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 complaintssince 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 status6-8 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 (Perthes
  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