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
- 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.