Chiropractic Radiologists Research Articles

Critical Evaluation of the 2016 SOSORT Clinical Guidelines on the Detection and Clinical Management of Adolescent Idiopathic Scoliosis Using the AGREE II Tool: A Chiropractic Perspective

ObjectiveThe objective of this study is to assess the methodological quality of the 2016 Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) guidelines for the detection and management of adolescent idiopathic scoliosis. MethodsA diverse group of experts, including practicing chiropractors, chiropractors with a Diplomate by the American Chiropractic Board of Radiology, chiropractors with PhD degrees, and chiropractors involved in teaching within chiropractic programs was invited to participate in the study. Experts independently evaluated the guidelines using the Appraisal of Guidelines for Research and Evaluation II tool. Individual scaled scores were calculated for each item and the 6 domains, with methodological quality considered good if the score was equal to or greater than 70%. ResultsThe 19 experts, including 6 clinicians, 4 chiropractic radiologists, 6 researchers, and 3 lecturers, represented Canada (n = 3), United states (n = 4), France (n = 2), Australia (n = 1), United Kingdom (n = 1), Switzerland (n = 1), Sweden (n = 3), Denmark (n = 2), China (n = 1), and Côte d'Ivoire (n = 1). Domain scaled scores ranged from 38% to 90%. The 4 items of the applicability domain scored between 26% and 45%. The experts made suggestions for improving the applicability of the guidelines’ recommendations. ConclusionThe methodological quality of the 2016 SOSORT clinical practice guidelines was deemed good. However, strategies should be devised to improve their applicability. This could be achieved by involving a more diverse representation of healthcare professions in the development of future guidelines.

Influence of Prior Imaging Review on Recommendations for Additional Diagnostic Testing: Retrospective Analysis of Imaging Reports in a Chiropractic Radiology Practice

ObjectiveThe purpose of this study was to assess the influence of prior imaging review on recommendations for additional diagnostic testing in an academic chiropractic radiology practice. A secondary aim was to explore the influence of prior imaging review on radiographic interpretation. MethodsWe retrospectively reviewed radiology reports generated from July 18, 2022, to July 18, 2023, from the Palmer College of Chiropractic main campus (Davenport, Iowa) clinic system. Imaging interpretation included an automated search for prior images in an internal picture archival and communication system (PACS). Images from regional health system databases were available and sought by radiologists when (1) unclear radiologic findings had potential clinical implications or (2) prior imaging could clarify potential problems detected in a clinical history. Data were abstracted to a secure adaptive electronic questionnaire and analyzed descriptively. ResultsWe reviewed 1712 radiographic and 165 musculoskeletal diagnostic ultrasound reports for 1552 unique individuals (811 [52.3%] females and 741 [47.7%] males) with a mean age of 42.1 years (range, 2-93 years). Prior imaging was described in 417 (22.2%) reports; 246 (58.9%) indicated images from internal PACS, 192 (46.0%) indicated images from external PACS, and 21 noted both internal and external PACS. Prior imaging findings were credited with answering a clinical question in 98 (23.5%), and a radiographic question in 228 (54.7%) of 417 reports. The process negated the need for follow-up diagnostic testing recommendations in 119 (28.5%) instances, leading to additional imaging recommendations in 19 (4.6%). ConclusionData obtained in this study suggest that comparing current and previous imaging may help reduce unnecessary additional imaging or follow-up diagnostic testing recommendations. Prior imaging review may also facilitate diagnostic confidence and interpretation clarity.

