Chiropractic treatment guidelines
The following sets of guidelines have been proposed to help practicing chiropractors design appropriate treatment plans for their patients and to help third party payers recognize and differentiate appropriate and inappropriate care patterns.
The Counsel on Chiropractic Guidelines and Practice Parameters (CCGPP) is currently working on a new set of guidelines for the profession. This committee consists of representation by of the Foundation for Chiropractic Education and Research (FCER), the Association of Chiropractic Colleges (ACC), the American Chiropractic Association (ACA), and seven District Delegates from the College of Chiropractic State Associations (COCSA).
In 1992 a previous version of this body created the "Mercy Conference Guidelines for Chiropractic Quality Assurance and Practice Parameters." The Mercy Guidelines were probably the most ambitious undertaking of its kind at that time, but the guidelines have recently been rescinded. The Ohio Guidelines, as endorsed and adapted by the North Dakota Chiropractic Association, are considered by the CCGPP to be one of
the most valid current guidelines for general care.
As you can imagine, in a profession as diverse as chiropractic any set of guidelines is going to have its detractors. No matter how authoritative the design team and how solid the consensus agreement of the brain trust, there is going to be some passionate disagreement from those who feel the guidelines are impacting them negatively.
The debate will surely go on. Several states have designed their own guidelines, usually using another guideline as a starting point. There are also guidelines created by private enterprise based on statistical data gathered in surveys.
If you are a patient reading these guidelines, you might be able to get a general idea of whether or not your doctor is fitting into mainstream thought. There are, however, a few things you should understand before you jump to any conclusions about whether your chiropractor is treating you too much or not enough.
These guidelines are not recipes. Every patient has his or her own set of circumstances. Rate of response to treatment varies considerably. There are a number of established and well-accepted "complicating factors" that may make your case more difficult to resolve. These may not all be evident at the onset of care but may appear as time goes by. To make matters worse, you may have a body that just has a slower than average healing rate.
On the other end of the spectrum, you may heal quicker than expected. You may be blessed with quicker healing times than average or your doctor may have over-estimated the severity of your injury. Maybe you are an exceptionally motivated and compliant patient who is being very dedicated with your home care instructions.
Some doctors, by nature, treat more aggressively than others, some more conservatively or passively. That's okay. But if your doctor has you set up for three visits a week for three months or, at the other extreme, treats you once for a significant injury and then does not schedule any follow-up, consider a second opinion.
And remember, even if your treatment is well within the guidelines in terms of frequency, you must be responding favorably to treatment (as measured by some legitimate outcome measure) to justify continuing treatment. If you have a lengthy treatment plan set up by your doctor with no apparent effort to modify the plan as your rate of response unfolds, you may want to get a second opinion. You will notice that both the Mercy and the Canadian guidelines require a redirection of care after two weeks if there is no demonstrable improvement.
The North Dakota Chiropractic Association's Guidelines
Adapted by the NDCA, as developed by the Ohio Chiropractic Association.
Management of Acute Conditions
(New conditions, most frequently related to an injury and not exceeding 12 month's duration.)
Mild Condition*:
* 3-7 visits per week for 1-15 days, followed by...
- 1 to 3 visits per week for 0-30 days
Moderate Condition**:
* 3-7 visits per week for 7-21 days, followed by...
* 1-3 visits per week for 30-60 days, followed by...
* 2-4 visits per month for 30-60 days, followed by...
* 1-2 visits per month for 0-3 months, followed by...
Severe Condition***:
* 3-7 visits per week for 21-45 days, followed by...
* 1-3 visits per week for 30-90 days, followed by...
* 2-4 visits per month for 45-90 days, followed by...
* 1-2 visits per month for 3-5 months, followed by...
Management of Chronic Conditions
(Old condition; arbitrarily set at greater than 12 months duration with long-standing or recurring symptomatology. May be history of trauma or repeated microtrauma.)
Mild Condition****:
* 2-3 visits per week for 14-45 days, followed by...
