GUIDELINES FOR CHIROPRACTIC QUALITY ASSURANCE AND PRACTICE PARAMETERS AKA THE MERCY CONFERENCE ~ MAJOR RECOMMENDATIONS
 
   

Guidelines for Chiropractic Quality Assurance
and Practice Parameters

The Mercy Conference ~ Major Recommendations

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:
  Frankp@chiro.org
 
   

1993 Aspen Publishers, Inc.

Thanks to the National Guideline Clearinghouse™ (NGC), a public resource for evidence-based clinical practice guidelines, for the use of this document!

Note from National Guideline Clearinghouse (NGC):   The recommendations, presented below, were the most important part of the proceedings. At all times, however, it must be kept in mind that the recommendations should not be perceived as free floating statements. Each recommendation must be placed in the context of the entire document. The scientific and theoretical base of a recommendation must be kept in mind, as well as its relationship to other recommendations. The definitions of the ratings for the documents - the practice rating (e.g., "necessary"), the quality of evidence in support, and the consensus level - are provided in the "Rating Scheme" field of the NGC full summary and are repeated at the end of this major recommendations section. The following excerpt of the major recommendations of the guideline is provided for reference purposes only.

MAJOR RECOMMENDATIONS:

I.    History and Physical Examination

II.    Diagnostic Imaging

III.    Instrumentation

IV.    Clinical Laboratory

V.    Record Keeping and Patient Consents

VI.    Clinical Impression

VII.    Modes of Care

VIII.    Frequency and Duration of Care

IX.    Reassessment

X.    Outcome Assessment

XI.    Collaborative Care

XII.    Contraindications and Complications

XIII.    Preventive Maintenance Care and Public Health

XIV.    Professional Development

DEFINITIONS



  1. History and Physical Examination:

    1. History
      1. The process by which one determines the diagnosis should be adequately recorded and interpretable.

      2. Rating: Necessary
        Evidence: Class II, III
        Consensus Level: 1

      3. The history plays a critical role in the diagnostic process. A well-performed history will appropriately identify the region to be examined and the extent of the condition.

      4. Rating: Established
        Evidence: Class I, II, III
        Consensus Level: 1

      5. The components of the history may include any or all of the following, dependent on the presentation of the patient and the judgment of the practitioner.

        1. Data on identity, including age and sex

        2. Chief complaint (problem list)

        3. History of present complaint

          • history of trauma
          • description of chief complaint(s)
          • quality/character
          • intensity frequency
          • location and radiation
          • onset
          • duration
          • palliative and provocative factors
        4. Family history

        5. Past health history

          • general state of health
          • prior illness
          • surgical history
          • previous injuries, i.e., MVA, workers’ comp.
          • past hospitalizations
          • previous treatment and diagnostic tests
          • medications
          • allergies
        6. Psycho-social history

          • occupation
          • activities
          • recreational activities
          • exercise
        7. Social history

          • marital status
          • level of education
          • social habits
        8. Review of systems

          • musculoskeletal
          • cardiovascular
          • respiratory
          • gastrointestinal
          • genitourinal
          • central nervous system
          • eye, ear, nose and throat
          • endocrine
          • peripheral vascular disease
          • psychiatric
          Rating: Necessary
          Evidence: Class I, II, III
          Consensus Level: 1

    2. Examination

      1. Practitioners may use any or all diagnostic procedures pertinent to the physical examination, however sophisticated, dependent on individual training and the legal statutory framework within which they work.
        Rating: Necessary
        Evidence: Class II, III
        Consensus Level: 1

      2. Examination procedures regardless of chief complaint(s) may include:

        1. Evaluation of blood pressure and pulse rate

        2. Recording of height and weight

        3. Record of temperature in the presence of pertinent subjective complaints

        Rating: Recommended
        Evidence: Class III
        Consensus Level: 1

      3. In the presence of head complaints evaluation may include examination of the neck and adjacent structures as well as appropriate vascular and cranial nerve testing.
        Rating: Established
        Evidence: Class II, III
        Consensus Level: 1

      4. In the presence of reported or observed changes in cognition, coordination, special sensory function or recent head trauma, it is necessary to perform a neurologic evaluation or obtain a more extensive neurologic/vascular workup in a timely fashion.
        Rating: Established
        Evidence: Class II, III
        Consensus Level: 1

      5. Examination of the neck and adjacent structures may include:

        1. Inspection and observation to include postural presentation of the region

        2. Regional palpation

        3. Range of motion including active and/or passive movement

        4. Muscle strength

        5. Provocative maneuvers which might include compression and stretching

        6. Neurologic examination

        7. Vascular examination as is safe and effective in diagnosing the patient

        Rating: Established
        Evidence: Class II, III
        Consensus Level: 1

      6. Examination procedures for thoracic and/or chest complaints may include:

        1. Inspection and observation to include postural presentation of the region

        2. Regional palpation

        3. Auscultation of the chest in the presence of pertinent subjective complaints to be performed by the practitioner or appropriate specialist

        4. Auscultation of heart sounds in the presence of pertinent subjective complaints to be performed by the practitioner or appropriate specialist

        5. Auscultation and palpation of the abdomen

        6. Range of motion including passive and/or active movements

        7. Muscle strength

        8. Provocative maneuvers which may include compression and stretching

        9. Neurologic examination as is safe and effective in diagnosing the patient

        Rating: Established
        Evidence: Class II, III
        Consensus Level: 1

      7. Examination procedures for lower back and adjacent structures may include:

        1. Inspection and observation to include postural presentation of the region

        2. Regional palpation

        3. Evaluation of the abdominal aorta to include palpation and auscultation in the presence of pertinent subjective and objective findings

        4. Evaluation of the abdominal/pelvic viscera to include palpation and/or auscultation in the presence of pertinent subjective complaints

        5. Range of motion including passive and/or active movements

        6. Muscle strength

        7. Provocative maneuvers which may include compression and stretching

        8. Neurologic examination

        9. Vascular examination

        10. Recording the circumference of the involved extremity in the presence of pertinent subjective complaints is safe and effective in diagnosing the patient

        Rating: Established
        Evidence: Class I, II, III
        Consensus Level: 1

      8. Examination procedures for extremity complaints may include:

        1. Vascular examination

        2. Neurologic examination

        3. Regional palpation

        4. Range of motion including passive and/or active movements

        5. Provocative maneuvers which may include compression and stretching.

        6. Recording the circumference measurements of the involved extremity in the presence of pertinent subjective complaints is safe and effective in diagnosing the patient

        Rating: Established
        Evidence: Class I, II, III
        Consensus Level: 1

      9. Independent chiropractic examinations (ICE) should be performed in accordance with the recommendations put forth in this chapter.
        Rating: Recommended
        Evidence: Class II
        Consensus Level: 1


  2. Diagnostic Imaging:

    1. Sequence of Services

      The practitioner, in most instances, is the person that initiates a radiographic study. The study is performed by the technologist or qualified person in a safe environment in a manner consistent with published guidelines regarding quality and performance. It is the standard of care that all studies are viewed for interpretation by the practitioner or radiologist to obtain the maximum level of diagnosis which is achievable based on the type of study performed. Standard and customary billing procedures are followed.

      Rating: Established
      Evidence: Class III
      Consensus Level: 1

    2. Patient Selection Procedures

      The decision on whether or not to use diagnostic imaging studies is made following a carefully performed history, physical and regional evaluation, and consideration of cost/ benefit/radiation exposure ratios. It is based on sound clinical reasoning and the likelihood that significant information can be obtained from the study in regards to diagnosis, prognosis and therapy. The decision remains solely the domain of the examining (primary) practitioner.

      Rating: Established
      Evidence: Class I, II, III
      Consensus Level: 1

      Comment:   It is difficult to weigh the impact of the political, litigious, and social climate on the perceived need of many practitioners to have prior radiographic evidence of the area to be manipulated. This issue needs further study before firm conclusions about the prophylactic acquisition of radiographs can be made.

    3. Radiographic Interpretation and Reporting

      Imaging studies are performed primarily to contribute to a diagnostic impression. Interpretation of each imaging study should be documented in the patient’s permanent record.

      Rating: Established
      Evidence: Class II, III
      Consensus Level: 1

    4. Legal Issues in Radiography

      Federal regulations (Public Law 97-35 sec. 978) state that radiography, as applied to chiropractic practice, is used for diagnostic purposes only, and not for radio-therapeutic purposes. The National Council on Radiation Protection has established recommendations for the safe and effective use of radiography. It is the responsibility of every practitioner to be informed of and abide by all relevant legal requirements.

      Rating: Established
      Evidence: Class III
      Consensus Level: 1

    5. Radiation Technology and Protection

      Practitioners should keep the radiation exposure of patients as low as reasonably achievable. This includes use of modem equipment and techniques as outlined in the literature review section of this document. A suboptimal radiograph should be repeated. The decision on whether or not to expose a patient to radiation is only valid before the series is ordered. Once committed to the acquisition of a series, the practitioner is obligated to produce high quality radiographs.

      Rating: Established
      Evidence: Class I, II, III
      Consensus Level: 1

    6. Plain Film Radiographs

      The plain film radiograph is considered an adequate first step in the evaluation of degenerative and inflammatory joint disease, fracture, infection and neoplasm. Not every patient with these conditions will require radiography for diagnosis. Orthogonal views are a necessary minimum for visualizing any body area. Additional views are used as appropriate to demonstrate conditions that could exist given the findings of the clinical diagnosis.

      Rating: Established
      Evidence: Class I, II, III
      Consensus Level: 1

      For postural and biomechanical assessment.

      Rating: Promising
      Evidence: Class II, III
      Consensus Level: 1

    7. Full Spine Radiography

      For scoliosis evaluation where indicated by clinical examination.

      Rating: Established
      Evidence: Class I, II, III
      Consensus Level: 1

      For evaluation of complex biomechanical or postural disorders and the evaluation of multi-level spinal complaints as a result of biomechanical compensation.

      Rating: Promising
      Evidence: Class II, III
      Consensus Level: 1

    8. Stress Radiography
    9. Stress views are often of value in the assessment of degenerative, traumatic or post-surgical instabilities with the exception of those that carry the risk of neurologic injury. They provide unique diagnostic information.

      Rating: Established
      Evidence: Class I, II, III
      Consensus Level: 1

      For other conditions and circumstances.

      Rating: Equivocal
      Evidence: Class II, III
      Consensus Level: 1

    10. Videofluoroscopy (cinefluoroscopy)

      For kinematic and other biomechanical purposes.

      Rating: Promising
      Evidence: Class II, III
      Consensus Level: 1

      Comment:   The authors of the Quebec Task Force (1987) have outlined the limited use criteria that currently appear valid.

      For instability of the wrist and contrast studies.

      Rating: Established
      Evidence: Class I, II, III
      Consensus Level: 1

    11. Plain Film Contrast Studies

      Provide valuable unique information in special circumstances. These studies should only be performed by a radiologist.

      Rating: Established
      Evidence: Class I, II, III
      Consensus Level: 1

    12. Computed Tomography
    13. Valuable in the assessment of most musculoskeletal conditions requiring sectional imaging. Of particular utility in the evaluation of complex fractures in flat bones or the posterior arch of any spinal level. Adequately sensitive and specific for the evaluation of complicated degenerative conditions and herniated nucleus pulposus of the lumbar spine. Ordered only in the presence of specific clinical indications.

      Rating: Established
      Evidence: Class I, II, III
      Consensus Level: 1

    14. Magnetic Resonance Imaging

      The study of choice in the pre-operative evaluation of many internal derangements of articulations, and the evaluation of many central nervous system disorders. Comparisons between CT and MRI have shown similar sensitivity. Limited spatial resolution capabilities and cost are drawbacks. Ordered only in the presence of specific clinical indications.

      Rating: Established
      Evidence: Class I, II, III
      Consensus Level: 1

    15. Radionuclide Bone Scanning

      Has an established role in the evaluation of bone disease. Adequately sensitive, put poorly specific. Ordered only in the presence of specific historical and diagnostic information.

      Rating: Established
      Evidence: Class I, II, III
      Consensus Level: 1

    16. Diagnostic Ultrasound

      Utility and accuracy in the evaluation of musculoskeletal conditions remains limited, but diagnostic ultrasound has promise as a non-invasive, inexpensive alternative to MRI and arthrography. An established modality for evaluation of many intra-abdominal and pelvic organs.

      Rating: Established
      Evidence: Class I, II, III
      Consensus Level: 1


  3. Instrumentation:

    Perceptual Measurements

    1. Questionnaires as Instruments

      Questionnaire instruments are safe and effective. Several instruments have been fully validated, are widely used and well established. Their use is supported by both Class I (modified to the discipline of measurement) and Class II evidence.

      Strength of recommendation: Type A.
      Consensus Level: 1

    2. Screening Questionnaire

      Their use is safe and effective, supported by Class II and Ill evidence.

      Strength of recommendation: Type C.
      Consensus Level: 1

    3. Pressure Algometry

      Pressure algometry is safe and effective when contrasted with normative values for region and gender. It is a new procedure that is not yet in wide use but is promising. Its use is supported by Class II and Class III evidence.

      Strength of recommendation: Type B.
      Consensus Level: 1


    Functional Measurements

    1. Measurement of Position/Clinical Anthropometry (Posture)
      1. Plumbline Analysis

        Plumbline analysis is safe and effective when used to assess upright posture. It can be administered by persons with minimal training but should be interpreted by a professional health-care provider. The procedure is widely used, established and supported by both Class II and Class III evidence.

        Strength of recommendation: Type B.
        Consensus Level:1

      2. Scoliometry

        Scoliometry is safe and effective and can be administered by persons with minimal training but should be interpreted by a professional health care provider. The procedure is well established and supported by both Class I and Class II evidence.

        Strength of recommendation: Type A.
        Consensus Level: 1

      3. Photogrammetry Methods

        Photogrammetry methods are safe and effective means to quantify topographical or structural anomaly and work postures. Training is necessary to avoid error sources and assure reliability of measures. The procedures are well established and supported by evidence in Classes I, II and III.

        Strength of recommendation: Type A.
        Consensus Level: 1

      4. Moire Topography

        Moire topography is safe and can be administered by persons with minimal training but requires oversight on technical procedures. It is of limited effectiveness. The procedure is promising only as a qualitative screening method supported by Class II and Class III evidence.

        Strength of recommendation: Type B.
        Consensus Level: 1

      5. Bilateral Weight Distribution

        Bilateral weight scales are safe but their effectiveness is unknown and is rated as equivocal. Class II and III evidence is available.

        Strength of recommendation: Type C.
        Consensus Level: 1

      6. Automated Measurements of Posture

        Automated methods have received limited acceptance and are rated as promising. They are safe to administer but their effectiveness is limited by the training and practice of the operator. Fundamental difficulty in landmark identification and limited information on reliability restricts the use to screening purposes. Their use is supported by Class II and Class III evidence.

        Strength of recommendation: Type B.
        Consensus Level: 1

    2. Measurement of Movement
      1. Goniometers

        Goniometers are widely used, safe and effective. They are established to measure peripheral joint motion although the margin of error remains high. Class I and Class II evidence supports their use.

        Strength of recommendation: Type A.
        Consensus Level: 1

      2. Inclinometers

        Inclinometers are established for measurements of spinal motion. Their common use is supported by Class I and Class II evidence and is safe and effective.

        Strength of recommendation: Type A.
        Consensus Level: 1

      3. Optically Based Systems

        Optically based systems are established for evaluating specific gait abnormalities or risky positions related to work tasks. They are safe and effective when evaluated by specially trained personnel and are supported by Class II evidence.

        Strength of recommendation: Type B.
        Consensus Level: 1

      4. Computer Assisted Range of Motion Systems

        Computer assisted range of motion systems provide improved levels of precision and reproducibility. They are safe, effective and non-invasive. They require specialized training and should be interpreted by a qualified health care provider. Clinical applications are promising. Class II and III evidence is available.

        Strength of recommendation: Type B.
        Consensus Level: 1

    3. Measurement of Strength
      1. Manual Strength Testing

      2. Manual strength testing is widely used, safe and largely ineffective for strength differences less than 35%. Hand held load cells may assist in finding smaller differences in extremity muscle strengths. It is established as a screening procedure and is supported by Class I and Class II data.

        Strength of recommendation: Type A.
        Consensus Level: 1

      3. Isometric Strength Testing

        Isometric strength testing is an established procedure that is effective for limited applications involving employment evaluation and post-injury assessment where relevant standards can be determined. The methods are safe when performed by trained personnel who can make appropriate clinical judgments with respect to patient limitations during the procedure and when contraindications are observed. Class I and Class II data are available.

        Strength of recommendation: Type A.
        Consensus Level: 1

      4. Isokinetic Strength Testing

        Isokinetic strength testing is widely used, safe for non-acute disorders and effective for making bilateral comparisons or contrasting performance to normative data. The procedures are well established in sports applications and promising for post-injury use after the acute phase of treatment has passed. Class II and Class III evidence supports its use.

        Strength of recommendation: Type B.
        Consensus Level: 1

      5. Isoinertial Strength Testing

        Isoinertial strength testing is a promising procedure for employment selection and post-injury applications. It is safe for non-acute disorders when carried out by trained personnel. Class II and Class III evidence has been reported.

        Strength of recommendation: Type C.
        Consensus Level: 1


    Physiologic Measurements

    1. Thermographic Recordings
      1. Thermocouple Devices

        Thermocouple devices are still in use. While they are safe, there is no evidence to support a claim of effectiveness. Their use is rated doubtful and is supported by Class II and Class III evidence.

        Strength of recommendation: Type D.
        Consensus Level: 3

      2. Infrared Thermography

        Infrared thermography is a safe procedure of intense controversial effectiveness. Its use requires specially trained personnel and specially adapted surroundings. Its rating as equivocal/promising is supported by continuing controversy from Class II and Class III evidence.

        Strength of recommendation: Type C because of the controversy.
        Consensus Level: 3

    2. Galvanic Skin Response

      These types of measurement are safe, but generally ineffective as a result of questions remaining on reliability and validity from Class II and Class III types of evidence. For general arousal studies they are considered investigational.

      Strength of recommendation: Type D.
      Consensus Level: 1

      For acupuncture point finding and for assessing spine-related disorders, they are considered as doubtful.

