Frequency and duration of care are issues which the chiropractic profession has established formal guidelines in Canada since 1993. This evidence based practice covers three areas: acute, uncomplicated pain; acute, complicated or chronic pain; and supportive or maintenance care.
Acute, uncomplicated pain applies to patients with pain of less than 3 weeks duration and with a common diagnosis of mechanical back pain (strain/dysfunction). The protocol for these patients is to provide up to 3 treatments per week for 4 weeks. If there is no improvement after 2 weeks, treatment should be modified. If there is no improvement by 4 weeks or symptoms are progressive, treatment should stop and the patient be referred out to another health professional. Typically, if the patient is showing improvement, there is an encouragement to return to modified activities and an exercise component is introduced with a decrease in visit frequency (e.g. to weekly) for another 4 weeks, for a total time of 8 weeks. When maximum medical recovery is reached, the patient may either be discharged or maintenance care may be recommended.
Acute, complicated or chronic pain applies to patients with complications (significant trauma, significant underlying spinal degeneration, a disc problem with neurological referral, etc) or chronic pain (recurrent, disabling attacks of spinal pain or pain for 12 weeks or more duration). Treatment may be slightly more frequent (e.g. 3 times a week for 4-6 weeks, than 2 times a week for another 4-6 weeks) and for a longer duration (e.g. up to a total of 16 weeks). Patients would be typically reassessed every 2-4 weeks to determine if there is improvement in symptoms and function, and whether to continue treatment or to refer to another health professional. Advice on return to modified activities and specific exercise would be accompanied with a discussion on pain behavior. If the patient has not returned to pre-episode status, a period of treatment withdrawal may determine if they have reached maximum medical recovery and whether they should be discharged or recommendations of supportive care be given. If maximum medical recovery has been reached, either discharge or maintenance care may be recommended.
Guidelines define two different forms of longer term chiropractic treatment. Supportive care is for patients who have reached maximum improvement, but fail to sustain this improvement and who progressively deteriorate when treatment is withdrawn. This treatment is determined to be therapeutically necessary, but must be determined on an individual basis. Maintenance or preventative care is treatment for a patient who has no present symptoms but may seek to prevent recurrent episodes of back pain and promote health. Typically, chiropractors have recommended monthly maintenance care.
