http://www.chiropractic.org/guidelines/ChapterThree.pdf
Chapter Outline
I. Overview
II. History and Chiropractic Examination
III. Instrumentation
IV. Radiographic and Other Imaging
V. Clinical Impression and Assessment
VI. Reassessment and Outcomes Assessment
VII. Modes of Adjustive Care
VIII. Duration of Care for Correction of Vertebral Subluxation
IX. Chiropractic Care for Children
X. Patient Safety
XI. Professional Development
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I. Overview
This component of the International Chiropractors Association protocols and guidelines
represents the incorporation of a fully compatible clinical practice document developed
by a parallel guidelines committee. The focus of this section is on the subluxation, the
core of chiropractic clinical responsibility. In many respects, this chapter is a summary
document that addresses in an efficient and concentrated format the essentials of
subluxation detection and care.
This section is the intellectual product of an independent panel of chiropractic
researchers, educators and practitioners, the Council on Chiropractic Practice (CCP),
consisting of William Ralph Boone, Ph.D., DC, Terry A. Rondberg, DC, Harold G.
McCoy, DC, Emmanuel T. Akporiaye, Ph.D., Robert Blanks, Ph.D., Patrick Gentempo,
DC, John J. Gerhardt, M.D., Veronica Gutierrez, DC, Jonathan Hatch, Esq., Jay Holder,
DC, Carol James (consumer representative), Matthew McCoy, DC, Stephen F. Renner,
DC and Steven Shochat, DC. This panel was chaired by Christopher Kent, DC, who
also served as a member of the ICA Guidelines Committee. The CCP effort came to
fruition in 1998, and this text has been incorporated into the ICA protocols and
guidelines with the permission of the CCP and upon vote of the ICA Board of Directors.
These guidelines were specifically compiled according to strict evidenced-based
guidelines development procedures. Evidence-based clinical practice is defined as
“The conscientious, explicit and judicious use of the current evidence in making
decisions about the care of individual patients…(it) is not restricted to randomized trials
and meta-analysis. It involves tracking down the best external evidence with which to
answer our clinical questions.” (Sackett, DL. Editorial: Evidence Based Medicine,
Spine, 1998; 23(10):1085.
RATINGS AND CATEGORIES OF EVIDENCE
RATINGS
Established: Accepted as appropriate for use in chiropractic practice for the
indications and applications stated.
Investigational: Further study is warranted. Evidence is equivocal, or insufficient to
justify a rating of “established”.
Inappropriate: Insufficient favorable evidence exists to support the use of this
procedure in chiropractic practice.
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CATEGORIES OF EVIDENCE
E. Expert opinion based on clinical experience, basic scientific rationale, and/or
individual case studies. Where appropriate, this category includes legal opinion.
L. Literature support in the form of reliability and validity studies, observational studies,
“pre-post” studies, and/or multiple case studies. Where appropriate, this category
includes case law.
C. Controlled studies, including randomized and non-randomized clinical trials of
acceptable quality.
The entire following text represents the unaltered work of the CCP panel. The
International Chiropractors Association wishes to express sincere appreciation for the
efforts of those who participated in this important endeavor. ICA wishes to highlight the
full compatibility of the findings of this group with those of the ICA Guidelines
Committee. That these parallel yet independent efforts developed such highly
consistent findings is an indication of the fundamental validity of the respective
conclusions and practice recommendations.
History and Chiropractic Examination
II CASE HISTORY
RECOMMENDATION
A thorough case history should precede the initiation of chiropractic care. The elements
of this history should include general information, reason for seeking chiropractic care,
onset and duration of any symptomatic problem, family history, past health history,
occupational history, and social history.
Rating: Established
Evidence: E, L
Commentary
The purpose of the case history is to elicit information which might reveal salient points
concerning the patient’s spinal and general health that lead the chiropractor to elect
appropriate examination procedures. The case history may provide information which
will assist the chiropractor in determining the safety and appropriateness of chiropractic
care as well as the nature of additional analytical procedures to be performed. History
taking is considered a key element of quality patient care necessary for effective doctorpatient
communication and improved patient health outcomes.(1-4) Verbal, nonverbal
and cognitive assessment are also included in the patient history. The chiropractic case
history should emphasize eliciting information relevant to the etiology and clinical
manifestations of vertebral subluxation.
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CHIROPRACTIC EXAMINATION
RECOMMENDATION
The initial chiropractic examination shall include a case history and an assessment for
the presence of vertebral subluxation, which, if present, is to be noted with regard to
location and character. A review of systems may be conducted at the discretion of the
practitioner, consistent with individual training and applicable state laws.
Reassessments may be conducted periodically throughout a course of chiropractic care
to assess patient progress. Such reassessments typically emphasize re-examination of
findings which were positive on the previous examination, although need not be limited
to same. Reassessment is also indicated in the case of trauma or change in the clinical
status of a patient.