A Tale of Specialization in 2 Professions: Comparing the Development of Radiology in Chiropractic and Medicine

ObjectiveThe purpose of this article is to describe the development of radiology as a specialty in chiropractic with a comparison to the development of the specialty of radiology in medicine. DiscussionSpecialization in medicine has been notably successful, with advanced training and enhanced capabilities in specialized skills leading to better outcomes for patients and increased prestige for practitioners. However, with chiropractic, as with other complementary and alternative medicine professions, no specialization has been recognized within it. Specialist radiology training in chiropractic bears a resemblance to that of medicine, with competitive entry for residencies, certification exams, and the creation of a journal and specialist professional organizations. To facilitate the comparison, I have divided the development of radiology into 4 phases from the chiropractic perspective. Phase 1 started with the discovery of x-rays in 1895, in which medicine adopted them but chiropractic did not. Phase 2 began in 1910 when B. J. Palmer introduced radiography to show chiropractic subluxations. Phase 3 started in 1942 when Waldo Poehner advocated for the mainstream diagnostic use of radiography in addition to subluxation analysis. Phase 4 started in 1957 when an examining board for certification in diagnostic radiology was assembled and many chiropractors began to embrace the mainstream medical use of radiography. ConclusionIn this tale of 2 professions, radiology gained official specialty designation in the field of medicine. The medical profession had a monopoly on health care, and thus had few internal and external barriers to overcome. Chiropractic was oppressed by organized medicine, which helped to create the unofficial specialty of chiropractic radiology but which also later helped to limit the specialty. Chiropractic radiology has maintained its independence and autonomy, but also remains on the fringe of mainstream health care.

Ulnar nerve instability in the cubital tunnel of asymptomatic volunteers.

Ulnar nerve instability (UNI) in the cubital tunnel is defined as ulnar nerve subluxation or dislocation. It is a common disorder that may be noted in patients with neuropathy or in the asymptomatic. Our prospective, single-site study utilized high-resolution ultrasonography (US) to evaluate the ulnar nerve for cross-sectional area (CSA) and measures of shear-wave elastography (SWE). Mechanical algometry was obtained from the ulnar nerve in the cubital tunnel to assess pressure pain threshold (PPT). Forty-two asymptomatic subjects (n = 84 elbows) (25 males, 17 females) aged 22-40 were evaluated. Two chiropractic radiologists, both with 4years of ultrasound experience performed the evaluation. Ulnar nerves in the cubital tunnel were sampled bilaterally in three different elbow positions utilizing US, SWE, and algometry. Descriptive statistics, two-way ANOVA, and rater reliability were utilized for data analysis with p ≤ 0.05. Fifty-six percent of our subjects demonstrated UNI. There was a significant increase in CSA in subjects with UNI (subluxation: 0.066mm2 ± 0.024, p = 0.027; dislocation: 0.067mm2 ± 0.024, p = 0.003) compared to controls (0.057mm2 ± 0.017) in all three elbow positions. There were no significant group differences in SWE or algometry. Inter- and intra-observer agreements for CSA of the ulnar nerves within the cubital tunnel were assessed using intraclass correlation coefficient (ICC) and demonstrated moderate (ICC 0.54) and excellent (ICC 0.94) reliability. Most of the asymptomatic volunteers demonstrated UNI. There was a significant increase in CSA associated with UNI implicating it as a risk factor for ulnar neuropathy in the cubital tunnel. There were no significant changes in ulnar nerve SWE and PPT. Intra-rater agreement was excellent for the CSA assessment of the ulnar nerve in the cubital tunnel. High-resolution US could be utilized to assess UNI and monitor for progression to ulnar neuropathy.

Combining independent decisions increases diagnostic accuracy of reading lumbosacral radiographs and magnetic resonance imaging

Diagnosing the causes of low back pain is a challenging task, prone to errors. A novel approach to increase diagnostic accuracy in medical decision making is collective intelligence, which refers to the ability of groups to outperform individual decision makers in solving problems. We investigated whether combining the independent ratings of chiropractors, chiropractic radiologists and medical radiologists can improve diagnostic accuracy when interpreting diagnostic images of the lumbosacral spine. Evaluations were obtained from two previously published studies: study 1 consisted of 13 raters independently rating 300 lumbosacral radiographs; study 2 consisted of 14 raters independently rating 100 lumbosacral magnetic resonance images. In both studies, raters evaluated the presence of “abnormalities”, which are indicators of a serious health risk and warrant immediate further examination. We combined independent decisions of raters using a majority rule which takes as final diagnosis the decision of the majority of the group. We compared the performance of the majority rule to the performance of single raters. Our results show that with increasing group size (i.e., increasing the number of independent decisions) both sensitivity and specificity increased in both data-sets, with groups consistently outperforming single raters. These results were found for radiographs and MR image reading alike. Our findings suggest that combining independent ratings can improve the accuracy of lumbosacral diagnostic image reading.

