J Manipulative Physiol Ther 2010 (Sep); 33 (7): 484–492 ~ FULL TEXT
Ronald J. Farabaugh, DC, Mark D. Dehen, DC, Cheryl Hawk, DC, PhD
Chiropractic Guidelines and Practice Parameters,
Lexington, SC, USA.
Objective Chronic spine-related conditions are very problematic in terms of treatment and indemnity costs, diagnostic complexity, and appropriate case management. Currently no chiropractic-directed guideline exists related to chiropractic management of the chronic spine pain patient. The purpose of this project was to develop a broad-based multidisciplinary consensus of medical and chiropractic clinical experts representing mainstream medical and chiropractic practice to produce a document designed to provide standardized parameters of care and documentation.
Methods Background materials were provided to the panelists prior to the consensus process and served as the basis for the 29 seed statements. Delphi rounds were conducted electronically, and the Nominal Group Panel was conducted via conference call. The RAND/UCLA methodology was used to reach consensus, which was considered present if both the median rating was 7 or higher and at least 80% of panelists rated the statement 7 or higher. Consensus was reached through a combination of Delphi rounds and Nominal Group Panel. Of 29 panelists, 5 were non–doctors of chiropractic.
Results Specific recommendations regarding treatment, frequency and duration, as well as outcome assessment and contraindications for manipulation, were agreed upon by the panel.
Conclusions A multidisciplinary panel of experienced practitioners was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for complex patients with chronic spine-related conditions, based on both the scientific evidence and their clinical experience.
Key Indexing Terms: Chiropractic, Chronic Spine Pain, Manipulation
From the Full-Text Article:
Scope of the Chronic Pain Problem
Chronic pain is considered the most underestimated health care problem impacting quality of life. Today, chronic pain is one of the most common reasons for patients to seek medical care; it is estimated that 35% of the US population in general, 25% of children younger than 18 years, and 50% of community-dwelling older adults experience chronic pain. [1, 2] The majority of chronic pain is spine-related.  Health care costs associated with spine problems, including low back pain (LBP) and neck pain, were estimated at $102 billion in the United States in 2004.  Total estimated expenditures among individuals with spine problems increased 65% (adjusted for inflation) from 1997 to 2005, more rapidly than overall health expenditures. 
Pharmacological Management and Associated Costs
Frequent use of opioids in managing chronic non-cancer pain has been a major issue for health care in the United States, with significant concerns related to adverse effects, misuse, abuse, and addiction.  While these medications serve as powerful pain killers, they have also been implicated for potential drug abuse. A 2006 Centers for Disease Control and Prevention report showed that the rise in drug overdose mortality was due to increasing deaths from prescription drugs, rather than from illicit drugs such as heroin and cocaine.  Furthermore, approximately 21% of people with chronic pain find their care unsatisfactory, and only 30% find that prescription medications adequately address their pain. 
Most chronic pain sufferers initially try to self-manage their symptoms with over-the-counter analgesic drugs. Perhaps because of their ready availability to the general public, over-the-counter drugs are a significant source of morbidity and mortality in the United States, especially acetaminophen, salicylates, and nonsteroidal anti-inflammatory drugs such as ibuprofen and naproxen. 
Chiropractic practice has long been associated with managing neuromusculoskeletal conditions, predominantly back pain. There is a substantial body of literature to support the effectiveness of this care.  A synthesis of recommendations for acute LBP suggests that clinicians should educate patients about its etiology (eg, unknown and nonspecific), prognosis (eg, likely to improve within weeks with or without care), recurrence (eg, future occurrences are common). They should also recommend that patients stay active despite discomfort and rely mostly on acetaminophen, nonsteroidal anti-inflammatory drugs or spinal manipulative therapy for short-term symptomatic relief. Those recommendations also held true for the management of chronic LBP, with the judicious addition of one or more interventions, such as back exercises, behavioral therapy, acupuncture, yoga, massage therapy, multidisciplinary rehabilitation, and adjunctive or strong opioid analgesics. [4, 9]
There is also moderate quality evidence that spinal manipulation/mobilization combined with exercise is effective for chronic non-specific neck pain.  There is low-quality evidence supporting the clinical benefit of mobilization and manipulation for pain, function and global perceived effect for patients with chronic cervicogenic headache, compared to controls at intermediate and long-term follow-up. 
In 2007 the American College of Physicians and the American Pain Society released a joint guideline related to the diagnosis and treatment of low back pain. According to their review of the literature, spinal manipulation was recommended for both acute and chronic low back pain. 
