Clinical Practice Guideline: Chiropractic Care for Low ... RECERT ARTICLE 1.pdf · 5/20/2015 · Chiropractic Guidelines and Practice Parameters (CCGPP) in1995.6 Theorganization

CLINICAL PRACTICE GUIDELINE: CHIROPRACTIC

CARE FOR LOW BACK PAIN

Gary Globe, PhD, MBA, DC, a Ronald J. Farabaugh, DC, b Cheryl Hawk, DC, PhD, c Craig E. Morris, DC, dGreg Baker, DC, e Wayne M. Whalen, DC, f Sheryl Walters, MLS, g Martha Kaeser, DC, MA, hMark Dehen, DC, i and Thomas Augat, DC j

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ABSTRACT

Objective: The purpose of this article is to provide an update of a previously published evidence-based practiceguideline on chiropractic management of low back pain.Methods: This project updated and combined 3 previous guidelines. A systematic review of articles published betweenOctober 2009 through February 2014 was conducted to update the literature published since the previous Council onChiropractic Guidelines and Practice Parameters (CCGPP) guideline was developed. Articles with new relevant informationwere summarized and provided to the Delphi panel as background information along with the previous CCGPP guidelines.Delphi panelists who served on previous consensus projects and represented a broad sampling of jurisdictions and practiceexperience related to low back pain management were invited to participate. Thirty-seven panelists participated; 33 weredoctors of chiropractic (DCs). In addition, public comment was sought by posting the consensus statements on the CCGPPWeb site. The RAND-UCLA methodology was used to reach formal consensus.Results: Consensus was reached after 1 round of revisions, with an additional round conducted to reach consensus onthe changes that resulted from the public comment period. Most recommendations made in the original guidelineswere unchanged after going through the consensus process.Conclusions: The evidence supports that doctors of chiropractic are well suited to diagnose, treat, co-manage, andmanage the treatment of patients with low back pain disorders. (J Manipulative Physiol Ther 2015;xx:1-22)
Key Indexing Terms: Chiropractic; Low Back Pain; Manipulation, Spinal; Guidelines
Early development of the chiropractic profession inthe 1900s represented the application of accumulatedwisdom and traditional practices.1,2 As was the

practice of medicine, philosophy and practice of chiroprac-

ger, Global Health Economics, Amgen, Inc.A.ice, Columbus, OH.irector, Northwest Center for Lifestyle andine, University of Western States, Portland, ORice, Torrance, CA.ice, Chatsworth, GA.ce, Santee, CA.brarian, Logan University, Chesterfield, MO.demicAssessment, LoganUniversity, Chesterfield,MOce, Mankato, MN.ce, Brunswick, ME.sts for reprints to: Greg Baker, DC, GGCPP. Market St., Chatsworth, GA [email protected]).out this paper: Gary Globe, PhD, MBA, DCamgen.com).ed May 20, 2015; in revised form September 24ctober 2, 2015.

2015 by National University of Health Sciencesd.rg/10.1016/j.jmpt.2015.10.006

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tic were informed to a large extent by an apprenticeship andclinical experiential model in a time predominantly absentof clinical trials and observational research.

The traditional chiropractic approach, in which a trial ofnatural and less invasive methods precedes aggressivetherapies, has gained credibility. However, the chiropracticprofession can gain wider acceptance in the role as the firstpoint of contact health care provider to patients with low backdisorders, particularly within integrated health care deliverysystems, by embracing the scientific approach integral toevidence-based health care.3–7 It is in this context that theseguidelines were developed and are updated and revised.8–12

By today’s standards, it is the responsibility of a healthprofession to use scientific methods to conduct research andcritically evaluate the evidence base for clinical methodsused.13,14 This scientific approach helps to ensure that bestpractices are emphasized.15 With respect to low backdisorders, clinical experience suggests that some patientsrespond to different treatments. The availability of otherclinical methods for conditions that are unresponsive tomore evidence-informed approaches (primary nonre-sponders) introduces the opportunity for patients to achieveimproved outcomes by alternative and personalized ap-proaches that may be more attuned to individual differences

Table 1. Eligibility Criteria for the Literature Search

Inclusion Exclusion

Published betweenOctober 2009-February 2014

Case reports and case series

English language CommentariesHuman participants Conference proceedingsAge N17 y In-patientsManipulation LettersLBP Narrative and qualitative

reviewsDuration chronic (N3 mo) Non–peer-reviewed

publicationsPatient outcomes reported Pilot studiesNonmanipulation comparison group Pregnancy-related LBPRCTs, cohort studies, systematic

reviews, and meta-analysesSecondary analyses anddescriptive studies

LBP, low back pain; RCT, randomized controlled trial.

2 Journal of Manipulative and Physiological TherapeuticsGlobe et alMonth 2015Chiropractic Care for Low Back Pain

that cannot be informed by typical clinical trials.16–18 To alarge degree, variability in the selection of treatmentmethods among doctors of chiropractic (DCs) continuesto exist, even though the large body of research on low backpain (LBP) has focused on the most commonly usedmanipulative methods.17,19,20

Although the weight of the evidence may favor theevidence referenced in a guideline for particular clinicalmethods, an individual patient may be best served insubsequent trials of care by treatment that is highlypersonalized to their own mechanical disorder, experienceof pain and disability, as well as preference for a specifictreatment approach. This is consistent with the 3 compo-nents of evidence-based practice: clinician experience andjudgment, patient preferences and values, and the bestavailable scientific evidence.3,13

Doctors of chiropractic use methods that assist patientsin self-management such as exercise, diet, and lifestylemodification to improve outcomes and their stabilization toavoid dependency on health care system resources.19,21

They also recognize that a variety of health care providersplay a critical role in the treatment and recovery process ofpatients at various stages, and that DCs should consult, referpatients, and co-manage patients with them when in thepatient’s best interest.19

To facilitate best practices specific to the chiropracticmanagement of patients with common, primarily musculo-skeletal disorders, the profession established the Council onChiropractic Guidelines and Practice Parameters (CCGPP)in 1995.6 The organization sponsored and/or participated inthe development of a number of “best practices” recom-mendations on various conditions.21–32 With respect tochiropractic management of LBP, a CCGPP team produceda literature synthesis8 which formed the basis of the firstiteration of this guideline in 2008.9 In 2010, a newguideline focused on chronic spine-related pain waspublished,12 with a companion publication to both the2008 and 2010 guidelines published in 2012, providingalgorithms for chiropractic management of both acuteand chronic pain. 10 Guidelines should be updatedregularly.33,34 Therefore, this article provides the clinicalpractice guideline (CPG) based on an updated systematicliterature review and extensive and robust consensusprocess.9–12

METHODS

This project was a guideline update based on currentevidence and consensus of a multidisciplinary panel ofexperts in the conservative management of LBP. It has beenrecommended that, although periodic updates of guidelinesare necessary, “partial updating often makes more sensethan updating the whole CPG because topics andrecommendations differ in terms of the need for

updating.”33 Logan University Institutional Review Boarddetermined that the project was exempt. We used Appraisalof Guidelines for Research & Evaluation (AGREE) indeveloping the guideline methodology.

Systematic ReviewBetween March 2014 through July 2014, we conducted

a systematic review to update the literature published sincethe previous CCGPP guideline was developed. The searchincluded articles that were published between October 2009through February 2014. Our question was, “What is theeffectiveness of chiropractic care including spinal manip-ulation for nonspecific low back pain?” Table 1 summarizesthe eligibility criteria for the search.

Search StrategyThe following databases were included in the search:

PubMed, Index to Chiropractic Literature, CINAHL, andMANTIS. Details of the strategy for each database areprovided in Figure 1. Articles and abstracts were screenedindependently by 2 reviewers. Data were not furtherextracted.

Evaluation of ArticlesWe evaluated articles using the Scottish Intercollegiate

Guideline Network checklists (http://www.sign.ac.uk/methodology/checklists.html) for randomized controlledtrials (RCTs) and systematic reviews/meta-analyses. Forguidelines, the AGREE 2013 instrument35 was used. Atleast 2 of the 3 investigators conducting the review (CH,SW, MK) reviewed each article. If both reviewers rated thestudy as either high quality or acceptable, it was includedfor consideration; if both reviewers rated it as unacceptable,it was removed. For AGREE, we considered “unaccept-able” to be a sum of b4. If there was disagreement betweenreviewers, a third also reviewed the article, and the majorityrating was used.