Criteria to Screen for Traumatic Cervical Spine Instability: A Consensus of Chiropractic Radiologists

ObjectiveThe purpose of this study was to establish consensus on a radiographic definition for cervical instability for routine use in chiropractic patients who sustain trauma to the cervical spine. MethodWe conducted a modified Delphi study with a panel of chiropractic radiologists. Panelists were asked to rate potential screening criteria for traumatic cervical spine instability when assessing cervical spine radiographs. Items rated as important for inclusion by at least 60% of participants in round 1 were submitted for a second round of voting in round 2. Items rated for inclusion by at least 75% of the participants in round 2 were used to create the consensus-based list of screening criteria. Participants were asked to vote and reach agreement on the final screening criteria list in round 3. ResultsTwenty-nine chiropractic radiologists participated in round 1. After 3 rounds of survey, 85% of participants approved the final consensus-based list of criteria for traumatic cervical spine instability screening, including 6 clinical signs and symptoms and 5 radiographic criteria. Participants agreed that the presence of 1 or more of these clinical signs and symptoms and/or 1 or more of the 5 radiographic criteria on routine static radiographic studies suggests cervical instability. ConclusionThe consensus-based radiographic definition of traumatic cervical spine instability includes 6 clinical signs and symptoms and 5 radiographic criteria that doctors of chiropractic should apply to their patients who sustain trauma to the cervical spine.

Historical influence on the practice of chiropractic radiology: part II - thematic analysis on the opinions of diplomates of the American Chiropractic College of Radiology about the future

BackgroundOver the past 20 years, various authors have addressed the question of the future of chiropractic. Most were positive about the future, with some advocating evidence-based practice and integration with mainstream healthcare, some advocating continued separation with an emphasis on subluxation-based care or the traditional/historical paradigm of chiropractic, and some calling for tolerance and unity. No papers were found specifically inquiring about the future of chiropractic radiology.MethodsThe study population consisted of all current members of the American Chiropractic College of Radiology (ACCR), estimated at 190 people, known as chiropractic radiologists or Diplomates of the American Chiropractic Board of Radiology (DACBRs). An internet-based, anonymous survey using SurveyMonkey was implemented, supplemented by hard copies distributed at a conference. The main point of interest for this paper is the final item of the overall questionnaire. This item inquired about the future of chiropractic radiology. Thematic analysis was used on the responses, coded in both constructionist and inductive ways to extract both a general outlook and more specific themes. The inductive themes were also assigned secondarily to a SWOT (strengths, weaknesses, opportunities, and threats) analysis.ResultsThe overall response rate to the survey was 38% (73/190); within the group of respondents, 71 of 73 (98%) answered the item that is the subject of this paper. Opinions on the outlook for chiropractic radiology in the future were more negative than positive, with 14 respondents giving a positive outlook, 26 negative, and 14 non-committal. 28 respondents advocated integration with the wider healthcare community, 11 recommended emphasising separateness or a focus on working within chiropractic, and 15 did not express an opinion on this issue. Ten strengths were noted, 11 weaknesses, 57 opportunities, and 30 threats.ConclusionsThe increasing necessity of demonstrating evidence for diagnostic and therapeutic procedures in healthcare makes it likely that chiropractic radiologists and the wider chiropractic profession will need to take a more active position on evidence-based practice. Re-evaluation of guidelines and legislation as well as enforcement policies and practices will be necessary. The consequences of failing to do so may include increased marginalisation and reduced viability as a profession.

