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

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

Diagnostic Imaging Practice Guidelines
For Musculoskeletal Complaints in Adults

	Introduction J Manipulative Physiol Ther 2007 (Nov); 30 (9): 617–683 ~ FULL TEXT 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.
	Part 1: Lower Extremity Disorders J Manipulative Physiol Ther 2007 (Nov); 30 (9): 684–717 ~ FULL TEXT 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.
	Part 2: Upper Extremity Disorders J Manipulative Physiol Ther 2008 (Jan); 31 (1): 2–32 ~ FULL TEXT 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 for upper extremity disorders.
	Part 3: Spinal Disorders J Manipulative Physiol Ther 2008 (Jan); 31 (1): 33–88 ~ FULL TEXT 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 for spinal disorders.

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.

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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.

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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. [9–11]

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.

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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]

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