PubMed search strategy:

The following search string:("Low Back Pain"[mh] OR "back pain" OR “lumbar spine”) AND (chiropractic OR

"musculoskeletal manipulations" OR "spinal manipulation" OR "manual therapy" OR "manual therapies" OR “Manipulation, Orthopedic”[mh] OR “Manipulation, Chiropractic”[mh] OR “Manipulation, Osteopathic”[mh] OR "Manipulation, Spinal"[mh]) AND English[la]

Combined with:1. Systematic Reviews, 10/01/09 - 06/30/142. Meta-Analysis, 10/01/09 - 06/30/143. Practice Guideline, 10/01/09 - 06/30/144. Guideline, 10/01/09 - 06/30/145. Randomized Controlled Trial, 01/01/12 - 06/30/14

Index to Chiropractic Literature search strategy:

1. Subject:"Back Pain" OR Subject:"Low Back Pain", Year: from 2009 to 2014, Peer Review only, Publication Type:Systematic Review

2. Subject:"Back Pain" OR Subject:"Low Back Pain", Year: from 2009 to 2014, Peer Review only, Publication Type:Practice Guideline

3. Subject:"Back Pain" OR Subject:"Low Back Pain", Year: from 2012 to 2014, Peer Review only, Publication Type:Randomized Controlled Trial

4. Subject:"Back Pain" OR Subject:"Low Back Pain" AND All Fields:"randomized controlled trial", Year: from 2012 to 2014, Peer Review only

5. Subject:"Back Pain" OR Subject:"Low Back Pain" AND All Fields:"systematic review", Year: from 2009 to 2014, Peer Review only, Publication Type:Article

6. Subject:"Back Pain" OR Subject:"Low Back Pain" AND All Fields:"meta analysis", Year: from 2009 to 2014, Peer Review only, Publication Type:Article

CINAHL search strategy

The following search string:"back pain" AND (chiropractic OR "musculoskeletal manipulations" OR "spinal manipulation" OR "manual therapy" OR "manual therapies")

Combined with:1. Limiters - Published Date: 20091001-20140631; English Language; Peer

Reviewed; Publication Type: Systematic Review, Search modes - Boolean/Phrase

2. Limiters - Published Date: 20091001-20140631; English Language; Peer Reviewed; Publication Type: Meta Analysis, Search modes - Boolean/Phrase

3. Limiters - Published Date:20091001-20140631; English Language; Peer Reviewed; Publication Type: Practice Guidelines, Search modes - Boolean/Phrase

4. Limiters - Published Date: 20120101-20140631; English Language; Peer Reviewed; Publication Type: Randomized Controlled Trial, Search modes -Boolean/Phrase

MANTIS search strategy

1. (back pain[all] AND (chiropractic[all] OR manipulation[all] OR manual therapy[all])) AND systematic review[all], Limit 01/01/09 - 07/22/14, Peer Review, English

2. (back pain[all] AND (chiropractic[all] OR manipulation[all] OR manual therapy[all])) AND meta analylsis[all], Limit 01/01/09 - 07/22/14, Peer Review, English

3. (back pain[all] AND (chiropractic[all] OR manipulation[all] OR manual therapy[all])) AND guideline[all], Limit 01/01/09 - 07/22/14, Peer Review, English

4. (back pain[all] AND (chiropractic[all] OR manipulation[all] OR manual therapy[all])) AND randomized controlled trial[all], Limit 01/01/12 - 07/22/14, Peer Review, English

Fig 1. Search strategies used in the literature search.

3Globe et alJournal of Manipulative and Physiological TherapeuticsChiropractic Care for Low Back PainVolume xx, Number

Results of Literature ReviewThis search yielded 270 articles. Screening the articles

for eligibility resulted in 18 articles included for evaluation,as detailed in Figure 2, using the Preferred Reporting Itemsfor Systematic Reviews and Meta-Analyses flowchart.36

Of the 18 articles included after screening, 16 wereretained as acceptable/high quality12,17,37–50 and 251,52

(both systematic reviews) were excluded as being ofunacceptable quality according to the Scottish Intercolle-giate Guideline Network checklist. Those with new relevantinformation were summarized and provided to the Delphi

panel as background information. Table 2 lists the articlesby lead author and date, and the topic addressed, if newfindings were present.

Seed Documents and Seed StatementsAlong with the literature summary, seed documents were

comprised of the 3 previous CCGPP guidelines9,10,12; linkswere provided to full text versions. The original guidelineshad been developed based on the evidence, includingguidelines and research available at the time.16,53–63 The

Records identified through database searching

(n = 266)

Additional records identified through other sources (hand

search) (n =4)

Total recordsidentified(n =191)

Records screened(n =191)

Records excludedAbstract/ commentary (n =13)

Pilot/protocol only (n=7)Not chiropractic manipulation

for LBP (n=68)Not patient outcomes (n=35)Special populations (n=10)

No non-manipulation comparison group (n=4)

Total (n=137)

Full-text articles assessed for eligibility

(n =54)

Included in other systematic review (n=12)

No patient outcomes (n=11)Not chiropractic manipulation

for LBP (n=5)Not RCT or SR (n=6)No non-manipulation

comparison group (n=2)Total (n=36)

Studies included in qualitative synthesis

(n =18)

Duplicates removed (n=79)

Fig 2. Flow diagram for literature search. LBP, low back pain; RCT, randomized controlled trial; SR, systematic reviews.


steering committee, composed of authors on these previousguidelines, developed 51 seed statements based on thebackground documents, revising the previous statements ifit seemed advisable based on the literature. The steeringcommittee did not conduct a formal consensus process;however, the seed statement development was a team effort,with changes only made if all members of the steeringcommittee were in agreement. Before conducting thisproject, these seed statements had gone through a localDelphi process among clinical and academic faculty atLogan University as part of their development of carepathways for their clinical faculty. This was done to assessthe readability of the seed statements to a group ofpracticing clinicians. In the Delphi process, 7 statementswere slightly modified from the original, and none of thosechanges were substantive, but rather for purposes ofclarification. Consensus was reached for the seed docu-ment, which was then adopted by that institution for use inits teaching clinics. That document formed the seeddocument for the current project. For the Delphi rounds,

the 51 statements were divided into 3 sections to be lessonerous for the panelists to rate in a timely manner.

Delphi PanelPanelists who served on the 3 previous consensus

projects10–12 related to LBP management were invited toparticipate. Steering committee members made additionalrecommendations for experts in management of LBP whowere not DCs to increase multidisciplinary input. Therewere 37 panelists; 33 were DCs, one of whom had duallicensure—DC and massage therapist. The 4 non-DCpanelists consisted of an acupuncturist who is also amedical doctor, a medical doctor (orthopedic surgeon), amassage therapist, and a physical therapist. Thirty-three ofthe 37 panelists were in practice (89%); the mean number ofyears in practice was 27. Seventeen were also affiliated witha chiropractic institution (46%), with 2 of these associatedwith Logan University; 3 were affiliated with a differenthealth care professional institution (8%); and 1 was

Table 2. Articles Evaluated

Lead Author Year Relevant New Findings

Guidelines and systematic reviewsClar17 2014 NoneDagenais38 2010 Standards for

assessment of LBPDagenais37 2010 Standards for

assessment of LBPFarabaugh12 2010 Basis for current updateFurlan39 2010 NoneGoertz40 2012 NoneHidalgo41 2014 NoneKoes42 2010 NoneMcIntosh43 2011 NonePosadzki44 2011 NoneRubinstein45 2013 NoneRubinstein46 2011

Excluded as unacceptable qualityErnst51 2012Menke52 2014

RCTsHaas47 2013 Dosage informationSenna48 2011 Dosage informationVon Heymann49 2013 NoneWalker50 2013 None

LBP, low back pain; RCT, randomized controlled trial.


employed with a government agency. Because thisguideline focuses primarily on chiropractic practice in theUnited States, geographically, all panelists were from theUnited States, with 19 states represented. These wereArizona (1), California (4), Florida (3), Georgia (3), Hawaii(2), Iowa (2), Illinois (3), Kansas (1), Michigan (1),Minnesota (1), Missouri (3), North Carolina (1), NewJersey (2), New York (5), South Carolina (1), South Dakota(1), Texas (1), Virginia (1), and Vermont (1). Of the 33DCs, 21 (64%) were members of the American ChiropracticAssociation, 2 (6%) were members of the InternationalChiropractors Association, and 10 (30%) did not belong toany national chiropractic professional organization.

