Note from Council on Chiropractic Practice: This document contains the changes, additions and revisions to the 1998 (1st Edition) and 2003 (2nd Edition) Council on Chiropractic Practice Clinical Guideline. Vertebral Subluxation in Chiropractic Practice. If a recommendation or sub-recommendation was added that was not included in the 1998 or 2003 Guidelines, these are noted. If a recommendation or sub-recommendation remains as it did in the 2003 guidelines, a simple statement that the recommendation remains "unchanged" follows that section/topic.
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 (Unchanged) |
| 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 (Unchanged) |
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.
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Rating: Established
Evidence: E, L
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Instrumentation
| Recommendation (Unchanged) |
| 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 (Unchanged) |
| 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 (Unchanged) |
| 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 (Unchanged) |
| 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
| Sub-Recommendation (Unchanged) |
| 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 (Unchanged) |
| 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 (Unchanged) |
| 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 (Unchanged) |
| 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 (Unchanged) |
| 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 (Unchanged) |
| Somatosensory evoked potentials may be used for localizing neurological dysfunction associated with vertebral subluxations. |
Rating: Established
Evidence: E, L
|
Skin Temperature Instrumentation
| Sub-Recommendation (Unchanged) |
| Temperature reading devices employing thermocouples, infrared thermometry, or thermography (liquid crystal, telethermography, multiple infrared [IR] detectors, 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 (Unchanged) |
| 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 subluxation. |
Rating: Established
Evidence: E, L, C
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Muscle Strength Testing
| Sub-Recommendation (Unchanged) |
| Muscle strength testing may be used to determine bilateral differences or other differences in patient resistance. These differences 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 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 (Unchanged) |
| 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
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Heart Rate Variability
| Sub-Recommendation (Unchanged) |
| Heart rate variability may be used to assess autonomic dysfunction associated with vertebral subluxation. |
Rating: Established
Evidence: E, L
|
Computer Assisted Differential Spinal Compliance
| Sub-Recommendation (New) |
| Computer assisted differential spinal compliance instruments may be used to assess changes in spinal and paraspinal tissue compliance associated with vertebral subluxation. |
Rating: Established
Evidence: E, L
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Radiographic and Other Imaging
| Recommendation (Unchanged) |
| 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. |
Rating: Established
Evidence: E, L
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Plain Film Radiography
| Sub-Recommendation (Unchanged) |
| 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 (Unchanged) |
| 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 (Unchanged) |
| 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
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Magnetic Resonance Imaging (MRI)
| Sub-Recommendation (Unchanged) |
| 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 (Unchanged) |
| 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. |
Rating: Established
Evidence: E, L
|
Spinal Ultrasonography
| Sub-Recommendation (Unchanged) |
| Spinal ultrasonography may be used to evaluate the size of the spinal canal (SC) and to detect pathologies 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 (SC size)
E, L (inflammation)
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Radioisotope Scanning (Nuclear Medicine Studies)
| Sub-Recommendation (Unchanged) |
| 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 (Unchanged) |
| 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 (Unchanged) |
| 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
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Record Keeping
| Sub-Recommendation (Unchanged) |
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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.
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Rating: Established
Evidence: E, L
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Reassessment and Outcomes Assessment
| Recommendation (Unchanged) |
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.
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Rating: Established
Evidence: E, L
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Modes of Adjustive Care
| Recommendation (Unchanged) |
| 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
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Duration of Care for Correction of Vertebral Subluxation
| Recommendation (Unchanged) |
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.
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Rating: Established
Evidence: E, L
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Chiropractic Care of Children
| Recommendation (Unchanged) |
| 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 Chiropractic Care
| Recommendation (Unchanged) |
| In pregnancy a woman's body experiences numerous biomechanical adaptations and physiological changes. These changes often have an adverse affect on her neuro-musculo-skeletal system affecting quality of life in pregnancy, birth outcome, and the future well-being of her baby. Because of these physiological compensations, practitioner care must be taken to select the specific analysis and adjustment most appropriate for the complex changes throughout the various stages of pregnancy. The increased potentials 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
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Subluxation and Well-Being
| Recommendation (New) |
"Doctors of Chiropractic advise and educate patients and communities in structural and spinal hygiene and healthful living practices." (Association of Chiropractic Colleges, 2009)
"Doctors of Chiropractic establish a doctor/patient relationship and utilize adjustive and other clinical procedures unique to the chiropractic discipline. Doctors of Chiropractic may also use other conservative patient care procedures, and, when appropriate, collaborate with and/or refer to other health care providers." (Association of Chiropractic Colleges, 2009)
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Rating: Established
Evidence: E, L
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Behavioral and Mental Health Issues
| Recommendation (New) |
| Chiropractic is not a treatment for specific behavioral or mental health conditions. However, chiropractic care is established as a clinical strategy that may improve the clinical strategy that may improve the clinical status of persons with general health issues and certain behavioral or mental health conditions. |
Rating: Established
Evidence: E, L
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Patient Safety, Privacy, and Advocacy
Patient Safety
| Recommendation (Unchanged) |
| 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
|
Patient Privacy
| Recommendation (Unchanged) |
| 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
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Patient Advocacy
| Recommendation (New) |
| Patient advocacy is an important part of advancing safety, efficacy, and utilization of chiropractic services. Effective patient advocacy programs promote quality, safety, appropriateness of service, support patient choice of adjustive care, and appropriateness of referrals inside and outside the profession. |
Rating: Established
Evidence: E, L
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Professional Development
| Recommendation (Unchanged) |
The science, art, and philosophy of chiropractic, and hence its practice, continues 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.
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Rating: Established
Evidence: E, L
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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.
