GUIDELINES FOR CHIROPRACTIC CARE

Alan M. Immerman, D.C.

            Herein I will document what is generally accepted for frequency and duration of chiropractic care by the chiropractic profession. I will determine general acceptance based on what is advocated by the two major national chiropractic associations, the American Chiropractic Association (ACA) and the International Chiropractic Association (ICA), together with what is expounded by modern scientific peer-reviewed literature. There will be several key documents that I will reference.

FREQUENCY AND DURATION GUIDELINES OF NATIONAL ASSOCIATIONS

 

AMERICAN CHIROPRACTIC ASSOCIATION (ACA)

 

LOW BACK PAIN

 

Low Back Pain Guidelines

 

The American Chiropractic Association encourages the use of chiropractic specific guidelines in conjunction with the Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians and therefore also adopts, but is not limited to, the clinical practice guideline from the Council on Chiropractic Guidelines and Practice Parameters (CCGPP), to provide specific guidance in the management or co-management of a patient within a chiropractic office.

 

Ratified by the ACA House of Delegates: 2017

The American Chiropractic Association urges organizations that have developed practice parameters to recognize that practice parameters are educational tools, not mechanisms to determine reimbursement or credentialing, to assist physicians in clinical decision making and are not replacements for clinical decision making. Physicians must retain autonomy to vary from practice parameters without retribution in order to provide the quality of care that meets the individual needs of their patients; and encourages doctors of chiropractic to be cost conscious and to exercise discretion, consistent with good chiropractic care, when implementing practice parameters.

 

 

 

 

 

 

 

 

CLINICAL PRACTICE GUIDELINE: CHIROPRACTIC

CARE FOR LOW BACK PAIN

 

Morris, DC,d Greg Baker, DC,e Wayne M. Whalen, DC,f Sheryl Walters, MLS, g Martha Kaeser, DC, MA,h Mark Dehen, DC, i and Thomas Augat, DCj

 

(Author’s note: This is an update to the Mercy Guidelines)

 

Examination Procedures

 

Thorough history and evidence-informed examination

procedures are critical components of chiropractic clinical

management. These procedures provide the clinical rationale

for appropriate diagnosis and subsequent treatment

planning.

 

Assessment should include but is not limited to the

following38:

 

• Health history (eg, pain characteristics, red flags,

review of systems, risk factors for chronicity)

 

• Specific causes of LBP (eg, aortic aneurysm, inflammatory

disorders)

 

• Examination (eg, reflexes, dermatomes, myotomes,

orthopedic tests)

 

• Diagnostic testing (indications) for red flags (eg,

imaging and laboratory tests)

 

Routine imaging or other diagnostic tests are not

recommended for patients with nonspecific LBP.55

 

Imaging and other diagnostic tests are indicated in the

presence of severe and/or progressive neurologic deficits or

if the history and physical examination cause suspicion of

serious underlying pathology.55

 

Patients with persistent LBP accompanied by signs or

symptoms of radiculopathy or spinal stenosis should be

evaluated, preferably, with magnetic resonance imaging or

computed tomography.55

 

Imaging studies should be considered when patients fail

to improve following a reasonable course of conservative

care or when there is suspicion of an underlying anatomical

anomaly, such as spondylolisthesis, moderate to severe

spondylosis, post trauma with worsening symptomology

(consider imaging, referral, or co-management) with

evidence of persistent or increasing neurological (ie, reflex,

motor, and/or sensory) compromise, or other factors which

might alter the treatment approach. Lateral view flexion/

extension studies may be warranted to assess for mechanical

instability due to excessive intervertebral translation

and/or wedging. Imaging studies should be considered only

after careful review and correlation of the history and

examination.65

(Emphasis added)

 

Treatment Frequency and Duration

 

Although most patients respond within anticipated time

frames, frequency, and duration of treatment may be

influenced by individual patient factors or characteristics

that present as barriers to recovery (e.g., comorbidities,

clinical yellow flags). Depending on these individualized

factors, additional time, and treatment may be required to

observe a therapeutic response. The therapeutic effects of

chiropractic care/treatment should be evaluated by subjective

and/or objective assessments after each course of

treatment (see “Outcome Measurement”).

