J Manipulative Physiol Ther 2008 (Nov); 31 (9): 651–658 ~ FULL TEXT
Gary A. Globe, MBA, DC, PhD, Craig E. Morris, DC,
Wayne M. Whalen, DC, Ronald J. Farabaugh, DC, Cheryl Hawk, DC, PhD
Cheryl Hawk, DC, PhD,
Vice President of Research and Scholarship,
Cleveland Chiropractic Research Center.
Kansas City and Los Angeles, USA
OBJECTIVE: Although a number of guidelines addressing manipulation, an important component of chiropractic professional care, exist, none to date have incorporated a broad-based consensus of chiropractic research and clinical experts representing mainstream chiropractic practice into a practical document designed to provide standardized parameters of care. The purpose of this project was to develop such a document.
METHODS: Development of the document began with seed materials, from which seed statements were distilled. These were circulated electronically to the Delphi panel until consensus was reached, which was considered to be present when there was agreement by at least 80% of the panelists.
RESULTS: The panel consisted of 40 clinically experienced doctors of chiropractic, representing 15 chiropractic colleges and 16 states, as well as both the American Chiropractic Association and the International Chiropractic Association. The panel reached 80% consensus of the 27 seed statements after 2 rounds. Specific recommendations regarding treatment frequency and duration, as well as outcome assessment and contraindications for manipulation were agreed upon by the panel.
CONCLUSIONS: A broad-based panel of experienced chiropractors was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for patients with low back pain, based on both the scientific evidence and their clinical experience.
From the FULL TEXT Article
The current document incorporates the consensus-based seed statements with additional explanatory material.
The findings of the CCGPP literature synthesis particularly support, although clinical practice is not limited to, the use of manual therapeutic techniques (such as manipulation and mobilization procedures), patient education regarding reassurance, staying active and avoiding illness behavior, and also rehabilitative exercise as the therapeutic basis for care for low back conditions. It is also important to note that the CCGPP recommendations in support of manipulation for both acute and chronic low back pain closely mirror many other systematic reviews of the literature. For example, Bronfort et al6 have also recently concluded that manual therapeutic methods, such as spinal manipulation and mobilization methods, combined with active care/exercises have been shown to be effective in the management of chronic back pain.
The current document is intended to further define and clarify the clinical application of research from a chiropractic evidence-influenced perspective, using a consensus process with a national panel of chiropractic clinical experts.
Most acute pain, typically the result of injury (micro- or macrotrauma), responds to a short course of conservative treatment. If effectively treated at this stage, patients often recover with full resolution of pain, although recurrences are common. Delayed or inadequate early clinical management may result in increased risk of chronicity and disability. Furthermore, those responding poorly in the acute stage and those with increased risk factors for chronicity must also be identified as early as possible.
Clinicians must continually be vigilant for the appearance of clinical red flags (see clinical red flags section below) that may arise at any point during patient care. In addition, biopsychosocial factors (also known as clinical yellow flags) should be identified and addressed as early as possible as part of a comprehensive approach to clinical management.
Chiropractic doctors are skilled in multiple approaches of functional assessment and treatment. Depending on the clinical complexity, DCs can work independently or as part of a multidisciplinary team approach to functional restoration of patients with acute and chronic low back pain.
Finally, it is the ultimate goal of chiropractic care to improve patients' functional capacity and educate them to independently accept the responsibility for their own health. In an era of costly health care, the greatest savings can be realized by keeping healthy patients out of doctor's offices and allowing limited health care resources to be used by those truly in need of them.
Informed consent is the process of proactive communication between a patient and physician that results in the patient's authorization or agreement to undergo a specific medical intervention. Informed consent should be obtained from the patient, performed within the local and/or regional standards of practice.
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. The review of evidence-informed examination procedures is beyond the scope of this document. The reader is advised that there are many excellent sources of evidence-based information by which to conduct a thorough and well-informed examination of the injured low back patient.