      Strength of recommendation: Type E.
      Consensus Level: 1

    3. Electrophysiologic Recordings

      All of the electrodiagnostic methods are safe when carried out by specially trained personnel. Interpretation should be carried out only by physicians with extensive training in the technical and clinical considerations that can readily confound the findings.

      1. Kinesiologic Surface (Scanning) EMG

        Kinesiologic surface (scanning) EMG is a rapidly proliferating, safe procedure that has not been shown effective with the exception of limited use for flexion/relaxation and mean/ median frequency shifting measures. Generally, its use remains investigational. Specific procedures of flexion/relaxation and mean/median frequency shift evaluation are considered promising based on Class II and Class III evidence.

        Strength of recommendation - scanning surface
        EMG: Type C.
        Consensus Level: 2

        Strength of recommendation - flexion/relaxation and mean/median frequency shift measures: Type B.
        Consensus Level: 1

      2. Surface Electrodiagnostic Procedures (NCV, F-wave, H-Reflex, SSEP)

        Surface electrodiagnostic procedures (NCV, F-wave, H-reflex, SSEP) are established procedures effective for examination of peripheral nerve disorders and are supported by Class I and Class II evidence. Somatosensory evoked potentials are established for limited applications to peripheral nerve disorders and lesions affecting the long sensory tracks of the spinal cord.

        Strength of recommendation: Type A.
        Consensus Level: 1

      3. Needle Electrodiagnostic Procedures (EMG, NCV, F-wave, H-reflex, SSEP)

        Needle electrodiagnostic procedures (EMG, NCV, F-wave, H-reflex, SSEP) are widely used, established procedures that are affective in assessing functional effects of pathology affecting the central and peripheral nervous system and muscle. Class I and Class II evidence is available.

        Strength of recommendation: Type A.
        Consensus Level: 1

      4. Electrocardiography

        ECG is a widely used, safe, effective and established procedure for aiding in the differential diagnosis of complaints that may be cardiopulmonary in origin. Interpretation requires specialized training. Class I and Class II evidence is available.

        Strength of recommendation: Type A.
        Consensus Level: 1

    4. Procedures

      Clinical laboratory testing is an established approach that is widely used, safe and effective when used in differential diagnosis. Test procedures require appropriate technical instrumentation operated by specially trained and certified staff as determined by law. Equipment must be kept calibrated and standardized. Quality assurance procedures must be followed to ensure accuracy and reliability. Class I, II and III evidence is available.

      Strength of recommendation: Type A.
      Consensus Level: I

    5. Other Instrument Measures
      1. Doppler Ultrasound

        Doppler measures are well established, safe and effective as means to quantify the presence of vascular disease. Special training is necessary and a trained health care provider should interpret results. Both Class II and Class III data are available.

        Strength of recommendation: Type B.
        Consensus Level: 1

      2. Plethysmography

        Plethysmography is used on occasion. It is safe and effective when tissue volume changes and a symptom or peripheral vascular differential diagnosis is needed. Use for these purposes is well established. Special training is necessary and a trained health care provider should interpret results. Its effectiveness as a monitor of treatment of spine disorders is not determined and use for this purpose should be considered investigational. Class II and Class III data are available.

        Strength of recommendation - differential diagnosis: Type B.
        Consensus Level: 1

        Strength of recommendation - monitor spine disorders: Type D.
        Consensus Level: 1

      3. Spirometry

        Pulmonary function testing is established as a method to assess effect of severe scoliosis and the differential diagnosis of lung disease. These uses are backed by Class I and Class II evidence. The procedures are safe and effective when performed by appropriately trained personnel.

        Strength of recommendation: Type A.
        Consensus Level: 1



  4. Clinical Laboratory:

    1. General
      1. The Role of Laboratory Procedures in Chiropractic Practice

        The appropriate use of clinical laboratory procedures in chiropractic practice is for diagnosis, screening, and patient management.

        Comment: Clinical laboratory tests are used by the practitioner to (1) aid in the diagnostic process; (2) screen for early recognition of preventable health problems; and (3) monitor patient progress and outcomes. It is inappropriate to utilize clinical laboratory procedures for other purposes (e.g., for defensive testing or economic gain).

        Rating: Established
        Evidence: Class III
        Consensus Level: 1

      2. Laboratory Selection

        It is recommended that the practitioner who uses the services of a clinical laboratory should be aware of the laboratory’s scope of services, recognition (licensure and accreditation), and reputation.

        Rating: Established
        Evidence: Class III
        Consensus Level: 1

      3. Office Laboratories

        The practitioner who performs office laboratory procedures should carry out testing in a manner that meets state and/or federal regulations, and is consistent with quality laboratory practice.

        Comment: State and federal regulations define the scope of testing, qualification of laboratory personnel, and the need and extent of quality assurance and proficiency testing.

        Rating: Established
        Evidence: Class III
        Consensus Level: 1

      4. Proper Patient Preparation

        The practitioner should make sure the patient is adequately prepared for laboratory testing, verifying that the patient understands any special instructions to assure adequate specimens necessary to generate valid laboratory results.

        Rating: Established
        Evidence: Class III
        Consensus Level: 1

      5. Specimen Collection and Preservation

        The practitioner should assure that in-office laboratory specimens are appropriately collected and preserved.

        Rating: Established
        Evidence: Class III
        Consensus Level: 1

      6. The Need for Laboratory Testing

        Laboratory procedures may be appropriate when the information available from the history, clinical examination, and previous evaluation is considered insufficient to address the clinical questions at hand.

        Comment: The decision to order and/or perform a given test or procedure is made on the assumption that the results will appreciably reduce the uncertainty surrounding a given clinical question and significantly change the pre-test probability that the disorder is present.

        Rating: Established
        Evidence: Class I, II, III
        Consensus Level: 1

      7. Laboratory Test Selection in Diagnosis

        The practitioner should select a laboratory test(s) appropriate for the purpose of ruling out a specific condition(s) or confirming a strong clinical suspicion by considering the sensitivity and specificity of the test(s) and estimating the likelihood of the condition(s) (pretest probability) based on his or her assessment of the available clinical information.

        Rating: Promising
        Evidence: Class I, II, III
        Consensus Level: 1

      8. Laboratory Test Selection in Screening

        The use of laboratory tests for screening purposes should include selection of a highly sensitive laboratory test(s) and the appropriate application of the test(s) to health problem(s) which are common, have significant morbidity/mortality and are preventable and/or amenable to effective care.

        Rating: Established
        Evidence: Class I, II, III
        Consensus Level: 1

      9. Laboratory Test Selection in Patient Management (Monitoring)

        The reproducibility (precision) of the test is the most important characteristic when selecting laboratory tests for monitoring.

        Comment: The optimal frequency for monitoring patients cannot be predicted solely on the basis of knowledge of the disorder or the effectiveness of chiropractic care. It requires the application of normal physiology, knowledge of the natural history of the underlying disorder, tests or procedures used to monitor the disorder and awareness of factors other than the disorder that may influence the test results.

        Rating: Established
        Evidence: Class I, II, III
        Consensus Level: 1

      10. Interpretation of Laboratory Reference Values

        The practitioner should have an understanding of "normality" as it applies to conventional laboratory reference values in order to appropriately interpret laboratory results.

        Rating: Established
        Evidence: Class I, II, III
        Consensus Level: 1

      11. Integration of Clinical Laboratory Data with Other Examination Findings

        Clinical laboratory data should be integrated with results from other examinations as part of the clinical decision-making process when monitoring the patient’s clinical status.

        Rating: Established
        Evidence: Class I, II, III
        Consensus Level: 1

      12. Communication of Laboratory Procedures and Results to the Patient

        The practitioner should effectively discuss with the patient the purposes, possible complications, and clinical significance of the results of laboratory studies conducted or ordered.

        Rating: Established
        Evidence: Class III
        Consensus Level: 1

      13. Recording Laboratory Results:

        Clinical laboratory results should be recorded in the patient case record.

        Rating: Established
        Evidence: Class III
        Consensus Level: 1

      14. Consultation on Laboratory Procedures

        The practitioner should seek assistance when uncertain about appropriate test selection, patient preparation, and/or interpretation of laboratory results.

        Rating: Established
        Evidence: Class III
        Consensus Level: 1

      15. Use of Focused Organ/Health Problem-Oriented Test Profiles

        The use of profiles which focus on an organ system and/or health problem in a symptomatic patient can be considered a cost-effective and efficient procedure for generating appropriate laboratory data to help confirm or rule out a diagnosis or clinical impression.

        Rating: Established
        Evidence: Class I, II, III
        Consensus Level: 1

      16. Use of Investigational Laboratory Tests

        Laboratory tests which are considered to be investigational should be used in clinical settings only when part of an acceptable research protocol which is supervised by the staff of a recognized research institution.

        Comments: Research protocols for the evaluation of investigational clinical laboratory tests should take into consideration the actual need for the tests, the inherent properties of the tests, the population characteristics to which the tests are applied, the existence of gold standard tests, the required study population size, and the tests’ discrimination abilities relative to sensitivity, specificity, and predictive value (Adams, 1990). Research protocols should be approved by an institutional review board.

        Rating: Established
        Evidence: Class I, II, III
        Consensus Level: 1

      17. The Novel Application of Established Laboratory Procedures in Chiropractic Practice

        Novel application of established laboratory procedures should not be used in chiropractic practice as a substitute for conventional application of laboratory procedures in the clinical decision-making process.

        Comment: Novel applications of established tests should be evaluated by appropriate research methods. If used in a patient care setting, informed consent is necessary.

        Rating: Established
        Evidence: Class I, II, III
        Consensus Level: 1

    2. Guidelines for Ordering Commonly Utilized Laboratory Procedures
      1. Guidelines for Ordering a Urinalysis

        1. Outpatient Screening/Case-Finding

          i. A urinalysis is not indicated in asymptomatic individuals whose history and physical examination findings are within the normal ranges for age and sex.

          ii. In specific subsets of the population with higher prevalence of renal disease, urinary tract infections, liver disease, and diabetes mellitus, the urinalysis may be useful to identify those who are significantly at risk, including but not limited to the following:

          • Pregnancy
          • Elderly (> 60 years) men and women
          • Obese individuals with a positive family history of diabetes mellitus
          • Individuals taking hepato- or nephrotoxic drugs
          • Individuals routinely exposed to toxic chemicals in the work or home environment
        2. Diagnosis

          i. The urinalysis is indicated in patients where there are clinical findings suggestive of urinary tract infections, renal disease, diabetes mellitus, and liver disease. The urinalysis should include physical, chemical, and microscopic evaluation.

          ii. The urinalysis may be useful in patients with previous positive findings for proteinuria, microhematuria, bacteriuria, pyuria, or diabetes mellitus.

        3. Monitoring

          i. Repeat urinalysis is not indicated in patients in whom no abnormality is suspected.

          ii. Repeat urinalysis may be useful in the following:

          • Documenting evidence of response to treatment for urinary tract infections, renal disease, and diabetes mellitus
          • Patients in whom there is concern that treatment has not been effective
          • Patients taking medications which are hepato- or nephrotoxic
          • Individuals routinely exposed to toxic chemicals
          • Pregnancy
          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      2. Guidelines for Ordering a Complete Blood Count (CBC)

        1. Outpatient Screening/Case-Finding

          i. CBCs are not indicated in asymptomatic individuals whose history and physical examination findings are within reference for age and sex.’

          • Routine use of CBCs in populations of low disease prevalence have a low diagnostic yield

          ii. In specific subsets of the population with higher prevalence of anemia, the CBC may be useful to identify those who are significantly anemic because of poor nutrition or undiagnosed chronic illness, including but not limited to the following:

          • Pregnant women in whom there is a suspicion that iron supplementation or nutrition has not been adequate
          • The elderly (>75 years old)
          • Recent immigrants from Third World countries, especially persons at increased risk of malnourishment
          • Individuals on diets which are nutritionally unbalanced
        2. Diagnosis of Suspected Abnormality

          i. The CBC is useful in the diagnosis of infection or primary hematological disorders.

          • The CBC is indicated in patients in whom there are clinical findings suggestive of anemia, including fatigue, mucous-membrane pallor, sore tongue, peripheral neuropathy, abnormal bleeding, or findings suggestive of polycythemia

          ii. The CBC may be useful in conditions that may be associated with anemia and/or abnormal leukocyte counts, such as rheumatoid arthritis, malignancy (e.g., lymphoma)and renal insufficiency.

          iii. The CBC may be useful when fever is present or when infection is suspected, especially when other confirmatory findings are absent.

        3. Monitoring

          i. Repeat CBCs are not indicated in patients in whom no abnormality is suspected.

          ii. Repeat CBCs may be useful in the following:

          • Patients in whom there is concern that treatment has not been effective
          • Documenting evidence of response to treatment for anemia
          • Patients with infection not improving clinically under collaborative care
          • Patients with leukopenia (leukocyte count is less than 4,500/j.d)
          • Patients taking cytotoxic medications
          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      3. Guidelines for Ordering the Erythrocyte Sedimentation Rate (ESR) Test

        1. Outpatient Screening/Case-Finding

          i. The ESR is not indicated in asymptomatic persons.

          ii. An ESR should be ordered/performed selectively and interpreted with caution in patients whose symptoms are not adequately explained by a careful history and physical examination.

          • Significant infections or inflammatory or neoplastic disease are unlikely in such patients, and the ESR must be markedly elevated to be diagnostically useful.

          • Extreme elevation of the ESR seldom occurs in patients with no evidence of serious disease.

        2. Diagnosis

          i. The ESR is useful for the diagnosis of temporal arteritis (giant cell arteritis) and polymyalgia rheumatica.

          • A normal ESR virtually excludes the diagnosis of temporal arteritis in most patients who are suspected of having the disease.

          • When there is strong clinical evidence for temporal arteritis and the ESR is normal, further efforts to diagnose temporal arteritis are required.

          ii. A careful history and physical examination are the most reliable means of making a diagnosis of rheumatoid arthritis. In patients with an equivocal examination, an ESR may be indicated and an abnormal result is a clue to the presence of this disease.

          iii. The ESR may be indicated in the differential diagnosis of solitary bone lesions.

          iv. The ESR may be indicated in the diagnosis of metastatic breast cancer.

          v. The ESR may be indicated as a means of excluding suspected vertebral osteomyelitis.

          vi. The ESR may assist in the differential diagnosis of certain infectious, inflammatory, and malignant disorders.

          vii. The ESR may provide assistance in distinguishing spinal pain of organic origin from mechanical origin.

        3. Monitoring

          i. The ESR is useful for monitoring temporal arteritis and polymyalgia rheumatica.

          ii. The judicious use of the ESR combined with other clinical and laboratory observations may be of value in patients with rheumatoid arthritis and systemic lupus erythematosus.

          iii. The ESR may be indicated for monitoring patients with Hodgkin’s disease.

          iv. The ESR may be indicated for monitoring patients with acute rheumatic fever.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      4. Guidelines for Ordering Biochemical Profiles

        1. Outpatient Screening/Case-Finding

          i. Biochemical profiles are not routinely indicated for screening asymptomatic patients.

          ii. Selected components of biochemical profiles may be indicated for screening and/or case-finding in adults: serum glucose, cholesterol and creatinine.

          iii. Specific components of biochemical profiles that are not indicated for screening include the following: serum calcium, alkaline phosphatase, uric acid, sodium, potassium, chloride, AST, lactic dehydrogenase (LDH), total protein, albumin, and total bilirubin.

          iv. In cases where current technology and/or cost prohibit selective test ordering, biochemical profiles should be used with caution because of a greater likelihood of false-positive findings in low disease-prevalent populations.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      5. Guidelines for Ordering a Serum or Plasma Glucose Test.

        1. Outpatient Screening/Case-Finding

          i. A serum or plasma glucose test is not routinely indicated to screen for diabetes mellitus in asymptomatic, nonpregnant adults.

          ii. A serum or plasma glucose test may be indicated in individuals who are at increased risk for diabetes mellitus.

          • Risk factors for diabetes mellitus include age (>50 years), family history in a first degree relative, personal history of gestational diabetes, body weight that exceeds generally accepted standards by at least 25 percent, or membership in an ethnic group that has a high prevalence of diabetes.

          iii. A serum or plasma glucose test is recommended for all pregnant women to screen for gestational diabetes.

          • A serum or plasma glucose test obtained after a 50-gram glucose load is the preferred screening procedure.

        2. Diagnosis

          i. A fasting or random plasma glucose measurement is useful for the diagnosis of diabetes mellitus in persons who present with symptoms of hyperglycemia (rapid weight loss, polyuria, polydipsia) and/or diabetes (for example, peripheral neuropathy or peripheral vascular disease).

          • An oral glucose tolerance test may be indicated to confirm equivocal tests.

          ii. In patients with clinical findings of hypoglycemia, a serum or plasma glucose should be ordered.

          • The true hypoglycemia syndrome refers to the presence of adrenergic (sweating, tremor, tachycardia, anxiety, and hunger) or neuroglycopenic (dizziness, headache, clouded vision, blunted mental acuity, confusion, abnormal behavior, coma) signs and symptoms in the presence of a low serum or plasma glucose concentration.

        3. Monitoring

          i. A plasma or serum glucose test is not optimal as the primary modality for monitoring glycemia in insulin-dependent (Type I) diabetic patients with diabetes.

          • Daily self-monitored blood glucose measurement, along with periodic (3-4 times per year) measurement of glycated hemoglobin (glycosylated hemoglobin) are appropriate monitoring evaluations

          ii. In non-insulin dependent (Type II) diabetes, laboratory performed plasma or serum glucose testing may be indicated every three months.

          • Self-monitored blood glucose measurement may be indicated one or two times per day to assess glycemia

          • Glycated hemoglobin measurements are indicated at least two times per year to provide an index of mean glucose levels as a measure of overall chronic glucose control

          iii. Laboratory performed fasting and postprandial plasma glucose measurements are indicated in diet-treated gestational diabetes every one to two weeks from time of diagnosis until 30 weeks’ gestation, and once or twice weekly thereafter.

        Rating: Established
        Evidence: Class I, II, III
        Consensus Level: 1

      6. Guidelines for Ordering Serum Urea Nitrogen and Creatinine Test

        1. Outpatient Screening/Case-Finding

          i. Serum urea nitrogen and creatinine tests are not indicated in asymptomatic individuals whose history and physical examination findings are within reference ranges.

          ii. Individuals who have a higher likelihood of developing renal dysfunction may benefit from measuring serum urea nitrogen and creatinine concentrations

          • Patients with hypertension, diabetes mellitus, congestive heart failure, cirrhosis, prostatic hypertrophy, exposure to nephrotoxic agents, taking diuretics, eating a high-protein diet, and over 75 years of age, are candidates for these tests.