* 2 visits per week to 2 visits per month for 45-90 days, followed by...
* 1-2 visits per month for 3-6 months, followed by...
Moderate Condition*****:
* 3-7 visits per week for 14-45 days, followed by...
* 2-3 visits per week for 45-90 days, followed by...
* 2 visits per week to 2 visits per month for 90-180 days, followed by...
* 1-2 visits per month for 6-12 months, followed by...
Severe Condition******:
* 3-7 visits per week for 30-60 days, followed by...
* 3 visits per week to 2 visits per month for 60-120 days, followed by...
* 2 visits per week to 2 visits per month for 90-180 days, followed by...
* 2 visits per month to 1 visit per 3 months for 6-18 months, followed by...
"Acute" in these guidelines is defined as "Sharp, poignant; having a short and relatively severe course. Acute in this instance is meant to designate the new condition of less than 12 months duration."
"Chronic" is defined in these guidelines as "Persisting over a long period of time. Chronic in this instance is meant o designate the long-standing, recurring condition of more than 12 months duration."
*Mild Acute Condition, example: "strain of the lower back or neck, no major joint involvement, recent onset, no past history of similar complaints and no complicating factors readily apparent."
**Moderate Acute Condition, example: "Mild-to-moderate lumbosacral sprain/strain injury or cervical hyperflexion/hyperextension injury, recent onset with significant trauma, complicated by concomitant or related conditions such as sciatica, neuralgia, lumbar fixations or headaches, nausea, cervico-brachial syndrome."
***Severe Acute Condition, example: "Joint, muscle, ligament and/or nerve damage, such a lumbar and cervical disc syndromes or moderate, complicated sprain/strain injuries."
****Mild Chronic Condition, example: "Chronic muscle strain from aberrant biomechanics, myofascitis/fibromyositis, without major complicating factors."
*****Moderate Chronic Condition, example: "Degenerative joint disease, muscle weakness, ligamentous instability, disc degeneration, with numerous complications and concomitant conditions.
******Severe Chronic Condition, example: "Disc, joint and neurologic involvement, post laminectomy syndrome, history of serious and/or numerous traumatic events, numerous complicating factors noted as well as related conditions and concomitant complaints."
Clinical Guidelines For Chiropractic Practice In Canada
Proceedings of a Consensus Conference
Commissioned by the Canadian Chiropractic Association
Held at the Glenerin Inn
Mississauga, Ontario, Canada
April 3-7, 1993
These guidelines can be summarized as follows:
Algorithm #1
For acute pain less than 3 weeks in duration, no significant trauma-
* 3-5 treatments a week for 1-2 weeks
* If no improvement, use a different approach for 3-5 visits per week for 2 more weeks (if patient is sincere, compliant, and suitable for manual therapy, and symptoms are not progressing. If not, refer or discharge.) At this point, if onset was greater than 8 days before initiation of treatment, or if pain complaint is severe, or if there
were more than 3 previous episodes of pain in that area, or if there are underlying structural changes, go to Algorithm #2.
* If improved after first trail of treatment, continue to treat with decreased frequency, emphasizing active care components, for up to a maximum total of 8 weeks based on results of reassessment.
* If, after 8 weeks, maximum clinical and functional improvement is not reached, consider complicating factors not previously considered or else refer or discharge.
Annotation A: Promotion of active care and the prescription of exercises should be initiated as soon as possible.
Annotation B: Improvement should be measured objectively, e.g., Pain Disability Questionnaires, pain scales, or physiological measurements such as a range of motion or muscle strength.
Annotation C: Patients may present with underlying conditions that make spinal manual therapy inappropriate or that require psychological assessment.