Delphi Rounds and Rating SystemThe consensus process was conducted by e-mail. For

purposes of analyzing the ratings and comments, panelistswere identified by an ID number only. The Delphi panelistswere not aware of other panelists’ identity during theduration of the study. As in our previous projects, we usedthe RAND-UCLA methodology for formal consensus.64

This methodology uses an ordinal scale of 1-9 (highlyinappropriate to highly appropriate) to rate each seedstatement. RAND/UCLA defines appropriateness to meanthat expected patient health benefits are greater thanexpected negative effects by a large enough margin thatthe action is worthwhile, without considering costs.64

After scoring each Delphi round, the project coordinatorprovided the medians, percentages, and comments (as aWord table) to the steering committee. They reviewed all

comments and revised any statements not reachingconsensus as per these comments. The project coordinatorcirculated the revised statements, accompanied by thedeidentified comments, to the Delphi panel for thenext round.

We considered consensus on a statement’s appropriate-ness to have been reached if both the median rating was 7 orhigher and at least 80% of panelists’ ratings for thatstatement were 7 or higher. Panelists were provided withspace to make unlimited comments on each statement. Ifconsensus could not be reached, it was planned thatminority reports would be included.

Public CommentsAs per recommendations for guideline development such

as AGREE, we invited public comment on the draft CPG.This was accomplished by posting the consensus statementon the CCGPP Web site. Press releases and direct e-mailcontacts announced a 2-week public comment period, withcomments collected via an online Web survey application.Organizations and institutions who were contacted includedthe following: all US chiropractic colleges; members of allchiropractic state organizations; state boards of chiropracticexaminers; chiropractic practice consultants; chiropracticattorneys; chiropractic media (including 1 publication sentto all US-licensed DCs); and chiropractic vendors, whosecontacts also included interested laypersons. The steeringcommittee then crafted additional or revised statements asper the comments collected through this method, and thesestatements were then recirculated through the Delphi paneluntil consensus was reached.

Data AnalysisFor scoring purposes, ratings of 1-3 were collapsed as

“inappropriate,” 4-6 as “uncertain,” and 7-9 as “appropriate.”If a panelist rated a statement as “inappropriate,” he or shewas instructed to articulate a specific reason and provide acitation from the peer-reviewed literature to support it, ifpossible. The project coordinator entered ratings into adatabase (SPSS v. 22.0, Armonk, NY: IBM Corp, 2013).

RESULTS

The verbatim evidence-informed consensus-based seedstatements, as approved by the Delphi panel, are presentedbelow. Consensus was reached after 1 round of revisions,with an additional round conducted to reach consensus onthe changes that resulted from the public comment period.No minority reports are included because consensus wasreached on all statements. There were 7 comments received,6 from DCs and 1 from a layperson. Three did not require aresponse; statements were added or modified in response tothe other 4 comments.

Table 3. Frequency and Duration for Trial(s) of ChiropracticTreatment

Stage Trials of Care Reevaluation

Acute a and subacute a 2-3× weekly,2-4 wk

2-4 wk (per trial)

Recurrent/flare-up 1-3× weekly,1-2 wk

1-2 wk

Chronic b 1-3× weekly,2-4 wk

2-4 wk

Exacerbation(mild) of chronic b

1-6 visitsper episode

At beginning of eachepisode of care

Exacerbation(moderate or severe)of chronic b

2-3× weeklyfor 2-4 wk

Every 2-4 wk,following acutecare guidelines

Scheduled ongoingcare for managementof chronic pain b

1-4 visitsper month

At minimum every6 visits, or as necessaryto document conditionchanges.

a For acute and subacute stages; up to 12 visits per trial of care. Ifadditional trials of care are indicated, supporting documentation should beavailable for review, including, but not necessarily limited to, documentation of complicating factors and/or comorbidities coupled with evidenceof functional gains from earlier trial(s). Efforts toward self-carerecommendations should be documented.

b For chronic presentations, exacerbations, and scheduled ongoingcare for management of chronic pain, additional care must be supportedwith evidence of either functional improvement or functional optimizationSuch presentations may include, but are not limited to, the following: (1)substantial symptom recurrences following treatment withdrawal, (2)minimization/control of pain, (3) maintenance of function and ability toperform common ADLs, (4) minimization of dependence on therapeuticinterventions with greater risk(s) of adverse events, and (5) care whichmaintains or improves capacity to perform work. Efforts toward self-carerecommendations should be documented.


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.

General ConsiderationsMost acute pain, typically the result of injury (micro- or

macrotrauma), responds to a short course of conservativetreatment (Table 3). If effectively treated at this stage,patients often recover with full resolution of pain andfunction, although recurrences are common. Delayed orinadequate early clinical management may result inincreased risk of chronicity and disability. Furthermore,those responding poorly in the acute stage and those withincreased risk factors for chronicity must also be identifiedas early as possible.

Clinicians must continually be vigilant for the appear-ance of clinical red flags that may arise at any point duringpatient care. In addition, biopsychosocial factors (alsoknown as clinical yellow flags) should be identified andaddressed as early as possible as part of a comprehensiveapproach to clinical management.

Chiropractic doctors are skilled in multiple approachesof functional assessment and treatment. Depending on theclinical complexity, DCs can work independently or as partof a multidisciplinary team approach to functional restora-tion of patients with acute and chronic LBP.

It is the ultimate goal of chiropractic care to improvepatients' functional capacity and educate them to acceptindependently the responsibility for their own health.

Informed ConsentInformed consent is the process of proactive communi-

cation between a patient and physician that results in thepatient's authorization or agreement to undergo a specificmedical intervention. Informed consent should be obtainedfrom the patient and performed within the local and/orregional standards of practice. The DC should explain thediagnosis, examination, and proposed procedures clearlyand simply and answer patients’ questions to ensure thatthey can make an informed decision about their health carechoices. He or she should explain material risks* of carealong with other reasonable treatment options, including therisks of no treatment. (*Note: The legal definition of ma-terial risk may vary state by state.)

Examination ProceduresThorough history and evidence-informed examination

procedures are critical components of chiropractic clinicalmanagement. These procedures provide the clinical ratio-nale for appropriate diagnosis and subsequent treatmentplanning.

Assessment should include but is not limited to thefollowing38:

• Health history (eg, pain characteristics, red flags,review of systems, risk factors for chronicity)

• Specific causes of LBP (eg, aortic aneurysm, inflam-matory disorders)

• Examination (eg, reflexes, dermatomes, myotomes,orthopedic tests)

• Diagnostic testing (indications) for red flags (eg,imaging and laboratory tests)

Routine imaging or other diagnostic tests are notrecommended for patients with nonspecific LBP.55

Imaging and other diagnostic tests are indicated in thepresence of severe and/or progressive neurologic deficits orif the history and physical examination cause suspicion ofserious underlying pathology.55

Patients with persistent LBP accompanied by signs orsymptoms of radiculopathy or spinal stenosis should beevaluated, preferably, with magnetic resonance imaging orcomputed tomography.55

Imaging studies should be considered when patients failto improve following a reasonable course of conservativecare or when there is suspicion of an underlying anatomicalanomaly, such as spondylolisthesis, moderate to severespondylosis, posttrauma with worsening symptomatogy(consider imaging, referral, or co-management) with


evidence of persistent or increasing neurological (ie, reflex,motor, and/or sensory) compromise, or other factors whichmight alter the treatment approach. Lateral view flexion/extension studies may be warranted to assess for mechan-ical instability due to excessive intervertebral translationand/or wedging. Imaging studies should be considered onlyafter careful review and correlation of the history andexamination.65

Severity and Duration of ConditionsConditions of illness and injury are typically classified

by severity and/or duration. Common descriptions of thestages of illness and injuries are acute, subacute, chronic,and recurrent, and further subdivided into mild, moderate,and severe.

• Acute—symptoms persisting for less than 6 weeks.

• Subacute—symptoms persisting between 6 and 12weeks.

• Chronic—symptoms persisting for at least 12 weeks'duration.

