T HERE HAS BEEN A LOT OF NEWS LATELY REGARDING THE COUN-cil on Chiropractic Guidelines and Practice Parameters (CCGPP) and its validity in the chiropractic clinical setting. I have been anticipating the release of these clinical compass guidelines because I practice and teach evidence-based practice protocols. I was anxiously waiting (hoping) for a set of objective guidelines that would be useful in determining frequency and duration for my patients. Much to my dismay, I have been sorely disappointed at the type of political and biased rhetoric that has been produced thus far. The only thing 1 can say is, "Nice try, but you can't pull the wool over the eyes of this profession for your own personal gain by selling out the members of this profession!!!" With that said we have no other option but to look at the previously published works to guide us in determining what would be a reasonable and sensible case management strategy for frequency and duration of care for our patients. To determine appropriate levels of frequency and duration of care, we can look at several documents: 1) The Guidelines for the Chiropractic Quality Assurance and Practice Parameters (Mercy), 2) the Council on Chiropractic Practice (CCP) document and 3) Foreman and Croft's Whiplash Treatment Guidelines. Determining Frequency and Duration of Care for a Commercial Insurance Patient First, for commercial insurance patients, the doctor can follow the Mercy Guidelines. The Mercy document was designed to conservatively treat low back pain in a reasonable amount of time and focuses on shifting the care to the home or to more radical approaches, such as neurologists and orthopedists. Mercy was neither designed nor mentions frequency and duration of care for neck pain and/or cervical acceleration/deceleration (CAD) injuries. The Mercy document does mention stages of care (sec Table 1) and gives recommendations on the frequency and duration of care for each stage. Passive care is for acute intervention and the doctor should be focused on decreasing muscular spasm, inflammation and pain. This particular stage is highlighted by the fact that the doctor is performing most of the work whereas, in active care, the patient and doctor are doing the work together and it is highlighted by an increase in rehabilitation exercises. Each stage can have durations of up to twenty-four visits and the frequency can be three times per week for eight weeks. These statements are rather significant because insurance companies commonly refuse to pay for more than twelve to fifteen visits or make accusations that the patient should have recovered in four to six weeks. These types of accusations by the insurance companies can't be proven because they can- Table 1. Stages of Care: The Mercy Document (Table II, Pg. 120, Mercy) Passive Care The doctor is doing most of the work Acute Intervention To promote anatomical rest To diminish muscular spasm 3. To reduce inflammation 4. To alleviate pain Active Care ■ The doctor and patient are doing the work together Remobilization 1. To increase pain-free ROM 2. To minimize deconditioning Rehabilitation 1. To restore strength and endurance 2. To increase physical work capacity Life Style Adaptations To modify social and recreational activity _ To diminish work environment risk factors 3. To adapt psychological factors affecting or altered by the spinal disorder Table 2. Complicating Factors Criteria for Expanding & Increasing Treatment Plans (Pg.124, Mercy Doc.) Symptoms present more than eight (8) days Four to seven (4-7) previous episodes Presence of skeletal anomalies Presence of severe pain a. If the duration of the symptoms were present for more than 8 days, recovery may take 1.5 times longer. a. If the number of previous episodes is 0 to 3, no anticipated delay in recovery is antici pated. b. If the number of previous episodes is 4 to 7, recovery time may take up to 1.5 to 2 times longer. a. If there is a skeletal anomaly present, recov ery may be increased 1.5 to 2 times longer. b. If there is structural pathology, recovery may be increased 1.5 to 2 times longer. a. If severe pain is present, recovery may take up to 2 times longer. b. If mild pain is present, no delay on recovery is anticipated. not come up with any competing guidelines to confirm these statements. Although the Mercy document allows for at least forty-eight treatments, the treating chiropractor may receive more visits based on various complicating factors—complicating factors such as those found in Table 2. With a thorough history and objective examination findings, a doctor of chiropractic could realistically treat a patient approximately ninety-six visits. Additional Guidelines to Determine the Frequency and Duration of Care for the Commercial Insurance Patient There is another set of guidelines the doctor of chiropractic can utilize to objectively determine the frequency and duration of care for their patients. These guidelines are the CCP Guidelines. CCP Guidelines have been accepted by the National Guideline Clearinghouse (NGC), found on the Internet at http:// www.guideline.gov/index.asp. In fact, the CCP Guidelines is the only such chiropractic document listed by NGC. The NGC is a public resource for evidence-based clinical practice guidelines. NGC is sponsored by the Agency for Healthcare Research and Quality (AHRQ) (formerly the Agency for Health Care Policy and Research in partnership with the American Medical Association and the American Association of Health