Algorithm #2
For acute pain with complications (such as significant trauma, severe pain, significant underlying spinal degeneration, a disc problem with referred pain to the leg, etc.) or recurring or chronic pain (e.g., this is the most recent of several disabling attacks of spinal pain, or the back pain/shoulder pain/headache/leg pain has been experienced for many weeks or months)-
* 3-5 visits a week for 2 weeks, active care included if appropriate
* If no improvement, use a different approach for 3-5 visits per week for 4 weeks (if patient is sincere, compliant, and suitable for manual therapy, and symptoms are not progressing. If not, refer or discharge.)
* If demonstrating improvement is signs, symptoms, or function, continue care for up to 6 weeks. Emphasize active care components, rehabilitation, specific exercises, and discussion of pain behavior. After 6 weeks reassess.
* If patient is not returned to pre-episode status but is demonstrating continued clinical or functional improvement, continue care as required for up to 10 more weeks. Generally, after 6 weeks, treatment frequency should not exceed 2 visits per week. Clinical necessity may mandate more frequent care.
* If, after 16 weeks, patient has not returned to pre-episode status, go to algorithm #3.
Annotation A: Improvement should be measured objectively, e.g., Pain Disability Questionnaires, pain scales, or physiological measurements such as a range of motion or muscle strength.
Annotation B: During a period of continued care, reassessment at frequent intervals (maximum 6 weeks) should be made to determine need for care.
Algorithm #3
For supportive care after acute or chronic pain treatment has ended (see Annotations below for definitions) defined as therapeutically necessary care of patients who, despite rehabilitative exercises and other lifestyle modifications, fail to sustain therapeutic gains after treatment withdrawal. Reasons may include the ongoing stresses of work and other activities of daily living. (Editor's note: The guidelines define this
treatment is defined as necessary, and it is differentiated from elective care, which is at the option of the patient who wishes to maintain optimum function with preventive/maintenance care.)
- With supportive care, symptoms improve or return to pre-withdrawal stage
- When symptoms return, supportive care is continued with episodes of treatment withdrawal, with a final goal of discharge or shift to elective care.
* (Editor's note: In his book, The Chiropractic Profession, David Chapman-Smith provides an idea of what this could entail when he writes that supportive care might typically involve 3-6 treatments over a 2 week period to arrest returning pain and disability, then one treatment every 2-4 weeks for a settling period of a few months and then another attempt at complete withdrawal of care. The frequency of treatment must be determined on an individual basis as dictated by therapeuticnecessity)
Annotation A: Supportive care is therapeutically necessary care for patients who, despite rehabilitative exercises and other lifestyle modifications, fail to sustain therapeutic gains after treatment withdrawal. Reasons may include the ongoing stresses of work and other activities of daily living.
Annotation B: Elective care/treatment is at the option of the patient who wishes to maintain optimum function with preventive/maintenance care. Some patients, for example, wish to have functional pathology treated before pain and disability develop.
The Rand Corporation Guidelines
From The Chiropractic Profession by David Chapman-Smith:
"The unanimous conclusion of a 1991 RAND Corporation expert panel reporting on The Appropriateness of Spinal Manipulation for Low-Back Pain, comprised of three chiropractors, two medical orthopedists, an internist, a family practitioner, a neurologist and an osteopath, was:
"An adequate trial of spinal manipulation is a course of two weeks for each of two different types of spinal manipulation (four weeks total) after which, in the absence of documented improvement, spinal manipulation is no loner indicated."
--Shekelle PG, Adams AH, et al. The appropriateness of spinal manipulation for low-back pain: indications and ratings by a multidisciplinary expert panel. Santa Monica, California: RAND, 1991:
Monograph No.R-4025/2-CCR/FCER
The Croft Guidelines for Treatment of CAD Trauma (Whiplash Injuries)
Per Dr. Arthur Croft of the Spine Research Institute of San Diego
Frequency and Duration of Care in Cervical Acceleration/Deceleration (CAD) Trauma
Dr. Arthur Croft is the director of the Spine Research Institute of San Diego and co-author of the respected text, Whiplash Injuries: The Cervical Acceleration/Deceleration Syndrome.