• Recurrent/flare-up—return of symptoms perceived tobe similar to those of the original injury at sporadicintervals or as a result of exacerbating factors.

Treatment Frequency and DurationAlthough most patients respond within anticipated time

frames, frequency and duration of treatment may beinfluenced by individual patient factors or characteristicsthat present as barriers to recovery (eg, comorbidities,clinical yellow flags). Depending on these individualizedfactors, additional time and treatment may be required toobserve a therapeutic response. The therapeutic effects ofchiropractic care/treatment should be evaluated by subjec-tive and/or objective assessments after each course oftreatment (see “Outcome Measurement”).

Recommended therapeutic trial ranges are representativeof typical care parameters. A typical initial therapeutic trialof chiropractic care consists of 6 to 12 visits over a 2- to4-week period, with the doctor monitoring the patient'sprogress with each visit to ensure that acceptable clinicalgains are realized (Table 3).

For acute conditions, fewer treatments may be necessaryto observe a therapeutic effect and to obtain completerecovery. Chiropractic management is also recommendedfor various chronic low back conditions where repeatedepisodes (or acute exacerbations) are experienced by thepatient, particularly when a previous course of care hasdemonstrated clinical effectiveness and reduced the long-term use of medications.

Initial Course of Treatments for Low Back DisordersTo be consistent with an evidence-based approach, DCs

should use clinical methods that generally reflect the bestavailable evidence, combined with clinical judgment, experi-ence, and patient preference. For example, currently, the mostrobust literature regarding manual therapy for LBP is basedprimarily on high-velocity, low-amplitude (HVLA) tech-niques, and mobilization (such as flexion-distraction).17,20,66

Therefore, in the absence of contraindications, these methodsare generally recommended. However, best practices forindividualized patient care, based on clinical judgment andpatient preference, may require alternative clinical strategiesfor which the evidence of effectiveness may be less robust.

The treatment recommendations that follow, based onclinical experience combined with the best availableevidence, are posited for the “typical” patient and do notinclude risk stratification for complicating factors. Compli-cating factors are discussed elsewhere in this document.

An initial course of chiropractic treatment typicallyincludes 1 or more “passive” (ie, nonexercise) manualtherapeutic procedures (ie, spinal manipulation or mobili-zation) and physiotherapeutic modalities for pain reduction,in addition to patient education designed to reassure andinstill optimal strategies for independent management.

Although the evidence reviewed does not generallysupport the use of therapeutic modalities (ie, ultrasonogra-phy, electrical stimulation, etc) in isolation,67 their use aspart of a passive-to-active care multimodal approach to LBPmanagement may be warranted based on clinician judgmentand patient preferences. Because of the scarcity of definitiveevidence,68 lumbar supports (bracing/taping/orthoses) arenot recommended for routine use, but there may be someutility in both acute and chronic conditions based uponclinician judgment, patient presentation, and preferences.Caution should be exercised as these orthopedic devicesmay interfere with conditioning and return to regularactivities of daily living (ADLs).

The initial visits allow the doctor to explain that the clinicianand the patientmust work as a proactive team and to outline thepatient's responsibilities. Although passive care methods forpain or discomfort may be initially emphasized, “active” (ie,exercise) care should be increasingly integrated to increasefunction and return the patient to regular activities. Table 3 listsappropriate frequency and duration ranges for trials ofchiropractic treatment for different stages of LBP.

Reevaluation and ReexaminationAfter an initial course of treatment has been concluded, a

detailed or focused reevaluation should be performed. Thepurpose of this reevaluation is to determine whether thepatient has made clinically meaningful improvement. Adetermination of the necessity for additional treatmentshould be based on the response to the initial trial of careand the likelihood that additional gains can be achieved.


As patients begin to plateau in their response totreatment, further care should be tapered or discontinueddepending on the presentation. A reevaluation is recom-mended to confirm that the condition has reached a clinicalplateau or has resolved. When a patient reaches complete orpartial resolution of their condition and all reasonabletreatment and diagnostic studies have been provided, thenthis should be considered a final plateau (maximumtherapeutic benefit, MTB). The DC should perform a finalexamination, typically following a trial of therapeuticwithdrawal, to verify that MTB has been achieved andprovide any necessary patient education and instructions ineffective future self-management and/or the possible needfor future chiropractic care to retain the benefits achieved.

Continuing Course of TreatmentIf the criteria to support continuing chiropractic care

(substantive, measurable functional gains with remainingfunctional deficits) have been achieved, a follow-up course oftreatment may be indicated. However, one of the goals of anytreatment plan should be to reduce the frequency of treatmentsto the point where MTB continues to be achieved whileencouraging more active self-therapy, such as independentstrengthening and range ofmotion exercises and rehabilitativeexercises. Patients also need to be encouraged to return tousual activity levels as well as to avoid catastrophizing andoverdependence on physicians, including DCs. The frequen-cy of continued treatment generally depends on the severityand duration of the condition. Patients who are interested inwellness care (formerly calledmaintenance care11) should begiven those options as well. (Wellness or maintenance carewas defined by Dehen et al11 as “care to reduce the incidenceor prevalence of illness, impairment, and risk factors and topromote optimal function.”)

When the patient's condition reaches a plateau or no longershows ongoing improvement from the therapy, a decisionmust be made on whether the patient will need to continuetreatment. Generally, progressively longer trials of therapeuticwithdrawal may be useful in ascertaining whether therapeuticgains can be maintained without treatment.

In a case where a patient reaches a clinical plateau in theirrecovery (MTB) and has been provided reasonable trials ofinterdisciplinary treatments, additional chiropractic care maybe indicated in cases of exacerbation/flare-up or whenwithdrawal of care results in substantial, measurable declinein functional or work status. Additional chiropractic care maybe indicated in cases of exacerbation/flare-up in patients whohave previously reached MTB if criteria to support such care(substantive, measurable prior functional gains with recur-rence of functional deficits) have been established.

Outcome MeasurementFor a trial of care to be considered beneficial, it must be

substantive, meaning that a definite improvement in the

patient's functional capacity has occurred. Examples ofmeasurable outcomes and activities of daily living andemployment include the following:

1. Pain scales such as the visual analog scale and thenumeric rating scale.

2. Pain diagrams that allow the patient to demonstratethe location and character of their symptoms.

3. Validated ADL measures, such as the RevisedOswestry Back Disability Index, Roland MorrisBack Disability Index, RAND 36, and BournemouthDisability Questionnaire.

4. Increases in home and leisure activities, in addition toincreases in exercise capacity.

5. Increases in work capacity or decreases in prior workrestrictions.

6. Improvement in validated functional capacity testing,such as lifting capacity, strength, flexibility, andendurance.

Spinal Range of Motion AssessmentRange of motion testing may be used as a part of the

physical examination to assess for regional mobility,although evidence does not support its reliability indetermining functional status.69

Benefit vs RiskCare rendered by DCs has been documented to be quite

safe and effective compared with other common medicaltreatments and procedures. A 2010 systematic reviewconcluded that serious adverse events were no more than1 per million patient visits for lumbar spine manipulation.20

Another systematic review found that the risk of majoradverse events with manual therapy is low, but manypatients experience minor to moderate short-lived (b48hours) adverse events after treatment.70

These are usually brief episodes of muscle stiffness orsoreness.20 The relative risk (RR) of adverse events appearsgreater with drug therapy but less with usual medical care.70

Comparatively, an earlier study from 1995 related tocervical manipulation found that the RR for high-velocitymanipulation causing minor/moderate adverse events wassignificantly less than the RR of the comparison medication(usually nonsteroidal anti-inflammatory drugs [NSAIDs]).71

The risk of death from NSAIDs for osteoarthritis wasestimated to be 100-400 times the risk of death fromcervical manipulation.71 Because lumbar spine manipulationis considered lower risk than cervical manipulation, it isreasonable to extrapolate that NSAIDs pose at least thesame comparative risk when prescribed for the treatment ofLBP. Special attention must be given to each patient’sindividual history and presentation. In that context, itshould be noted that for patients who are not good

Fig 3. Contraindications for high-velocity manipulation to the lumbar spine (red flags). aIn some cases, soft-tissue, low-velocitylow-amplitude mobilization procedures may still be clinically reasonable and safe.


candidates for HVLAmanipulation, DCs shouldmodify theirmanual approach accordingly.

