Council on Chiropractic Practice Clinical Practice Guideline Number 1 Vertebral Subluxation in Chiropractic Practice 1998 1 Clinical Practice Guideline: Vertebral Subluxation in Chiropractic Practice Published by: Council on Chiropractic Practice Copyright © 1998 by Council on Chiropractic Practice All rights reserved. This publication may not be reproduced, stored in a retrieval system, or transmitted in whole or in part, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission of the publisher. Library of Congress Catalog Number: 98-073514 ISBN: 0-9666598-0-5 Panel Members Christopher Kent, D.C., F.C.C.I. John J. Gerhardt, M.D. President, Council on Consultant in Physical Medicine Chiropractic Practice and Rehabilitation Post-graduate Faculty Shriners Hospital and Veterans Affairs Life University, Marietta, Georgia Hospital Medical Center Ramsey, New Jersey Portland, Oregon William Ralph Boone, Ph.D., D.C. Veronica Gutierrez, D.C. Vice President, Council on Member of the Washington State Chiropractic Practice Quality Assurance Commission Editor, Journal of Vertebral Private Practice Subluxation Research Arlington, Washington Irvine, California Jonathan Hatch, Esquire Member Washington State Terry A. Rondberg, D.C. Bar Association Secretary, Council on Member Snohomish County Chiropractic Practice Bar Association President, World Chiropractic Alliance Lynnwood, Washington Chandler, Arizona Jay Holder, D.C., M.D., Ph.D. Harold G. McCoy, D.C. President, American College of Treasurer, Council on Addictionology and Compulsive Chiropractic Practice Disorders President, International Private Practice Spinal Health Institute Miami Beach, Florida Private Practice Kirkland, Washington Carol James Consumer Member Emmanuel T. Akporiaye, Ph.D. Bellevue, Washington Associate Professor of Microbiology and Immunology Matthew McCoy, D.C. Arizona Health Sciences Center Vice President, University of Arizona International Spinal Health Institute Tucson, Arizona Private Practice Kirkland, Washington Robert Blanks, Ph.D. Professor, Department of Anatomy and Stephen F. Renner, D.C. Neurobiology Member American Board of University of California, Irvine Forensic Examiners Irvine, California Private Practice Spokane, Washington Patrick Gentempo, D.C. President, Chiropractic Steven Shochat, D.C. Leadership Alliance Private Practice Paterson, New Jersey Tucson, Arizona iii Contents Introduction and Methodology ...........................viii 1. History and Chiropractic Examination .....................1 Case History ...................................1 Recommendation ..............................1 Commentary ...................................1 Chiropractic Examination ............................1 Recommendation ..............................1 Commentary .................................2 Elements of the Examination ..........................2 History ....................................2 Chiropractic Analysis ..............................4 Clinical Impression ...............................6 Initial Consultation................................6 References ....................................7 2. Instrumentation .................................19 Recommendation ..............................19 Commentary ................................19 Postural Analysis ................................19 Sub-Recommendation ...........................19 Bilateral and Four-Quadrant Weight Scales..................20 Sub-Recommendation ...........................20 Moiré Contourography .............................20 Sub-Recommendation ...........................20 Inclinometry...................................20 Goniometry ...................................20 Sub-Recommendation ...........................20 Algometry ....................................21 Sub-Recommendation ...........................21 Current Perception Threshold (CPT) Testing .................21 Sub-Recommendation ...........................21 Electroencephalography (EEG) ........................21 Sub-Recommendation ...........................21 Somatosensory Evoked Potentials (SSEP) ..................22 Sub-Recommendation ...........................22 Skin Temperature Instrumentation.......................22 Sub-Recommendation ...........................22 Surface Electromyography ...........................23 Sub-Recommendation ...........................23 Muscle Strength Testing ............................23 Sub-Recommendation ...........................23 v Vertebral Subluxation in Chiropractic Practice Questionnaires .................................24 Sub-Recommendation ...........................24 References....................................25 3. Radiographic and Other Imaging .......................39 Recommendation ..............................39 Sub-Recommendation ...........................39 Commentary ................................39 Sub-Recommendation ...........................39 Videofluoroscopy ................................40 Sub-Recommendation ...........................40 Commentary ................................40 Conclusion .................................41 Sub-Recommendation ...........................41 Magnetic Resonance Imaging (MRI) ...................41 Commentary ................................41 Conclusion .................................41 Sub-Recommendation ...........................42 Computed Tomography (CT) .......................42 Commentary ................................42 Conclusion .................................42 Sub-Recommendation ...........................42 Spinal Ultrasonography ..........................42 Commentary ................................42 Conclusion .................................43 Sub-Recommendation ...........................43 Radioisotope Scanning (Nuclear Medicine Studies) ...........43 Commentary ................................43 Conclusion .................................43 References .................................44 4. Clinical Impression and Assessment .....................59 Recommendation ..............................59 Commentary ................................59 References ...................................61 5. Reassessment and Outcomes Assessment...................65 Recommendation ..............................65 Commentary ................................65 References ...................................66 6. Modes of Adjustive Care ............................73 Recommendation ..............................73 Commentary ................................73 Conclusion .................................75 References ...................................77 vi Contents 7. Duration of Care for Correction of Vertebral Subluxation .........83 Recommendation ..............................83 Commentary ................................83 References ...................................85 8. Chiropractic Care of Children .........................87 Recommendation ..............................87 Commentary ................................87 References ...................................91 9. Patient Safety ..................................95 Recommendation ..............................95 Commentary ................................95 References ...................................98 10. Professional Development ..........................101 Recommendation .............................101 Commentary ...............................101 References ..................................102 Contributors and Panel Members .........................103 Peer Reviewers ...................................108 Index .........................................119 vii Vertebral Subluxation in Chiropractic Practice Introduction and Methodology The Council on Chiropractic Practice In the summer of 1995, chiropractic history was made in Phoenix, Arizona with the formation of the Council on Chiropractic Practice (CCP). The meeting was attended by an interdisciplinary assembly of distinguished chiropractors, medical physicians, basic scientists, attorneys, and consumer representatives. The CCP is an apolitical, non-profit organization. It is not affiliated with any other chiropractic association. The CCP represents a grass-roots movement to pro- duce practice guidelines which serve the needs of the consumer, and are consistent with “real world” chiropractic practice. The mission of the CCP is “To develop evidence-based guidelines, conduct research and perform other functions that will enhance the practice of chiropractic for the benefit of the consumer.” Evidence-Based Practice Evidence-based clinical practice is defined as “The conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of indi- vidual patients... (it) is not restricted to randomized trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions.” (1) This concept was embraced by the Association of Chiropractic Colleges in its first position paper. This paper stated: Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation. A subluxation is a complex of functional and/or structural and/or patholog- ical articular changes that compromise neural integrity and may influence organ system function and general health. A subluxation is evaluated, diagnosed, and managed through the use of chi- ropractic procedures based on the best available rational and empirical evi- dence. (2) The CCP has developed practice guidelines for vertebral