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The moment the American Chiropractic Association joined the Choosing Wisely campaign, the chiropractic world gained something it had long needed: a public, evidence-focused checklist of things clinicians and patients should stop doing automatically. That may not sound like fireworks, but in health care, telling professionals to do less can be more dramatic than a soap opera cliffhanger. Tests, treatments, X-rays, braces, and “just in case” procedures often feel reassuring. The problem is that reassurance can get expensive, unnecessary, and occasionally harmful when it is not guided by evidence.

The title of this debate comes from a pointed challenge associated with Mark Crislip, a physician and science-based medicine commentator, who wondered whether chiropractic could identify standard practices that should be avoided. Years later, the American Chiropractic Association, or ACA, released five Choosing Wisely recommendations. The response was not perfect, and critics argued that the list played it safe. Still, the move mattered because it placed chiropractic care inside a larger national conversation about overuse, low-value care, patient safety, and evidence-based decision-making.

At its best, the Choosing Wisely campaign is not about denying care. It is about asking better questions before care begins. Do we need this test? Will it change treatment? Are there red flags? Could this intervention create more confusion than clarity? In other words, Choosing Wisely is the medical equivalent of checking the recipe before dumping every spice in the cabinet into the soup.

What Is the Choosing Wisely Campaign?

Choosing Wisely was launched by the ABIM Foundation to encourage conversations between clinicians and patients about tests, treatments, and procedures that may be unnecessary or overused. The campaign grew through partnerships with specialty societies, each asked to identify practices that patients and clinicians should question. The core idea is simple: more care is not always better care.

That idea can be hard to accept. Many patients naturally assume that an X-ray, scan, brace, or machine-based treatment represents thorough care. Clinicians may also order tests because they want certainty, want to reassure patients, or fear missing a rare but serious problem. Choosing Wisely does not pretend medicine is easy. Instead, it offers a structure for slowing down and asking whether an intervention is supported by evidence, necessary, not duplicative, and likely to help more than harm.

In the context of chiropractic care, this conversation is especially important. Chiropractic is widely used for back pain, neck pain, headaches, and other musculoskeletal complaints. Some approaches, such as spinal manipulation for low back pain, have evidence suggesting modest benefit for selected patients. Other claims, particularly those suggesting spinal manipulation can treat broad non-musculoskeletal diseases, are much less supported. That gap between reasonable musculoskeletal care and overextended claims is where the Choosing Wisely discussion becomes useful.

Why the ACA’s Participation Was Newsworthy

The American Chiropractic Association’s decision to participate stood out because it made ACA the first chiropractic organization to join the Choosing Wisely campaign. The ACA released five recommendations focused mainly on low back pain, spinal imaging, passive therapy, psychosocial screening, and lumbar supports. These were not obscure issues. Low back pain is one of the most common reasons Americans seek care, and back pain affects a large share of U.S. adults each year.

For many patients, the first instinct after sudden low back pain is to want imaging. “Can we just get an X-ray?” sounds reasonable, especially when your back feels like it has filed for divorce from the rest of your body. But routine imaging in the first six weeks of uncomplicated low back pain usually does not improve outcomes. It can uncover incidental findings that may look scary but have little to do with the pain. Those findings can lead to more tests, more anxiety, and sometimes unnecessary procedures.

The ACA’s Choosing Wisely list was therefore a significant public statement: chiropractic care should not be built on routine imaging, endless passive modalities, or long-term supports without a clear reason. It was also an invitation for patients to ask practical questions instead of simply assuming that every available tool belongs in the treatment plan.

The Five ACA Choosing Wisely Recommendations Explained

1. Avoid routine spinal imaging for acute low back pain without red flags

The first recommendation advises clinicians not to obtain spinal imaging, such as X-rays, for patients with acute low back pain during the first six weeks unless red flags are present. Red flags may include a history of cancer, suspected fracture, progressive neurological symptoms, infection, severe trauma, or other signs that a serious underlying condition might be present.

This recommendation aligns with broader medical guidance from radiology, internal medicine, family medicine, and emergency medicine groups. For uncomplicated low back pain, imaging often does not change treatment. Most acute low back pain improves with time, movement, reassurance, and conservative care. The scan may look impressive, but impressive is not the same as useful.

2. Do not repeat imaging just to monitor progress

The second recommendation tells chiropractors not to perform repeat imaging simply to track patient progress. This matters because pain improvement is usually measured through symptoms, function, physical examination, and patient goalsnot through repeated pictures of the spine. A patient who can walk farther, sleep better, return to work, and tie shoes without sounding like a haunted accordion is probably improving, even if a spinal image looks mostly unchanged.

Repeat imaging can expose patients to unnecessary radiation, add costs, and create confusion. It should be reserved for situations where new symptoms, worsening neurological signs, trauma, suspected infection, or another legitimate clinical concern changes the risk picture.

