Objective: To systematically review clinical guidelines and related literature to determine whether the evidence supporting recommendations affecting the use of imaging in chiropractic practice includes studies that have directly compared outcomes of chiropractic care guided by radiographic findings versus chiropractic care delivered without radiographic guidance.
Methods: A systematic search of PubMed, Google Scholar, Index to Chiropractic Literature, Cochrane Library, and Guideline repositories was performed for English language publications between January 2007 and March 2026. Searches used combinations of keywords related to chiropractic practice, spinal imaging, radiography, spinal pain, and imaging recommendations. Chiropractic imaging guidelines, consensus statements, systematic reviews, rapid reviews, and narrative reviews addressing spinal imaging relevant to chiropractic practice were eligible for inclusion. Included publications and their reference lists were examined to identify studies directly comparing outcomes of chiropractic care in which radiographic findings informed assessment or treatment planning versus chiropractic care delivered without radiography informed management. Studies that did not address spinal imaging recommendations were excluded.
Results: A total of 249 publications met initial screening criteria and 26 guidelines and review articles were included after full text evaluation. These guidelines commonly recommended selective imaging based primarily on the presence of red flags, suspicion of pathology, or anticipated changes in patient management. Across the guidelines included and their cited reference lists, no direct comparative clinical trials were identified evaluating chiropractic care delivered with radiography guided biomechanical analysis versus comparable care delivered without radiographic guidance. The evidence cited in support of guideline recommendations primarily consisted of studies addressing diagnostic yield, prevalence of radiographic findings, radiation exposure risk modeling, and healthcare utilization patterns rather than comparative clinical outcome trials.
Conclusion: Within the guideline and review literature examined, direct comparative evidence evaluating the clinical effectiveness of radiography guided chiropractic care versus care delivered without such imaging guidance was not identified. Accordingly, the existing guideline literature neither confirms nor refutes the effectiveness of radiography guided biomechanical decision making in chiropractic practice. This represents an evidence gap rather than evidence of ineffectiveness. Future controlled comparative studies are needed to determine whether imaging informed biomechanical assessment influences patient outcomes in chiropractic care.
Author Keywords: Chiropractic; Diagnostic Imaging; Radiography; Spinal Manipulation; Low Back Pain; Neck Pain; Practice Guidelines as Topic
Author Affiliations: Gonstead Clinical Studies Society
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