        2. Diagnosis

          i. Serum urea nitrogen and creatinine tests are useful in the diagnosis of renal disorders.

          • These tests are indicated in patients with clinical findings suggestive of renal dysfunction, such as pallor, anemia, anorexia, unexplained weight loss, polyuria, urinary hesitancy, nocturia, renal colic, dehydration, retinopathy, hypertension, skin lesions of vasculitis, and/or an abnormal urinalysis (high specific gravity, proteinuria, hematuria, pyuria, presence of crystals and/or casts).

          ii. Measuring serum urea nitrogen and creatinine concentration, or creatinine alone, may be useful in hypertension or diabetes patients.

          iii. Conditions in which both the serum urea nitrogen and creatinine concentration may be indicated include but are not limited to the following:

          • Gastrointestinal bleeding, complicated by some degree of renal insufficiency
          • A suspected diagnosis of water intoxication
          • Syndrome of inappropriate antidiuretic hormone secretion
        3. Monitoring

          i. Measuring serum urea nitrogen and serum creatinine concentration, or creatinine alone, may be useful for the following conditions and at the following frequencies:

          • Uncomplicated hypertensive patients, every one to two years
          • Chronic renal disease, every four to six months
          • Patients in acute renal failure, every one to two days
          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      7. Guidelines for Ordering a Serum Calcium Test

        1. Outpatient Screening/Case-Finding

          i. The serum calcium test is not indicated in asymptomatic individuals whose history and physical examination findings are within reference limits for age and sex.

          ii. The use of serum calcium as a screening test for occult metabolic bone disease or malignancy will result in a low diagnostic yield.

          • For most of these conditions, the post-test probability of disease after abnormal calcium results is not sufficiently high to warrant the inclusion of calcium determinations in a screening profile.

        2. Diagnosis

          i. The serum calcium test is useful in the evaluation of patients who present with clinical evidence of hypercalcemia (anorexia, nausea, constipation, polyuria, polydipsia, bone pain, and mental or neurologic aberrations) or hypocalcemia (paresthesias, muscle cramps, tetany, weakness, convulsions).

          ii. The serum calcium test may be useful in the evaluation of patients with hypertension, renal calculi, peptic ulcer disease, metabolic bone disease, malignant disorders, history of previous neck surgery, alcoholism, and acid-base imbalance.

        3. Monitoring

          i. Repeat serum calcium measurement is not indicated in patients in whom no abnormality is suspected.

          ii. Serum calcium may be used to follow the course of hypercalcemia and hypocalcemic disorders and their response to care.

          • A serum calcium level should be interpreted with knowledge of the serum albumin level

          Rating: Established
          Evidence: Class II, III
          Consensus Level: 1

      8. Guidelines for Ordering a Serum Inorganic Phosphorus Test

        1. Outpatient Screening/Case-Finding

          i. The serum inorganic phosphorus test is not indicated in asymptomatic individuals whose history and physical examination findings are within reference limits for age and sex.

          ii. The use of serum inorganic phosphorus as a screening test for various malignant, inflammatory, bony, renal and metabolic disorders will result in a low diagnostic yield.

          • For most of these conditions, the post-test probability of disease after abnormal inorganic phosphorus results is not sufficiently high to warrant the inclusion of inorganic phosphorus determinations in a screening profile.

        2. Diagnosis

          i. The serum inorganic phosphorus test is useful in the evaluation of patients suspected of having metabolic bone disease, renal disorders, endocrime disorders, and acid-base imbalance.

        3. Monitoring

          i. Repeat serum inorganic phosphorus measurement is not indicated in patients in whom no abnormality is suspected.

          ii. Serum inorganic phosphorus may be used to follow the course of hyperphosphatemic and hypophosphatemic disorders and their response to care.

          • A serum inorganic phosphorus level should be interpreted with knowledge of the serum urea nitrogen level.

          Rating: Established
          Evidence: Class II, III
          Consensus Level: 1

      9. Guidelines for Ordering Serum Total Protein and Albumin Test

        1. Outpatient Screening/Case-Finding

          i. The serum total protein and albumin tests are not indicated in asymptomatic individuals whose history and physical examination findings are within reference limits for age and sex.

          ii. The use of serum total protein and albumin as screening tests for malnutrition, protein loss or breakdown, and impaired protein synthesis will result in a low diagnostic yield.

        2. Diagnosis

          i. The serum total protein and albumin tests may be useful in the evaluation of patients with suspected malnutrition, liver disorders, renal disease, malabsorption, recurrent infections, blood dyscrasias, and malignancies such as multiple myeloma.

          ii. Results which fall outside the reference range for these tests may require a protein electrophoresis determination and/or immunoelectrophoresis.

        3. Monitoring

          i. Repeat serum total protein and albumin measurements are not indicated in patients in whom no abnormality is suspected.

          ii. Serum total protein and albumin determinations have limited value in monitoring disorders associated with changes in serum protein levels.

          Rating: Established
          Evidence: Class II, III
          Consensus Level: 1

      10. Guidelines for Ordering a Serum Cholesterol Test

        1. Outpatient Screening/Case-Finding

          i. A total serum cholesterol measurement is recommended at least once in early adulthood and at intervals of five or more years up to age 70.

          • The LDL and HDL cholesterol and serum triglyceride levels should be measured in persons with an elevated total serum cholesterol.

          ii. In patients who demonstrate risk factors for coronary artery disese, a serum total cholesterol is indicated to assess cardiac risk.

          • Risk factors for coronary artery disease include: being male or postmenopausal female, positive family history, smoker, hypertension, history of hyper-cholesterolemia, low HDL-cholesterol levels, diabetes mellitus, previous stroke, peripheral vascular disease, or severe obesity.

        2. Diagnosis

          i. The total serum cholesterol is useful in the diagnosis of patients with coronary artery disease and peripheral vascular disease.

          ii. The total serum cholesterol may be useful in the diagnosis of nephrotic syndrome, pancreatitis, and liver disease.

        3. Monitoring

          i. Total serum cholesterol may be used to follow up hypercholesterolemic related disorders and their response to care.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      11. Guidelines for Ordering a Serum Alkaline Phosphatase Test

        1. Outpatient Screening/Case-Finding

          i. The serum alkaline phosphatase test is not indicated in asymptomatic individuals whose history and physical examination findings are within reference limits for age and sex.

          ii. The use of serum alkaline phosphatase as a screening test for unsuspected skeletal and hepatobiliary diseases provides a low diagnostic yield.

          • The pretest probability is low in the general population for those disorders most strongly associated with an elevated alkaline phosphatase.

          • The serum alkaline phosphatase test is not specific for any particular disorder or sensitive enough to identify most patients with any single disease.

        2. Diagnosis

          i. The serum alkaline phosphatase may be useful in the evaluation of patients who present with clinical evidence of a skeletal disorder with increased osteoblastic activity, and are suspected of having either Paget’s disease of bone (osteitis deformans), osteomalacia, primary bone tumors, metastatic bone tumors or primary hyperparathyroidism.

          • Clinical evidence may include backache, bone pain, bone swelling, abnormal plain film bone radiographs, and bone scans.

          ii. The serum alkaline phosphatase test may be useful in the evaluation of patients who present with clinical evidence of a hepatobiliary disorder such as cholelithiasis with obstruction, drug-induced cholestasis, metastatic tumor or space-occupying lesion in the liver, cirrhosis, hepatitis, and alcoholism.

          • Clinical evidence may include fever, nausea, vomiting, abdominal pain, jaundice, certain medication use, and abnormal liver function tests.

          iii. The serum alkaline phosphatase test may exhibit abnormal results in a number of other disorders.

          • These conditions include intestinal disorders, malignancy, malnutrition, congestive heart failure, renal disorders, thyroid dysfunction, diabetes mellitus, and physiological influences (age, pregnancy, non-fasting patient).

        3. Monitoring

          i. Repeat serum alkaline phosphatase measurement is not indicated in patients in whom no abnormality is suspected.

          ii. Periodic determinations of serum alkaline phosphatase may be used to follow the course of a disorder and its response to care.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      12. Guidelines for Ordering Serum Prostatic Acid Phosphatase

        1. Outpatient Screening/Case-Finding

          i. The serum prostatic acid phosphatase test is not indicated in asymptomatic individuals whose history and physical examination findings are within reference limits for age and sex.

          ii. The use of serum prostatic acid phosphatase as a screening test for unsuspected cancer of the prostate provides a low diagnostic yield.

          • Assays for serum prostatic acid phosphatase are not sufficiently sensitive to detect prostatic carcinoma in 70 to 80 percent of patients with localized disease (Stage A or B) or S to 15 percent of patients with metastatic prostatic disease.

          • Specificity is low because nearly every method devised for detecting prostatic acid phosphatase exhibits cross-reactivity with other acid phosphatase isoenzymes found widely in human tissues.

        2. Diagnosis

          i. The serum prostatic acid phosphatase test may be useful in the evaluation of patients with clinical evidence of prostatic carcinoma.

          • Patients may present with obstructive symptoms (hesitancy, diminished urine stream, dribbling, intermittency), lumbar and/or sacral pain, and have induration or nodular irregularities of the prostate discovered by digital rectal examination.

        3. Monitoring

          i. Repeat serum prostatic acid phosphatase measurement is not indicated in patients in whom no abnormality is suspected.

          ii. Serum prostatic acid phosphatase measurement may be used to monitor cancer patients for recurrence after prostatectomy or other ablative care.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      13. Guidelines for Ordering Serum Prostate-Specific Antigen (PSA)

        1. Outpatient Screening/Case-Finding

          i. The serum prostate-specific antigen (PSA) test is not indicated in asymptomatic individuals whose history and physical examination findings are within reference limits for age and sex.

          ii. The use of serum PSA as a screening test for unsuspected cancer of the prostate provides a low diagnostic yield.

          • Serum PSA measurements are not sufficiently sensitive to be used alone as a screening test.

          • The specificity of PSA is limited, due to elevations of the antigen occurring in men with benign prostatic hyperplasia or prostatitis.

        2. Diagnosis

          i. The serum prostate-specific antien is a useful test in the evaluation of patients with clinical evidence of prostatic carcinoma.

          • Serum PSA measurement is a useful addition to rectal examination and ultrasonography in the detection of prostate cancer.

          • PSA is more sensitive but less specific than prostatic acid phosphatase for prostatic cancer.

        3. Monitoring

          i. Repeat serum prostate-specific antigen measurement is not indicated in patients in whom no abnormality is suspected.

          ii. Serum PSA measurements may be useful to detect recurrences of prostate cancer.

          iii. Serum PSA measurements may be useful in monitoring the response to care for prostate cancer.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      14. Guidelines for Ordering a Serum Aspartate Aminotransferase (AST) Test

        NOTE: This test was formerly known as glutamic-oxaloacetic transaminase (SGOT).

        1. Outpatient Screening/Case-Finding

          i. The serum AST is not indicated in asymptomatic individuals whose history and physical examination findings are within reference limits for age and sex.

          ii. The use of serum AST as a sreening test for liver disorders, cardiac disease, and skeletal muscle disorders will result in a low diagnostic yield.

        2. Diagnosis

          i. The serum AST test may be useful in the evaluation of patients with suspected liver disorders.

        3. Monitoring

          i. Repeat serum AST measurement is not indicated in patients in whom no abnormality is suspected.

          ii. Serum AST may be used to follow the course of various liver disorders and their response to care.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      15. Guidelines for Ordering Serum Creatine Kinase (CK)

        NOTE: This test was formerly known as Creatine Phosphokinase (CPK).

        1. Outpatient Screening/Case-Finding

          i. The serum creatine kinase (CK) test is not indicated in asymptomatic individuals whose history and physical examination findings are within reference limits for age and sex.

          ii. The use of the serum creatine kinase (CK) as a screening test for cardiac, skeletal muscle, and central nervous system disorders will result in a low diagnostic yield.

        2. Diagnosis

          i. The serum creatine kinase (CK) test is useful in the evaluation of patients who present with clinical evidence of acute myocardial infarction.

          • Fractionation and measurement of CK isoenzymes (CK-MB primarily) augments total CK results.

          ii. The serum creatine kinase (CK) test may be useful in the differential diagnosis of chest pain, hypothyroidism and in the detection of skeletal muscle disorders that are not of neurogenic origin, such as Duchenne Muscular Dystrophy.

        3. Monitoring

          i. Measurement of serial levels of serum CK and CK-MB isoenzymes are used to monitor care in acute myocardial infarction.

          ii. Total serum CK may be used to follow patients with certain primary myopathies.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      16. Guidelines for Ordering Thyroid Function Tests

        1. Outpatient Screening/Case-Finding

          i. Routine testing for thyroid disorders is not indicated in asymptomatic individuals.

          ii. Case-finding is indicated in women over 50 years of age who have general symptoms that could be associated with thyroid dysfunction.

        2. Diagnosis

          i. The sensitive thyrotropin assay (sTSH) is useful in the evaluation of patients of either sex who present with clinical evidence of thyroid dysfunction.

          • If sTSH is not available, the Free T3, Free T4, or Free T4 Index can be used in the evaluation of suspected hyperthyroidism.

          • For the diagnosis of hypothyroidism, the Free T4 or Free T4 Index, followed by a serum thyrotropin (TSH) test, is acceptable. For patients suspected of having thyroiditis, antithyroid antibody studies may be useful.

        3. Monitoring

          i. The sTSH test is indicated for monitoring patient response to care.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      17. Guidelines for Ordering a Serum Uric Acid Test

        1. Outpatient Screening/Case-Finding

          i. The serum uric acid test is not indicated in asymptomatic individuals whose history and physical examination findings are within reference limits for age and sex.

          ii. The use of serum uric acid as a screening test for gout will provide a low diagnostic yield.

          • On the basis of established prevalences, if asymptomatic individuals were screened, those with an elevated uric acid have only a 5 percent chance of having gout

          iii. For case finding, with a pretest probability of 10 percent (prevalence of gout in the U.S. is estimated at 0.3%), the probability that a correct diagnosis will be derived from a positive test is less than 50%.

        2. Diagnosis

          i. The serum uric acid test is useful in the evaluation of patients who present with clinical evidence of monoarticular arthritis and are suspected of having gout.

            • Gout is a disorder of purine metabolism where the presence of an elevated serum uric acid level is but one of several criteria necessary for diagnosis.

            ii. The serum uric acid test may be elevated in a number of disorders other than gout which affect urate production or excretion, or both.

            • These conditions include: (1) increased nucleic acid turnover related to hematological disorders, malignancy and psoriasis; (2) reduced excretion due to renal dysfunction, certain drugs, and organic acidosis, and (3) miscellaneous causes such as arteriosclerosis and hypertension.

            iii. Serum uric acid measurement is not useful as a test for renal function because the reference range is wide and the rise in uric acid in renal dysfunction is not constant.

        3. Monitoring

          i. Repeat serum uric acid measurement is not indicated in patients in whom no abnormality is suspected.

          ii. Periodic determinations of serum uric acid may be useful in monitoring patients under care for gout.

          iii. Serial serum uric acid analyses are sometimes of value in estimating prognosis in toxemia of pregnancy.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      18. Guidelines for Ordering a Rheumatoid Factor Test

        1. Outpatient Screening/Case-Finding

          i. The rheumatoid factor test is not indicated in asymptomatic individuals whose history and physical examination findings are within reference ranges for age and sex.

          ii. The use of rheumatoid factor as a screening test for rheumatoid arthritis will result in a low diagnostic yield.

          • If the rheumatoid factor test is ordered when there is little likelihood of rheumatoid arthritis (e.g., low-back pain) and where the pretest probability is low (1 percent). the predictive value will be very low.

          iii. For case finding, with a pretest probability of 10 percent (prevalence of rheumatoid arthritis in the U.S. is estimated at 0.5% to 3%), the probability that a correct diagnosis will be derived from a positive test is less than 50%.

          iv. Many more false-positive results as compared to true-positive results will occur from screening.

          • There is less than a one in five chance in a screening program that an individual with a positive rheumatoid factor test will have rheumatoid arthritis.

        2. Diagnosis of Rheumatoid Arthritis and Related Disorders

          i. The rheumatoid factor test is useful in the evaluation of patients who present with clinical evidence of symmetric polyarthritis and are suspected of having rheumatoid arthritis.

          ii. Seronegative patients suspected of having rheumatoid arthritis should be retested in six months.

          iii. The usefulness of the rheumatoid factor test among patients already known to have rheumatoid arthritis is primarily prognostic. Patients with high titers of rheumatoid factor tend to have more severe disease, subcutaneous nodules, vasculitis, and poorer long-term prognosis. However, individual patients will vary with these manifestations.

          • Rheumatoid factor is positive in a significant subset of patients with other rheumatic and nonrheumatic diseases, but its presence or absence weighs little in the diagnosis of the majority of such diseases.

          • The disappearance of the rheumatoid factor in a patient with Sjogren’s syndrome may herald the onset of lymphoma.

          • The rheumatoid factor is frequently positive in cryoglobulinemia.

        3. Monitoring

          i. Repeat rheumatoid factor tests are not indicated in patients in whom rheumatoid arthritis is not suspected.

          ii. The use of the rheumatoid factor test to guide treatment in patients with rheumatoid arthritis is not recommended. There is little evidence to suggest that an individual rheumatoid arthritis patient with a highly positive rheumatoid factor test will fare better if treated earlier or more aggressively.

          iii. The rheumatoid factor test is not a generally accepted measure of improvement in rheumatoid arthritis.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      19. Guidelines for Ordering the Anti-Nuclear Antibody Test (ANA)

        1. Outpatient Screening/Case-Finding

          i. The ANA test is not indicated in asymptomatic individuals whose history and physical examination findings are within reference ranges for age and sex.

          ii. The use of the ANA as a screening test for systemic lupus erythematosus, drug-induced lupus, or mixed connective tissue disease where a moderate pretest probability is low will result in a low diagnostic yield.

        2. Diagnosis

          i. The ANA test is useful in the evaluation of patients suspected of having systemic lupus erythematosus, drug-induced lupus, or mixed connective tissue disease where a moderate pretest probability is estimated based on the clinical criteria present.

          ii. A positive test, while nonspecific, increases the post-test probability of disease.