Historical influence on the practice of chiropractic radiology: Part I - a survey of Diplomates of the American Chiropractic College of Radiology

BackgroundIt is known that not all chiropractors follow mainstream guidelines on the use of diagnostic ionising radiation. Various reasons have been discussed in the literature, including using radiography to screen for congenital anomalies, to perform postural analysis, to search for contraindications to spinal manipulation, and to document chiropractic subluxations, i.e., tiny anatomical displacements of vertebrae thought to affect nerves and health. The visualisation of subluxations was the reason chiropractic first adopted the x-ray in 1910. There has never been a study of the influence of this historical paradigm of radiography on the practices of chiropractic radiologists (DACBRs or Diplomates of the American Chiropractic College of Radiology).MethodsA survey was administered with a modified Dillman method using SurveyMonkey and supplemented by hard copies distributed at a professional conference. The target population was all active DACBRs. There were 34 items, which consisted of multiple choice and open-ended interrogatives on all three areas in which chiropractic radiologists work: education, clinical practice, and radiology practice.ResultsThe response rate was 38% (73 of 190 DACBRs). Respondents reported that the historical paradigm of radiography was found in all areas of practice, but not as a major aspect. The majority of respondents did not condone that historical paradigm, but many tolerated it, particularly from referring chiropractors. Radiographic subluxation analysis was reportedly perpetuated by private clinical practitioners as well as technique instructors and supervising clinicians in the teaching institutions.ConclusionsWithin the chiropractic profession, there is a continuing belief in radiographically visible subluxations as a cause of suboptimal health. This situation is sustained in part due to the reticence of other chiropractors to report these practices to licensing and registration boards. Investigation into other structures supporting a vitalistic belief system over science in chiropractic is recommended. In addition, it may be useful to explore remunerative systems that move beyond the inherently conflicted fee-for-service model.

Diagnostic Accuracy of Lumbosacral Spine Magnetic Resonance Image Reading by Chiropractors, Chiropractic Radiologists, and Medical Radiologists.

A cross-sectional diagnostic accuracy study was conducted in 2 sessions. It is important to know whether it is possible to accurately detect "specific findings" on lumbosacral magnetic resonance (MR) images and whether the results of different observers are comparable. Health care providers frequently use magnetic resonance imaging in the diagnostic process of patients with low back pain. The use of MR scans is increasing. This leads to an increase in costs and to an increase in risk of inaccurately labeling patients with an anatomical diagnosis that might not be the actual cause of symptoms. A set of 300 blinded MR images was read by medical radiologists, chiropractors, and chiropractic radiologists in 2 sessions. Each assessor read 100 scans in round 1 and 50 scans in round 2. The reference test was an expert panel.For all analyses, the magnetic resonance imaging findings were dichotomized into "specific findings" or "no specific findings." For the agreement, percentage agreement and κ values were calculated and for validity, sensitivity, and specificity. Sensitivity analysis was done for classifications A and B (prevalence of 31% and 57%, respectively). The intraobserver κ values for chiropractors, chiropractic radiologists, and medical radiologists were 0.46, 0.49, and 0.69 for A and 0.55, 0.75, and 0.64 for B, respectively.The interobserver κ values were lowest for chiropractors (0.28 for A, 0.37 for B) and highest for chiropractic radiologists (0.50 for A, 0.49 for B).The sensitivities of the medical radiologists, chiropractors, and chiropractic radiologists were 0.62, 0.71, and 0.75 for A and 0.70, 0.74, 0.84 for B, respectively.The specificities of medical radiologists, chiropractic radiologists, and chiropractors were 0.82, 0.77, and 0.70 for A and 0.74, 0.52, and 0.61 for B, respectively. Agreement and validity of MR image readings of chiropractors and chiropractic and medical radiologists is modest at best. This study supports recommendations in clinical guidelines against routine use of magnetic resonance imaging in patients with low back pain. 3.

