A Review of Common Guidelines and Best Practices For Chiropractic Care


Many third party payors utilize guidelines or care paths for determining the proper frequency and duration of Chiropractic treatment. These are usually created in-house by the payors, adopted from those produced by for-profit private consulting agencies, or based on the opinion of independent Chiropractic consultants. All of these sources are problematic in that they are often are at odds with many currently published guidelines and best practices which were developed from a rigorous review of the research evidence, and the consensus of rational and ethical in-field Chiropractic physicians (such as those listed below).

In a profession as diverse as the Chiropractic profession, universal agreement on a set of guidelines for appropriate care is unreasonable. However, reviewing many of these documents can give us a clearer picture of what constitutes mainstream Chiropractic practice.

Before reviewing these, a few points need to be made before making jumping to the conclusion that a doctor has provided appropriate or inappropriate care:

  1. Guidelines and best practices are not recipes or formulas. They advise and guide, not dictate treatment. They do not form or constitute a standard of care. They can only provide a general orientation of necessary care.
  2. Each patient needs to be evaluated on a case-by-case basis. An individual’s rate of response to treatment varies considerably based on age, lifestyle, ergonomics, psychosocial factors, co-morbidities and confounders, and other elements of an individual’s life. There are a number of established and well-accepted “complicating factors” that may make a case more difficult to resolve.  These may not all be evident at the onset of care but may appear as time goes by.
  3. Doctors may over-estimate the severity of an injury and need to edit the care plan as the patient progresses.
  4. Patient motivation and compliance are intangibles that greatly affect the clinical outcomes.
  5. Some doctors, by nature, treat more aggressively than others, some more conservatively or passively. Therefore, all estimates of the frequency and duration of care will fall within ranges rather than specific metric points.


Council for Chiropractic Guidelines and Practice Parameters (CCGPP)

Acute Care*:

Therapeutic trial of up to 12 visits within 4 weeks.

If improvement occurs and patient is not at MTB**. An additional course of care is warranted, up to 12 visits within 4 weeks.

If ongoing improvement occurs and patient is not at MTB. An additional course of care is warranted, up to 12 visits within 4 weeks.


Chronic or Recurrent Care:

Follow Acute care guidelines until MTB is reached.

For mild exacerbation, treat up to 6 visits.

For ongoing or frequently recurrent conditions, treat up to 4 times per month, re-evaluating every 12 visits.


*Complicating factors ( This list is not all-inclusive):
These will frequently necessitate additional courses of care.

Patient characteristics Injury characteristics History
  • Older age
  • Psychosocial factors
  • Delay treatment >7 days
  • Non-compliance
  • Lifestyle habits
  • Obesity**
  • Type of work activities
  • Severe initial injury
  • > 3 previous episodes
  • Severe signs and symptoms
  • Number/severity previous exacerbations
  • Treatment withdrawal fails to sustain MTI
  • Pre-existing pathology/surgery
  • History of lost time
  • History of prior treatment
  • Congenital anomalies
  • Symptoms persist despite previous treatment

** MTB= maximum therapeutic benefit

 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.”


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    ***     ***     ***


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)


I       Primary rear impact

II      Primary side impact

III     Primary frontal impact



I       Minimal: no limitation of motion, no ligamentous injury or neurological findings.

II      Slight: limitation of motion; no ligamentous or neurological findings.*

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.



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.


Advance Age

Disc protrusion/herniation

Prior vertebral facture

Metabolic disorders

Spondylosis and/or facet arthrosis

Osteoporosis or bone disease

Congenital anomalies of the spine

Arthritis of the spine Spinal or foraminal stenosis

Development anomalies of the spine

AS or other spondylarthropathy


Degenerative disc disease Prior cervical or lumbar spine surgery Prior spinal injury; scoliosis


Canadian Chiropractic Guideline Initiative

“Our mission is to develop evidence-based clinical practice guidelines (CPGs) and best practice recommendations, and facilitate their dissemination and implementation within the chiropractic profession.  CCGI is funded by provincial and national chiropractic associations and regulatory boards.”  – 2015




Acute (less than 3 months) Non-Specific Neck Pain:

  • Spinal manipulative therapy (SMT) is recommended for the treatment of acute neck pain for both short- and long-term benefit (days to recovery, pain) when used in combination with other treatment modalities (advice, exercise, and mobilization).
  • Up to 15 treatment sessions over 12 weeks.
  • Home exercise with advice or training is recommended in the treatment of acute neck pain for both short and long-term benefits (neck pain).