          • A positive ANA test (titer> 1:40) should be followed up with more specific tests such as anti-nDNA and precipitating antibodies (against RNP, Sm, Ro/SS-A).

          • However, in a patient over 70 years of age, a titer of 1:40 may be insignificant, and repeat measurement should be obtained to see if the titer increases or is stable.

          iii. A negative ANA test result is extremely powerful in reducing the probability of these diseases.

          • In patients who have high probability of systemic lupus erythematosus based on clinical criteria but who have a negative antinuclear antibody assay, a determination for anti-Ro or antiphospholipid antibodies may be helpful.

        3. Monitoring

          i. Repeat measurements of antinuclear antibodies were not indicated in patients in whom connective tissue disease is not suspected.

          ii. The ANA test can be used as an aid in the assessment of systemic lupus erythematosus disease activity and as a guide for treatment.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      20. Guidelines for Ordering the HLA-B27 Test

        1. Outpatient Screening/Case-Finding

          i. The HLA-B27 test is not indicated in asymptomatic individuals whose history and physical examination findings are within reference ranges for age and sex.

          ii. The use of the HLA-B27 as a screening test for ankylosing spondylitis in patients presenting with low-back pain will result in a low diagnostic yield.

        2. Diagnosis

          i. The HLA-B27 test is not useful for confirmation of the diagnosis of spondyloarthropathies (e.g., ankylosing spondylitis and Reiter’s syndrome) when adequate clinical and radiologic criteria are present.

          ii. However, the HLA-B27 test may be useful in patients with low-back pain of insidious onset, minimal tenderness over the sacroiliac joints, normal spinal movement and chest expansion and equivocal radiographic findings where the pretest probability is close to 50 percent for ankylosing spondylitis.

          • A positive HLA-B27 test increases the likelihood of ankylosing spondylitis significantly and a negative result lowers the likelihood.

          iii. The HLA-B27 test may be useful in children with spondyloarthropathy, especially those with a history of juvenile chronic polyarthritis, to help establish the diagnosis of ankylosing spondylitis.

          iv. The HLA-B27 test may be useful in helping to differentiate incomplete Reiter’s syndrome from seronegative rheumatoid arthritis and gonococcal arthropathy.

        3. Monitoring

          i. The HLA-B27 test is not useful for monitoring spondyloarthropathies including the establishment of prognosis, genetic counseling, and patient management.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      21. Guidelines for Ordering the C-Reactive Protein (CRP) Test

        1. Outpatient Screening/Case Finding

          i. The CRP is not indicated in asymptomatic persons.

          ii. The CRP test should be used selectively and interpreted with caution in patients with symptoms that are not explained by a careful history and physical examination.

          • Significant infections or inflammatory or neoplastic disease is unlikely in such patients, and the CRP must be markedly elevated or positive to be diagnostically useful.

        2. Diagnosis

          i. Measurement of CRP by quantitative methods provides the most clinically useful information.

          ii. The CRP is useful for the diagnosis of temporal arteritis (giant cell arteritis) and polymyalgia rheumatica.

          iii. A CRP test may be indicated in patients suspected of rheumatoid arteritis where clinical examination findings are equivocal.

          iv. Measurement of CRP may be useful in the differential diagnosis of peripheral joint pain.

          v. The CRP may be indicated in the differential diagnosis of solitary bone lesions.

          vi. The CRP may be indicated in the diagnosis of metastatic breast cancer.

          vii. The CRP may be indicated as a means of excluding suspected vertebral osteomyelitis.

          viii. The CRP may assist in the differential diagnosis of certain infectious, inflammatory, and malignant disorders.

          ix. The CRP may provide assistance in distinguishing spinal pain of organic from mechanical origin.

        3. Monitoring

          i. Measurement of CRP by quantitative methods provides the most clinically useful information.

          ii. The CRP is indicated for monitoring temporal arteritis and polymyalgia rheumatica.

          iii. The judicious use of the CRP test combined with other clinical and laboratory observations may be of value in patients with rheumatoid arthritis and systemic lupus erythematosus.

          iv. The CRP may be indicated for monitoring patients with Hodgkin’s disease.

          v. The CRP may be indicated for monitoring patients with acute rheumatic fever.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      22. Guidelines for Ordering a Serum Potassium Test

        1. Outpatient Screening/Case-Finding

          i. A serum potassium test is not indicated in asymptomatic individuals whose history and physical examination are within reference limits for age and sex.

          ii. Measurement of serum potassium levels is not useful in general screening of ambulatory care patient populations.

        2. Diagnosis

          i. Serum potassium measurement is useful in patients with chronic renal disease, including diabetic renal insufficiency.

          ii. Serum potassium measurement is useful in patients with hypertension to detect primary hyper-aldosteronism.

          • Measurements should be made at time of diagnosis and before initiation of care.

          iii. Serum potassium measurement is useful in patients with symptoms or signs suggestive of renal tubular acidosis.

          iv. Serum potassium measurement is useful in patients with signs and symptoms suggestive of altered serum potassium concentration, including generalized or proximal weakness, new atrial tachyarrhythmias, nocturia, polyuria, or ileus.

        3. Monitoring

          i. Serum potassium measurement is indicated one to two times a year in patients with diabetic renal disease.

          ii. Serum potassium measurement is indicated in hypertensive patients receiving diuretic therapy.

          iii. Serum potassium measurement may be useful every six months in diuretic-treated patients concurrently receiving digitalis.

          iv. Serum potassium measurements may be useful in patients with renal dysfunction, cardiac arrhythmias, diarrhea, dehydration, and metabolic acidosis in whom there is a change in clinical status.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      23. Guidelines for Ordering a Serum Sodium Test

        1. Outpatient Screening

          i. A serum sodium test is not indicated in asymptomatic individuals whose history and physical examination are within reference limits for age and sex.

          ii. Measurement of serum sodium levels is not useful in general screening of ambulatory care patient populations.

        2. Diagnosis

          i. Serum sodium measurement may be indicated in patients with the following signs or symptoms:

          • Rapid change in weight
          • Rapid change in fluid balance (severe vomiting, diarrhea, polyuria)
          • Rapid change in mental status
          • Clinical evidence of dehydration or volume depletion

          ii. Serum sodium concentration is not indicated in hypertensive patients to identify primary aldosteronism.

        3. Monitoring

          i. Serum sodium measurement may be useful as an index of hydration, especially in elderly persons or others who may fail to ingest adequate quantities of water to maintain water balance.

          ii. Serum sodium measurement may be useful in patients with chronic renal insufficiency at the following frequencies:

          • At the time of change in clinical status
          • When serum creatinine reaches 7 to 8 mg/dL; thereafter, every two to three months

          iii. Serum sodium measurement may be indicated in most patients at the time of change in clinical status, especially change in mental or neurologic status, fluid balance, weight, or dehydration or volume depletion.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      24. Guidelines for Ordering Serum Iron and Total Iron Binding Capacity (TIBC) Tests

        1. Outpatient Screening/Case-Finding

          i. The serum iron and total iron binding capacity (TIBC) tests are not indicated in asymptomatic individuals whose history and physical examination findings are within reference limits for age and sex.

          ii. In individuals with a moderate to high pretest probability of iron deficiency (e.g., pregnant women, premenopausal female with hemorrhagia, premature infants, and the malnourished) a serum iron and TIBC may be useful.

          iii. Measurement of serum iron and TIBC may be useful in screening for iron overload.

        2. Diagnosis

          i. Measurement of serum iron and TIBC are useful in patients whose complete blood count results are consistent with a microcytic hypochromic anemia.

          • Calculation of transferrin saturation from the serum iron and TIBC may provide additional diagnostic information.

          ii. Patients who present with clinical features of iron deficiency may benefit from measurement of serum iron and TIBC tests.

          iii. Serum iron and TIBC measurements may be useful in the differential diagnosis of microcytic hypochromic anemias.

          iv. Measurement of serum iron and TIBC may be useful in the confirmation of iron overload.

        3. Monitoring

          i. Measurement of serum iron and TIBC have limited value in monitoring the management of patients with iron deficiency anemia.

          ii. A complete blood count (CBC) and an absolute reticulocyte count are useful tests to monitor the management of iron-deficiency anemia.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      25. Guidelines for Ordering a Fecal Occult Blood Test

        1. Outpatient Screening/Case-Finding

          i. Screening with fecal occult blood tests is not indicated for asymptomatic patients under 40 years of age.

          ii. For persons 40 years and older who have familial polyposis coli, inflammatory bowel disease, or a history of colon cancer in a first-degree relative, screening with fecal occult blood tests is recommended annually.

          • Due to the nature of gastrointestinal bleeding, it is recommended that three consecutive samples be obtained.

          • Screening for colorectal cancer with air-contrast barium enema or colonoscopy in addition to annual fecal occult blood tests is recommended every 3 to 5 years.

          iii. Screening with fecal occult blood tests is recommended annually for persons 50 years of age and older.

          iv. Every 3 to 5 years, in addition to the annual fecal occult blood test, a sigmoidoscopic examination should be performed.

        2. Diagnosis

          i. Patients with significant colorectal symptoms (abdominal pain, localized tenderness, diarrhea or constipation, gastrointestinal bleeding) should have a fecal occult blood test performed as part of a colorectal examination.

          ii. A fecal occult blood test result should be interpreted with caution.

          • The influence of diet and nutritional supplements (Vitamin C and iron) should be considered as possible causes of false-positive and false-negative results.

          • Further evaluation of patients with a positive occult blood test may include an air contrast barium enema plus colonoscopy.

          Rating: Established
          Evidence: Class II, III
          Consensus Level: 1

      26. Guidelines for Ordering a Serum Ferritin Test

        1. Outpatient Screening/Case-Finding

          i. The serum ferritin test is not indicated in asymptomatic individuals whose history and physical examination findings are within reference limits for age and sex.

          ii. In individuals with a moderate to high pretest probability of iron deficiency and with CBC and serum iron/TIBC levels within reference ranges, the serum ferritin test may be useful in detecting the early stages of iron depletion.

        2. Diagnosis

          i. Measurement of serum ferritin is useful in anemic patients who are suspected of having iron depletion but have equivocal serum iron and TIBC test results.

          ii. Serum ferritin measurements may be useful in the differentiation of anemia of chronic disease from iron deficiency anemia.

          • A CRP determination should be performed along with serum ferritin to identify possible effects of chronic disease state on ferritin results.

          iii. Measurement of serum ferritin may be useful in the detection of iron overload.

        3. Monitoring

          i. Serum ferritin measurement may be useful in the determination of the end-point to oral iron therapy.

          ii. Measurement of serum ferritin may be useful in monitoring iron status of patients with chronic renal disease.

          iii. Serum ferritin measurement may be useful in monitoring the rate of iron accumulation in iron overload.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

    3. Investigational Clinical Laboratory Procedures
      1. Analysis of Trace Minerals in Hair

        1. Outpatient Screening/Case Finding

          i. Hair analysis is not indicated for screening of nutritional status in asymptomatic individuals.

          ii. In specific subsets of the population who are at risk for nutritional imbalances, the use of hair analysis has not been found to be superior to traditional methods of assessing nutritional status.

        2. Diagnosis

          i. Hair analysis for trace minerals is not indicated in the determination of nutritional imbalances.

          • Measurement of some elements (e.g., iron) have not been found to be superior to traditional methods of assessment.

          ii. Hair analysis suffers from many problems with interpretation of results

          • Hair mineral content can be affected by shampoo, bleaches, hair dyes and other environmental factors.

          • The level of certain minerals can be affected by color, diameter, rate of growth of an individual’s hair and the season of the year.

          • Most commercial hair analysis laboratories have not validated their analytical techniques.

          • Reference ranges for hair minerals have not been adequately established.

          • For most elements no correlation has been established between hair levels and other known indicators of nutritional status.

          iii. Hair analysis may be useful in experimental studies of nutritional status.

          • More human and animal studies are needed to validate this technique.

        3. Monitoring

          i. Repeat hair analysis for trace minerals is not indicated.

          ii. The beneficial effects of nutritional therapy based on hair analysis have not been adequately documented.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      2. Live Cell Analysis

        1. Outpatient Screening/Case Finding

          i. Live cell analysis is not indicated for screening health problems including nutritional imbalances in asymptomatic patients.

          ii. In specific subsets of the population who are "at risk" for various health problems, the use of live cell analysis has not been found to be superior to traditional laboratory procedures utilized in case finding.

        2. Diagnosis

          i. Live cell analysis is not indicated in the determination of organ pathologies, infections, immune status or nutritional status.

          • Blood indicators which live cell analysis claims are useful in diagnosing health problems have not been validated by adequate scientific studies

          ii. Additional studies on the use of dark field microscopy for various diagnoses are needed.

        3. Monitoring

          i. Repeat live cell analysis for various health conditions is not indicated.

          ii. The beneficial effects of patient care based on live cell analysis results have not been adequately documented.

          Rating: Investigational
          Evidence: Class I, II, III
          Consensus Level: 1

      3. Biochemical Biopsy: (Multiple Test Analysis Including Protein Electrophoresis and Isoenzyme Fractionation with Predictive Interpretation of Results)

        Biochemical biopsy utilizes a comprehensive approach to laboratory testing where a multitest biochemical test profile is ordered along with isoenzyme fractionation of common enzymes and a serum protein electrophoresis. It may also include other serum protein analyses and complete blood count. The rationale behind the use of this approach is detection of early pathologies in the subclinical phase.

        1. Outpatient Screening/Case Finding

          i. Biochemical biopsy is not indicated for screening of health problems in asymptomatic patients.

          ii. This approach has not met the criteria as an effective screening procedure. The biochemical biopsy may not be sensitive enough to detect early pathology and is indiscriminate as is currently applied to patients with health problems that don’t fit the criteria for screening.

          • This approach increases the probability of test results being outside the reference range and generates a significant number of false-positive results which leads the clinician to follow up on these laboratory abnormalities.

          iii. Additional research is needed to determine the validity of this approach.

        2. Diagnosis

          i. The biochemical biopsy approach to testing is not useful for diagnosis of specific health problems and/or vague multisystem patient complaints.

          ii. The role of the biochemical biopsy as an aid to diagnosis requires further scientific investigation.

        3. Monitoring

          i. Repeat determinations of the laboratory tests in the biochemical biopsy is not indicated.

          ii. The beneficial effects of the biochemical biopsy approach to testing on patient management and health outcomes has not been documented.

          Rating: Investigational
          Evidence: Class I, II, III
          Consensus Level: 1

      4. Determination of "Optimal" Reference Values for Laboratory Tests without Following Acceptable Procedures for the Establishment of Reference Ranges.

        1. Outpatient Screening/Case Finding

          i. This approach to interpretation of lab reference values results is not recommended for screening and/or case findings in asymptomatic patients.

        2. Diagnosis

          i. The optimal reference value approach to the interpretation of lab values is not useful in the diagnosis of specific health problems and nutritional imbalances because of its unusual way of determining reference ranges and because this approach does not take into consideration biological, analytical and statistical variations.

          • The reference ranges are determined by measurements performed on a large number of subjects and arbitrarily defined as the range encompassed by two standard deviations.

          • The distribution curve of test results is skewed rather than symmetric.

          • The population used to calculate reference ranges is not necessarily healthy.

          ii. Further research is necessary to determine the validity of this approach to the establishment of laboratory reference ranges.

        3. Monitoring

          i. Utilizing the optimal value approach to laboratory interpretation is not useful in monitoring changes in patients’ health status.

          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

    4. Inappropriate Clinical Laboratory Procedures
      1. Cytotoxic Testing for Food Allergies

        1. Based on the data derived from controlled investigations, there is poor test reliability.

        2. This test has not been shown to produce results that can be consistently correlated with other examination findings.

        3. This test lacks an acceptable scientific rationale, lacks sensitivity and specificity and lacks evidence of clinical effectiveness.

        4. Class I, II, III
          Rating: Inappropriate
          Evidence:
          Consensus Level: 1

      2. Reams Testing and Interpretation of Urine

        1. There is no clinical or scientific evidence for the use of this procedure in chiropractic or other related health science literature.

        2. This test has not been shown to produce results that can be consistently correlated with examination findings.

        3. This test lacks an acceptable scientific rationale, lacks sensitivity and specificity and lacks evidence of clinical effectiveness.

        4. Rating: Inappropriate
          Evidence: Class I, II, III
          Consensus Level: 1


  5. Record Keeping and Patient Consents:

    Disclaimer — These guidelines may necessarily be superceded by statutory law in respective state or provincial jurisdictions. They do not purport to convey legal advice. It is recommended that each practitioner should obtain his/her own independent legal advice.

    1. Internal Documentation

      (Records generated within the chiropractor’s office.)

      1. The Patient File

        When a new patient enters the office, a file is created which becomes the foundation of the patient’s permanent record. Adequate systems may include personal patient data (e.g., name, address, phone numbers, age, sex, occupation); insurance and billing information; appropriate assignments and consent forms; case history; examination findings; imaging and laboratory findings; diagnosis; work chart for recording ongoing patient data obtained on each visit; the service rendered; health care plan; copies of insurance billings; reports; correspondence; case identification (e.g., by number) for easy storage and retrieval of patient’s documents, etc.

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

        A folder is used to house most of the patient’s records. This may also be part of the record, if the practitioner writes patient data on the folder, such as patient personal information or x-ray/examination/treatment plan data. The practitioner may attach a patient work chart to the inside of the folder along with the other items in the patient’s file. On periodic file review, outdated portions may be removed and stored in an archive file. A permanent note should be kept in the active file indicating that the patient has additional records.

        Rating: Recommended
        Evidence: Class II, III
        Consensus Level: 1

      2. Doctor/Clinic Identification

        Basic information identifying the practitioner or facility should appear on documents used to establish the doctor-patient relationship. This can be preprinted on forms, affixed by rubber stamp or adhesive labels or typed or handwritten in ink. Basic information should include:

        • practitioner’s name/specialty
        • specialty designation (if applicable)
        • facility name (if different)
        • legal trade name (if applicable)
        • street address and mailing address (if different)
        • telephone number(s)

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

      3. Patient Identification

        Clear identification of the patient with relevant demographic information (see item #4 below) is a necessary component of the chart. This information can be obtained with ease by using preprinted forms for completion by the patient. Identifying information may include:

        • case/file number (if applicable)
        • name (prior/other names)
        • birthdate, age
        • name of consenting parent or guardian (if patient is a minor or incapacitated)
        • copy letter of guardianship (where appropriate)
        • address(es)
        • telephone number(s)
        • social security number (if applicable)
        • radiograph/lab identification (if applicable)
        • contact in case of emergency (closest relationship name/ phone number)

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

      4. Patient Demographics

        • Sex (M or F)
        • occupation (special skills)

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

        • marital status
        • race
        • number of dependents
        • employer, address, phone number
        • spouse’s occupation

        Rating: Discretionary
        Evidence: Class I, II, III
        Consensus Level: 1

      5. Health Care Coverage

        Health care coverage information is important for the business function of a health care facility, and such records are a part of the health care record. However, the information obtained and the format used are at the discretion of the practitioner.