Ultrasonography and Radiography to Identify Early Post Traumatic Myosistis Ossificans in an 18-Year-Old Male: A Case Report

ObjectiveThe purpose of this case report is to describe a patient with post traumatic myositis ossificans (PTMO) of the anterior thigh following blunt trauma and discuss the incidence, clinical presentation, management, and imaging findings. Clinical featuresAn 18-year-old male presented to a chiropractic clinic with a chief complaint of left knee pain and reduced range of motion after an impact injury to his left anterior thigh during hurdling 6 weeks earlier. Immediately after the injury, he presented to the emergency department where radiography of the left knee was negative and he was diagnosed with a muscle sprain. Follow-up radiography and ultrasonography of the left knee in a chiropractic radiology department revealed ossification consistent with PTMO within his vastus intermedius. Intervention and outcomeThe patient underwent a course of rehabilitation for 2 months including ice, class IV cold laser and vibration applied to his anterior thigh, and myofascial release of his quadriceps musculature with targeted and progressive rehabilitative exercises. His left knee pain resolved within 2 weeks of care. He resumed sports participation (American football) pain-free, while wearing protective padding over the affected thigh, 1 month after presentation, which was approximately 2 1/2 months following his injury. ConclusionThis case demonstrates that ultrasonography may have the capability to detect early phases of PTMO approximately 2 weeks prior to radiographic evidence and to monitor progression throughout its course.

Evaluation of three different methods of distance learning for postgraduate diagnostic imaging education: A pilot study.

Objective : The purpose of this study was to evaluate the perceived effectiveness and learning potential of 3 Web-based educational methods in a postgraduate radiology setting. Methods : Three chiropractic radiology faculty from diverse geographic locations led mini-courses using asynchronous discussion boards, synchronous Web conferencing, and asynchronous voice-over case presentations formatted for Web viewing. At the conclusion of each course, participants filled out a 14-question survey (using a 5-point Likert scale) designed to evaluate the effectiveness of each method in achieving specified course objectives and goals and their satisfaction when considering the learning potential of each method. The mean, standard deviation, and percentage agreements were tabulated. Results : Twenty, 15, and 10 participants completed the discussion board, Web conferencing, and case presentation surveys, respectively. All educational methods demonstrated a high level of agreement regarding the course objective (total mean rating >4.1). The case presentations had the highest overall rating for achieving the course goals; however, all but one method still had total mean ratings >4.0 and overall agreement levels of 70%-100%. The strongest potential for interactive learning was found with Web conferencing and discussion boards, while case presentations rated very low in this regard. Conclusions : The perceived effectiveness in achieving the course objective and goals was high for each method. Residency-based distance education may be a beneficial adjunct to current methods of training, allowing for international collaboration. When considering all aspects tested, there does not appear to be a clear advantage to any one method. Utilizing various methods may be most appropriate.

Teaching, leadership, scholarly productivity, and level of activity in the chiropractic profession: a study of graduates of the Los Angeles College of Chiropractic radiology residency program

ObjectiveThe purpose of this study was to track the graduates of the Los Angeles College of Chiropractic (LACC) radiology residency program, review their scholarly productivity, and report those involved in teaching and leadership positions. MethodsFormer LACC residents’ career information was identified through publicly available electronic documents including Web sites and social media. PubMed and the Index to Chiropractic Literature databases were searched for chiropractic graduate job surveys, and proportional comparisons were made between the career paths of LACC radiology residency graduates and those of non–residency-trained chiropractors. ResultsOf 47 former LACC residents, 28 (60%) have or previously had careers in tertiary (chiropractic) education; and 12 (26%) have attained a department chair position or higher at tertiary teaching institutions. Twenty-two (47%) have or previously had private radiology practices, whereas 11 (23%) have or previously had clinical chiropractic practices. Often, residency graduates hold or have held 2 of these positions at once; and one, all 3. Chapters or books were authored by 13 (28%). ConclusionRadiology residency LACC graduates are professionally active, particularly in education, and demonstrate scholarly productivity.

