American Chiropractic Association

View all recommendations from this society

August 15, 2017; updated June 11, 2019, References updated July 12, 2021

Avoid routine spinal imaging in the absence of clear clinical indicators for patients with acute low back pain of less than six (6) weeks duration.

Multidisciplinary evidence-based guidelines recommend against the routine use of spinal imaging for patients with acute low back pain of less than six weeks duration in the absence of clear clinical indicators. Such indicators include, but are not limited to, history of cancer, fracture or suspected fracture based on clinical history, progressive neurologic symptoms, and infection. Doctors of chiropractic must also consider conditions that potentially preclude a dynamic thrust to the spine, which include but are not limited to, osteopenia, osteoporosis, axial spondyloarthritis and tumors. Unnecessary imaging incurs monetary cost, exposes the patient to ionizing radiation, and can result in labeling patients with conditions that are not clinically meaningful, creating a false sense of vulnerability and disability. Indeed, several studies have shown that the routine use of radiographs in the care of low back pain may result in worse outcomes than without their use.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

The American Chiropractic Association (ACA) utilized its Committee on Quality Assurance and Accountability (CQAA) to serve as an expert task force of doctors of chiropractic (DCs) to identify areas/items common to the practice of chiropractic for which recommendations were supported by clinical research and would result in high-value, cost-effective services and improved patient outcomes. A literature search was conducted and the task force collaboratively identified a draft list of six recommendations based upon established Choosing Wisely® criteria. The list was submitted to the ACA Board of Governors for initial review. After further refinement, the final list of five strategies was selected, submitted to and approved by the ACA Board of Governors.

Choosing Wisely® recommendations 1 and 2 are performance measures approved by Centers for Medicare and Medicaid Services (CMS) for the 2017 Spine IQ Qualified Clinical Data Registry for Conservative Spine Care.

ACA’s disclosure and conflict of interest policy can be found at


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Kendrick D, Fielding K, Bentley E, Miller P, Kerslake R, Pringle M. The role of radiography in primary care patients with low back pain of at least 6 weeks duration: a randomised (unblinded) controlled trial. Health Technol Assess. 2001;5(30):1-69.

National Guideline Clearinghouse (NGC). Guideline summary: ACR Appropriateness Criteria® low back pain. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); [2016 Jan 22]. Available from:

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