        • current incident result of accident or injury?
        • insurance company or responsible party (auto/work comp/health/other)
        • group and policy numbers, effective date
        • spouse’s insurance company and policy information (if applicable)

        Rating: Discretionary
        Evidence: Class III
        Consensus Level: 1

      6. Patient History

        This is the foundation of the clinical database for each patient. The practitioner may choose to enter this data on a formatted or unformatted page. There should be an adequate picture of the patient’s subjective perception of the history. Important elements of the history may include:

        • date history taken
        • present complaint/chief complaint
        • description of accident/injurious event or other etiology
        • past history, family history, social history (work history and recreational interests, hobbies as appropriate)
        • review of systems (as appropriate)
        • past and present medical/chiropractic treatment and attempts at self-care
        • signature or initials of person eliciting history

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

        When possible, history questionnaires, drawings and other information personally completed by the patient should be included in the initial documentation.

        Rating: Recommended
        Evidence: Class I, II, III
        Consensus Level: 1

      7. Examination Findings

        Objective information relative to the patient’s history is obtained by physical assessment/examination of the area of complaint and related areas and/or systems. Gathering and recording this information may be facilitated by use of preprinted and formatted examination forms. If abbreviations are used, a legend should be available. Such documentation should include the date of the examination and name or initials of the examining practitioner. If persons other than the primary examining practitioner perform and/or record elements of the objective examination, their names and/or initials should appear on the exam/data form. Such evaluations may include:

        • vital signs
        • physical examination
        • neuromusculoskeletal examination
        • instrumentation
        • other chiropractic examination procedures

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

      8. Findings of Special Studies

        Documented results of special studies become a component part of the contemporaneous file. This documentation should include date of study, facility where performed, name of technician, name of interpreting practitioner, and relevant findings. Special studies ordered by practitioner may include:

        • diagnostic imaging (e.g., plain film radiography; tomography or computed tomography; magnetic resonance imaging; diagnostic ultrasound; radionuclide bone scan)

        • neurophysiologic/ electrodiagnostic testing (e.g., nerve conduction velocities; electromyography; somatosensory evoked responses)

        • other laboratory tests

        Rating: Recommended
        Evidence: Class I, II, III
        Consensus Level: 1

      9. Miscellaneous Assessment and Outcome Instruments

        Various assessment and outcome instruments can contribute to clinical management and become part of the case record. Many of these instruments are used in a repeated or serial fashion, which makes it essential for the record to identify the date(s) of completion and name(s) of scoring practitioner/ technician. Measurement instruments currently in use include:

        • visual analog scale
        • pain diagrams
        • pain questionnaires (e.g., McGill)
        • pain disability instruments (e.g., Oswestry, Neck Disability Index)
        • health status indices (e.g., SF-36, Sickness Impact Profile)
        • patient satisfaction indices
        • other outcome measures

        Rating: Recommended
        Evidence: Class I, II, III
        Consensus Level: 1

      10. Clinical Impression

        Upon completion of the subjective and objective data base, the practitioner formulates a clinical impression or diagnosis. This may be preliminary only, and may comprise more than one diagnosis. This clinical impression should be recorded within the file or in the contemporaneous visit record. As the clinical impression may change with new clinical information or in response to treatment, it is important that each clinical impression be dated. The record may include:

        • primary, secondary and/or tertiary elements of diagnosis
        • appropriate diagnostic coding (e.g., lCD-CM)

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

      11. Treatment Plan

        This arises from the accumulation of clinical data and the formulation of the initial clinical impression. The plan may include further diagnostic work to monitor progress, or a therapeutic trial to test clinical impressions and assess appropriateness of treatment procedures selected. The treatment plan documents the approach to management by the practitioner and staff (e.g., spinal adjusting, therapy modalities, recommended exercise regime, lifestyle and dietary modifications). Any plan for referral to or consultation with other health care providers is appropriately listed in the record. The written treatment plan may appear on a form dedicated to the clinical work-up, or in the contemporaneous visit record, and may include:

        • diagnostic/reassessment plan
        • practitioner’s treatment plan (modes and frequency of care)
        • patient’s education and self-care plan
        • intra- or interdisciplinary referral or consultation

        Rating: Recommended
        Evidence: Class I, II, III
        Consensus Level: 1

      12. Chart/Progress Notes

        Once the initial patient work-up has been completed, all record entries should be made in a systematic organized manner.

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

        Clinical Information. The patient’s records must be sufficiently complete to provide reasonable information requested by a subsequent health care provider, insurance company, and/or attorney (e.g., progress notes, SOAP notes, SORE notes). A dated record of what occurred on each visit, and any significant changes in the clinical picture or assessment or treatment plan need to be noted. The method in which chart notes are recorded is a matter of preference for each practitioner.

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

        There are many different adjusting/manipulation/manual techniques. It is important to record what area was adjusted/manipulated/treated and the procedure used.

        Rating: Necessary
        Evidence: Class II, III
        Consensus Level: 1

        Anyone other than the attending practitioner who enters data into the contemporaneous chart must initial the entry.

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

      13. Re-examination/Reassessment:

        All relevant information from every reassessment and reexamination must be recorded in the patient file.

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

      14. Financial Records

        Financial records are important for the business function of a health care facility, and such data are part of the health care record:

        • patient account ledgers
        • billing statements
        • explanation of benefits (EOB) from payers, proof of payment

        Rating: Necessary
        Evidence: Class I, III
        Consensus Level: 1

        The precise information obtained and the means of storage and retrieval are at the discretion of the chiropractor.

        Rating: Discretionary
        Evidence: Class III
        Consensus Level: 1

      15. Internal Memoranda Regarding Patient

        • patient sign-in sheets
        • staff messages (intra-office)
        • phone messages and summaries/transcription of phone conversations

        Rating: Discretionary
        Evidence: Class I, III
        Consensus Level: 1

    2. External Documentation

      External documentation includes all records arising from outside the practitioner’s office, but also includes any communication with third parties.

      1. Direct Correspondence

        Correspondence in the form of letters or memoranda that leave the office should have information identifying the practitioner and/or clinic, address, and telephone number and be contemporaneously dated. A copy must always be kept on file.

        • introductory letter(s) to or from referring practitioner (DC, MD, etc.)
        • general correspondence to or from other practitioners
        • general correspondence to or from attorney(s)
        • general correspondence to or from patient
        • general correspondence to or from various payer groups

        Rating: Recommended
        Evidence: Class II, III
        Consensus Level: 1

      2. Health Records

        • pertinent copies of health records from previous or concurrent health care providers
        • special consultative reports
        • reports of special diagnostic studies

        Rating: Recommended
        Evidence: Class II, III
        Consensus Level: 1

      3. Diagnostic Imaging

        • When indicated, a reasonable attempt should be made to obtain recent x-rays (or copies) relevant to the presenting problem of the patient, and summarize and record pertinent information.

        • Copies of external radiology reports.

        • Rating: Established
          Evidence: Class II, III
          Consensus Level: 1

      4. External Reports

        Frequently a practitioner will be required to write various reports. The information for these reports comes from patient records. Adequate reporting usually requires the practitioner to review the patient’s history, examination findings, diagnosis, treatment procedures, progress notes/work chart and other reports that may have been written together with records from other health care providers that have treated or evaluated the patient. There are many types of reports that serve various needs. There are many acceptable styles and formats.

        Rating: Recommended
        Evidence: Class II, III
        Consensus Level: 1

    3. Chart/File Organization
      1. General Considerations

        Records should be kept in chronological order and entered as contemporaneously as possible. They should not be backdated or altered. Corrections or additions should be dated and initialled. The chart or file should be fully documented and contain all relevant, objective information; extraneous information should not be included. The record must be complete enough to provide the practitioner with information required for subsequent patient care or reporting to outside parties.

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

      2. Use of Pre-printed Forms

        The use of forms can assist in tasks such as obtaining case history, noting examination findings and charting case progress. Use of forms is at the discretion of the individual practitioner but should favor comprehensiveness and completeness rather than brevity.

        Rating: Discretionary
        Evidence: Class II, III
        Consensus Level: 1

      3. Legibility and Clarity

        Health records should be neat, organized and complete. Entries in charts should be written legibly in ink. Entries must not be erased or altered with correction fluid (whiteout) or tape or adhesive labels, etc. If the contents of any document are changed, the practitioner should initial and date such changes in the corresponding margin.

        Rating: Necessary
        Evidence: Class II, III
        Consensus Level: 1

      4. Use of Abbreviations/Symbols

        Use of abbreviations or coding can save record space and time. A legend of the codes or abbreviations should appear on the form or be available in the office in order that another practitioner or interested person can interpret and use the information. The legend can also be used for intra-office communications and as a dictation aid.

        Rating: Recommended
        Evidence: Class II, III
        Consensus Level: 1

    4. Maintenance of Records
      1. Confidentiality

        The rule of confidentiality requires that all information about a patient gathered by a practitioner as any part of the doctor/patient relationship be kept confidential unless its release is authorized by the patient or is compelled by law. The rule is an ethical responsibility as well as a legal one. Assurance of confidentiality is necessary if individuals are to be open and forthright with the practitioner. Patients rightly expect that such information as their health will remain private and secure from public scrutiny. Thus the principle that all doctor-patient communications are privileged and confidential.

        Rating: Necessary
        Evidence: Class I, III
        Consensus Level: 1

      2. Records Retention and Retrieval

        Health records should be retained, and in a way that facilitates retrieval. To the extent possible, they should be kept in a centralized location. In most circumstances, recent records are maintained on premises either as hard copy or electronically, and after a period of time can be archived, microfilmed or microfiched and placed in storage. The length of time that records, in whatever form, must be kept varies. Many states/ provinces have legislated minimum periods of time for retention of health records, usually between five to fifteen years. When the decision is made to dispose of health records, the manner of disposal must protect patient confidentialiy. If a chiropractic office closes or changes ownership, secure retention of the health care record must be ensured.

        Rating: Necessary
        Evidence: Class I, II
        Consensus Level: 1

        Even when legal time limits have elapsed, it is advisable to continue to retain records because of the valuable information they contain.

        Rating: Discretionary
        Evidence: Class III
        Consensus Level: 1

      3. Administrative Records

        Administrative records are primarily those relating to the non-clinical side of practice, but there is some overlap into the doctor/patient relationship. Examples of administrative records may include: telephone logs, schedule and record of appointments, patient personal data information, insurance forms and billing, collection and patient billing, routine correspondence, a record filing system that makes for accurate retrieval of patient data. These records must be maintained in a legible and retrievable format.

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

      4. Records Transfer

        It is mandatory that health care data (excluding data and reports from outside sources) requested by another provider currently treating a present or former patient be forwarded upon receipt of an appropriate request and patient consent. In some jurisdictions, this duty to forward information to another treating health professional is imposed by statute also. However, even m the absence of a statutory requirement a practitioner has a responsibility to comply with such a request, and as expeditiously as possible.

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

      5. Clinic Staff Responsibilities

        The practitioner is responsible for staff actions regarding record keeping and consent forms, and for assuring that administrative tasks are handled correctly and promptly. Any employee involved in the preparation, organization, or filing of records should fully understand professional and legal requirements, including the rules of confidentiality.

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

    5. Patient Consents
      1. Informed Consent/Consent to Treatment – Generally

        Patient consent to treatment is always necessary. It is often implied rather than expressed. However, where there is risk of significant harm from the treatment proposed, this risk must be disclosed, understood, and accepted by the patient. Such informed consent is required for ethical and legal reasons. The best record of consent is one that is objectively documented (e.g., a witnessed written consent or videotape).

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

      2. Consent to Treatment - Competence

        A patient must be competent to give consent to treatment. The treatment of minors (age of majority varies from 14 to 21 according to jurisdiction) and mentally incompetent adults requires the prior consent of a guardian in most circumstances.

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

      3. Authorization to Release Patient Information

        With the consent of a competent patient or guardian, records may, and in most situations must, be provided to third parties with a legitimate need for access. The patient consent should not be more than 90 days old, or as provided by law. Whenever health care information is released pursuant to authorization from a patient, documentation of the authorization should be requested and retained (except in some emergencies). If the request is for all or part of the health care record, the original record should never be released, unless compelled by law, only copies. Before the copy chart or other records are sent out, they should be reviewed to make certain they are complete.

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

      4. Financial Assignments

        While financial data is important for the business function of a health care facility, and such records are indeed part of the health care record, the information obtained and the method of acquiring such information is at the discretion of the practitioner. Any alteration of standard fees charged necessitates documentation (e.g, in cases of financial hardship).

        Rating: Discretionary
        Evidence: Class III
        Consensus Level: 1

      5. Consent to Participate in Research

        When a practitioner engages in research, the ethical basis of the doctor-patient relationship changes to an investigator-subject interaction. The new relationship must meet a new set of criteria different from clinical practice.

        If a patient is requested to participate in a research study or project the request must be accompanied by informed consent that meets the minimum request for the protection of human subjects as established by competent authorities (e.g., NIH/ NSF or state/provincial law).

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

      6. Publication/Photo/Video Consent

        All records from which a patient may be identified (e.g., photographs, videotapes, audiotapes) should only be created once consent has been obtained. Such consents should identify the purposes of the record and the circumstances under which it will be released.

        1. records for clinical management

        2. Rating: Recommended
          Evidence: Class I, II, III
          Consensus Level: 1

        3. records for all other purposes (e.g., research, training, distribution)

        4. Rating: Necessary
          Evidence: Class I, II, III
          Consensus Level: 1

      7. Authority to Admit Observers

        Persons not participating in the treatment of the patient should not be permitted to watch examinations or procedures without authorization from the patient. This principle is subject to some exceptions where the patient is a minor.

        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1


  6. Clinical Impression:

    1. Necessity

      Arrival at a clinical impression or diagnosis, or diagnostic conclusion or analysis, is a necessary outcome of the patient encounter.

      Comment: The responsibility of a chiropractic practitioner does not change with the terminology used to describe clinical findings. The practitioner is required to assess the patient upon presentation and respond to the clinical situation in a manner consistent with the best interests of the patient, the practitioner’s clinical judgment, and the law of the jurisdiction in question.

      Rating: Necessary
      Evidence: Class I, II, III
      Consensus Level: 1

    2. Initial Responsibility

      The initial level of responsibility of the practitioner involves the immediate discernment as to the nature and status of the patient on initial presentation. A practitioner should be expected to recognize and respond to life-threatening situations in a manner consistent with the patient’s best interest.

      Rating: Necessary
      Evidence: Class I, II, III
      Consensus Level: 1

    3. Subsequent Responsibility

      After the initial evaluation has been completed the practitioner begins a series of differentiations that result in many clinical decisions being implemented. This process is not an end in itself, but merely designates suspected conditions that become the focus for prognostic judgments, further assessment and patient management. Initiation of chiropractic care, additional studies, referral with or without continuing chiropractic care and cessation of chiropractic care are possible.

      Rating: Necessary
      Evidence: Class I, II, III
      Consensus Level: 1

    4. Terminology

      The terminology utilized to describe a clinical impression, diagnosis, diagnostic conclusion, or analysis should be consistent with appropriate usage in chiropractic (e.g., subluxation complex/fixation/misalignment) and related health care communities. If a practitioner is required to use specific terminology, or is prohibited from the use of such terminology by law, then that legal requirement is the guiding factor.

      Rating: Recommended
      Evidence: Class II, III
      Consensus Level: 1

    5. Content

      Patients may have various conditions/symptoms/findings that result in a number of unrelated clinical impressions. The primary clinical impression, diagnosis, diagnostic conclusion, or analysis should address the chief complaint expressed by the patient. Secondary diagnoses should be prioritized and addressed as needed and may be of greater clinical consequence to the patient.

      Rating: Recommended
      Evidence: Class II, III
      Consensus Level: 1

      The clinical impression, diagnosis, diagnostic conclusion, or analysis should reflect a classification scheme that consists of statements reflective of severity, region, and organ/ tissue involvement.

      Rating: Recommended
      Evidence: Class II, III
      Consensus Level: 1

      The clinical impression, diagnosis, diagnostic conclusion or analysis should be related to the subjective and/or objective findings of the patient, and be consistent with evidence-based criteria.

      Rating: Established
      Evidence: Class I, II, III
      Consensus Level: 1

    6. Process

      When additional confirmatory tests are required to establish the clinical impression, diagnosis, diagnostic conclusion, or analysis it is the practitioner’s responsibility to ensure that these studies are completed in as timely and efficient a manner as possible. Practitioners may perform such procedures consistent with their qualifications and the law, or they may seek to have such procedures performed by other qualified parties.

      Rating: Necessary
      Evidence: Class I, II, III
      Consensus Level: 1

      Where procedures relevant to a diagnosis, clinical impression, diagnostic conclusion, or analysis are not within the qualifications or competence of a practitioner, the practitioner should make appropriate consultations with others.

      Rating: Recommended
      Evidence: Class II, III
      Consensus Level: 1

      The clinical impression, diagnosis, diagnostic conclusion, or analysis should be recorded in the patient’s record and qualified as to its certainty.

      Rating: Necessary
      Evidenc: Class I, II, III
      Consensus Level: 1

    7. Dynamics

      The clinical impression, diagnosis, diagnostic conclusion, or analysis should be a working hypothesis that may change over time, given additional information and/or changes in the condition of the patient.

      Rating: Necessary
      Evidence: Class I, II, III
      Consensus Level: 1

    8. Communication

      The practitioner should communicate the diagnosis or clinical impression or diagnostic conclusion or analysis, and its significance, to the patient in understandable terms, and convey such findings to other providers or agencies as the patient requests and consents to, or as the law requires.