Cautions and ContraindicationsChiropractic-directed care, including patient education,

and passive and active care therapy, is a safe and effectiveform of health care for low back disorders. As stated in theprevious section, there are certain clinical situations whereHVLA manipulation or other manual therapies may becontraindicated. It is incumbent upon the treating DC toevaluate the need for care and the risks associated with anytreatment to be applied. Many contraindications are consid-ered relative to the location and stage of severity of themorbidity, whether there is co-management with one or morespecialists, and the therapeutic methods being used by thechiropractic physician. Figure 3 lists contraindications forhigh-velocity manipulation to the lumbar spine (red flags);however, these do not necessarily prohibit soft-tissue,low-velocity, low-amplitude procedures and mobilization.

Conditions Contraindicating Certain Chiropractic-Directed Treatments Suchas Spinal Manipulation and Passive Therapy

In some complex cases where biomechanical, neurolog-ical, or vascular structure or integrity is compromised, the

,

clinician may need to modify or omit the delivery ofmanipulative procedures. Chiropractic co-managementmay still be appropriate using a variety of treatments andtherapies commonly used by DCs. It is prudent to documentthe steps taken to minimize the additional risk that theseconditions may present. Figure 4 lists conditions whichpresent contraindications to spinal manipulation andpassive therapy, along with conditions requiring co-man-agement and/or referral.

During the course of ongoing chronic pain managementof spine-related conditions, the provider must remain alertto the emergence of well-known and established “red flags”that could indicate the presence of serious pathology.Patients presenting with “red flag” signs and/or symptomsrequire prompt diagnostic workup which can includeimaging, laboratory studies, and/or referral to anotherprovider. Ignoring these “red flag” indicators increases thelikelihood of patient harm. Figure 5 summarizes red flagsthat present contraindications to ongoing HVLA spinalmanipulation.

Management of Chronic LBPDefinition of chronic pain patients. Note: MTB is

defined as the point at which a patient's condition has

Fig 4. Conditions contraindicating certain chiropractic-directed treatments such as spinal manipulation and passive therapy.

• Severity of symptoms and objective findings• Patient compliance and/or non-compliance factors• Factors related to age• Severity of initial mechanism of injury• Number of previous injuries (N3 episodes)• Number and/or severity of exacerbations• Psycho-social factors (pre-existing or arising during care)• Pre-existing pathology or surgical alteration• Waiting >7 days before seeking some form of treatment• Ongoing symptoms despite prior treatment• Nature of employment / work activities or ergonomics• History of lost time• History of prior treatment• Lifestyle habits• Congenital anomalies• Treatment withdrawal fails to sustain MTB

Fig 5. Complicating factors that may document the necessity of ongoing care for chronic conditions.


plateaued and is unlikely to improve further. Chronic painpatients are those for whom ongoing supervised treatment/care has demonstrated clinically meaningful improvementwith a course of management and who have reached MTB,but in whom substantial residual deficits in activityperformance remain or recur upon withdrawal of treatment.The management for chronic pain patients ranges fromhome-directed self-care to episodic care to scheduledongoing care. Patients who require provider-assistedongoing care are those for whom self-care measures,

although necessary, are not sufficient to sustain previouslyachieved therapeutic gains; these patients may be expectedto progressively deteriorate as demonstrated by previoustreatment withdrawals.

Chronic Care Goals

• Minimize lost time on the job• Support patient's current level of function/ADL• Pain control/relief to tolerance


• Minimize further disability• Minimize exacerbation frequency and severity• Maximize patient satisfaction• Reduce and/or minimize reliance on medication

Application of Chronic Pain ManagementChronic pain management occurs after the appropriate

application of active and passive care including lifestylemodifications. It may be appropriate when rehabilitativeand/or functional restorative and other care options, such aspsychosocial issues, home-based self-care, and lifestylemodifications, have been considered and/or attempted, yettreatment fails to sustain prior therapeutic gains andwithdrawal/reduction results in the exacerbation of thepatient's condition and/or adversely affects their ADLs.

Ongoing care may be inappropriate when it interfereswith other appropriate care or when the risk of supportivecare outweighs its benefits, that is, physician dependence,somatization, illness behavior, or secondary gain. However,when the benefits outweigh the risks, ongoing care may beboth medically necessary and appropriate.

Appropriate chronic pain management of spine-relatedconditions includes addressing the issues of physiciandependence, somatization, illness behavior, and secondarygain. Those conditions that require ongoing supervisedtreatment after having first achieved MTB should haveappropriate documentation that clearly describes them aspersistent or recurrent conditions. Once documented aspersistent or recurrent, these chronic presentations shouldnot be categorized as “acute” or uncomplicated.

Factors Affecting the Necessity for Chronic Pain Management of LBPPrognostic factors that may provide a partial basis for the

necessity for chronic pain management of LBP after MTBhas been achieved include the following:

• Older age (pain and disability)• History of prior episodes (pain, activity limitation,disability)

• Duration of current episode N1 month (activitylimitation, disability)

• Leg pain (for patients having LBP) (pain, activitylimitation, disability)

• Psychosocial factors (depression [pain]; high fear-avoidance beliefs, poor coping skills [activitylimitation]; expectations of recovery)

• High pain intensity (activity limitation; disability)• Occupational factors (higher job physical or

psychological demands [disability])

The list above is not all-inclusive and is provided torepresent prognostic factors most commonly seen in theliterature. Other factors or comorbidities not listed above

may adversely affect a given patient's prognosis andmanagement. These should be documented in the clinicalrecord and considered on a case-by-case basis.

Each of the following factors may complicate thepatient's condition, extend recovery time, and result in thenecessity of ongoing care:

• Nature of employment/work activities or ergonomics:The nature and psychosocial aspects of a patient'semployment must be considered when evaluating theneed for ongoing care (eg, prolonged standing posture,high loads, and extended muscle activity).

• Impairment/disability: The patient who has reachedMTB but has failed to reach preinjury status has animpairment/disability even if the injured patient hasnot yet received a permanent impairment/disabilityaward.

• Medical history: Concurrent condition(s) and/or use ofcertain medications may affect outcomes.

• History of prior treatment: Initial and subsequent care(type and duration), as well as patient compliance andresponse to care, can assist the physician in developingappropriate treatment planning. Delays in the initiationof appropriate care may complicate the patient'scondition and extend recovery time.

• Lifestyle habits: Lifestyle habits may impact themagnitude of treatment response, including outcomesat MTB.

• Psychological factors: A history of depression,anxiety, somatoform disorder, or other psychopathol-ogy may complicate treatment and/or recovery.

Treatment Withdrawal Fails to Sustain MTBDocumented flare-ups/exacerbations (ie, increased pain

and/or associated symptoms, which may or may not berelated to specific incidents), superimposed on a recurrentor chronic course, may be an indication of chronicity and/orneed for ongoing care.

Complicating/Risk Factors for Failure to Sustain MTBFigure 5 lists complicating factors that may document

the necessity of ongoing care for chronic spine-relatedconditions. Such lists of complicating/risk factors are notall-inclusive. Individual factors from this list may ade-quately explain the condition chronicity, complexity, andinstability in some cases. However, most chronic cases thatrequire ongoing care are characterized by multiplecomplicating factors. These factors should be carefullyidentified and documented in the patient's file to support thecharacterization of a condition as chronic.


Risk Factors for the Transition of Acute/Subacute Spine-Related Conditionsto Chronicity (Yellow Flags)

A number of prognostic variables have been identified asincreasing the risk of transition from acute/subacute tochronic nonspecific spine-related pain. However, theirindependent prognostic value is low. A multidimensionalmodel, that is, a number of clinical, demographic, psycho-logical, and social factors are considered simultaneously, hasbeen recommended. This model emphasizes the interactionamong these factors, as well as the possible overlap betweenvariables such as pain beliefs and pain behaviors.

Chronicity may be described in terms of pain and/oractivity limitation (function) and/or work disability. Riskfactors for chronicity have been categorized by similardomains:

• Symptoms• Psychosocial factors• Function• Occupational factors

Factors directly associated with the clinician/patientencounter may influence the transition to chronicity:

• Treatment expectations: Patients with high expecta-tions for a specific treatment may contribute to betterfunctional outcomes if they receive that treatment.

• Significant others' support: Patients’ risk of chronicitymay be reduced when family members encourage theirparticipation in social and recreational activities.