Practice Analysis of Chiropractic Radiology: Identifying Items for Part I of the Clinical Competency Examination

ObjectiveThe purpose of this study was to describe the current scope of practice of chiropractic radiologists by identifying frequent tasks conducted as well as those conditions most often seen and those that present the greatest risk of harm to patients. MethodsA mixed-methods approach was used. An online survey was conducted with 91 diplomates listed with the American Chiropractic Board of Radiology. Participants rated the frequency of tasks they perform and conditions they see on a 5-point scale from “never” to “daily.” They also rated the level of risk each condition presents to patients on a 5-point scale from “no risk” to “severe risk.” Frequency and risk ratings were then presented in rank order to 22 subject matter experts at 3 focus groups. ResultsThe most frequent task reported was writing radiology reports (mean [SD], 4.29 [1.58]). Ratings of the frequency of conditions seen in practice and the risk they present to patients were ranked from the highest to lowest for frequency and risk separately. The most frequent conditions seen were reportedly those with structural or joint derangement; the highest risk conditions seen are those that are systemic. Focus group members recommended that some conditions receive higher rankings and that certain conditions be recategorized for future practice analyses. ConclusionsThis study helps to define the current scope of practice of chiropractic radiologists and identify frequent tasks and conditions. These results inform the development of a new test outline for Part I of the chiropractic radiology certification examination to ensure that examinees are tested on the most important conditions chiropractic radiologists see in practice.

A Comparison of Empirical Ranking Methods of Frequency and Severity Ratings of Clinical Presentations

This study compares five methods of ranking Likert ratings on frequency and severity scales. Data were drawn from an international online survey conducted as part of a practice analysis with 91 diplomates of the American Chiropractic Board of Radiology. A total of 129 clinical presentations had been rated on two scales. The frequency scale specifies how often each condition is seen in practice from 1 (never) to 5 (daily). The severity scale indicates how severe each condition is to the patient from 1 (no risk) to 5 (severe risk). These ratings were used in five methods of ranking to identify the 10 most important conditions reported by chiropractic radiologists. The similarity of ranks across the five methods was then analyzed with Spearman's rank correlations. The results of the study indicate that the Rasch model provides the most precise results about the importance of conditions seen in practice.

Vertebral Artery Hypoplasia: Prevalence and Reliability of Identifying and Grading its Severity on Magnetic Resonance Imaging Scans

Objective The purpose of this study is to examine the inter- and intraexaminer reliability of determining the prevalence of vertebral artery hypoplasia on magnetic resonance imaging (MRI) as well as the reliability of assigning a severity grading of mild, moderate, or marked hypoplasia. Methods Two chiropractic radiologists independently evaluated the MR images of 131 adult patients retrospectively for visual vertebral artery hypoplasia. Severity of hypoplastic was graded. The side of hypoplasia and sex of the patient were recorded. The process was repeated after 1 month. Descriptive statistics were calculated for prevalence, severity, and sex distribution of hypoplasia. The κ statistic was calculated for the reliability of detecting and grading the hypoplasia. Results Interexaminer reliability was substantial for both readings ( κ = 0.68, 83% agreement for the first reading; κ = 0.75, 86% agreement for the second reading). Interexaminer reliability for grading the severity of asymmetry was substantial ( κ = 0.73, 83% agreement for the first read; κ = 0.69, 81% agreement for the second reading). Intraexaminer reliability readings provided a κ of 0.71 (substantial) and 83% agreement for examiner 1. Examiner 2 had a κ of 0.85 (almost perfect) with 92% agreement. Overall, 57 (43.5%) of the 131 patients demonstrated hypoplasia. Hypoplasia was more common in women (49%) than men (35.8%). Seven arteries demonstrated severe hypoplasia. Six of these 7 patients were women. Conclusions Vertebral artery hypoplasia is common and can be reliably diagnosed and categorized on cervical MRI scans. Vertebral artery hypoplasia was more common in women than men in this group of patients.

Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults—An Evidence-Based Approach—Part 3: Spinal Disorders

Purpose 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. 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 an 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 practicing 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 spine disorders are provided, supported by more than 385 primary and secondary citations. The overall quality of available literature is low, however. On average, 45 Delphi panelists completed 1 of 2 rounds, reaching more than 85% agreement on all 55 recommendations. Peer review by specialists reflected high levels of agreement, perceived ease of use of guidelines, and implementation feasibility. Dissemination and implementation strategies are discussed. Conclusions The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be updated regularly. Future research is needed to validate their content.

