Definitions of the Recommendation Ratings and Categories of Evidence are provided at the end of the "Major Recommendations" field.
History and Chiropractic Examination
Case History
Recommendation
A thorough case history should precede the initiation of chiropractic care. The elements of this history should include general information, reason for seeking chiropractic care, onset and duration of any symptomatic problem, family history, past health history, occupational history, and social history.
Rating: Established
Evidence: E, L
Chiropractic Examination
Recommendation
The initial chiropractic examination shall include a case history and an assessment for the presence of vertebral subluxation, which, if present, is to be noted with regard to location and character. A review of systems may be conducted at the discretion of the practitioner, consistent with individual training and applicable state laws.
Reassessments may be conducted periodically throughout a course of chiropractic care to assess patient progress. Such reassessments typically emphasize re-examination of findings which were positive on the previous examination, although need not be limited to same. Reassessment is also indicated in the case of trauma or change in the clinical status of a patient.
Rating: Established
Evidence: E, L
Instrumentation
Recommendation
Instrumentation is indicated for the qualitative and/or quantitative assessment of the biomechanical and physiological components of vertebral subluxation. When using instrumentation, baseline values should be determined prior to the initiation of care.
Rating: Established
Evidence E, L
Postural Analysis
Sub-Recommendation
Postural analysis using plumb line devices, computerized and non-computerized instruments may be used to evaluate changes in posture associated with vertebral subluxation.
Rating: Established
Evidence: E, L
Bilateral and Four-Quadrant Weight Scales
Sub-Recommendation
Bilateral and four-quadrant weight scales may be used to determine the weight distribution asymmetries indicative of spinal abnormalities.
Rating: Established
Evidence: E, L
Moiré Contourography
Sub-Recommendation
Moiré contourography may be used to provide a photographic record of changes in body contour associated with vertebral subluxation.
Rating: Established
Evidence: E, L
Inclinometry
Inclinometry may be used as a means of measuring motion against a constant vertical component of gravity as a reference. Changes in ranges of spinal motion may be associated with vertebral subluxation.
Rating: Established
Evidence: E, L
Goniometry
Sub-Recommendation
Goniometry, computer associated or not, may be used to measure joint motion. Inclinometry is superior to goniometry when standardized procedures are employed.
Rating: Established
Evidence: E, L
Algometry
Sub-Recommendation
Algometry may be used to measure pressure-pain threshold. Changes in sensory function associated with vertebral subluxation may produce changes in pressure-pain thresholds.
Rating: Established
Evidence: E, L
Current Perception Threshold (CPT) Testing
Sub-Recommendation
Current perception threshold devices may be used for the quantitative assessment of sensory nerve function. Alterations in sensory nerve function may be associated with vertebral subluxation.
Rating: Established
Evidence: E, L
Electroencephalography (EEG)
Sub-Recommendation
Electroencephalographic techniques, including brain mapping and spectral analysis, may be used to assess the effects of vertebral subluxation and chiropractic adjustment associated with brain function.
Rating: Established
Evidence: E, L
Somatosensory Evoked Potentials (SSEP)
Sub-Recommendation
Somatosensory evoked potentials may be used for localizing neurological dysfunction associated with vertebral subluxations.
Rating: Established
Evidence: E, L
Skin Temperature Instrumentation
Sub-Recommendation
Temperature reading devices employing thermocouples, infrared thermometry, or thermography (liquid crystal, telethermography, multiple infrared [IR] detector, etc.) may be used to detect temperature changes in spinal and paraspinal tissues related to vertebral subluxation.
Rating: Established
Evidence: E, L
Surface Electromyography
Sub-Recommendation
Surface electrode electromyography, using hand-held electrodes or affixed electrodes, may be used for recording changes in the electrical activity of muscles associated with vertebral subluxations.