Diagnosis of Chronic LBPThe diagnosis should never be used exclusively to

determine need for care (or lack thereof). The diagnosismust be considered with the remainder of case documen-tation to assist the physician or reviewer in developing acomprehensive clinical picture of the condition/patientunder treatment.

Clinical Reevaluation InformationClinical information obtained during reevaluation that

may be used to document the necessity of chronic painmanagement for persistent or recurrent spine-relatedconditions includes, but is not limited to, the following:

• Response to date of care management for the currentand previous episodes.

• Response to therapeutic withdrawal (either gradual orcomplete withdrawal) or absence of care.

• MTB has been reached and documented.• Patient-centered outcome assessment instruments.• Analgesic use patterns.• Other health care services used.

Clinical Reevaluation Information to Document Necessity for Ongoing Careof Chronic LBP

In addition to standard documentation elements (ie, date,history, physical evaluation, diagnosis, and treatment plan),the clinical information typically relied upon to documentthe necessity of ongoing chronic pain management includesthe following:

• Documentation of having achieved a clinicallymeaningful favorable response to initial treatment ordocumentation that the plan of care is to be amended.

• Documentation that the patient has reached MTB.• Substantial residual deficits in activity limitations arepresent at MTB.

• Documented attempts of transition to primaryself-care.

• Documented attempts and/or consideration of alterna-tive treatment approaches.

• Documentation of those factors influencing thelikelihood that self-care alone will be insufficient tosustain or restore MTB.

Once the need for additional care has been documented,findings of diagnostic/assessment procedures that mayinfluence treatment selection include the following:

• Neurological/provocative testing (standard neurologi-cal testing, orthopedic tests, manual muscle testing);

• Diagnostic imaging (radiography, computed tomogra-phy, magnetic resonance imaging);

• Electrodiagnostics;• Functional movement/assessment (eg, ambulatoryassessment/limp);

• Chiropractic analysis procedures;• Biomechanical analysis (pain, asymmetry, range ofmotion, tissue tone changes);

• Palpation (static, motion);• Nutritional/dietary assessment with respect to factorsrelated to pain management (such as vitamin D intake).

This list is provided for guidance only and is notall-inclusive. All items are not required to justify the needfor ongoing care. Each item of clinical information shouldbe documented in the case file to describe the patient'sclinical status, present and past.

In the absence of documented flare-up/exacerbation, theongoing treatment of persistent or recurrent spine-relateddisorders is not expected to result in any clinicallymeaningful change. In the event of a flare-up orexacerbation, a patient may require additional supervisedtreatment to facilitate return to MTB status. Individualcircumstances including patient preferences and previousresponse to specific interventions guide the appropriateservices to be used in each case.


Chronic Pain Management Components in Physician-Directed CaseManagement

Case management of patients with chronic LBP should bebased upon an individualized approach to care that combinesthe best evidence with clinician judgment and patientpreferences. In addition to spinal manipulation and/ormobilization, an active care plan for chronic pain manage-ment may include, but is not restricted to, the following:

Procedures• Massage therapy• Other manual therapeutic methods• Physical modalities• Acupuncture• Bracing/orthosesBehavioral and exercise recommendations• Supervised rehabilitative/therapeutic exercise• General and/or specific exercise programs• Mind/body programs (eg, yoga, Tai Chi)• Multidisciplinary rehabilitation• Cognitive behavioral programsCounseling recommendations• ADL recommendations• Co-management/coordination of care with otherphysicians/health care providers

• Ergonomic recommendations• Exercise recommendations and instruction• Home care recommendations• Lifestyle modifications/counseling• Pain management recommendations• Psychosocial counseling/behavioral modification/riskavoidance counseling

• Monitoring patient compliance with self-carerecommendations

Chronic Pain Management Treatment PlanningA variety of functional and physiological changes may

occur in chronic conditions. Therefore, a variety oftreatment procedures, modalities, and recommendationsmay be applied to benefit the patient. The necessity forongoing chronic pain management of spine-related condi-tions for individual patients is established when there is areturn of pain and/or other symptoms and/or pain-relateddifficulty performing tasks and actions equivalent to theappropriate minimal clinically important change value formore than 24 hours, for example, change in numeric ratingscale of more than 2 points for chronic LBP.

Although the visit frequency and duration of supervisedtreatment vary and are influenced by the rate of recoverytoward MTB values and the individual's ability to self-manage the recurrence of complaints, a reasonable therapeu-tic trial for managing patients requiring ongoing care is up to4 visits after a therapeutic withdrawal. If reevaluationindicates further care, this may be delivered at up to 4 visits

per month. (Caution: The majority of chronic pain patientscan self/home-manage, be managed in short episodic burstsof care, or require ongoing care at 1-2 visits per month, to bereevaluated at a minimum of every 12 visits. It is rare that apatient would require 4 visits per month to manage evenadvanced or complicated chronic pain.) Clinicians shouldroutinely monitor a patient's change in pain/function todetermine appropriateness of continued care. An appropriatereevaluation should be completed at minimum every 12visits. Reevaluation may be indicated more frequently in theevent a patient reports a substantial or unanticipated change insymptoms and/or there is a basis for determining the need forchange in the treatment plan/goals.

Scheduled Ongoing Chronic Pain Management Treatment PlanningWhen pain and/or ADL dysfunction exceeds the

patient's ability to self-manage, the medical necessity ofcare should be documented and the chronic care treatmentplan altered appropriately.

Patient recovery patterns vary depending on degrees ofexacerbations. Mild exacerbation episodes may be man-ageable with 1-6 office visits within a chronic caretreatment plan. There is not a linear effect between theintensity of exacerbation and time to recovery.

Moderate and severe exacerbation episodes within achronic care treatment plan require acute care recommen-dations and case management.12

AlgorithmsFigure 6 summarizes the pathways for the chiropractic

management of LBP.

DISCUSSION

With the chiropractic profession’s establishment of theCCGPP to facilitate the development of best practices, 3guidelines addressing the management of low backdisorders were ultimately published.9,10,12 This set inmotion an effort to improve clinical methods by reducingvariation in chiropractic treatment patterns that has longbeen unaddressed by any other evidence-informed andconsensus-driven official guideline.16,54,55,62,63,72 The ap-proach to the development of these recommendations hasbeen evolutionary so as to guide the profession toward theutilization of more evidence-informed clinical methodsintended to improve patient outcomes. Historically, thisalso explains why the initial low back guideline, publishedin 2008, required 2 subsequent additional guidelines toexpand on acute and chronic conditions. This was practicalto introduce additional guidance in a stepwise fashion.

The focus of these recommendations has been patientcentered and not practitioner centered. Practices andtechniques that have not demonstrated superior efficacy in

General Algorithm

This is a new patient

Patient presents with low back pain

This is an established patient with a new condition or a

moderate-severe exacerbation of a pre-

existing condition

This is an established patient with a mild episode of a

previously treated (usually chronic) condition.

Perform New Patient Evaluation1

Perform Established Patient Evaluation1

Perform Evaluation1 (Often condition

focused rather than general)

Go to Acute Care Algorithm

Go to Chronic Care Algorithm

Pain < 3 mo. duration

Pain ≥ 3 mo. duration

HistoryExamination

Imaging if warrantedPossible Outcomes Assessment Tools—choice based on clinician’s judgment.

Pain intensity scalesPain diagramsPain and disability questionnairesFunctional outcomes questionnairesGeneral health questionnairesPsychological profiles

• •

• •

• • • • • •

1Evaluation components

Fig 6. Algorithms for chiropractic management of LBP.


published studies may be used as alternative approaches tothose methods that have more robust evidence. No otherguidelines have been specific to this purpose within thechiropractic profession and endorsed as broadly, makingthis guideline unique. It is also important to consider thatguidelines specific to other professions may or may notinclude clinical approaches that do not best informchiropractic management of low back disorders. Al-though evidence produced under the auspices of otherprofessions is important to consider, it is also importantto consider whether this evidence informs a conservativecare approach. For example, from a chiropractic view-point, drug and surgical treatment approaches aregenerally regarded as more invasive and should beconsidered as second- and third-line approaches to thetreatment of low back disorders. That is why we believethat professional guidelines specific to a profession’sscope and approach to intervening in the natural courseof disease are important.