      Rating: Necessary
      Evidence: Class I, II, III
      Consensus Level: 1



  7. Modes of Care:

    1. Manual, Articular Manipulative and Adjustive Procedures
      1. Specific Contact Thrust Procedures

        1. High Velocity Thrust: High-velocity thrust procedures (also referred to as osseous adjusting procedures) are probably the most commonly recognized, most widely taught, and most widely used of the adjustive and manipulative techniques within the chiropractic profession.
          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

          Rating: Established for the care of patients with many other neuromusculoskeletal problems.
          Evidence: Class II, III
          Consensus Level: 1

          Rating: Equivocal for other purposes.
          Evidence: Class II, III
          Consensus Level: 1

          Comments: These procedures must be considered in light of their intended application, types of patients and conditions independently managed, and the nature of the thrust.

        2. High Velocity Thrust with Recoil: There is little evidence in the literature specifically evaluating the effectiveness of thrust with recoil as compared to non-recoil thrust. Although distinct in application due to the recoil, typical joint cavitation and movement occurs with this procedure as it does with dynamic thrust without recoil. It is reasonable to assume that similar physiologic responses occur with both forms of thrust. Although comparative trials are needed, this modification is not controversial and it is reasonable to assume that studies evaluating thrust with or without recoil would have similar outcomes.
          Rating: Promising to established for the care of patients with neuromusculoskeletal problems.
          Evidence: Class II, III
          Consensus Level: 1

          Rating: Equivocal for other purposes
          Evidence: Class II, III
          Consensus Level: 1

          Comments: These procedures must be considered in light of their intended application, types of patients and conditions independently managed, and the nature of the thrust.

        3. Low-Velocity Thrust: Low-velocity thrust may or may not result in joint gapping, depending on degree of pre-stress and amplitude. In the absence of specific comparative studies on low-velocity thrust, it is reasonable that any low-velocity thrust that results in joint gap is likely to have effects similar to high velocity thrusts from a mechanical point of view. For low-velocity thrust that does not cause cavitation, the literature on mobilization is thought to be representative if substantial range of motion to joints and soft tissues is induced. Reflex and global (widespread) effects of such procedures have not been well studied and are addressed in the section on reflex procedures.
          Rating: Equivocal to promising for the care of patients with neuromusculoskeletal problems.
          Evidence: Class II, III
          Consensus Level: 1

          Rating: Investigational to equivocal for the care of patients with some organic conditions.
          Evidence: Class II, III
          Consensus Level: 1

          Comments: These procedures must be considered in light of their intended application, types of patients and conditions independently managed, and the nature of the thrust.

      2. Non-Specific Contact Thrust Procedures

        Mobilization: Mobilization (passive movement through the physiologic joint range) does not exceed the passive end range and therefore involves no cavitation of the joint and hence is distinct from manipulation. The purpose of mobilization is to increase range of motion within a restricted joint. Much of the clinical outcome literature on mobilization is blended with the manipulation literature.

        Rating: Established
        Evidence: Class I, II, III
        Consensus Level: 1

      3. Manual Force, Mechanically Assisted Procedures

        1. Drop Tables and Terminal Point Adjustive Thrust: This procedure is a dynamic thrust with or without recoil that is in widespread use within the profession. The thrust involves positioning and pre-stress of joints in similar and modified fashion to other dynamic thrust procedures but involves small translational movement of a section of the adjusting table beneath the patient and the segment to which the thrust is applied.
          Rating: Promising to established for the care of patients with neuromusculoskeletal problems.
          Evidence: Class III
          Consensus Level: 1

          Rating: Investigational to equivocal for other purposes
          Evidence: Class III, with probable applicability of Class II studies involving high velocity thrust without mechanical assistance
          Consensus Level: 3

          Comments: These procedures must be considered in light of their intended application, types of patients and conditions independently managed, and the nature of the thrust.

        2. Flexion-Distraction Tables: These devices allow for manually assisted mechanical distraction to be applied primarily to the lumbar and thoracic spine along with other ranges of motion. This approach of flexion-distraction is a standard, widely taught procedure. There is a great deal of supportable and reasonable mechanical and physiologic rationale in the literature for the appropriate use of these procedures for the care of patients with neuromusculoskeletal problems.
          Rating: Established
          Evidence: Class II, III
          Consensus Level: 2

        3. Pelvic Blocks: These paired wedges are used primarily for positioning the lumbosacral and sacroiliac joints to produce a sustained stretch. This procedure is in fairly common use, and there is reasonable rationale and expert opinion on its utility in certain situations.
          Rating: Promising for the care of patients with neuromusculoskeletal problems.
          Evidence: Class III
          Consensus Level: 1

      4. Mechanical Force, Manually Assisted Procedures

        1. Fixed Stylus, Compression Wave Instruments: These devices are typically used in the upper cervical spine. A non-moving stylus is positioned against a pre-stressed motion segment. A moving piston strikes the stylus producing a compression wave along the stylus. It is speculated that a force is transmitted to the adjacent tissue and transmitted to the osseous and articular structures. With minimal tissue deformation and no amplitude change, the pliability and elasticity of the intermediate soft tissue is likely to absorb and disperse some or all of the force transmitted.
          Rating: Equivocal
          Evidence: Class III
          Consensus Level: 1

          Comments: Rationale for procedure is poorly substantiated and good efficacy studies are lacking. There are no direct safety concerns with proper application. These sorts of instruments suffer from the same limitations as low-force thrusts and will require significant investigation over time. Although use is not widespread, such instruments and protocols are taught in the curriculum of a few institutions and are not known to be restricted by regulatory agencies. There is clinical opinion and some case study information suggesting utility.

        2. Moving Stylus Instruments: Spring loaded and piston activated adjusting instruments can be adjusted by amplitude, position and/or acceleration. One instrument known as an "Activator" has an adjustable amplitude with a spring loaded cocking mechanism that permits an adjustable range of reproducible accelerations. This instrument has been tested in animal models using pressure transducers and accelerometers and has demonstrated small but reproducible oscillation of bony vertebrae. Other devices employing similar mechanisms (such as the Pettibon instrument) may have similar effects.

          These instruments when applied by and for rationales similar to dynamic thrust are likely to produce effects similar to some low-amplitude manual thrusting or mobilization procedures. They are also likely to stimulate cutaneous nerve endings and produce reflex effects. However, more investigation is required regarding rationales for application for several of these instruments.

          Rating: Promising to established
          Evidence: Class I, II, III
          Consensus Level: 1

    2. Manual, Nonarticular Manipulative and Adjustive Procedures
      1. Manual Reflex and Muscle Relaxation Procedures

        1. Muscle Energy Techniques: A variety of procedures fall under this classification including post-facilitation stretch, post-isometric relaxation, and reciprocal inhibition, among others. In addition, there are several chiropractic techniques that use procedures mechanically and physiologically similar to these as part of their therapeutic armamentarium. The rationale for such procedures is based on the concept of reciprocal innervation and inhibition between agonist and antagonist muscles. Treatment is directed at finding such sites and having the patient do movements and muscle contractions, typically against some kind of active resistance in order to cause a relaxation of a hypertonic muscle. These techniques are commonly in use and are the subject of much investigation.
          Rating: Promising
          Evidence: Class II, III
          Consensus Level: 1

        2. Neurologic Reflex Techniques: These are a variety of techniques that attempt to stimulate proprioceptive and other sensory nerve endings by application of light touch or sustained pressure on various soft tissue or bony structures.
          Rating: Equivocal for muscle relaxation
          Evidence: Class III
          Consensus Level: 1

          Rating: Investigational for other purposes
          Evidence: Class III
          Consensus Level: 1

          Comments: There is evidence that demonstrates that mechanical stimulation may influence muscle relaxation, sudomotor activity, vasoconstriction/dilation, gastric secretions.

          Some practitioners use varieties of passive spring tension "plunger" devices for this purpose. Persuasive clinical studies only exist for somatic conditions. Procedures that result in only slight temporary soft tissue deformation or none at all (such as brief or sustained touch-like pressure to the skin) are not presently represented in the literature, and no well-articulated or substantiated physiologic rationales exist for effectiveness. These procedures would benefit from detailed investigation.

        3. Myofascial Ischemic Compression Procedures: Ischemic compression involves placing a sustained compressive force on a tight or contracted muscle. This is thought to relax the muscle and thereby reduce stress to any joints to which the muscle is attached. The chiropractic profession has employed myofascial ischemic compression procedures and other soft tissue procedures as part of a care regimen for a long time (e.g., Receptor-tonus Technique, myofascial trigger point therapy).
          Rating: Established for muscle relaxation
          Evidence: Class II, III
          Consensus Level: 1

        4. Miscellaneous Soft Tissue Techniques: There are many different kinds of muscle work in widespread use. They involve applying manual pressure in order to relieve muscle spasm. Some common techniques of muscle work include: massage (superficial, effleurage, petrissage, percussion), pressure point work (acupressure and shiatsu), and deep tissue techniques (Rolfing). There is little controversy regarding the clinical utility of such procedures for relaxation and uncomplicated musculoskeletal dysfunction. However, comparative clinical investigations are sparse. Light massage has occasionally been used as a placebo control in manipulation studies.
          Rating: Established
          Evidence: Class II, III
          Consensus Level: 1

      2. Miscellaneous Procedures

        1. Neural Retraining Techniques: A variety of procedures aimed at developing neuromuscular coordination exist within the chiropractic profession. Such procedures constitute portions of some popular techniques. Primarily, these approaches involve repeated active movements under a variety of mechanical conditions in order to "pattern" the motor system for particular activities. There is rationale and support in the exercise physiology, kinesiology, and neurologic rehabilitation literature for many of these practices. There is overlap with other reflex procedures including muscle energy techniques. In terms of training for developing coordination and conditioning there is little controversy due to the plausibility of rationale, but a minimum of outcome investigations. Examples of these approaches include Janda, Feldenkrais, Alexander, cross crawl, etc.
          Rating: Equivocal to promising in some conditioning and neuromuscular coordination contexts.
          Evidence: Class II, III
          Consensus Level: 1

          Rating: Investigational for other purposes
          Evidence: Class II, III
          Consensus Level: 1

          Comment: There are proponents of other neural "organization" or "reeducation" procedures that claim a variety of clinical applications including the treatment of visceral, psychologic, and genetic conditions. There are poorly described rationales that may offer a starting point for model development, but no truly scholarly efforts are available to date. There is little or no literature available which documents effectiveness and such protocols are rarely taught as core material at accredited institutions. At best these procedures should be considered investigational, and, depending on the plausibility of certain applications, may be considered inappropriate to doubtful.

        2. Conceptual Mind-Body Approaches: These approaches are based on the idea that mental thought (by the clinician) can influence physiological function of the patient. However, there is no information that suggests that a given doctor can directly influence a patient’s physiology or disease process in specific situations. Although interesting, application to chiropractic care is speculative.
          Rating: Inappropriate
          Evidence: Class III
          Consensus Level: 1

          Comment: There is widespread acceptance of the importance of the doctor-patient relationship in the healing process. There is also burgeoning popular support for the mind-body relationship in the healing process. Facilitating this process in all types of therapeutic encounters is likely to be of benefit for patients’ mental and social states. However, there is no justification for the substitution of metaphysical modalities for standard mechanical and chiropractic interventions. These issues are important fields in and of themselves (psychology, psychoneuroimmunology). It should be noted that one well-designed prospective, randomized, controlled trial of intercessory prayer on 393 hospitalized cardiac patients did demonstrate beneficial therapeutic effects.

        3. Surrogate Approaches: All chiropractic treatment approaches that utilize another person or a device as a mediator for receiving treatment on behalf of the patient have no defensible rationale or documentation of effectiveness and are therefore unacceptable in chiropractic practice.
          Rating: Inappropriate
          Evidence: Class III
          Consensus Level: 1

    3. Nonmanual Procedures
      1. Exercise and Rehabilitation

        1. Mobility and Stretching Exercise: Active mobility maintenance and stretching by the patient are traditionally encouraged in chiropractic practice. Training, counseling and advice in stretching and mobility exercises are common, and various descriptions of chiropractic programs exist in the literature. Trials on exercise in chiropractic settings have not been published, but there is function and performance information available in exercise physiology and sports medicine literature.
          Rating: Promising to established
          Evidence: Class I, II, III
          Consensus Level: 1

        2. Strengthening, Conditioning and Rehabilitation: Active conditioning exercise is thought to be helpful for both healing and prevention of many mechanical back and neck problems. Conditioning and spinal stabilization programs are becoming more common for chiropractic management of low-back conditions. In addition, numerous programs are in place that involve job simulation and work hardening protocols that are directed at chiropractic management and conditioning for specific tasks.
          Rating: Promising to established
          Evidence: Class I, II, III
          Consensus Level: 1

        3. Passive Stretch: Passive stretch is gentle sustained muscle lengthening applied by the practitioner or therapist. Its use is common within the chiropractic profession. There are a number of variations of application including several modalities to distract the patient from potential discomfort such as I. cryotherapy (ice, coolant sprays, etc.) and 2. analgesic balms. These distractors are usually applied just before or simultaneous with the passive stretch and are for the purpose of distracting the patient from the possible discomfort of sustained stretch on the muscles and tissues. Practitioners, especially within the field of sports chiropractic, teach and use these procedures frequently.
          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

      2. Educational Programs

        1. Back School/Spinal Care Courses: Knowledge about how to take care of one’s health problems and how to modify behavior or lifestyle is likely to be beneficial for most patients. Back school programs and patient education have traditionally been an integral part of chiropractic case management. It is supportable when used as an appropriate teaching aid.
          Rating: Promising to established
          Evidence: Class I, II, III
          Consensus Level: 1

        2. Wellness Care/Disease Prevention/Health Promotion: A relatively new area of interest in chiropractic as a distinct service, prevention has long been a primary consideration of the chiropractic profession’s approach to health care. Typical disease prevention programs, smoking cessation, weight reduction efforts and the like fit well within chiropractic practice scopes. Organizations such as the American Chiropractic Association, International Chiropractors’ Association and the Chiropractic Forum of the American Public Health Association have adopted policies or expressed support for such programs and practitioners with a particular expertise and interest in this area are increasing in number.
          Rating: Promising to established
          Evidence: Class II, III
          Consensus Level: 1

        3. Nutritional Counseling: Nutritional training is included in the chiropractic curriculum. As a general issue concerning scope of practice, there is little disagreement regarding the capability or qualifications of practitioners to counsel patients concerning nutritional matters.
          Rating: Established
          Evidence: Class I, II, III
          Consensus Level: 1

          Comment: Specific nutritional therapy is an extensive field that requires a great deal of delineation. This should be addressed in the future.

        4. Biofeedback: Some practitioners have begun to use biofeedback training as a means of teaching patients to control stress and other conditions. Its utility has been fairly well documented and its clinical application in chiropractic case management may be beneficial.
          Rating: Promising to established
          Evidence: Class II, III
          Consensus Level: 1

      3. Electrical Modalities

        Electrical modalities (e.g., muscle stimulating, electrochemical, electroacupuncture) have long been a part of chiropractic education and they are specifically included in scope of practice regulations in most jurisdictions. Standard electrical modalities are often used as ancillary to chiropractic manual procedures, and although there has been historical and political controversy regarding the clinical utility of all physiotherapeutic modalities in chiropractic practicetheir inclusion in chiropractic scope of practice is not a significant area of debate. Protocols are well delineated. Muscle stimulation, galvanic current, microcurrent, iontophoresis, and TENS among others are representative modalities within this grouping. There is good evidence that many of these procedures produce therapeutic changes in muscle tone. There is some conflicting evidence for the effectiveness of electroanalgesia. lontophoresis of some compounds may be regulated specifically in some jurisdictions.

        Rating: Promising to established
        Evidence: Class I, II, III
        Consensus Level: 1

      4. Thermal Modalities

        These include cryotherapy, infrared, hydrotherapy, hydrocollator, diathermy and others. These are standard within the chiropractic scope of practice in most jurisdictions. Protocols are documented and standardized. Cooling modalities are well established in the control of inflammation whereas heating modalities tend to promote palliation and general relaxation.

        Rating: Established
        Evidence: Class I, II, III
        Consensus Level: 1

      5. Ultraviolet

        Ultraviolet radiation is a conservative procedure used in the treatment of superficial cutaneous and mucosal conditions. It is typically included as a physiotherapeutic modality in most chiropractic jurisdictions.

        Rating: Established
        Evidence: Class II, III
        Consensus Level: 1

      6. Ultrasound and Phonophoresis

        Ultrasound is thought to be beneficial in increasing metabolic activity through deep heating and micromassage. Standard ultrasound and phonophoresis are typically included as standard ancillary procedures in chiropractic care. However, limitations may exist regarding phonophoresis of regulated compounds. Protocols are documented and standardized but may vary between jurisdictions.

        Rating: Established
        Evidence: Class I, II, III
        Consensus Level: 1

      7. Bracing, Casting, and Supports

        Supports, braces, casting, orthotics and the like are often useful components of chiropractic care. Practitioners are trained for the application of many such appliances. However, more specialized training is required for scoliosis appliance prescription and other complex procedures.

        Rating: Promising to established
        Evidence: Class II, III
        Consensus Level: 2

      8. Traction

        Mechanical traction is frequently employed to stretch muscles, joints, and intervertebral discs. Its use is typically included in chiropractic education and is considered as a viable mechanical modality.

        Rating: Promising to established
        Evidence: Class I, II, III
        Consensus Level: 1

    4. Special Interest Areas
      1. Manipulation Under Sedation/Anesthesia (MUS/ MUA)

        Manipulation under sedation has been included in medical and osteopathic practice for some time. Chiropractic practitioners, because of their expertise in manual methods, have begun participating in the application of these procedures in the hospital setting in conjunction with anesthesiologists. These programs are subject to strict protocols as well as state and federal regulations.

        Rating: Equivocal
        Evidence: Class II, III
        Consensus Level: 1

        Comment: Although MUS/MUA is considered potentially useful, chiropractic involvement in such programs is a new area of special interest that requires further exploration.

      2. Acupuncture

        Acupuncture is a healing art that has been utilized for over 5,000 years. It is taught at some chiropractic colleges and is utilized by some practitioners. Its primary clinical use is for pain control.

        Rating: Promising
        Evidence: Class I, II, III
        Consensus Level: 1

        Comment: This is a complex field that warrants special training. A thorough discussion is beyond the scope of this document. Use may be regulated in some jurisdictions.

