In my last blog post, I talked about the unprecedented opportunity the chiropractic profession has to make a critical difference in areas of great public health impact, such as low back pain. I strongly believe that if we do the right thing right now, the chiropractic profession is uniquely positioned to significantly impact the quality of spine care delivery, increasing access to chiropractic care for millions of patients who desperately need conservative treatment for spine-related conditions. The flipside is that if we don’t take right action now, chiropractic risks becoming a marginalized profession that’s on the outside looking in as other health care providers take ownership of musculoskeletal conditions and spinal manipulation.
So what is right action? Recently, I asked this question of several of my colleagues who influence policy at the highest levels of research and/or health care delivery in the United States. One of those people was Francis Collins, MD, PhD, director of the National Institutes of Health.1 Dr. Collins responded by saying:
“Chiropractic’s commitment to evidence-based practice and to addressing gaps in the scientific basis of chiropractic care is vital for the progress of the field. Robust research on the safety and effectiveness of chiropractic therapies in the management of common musculoskeletal complaints must continue to be a high priority for the profession. Advancing evidence-based chiropractic care will further the integration of chiropractic into medical systems at a time when the need for effective approaches to improve outcomes for patients with chronic pain could not be more pressing.”
There are two important concepts captured in Dr. Collins’ statement – that we make conducting research a high priority within the profession and that we take an evidence-based approach to chiropractic care delivery in everyday practice. I could not agree more with both recommendations. So how do we operationalize this excellent advice? I will make a number of suggestions in my next several blog posts, but let’s start with a very concrete example: the adoption and use of guidelines and clinical care pathways for low back pain. We are somewhat far behind on this issue when compared to other health-related professional associations. The American Osteopathic Association developed guidelines for low back pain, which includes spinal manipulation, in 2010 and then updated them in 2016.<sup>2</sup> The American Physical Therapy Association has had low back pain guidelines since 2012.<sup>3</sup> In March, the chiropractic profession also took a leadership role in this area when the American Chiropractic Association adopted both the American College of Physicians’ recent low back pain guideline<sup>4</sup>, as well as the Clinical Compass (formerly CCGPP)<sup>5</sup> Clinical Practice Guideline: Chiropractic Care for Low Back Pain.<sup>6</sup> The Clinical Compass guidelines provide recommendations regarding the frequency and length of chiropractic treatment for episodes of acute, subacute and chronic low back pain, based on a combination of existing scientific literature and expert opinion. To give you some sense of what these guidelines look like, below is Table 3 (reprinted with permission), outlining the recommended frequency and duration of chiropractic treatment for acute, subacute and chronic low back pain.
|.s1Table3 Frequency and Duration for Trial(s) of Chiropractic Treatment|
|Stage||Trials of Care||Reevaluation|
|Acuteaand subacutea||2-3× weekly, 2-4 wk||2-4 wk (per trial)|
|Recurrent/flare-up||1-3× weekly, 1-2 wk||1-2 wk|
|Chronicb||1-3× weekly, 2-4 wk||2-4 wk|
|Exacerbation (mild) of chronicb||1-6 visits per episode||At beginning of each episode of care|
|Exacerbation (moderate or severe) of chronicb||2-3× weekly for 2-4 wk||Every 2-4 wk, following acute care guidelines|
|Scheduled ongoing care for management of chronic painb||1-4 visits per month||At minimum every 6 visits, or as necessary to document condition changes.|
a For acute and subacute stages; up to 12 visits per trial of care. If additional trials of care are indicated, supporting documentation should be available for review, including, but not necessarily limited to, documentation of complicating factors and/or comorbidities coupled with evidence of functional gains from earlier trial(s). Efforts toward self-care recommendations should be documented.
b For chronic presentations, exacerbations, and scheduled ongoing care for management of chronic pain, additional care must be supported with evidence of either functional improvement or functional optimization. Such 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 to perform common ADLs, (4) minimization of dependence on therapeutic interventions with greater risk(s) of adverse events, and (5) care which maintains or improves capacity to perform work. Efforts toward self-care recommendations should be documented.
Since the Mercy Conference Proceedings 25 years ago, I’ve had many discussions with my chiropractic colleagues regarding the adoption of low back pain guidelines. Concerns have ranged from “my patients are sicker than everybody else’s” to “we can’t let ourselves be pigeonholed into low back pain in this way.” However, these discussions have been, for the most part, theoretical in that very few of us have actually implemented a guideline into routine clinical practice. To address this issue, I am proposing the Clinical Compass Chiropractic Guideline for Low Back Pain Challenge. This challenge includes three components:
- Read the Guideline in its entirety, which can be found here.6
- Implement the guideline in your practice for one month.
- Come back to this post and comment below about your experience in doing so.
Was it easy or hard to implement? How different are the Guideline recommendations than the way you practice currently? If you are practicing differently, is it affecting clinical outcomes? If so, how? I look forward to hearing about, and responding to your Challenge experiences!
Dr. Goertz is senior scientific advisor for the ACA. She also serves as vice chancellor for research and health policy at Palmer College of Chiropractic and CEO of the Spine Institute for Quality (Spine IQ).
- “Francis Collins,” Wikipedia, accessed May 10, 2017, https://en.wikipedia.org/wiki/Francis_Collins.
- “American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients With Low Back Pain,” PubMed.gov: https://www.ncbi.nlm.nih.gov/pubmed/27455103.
- “Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association,” Journal of Orthopaedic & Sports Physical Therapy (2012): http://www.jospt.org/doi/pdf/10.2519/jospt.2012.42.4.A1?code=jospt-site.
- Qaseem A, Wilt TJ, McLean RM, Forciea MA. “Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians.” Ann Intern Med. (2017): Feb 14: http://annals.org/aim/article/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice
- The Clinical Compass, accessed May 10, 2017, http://clinicalcompass.org/
- Gary et al. “Clinical Practice Guideline: Chiropractic Care for Low Back Pain.” Journal of Manipulative & Physiological Therapeutics, Volume 39 , Issue 1 (2016): 1 – 22: http://www.jmptonline.org/article/S0161-4754(15)00184-0/fulltext.