It is the responsibility of a profession to periodicallyupdate guidelines to ensure consistency with new researchfindings and subsequent clinical experience. As such, anupdated literature review was conducted, and the previousbest practice guidelines were revised. The evidencereviewed has informed several important new recommen-dations to this updated guideline. For example, the evidenceinforms us that the routine use of radiographic imagingstudies is not in the best interest of most patients withnonspecific LBP.53,55 However, there may be exceptions tothis based upon history and clinical examination character-istics. Doctors of chiropractic are advised that it isfrequently in the best interest of patients to select manualmethod approaches that do not rely on radiographs todetermine the method of manipulation or adjustment.69 Inaddition, it is not in the patient’s best interest for the DC touse the least evidence-informed chiropractic techniques astheir first-line approach over those where the evidence ismore robust.

Acute Care Algorithm

Patient presents with acute spine related

pain

Continue on next page

Improvement evident at midpoint?

Yes

No

Is condition outside scope of practice or skill

set?

Isco-management

required?

Consult with/refer to appropriate

provider/facility

Refer to appropriate

provider/facility

Yes No Yes

Yes or No

Begin therapeutic trial of up to12 visits within 4

weeks

Assess for improvement at mid-point of trial using any accepted

measurement tool

ConsiderModifying treatment methodsAdditional diagnostic procedures


provider/facility

Symptoms resolved?

NoContinue trial

Perform reassessment

evaluation

Yes

• • • Referral or co-management

Fig 6. (Continued)


While adding important new recommendations, it isuseful to note that the updated literature synthesis did notultimately require many other changes from the originalguideline recommendations. The changes reflected in thiscurrent update were as follows: (1) a brief description of keyelements that should standardly be included during aninformed consent discussion; (2) the recommendation thatroutine radiographs, other imaging, and other diagnostictests are not recommended for patients with nonspecificLBP (along with recommendations for when these studiesshould be considered); (3) recommendation that thehierarchy of clinical methods used in patient care should

generally correspond to the supporting level of existingevidence; (4) additional clarification about the limited useof therapeutic modalities and lumbar supports that reflectspatient preferences with the intention to best facilitate theshift from passive-to-active care and not dependency onpassive modalities with limited evidence of efficacy; (5)recognition that although range of motion testing may beclinically useful as a part of the physical examination toassess for regional mobility, the evidence does not supportits reliability in determining functional status; and (6)inclusion of a brief summary of the evidence informingmanipulation risk vs benefit assessment.

Continued from previous page

MTB achieved?1NoYes

Dosignificant

symptoms and/or functional deficits

remain?

Yes

Is condition stable

or resolved?

Release with home care

instructions or transition to

wellness care

Yes

Trial withdrawal desired?2

No

Refer

Consider co-management

Yes

Provide home care instructions and initiate trial

withdrawal.

Functional/symptom

improvements?

No/Not Sure

Additional improvement

likely?

Yes

Othertreatment

options availablein this

facility?

No

Refer

Continue up to 12 visits within

4 weeks.

No

Yes

Yes

No

No/not sure

Reassess condition status

Has condition deteriorated?

Go to Chronic Care Algorithm

No

Yes

1 MTB= maximum therapeutic benefit2Trial withdrawal may be necessary once a patient reaches maximum therapeutic improvement. This helps todetermine if the condition recovery is stable. If the condition has deteriorated after the trial, then chronic or ongoing care may be necessary to maintain function and minimize symptoms. The therapeutic withdrawal can be gradual, where the patient’s care is tapered off. It can alsobe abrupt, with the patient instructed to return if the symptoms recur; or the patient can be scheduled for an evaluation at a later date to determine if there is any regression.

Fig 6. (Continued)


Although this revision contemplates new guidance onkey practice areas, it is not expected that these newrecommendations will necessarily apply to every patientseen by a DC.

Similarly, with respect to the dosage recommendations(ie, treatment frequency and duration) within this guide-line, dosage should be modified to fit the individualpatient’s needs. For example, the majority of chronic pain

patients can self-manage, can be managed in short episodicbursts of care, or require ongoing care at 1-2 visits permonth, to be reevaluated at a minimum of every 12 visits. Itis rare that a patient would require 4 visits per month tomanage advanced or complicated chronic pain. Thus, it isimportant to consider this guideline’s recommendationsfor visit frequency as ranges rather than specific numbers.In addition, with regard to continuing assessments to

Chronic Care Algorithm

Patient presents with chronic/recurrent spine related pain

This visit follows a trial withdrawal and there is a

recurrence or worsening of symptoms.


provider/facility or provide home management Instructions.

Refer to appropriate provider/facility.

Do thebenefits of

chronic pain manage-ment outweigh

the risks?

This is a symptom flare for a known chronic

condition or recurrence of acute condition.

YesNo Yes

No or yes but appropriately managed.

This is a scheduled visit for ongoing/recurrent care for a

patient expected to progressively deteriorate

based on previous treatment withdrawals.

Treat according to ongoing/recurrent

care plan (up to 4 visits per month).

Re-evaluate every 12 visits at minimum.

Red flags present?(See red flag list.1)

Consider imaging

Traumatic cause of exacerbation?

Mildexacerbation?

Yes

No

NoModerate to severe

exacerbations follow Acute Care

Algorithm.

Continue on next page

Yes

Progressive neurological disordersCauda equina syndromeBone weakening disorders; ie; acute spinal fracture, spinal infection, spinal/extra-vertebral bony malignanciesTumorArticular derangements indicating instability; ie, active avascular necrosis in weight-bearing joints

1 Red Flags

Fig 6. (Continued)


evaluate the effectiveness of treatment, after the initialround of up to 6 visits, a brief evaluation should beperformed to evaluate the progress of care. Suchreevaluations at a minimum should include assessment ofsubjective and/or objective factors. These might includeusing pain scales such as the visual analog scale, thenumeric rating scale, pain diagrams, and/or validated ADLmeasures, such as the Revised Oswestry Back DisabilityIndex, Roland Morris Back Disability Index, RAND 36, or

the Bournemouth Disability Questionnaire. Additionalorthopedic/neurological tests may be considered on acase-by-case basis.

Nothing in this guideline should be interpreted as sayingthat patients should never have imaging ordered based uponexamination and clinical judgment. Similarly, the conclu-sion should not be that every patient should only receivetreatment methods with the highest level of evidence. It isthe recommendation of this guideline that imaging and

Continued from previous page

Treat for up to 6 visits.

Has patient returned to pre-episode status?

Consider further diagnostic testing

Doescondition

worsen upon repeated attempts to withdraw care?See rationale for

ongoingcare2

Release patient;provide home management

recommendations if appropriate

YesNo No

Consider ongoing/recurrent care plan of up to 4 visits per month. Re-evaluate at least

every 12 visits.

Red flagspresent or other

conditions outside of scope or skill

set?

Refer toappropriate

provider/facility

Yes

Symptoms Improved?/Are chronic

care goals being met?

MTB3/Pre-Episode status?

Yes

No

Othertreatment options available at this

facility?

Yes

No

Discontinue care and refer to appropriate provider/facility for

opinion/management

No

No

Treat for up to 6 visits. Consider multimodal, multidisciplinary care.

Yes

Yes

addition to standard documentation):*

Maximum therapeutic benefit (MTB)Significant residual activity limitationsAttempts to transition to self-careConsideration of alternative treatment approachesFactors affecting likelihood that self-care alone will sustain MTI (see Complicating Factors)

3MTB=maximum therapeuticbenefit

Fig 6. (Continued)


clinical methods have evidence to inform their use. Inaddition, patients should be informed when their careappears to require a trial of an alternate, less evidence-informed strategy.

Regarding the evidence used to support these guidelines,most clinical trials are limited in duration and usually reflecta target patient population that is not necessarily represen-tative of all patients encountered in standard practice.Patients possess characteristics that include risk factors (ie,age, history of previous episodes of LBP, etc) and other

clinical characteristics that were not specifically assessed inclinical trials. Therefore, it is important to view practiceguidelines in this context and that a 1-size-fits-all approachwill not fit all patients. It is the collective judgment ofCCGPP, the Delphi panelists, and the authors thatunexplainable and unnecessary variation in treatmentpatterns for standard presentations of nonspecific LBP,without considering or using the best evidence, will notnecessarily lead to improvements in clinical methods andimproved patient outcomes.