 

Recommended therapeutic trial ranges are representative

of typical care parameters. A typical initial therapeutic trial

of chiropractic care consists of 6 to 12 visits over a 2- to

4-week period, with the doctor monitoring the patient's

progress with each visit to ensure that acceptable clinical

gains are realized (Table 3).

 

For acute conditions, fewer treatments may be necessary

to observe a therapeutic effect and to obtain complete

recovery. Chiropractic management is also recommended

for various chronic low back conditions where repeated

episodes (or acute exacerbations) are experienced by the

patient, particularly when a previous course of care has

demonstrated clinical effectiveness and reduced the long term

use of medications.

 

Initial Course of Treatments for Low Back Disorders

 

To be consistent with an evidence-based approach, DCs

should use clinical methods that generally reflect the best

available evidence, combined with clinical judgment, experience,

and patient preference. For example, currently, the most

robust literature regarding manual therapy for LBP is based

primarily on high-velocity, low-amplitude (HVLA) techniques,

and mobilization (such as flexion-distraction).17,20,66

Therefore, in the absence of contraindications, these methods

are generally recommended. However, best practices for

individualized patient care, based on clinical judgment and

patient preference, may require alternative clinical strategies

for which the evidence of effectiveness may be less robust.

The treatment recommendations that follow, based on

clinical experience combined with the best available

evidence, are posited for the “typical” patient and do not

include risk stratification for complicating factors. Complicating

factors are discussed elsewhere in this document.

 

An initial course of chiropractic treatment typically

includes 1 or more “passive” (i.e., nonexercise) manual

therapeutic procedures (i.e., spinal manipulation or mobilization)

and physiotherapeutic modalities for pain reduction,

in addition to patient education designed to reassure and

instill optimal strategies for independent management.

Although the evidence reviewed does not generally

support the use of therapeutic modalities (i.e., ultrasonography,

electrical stimulation, etc.) in isolation,67 their use as

part of a passive-to-active care multimodal approach to LBP

management may be warranted based on clinician judgment

and patient preferences. Because of the scarcity of definitive

evidence,68 lumbar supports (bracing/taping/orthoses) are

not recommended for routine use, but there may be some

utility in both acute and chronic conditions based upon

clinician judgment, patient presentation, and preferences.

Caution should be exercised as these orthopedic devices

may interfere with conditioning and return to regular

activities of daily living (ADLs).

 

The initial visits allow the doctor to explain that the clinician

and the patient must work as a proactive team and to outline the

patient's responsibilities. Although passive care methods for

pain or discomfort may be initially emphasized, “active” (i.e.,

exercise) care should be increasingly integrated to increase

function and return the patient to regular activities. Table 3 lists

appropriate frequency and duration ranges for trials of

chiropractic treatment for different stages of LBP.

 

 

Table 3. Frequency and Duration for Trial(s) of Chiropractic

Treatment

 

Stage Trials of Care

 

Acute and subacute

2-3× weekly,

2-4 wk.

Reevaluation

2-4 wk. (per trial)

 

Recurrent/flare-up

1-3× weekly,

1-2 wk.

Reevaluation

1-2 wk.

 

Chronic

1-3× weekly,

2-4 wk.

Reevaluation

2-4 wk.

 

Exacerbation

(mild) of chronic

1-6 visits

per episode

At beginning of each

episode of care

 

Exacerbation

(moderate or severe)

of chronic

2-3× weekly

for 2-4 wk.      

 

Reevaluation

Every 2-4 wk.,

following acute

care guidelines

                                        

Scheduled ongoing

care for management

of chronic pain

1-4 visits

per month

 

Reevaluation

At minimum, every

6 visits, or as necessary

to document condition

changes.

 

Continuing Course of Treatment

 

If the criteria to support continuing chiropractic care

(substantive, measurable functional gains with remaining

functional deficits) have been achieved, a follow-up course of

treatment may be indicated. However, one of the goals of any

treatment plan should be to reduce the frequency of treatments

to the point where MTB continues to be achieved while

encouraging more active self-therapy, such as independent

strengthening and range of motion exercises and rehabilitative

exercises. Patients also need to be encouraged to return to

usual activity levels as well as to avoid catastrophizing and

overdependence on physicians, including DCs. The frequency

of continued treatment generally depends on the severity

and duration of the condition. Patients who are interested in

wellness care (formerly called maintenance care11) should be

given those options as well. (Wellness or maintenance care

was defined by Dehen et al11 as “care to reduce the incidence

or prevalence of illness, impairment, and risk factors and to

promote optimal function.”)