      3. Homeopathic Remedies

        Homeopathic remedies are thought to be of therapeutic value in some circumstances. Many homeopathic preparations are in use by some practitioners. Typically used for the relief of immediate symptoms and pain, homeopathic preparations are usually non-toxic to the patient and protocols for their usage are standardized and documented.

        Rating: Equivocal
        Evidence: Class II, III
        Consensus Level: 1

        Comment: This is a complex field that warrants special training. A thorough discussion is beyond the scope of this document. Use may be regulated in some jurisdictions.



  8. Frequency and Duration of Care:

    1. Short and Long Range Treatment Planning:

      At the outset of treatment/care, a written estimated time frame for reaching intermediate functional milestones (short term goals, e.g., the ability to move the affected part, exert force, walk, etc.) and treatment/care outcomes (long term goals, e.g., return to work, renew sports, full activity, etc.) should be made. The length of time to reach these objectives can be affected by specific historical factors.

      NOTE: These factors, when combined (two or more), do not necessarily imply combined delay in recovery, but must be evaluated on a case-by-case basis.

      1. Preconsultation Duration of Symptoms. Pain less than eight days: No anticipated delay in recovery. Pain more than eight days: Recovery may take 1.5 times longer.

      2. Typical Severity of Sympoms. Mild pain: No anticipated delay in recovery. Severe pain: Recovery may take up to two times longer.

      3. Number of Previous Episodes. 0-3: No anticipated delay in recovery. 4-7: Recovery may take up to two times longer.

      4. Injury Superimposed on Preexisting Condition(s). Skeletal anomaly: May increase recovery time by 1.5-2 times. Structural pathology: May increase recovery time by 1.5-2 times.

      5. Rating: These recommendations are safe and have limited effectiveness in predicting recovery rate. They have a rating of promising based on Class II and III evidence.

        Consensus Level: I

        Strength of Recommendation: Type B

    2. Treatment/Care Frequency:

      Specific recommendations related to acute, subacute and chronic presentations are given below. In general, more aggressive in-office intervention (three to five sessions per week for one to two weeks) may be necessary early. Progressively declining frequency is expected to discharge of the patient, or conversion to elective care.

      Rating: The general approach to frequency is safe and effective provided it is carried out within the guidelines of natural history. The rating is established and is supported by Class II and III evidence.

      Consensus Level: 1

      Strength of Recommendation: Type B

    3. Patient Cooperation:

      The nature of the patient’s disorder and the purpose and strategy of the treatment plan should be adequately explained to the patient. Patients who prove to be insincere or non-compliant to treatment/care recommendations should be discharged from care, with referral when appropriate.

      Rating: This recommendation is safe and effective. The rating of promising is given when used in an effort to avoid physician dependence and overuse of services based on Class II and HI evidence.

      Consensus Level: 1

      Strength of Recommendation: Type B

    4. Failure to Meet Treatment/Care Objectives:
      1. Acute Disorders: After a maximum of two trial therapy series of manual procedures lasting up to two weeks each (four weeks total) without significant documented improvement, manual procedures may no longer be appropriate and alternative care should be considered.

      2. Unresponsive Acute, Subacute, or Chronic Disorders: Repeated use of passive treatment/care normally designed to manage acute conditions should be avoided as it tends to promote physician dependence and chronicity.

      3. Systematic interview of the patient and immediate family should be carried out in search for complicating or extenuating factors responsible for prolonged recovery.

      4. Specific treatment/care goals should be written to address each issue.

      5. Continued failure should result in patient discharge as inappropriate for chiropractic care, or having achieved maximum therapeutic benefit.

      6. Rating: Safe and effective procedures that are established and supported by Class I, II, and III evidence.

        Consensus Level: 1

        Strength of Recommendation: Type A

    5. Uncomplicated Cases: (acute episode)

      Observing the consistency of practice experience defined by the studies listed in the review of literature for passive care, only acute episodes can truly be considered uncomplicated. Acute episode (first occurrence, recurrent, or exacerbation of a chronic condition).

      1. Symptom Response: Significant improvement within 10-14 days; three to five treatments per week.

      2. Activities-of-Daily-Living (ADL): The promotion of rest, elevation, active rest, and remobilization, as needed, are expected to improve ADL followed by a favorable response in symptoms.

      3. Return to Pre-episode Status: six to eight weeks; up to three treatments per week.

      4. Supportive Care: Inappropriate.

      5. Rating: These recommendations are safe and effective in meeting the desired objectives. It has an established rating based upon the relationship to natural history. It is supported by Class I, II, and III evidence.

        Consensus Level: 1

        Strength of Recommendation: Type A.

    6. Complicated Cases:

      Implementation of up to two independent treatment plans relying on repeated use of passive care is generally acceptable in the management of cases undergoing prolonged recovery.

        1. Signs of Chronicity: All episodes of symptoms that remain unchanged for two to three weeks should be evaluated for risk factors of pending chronicity.

        2. Patients at risk for becoming chronic should have treatment plans altered to de-emphasize passive care and refocus on active care approaches.

          Rating: Criteria for chronicity are established, safe and effective with Class I, II, and III evidence.

          Consensus Level: 1

          Strength of Recommendation: Type A

        3. Subacute Episode:

          1. Symptom Response: Symptoms have been prolonged beyond six weeks, and passive care in this phase is as necessary, not generally to exceed two treatments per week, to avoid promoting chronicity or physician dependence.

          2. Activities of Daily Living (ADL): Management emphasis shifts to active care, dissuasion of pain behavior, patient education, flexibility and stabilization exercises. Rehabilitation may be appropriate.

          3. Return to Pre-episode Status: 6-16 weeks.

          4. Supportive Care: Inappropriate.

          5. Rating: These recommendations are safe and effective in reaching the desired objective. They have a promising rating based upon the relationship to natural history and are supported by Class II and III evidence.

            Consensus Level: 1

            Strength of Recommendation: Type B

        4. Chronic Episode

          1. Symptom Response: Symptoms have been prolonged beyond 16 weeks, and passive care is for acute exacerbation only.

          2. Activities of Daily Living (ADL): Supervised rehabilitation and life style changes are appropriate.

          3. Return to Preinjury Status: May not return. Maximum therapeutic benefit and declaration should be considered.

          4. Supportive Care: Supportive care using passive therapy may be necessary if repeated efforts to withdraw treatment/care result in significant deterioration of clinical status.

          5. Rating: These chronic episode recommendations are safe and effective in reaching the desired objectives of sustaining the optimal health status under the circumstances. The rating is promising. Chronic disorder treatment/care is supported by Class II and III evidence.

            Consensus Level: 1

            Strength of Recommendation: Type B.

    7. Elective Care:

      Under specific circumstances for individual cases, elective care may be safe and effective. Elective care must be designed to avoid physician dependence and chronicity. Therapeutic necessity is absent by definition.

      Rating: Unrated

      Consensus Level: 1


  9. Reassessment:

    1. Reassessments - General Principles

      Reassessments are an integral component of case management and should be made following an appropriate period of care.

      Rating: Necessary
      Evidence: Class II, III
      Consensus Level: 1

      The necessity for and the content of reassessments are determined by the patient’s response. Patients responding as expected might be reassessed later and with fewer tests; those not responding or responding more slowly should be re-evaluated sooner and possibly more thoroughly. A knowledge of the natural history of the condition greatly facilitates decisions concerning the timing of reassessment.

      Rating: Necessary
      Evidence: Class II, III
      Consensus Level: 1

      Appropriate reassessment shall be made as soon as possible if the patient demonstrates a marked worsening of clinical status.

      Rating: Necessary
      Evidence: Class III
      Consensus Level: 1

      Appropriate reassessment shall be made if the patient begins to manifest clinical signs or symptoms in areas not previously evaluated.

      Rating: Necessary
      Evidence: Class II, III
      Consensus Level: 1

      Reassessment should be performed by persons appropriately trained and qualified in the specific procedures.

      Rating: Necessary
      Evidence: Class II, III
      Consensus Level: 1

      Reassessment should be performed, as closely as possible, in the same manner as the initial assessment.

      Rating: Recommended
      Evidence: Class I, II, III
      Consensus Level: 1

      Reassessments performed solely to satisfy third party interests should be performed with due regard for all the recommendations presented in this chapter.

      Rating: Recommended
      Evidence: Class III
      Consensus Level: 1

      Interactive reassessment should be performed during each patient encounter for the purpose of confirming or modifying a clinical impression.

    2. Interactive Reassessment
      Rating: Necessary
      Evidence: Class III
      Consensus Level: 1

    3. Periodic Reassessment

      Periodic reassessment should be performed only after it would be reasonably expected that some measurable change in the patient’s clinical condition would have occurred.

      Rating: Necessary
      Evidence: Class III
      Consensus Level: 1

      Periodic reassessment should be made in all areas in which there were prior positive clinical findings.

      Rating: Necessary
      Evidence: Class III
      Consensus Level: 1



  10. Outcome Assessment:

    NOTE: The recommendations on the following procedures or methods refer specifically to their use as outcome assessments and not necessarily to their use for other clinical purposes such as for diagnosis, prognosis, or for designing treatment plans.

    1. Functional Outcome Assessments (By Questionnaire)

      As a category, functional outcome assessments of everyday tasks are very suitable for evaluating treatment of dysfunctions of the neuromusculoskeletal system. Many questionnaires could be used; choice should depend upon the validity, reliability, responsiveness, and practicality demonstrated in the scientific literature.

      Rating: Establishing for assessing patients with neuromusculoskeletal disorders.
      Evidence: Class I, II, III
      Consensus Level: 1

    2. Patient Perception Outcome Assessments

      Pain: Pain measurement is generally a relevant, valid, reliable, responsive, and safe outcome assessment. Practicality may vary depending on the specific procedure used.

      Rating: Established
      Evidence: Class I, II, III
      Consensus Level: 1

      Patient Satisfaction Measures: Patient satisfaction measures are an important marker of quality and are useful in clinical practice. Satisfaction is best assessed using standard questionnaires measuring a number of dimensions. Scales may be found in the scientific literature. Although additional research as satisfaction relates to chiropractic practice is required, validity, reliability, responsiveness, relevance, safety and practicality are scientifically supported.

      Rating: Established
      Evidence: Class I, II, III
      Consensus Level: 1

    3. General Health Outcome Assessments

      As a category of outcomes, general health is possible and desirable to assess. Depending on the particular scale chosen, validity, reliability, and responsiveness have been demonstrated. The measures are safe; some are more practical than others. General health assessments should be used along with condition specific assessments.

      Rating: Established
      Evidence: Class I, II, III
      Consensus Level: 1

    4. Physiological Outcomes

      Range of Motion: Depending upon the method applied, assessment of range of motion is a valid, reliable, responsive, safe outcome assessment. Depending on the level of automation, practical considerations may vary.

      Rating: Established
      Evidence: Class I, II, III
      Consensus Level: 1

      Thermography: Thermographic exams of the trunk and extremities with infrared or liquid crystal may be valid for certain diagnoses of the neuromusculoskeletal system. The validity of the numerous single and dual probe type hand-held instruments is less clear. The few reliability studies that exist are not particularly encouraging. There is very little scientific data to support the responsiveness of thermographic measurements to changes in health status. The procedures are generally safe, but the practicality of thermography depends upon the equipment and the examination procedures used. Thermograms should be interpreted by those trained in the procedure.

      Rating: Investigation to equivocal as an outcome assessment for patients with neuromusculoskeletal conditions.
      Evidence: Class II, III (For minority opinion)
      Consensus Level: 3

      Muscle Function: There are many methods of assessing the parameters of muscle function. Manual methods have not been explored adequately enough to assure validity, reliability, relevance and responsiveness to care. Manual methods, however, are practical and generally safe and tend to be popular. Studies with automated methods (e.g., Cybex, etc.) have suggested a greater level of confidence, but require expert training, and are time-consuming.

      Rating: Established for instrumented methods to measure muscle function.
      Evidence: Class I, II, III
      Consensus Level: 1

      Rating: Equivocal for manual methods to measure muscle function.
      Evidence: Class II, III
      Consensus Level: 1

      Postural Evaluations: Certain postural parameters may be responsive to treatment, but validity, reliability and relevance issues still need to be addressed scientifically. Depending on the method, postural observations are probably practical and safe.

      Rating: Promising
      Evidence: Class II, III
      Consensus Level: 1

    5. Subluxation Syndrome

      The subluxation syndrome provides decision-making information for application of chiropractic treatment methods, primarily adjustments and manipulations. Regarding outcome assessments, the various components must be considered separately. These are discussed below.

      Vertebral Position Assessed Radiographically: The clinical relevance of small changes in vertebral position is scientifically controversial. Responsiveness of vertebral position to manipulative/adjustive treatment care has been established in some cases. Observational studies have not ruled it out. Many practitioners accept measurement of vertebral position as routine and customary. The risk/benefit ratio of using radiographs for measuring vertebral position as an outcome assessment should be carefully considered.

      Rating: Equivocal
      Evidence: Class II, III
      Consensus Level: 1

      Abnormal Segmental Motion/Lack of Joint End-play Assessed by Palpation: There are a few validity studies of joint palpation although the existing literature on reliability is disappointing. There are studies suggesting that palpatory signs diminish with treatment, but the degree of responsiveness has been difficult to quantify. In skilled hands, palpation is safe.

      Rating: Equivocal to Promising (as an outcome assessment for patients with neuromusculoskeletal conditions
      Evidence: Class II, III
      Consensus Level: 1

      Abnormal Segmental Motion Assessed Radiographically: There are few validity studies, reliability has been questioned, and the relevance is controversial. While responsiveness of segmental motion to treatment has not been confirmed experimentally, observational studies have not ruled it out. The risk/benefit ratio of radiographs to assess this outcome must be seriously considered.

      Rating: Investigational (as an outcome assessment for patients with neuromusculoskeletal conditions)
      Evidence: Class II, III
      Consensus Level: 1

      Soft-Tissue Compliance and Tenderness: Clinical studies indicate a relationship between tenderness and painful neuromusculoskeletal conditions. Clinical reliability has been established. Compliance and tenderness appear to be responsive to treatment. Algometers, tissue compliance meters, and palpatory methods appear to be practical and safe.

      Rating: Promising (as an outcome measure for patients with neuromusculoskeletal conditions)
      Evidence: Class I, II, III
      Consensus Level: 1

      Asymmetric or Hypertonic Muscle Contraction: There is no question that surface EMG procedures measure some aspects of muscle activity. However, clinical relevance and reliability have been more difficult to demonstrate scientifically. The responsiveness of EMG measurements to treatment has not been confirmed experimentally to any great degree. Surface methods are safe.

      Rating: Equivocal for fixed electrodes as an outcome assessment for patients with neuromusculoskeletal conditions.
      Evidence: Class I, II, III
      Consensus Level: 1

      Rating: Investigational to Equivocal for scanning EMG as an outcome assessment for neuromusculoskeletal conditions.
      Evidence: Class II, III
      Consensus Level: 3

    6. Principles of Application

      The subluxation syndrome should be used as an outcome assessment only when the actual parameters being measured have been explicitly identified.

      Rating: Recommended
      Evidence: Class II, III
      Consensus Level: 1

      Outcome assessments should only be performed and interpreted by appropriately trained and qualified individuals.

      Rating: Necessary
      Evidence: Class II, III
      Consensus Level: 1

      When outcome assessments are used, consideration must be made for their established test properties, for patient compliance, and for the nature of the condition(s) being assessed.

      Rating: Necessary
      Evidence: Class II, III
      Consensus Level: 1

      Patient outcomes should be assessed at appropriate intervals during case management depending upon the nature of the condition and the patient’s progress.

      Rating: Necessary
      Evidence: Class II, III
      Consensus Level: 1

      Generic functional and health status outcome measurements are essential for comparing outcomes across different patient populations and treatment interventions, while disease or condition-specific measures assess the special concerns of patients with certain diagnoses. Outcome information is very valuable to doctors of chiropractic, and to the chiropractic profession. Therefore, whenever feasible, a general health outcome of chiropractic care should be assessed by a standardized, commonly accepted method; and whenever feasible, a condition specific outcome of chiropractic care should be assessed by a standardized, commonly accepted method.

      Rating: Recommended
      Evidence: Class II, III
      Consensus Level: 1



  11. Collaborative Care:

    1. The Patient and the Primary Care Provider

      Patients are entitled to a clear explanation of why the participation of other health professionals has been determined to be necessary.
      Rating: Necessary
      Evidence: Class II, III
      Consensus Level: 1

    2. Freedom of Choice and Informed Consent

      All health care professionals should recognize and respect the right of the patient to select his/her own method of health care and the setting in which that care is delivered, as well as the right of the patient to change providers at will.

      Rating: Necessary
      Evidence: Class III
      Consensus Level: 1

      2. Primary health care providers should supply sufficient information to enable the patient to make an informed decision regarding choices in treatment/care and of providers.

      Rating: Necessary
      Evidence: Class III
      Consensus Level: 1

    3. Professional Knowledge and Understanding

      1. Chiropractic practitioners should be familiar with medical procedures and terminology as needed, so as to effectively understand and relate medical care delivered to or recommended to a patient.

      Rating: Recommended
      Evidence: Class II, III
      Consensus Level: 1

      2. Chiropractic practitioners should make every reasonable effort to be familiar with alternative health care providers whose care my have implications for the care of their patients, and should strive to communicate such information, as appropriate, to the patient.

      Rating: Recommended
      Evidence: Class III
      Consensus Level: 1

    4. Referrals

      1. Primary health care providers should consult or refer if the needs of the patient so indicate.

      Rating: Necessary
      Evidence: Class I, II, III
      Consensus Level: 1

      2. Chiropractic practitioners should accept referrals from other health care providers.

      Rating: Recommended
      Evidence: Class III
      Consensus Level: 1

    5. Exchange of Information and Records between Providers
      1. Chiropractic practitioners referring a patient to a peer or another professional should take all necessary steps to provide information from the case history and diagnostic findings to the practitioner receiving the referral in an effort to minimize unnecessary testing or repetition of diagnostic procedures.
        Rating: Recommended
        Evidence: Class III
        Consensus Level: 1

      2. Postreferral communication between referring and receiving practitioners should be complete and adequately detailed. Appropriate records of clinical findings or recommendations should be exchanged.
        Rating: Recommended
        Evidence: Class III
        Consensus Level: 1

      3. Questions about care decisions made or recommended by another provider should be addressed directly to that provider in a constructive manner. Relying on the patient to be an effective messenger of critical information is inappropriate.
        Rating: Recommended
        Evidence: Class III
        Consensus Level: 1

      4. Response to requests for records should occur in a timely fashion. Likewise, records requested by the practitioner that are another practitioner’s property should be retured in a timely fashion.
        Rating: Recommended
        Evidence: Class III
        Consensus Level: 1

    6. Professional Interaction in the Hospital or Other Institutional Setting
      1. In a collaborative or cooperative care setting, every effort should be made to develop and present to the patient a consensus among all participating practitioners on the recommended course of care.