Severity and Duration of Conditions
Conditions of illness and injury are typically classified by severity and/or duration. Common descriptions of the stages of illness and injuries are acute, subacute, chronic, and recurrent, and further subdivided into mild, moderate, and severe. 
- Acute—symptoms persisting for less than 6 weeks.
- Subacute—symptoms persisting between 6 and 12 weeks.<
- Chronic—symptoms persisting for at least 12 weeks' duration.
- Recurrent/flare-up—return of symptoms perceived to be similar to those of the original injury at sporadic intervals or as a result of exacerbating factors.
Treatment Frequency and Duration
Although most patients respond within anticipated timeframes, frequency and duration of treatment may be influenced by individual patient factors or characteristics that present as barriers to recovery (eg, 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.
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
The treatment recommendations that follow (Table 1), 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.
An initial course of chiropractic treatment typically includes 1 or more “passive” (ie, non-exercise) manual therapeutic procedures (ie, spinal manipulation or mobilization) and physiotherapeutic modalities for pain reduction, in addition to patient education designed to reassure and instill optimal concepts for independent management. 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” (ie, exercise) care should be increasingly integrated to increase function and return the patient to regular activities.
Reevaluation and Reexamination
A detailed or focused reevaluation designed to determine the patient’s progress and response to treatment should be conducted at the end of each trial of treatment.
In addition, a brief assessment of the patients response to treatment should be noted after each treatment is completed, and recorded in the progress notes (ie, SOAP notes). A patient's condition should be monitored for progress with each visit. Near the midway point of a trial of care (ie, end of the second week of 4-week trial), the practitioner should reassess whether the current course of care is continuing to produce satisfactory clinical gains using commonly accepted outcomes assessment methods (see Outcome Measurement).
When a patient begins to demonstrate a delay in expected progress (ie, stalled functional gains), the DC should reassess and consider other clinically appropriate options (ie, other chiropractic methods, outside referral/treatment, diagnostic testing, and co-management).
A separate reexamination procedure should be performed at the end of the trial of care or in the event of an unexpected, significant change in the patient's condition. Patients who fail to achieve measurable gains should be considered for a modified treatment plan, additional diagnostic evaluation and/or specialist referral, co-management, or an alternative therapeutic approach. As with the other health care disciplines, there are chiropractic physicians with additional postgraduate training and board certifications who may be optimal choices for consultation, referral, or perhaps co-management of cases.
After an initial course of treatment has been concluded, a detailed or focused reevaluation should be performed. The purpose of this reevaluation is to determine whether the patient has made clinically meaningful improvement. A determination of the necessity for additional treatment should be based on the response to the initial trial of care and the likelihood that additional gains can be achieved.
As patients begin to plateau in their response to treatment, further care should be tapered or discontinued depending on the presentation. A reevaluation is recommended to confirm that the condition has reached a clinical plateau or has resolved. When a patient reaches complete or partial resolution of their condition and all reasonable treatment and diagnostic studies have been provided, then this should be considered a final plateau (maximal therapeutic benefit). The DC should perform a final examination to verify that maximum therapeutic benefit has been achieved and provide any necessary patient education and instructions in effective future self-management.
Continuing Course of Treatments
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 maximum therapeutic benefit 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 despite residual pain, as well as to avoid catastrophizing and overdependence on physicians, including DCs. They need to be reassured that, “hurt is not the same thing as harm.” The frequency of continued treatment generally depends on the severity and duration of the condition.
Upon completion of the initial trial of care, if the appropriate criteria have been met, the following parameters of continued treatment are recommended, based on clinical experience combined with the best available evidence (Table 2). 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 absent treatment.
In a case where a patient reaches a clinical plateau in their recovery (maximum therapeutic benefit) 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.
For a trial of care to be considered beneficial, it must be substantive, meaning that a definite improvement in the patient's functional capacity has occurred. Examples of measurable outcomes and activities of daily living and employment include:
- Pain scales such as the visual analog scale and the numeric rating scale.