Chronic (less than 3 months) Non-Specific Neck Pain:

  • Spinal manipulative therapy is recommended in the treatment of chronic neck pain for short- and long-term benefit (pain, disability).
  • 2 treatments per week for 9 weeks.
  • Spinal manipulative therapy is recommended in the treatment of chronic neck pain as part of a multimodal approach (including advice, upper thoracic spinal manipulative therapy, low-level laser therapy, soft tissue therapy, mobilizations, pulsed short wave diathermy, exercise, massage, and stretching) for both short- and long-term benefit (pain, disability, cROM).
  • 5 – 10 upper body/neck massage sessions lasting 60 – 75 minutes.



  • Spinal manipulationis recommended for the management of patients with episodic or chronic migraine with or without aura. This recommendation is based on studies that used a treatment frequency 1 to 2 times per week for 8 weeks.
  • Spinal manipulation is recommended for the management of patients with cervicogenic headache. This recommendation is based on 1 study that used a treatment frequency of 2 times per week for 3 weeks

 Persistent Non-Specific Low Back Pain: Spinal manipulation for period of up to 12 weeks.


Guidelines for the Practice of Chiropractic in North Carolina

                                    February 2006, updated May 2009

The following examples of neuro-muscular-skeletal conditions routinely treated by chiropractic physicians are grouped according to typical recovery times. This list is not exhaustive, and the recovery times are for simple cases devoid of complicating factors that could prolong the need for treatment. The recovery times are averages, and the progress of any individual patient may be faster or slower than the time stated.



Mild strain

Mild sprain

Mechanical/joint dysfunction, uncomplicated

Subluxation, uncomplicated

Acute facet syndrome


Mild tendonitis, capsulate, bursitis, synovitis

Mild sacroiliac syndrome

Acute myofascial pain syndrome

Mild symptomatic degenerative joint disease

Headaches, vertebrogenic, muscle contraction

Torticollis, acquired



Moderate-marked strain

Moderate sprain

Post-traumatic mild-moderate myofibrosis

Post-traumatic periarticular fibrosis and joint dysfunction with marked


bursitis, capsulitis, synovitis

Chronic tendonitis, bursitis, capsulitis, synovitis

Chronic facet syndrome

Moderate sacroiliac syndrome

Chronic sacroiliac syndrome with marked myofascial pain syndrome

Chronic myofascial pain syndrome

Mechanical/joint dysfunction, complicated

Subluxation, complicated

Moderate symptomatic degenerative joint disease

Mild inter-vertebral disc syndrome without myelopathy

Chronic headaches, vertebrogenic, muscle contraction, migraine, vascular

Mild temporomandibular joint dysfunction

Symptomatic spondylolisthesis

Mild clinical joint instability



Chronic facet syndrome associated with clinical vertebral instability

Marked strain associated with post-traumatic myofibrosis and/or joint


Marked sprain with associated instability/dysfunction

Thoracic outlet syndrome

Moderate inter-vertebral disc syndrome without myelopathy

Moderate-marked temporomandibular joint dysfunction

Adhesive capsulitis

Partial or complete dislocation



Marked inter-vertebral disc syndrome without myelopathy, with or

without radiculopathy

Lateral recess syndrome

Intermittent neurogenic claudication

Acceleration/deceleration injuries of the spine with myofascial


Cervicobrachial sympathetic syndromes

Sympathetic dystrophies

Severe strain/sprain of the cervical spine with myoligamentous


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