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:
- 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.
- 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.
- Doctors may over-estimate the severity of an injury and need to edit the care plan as the patient progresses.
- Patient motivation and compliance are intangibles that greatly affect the clinical outcomes.
- 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 |
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** 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 *** *** ***
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 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.
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.
POTENTIALLY COMPLICATING FACTORS THAT MAY PROLONG CARE:
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
Paraplegia/tetraplegia
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
http://www.chiropractic.ca/guidelines-best-practice/
Summary:
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.
Headache:
- 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.
CATEGORY ONE: 0-6 WEEKS OF TREATMENT
Mild strain
Mild sprain
Mechanical/joint dysfunction, uncomplicated
Subluxation, uncomplicated
Acute facet syndrome
Contusion
Mild tendonitis, capsulate, bursitis, synovitis
Mild sacroiliac syndrome
Acute myofascial pain syndrome
Mild symptomatic degenerative joint disease
Headaches, vertebrogenic, muscle contraction
Torticollis, acquired
CATEGORY TWO: 2-12 WEEKS OF TREATMENT
Moderate-marked strain
Moderate sprain
Post-traumatic mild-moderate myofibrosis
Post-traumatic periarticular fibrosis and joint dysfunction with marked
tendonitis,
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
CATEGORY THREE: 1-6 MONTHS OF TREATMENT
Chronic facet syndrome associated with clinical vertebral instability
Marked strain associated with post-traumatic myofibrosis and/or joint
dysfunction
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
CATEGORY FOUR: 2-12 MONTHS OF TREATMENT
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
complications
Cervicobrachial sympathetic syndromes
Sympathetic dystrophies
Severe strain/sprain of the cervical spine with myoligamentous
complications
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