3. Avoid prolonged passive therapy unless it supports an active plan

The third recommendation warns against long-term use of passive or palliative physical therapy modalities for low back pain unless they support an active treatment plan. Passive modalities can include heat, cold, ultrasound, electrical stimulation, or similar treatments. These may feel good in the short term, and there is nothing wrong with comfort. The issue is when comfort becomes the whole plan.

For low back pain, active care usually matters more: movement, exercise, graded activity, education, strength, flexibility, and confidence. Passive therapies should be helpers, not the main characters. A heating pad may be pleasant, but it should not be asked to carry the entire plot.

4. Do not provide long-term pain management without psychosocial screening

The fourth recommendation recognizes that chronic pain is rarely just a mechanical problem. Anxiety, depression, fear of movement, poor sleep, stress, job dissatisfaction, trauma history, and social factors can all affect pain intensity and recovery. A patient with long-term pain may need more than spinal manipulation or exercise advice. They may need screening, support, referral, or coordinated care.

This is a mature recommendation because it admits that pain lives in the whole person, not merely in a joint or disc. It also encourages chiropractors to recognize when a patient’s needs extend beyond the chiropractic office. Good care sometimes means saying, “This is bigger than my lane, and you deserve the right team.”

5. Do not prescribe lumbar supports or braces for long-term treatment or prevention

The fifth recommendation advises against long-term lumbar supports or braces for treating or preventing low back pain. A brace may be useful in select short-term circumstances, but long-term dependence can encourage fear, reduce movement confidence, and distract from strengthening and functional recovery.

Backs are not porcelain antiques. Most need appropriate movement, not permanent packaging. A brace can be a temporary tool, but it should not become a lifestyle accessory unless there is a clear medical reason.

What Critics Got Right About the ACA List

Critics of the ACA’s Choosing Wisely list argued that the recommendations were useful but cautious. The strongest criticism was that the list did not directly address some of the most controversial claims associated with chiropractic history and marketing, such as unsupported claims about treating non-musculoskeletal diseases through spinal adjustments. In that sense, the list may have tackled low-hanging fruit while leaving thornier branches untouched.

That criticism deserves attention. A truly bold Choosing Wisely chiropractic list might have included recommendations such as: do not claim spinal manipulation treats infections, asthma, immune function, colic, infertility, or systemic diseases without high-quality evidence; do not use X-rays to justify long-term correction packages in the absence of clinical need; and do not imply that every person needs lifelong maintenance adjustments. Those topics would have made the room much quieterand perhaps more useful.

Still, progress often arrives wearing sensible shoes instead of a superhero cape. The ACA list did identify real areas of overuse. It also gave patients and evidence-minded chiropractors language they could use in everyday care. Even a cautious list can help shift expectations if clinicians actually use it.

What the ACA List Got Right

The recommendations are strongest where they overlap with mainstream evidence-based low back pain care. Avoiding routine imaging in the absence of red flags is widely supported. Avoiding repeat imaging to “prove” progress is sensible. Encouraging active care over passive treatment is consistent with modern rehabilitation principles. Screening for psychosocial contributors to chronic pain reflects a more complete understanding of pain. Limiting long-term bracing supports function and independence.

The list also gives patients permission to question care without feeling difficult. A patient can ask, “Will this X-ray change what we do today?” or “How does this treatment help me become more active?” Those questions are not rude. They are responsible. Health care should not be a magic show where the clinician waves a wand and the patient applauds politely. It should be a conversation.

How This Changes the Patient-Chiropractor Conversation

The most practical value of the ACA Choosing Wisely recommendations is not the list itself. It is the conversation the list creates. A patient with new low back pain can walk into a chiropractic office and ask about red flags, expected recovery, self-care, exercise, and when imaging is truly needed. A chiropractor can explain why immediate imaging is not necessary and still provide a careful examination. That is better medicine and better communication.

For example, consider a healthy 35-year-old who strains the lower back while lifting a box. The pain is sharp, but there is no fever, trauma, cancer history, leg weakness, numbness, or bladder problem. In that case, routine imaging is unlikely to help. The better plan may include reassurance, staying active, gentle mobility, temporary pain relief strategies, and follow-up if symptoms worsen or fail to improve.

Now consider a 70-year-old patient with a history of cancer, unexplained weight loss, and new severe back pain. That is a very different story. Imaging may be appropriate, and referral may be urgent. Choosing Wisely does not say “never image.” It says, “Image for a reason.” That distinction is the whole ballgame.

Evidence-Based Chiropractic Care: Where It Fits

Chiropractic care is most defensible when it focuses on musculoskeletal conditions, especially low back pain, neck pain, and certain headache presentations. Spinal manipulation may provide modest short-term improvements in pain and function for some people with low back pain. It is not a miracle cure, and it should not be sold as one. But when delivered by a licensed, appropriately trained clinician, and when used as part of a broader plan that includes movement and education, it can be one reasonable option among several.