"It is important to stress, however, that guidelines are merely guides to care--not prescriptions for treatment schedules. The patient is always the ultimate guide to the need for care. Guidelines can alert the clinician to possibly missed or occult injuries, in the case where his treatment appears outside the guidelines, or to the possibility that his approach to care needs to be reevaluated." Arthur Croft, DC
Grade*Daily 3x/wk 2x/wk 1x/wk 1x/m TDN TN
I 1wks 1-2w 2-3w <4w *** 10w 21
II 1wks <4w <4w <4w <16w 29w 33
III 1-2wks<10w<10w<10w <24w 56w 76
IV 2-3wks<16w <12w<20w *** *** ***
V*
TD = treatment duration
TN = treatment number
*See Crofts' CAD Classification System elsewhere on this page to understand the grades.
**Grade V requires surgical stabilization. Chiropractic care would be post-surgery.
***Possible follow-up at one month
****May require permanent monthly or prn care.
The Croft CAD Injury Classification System (1992)
TYPE OF INJURY ...PRODUCED BY THIS TYPE OF IMPACT
I Primary rear impact
II Primary side impact
III Primary frontal impact
GRADE OF SEVERITY CLINICAL PRESENTATION
I Minimal: no limitation of motion, no ligamentous injury or neurological findings.
II Slight: limitation of motion; no ligamentous or neurologicalfindings.*
III Moderate: limitation of motion; some ligamentous injury**; neurological findings may be present.
IV Moderate to severe: limitation of motion; ligamentous instability; neurological findings present; fracture or disk derangement.***
V Severe: requires surgical management.
STAGE OF RECOVERY
I Acute: inflammatory stage (up to 72 hours)
II Subacute: repair stage (72 hours to 14 weeks)
III Remodeling stage (14 weeks to 12 months or more)
IV Chronic (permanent)
*Neurological findings can include subject complaints (numbness, tingling, paresthesias, blurred vision, PCS symptoms, radiating pain, etc.)
**Ligamentous injury can be inferred from radiographic findings.
***Fracture can include minimal end-plate fracture (not that minor fractures of articular pillars, vertebral bodies, uncinate processes, and vertebral endplates are often occult); disc derangement can include non-herniated forms (rim lesions and internal disruptions of the disc are common in whiplash injuries but are rarely visible on plain film x-rays.
****Duration of stages is dependent on severity of injuries and other factors.
"...an interesting finding of Brault et al. suggests that Grade I may be quite rare...nearly all volunteers--even those without symptoms--experiences significant losses of ROM (as measure pre- and post-test), even though the ranges fell within normal published values. So if a patient has pain, he's probably also lost some ROM and is, by
definition, a Grade II at least." Arthur Croft, DC
The Quebec Task Force Grading System for WAD* Injuries (1995)
GRADE OF SEVERITY CLINICAL PRESENTATION
0 No neck complaints, no physical signs.
I Neck pain, stiffness, or tenderness only; no physical signs.
II Neck complaint and physical signs.**
III Neck complaint and neurological signs.***
IV Neck complaint and fracture or dislocation.
*WAD = Whiplash Associated Disorders
** Musculoskeletal signs include decreased ROM and point tenderness.
***Neurological signs include decreased or absent deep tendon reflexes, weakness, and sensory deficits.
Table 7: Example of Levels of Treatment for the Texas Workers' Compensation Program
Level of Treatment
Duration of Time
Goal of Treatment
Primary
0-8 Weeks
Symptom control to facilitate rapid recovery and return to work before deconditioning or psychosocial barriers occur.
Secondary
0-8 Weeks
Arresting and preventing progressive physical deconditioning and appearance of psychosocial barriers to work return with a reactivation process, generally associated with the post-acute and early postoperative periods.
Tertiary
0-6 Weeks
To present the final phase of non-operative or postoperative treatment for severe cases, with the goal of giving injured workers an opportunity for cooperating actively in programs designed to achieve Maximum Medical Improvement.
Total
0-22 Weeks
I also ran across the ACOEM see the below site..
Moses
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