Diagnostic Imaging Guideline for Musculoskeletal Complaints in Adults—An Evidence-Based Approach—Part 2: Upper Extremity Disorders

Purpose 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. 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 an external review. A Delphi panel composed of international experts on the topic of musculoskeletal disorders in chiropractic radiology, clinical sciences, and research was invited to review and propose recommendations on the indications for diagnostic imaging. The guidelines were pilot tested and peer-reviewed by practicing chiropractors and by chiropractic and medical specialists. Recommendations were graded according to the strength of the evidence. Dissemination and implementation strategies are discussed. Results Recommendations for diagnostic imaging guidelines of adult upper extremity disorders are provided, supported by over 126 primary and secondary citations. The overall quality of available literature is low, however. On average, 44 Delphi panelists completed 1 of 2 rounds, reaching over 88% agreement on all 32 recommendations. Peer review by specialists reflected high levels of agreement and 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. Future research is needed to validate their content.

Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults—An Evidence-Based Approach: Part 1: Lower Extremity Disorders

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.

Use of Radiographic Imaging Protocols by Canadian Memorial Chiropractic College Interns

The purpose of this study was to determine if 4th-year interns plan to x-ray their patients, once they are in private practice, in accordance with the principles taught throughout their radiology program and with the evidence-based imaging guidelines outlined in the literature. Questionnaires were provided to all 4th-year interns. Each questionnaire consisted of 10 case scenarios representing possible chiropractic patients. Each intern was asked if he or she would radiograph the patient and, if so, which views would be taken. A "gold standard" was established by two chiropractic radiologists using evidence-based guidelines. Intern answers were compared with the gold standard using percent agreement. Sixty-eight interns completed the questionnaire. Agreement between the interns and the gold standards for the question of whether or not they would take x-rays ranged from 63.2% to 100%. The percent agreement for the correct radiographic views chosen ranged from 32.6% to 48.4%. Interns are generally aware of and plan to apply the radiographic guidelines for determining whether or not radiographs are indicated, as outlined in the current literature. However, interns are inconsistent in choosing the correct views.

Reliability and validity of lumbosacral spine radiograph reading by chiropractors, chiropractic radiologists, and medical radiologists.

A cross-sectional diagnostic study was conducted in two sessions. To determine and compare the reliability and validity of contraindications to chiropractic treatment (infections, malignancies, inflammatory spondylitis, and spondylolysis-listhesis) detected by chiropractors, chiropractic radiologists, and medical radiologists on plain lumbosacral radiographs. Plain radiography of the spine is an established part of chiropractic practice. Few studies have assessed the ability of chiropractors to read plain radiographs. Five chiropractors, three chiropractic radiologists and five medical radiologists read a set of 300 blinded lumbosacral radiographs, 50 of which showed an abnormality (prevalence, 16.7%), in two sessions. The results were expressed in terms of reliability (percentage and kappa) and validity (sensitivity and specificity). The interobserver agreement in the first session showed generalized kappas of 0.44 for the chiropractors, 0.55 for the chiropractic radiologists, and 0.60 for the medical radiologists. The intraobserver agreement showed mean kappas of 0.58, 0.68, and 0.72, respectively. The difference between the chiropractic radiologists and medical radiologists was not significant. However, there was a difference between the chiropractors and the other professional groups. The mean sensitivity and specificity of the first round, respectively was 0.86 and 0.88 for the chiropractors, 0.90 and 0.84 for the chiropractic radiologists, and 0.84 and 0.92 for the medical radiologists. No differences in the sensitivities were found between the professional groups. The medical radiologists were more specific than the others. Small differences with little clinical relevance were found. All the professional groups could adequately detect contraindications to chiropractic treatment on radiographs. For this indication, there is no reason to restrict interpretation of radiographs to medical radiologists. Good professional relationships between the professions are recommended to facilitate interprofessional consultation in case of doubt by the chiropractors.