 

When the patient's condition reaches a plateau or no longer

shows ongoing improvement from the therapy, a decision

must be made on whether the patient will need to continue

treatment. Generally, progressively longer trials of therapeutic

withdrawal may be useful in ascertaining whether therapeutic

gains can be maintained without treatment.

 

In a case where a patient reaches a clinical plateau in their

recovery (MTB) and has been provided reasonable trials of

interdisciplinary treatments, additional chiropractic care may

be indicated in cases of exacerbation/flare-up or when

withdrawal of care results in substantial, measurable decline

in functional or work status. Additional chiropractic care may

be indicated in cases of exacerbation/flare-up in patients who

have previously reached MTB if criteria to support such care

(substantive, measurable prior functional gains with recurrence

of functional deficits) have been established.

(Emphasis added)

 

 

 

 

 

Management of Chronic LBP

Definition of chronic pain patients. Note: MTB is

defined as the point at which a patient's condition has

plateaued and is unlikely to improve further. Chronic pain

patients are those for whom ongoing supervised treatment/

care has demonstrated clinically meaningful improvement

with a course of management and who have reached MTB,

but in whom substantial residual deficits in activity

performance remain or recur upon withdrawal of treatment.

The management for chronic pain patients ranges from

home-directed self-care to episodic care to scheduled

ongoing care. Patients who require provider-assisted

ongoing care are those for whom self-care measures,

although necessary, are not sufficient to sustain previously

achieved therapeutic gains; these patients may be expected

to progressively deteriorate as demonstrated by previous

treatment withdrawals. (Emphasis added)

 

• Nature of employment/work activities or ergonomics:

 

The nature and psychosocial aspects of a patient's

employment must be considered when evaluating the

need for ongoing care (eg, prolonged standing posture,

high loads, and extended muscle activity).

 

• Impairment/disability: The patient who has reached

MTB but has failed to reach preinjury status has an

impairment/disability even if the injured patient has

not yet received a permanent impairment/disability

award.

 

• Medical history: Concurrent condition(s) and/or use of

certain medications may affect outcomes.

 

• History of prior treatment: Initial and subsequent care

(type and duration), as well as patient compliance and

response to care, can assist the physician in developing

appropriate treatment planning. Delays in the initiation

of appropriate care may complicate the patient's

condition and extend recovery time.

 

• Lifestyle habits: Lifestyle habits may impact the

magnitude of treatment response, including outcomes

at MTB.

 

• Psychological factors: A history of depression,

anxiety, somatoform disorder, or other psychopathology

may complicate treatment and/or recovery.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment Withdrawal Fails to Sustain MTB

 

Documented flare-ups/exacerbations (i.e., increased pain

and/or associated symptoms, which may or may not be

related to specific incidents), superimposed on a recurrent

or chronic course, may be an indication of chronicity and/or

need for ongoing care.

 

 

Each of the following factors may complicate the

patient's condition, extend recovery time, and result in the

necessity of ongoing care

 

Complicating/Risk Factors for Failure to Sustain MTB

 

Figure 5 lists complicating factors that may document

the necessity of ongoing care for chronic spine-related

conditions. Such lists of complicating/risk factors are not

all-inclusive. Individual factors from this list may adequately

explain the condition chronicity, complexity, and

instability in some cases. However, most chronic cases that

require ongoing care are characterized by multiple

complicating factors. These factors should be carefully

identified and documented in the patient's file to support the

characterization of a condition as chronic.

 

Figure 5

• Severity of symptoms and objective findings

• Patient compliance and/or non-compliance factors

• Factors related to age

• Severity of initial mechanism of injury

• Number of previous injuries (N3 episodes)

• Number and/or severity of exacerbations

• Psycho-social factors (pre-existing or arising during care)

• Pre-existing pathology or surgical alteration

• Waiting >7 days before seeking some form of treatment

• Ongoing symptoms despite prior treatment

• Nature of employment / work activities or ergonomics

• History of lost time

• History of prior treatment

• Lifestyle habits

• Congenital anomalies

• Treatment withdrawal fails to sustain MTB

Fig 5. Complicating factors that may document the necessity of ongoing care for chronic conditions.