Rating: Established
Evidence: E, L, C
Muscle Strength Testing
Sub-Recommendation
Muscle strength and endurance testing may be used to ascertain and track muscle force generation and neuromuscular status. Clinically, it may be useful to quantify differences in strength between limbs or bodily segments. The evaluation of strength may be characterized by the experienced examiner based on various technologies. Manual, mechanized, and computerized muscle testing may be used to determine changes in the strength and other characteristics of muscles. These changes may be a result or a cause of alterations of function at various levels of the neuromuscular system and/or any other system related to the patient. Such changes may be associated with vertebral subluxation.
Rating: Established
Evidence: E, L
Questionnaires
Sub-Recommendation
Questionnaires may be used in the assessment of the performance of activities of daily living, pain perception, patient satisfaction, general health outcomes, patient perception outcomes, mental health outcomes, and overall quality of life throughout a course of chiropractic care. Questionnaires provide important information, but should not be used as a substitute for physical indicators of the presence and character of vertebral subluxations.
Rating: Established
Evidence: E, L
Heart Rate Variability
Sub-Recommendation
Heart rate variability may be used to assess autonomic dysfunction associated with vertebral subluxation.
Rating
: Established
Evidence
: E, L
Radiographic and Other Imaging
Recommendation
Diagnostic imaging procedures may be utilized to characterize the biomechanical manifestations of vertebral subluxation and to determine the presence of conditions which affect the safety and appropriateness of chiropractic care.
Plain Film Radiography
Sub-Recommendation
Plain film radiography is indicated to provide information concerning the structural integrity of the spine, skull, and pelvis; the misalignment component of the vertebral subluxation; the foraminal alteration component of the vertebral subluxation; and the postural status of the spinal column. Imaging procedures, including post-adjustment radiography, should be performed only when clinically necessary. It is common for lines of mensuration to be drawn on radiographs to assess subluxation and alignment. These procedures may be done by hand, or the chiropractor may utilize computerized radiographic digitization procedures.
Rating: Established
Evidence: E, L
Dosage and Shielding
Sub-Recommendation
Imaging procedures employing ionizing radiation should be performed consistent with the principles of obtaining films of high quality with minimal radiation. This may include the use of gonad shielding, compensating filters, and appropriate film-screen combinations.
Rating: Established
Evidence: E, L
Videofluoroscopy
Sub-Recommendation
Videofluoroscopy may be employed to provide motion views of the spine when abnormal motion patterns are clinically suspected. Videofluoroscopy may be valuable in detecting and characterizing spinal kinesiopathology associated with vertebral subluxation.
Rating: Established
Evidence: E, L
Magnetic Resonance Imaging (MRI)
Sub-Recommendation
Magnetic resonance imaging may be employed to assess suspected neoplastic, infectious, and degenerative conditions of the spine and related tissues as well as the stages of subluxation degeneration. Its use is generally restricted to instances where the desired information cannot be obtained by less costly procedures.
Rating: Established
Evidence: E, L
Computed Tomography (CT)
Sub-Recommendation
CT imaging may be employed to assess osseous and soft tissue pathology in the spine and contiguous tissues. Its use is generally restricted to instances where the desired information cannot be obtained by less costly procedures.
Spinal Ultrasonography
Sub-Recommendation
Spinal ultrasonography may be used to evaluate the size of the spinal canal and to detect pathology in the soft tissues surrounding the spine. Its applications in the assessment of the facet inflammation and nerve root inflammation remain investigational at this time.
Rating: Established for determining spinal canal size.
Investigational for facet and nerve root inflammation.
Evidence: E, L
Radioisotope Scanning (Nuclear Medicine Studies)
Sub-Recommendation
Radioisotope scans performed by qualified medical personnel may be used by a chiropractor to determine the extent and distribution of pathological processes which may affect the safety and appropriateness of chiropractic care when this information cannot be obtained by less invasive means.
Rating: Established
Evidence: E, L
Radiographic Digitizing Analysis
Sub-Recommendation
Computerized x-ray analysis may be used by chiropractors to objectively analyze the biomechanical and misalignment improprieties related to vertebral subluxation. Clinical necessity is justified for assessing the degree of insult and the effect upon the patient’s health and future well-being by way of impairment rating.
