Guidelines for Chiropractic Quality Assurance and Practice Parameters

1. Guidelines for Chiropractic Quality Assurance and Practice Parameters Proceedings of the Mercy Center Consensus Conference 1992

2. Mercy Center Conference • Convened by the Congress of Chiropractic State Associations (COCSA) • January 25-30, 1992 • Mercy Center, Burlingame, CA • Sponsoring agencies: COCSA, ACA, CCA, ICA, ACC, FCLB, FCER • Chair: Scott Haldeman, D.C., M.D., Ph.D.

3. Mercy Center Guidelines • What are they? • Guidelines or parameters for the practice of chiropractic • Voluntary • Intended to be flexible • What they are not • They are not standards of care

4. Mercy Center Guidelines • Disclaimers (page iv): • Adherence to them is voluntary • Alternative practices are possible and may be preferable under certain clinical circumstances • Does not take precedence over any federal, state or local law, rule, ordinance • They are not by themselves a proper basis for the evaluation of third party claims

5. Mercy Center Guidelines • Disclaimers (page iv) • any part of this publication is likely to be confusing and/or misinterpreted unless read in the context of the full document, which includes commentary, definitions, and explanations of ratings systems used

6. Frequency and Duration of Care • “The majority of quantitative information available addresses the management of low-back and leg complaints…since these recommendations were born from experience and from data on multivariate clinical circumstances, they may be extrapolated with appropriate case specific modifications to most of the common complaints for which chiropractic care is sought”

7. Frequency and Duration of Care • Adequate Trial of Treatment/Care (page 118) • “A course of two weeks each of two different types of manual procedures (four weeks total), after which, in the absence of documented improvement, manual procedures are no longer indicated

8. Frequency and Duration of Care • Triano, page 121 • “patients with chronic disorders may require more treatment.care to resolve symptomatic episodes than do other categories of complaints • Lordotic areas of the spine, on average, require twice the care of complaints involving the thoracic and transitional regions”

9. Frequency and Duration of Care • Triano, page 121 • “Most cases studied resolved well within six weeks of intervention consistent with the expectations from natural history • Patients for whom care is necessary beyond six weeks may require up to 11 additional sessions before reaching resolution”

10. Frequency and Duration of Care • The length of time to reach functional milestones can be affected by specific historical factors: • Preconsultation duration of symptoms. Pain more than eight days: Recovery may take 1.5 times longer • Typical severity of symptoms. Severe pain: Recovery may take up to two times longer

11. Frequency and Duration of Care • The length of time to reach functional milestones can be affected by specific historical factors: • Number of previous episodes. 4-7 episodes: Recovery may take up to two times longer • Injury superimposed on preexisting condition(s). Skeletal anomaly: May increase recovery time by 1.5-2.0 times. Structural pathology: May increase recovery time 1.5-2.0 times

12. Frequency and Duration of Care • Treatment/Care Frequency (page 124) • “Specific recommendations related to acute, subacute and chronic presentations are given below. In general, more aggressive in office intervention (three to five sessions per week for one to two weeks) may be necessary early. Progressively declining frequency is expected to discharge of the patient…”

13. Frequency and Duration of Care • Failure to meet treatment/care objectives: • “Acute disorders: After a maximum of two trial therapy series of manual procedures lasting up to two weeks each (four weeks total) without significant documented improvement, manual procedures may no longer be needed and alternative care may be needed.”

14. Frequency and Duration of Care • Uncomplicated Cases (acute episode) • only acute episodes can truly be considered uncomplicated • Significant improvement within 10-14 days, 3-5 visits per week • ADLs expected to improve • Return to pre-episode status:6-8 weeks, up to three visits per week

15. Frequency and Duration of Care • Complicated Case • Subacute episode: • symptoms prolonged beyond six weeks • generally not to exceed two visits per week • ADL emphasis on active care,patient education, rehabilitation • Return to pre-episode status: 6-16 weeks

16. Frequency and Duration of Care • Complicated Cases • Chronic episode • symptoms prolonged beyond 16 weeks • ADLs focused clearly on rehabilitation • Return to pre-injury status: may not return • Supportive care: supportive care using passive therapy may be necessary if repeated efforts to withdraw treatment/care result in a significant deterioration of clinical status

17. Contraindications and Complications • Contraindications and complications to care are grouped into four major areas: • Articular degeneration • Bone weakening and destructive disorders • Circulatory and cardiovascular disorders • Neurological disorders

18. Contraindications and Complications • Articular derangements: • Acute rheumatoid, rheumatoidlike and nonspecific arthropathies including acute ankylosing spondylitis with inflammation, demineralization, ligamentous laxity or dislocation • absolute contraindication to high velocity thrust procedures in anatomical regions of involvement

19. Contraindications and Complications • Articular derangements: • sub acute or chronic ankylosing spondylitis, other chronic arthropathies, without ligamentous laxity, anatomic subluxation or ankylosis • Not contraindications to high velocity thrust procedures to the area of pathology

20. Contraindications and Complications • Articular derangements: • DJD, osteoarthritis, degenerative discopathy, spondyloarthrosis, • not contraindications to high velocity thrust procedures to the area of pathology • spondylolysis and spondylolisthesis • not contraindication but with progressive slippage they may represent a relative contraindication

21. Contraindications and Complications • Articular derangements: • acute fractures,and dislocations, healed fractures, dislocations with signs of ligamentous rupture or instability • absolute contraindication • unstable os odontoideum • absolute contraindication • articular hypermobility with uncertain stability • relative contraindication

22. Contraindications and Complications • Articular derangements: • postsurgical joints or segments with no evidence of instability • not a contraindication • relative contraindication based on tolerance • acute injuries of osseous and soft tissues • not contraindicated • scoliosis • not contraindicated

23. Contraindications and Complications • Bone weakening and destructive disorder • Active juvenile avascular necrosis (Perthe’s Disease) • absolute contraindication • Demineralization of bone • relative contraindication • Benign bone tumors • relative to absolute contraindication

24. Contraindications and Complications • Bone weakening and destructive disorder • Malignancies • absolute contraindication • Infections of bone • absolute contraindication

25. Contraindications and Complications • Circulatory and cardiovascular disorders • clinical signs of vertebrobasilar artery insufficiency • relative to absolute contraindication • aneurysm • relative to absolute contraindication • anticoagulant therapies and blood dyscrasias • relative contraindications

26. Contraindications and Complications • Neurological disorders • signs and symptoms of acute myelopathy or acute cauda equina syndrome • absolute contraindication