 

 

 

Clinical Reevaluation Information to Document Necessity for Ongoing Care

of Chronic LBP

 

In addition to standard documentation elements (i.e., date,

history, physical evaluation, diagnosis, and treatment plan),

the clinical information typically relied upon to document

the necessity of chronic pain management includes

the following:

 

• Documentation of having achieved a clinically

meaningful favorable response to initial treatment or

documentation that the plan of care is to be amended.

 

• Documentation that the patient has reached MTB.

 

• Substantial residual deficits in activity limitations are

present at MTB.

 

• Documented attempts of transition to primary

self-care.

 

• Documented attempts and/or consideration of alternative

treatment approaches.

 

• Documentation of those factors influencing the

likelihood that self-care alone will be insufficient to

sustain or restore MTB.

 

Once the need for additional care has been documented,

findings of diagnostic/assessment procedures that may

influence treatment selection includes the following:

 

• Neurological/provocative testing (standard neurological

testing, orthopedic tests, manual muscle testing);

 

• Diagnostic imaging (radiography, computed tomography,

magnetic resonance imaging);

 

• Electrodiagnostics;

 

• Functional movement/assessment (e.g., ambulatory

assessment/limp).

 

• Chiropractic analysis procedures.

 

• Biomechanical analysis (pain, asymmetry, range of

motion, tissue tone changes).

 

• Palpation (static, motion).

 

• Nutritional/dietary assessment with respect to factors

related to pain management (such as vitamin D intake).

 

This list is provided for guidance only and is not

all-inclusive. All items are not required to justify the need

for ongoing care. Each item of clinical information should

be documented in the case file to describe the patient's

clinical status, present and past.

 

In the absence of documented flare-up/exacerbation, the

ongoing treatment of persistent or recurrent spine-related

disorders are not expected to result in any clinically

meaningful change. In the event of a flare-up or

exacerbation, a patient may require additional supervised

treatment to facilitate return to MTB status. Individual

circumstances including patient preferences and previous

response to specific interventions guide the appropriate

services to be used in each case.

 

 

 

 

Chronic Pain Management Components in Physician-Directed Case

Management

 

Case management of patients with chronic LBP should be

based upon an individualized approach to care that combines

the best evidence with clinician judgment and patient

preferences. In addition to spinal manipulation and/or

mobilization, an active care plan for chronic pain management

may include, but is not restricted to, the following:

 

Procedures

 

• Massage therapy

• Other manual therapeutic methods

• Physical modalities

• Acupuncture

• Bracing/orthoses

Behavioral and exercise recommendations

• Supervised rehabilitative/therapeutic exercise

• General and/or specific exercise programs

• Mind/body programs (e.g., yoga, Tai Chi)

• Multidisciplinary rehabilitation

• Cognitive behavioral programs

Counseling recommendations

• ADL recommendations

• Co-management/coordination of care with other

physicians/health care providers

• Ergonomic recommendations

• Exercise recommendations and instruction

• Home care recommendations

• Lifestyle modifications/counseling

• Pain management recommendations

• Psychosocial counseling/behavioral modification/risk

avoidance counseling

• Monitoring patient compliance with self-care

recommendations

 

 

 

 

CONCLUSION

 

This publication is an update of the best practice

recommendations for chiropractic management of

LBP.9,10,12 This guide summarizes recommendations

throughout the continuum of care from acute to chronic

and offers the chiropractic profession and other key

stakeholders an up-to-date evidence- and clinical practice

experience–informed resource outlining best practice

approaches for the treatment of patients with LBP.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INTERNATIONAL CHIROPRACTORS ASSOCIATION (ICA)

 

ICA BEST PRACTICES AND PRACTICE GUIDELINES

 

CHAPTER 11

FREQUENCY AND DURATION RECOMMENDATIONS

 

Uncomplicated Axial Pain Guidelines

  1. A. 5 visits per week for 4 weeks plus 1 visit per week for 4 weeks plus 1 follow-up visit, total 25 visits in 8 weeks

1      B. 4 visits per week for 5 weeks plus 1 visit per week for 4 weeks plus 1 follow-up visit, total 25 visits in 9 weeks

