical radiographic analysis. Spine. 2000;25(16):2072–8.
Harrison DE, Holland B, Harrison DD, Janik TJ. Further reliability analysis of the Harrison radiographic line-drawing methods: crossed ICCs for lateral posterior tangents and modified Risser-Ferguson method on APViews. J Manip Physiol Ther. 2002;25(2):93–8.
Owens JE. Line drawing analyses of static cervical X ray used in chiropractic. J Manip Physiol Ther. 1992;15(7):442–9.
Obeid I, Boissière L, Yilgor C, Larrieu D, Pellisé F, Alanay A, et al. Global tilt: a single parameter incorporating spinal and pelvic sagittal parameters and least affected by patient positioning. Eur Spine J. 2016;25(11):3644–9.
Dolphens M, Cagnie B, Coorevits P, Vleeming A, Danneels L. Classification system of the normal variation in sagittal standing plane alignment: a study among young adolescent boys. Spine. 2013;38(16):E1003–E12.
Chaléat-Valayer E, Mac-Thiong J-M, Paquet J, Berthonnaud E, Siani F, Roussouly P. Sagittal spino-pelvic alignment in chronic low back pain. Eur Spine J. 2011;20(5):634.
Grob D, Frauenfelder H, Mannion A. The association between cervical spine curvature and neck pain. Eur Spine J. 2007;16(5):669–78.
Murrie V, Dixon A, Hollingworth W, Wilson H, Doyle T. Lumbar lordosis: study of patients with and without low back pain. Clin Anat. 2003;16(2):144–7.
Chapman JT, Baldus CR, Lurie JD, Glassman SD, Schwab FJ, Shaffrey CI, et al. Baseline patient-reported outcomes correlate weakly with radiographic parameters: a multicenter, prospective NIH adult symptomatic lumbar scoliosis study of 286 patients. Spine. 2016;41(22):1701–8.
Stagnara P, De JM, Dran G, Gonon GP, Costanzo G, Dimnet J, et al. Reciprocal angulation of vertebral bodies in a sagittal plane: approach to references for the evaluation of kyphosis and lordosis. Spine. 1982;7(4):335–42.
Gelb DE, Lenke LG, Bridwell KH, Blanke K, McEnery KW. An analysis of sagittal spinal alignment in 100 asymptomatic middle and older aged volunteers. Spine. 1995;20(12):1351–8.
Christensen ST, Hartvigsen J. Spinal curves and health: a systematic critical review of the epidemiological literature dealing with associations between sagittal spinal curves and health. J Manip Physiol Ther. 2008;31(9):690–714.
Moustafa IM, Diab AAM, Hegazy FA, Harrison DE. Does rehabilitation of cervical lordosis influence sagittal cervical spine flexion extension kinematics in cervical spondylotic radiculopathy subjects? J. Back Musculoskelet. Rehabil. 2017;30(4):937–41.
Moustafa IM, Diab AA. Extension traction treatment for patients with discogenic lumbosacral radiculopathy: a randomized controlled trial. Clin Rehabil. 2013;27(1):51–62.
Diab AA, Moustafa IM. Lumbar lordosis rehabilitation for pain and lumbar segmental motion in chronic mechanical low back pain: a randomized trial. J. Manip. Physiol. Ther. 2012;35(4):246–53.
Perry M, Smith A, Straker L, Coleman J, O'Sullivan P. Reliability of sagittal photographic spinal posture assessment in adolescents. Adv Physiother. 2008;10(2):66–75.
Grimmer-Somers K, Milanese S, Louw Q. Measurement of cervical posture in the sagittal plane. J Manip Physiol Ther. 2008;31(7):509–17.
Norton BJ, Hensler K, Zou D. Comparisons among noninvasive methods for measuring lumbar curvature in standing. J Orthop Sports Phys Ther. 2002;32(8):405–14.
Barrett E, McCreesh K, Lewis J. Reliability and validity of non-radiographic methods of thoracic kyphosis measurement: a systematic review. Man Ther. 2014;19(1):10–7.
Horne JP, Flannery R, Usman S. Adolescent idiopathic scoliosis: diagnosis and management. Am Fam Physician. 2014;89(3):193–8.
Jenkins HJ, Hancock MJ, Maher CG, French SD, Magnussen JS. Understanding patient beliefs regarding the use of imaging in the management of low back pain. Eur J Pain. 2016;20(4):573–80.