Rating: Established
Evidence: E, L
Clinical Impression and Assessment
Recommendation
Practitioners should develop a method of patient assessment which includes a sufficient diversity of findings to support the clinical impression as related to vertebral subluxation. In this regard, it is considered inappropriate to render an opinion regarding the appropriateness of chiropractic care without a chiropractic assessment, including a physical examination of the patient by a licensed chiropractor. When management of patient care is carried out in the collaborative setting, the chiropractor, as a primary contact health care provider, is the only professional qualified to determine the appropriateness of chiropractic care. The unique role of the chiropractor is separate from other health disciplines and should be clarified for both the patient and other practitioners. The patient assessment, specific to the technique practiced by the chiropractor, should minimally include a biomechanical and neurophysiological component. It is inappropriate to make a retrospective determination of the clinical need for care rendered prior to the assessment.
Rating: Established
Evidence: E, L
Record Keeping
Sub-Recommendation
Since record-keeping practices may be technique/method specific and may depend on the practice objective of the practitioner, chiropractors should develop a method of reporting the care they provide to their patients that is consistent with their practice objectives. Record-keeping systems for practitioners who limit their care to the analysis and correction of vertebral subluxation should minimally reflect the segments/regions adjusted and the techniques or methods employed if they are not self-evident. Other pertinent information may be included on an as-needed basis.
Note: This Sub-recommendation is in no way meant to contradict other recommendations made in these Guidelines that address issues related to Outcome Assessment, History and Examination, Duration of Care, and Instrumentation.
Rating: Established
Evidence: E, L
Peer Review & Chiropractic Necessity
Sub-Recommendation
The purpose of chiropractic peer review is to determine if the services rendered to the patient were necessary from a chiropractic perspective.
The general standard for necessary care is any care, therapeutic treatment, or services reasonably expected to improve, restore, or prevent the progression of any illness, injury, disease, disability, defect, condition, or the functioning of any body member. This is understood to include care provided to detect the existence of vertebral subluxation and the care provided to reduce or correct it.
Rating: Established
Evidence: E, L
Reassessment and Outcomes Assessment
Recommendation
Determination of the patient's progress must be made on a per-visit and periodic basis. This process provides quantitative and qualitative information regarding the patient's progress, which is utilized to determine the frequency and duration of chiropractic care. Per-visit reassessment should include at least one analytical procedure previously used. This chosen testing procedure should be performed each time the patient receives chiropractic care.
Concomitant with this process, the effectiveness of patient care may also be monitored through the development of an outcomes assessment plan. Such a plan may utilize data from the patient examination, assessment, and reassessment procedures. Patient-reported quality of life instruments, mental health surveys, and general health surveys are encouraged as part of the outcomes assessment plan. The analysis of data from these sources may be used to change or support continuation of a particular regimen of patient care and/or change or continue the operational procedures of the practice.
Rating: Established
Evidence: E, L
Modes of Adjustive Care
Recommendation
Adjusting procedures should be selected which are determined by the practitioner to be safe and effective for the individual patient. No mode of care should be used which has been demonstrated by critical scientific study and field experience to be unsafe or ineffective in the correction of vertebral subluxation.
Rating: Established
Evidence: E, L
Duration of Care for Correction of Vertebral Subluxation
Recommendation
Since the duration of care for correction of vertebral subluxation is patient specific, frequency of visits should be based upon the reduction and eventual resolution of indicators of vertebral subluxation. Since neither the scientific nor clinical literature provides any compelling evidence that substantiates or correlates any specific time period for the correction of vertebral subluxation, this recommendation has several components which are expressed as follows:
- Based on the variety of assessments utilized in the chiropractic profession, the quantity of indicators may vary, thus affecting the periodicity of their appearance and disappearance, which is tantamount to correction of vertebral subluxation.
- Vertebral subluxation, not being a singular episodic event, such as a strain or sprain, may be corrected but reappear, which necessitates careful monitoring and results in a wide variation in the number of adjustments required to affect a longer-term correction.
- Based on the integrity of the spine in terms of degree and extent of degeneration, the frequency of assessments and the necessity for corrective adjustments may vary considerably.