Rating: Established
Evidence: E, L
Commentary
The term subluxation has a long history in the healing arts literature. It may be used
differently outside of the chiropractic profession. The earliest non-chiropractic English
definition is attributed to Randall Holme in 1668. Holme defined subluxation as “a
dislocation or putting out of joynt”(5) In medical literature, subluxation often refers to an
osseous disrelationship which is less than a dislocation.(6) However, B.J. Palmer, the
developer of chiropractic, hypothesized that the “vertebral subluxation” was unique from
the medical use of the term “subluxation” in that it also interfered with the transmission
of neurological information independent of what has come to be recognized as the
action potential. Since this component has yet to be identified in a quantitative sense,
practitioners currently assess the presence and correction of vertebral subluxation
through parameters which measure its other components.(7) These may include some
type of vertebral biomechanical abnormality,(8-14) soft tissue insult of the spinal cord
and/or associated structures(15-49) and some form of neurological dysfunction
involving the synapse separate from the transmission of neurological information
referred to by Palmer.(50-57)
As noted, chiropractic definitions of subluxation include a neurological component. In
this regard, Lantz (58) stated “common to all concepts of subluxation are some form of
kinesiologic[al…sic] dysfunction and some form of neurologic[al…sic] involvement.” In a
recently adopted position paper, The Association of Chiropractic Colleges accepted a
definition of subluxation as follows: “A subluxation is a complex of functional and/or
structural and/or pathological articular changes that compromise neural integrity and
may influence organ system function and general health.”(59) The case history and
examination are means of acquiring information pertinent to the location and analysis of
subluxation. This information is primarily used to characterize subluxation regarding its
presence, location, duration, and type. Additionally, the information gained through
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analysis guides the practitioner to ascertain which chiropractic techniques best suit
the patient to effect correction of the condition.
Data collected during the patient’s initial consultation and examination, pertaining to the
health history and presenting concerns, thus supports the decision-making process of
the practitioner. This information, relayed by the practitioner to the patient, further
serves to incorporate the patient into the decision-making process regarding
chiropractic care.
Elements of the Examination
History
Important elements of the case history include previous and present social and
occupational events revealed by the patient; unusual sensations, moods or actions
relative to the patient, with dates of occurrence and duration; previous chiropractic and
non-chiropractic intervention; and other factors. The case history usually includes the
following:
1. Patient clinical profile.
A. Age.
B. Gender.
C. Occupation.
D. Other information germane to the presenting complaint, if any.
2. Primary reasons for seeking chiropractic care.
A. Primary reason.
B. Secondary reason.
C. Other factors contributing to the primary and secondary reasons.
3. Chief complaint, if one exists. This may include onset and duration of symptoms
as well as their subjective and objective characteristics, and location, as well as
aggravating or relieving factors.
A Trauma, by etiology, when possible.
B. Chief complaint.
C. Characteristics of chief complaint.
D. Intensity/frequency/location, radiation/onset/duration.
E. Aggravating/arresting factors.
F. Previous interventions (including chiropractic care), treatments,
medications, surgery.
G. Quality of pain, if present.
H. Sleeping position and sleep patterns.
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4. Family history.
A. Associated health problems of relatives.
B. Cause of parents’ or siblings’ death and age of death.
5. Past health history.
A. Overall health status.
B. Previous illnesses.
C. Surgery.
D. Previous injury or trauma.
E. Medication and reactions.
F. Allergies.
G. Pregnancies and outcomes.
H. Substance abuse and outcomes.
6. Social and occupational history.
A. Level of education.
B. Job description.
C. Work schedule.
D. Recreational activities.
E. Lifestyle (hobbies, level of exercise, drug use, nature of diet).
F. Psychosocial and mental health.
Chiropractic Analysis
Complementing the case history is the necessity of conducting a thorough chiropractic
analysis. This involves procedures which indicate the presence, location, and character
of vertebral subluxation. Inherent in this process is the noting of unusual findings, both
related and unrelated to vertebral subluxation. This information is useful in determining
the safety and appropriateness of chiropractic care.
The analysis is based partly upon the recognition that vertebral subluxation may be
asymptomatic, yet still exert various physiological effects. Thus, by assimilating
information relative to certain body systems, the presence of vertebral subluxation may
be inferred. Examination protocols have been developed by field practitioners and
researchers. Many of these protocols have been deemed acceptable by the various
chiropractic educational institutions. This acceptance is expressed either through adding
the protocols to the curriculum, or awarding continuing education credit to post-graduate
seminars instructing these protocols, thus judging them to be sufficient in safety,
efficacy, and validity to be included in clinical practice.
Manual palpation is a basic element of the chiropractic examination. This aspect of
analysis includes palpation of the bony elements of the spine and includes assessment
of the motion of the spine as a whole as well as the individual vertebral motion
segments. Palpation of the numerous muscles which attach to and control the stability,
posture, and motion of the spine is included. Static vertebral position is analyzed for
abnormality. The chiropractor is additionally interested in locating areas of abnormal
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segmental motion to identify hypermobile segments and segments with decreased joint
play (hypomobility). Palpation may also include evaluation of soft tissue compliance,
tenderness, and asymmetric or hypertonic muscle contraction. The presence of
vertebral subluxation may bring with it varying degrees of attendant edema, capsulitis,
muscle splinting, and tenderness to digital palpation. There may be tenderness of the
spinous processes upon percussion of these structures when vertebral subluxation is
present.