The danger comes when chiropractic is marketed as a universal health solution. Evidence does not support spinal manipulation as a treatment for most non-musculoskeletal conditions. Patients should be cautious when any clinicianchiropractor, physician, influencer, or the guy at the gym who says he “did his own research”claims one intervention can fix everything from digestion to immunity to childhood ear infections.

The Bigger Lesson: Less Can Be Better

The Choosing Wisely campaign challenges a deeply rooted belief in American health care: that more tests equal better care. In reality, unnecessary tests can create cascades. A scan finds an incidental abnormality. The incidental abnormality triggers another test. The second test leads to a procedure. The procedure causes complications. Suddenly, the original backache has become an expensive medical scavenger hunt nobody wanted to play.

This does not mean patients should avoid care. It means care should be targeted. Evidence-based care is not stingy; it is focused. It asks whether the next step is likely to improve outcomes. If not, the wisest move may be education, watchful waiting, exercise, reassurance, or referral to the right professional.

Questions Patients Should Ask Before Chiropractic Imaging or Long Treatment Plans

Patients do not need to memorize clinical guidelines to protect themselves. A few simple questions can make a big difference:

• Do I have any red flags that make imaging necessary now?
• Will this X-ray, CT scan, or MRI change the treatment plan?
• What are the risks, costs, and alternatives?
• How will we measure progress: pain scores, function, sleep, work, movement, or imaging?
• What active steps can I take at home?
• When should I see a physician or specialist?

A trustworthy clinician should welcome these questions. If a provider becomes irritated because a patient asks for evidence, that is not patient-centered care. That is a sales pitch wearing a lab coat.

Experience-Based Reflections: What This Debate Looks Like in Real Life

In real-world care, the Choosing Wisely message often succeeds or fails in the first five minutes of the visit. A patient arrives with pain, fear, and a simple hope: “Please tell me what is wrong.” The clinician has a choice. One path is to order imaging quickly, creating the feeling of action. The other path is to slow down, take a careful history, perform an examination, explain the likely course of recovery, identify red flags, and describe why imaging may not help. The second path takes more communication skill. It is less flashy. It also tends to be better care for uncomplicated low back pain.

A common experience involves patients who believe their pain must mean something is “out of place.” They may have seen spine diagrams online or been told that a small postural asymmetry explains years of symptoms. Then they receive an X-ray showing age-related changes, mild degeneration, or disc narrowing. The image feels like proof, but these findings are common even in people without pain. Without careful explanation, the patient may leave believing their spine is fragile. That fear can reduce movement, delay recovery, and create dependence on repeated treatment.

Another common scenario is the passive-therapy loop. A patient receives heat, electrical stimulation, ultrasound, or brief manual treatment several times a week. The sessions feel pleasant, but daily life does not improve much. The patient is still afraid to bend, lift, walk, or exercise. Choosing Wisely pushes the clinician to ask: What is the active plan? How is this helping the patient return to normal function? If the answer is vague, the treatment plan needs a tune-up.

There are also positive examples. A chiropractor evaluates a patient with acute low back pain, rules out red flags, explains that imaging is not needed immediately, teaches simple mobility drills, encourages walking, discusses sleep and stress, and schedules a short follow-up window. The patient improves over two weeks and avoids an unnecessary X-ray. That is not “doing nothing.” That is doing the right things without adding clutter.

For chronic pain, the psychosocial recommendation may be the most human part of the ACA list. Many patients with long-term pain have already been told their scans are “not that bad,” which can feel dismissive. A better conversation says: your pain is real, and pain is influenced by tissues, nerves, sleep, stress, mood, movement, and meaning. Screening for anxiety, depression, fear avoidance, or work-related stress is not blaming the patient. It is widening the lens.

From a patient-experience perspective, the ACA’s Choosing Wisely participation is valuable because it gives both sides a script for smarter care. The patient can ask more confident questions. The chiropractor can explain why restraint is not neglect. The health system can reduce waste. Everyone gets a little less drama, which is nice because backs already bring plenty.

The biggest lesson is practical: good chiropractic care should make patients more capable, not more dependent. It should use imaging selectively, passive care sparingly, braces temporarily, and evidence honestly. The ACA’s list did not settle every controversy in chiropractic, but it moved the conversation toward accountability. In health care, that counts.

Conclusion

The American Chiropractic Association’s entrance into the Choosing Wisely campaign was both a milestone and a missed opportunity. It was a milestone because it publicly acknowledged that some common chiropractic tests and procedures should be questioned. It was a missed opportunity because the list avoided deeper controversies around unsupported chiropractic claims beyond musculoskeletal care.

Still, the five recommendations offer real value. They discourage routine early imaging for uncomplicated low back pain, reject repeat imaging as a progress meter, limit passive therapies, recognize psychosocial factors in chronic pain, and warn against long-term lumbar bracing. For patients, the takeaway is empowering: ask why, ask what changes, ask what helps you function, and ask whether a treatment is truly necessary.

Choosing wisely is not about choosing less care. It is about choosing better care. And when your back hurts, better care beats louder care every time.