Future StudiesThe work of developing and improving guidelines is a

never-ending and time-consuming task. Therefore, theauthors have suggested areas of patient management thatshould be considered during future revisions. Three areassuggested during the manuscript review process were (1)guidance on the evidence of the value of limited rest atvarious phases of recovery across the range of low backdisorders, (2) more detailed guidance as to what historyfindings would/should lead to imaging, and (3) review ofthe literature describing efforts to develop assessmentmethods and tools to characterize the predictors ofoutcomes and inform selection and greater standardizationof clinical methods.73,74 Two areas of focus for futureupdates are also strongly recommended by the coauthorsas well. The first concerns attempting to achieve a moredetailed understanding of the hierarchy of chiropractictechniques that should be used based upon variousarchetypal patient presentations across the range of lowback disorders. This would require reviewing head-to-head comparative research to determine relative efficacyof clinical methods using specific chiropractictechniques.

The authors recognize that some legacy outcomemeasures used in clinical practice and in clinical trialswere not developed specifically with patients who may beinterested in prioritizing conservative care approaches first.Also, because a measure’s ability to detect change andclinically minimal important difference (CMID) is linkeddirectly to the target population and contextual character-istics, it is unlikely that there is a monolithic CMID valuefor a clinical outcomes assessment tool (including patientrated outcome measures) across all contexts of use andpatient cohorts. More likely, there would be a range inCMID estimates that differs across varying patient cohortsand clinical trial contexts.75 The chiropractic profession hasrelied upon instruments that are less sensitive to changes inthe types of risks, adverse effects, symptoms, and impactsthat chiropractic patients might consider most important.This includes the benefits of avoidance of risks and adverseevents associated with medication use and surgicalinterventions. As such, a comprehensive review is recom-mended to determine the evidence for the use of theselegacy instruments in practice as well as, most critically,clinical trials that include the evaluation of the outcomes ofthe treatment of low back disorders that include chiropracticsubjects. This type of review should include members whohave a background in outcomes measurement and thedevelopment of de novo patient-reported outcomes instru-ments. Finally, an ever-broadening horizon of new andongoing areas of related research constantly needs to bescanned for updated and applicable learnings, such asimproved understanding of the interplay between functionalanatomy (eg, muscular and fascial) and the generationof LBP.76,77

LimitationsThis guideline did not address several important issues

that future efforts should focus on, including the following:the important issues of appropriate recommendations onlimited rest; guidance on how DCs should assess historyfindings that might require imaging; expanded review andassessment of comparative efficacy of chiropractic manip-ulative techniques; and a full-scale review of outcomemeasures used by chiropractors and chiropractic researchersto evaluate the suitability of legacy measures as well as therobustness of their reported CMID in the context ofpopulations frequently treated by chiropractors.78–80

Our Delphi panel may not have represented the broadestspectrum of DCs in terms of philosophy and approach topractice. In addition, this guideline is most applicable tochiropractic practice in the United States. Input from otherprofessions was present but also limited to 4 members fromother professions (acupuncture, massage therapy, medicine,and physical therapy). However, the panel had geographicdiversity and was clearly based upon practice expertise with33 of 37 panelists being in practice an average 27 years.

Another limitation relates to the literature included in thesystematic review, which extended through February 2014to provide time for project implementation. It is possiblethat articles were inadvertently excluded. An importantissue related to the literature is that issues of great practicalimportance, such as the determination of optimal proce-dures and protocols for specific patients, do not yet haveenough high-quality evidence to make detailed recommen-dations. An example of this is the use of a wide variety ofmanipulative techniques by DCs,19 even though mostrandomized trials use only HVLA manipulation, due to therequirements of the study design for uniformity of theintervention. As the evidence base for manipulativetechniques grows and expands its scope, it is essentialthat CPGs continue to be updated in response to newevidence. Although the authors did not task themselveswith the responsibility of developing a formal dissemina-tion plan, CCGPP is currently developing one to coordinatewith the timing of the publication of this guideline.

Finally, any guideline recommendations are limited bythose who would use partial statements, out of context, tojustify a treatment, utilization, and/or reimbursementdecision. It is critical to the appropriate use of this CPGthat recommendations are not misconstrued by being takenout of context by the use of partial statements. To avoidsuch practice, we strongly recommend that when a quotefrom this guideline is to be used, an entire paragraph beincluded to contextualize the recommendation being cited.

CONCLUSION

This publication is an update of the best practicerecommendations for chiropractic management of


LBP.9,10,12 This guide summarizes recommendationsthroughout the continuum of care from acute to chronicand offers the chiropractic profession and other keystakeholders an up-to-date evidence- and clinical practiceexperience–informed resource outlining best practiceapproaches for the treatment of patients with LBP.

CONTRIBUTORSHIP INFORMATION

Concept development (provided idea for the research):C.H., G.G., C.M., W.W., G.B.Design (planned the methods to generate the results):C.H., G.G.Supervision (provided oversight, responsible for orga-nization and implementation, writing of the manuscript):C.H., G.G., C.M.Data collection/processing (responsible for experiments,patient management, organization, or reporting data):C.H.Analysis/interpretation (responsible for statistical analy-sis, evaluation, and presentation of the results): C.H.,G.G., C.M., G.B.Literature search (performed the literature search): C.H.,M.K., S.W., R.F., G.G., C.M.Writing (responsible for writing a substantive part of themanuscript): C.H., R.F., G.G., C.M., W.W., G.B.Critical review (revised manuscript for intellectualcontent; this does not relate to spelling and grammarchecking): C.H., M.K., S.W., R.F., M.D., G.G., C.M.,W.W., M.D., G.B., T.A.

ACKNOWLEDGMENT

The authors thank Michelle Anderson, project coordi-nator, who ensured that all communications were complet-ed smoothly and in a timely manner. The experts, listedbelow, who served on the Delphi panel made this projectpossible by generously donating their expertise and clinicaljudgment.

Logan University panelists who developed the seeddocument that served as the basis for the consensus process:Robin McCauley Bozark, DC; Karen Dishauzi, DC, MEd;Krista Gerau, DC; Edward Johnnie, DC; Aimee Jokerst,DC; Jeffrey Kamper, DC; Norman Kettner, DC; JanineLudwinski, DC; Donna Mannello, DC; Anthony Miller,DC; Patrick Montgomery, DC; Michael J. Wittmer, DC.Muriel Perillat, DC, MS, Logan Dean of Clinics, alsoprovided an independent review of the document.

Delphi panelists for the consensus process: CharlesBlum, DC; Bryan Bond, DC; Jeff Bonsell, DC; JerrilynCambron, LMT, DC, MPH, PhD; Joseph Cipriano, DC;Mark Cotney, DC; Edward Cremata, DC; Don Cross, DC;Donald Dishman, DC; Gregory Doerr, DC; Paul Dough-erty, DC; Joseph Ferstl, DC; Anthony Q. Hall, DC; Michael

W. Hall, DC; Robert Hayden, DC, PhD; Kathryn Hoiriis,DC; Lawrence Humberstone, DC; Norman Kettner, DC;Robert Klein, DC; Kurt Kuhn, DC, PhD; William Lauretti,DC; Gene Lewis, DC, MPH; John Lockenour, DC; JamesMcDaniel, DC; Martha Menard, PhD, LMT; AngelaNicholas, DC; Mariangela Penna, DC; Dan Spencer, DC;Albert Stabile, DC; John S. Stites, DC; Kasey Sudkamp,DPT; Leonard Suiter, DC; John Ventura, DC; SivaramaVinjamury, MD, MAOM, MPH, LAc; Jeffrey Weber, MA,DC; Gregory Yoshida, MD.

FUNDING SOURCES AND CONFLICTS OF INTEREST

All authors and panelists participated without compen-sation from any organization. Logan University made anin-kind contribution to the project by allowing Drs. Hawkand Kaeser and Ms. Anderson and Walters to devote aportion of their work time to this project. The University ofWestern States also provided in-kind support for a portion ofDr. Hawk’s time. Dr. Farabaugh currently holds the positionof the National Physical Medicine Director of AdvancedMedical Integration Group, LP. Dr. Morris is a post-grad-uate faculty member of the National University of HealthSciences and receives access to library resources. Therewere no conflicts of interest were reported for this study.

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