Neurological components of the subluxation, postural distortions and other factors may
bring deep and superficial myospasm to muscles of the spine, pelvis and extremities.
Palpation may reveal myofascial trigger points which are associated with the articular
dysfunctions accompanying vertebral subluxations. Muscular involvement may manifest
as “taut and tender” fibers.
Visual inspection of the spine and paraspinal region may reveal areas of hypo- or
hyperemia associated with vertebral subluxation. Observation of patient posture is an
important element of chiropractic analysis.(60-62) Posture has far-reaching effects on
physiology, biomechanics, psychology, and esthetics.(63) Proper body alignment
relates to functional efficiency while poor structural alignment limits function. Changes in
posture are considered in some chiropractic approaches as a measure of outcome.(64-
69) Plain film radiographs, as well as other forms of imaging may provide information
concerning the integrity of osseous and soft tissues as well as juxtapositional
relationships. Other assessments such as leg length analysis,(70-94) palpatory and
strength challenges(95-130) are also employed to assess states of muscular responses
to neurological facilitation. Spinal distortions and resultant neurological interference may
create postural or neurological reflex syndromes which result in a functional change in
apparent leg length. This information is also combined with skin temperature
assessments(131-138) and/or electromyography(139-167, 175-180) as well as
technique-specific examination procedures to evaluate the integrity of the nervous
system.(181-182) Although clinical tradition supports the use of orthopedic and
neurological tests in chiropractic practice, research to support the applicability of many
of these tests to the assessment of vertebral subluxation is lacking or negative.(168-
174). Orthopedic and neurological tests are indicated only when relevant to the
assessment of vertebral subluxation, or when determining the safety and
appropriateness of chiropractic care.
It is recognized that research will continue to evolve the most efficacious applications of
assessment techniques described in this document. However, the literature is
sufficiently supportive of their usefulness in regard to the chiropractic examination to
warrant inclusion as components of the present recommendation.
The chiropractic examination may include, but not be limited to:
1. Clinical examination procedures.
A. Palpation (static osseous and muscular, motion).
B. Range of motion.
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C. Postural examination.
D. Muscle strength testing.
E. Orthopedic/neurological tests.
F. Mental status examination procedures.
G. Quality of life assessment instruments.
H. Substance abuse and outcomes.
2. Imaging and instrumentation
A. Plain film radiography.
B. Videofluoroscopy.
C. Computerized tomography.
D. Magnetic resonance imaging.
E. Range of motion.
F. Thermography.
G. Temperature reading instruments.
H. Electromyography.
I. Pressure algometry.
J. Nerve/function tests.
K. Electroencephalography.
3. Review of systems.
A. Musculoskeletal.
B. Cardiovascular and respiratory.
C. Gastrointestinal.
D. Genitourinary.
E. Nervous system.
F. Eye, ear, nose and throat.
G. Endocrine.
Clinical Impression
An appropriate interpretation of case history and examination findings is essential in
determining the appropriate application of chiropractic care within the overall needs of
the patient. The clinical impression derived from patient information acquired through
the examination process is ultimately translated into a plan of corrective care, including
those elements which are contraindicated. The clinical impression serves to focus the
practitioner on the patient’s immediate and long-term needs. It is through this process
that a clear picture is created regarding the patient’s status relative to chiropractic care.
Initial Consultation
The initial consultation serves the purpose of determining how chiropractic care can
benefit the patient. It is during this interchange that the practitioner presents and
discusses examination findings with the patient. Additionally, during the initial
consultation, the practitioner should take the opportunity to present his/her practice
objectives and terms of acceptance. The terms of acceptance provides the patient with
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information regarding the objectives, responsibilities and limitations of the care to be
provided by the practitioner. This reciprocal acknowledgment allows both practitioner
and patient to proceed into the plan of care with well-defined expectations.
While not limited to the following, it is suggested that the initial consultation include the
following parameters:
1. Description of chiropractic: Chiropractic is a primary contact health care
profession receiving patients without necessity of referral from other health care
providers. Traditionally, chiropractic focuses on the anatomy of the spine and its
immediate articulations, the existence and nature of vertebral subluxation, and a
scope of practice which encompasses the correction of vertebral subluxation, as
well as educating and advising patients concerning this condition, and its impact
on general health.
2. Professional responsibility: To assess the propriety of applying methods of
analysis and vertebral subluxation correction to patients; to recognize and deal
appropriately with emergency situations; and to report to the patient any
nonchiropractic findings discovered during the course of the examination, making
referral to other health professionals for care or for evaluation of conditions
outside the scope of chiropractic practice. Such referral does not obviate the
responsibility of the chiropractor for providing appropriate chiropractic care.
3. Practice objective: The professional practice objective of the chiropractor is to
correct or stabilize the vertebral subluxation in a safe and effective manner. The
correction of vertebral subluxation is not considered a specific cure or treatment
for any specific medical disease or symptom. Rather, it is applicable to any
patient exhibiting vertebral subluxation, regardless of the presence or absence of
symptoms and diseases.
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