Plans). It is the position of the Guideline Panel that individual differences in each patient and the unique circumstances of each clinical encounter preclude the formulation of "cookbook" recommendations for frequency and duration of care. The CCP Guidelines states that a chiropractor must adjust a subluxation until all indicators of subluxation are gone. The appropriateness of chiropractic care should be determined by OBJECTIVE indicators of the vertebral subluxation (Chapter 7, Pg 84). The recommendations from the Panel are that, since the duration of care for correction of a vertebral subluxation is patient specific, frequency of visits should be based upon the reduction and eventual resolution of indicators of the subluxation (Chapter 7, pg. 83). Determining the Frequency and Duration of Care of a CAD Injured Patient Firstly, the doctor in CAD injuries (the doctor of chiropractic) needs to be able to determine whether the patient has been injured or not. They must then determine the extent of the injury. After gathering the evidence, the doctor of chiropractic can place the patient into a GRADE that is based on those OBJECTIVE physical findings and the subjective complaints found during the examination process. Foreman and Croft have developed five grades of severity of CAD trauma (Table 3). (Pg. 525, Whiplash Injuries) In turn, by placing the patient into a category, the physician can then determine the approximate treatment schedule (frequency and duration) for the patient, based on the severity of the injury grade (Table 4). (Pg. 526, Whiplash Injuries 3rd Ed.) The treatment can be extended based on the number of complicating factors. Croft has developed a list (See Table 5 on page 50) of common factors potentially complicating CAD trauma management. (Pg. 525, Whiplash Injuries) So, as you can see, there are a number of FAIR and PRACTICAL guidelines that can be used to objectively determine the patient's frequency and duration of care. If one wants to "update" one's clinical approach to treating patients for the future, then buy these guidelines and read them and understand what it is going to take to survive in the health insurance realm in the coming years. I did not graduate in the "Mercedes Eighties" Continued on pg. 50 Table 3. Severity of Injury Grades 1. Grade I: no limitation of range of motion, no ligamentous injury, no neurological symptoms 2. Grade II: limitation of range of motion, no ligamentous injury, no neurological findings Grade III: limitation of range of motion, some ligamentous injury, neurological findings present Grade IV: limitation of range of motion, ligamentous instability, neurological findings present, fracture or disc derangement Grade V: requires surgical treat ment and stabilization Table 4. Frequency & Duration of Care for CAD Injuries Guidelines for the Frequency and Duration of Care in Cervical Acceleration/Deceleration Trauma Daily 3X/wk 2X/wk 1X/wk 1X/mo TDb TNb Grade I 1 wk 1-2 wk 2-3 wk <4wk ...c <10wk <21 Grade II 1 wk <4wk <4wk <4wk <4mo <29wk <33 Grade III 1-2 wk <10wk <10wk <10wk <6mo <56wk <76 Grade IV 2-3 wk <16wk <12wk <20wk ...d ...d ...d Grade V Surgical stabilization necessary—chiropractic care is post surgical 1 Adopted form Croft AC: treatment paradigm for cervical acceleration/deceleration injuries (whiplash). Am Chiro AsxocJChiro 30(\)A\-45, 1993. bTD indicates treatment duration; TN, treatment total number c Possible follow-up at 1 month d May require permanent monthly or p.m. treatment Frequency and Duration of Care for the Doctor of Chiropractic by Dwight Whynot, D.C.—Continued from pg. 44 where practice was not as time consuming and almost everything that you billed for was paid. I graduated in a time when doctors of ALL professions are being held more accountable for the care they are recommending and perfonning. Vince Lombardi once said, "The name of the game is to win, fairly, squarely, by the rules, but to win." I have just given some important rules to practice fairly and squarely by, so that you can win. Dr. Dwight C. Why not is in fulltime practice in Johnson City, Tennessee. Dr. Whynot gives license-renewal lectures on Evidence-Based Chiropractic Practices which are promoted by the EBC Seminars and sponsored by Myo-Logic and Spinal Logic Diagnostics. For questions regarding evidence-based practice proce- dures, email questions to drwhvnoKwcharter.net. For 6 and 12 hours CCE license renewal lecture dates and locations call Karl Parker Seminars at 1-HH8-437-5275 or visit uuw.EBCSeminars.com. References /. Foreman SM. Croft AC. Whiplash Injuries: the Cervical Acceleration/Deceleration Syndrome (3rd Edition). 2002. 2. Council on Chiropractic Practice. Clinical Practice Guideline: Ver- tebral Subluxation in Chiropractic Practice. 1998. 3. Haldeman S, Chapman-Smith D, Pcterscn DM. Guidelines for the Chiropractic Quality Assurance and Practice Parameters. 1993. Table 5. Croft has developed a list of common factors potentially complicating CAD trauma management (Pg. 525, Whiplash Injuries) Factors Complicating CAD Trauma Management Advanced age Metabolic disorders Congenital anomalies Developmental anomalies Degenerative disc disease 11. Prior cervical spinal surgery 12. Prior lumbar surgery 13. Prior vertebral fracture 14. Osteoporosis 15. Paget's disease or othe bone diseases Disc protrusion Facet arthrosis Rheumatoid arthritis Ankylosis spondylitis 10. Scoliosis 16. Spinal stenosis 17. Paraplegia/Quadriplegia 18. Prior spinal injury 19. Spondylosis