Espeland A, Baerheim A, Albrektsen G, Korsbrekke K, Larsen J. Patients' views on importance and usefulness of plain radiography for low Back pain. Spine. 2001;26(12):1356–63.
Ash L, Modic M, Obuchowski N, Ross J, Brant-Zawadzki M, Grooff P. Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. Am J Neuroradiol. 2008;29:1098–103.
Studdert DM, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K, et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. J Am Med Assoc. 2005;293(21):2609–17.
Miller RA, Sampson NR, Flynn JM. The prevalence of defensive orthopaedic imaging: a prospective practice audit in Pennsylvania. J Bone Joint Surg. 2012;94(3):e18.
Mettler FA Jr, Huda W, Yoshizumi TT, Mahesh M. Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology. 2008;248(1):254–63.
Webb D, Solomon S, Thomson J. Background radiation levels and medical exposure levels in Australia. Radiation Protection in Australia. 1999;16(2):25–32.
Kamiya K, Ozasa K, Akiba S, Niwa O, Kodama K, Takamura N, et al. Long-term effects of radiation exposure on health. Lancet. 2015;386(9992):469–78.
Leuraud K, Richardson DB, Cardis E, Daniels RD, Gillies M, O'hagan JA, et al. Ionising radiation and risk of death from leukaemia and lymphoma in radiation-monitored workers (INWORKS): an international cohort study. The Lancet Haematology. 2015;2(7):e276–e81.
Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012;380(9840):499–505.
Mathews JD, Forsythe AV, Brady Z, Butler MW, Goergen SK, Byrnes GB, et al. Cancer risk in 680 000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. Br Med J. 2013;346:f2360.
Baldwin J, Grantham V. Radiation hormesis: historical and current perspectives. J. Nucl. Med. Technol. 2015;43(4):242–6.
Wall B, Kendall G, Edwards A, Bouffler S, Muirhead C, Meara J. What are the risks from medical X-rays and other low dose radiation? Br J Radiol. 2014;79(940):285–94.
Sokol DK. “First do no harm” revisited. Br Med J. 2013;347:f6426.
Australian Government. Radiation protection in the application of ionizing radiation by chiropractors. 2009. http://www.arpansa.gov.au/publications/codes/rps19.cfm. Accessed 10 Jul 2018.
Glover MR, Kwasniewski T, Bull P, Jenkins H. The clinical significanc e of spina bifida occulta at C1: a case control study. Chiropractic Journal of Australia. 2013;43:27–30.
Flynn TW, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther. 2011;41(11):838–46.
Carragee E, Alamin T, Cheng I, Franklin T, van den Haak E, Hurwitz E. Are first-time episodes of serious LBP associated with new MRI findings? Spine J. 2006;6(6):624–35.
Panagopoulos J, Magnussen J, Hush J, Maher C, Crites-Battie M, Jarvik J, et al. Prospective comparison of changes in lumbar spine MRI findings over time between individuals with acute low Back pain and controls: an exploratory study. Am J Neuroradiol. 2017;38(9):1826–32.
Chou R, Fu R, Carrino J, Deyo R. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373:463–72.
Webster B, Bauer AS, Choi Y, Cifuentes M, Pransky G. Iatrogenic consequences of early MRI in acute work-related disabling low Back pain. Spine. 2013;38(22):1939–46.
Karel YH, Verkerk K, Endenburg S, Metselaar S, Verhagen AP. Effect of routine diagnostic imaging for patients with musculoskeletal disorders: a meta-analysis. Eur. J. Intern. Med. 2015;26(8):585–95.
Graves JM, Fulton-Kehoe D, Jarvik JG, Franklin GM. Early imaging for acute low back pain: one-year health and disability outcomes among Washington state workers. Spine. 2012;37(18):1617–27.
Jarvik JG, Gold LS, Comstock BA, Heagerty PJ, Rundell SD, Turner JA, et al. Association of early imaging for back pain with clinical outcomes in older adults. J Am Med Assoc. 2015;313(11):1143–53.
Modic M, Obuchowski N, Ross J, Bant-Zawadzki M, Grooff P, Mazanec D, et al. Acute low back pain: MR imaging findings and their prognostic role and effect on outcome. Radiology. 2005;237(2):597–604.