Due to the scope of chronic pain problem in the United States and the lack of clear guidelines related to chronic pain treatment rendered by chiropractic physicians, the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) conducted a formal consensus process with a multidisciplinary panel of experts to develop rational, appropriate patient-centered treatment guidelines for patients with chronic spine-related pain who prefer an alternative/complementary management strategy to pharmaceutical use.
Definition of “Chronic Pain Patients”
Chronic pain patients are those for whom ongoing supervised treatment/care has demonstrated clinically meaningful improvement with a course of management and have reached MTI, but in whom significant 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, while necessary, are not sufficient to sustain previously achieved therapeutic gains; these patients may be expected to progressively deteriorate as demonstrated by previous treatment withdrawals. Additional relevant definitions in common use are provided in Table 1.
|Table 1: Definitions of chronic pain-related terminology|
…return to pre-episode status: six to eight weeks 
A case where the patient, because of one or more identifiable factors, exhibits regression or retarded recovery in comparison with expectations from the natural history. 
…symptoms have been prolonged beyond 16 weeks 
Acute: 6-8 weeks
Subacute: 8-16 weeks
Chronic: >16 weeks 
An umbrella term for activity limitations and/or participation restrictions in an individual with a health condition, disorder or disease. 
Temporary worsening of a pre-existing condition. Following a transient increase in symptoms, signs, disability, and/or impairment, the person recovers to his or her baseline status, or what it would have been had the exacerbation never occurred. Given a condition whose natural history is one of progressive worsening, following a prolonged but still temporary worsening, return to pre-exacerbation status would not be expected, despite the absence of permanent residuals from the new cause. 
A significant deviation, loss, or loss of use of any body structure or function in an individual with a health condition, disorder, or disease. 
An impairment extant at the point of maximal medical improvement. 
Reappearance of the symptoms and/or signs of a disease after a remission (period during which the manifestations were absent or significantly diminished. 
Table 2 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.
|Table 2: Complicating factors that may document the necessity of ongoing care for chronic conditions|
- 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 (>3 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 MTI
It is important for the reader to recognize that these guidelines are intended to be flexible and may need to be modified. They are not standards of care. Adherence to them is voluntary. Alternative practices are possible and may be preferable under certain clinical conditions. The ultimate judgment regarding the propriety of any specific procedure must be made by the practitioner in light of individual circumstances presented by each patient. 
There is substantial agreement on the management of acute, and episodic chronic pain related to mild, moderate, and/or severe exacerbations for the typical patient presentation. Relative to low back pain, CCGPP's project, described in the 2008 publication, “
Chiropractic Management of Low Back Disorders: A Consensus Report” has addressed those patients.  Therefore, this project focused on the problematic category of patients whose chronic pain is not successfully controlled without ongoing care. Management of this category of patient contributes substantially to overall medico-legal complications and costs. Since no chiropractic guideline currently exists to address this problem, these patients may be inappropriately denied chiropractic care and must therefore turn to more expensive, more invasive, and often less effective therapies.
Although this document may provide some assistance to third party payers in the evaluation of care, it is not by itself a proper basis for evaluation. Many factors must be considered in determining clinical or medical necessity, including the best available scientific evidence, the clinical experience of the involved practitioners and the patient's personal preferences. Furthermore, guidelines require periodic re-evaluations as additional scientific and clinical information becomes available.
The chief limitation of this project was the lack of diversity in the consensus panel, which included only 5 non-DCs and only 2 International Chiropractors Association members. CCGPP had hoped to attract a broader, more multidisciplinary panel. Our inability to do so may reflect the longstanding isolation of the profession, as well as the factionalism within it. Another limitation may be related to the number of source documents available to provide to the panel as background chronic pain in use throughout the medical and research communities. Additional sources may have been useful for the panel to gain a broader understanding of common medical lexicon. We reviewed only a limited number of terms and perspectives centered on “chronic spine-related conditions.” There may be other terminology, definitions or perspectives which were not considered, although efforts were made to include those most commonly used in the health care arena. Limitations imposed by the Delphi process, as well as the limited diversity of the panel members may also have contributed to a bias in consideration of other definitions or terminology.
There is increasing evidence in the scientific literature supporting the long tradition of patients seeking chiropractic care when dealing with chronic spinal pain. As demonstrated above, there is also an obvious need for a safe, low-cost alternative to pharmaceutical chronic pain management. Therefore, it appears the time is right for chiropractic management of chronic pain for spine-related conditions to be embraced by the mainstream health care system.
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