      2. Rating: Recommended
        Evidence: Class III
        Consensus Level: 1

      3. Practitioners should seek access to other health care facilities and institutions as necessary to meet the needs of their patients. This may include authority to admit or co-admit the patient into the appropriate clinical setting or hospital.
        Rating: Recommended
        Evidence: Class III
        Consensus Level: 1

      4. In the process of concurrent care, each professional party should be aware of the care decisions made by other participants, and fully coordinate activities and information for the patient’s benefit.
        Rating: Recommended
        Evidence: Class III
        Consensus Level: 1

      5. The resolution of disputes between members of different professions on the course of care for a given patient should be based on: a) the best professional judgment of the practitioners involved; b) the objective evaluation of appropriate clinical options and intervention alternatives; and c) responsible family involvement where appropriate.

        Informed consent on the part of the patient continues to be necessary.

        Rating: Recommended
        Evidence: Class III
        Consensus Level: 1

      6. To facilitate patient access to the widest possible range of health care resources and options, practitioners are encouraged to seek participation in managed health care organizations (e.g., HMOs, PPOs, etc.).

      7. Rating: Recommended
        Evidence: Class III
        Consensus Level: 1

    7. Economic Considerations
      1. No referral should be sought or made on the basis of economic considerations and no financial relationship should exist between parties in a referral process. No fee, rebate or commission should be paid to any referring provider for the referral.
        Rating: Necessary
        Evidence: Class III
        Consensus Level: 1

      2. Primary providers should cooperate to secure proper insurance payment for all clinically-indicated health care services.
        Rating: Recommended
        Evidence: Class III
        Consensus Level: 1



  12. Contraindications and Complications:
    Note:
    General health problems which have been described in the literature as either contraindications to or complications of high-velocity thrust procedures include the following conditions. It should be understood that the listed conditions are not necessarily those for which high-velocity thrust procedures are intended. Rather they may be coincidentally present in a patient undergoing treatment. The fundamental object of treatment is a manipulable joint lesion (subluxation, dysfunction, blockage).

    1. Articular Derangements
      1. Acute rheumatoid, rheumatoidlike and nonspecific arthropathies including acute ankylosing spondylitis characterized by episodes of acute inflammation, demineralization, ligamentous laxity with anatomic subluxation or dislocation, represent an absolute contraindication to high-velocity thrust procedures in anatomical regions of involvement.

        Risk-of-Complication Rating:
        Severity: Moderate to High
        Condition Rating: Type III
        Quality of Evidence: Class II, III
        Consensus Level: 1

      2. Sub-acute and/or chronic ankylosing spondylitis and other chronic arthropathies in which there are no signs of ligamentous laxity, anatomic subluxation or ankylosis are not contraindications to high-velocity thrust procedures applied to the area of pathology.

        Risk-of-Complication Rating:
        Severity: Minimal
        Condition Rating: Type I, II
        Quality of Evidence: Class II, III
        Consensus Level: 1

      3. Degenerative joint disease, osteoarthritis, degenerative discopathy and spondyloarthrosis are not contraindications to high-velocity thrust procedures to the area of pathology but treatment modification may be warranted during active inflammatory phases.

        Risk-of-Complication Rating:
        Severity: Minimal
        Condition Rating: Type I, II
        Quality of Evidence: Class II
        Consensus Level: 1

      4. In patients with spondylolysis and spondylolisthesis caution is warranted when high-velocity thrust procedures are used. These conditions are not contraindications, but with progressive slippage they may represent a relative contraindication.

        Risk-of-Complication Rating:
        Severity: Minimal to Moderate
        Condition Rating: Type I, II
        Quality of Evidence: Class II
        Consensus Level: 1

      5. Acute fractures and dislocations, or healed fractures and dislocations with signs of ligamentous rupture or instability, represent an absolute contraindication to high-velocity thrust procedures applied to the anatomical site or region.

        Risk-of-Complication Rating:
        Severity: High
        Condition Rating: Type III
        Quality of Evidence: Class Ill
        Consensus Level: 1

      6. Unstable os odontoideum represents an absolute contraindication to high-velocity thrust procedures to the area of pathology.

        Risk-of-Complication Rating:
        Severity: High
        Condition Rating: Type III
        Quality of Evidence: Class III
        Consensus Level: 1

      7. Articular hypermobility, and circumstances where the stability of a joint is uncertain, represent a relative contraindication to high-velocity thrust procedures to the area of pathology.

        Risk-of-Complication Rating:
        Severity: Minimal
        Condition Rating: Type I, II
        Quality of Evidence: Class II, III
        Consensus Level: 1

      8. Postsurgical joints or segments with no evidence of instability are not a contraindication to high-velocity thrust procedures but may represent a relative contraindication depending on clinical signs (e.g., response, pretest tolerance or degree of healing).

        Risk-of-Complication Rating:
        Severity: Minimal
        Condition Rating: Type II
        Quality of Evidence: Class III
        Consensus Level: 1

      9. Acute injuries of osseous and soft tissues may require modification of treatment. In most cases, high-velocity thrust procedures to the area of pathology are not contraindicated.

        Risk-of-Complication Rating:
        Severity: Minimal to moderate
        Condition Rating: Type I, II
        Quality of Evidence: Class I, II
        Consensus Level: 1

      10. The presence of scoliosis is not a contraindication to high-velocity thrust procedure.

        Risk-of-Complication Rating:
        Severity: Minimal
        Condition Rating: Type I, II
        Quality of Evidence: Class II, Ill
        Consensus Level: 1

    2. Bone Weakening and Destructive Disorders
      1. Active juvenile avascular necrosis, specifically of the weight bearing joints (e.g., Perthes’ disease) represents an absolute contraindication to high-velocity thrust procedures to the area of pathology.

        Risk-of-Complication Rating:
        Severity: High
        Condition Rating: Type III
        Quality of Evidence: Class III
        Consensus Level: 1

      2. Demineralization of bone warrants caution with the use of high-velocity thrust procedures. This represents a relative contraindication to high-velocity thrust procedures to the area of pathology.

        Risk-of-Complication Rating:
        Severity: Minimal to Moderate
        Condition Rating: Type II
        Quality of Evidence: Class II, III
        Consensus Level: 1

      3. Benign bone tumors may result in pathological fractures and therefore represent a relative to absolute contraindication to high-velocity thrust procedures to the area of pathology.

        Risk-of-Complication Rating:
        Severity: Low to Moderate
        Condition Rating: Type II, III
        Quality of Evidence: Class III
        Consensus Level: 1

      4. Malignancies represent conditions for which high-velocity thrust procedures to the area of pathology are absolutely contraindicated.

        Risk-of-Complication Rating:
        Severity: Moderate to High
        Condition Rating: Type III
        Quality of Evidence: Class II, III
        Consensus Level: 1

      5. Infection of bone and joint represents an absolute contraindication to high-velocity thrust procedures to the area of pathology.

        Risk-of-Complication Rating:
        Severity: Minimal to High
        Condition Rating: Type III
        Quality of Evidence: Class II
        Consensus Level: 1

    3. Circulatory and Cardiovascular Disorders
      1. Clinical manifestations of vertebrobasilar insufficiency syndrome warrant particular caution and represent a relative to absolute contraindication to cervical high-velocity thrust procedures to the region of pathology.

        Risk-of-Complication Rating:
        Severity: Minimal to High
        Condition Rating: Type II, III
        Quality of Evidence: Class I, II, III
        Consensus Level: 1

      2. When a diagnosis of a significant aneurysm involving a major blood vessel has been made, a relative to absolute contraindication may exist for high-velocity thrust procedures within the area of pathology.

        Risk-of-Complication Rating:
        Severity: High
        Condition Rating: Type III
        Quality of Evidence: Class III
        Consensus Level: 1

      3. Bleeding is a potential complication of anticoagulant therapy or certain blood dyscrasias. Patients with these disorders represent a relative contraindication to high-velocity thrust procedures.

        Risk-of-Complication Rating:
        Severity: Minimal to High
        Condition Rating: Type II
        Quality of Evidence: Class III
        Consensus Level: 1

    4. Neurological Disorders
      1. Signs and symptoms of acute myelopathy or acute cauda equina syndrome represent an absolute contraindication to high-velocity thrust procedures applied to the anatomic site of involvement.

        Risk-of-Complication Rating:
        Severity: High
        Condition Rating: Type II, III
        Quality of Evidence: Class I, II
        Consensus Level: 1

        * Most dysfunctions or disease processes have variations or phases. Levels of severity and probability have been assigned on the basis that the condition displays usual and classical signs and symptoms. The difficulty in precisely detailing the degree or severity and probability of an individual patient’s overall physical and psychological response both to the condition and therapeutic procedure (subtleties of force, amplitude, direction, patient positioning, etc.) is acknowledged. Nevertheless, ratings have been assigned based on the literature and the current consensus process. These provide a starting point which will require ongoing review and refinement.

        Some conditions, such as scoliosis, are not level-specific and high-velocity thrust procedures used apply more to a region than a level.


  13. Preventive Maintenance Care and Public Health:

    1. Preventive/Maintenance Care
      1. Disclosure:

        Preventive/maintenance care is discretionary and elective on the part of the patient. When recommended, it is necessary for the practitioner to clearly identify the type and nature of this care and to give proper patient disclosure.

        Rating: Established
        Evidence: Class III
        Consensus Level: 1


      2. Use of Chiropractic Adjustments:

        The clinical experience of the profession developed over a period of nearly 100 years suggests that the use of chiropractic adjustments in a regimen of preventive/maintenance care has merit.

        Rating: Equivocal
        Evidence: Class III
        Consensus Level: 1

      3. Health Screening:

        The importance of health preventive strategies is widely recognized. These services may have value in identifying early or potential manifestations of a health problem.

        Rating: Promising to Established
        Evidence: Class II, III
        Consensus Level: 1

      4. Health Promotion:

        Preventive orientation to health through health promotion is well established. Health promotion provides the opportunity for chiropractic practitioners to promote health through assessment, education, and counseling on topics such as nutrition, exercise, stress reduction, life style patterns, weight reduction, smoking cessation, and ergonomics, among others.

        Rating: Established
        Evidence: Class I, II, III
        Consensus Level: 1

      5. Wellness Care:

        Chiropractic is the largest of the holistic-oriented professions. Wellness and health management lifestyle strategies have gained popularity and acceptance. Chiropractic practitioners may choose to expand their practices to include those interventions that may influence a person’s attainment of optimum performance and behavior, and in so doing, improve health status. This kind of care is performance specific (i.e., quality of life) rather than condition (e.g., symptom) specific.

        Rating: Equivocal
        Evidence: Class III
        Consensus Level: 1

    2. Public Health Considerations
      1. Community Screening:

        Community-based screening programs are commonly used by all disciplines to promote public health. Spinal screening and blood pressure checks offer excellent examples of such programs.

        Rating: Promising
        Evidence: Class II, III
        Consensus Level: 1

      2. Public Health Considerations:

        The chiropractic profession has recognized the need to engage in the local, state, national and international agendas of public health. Such programs provide opportunities for education and understanding programs regarding spinal health, nutrition, exercise and life styles, drugs, alcohol, tobacco, and infectious disease, as well as environmental and other social issues.

        Rating: Promising
        Evidence: Class II, III
        Consensus Level: 1



  14. Professional Development:

    1. Continuing Education
      1. It is expected that every practitioner shall participate in continuing education.

      2. Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

      3. Continuing education should be ongoing and should facilitate successful clinical performance.
        Rating: Recommended
        Evidence: Class I, II, III
        Consensus Level: 1

      4. Completion of mandatory continuing education requirements for license renewal does not necessarily assure continuing competency. Those requirements should include assessment of outcomes by administering institutions/organizations to evaluate the effectiveness of their programs.
        Rating: Recommended
        Evidence: Class I, II, III
        Consensus Level: 1

      5. Continuing education should allow for a variety of instructional formats.
        Rating: Recommended
        Evidence: Class II, III
        Consensus Level: 1

      6. Practitioners should continue to educate themselves through critical reading and review of clinical and/or scientific literature.
        Rating: Recommended
        Evidence: Class II, III
        Consensus Level: 1

    2. Postgraduate Education
      1. All chiropractic colleges are encouraged to provide residency programs for qualified graduates for the purpose of advanced research, education and clinical practice.
        Rating: Recommended
        Evidence: Class II, III
        Consensus Level: 1

      2. Colleges should provide opportunities for postgraduate programs for professional development which may lead to certification or specialty status.
        Rating: Recommended
        Evidence: Class II, III
        Consensus Level: 1

      3. Practitioners are encouraged to participate in certification or specialty postgraduate education programs (e.g., specialty programs). It is expected that every practitioner shall participate in continuing education.
        Rating: Discretionary
        Evidence: Class II, III
        Consensus Level: 1

      4. Where such postgraduate programs exist the impact and outcome should be measured appropriately.
        Rating: Recommended
        Evidence: Class II, III
        Consensus Level: 1

      5. Proprietary programs should affiliate with accredited educational institutions for the purposes of development, evaluation and implementation.
        Rating: Recommended
        Evidence: Class II, III
        Consensus Level: 1

    3. Graduate Education
        1. Practitioners are encouraged to participate in programs providing graduate education (e.g., masters or doctorate) offered by accredited educational institutions.
          Rating: Discretionary
          Evidence: Class II, III
          Consensus Level: 1

    4. Professional Organizations
      1. Practitioners should be members of one or more professional associations.
        Rating: Recommended
        Evidence: Class II, III
        Consensus Level: 1

        Comment: Professional organizations and associations provide a structure of responsibility through which members develop and maintain awareness of professional developments and gain enhanced professional competence. Practitioners also develop leadership abilities by participating in sponsored conventions, conferences, workshops and other gatherings; receive publications pertinent to the profession; support and encourage legislative programs and otherwise influence public policy in the interests of the public and the profession.


    5. Ethics/Standards of Conduct
      1. Practitioners should conduct themselves in a manner consistent with a professional code of ethics which addresses morality, honesty and all aspects of professional conduct.
        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

      2. Practitioners who advertise should do so in a responsible, ethical and professional manner.
        Rating: Necessary
        Evidence: Class I, II, III
        Consensus Level: 1

        Comment: The responsibility for regulation of advertising lies with professional associations and licensing boards. Professional organizations can assist by enforcing guidelines established for the membership; the state licensing boards promulgate rules to aid the profession and safeguard the public. Violation of state or provincial laws can result in fines or suspension or revocation of a license.


    6. Research
      1. Practitioners are encouraged to participate in research and support institutions/organizations conducting research, for the purposes of professional development and improved patient care. Valid research requires appropriate research protocols as approved by recognized institutional review boards.
        Rating: Recommended
        Evidence: Class I, II, III
        Consensus Level: 1



    DEFINITIONS:

    Procedure Ratings (System I)

    This system is suited to scientific/technical areas of practice.

    Quality of Evidence

    The following categories of evidence are used to support the ratings.

    Class I:Evidence provided by one or more well-designed controlled clinical trials; or well-designed experimental studies that address reliability, validity, positive predictive value, discriminability, sensitivity, and specificity.

    Class II:Evidence provided by one or more well-designed uncontrolled, observational clinical studies such as case control, cohort studies, etc.; or clinically relevant basic science studies that address reliability, validity, positive predictive value, discriminability, sensitivity and specificity; and published in refereed journals.

    Class III:Evidence provided by expert opinion, descriptive studies or case reports.

    Strength of Recommendation Ratings

    Type A: Strong positive recommendation. Based on Class I evidence or overwhelming Class II evidence when circumstances preclude randomized clinical trials.

    Type B: Positive recommendation based on Class II evidence.

    Type C: Positive recommendation based on strong consensus of Class II evidence.

    Type D: Negative recommendation based on inconclusive or conflicting Class II evidence.

    Type E: Negative recommendation based on evidence of ineffectiveness or lack of efficacy based on Class I or Class II evidence.

    Procedure Rating (System II)

    This system is suited to procedural/administrative aspects of practice. Accordingly it is used in chapters such as History and Physical Examination, Record Keeping and Patient Consents and Collaborative Care. One can discover which rating system is being used by looking at Part V (Assessment Criteria) of each chapter.

    Quality of Evidence

    The following categories of evidence are used to support the ratings.

    Class I:

    1. Evidence of clinical utility from controlled studies published in refereed journals.

    2. Binding or strongly persuasive legal authority such as legislation or case law.

    Class II:

    1. Evidence of clinical utility from the significant results of uncontrolled studies in refereed journals.

    2. Evidence provided by recommendation from published expert legal opinion or persuasive case law.

    Class III:

    1. Evidence of clinical utility provided by opinions of experts, anecdote and/or by convention.

    2. Expert legal opinion.

NGC STATUS:

The NGC summary, including these Major Recommendations, was completed by ECRI on May 5, 1999. The information was verified by the guideline developer as of June 30, 1999.

COPYRIGHT STATEMENT:

This NGC Summary, including these Major Recommendations, is based on the original guideline, which is copyrighted by Aspen Publishers, Inc. Sections of this NGC Summary are reprinted with permission from Haldeman S, Chapman-Smith D, Petersen DM Jr. Guidelines for Chiropractic Quality Assurance and Practice Parameters: Proceedings of the Mercy Center Consensus Conference, Copyright 1993 by Aspen Publishers, Inc. All rights reserved. The content available through the National Guideline Clearinghouse is protected by copyright and other intellectual property laws and may not be reproduced, sold, published, broadcast, or circulated to anyone, including but not limited to others in the same company or organization, without the express prior written consent of Aspen Publishers, Inc. Requests for permission to photocopy may be directed to Permissions Department, Aspen Publishers, Inc., 200 Orchard Dr, Gaithersburg, MD 20878; fax, (301) 417-7550


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