- Pain diagrams that allow the patient to demonstrate the location and character of their symptoms.
- Validated activities of daily living measures, such as the Oswestry Back Disability Index and the Roland Morris Back Disability Index, RAND 36, Bournemouth Disability Questionnaire.
- Increases in home and leisure activities, in addition to increases in exercise capacity.
- Increases in work capacity or decreases in prior work restrictions.
- Improvement in validated functional capacity testing, such as lifting capacity, strength, flexibility, and endurance.
Spinal Range of Motion Assessment
Range of motion is commonly used by practitioners for a variety of reasons. It has not been shown to be a valid functional outcome measure; however, it may be used as part of determining an impairment rating or to determine whether a patient responded positively to a single treatment session.
Cautions and Contraindications
Chiropractic care, including patient education, passive and active care therapy, is a safe and effective form of health care for low back disorders. There are certain clinical situations where high-velocity, low-amplitude manipulation or other manual therapies may be contraindicated. It is incumbent upon the treating DC to evaluate the need for care and the risks associated with any treatment to be applied. Many contraindications are considered relative to the location and stage of severity of the morbidity, whether there is co-management with 1 or more specialists, and the therapeutic methods being used by the chiropractic physician.
Contraindications for High-Velocity Manipulation Techniques on the Lumbar Spine (Red Flags)
Figure 1 summarizes injuries or pathologic conditions that present contraindications for high-velocity manipulation to the lumbar spine.
Fig 1. Contraindications for high-velocity manipulation to the lumbar spine (red flags)
- Region of local unstable fractures
- Severe osteoporosis
- Multiple myeloma
- Local primary bone tumors where osseous integrity is in question
- Local metastatic bone tumors
- Paget's disease
- Progressive or sudden (i.e. cauda equine syndrome) neurologic deficit
- Spinal cord tumors that clinically demonstrate neurological compromise or require specialty referral. In cases where the neoplasm has been properly assessed and is considered to be clinically quiescent and/or perhaps distant to therapeutic target site, then chiropractic manipulative therapy may be utilized.
- Rheumatoid arthritis in the active systemic, stage, or locally in the presence of inflammation or atlantoaxial instability.
- Inflammatory phase of ankylosing spondylitis
- Inflammatory phase of psoriatic arthritis
- Reactive arthritis (Reiter's syndrome)
- Unstable congenital bleeding disorders, typically requiring specialty co-management
- Unstable acquired bleeding disorders, typically requiring specialty co-management
- Unstable abdominal aortic aneurysm
- Structural instability (e.g., unstable spondylolithesis)
- Inadequate physical examination
- Inadequate manipulative training and skills
* Under certain procedures soft tissue low velocity, low amplitude or mobilization procedures may still be clinically reasonable and safe.
Conditions Contraindicating Certain Chiropractic-Directed Treatments Such as Spinal Manipulation and Passive Therapy
Generally the procedure or therapy is contraindicated over the relevant anatomy and not necessarily contraindicated for other areas:
- Local open wound or burn
- Prolonged bleeding time/hemophilia
- Artificial joint implants
- Pacemaker (contraindicated modality—electrotherapy)
- Joint infection
- Recent/healing fracture
- Increasing neurologic deficit.
Conditions Requiring Co-Management
- Cancer pain
- Postoperative surgical pain
Conditions Requiring Referral
Patients should be referred to another specialty health care practitioner or to emergency care in certain instances, such as the following:
- The patient's condition is not responding to the treatment rendered, when all reasonable alternative chiropractic methods have been exhausted.
- The patient's condition is worsening with treatment.
- The patient has a serious and/or progressive infectious condition.
- The patient experiences a medical emergency (eg, myocardial infarct, cerebrovascular accident, severe laceration, pneumothorax).
- Increasing neurologic deficits (ie, cauda equina syndrome).
A broad-based panel of experienced chiropractors were able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for patients with low back pain, based on both the scientific evidence and their clinical experience.