- Because the duration of care is being considered relative to the correction of vertebral subluxation, it is independent of clinical manifestations of specific dysfunctions, diseases, or syndromes. Treatment protocols and duration of care for these conditions are addressed in other guidelines, which may be appropriate for any practitioner whose clinical interests include alleviation of such conditions.
Rating: Established
Evidence: E, L
Chiropractic Care of Children
Recommendation
Since vertebral subluxation may affect individuals at any age, chiropractic care may be indicated at any time after birth. As with any age group, however, care must be taken to select adjustment methods most appropriate to the patient's stage of development and overall spinal integrity. Parental education by the subluxation-centered chiropractor concerning the importance of evaluating children for the presence of vertebral subluxation is encouraged.
Rating: Established
Evidence: E, L
Maternal Care
Recommendation
A woman’s body experiences numerous biomechanical adaptations and physiological changes during pregnancy. These changes may have an adverse affect on her neuromusculoskeletal system.
Because of these physiological and biomechanical compensations, practitioner care must be taken to select the specific analysis and adjustment most appropriate for the complex changes during the various stages of pregnancy.
The increased potential for spinal instability in the mother and the resulting subluxations in the woman’s spine throughout pregnancy affect the health and well-being of both her and her baby. This warrants regular chiropractic check ups in all women throughout pregnancy.
Patient education pertinent to chiropractic care in pregnancy is encouraged.
Rating: Established
Evidence: E, L
Patient Safety
Recommendation
Patient safety encompasses the entire spectrum of care offered by the chiropractor. Consequently, it is important to define at the onset, the nature of the practice as well as the limits of care to be offered. Minimally this should include a "Terms of Acceptance" document between the practitioner and the patient. Additionally, all aspects of clinical practice should be carefully chosen to offer the patient the greatest advantage with the minimum of risk.
Rating: Established
Evidence: E, L
Professional Development
Recommendation
The science, art, and philosophy of chiropractic, and hence its practice, continue to expand in understanding and development. Continuing professional development, as in all responsible health professions, is a necessary component of maintaining a high standard for both the practitioner and the profession. Continuing development should be directed to areas germane to each individual practice, including, but not limited to, credentialing, continuing education programs, participation in professional organizations, technique protocols and application, radiographic and other imaging, instrumentation, philosophy, research, practice liability issues, legal issues, and ethics.
Since all state licensing jurisdictions are ultimately responsible for patient health and safety, these guidelines recommend that all subjects congruent with state law be considered appropriate for continuing education credits in respective states.
Rating: Established
Evidence: E, L
Patient Privacy
Recommendation
Respecting patients' right of privacy has always been both an ethical and a legal duty. New federal regulations place specific, enforceable obligations on most chiropractors and their employees. Knowledge of and compliance with these regulations is essential in order to remain in practice.
Rating: Established
Evidence: E, L
Open/Community Adjusting Areas
Sub-Recommendation
It is acceptable for chiropractic care to be provided in a setting where more than one patient receives care in the same room. In such a case, the patients involved must consent to this arrangement. The chiropractor should have procedures where a patient who wishes to be examined or adjusted privately may do so.
Evidence: E
Patient Testimonials
Sub-Recommendation
A chiropractor must obtain written consent before disseminating any testimonial or case report where a specific patient may be identified. In all cases, use of testimonials must be in compliance with applicable state and federal laws, rules, and regulations.
Evidence: E
Definitions:
Recommendation Ratings:
Established. Accepted as appropriate for use in chiropractic practice for the indications and applications stated.
Investigational. Further study is warranted. Evidence is equivocal or insufficient to justify a rating of "established."
Inappropriate. Insufficient favorable evidence exists to support the use of this procedure in chiropractic practice.
Categories of Evidence:
E: Expert opinion based on clinical experience, basic science rationale, and/or individual case studies. Where appropriate, this category includes legal opinions.
L: Literature support in the form of reliability and validity studies, observational studies, "pre-post" studies, and/or multiple case studies. Where appropriate, this category includes case law.
C: Controlled studies, including randomized and non-randomized clinical trials of acceptable quality.