Fisher ES, Welch HG. Avoiding the unintended consequences of growth in medical care: how might more be worse? J Am Med Assoc. 1999;281(5):446–53.
Saini V, Garcia-Armesto S, Klemperer D, Paris V, Elshaug AG, Brownlee S, et al. Drivers of poor medical care. Lancet. 2017;390(10090):178–90.
Lange MB, Nielsen ML, Andersen JD, Lilholt HJ, Vyberg M, Petersen LJ. Diagnostic accuracy of imaging methods for the diagnosis of skeletal malignancies: a retrospective analysis against a pathology-proven reference. Eur J Radiol. 2016;85(1):61–7.
Edelstyn G, Gillespie P, Grebbell F. The radiological demonstration of osseous metastases. Experimental observations. Clin Radiol. 1967;18(2):158–62.
Pinto A, Brunese L. Spectrum of diagnostic errors in radiology. World J Radiol. 2010;2(10):377.
Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery. Spine. 2003;28(6):616–20.
Deyo RA. Cascade effects of medical technology. Annu Rev Public Health. 2002;23(1):23–44.
Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off? J. Am. Board Fam. Med. 2009;22(1):62–8.
Webster BS, Cifuentes M. Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010;52(9):900–7.
Webster BS, Choi Y, Bauer AZ, Cifuentes M, Pransky G. The Cascade of medical services and associated longitudinal costs due to nonadherent magnetic resonance imaging for low Back pain. Spine. 2014;39(17):1433–40.
Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, et al. A systematic review of the global prevalence of low back pain. Arthritis & Rheumatism. 2012;64(6):2028–37.
Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J. 2008;8(1):8–20.
Vasseljen O, Woodhouse A, Bjørngaard JH, Leivseth L. Natural course of acute neck and low back pain in the general population: the HUNT study. Pain. 2013;154(8):1237–44.
Grotle M, Brox JI, Veierød MB, Glomsrød B, Lønn JH, Vøllestad NK. Clinical course and prognostic factors in acute low back pain: patients consulting primary care for the first time. Spine. 2005;30(8):976–82.
Coste J, Delecoeuillerie G, De Lara AC, LeParc J, Paolaggi J. Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice. Br Med J. 1994;308(6928):577–80.
Harrison D, Harrison D, Kent C, Betz J. Practicing chiropractors' committee on radiology protocols for biomechanical assessment of spinal subluxation in chiropractic clinical practice. International Chiropractors Association. 2009.http://www.chiropractic.org/wp-content/uploads/2018/01/PCCRP-Radiology-Guidelines.pdf Accessed 24 Apr 2018.
Downie A, Williams C, Henschke N, Hancock M, Ostelo R, de Vet H, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. Br Med J. 2013;347:f7095.
Verhagen AP, Downie A, Maher CG, Koes BW. Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review. Pain. 2017;158(10):1860–8.
Premkumar A, Godfrey W, Gottschalk MB, Boden SD. Red flags for low Back pain are not always really red: a prospective evaluation of the clinical utility of commonly used screening questions for low Back pain. J Bone Joint Surg. 2018;100(5):368–74.
Suarez-Almazor M, Belseck E, Russell A, Mackel J. Use of lumbar radiographs for the early diagnosis of low back pain. Proposed guidelines would increase utilization. J Am Med Assoc. 1997;277(22):1782–6.
Jenkins HJ, Downie AS, Maher CG, Moloney NA, Magnussen JS, Hancock MJ. Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis. Spine J. 2018. https://doi.org/10.1016/j.spinee.2018.05.004
The Royal Australian College of General Practitioners and Osteoporosis Australia. Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age. 2nd ed. 2017. https://www.osteoporosis.org.au/sites/default/files/files/RACGP%20Osteoporosis%20Summary%20Guideline%204428%20Nov%202017.pdf Accessed 26 Jul 2018.
Patel ND, Broderick DF, Burns J, Deshmukh TK, Fries IB, Harvey HB, et al. ACR appropriateness criteria low back pain. J Am Coll Radiol. 2016;13(9):1069–78.
Ethics approval and consent to participate
Consent for publication
SDF is Deputy Editor-in-Chief of Chiropractic and Manual Therapies. He played no part in the assignment of this manuscript to Associate Editors or peer reviewers, and was blinded in the online editorial system for this manuscript from submission to final decision. Otherwise, the authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.