1      C. 3 visits per week for 7 weeks plus 1 visit per week for 4 weeks plus 1 follow-up visit, total 25 visits in 11 weeks

Slowly Recovering Uncomplicated Axial Pain Guidelines

For one extra block of 12 visit of care in 4 weeks

      2. A. 5 visits per week for 4 weeks plus 12 visits for 4 weeks plus 1 visit per week for 4 weeks plus 1 follow-up visit, which is 37 visits in 12 weeks; or,

      2. B. 4 visits per week for 5 weeks plus 12 visits for 4 weeks plus 1 visit per week for 4 weeks plus 1 follow-up visit, which is 37 visits in 13 weeks; or,

      2. C. 3 visits per week for 7 weeks plus 12 visits for 4 weeks plus 1 visit per week for 4 weeks plus 1 follow-up visit, which is 37 visits in 15 weeks

For two extra blocks of 12 visit of care in 4 weeks (24 in 8 weeks)

3         A. 5 visits per week for 4 weeks plus 24 visits for 8 weeks plus 1 visit per week for 4 weeks plus 1 follow-up visit, which is 49 visits in 16 weeks: or,

 

3      B.  4 visits per week for 5 weeks plus 24 visits for 8 weeks plus 1 visit per week for 4 weeks plus 1 follow-up visit, which is 49 visits in 16 weeks: or,

 

3      C.   3 visits per week for 7 weeks plus 24 visits for 8 weeks plus 1 visit per week for 4 weeks plus 1 follow-up visit, which is 49 visits in 16 weeks

Axial Pain with Complicating Factors

For 3 extra blocks of 12 visits of care in 4 weeks (36 visits in 12 weeks)

4.A. 5 visits per week for 4 weeks plus 36 visits for 12 weeks plus 1 visit per week for 4 weeks plus 1 follow-up visit, which is 61 visits in 20 weeks; or,

4.B.  4 visits per week for 5 weeks plus 36 visits for 12 weeks plus 1 visit per week for 4 weeks plus 1 follow-up visit, which is 61 visits in 21 weeks: or,

      4.C.  3 visits per week for 7 weeks plus 36 visits for 12 weeks plus 1 visit per week for 4 weeks plus 1 follow-up visit, which is 61 visits in 23 weeks.

For 4 extra blocks of 12 visits of care in 4 weeks (48 visits in 16 weeks)

5.A. 5 visits per week for 4 weeks plus 48 visits for 16 weeks plus 1 visit per week for 4 weeks plus 1 follow-up visit, which is 73 visits in 24 weeks; or,

5.B.  4 visits per week for 5 weeks plus 48 visits for 16 weeks plus 1 visit per week for 4 weeks plus 1 follow-up visit, which is 73 visits in 25 weeks: or,

      5.C.  3 visits per week for 7 weeks plus 48 visits for 16 weeks plus 1 visit per week for 4 weeks plus 1 follow-up visit, which is 73 visits in 27 weeks.

For 5 extra blocks of 12 visits of care in 4 weeks (60 visits in 20 weeks)

6.A. 5 visits per week for 4 weeks plus 60 visits for 20 weeks plus 1 visit per week for 4 weeks plus 1 follow-up visit, which is 85 visits in 28 weeks; or,

6.B.  4 visits per week for 5 weeks plus 60 visits for 20 weeks plus 1 visit per week for 4 weeks plus 1 follow-up visit, which is 85 visits in 28 weeks: or,

      6.C.  3 visits per week for 7 weeks plus 60 visits for 20 weeks plus 1 visit per week for 4 weeks plus 1 follow-up visit, which is 85 visits in 31 weeks.

          Fifty-five complicating factors are listed including advanced age, tissue damage, osteoarthritis, preexisting degenerative joint disease, and any major disease.

Motor Vehicle Accidents

          The ICA follows guidelines developed by Arthur Croft, D.C. which have also been endorsed by at least eleven states. Here is a table with the guidelines from ). Am Chiro Assoc J Chiro 30(1): 41-45, 1993:

            The Insurance Research Council (IRC) has reported that the average number of treatments in a chiropractic motor vehicle case was 32. This is consistent with both the Croft and ICA guidelines.

602-932-8113.