Frequency Protocols with Initial Chiropractic Care

By Mark Studin DC, FASBE(c), DAAPM

Anthony Onorato DC, MBA

Reference: Studin M., Onorato A., (2023) Frequency Protocols with Initial Chiropractic Care, American Chiropractor, 45 (3)

Determining a treatment plan cannot be a one-size-fits-all but must be a starting point to care. An evidence-based model should be considered and was defined by Sackett et al. (1992)[1] that included a doctor's clinical experience, the patient's feedback, and the evidence in scientific literature. Over the years, additional parameters have been added to Sackett's original model giving all in healthcare a direction for "published and yet unpublished" parameters in developing an effective treatment path.^[2],[3],[4]

A Chiropractor's scope of practice can be diverse and is state dependent. Scope diversity is evidenced by Massachusetts' definition of "Correcting subluxations/segmental and somatic dysfunction or treating illnesses, injuries, conditions or disorders"[5] and New York, which states "detecting and correcting by manual or mechanical means structural imbalance, distortion, or subluxations in the human body for the purpose of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column."[6] Despite the diversity, a commonality in all state boards is allowing a doctor of chiropractic to treat neck and back pain with mechanical etiology.

Singh, Andersson, and Watkins-Castillo (2019) reported, "Lumbar/low back pain and cervical/neck pain are among the most common medical conditions requiring medical care and affecting an individual's ability to work and manage the daily activities of life. Back pain is the most common physical condition for patients visiting their doctor. In any given year, 12% and 14% of the United States adult population age 18 and older visit their physician with complaints of back pain. The number of physician visits has increased steadily over the years. In 2013, more than 57.1 million patients visited a physician complaining of back pain, compared to 50.6 million in 2010.[7]

Eklund et al. (2019) reported, [Non-Specific] "LBP is not only a societal problem, it also has profound impacts on an individual level with both psychological and social consequences. The condition is still poorly managed clinically, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Since over 90% of LBP cases have no underlying spinal pathology or other specific disease-causing their pain (i.e., no structural diagnosis can be made), the target for clinical intervention in non-specific LBP cannot be identified from a biomedical perspective."[8]

Conversely, Ndetan et al. reported that over 96% of survey respondents with spine-related problems said the use of chiropractic manipulation stated they were helped with their spinal-related condition. Comparing these statistics to medicine, which persists in diagnosing 90-95% as non-specific low back and unable to identify the cause of the pain, with significant evidence of a perpetual failed care path, chiropractic has superior outcomes.[9]

To realize a 96% positive outcome for back pain, protocols must be in place in clinical practice that is consistent in academia and clinical practice. These protocols must be in a "Best Practice Model" (as explained herein), consistent with other healing disciplines in creating protocols or standards.

A baseline protocol is a reasonable approach to care based on an initial evaluation. An ophthalmologist, faced with a clinical finding of macular degeneration, would consider a treatment, fluorescein angiography (FA)-guided reduced-fluence photodynamic therapy (PDT), as an accepted protocol.[10] If a patient presents to the emergency room with an occlusive stroke, the protocol is a tissue plasminogen activator (r-tPA) within 4 hours.[11] A patient with worsening symptoms of gait abnormalities, weakness, and sensory changes and diagnosed with cervical spondylotic myelopathy with minimal symptoms without hard evidence of gait disturbance or pathologic reflexes warrants nonoperative treatment. Still, patients with demonstrable myelopathy and spinal cord compression are candidates for operative intervention.[12] This is an accepted protocol depending on all the factors the physician observes and documents. Orthodontists, as a treatment protocol to move teeth create a force-induced tissue strain to create alterations in vascularity.[13]

 The four sample protocols above are in different medical specialties, and each specialty has its protocol. Chiropractic is no different. Having "predetermined protocols" is what we call a "standard of care" and a diagnostic or treatment regimen to follow. Our predecessors, having treated millions in a Best Practice model, have already determined the standards of care which is in the public interest. Every healthcare profession has a regimen of diagnosis and care, and they call them "predetermined protocols."

As the evidence evolves in every healing discipline, so do treatment protocols, with large enough cohorts to further confirm the efficacy of care. In determining the necessity of initial x-rays, the American College of Radiology (2021) deemed initial imaging of radiography of the lumbar spine, with or without radiculopathy, usually appropriate,[14] removing any controversy on standards of care.

Whalen et al. (2019) reported an appropriate standard of care is "multimodal treatment, inclusive of a chiropractic spinal adjustment (manipulation) for 3X (three times) per week for four weeks in the acute and chronic patient. Treatment may be initially provided more frequently and tapered as the patient improves. Continuing treatment should be predicated on the demonstration of improvement in functional capacity and not only temporary reduction in subjective complaints. A small population of patients with chronic pain with more complex problems may require ongoing care after a plateau in subjective and functional status has been reached. Patients with severe pain (numeric rating scale >7 of 10) and findings consistent with moderate to severe functional limitations may warrant daily treatment for up to 1 week to manage pain and improve function… Patients with more complex presentations, significant comorbidities, chronic neck associated disorders or whiplash associated disorders may require longer periods to demonstrate subjective, objective, or functional improvement."[15]

Globe et al. (2019) reported, "After an initial course of treatment has been concluded, a detailed or focused reevaluation should be performed. The purpose of this reevaluation is to determine whether the patient has made a clinically meaningful improvement. A determination of the necessity for additional treatment should be based on the response to the initial trial of care and the likelihood that additional gains can be achieved."[16] Despite numerous guidelines covering the spectrum of care, a clinical evaluation is the most accurate determinant for future care. This is an academic standard taught in CCE-accredited chiropractic colleges and is why timely reevaluations are performed during ongoing care.

Regardless of the semantics, protocols or predetermined treatment plans are an essential part of a standard of care that protects the public in a Best-Practice Model. The concern is when those protocols are not followed without specific clinical findings confirming an alternative course of care.

Dr. Mark Studin is an Adjunct Assistant Professor of Chiropractic, University of Bridgeport, College of Chiropractic, an Adjunct Post Graduate Faculty, Cleveland University-Kansas City, College of Chiropractic, an Adjunct Professor, Division of Clinical Sciences, Texas Chiropractic College and a Clinical Instructor, The State University of New York at Buffalo, School of Medicine and Biomedical Sciences, Office of Continuing Medical Education. He can be reached at DrMark@AcademyOfChiropractic.com or at 631-786-4253

Dr. Anthony Onorato is currently the associate director of clinical education at the University of Bridgeport School of Chiropractic. He is supervising the attending physician for all clinical services. He is an associate professor of clinical sciences at Bridgeport and currently teaches physical diagnosis. Dr. Onorato was the associate dean of chiropractic at the University of Bridgeport, College of Chiropractic, for 20 years. He directed the entire academic program and was responsible for the initial and continued accreditation of the program by the Chiropractic Council on Education during his tenure. He also was a counselor for the Council on Chiropractic Education, the accrediting agency for all chiropractic programs recognized by the US Department of Education.

[1] Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B., &  Richardson, W. S. (1996). Evidence-based medicine: What it is and what it isn’t. British Medical Journal, 312, 71–72. doi: https://doi. org/10.1136/bmj.312.7023.71

[2] Hayes, B. K., & Chen, T. H. (2008). Clinical expertise and reasoning with uncertain categories. Psychonomic Bulletin Review, 15, 5, 1002–1007. doi: 10.3758/PBR.15.5.1002

[3] Satterfield, J. M., Spring, B., Brownson, R. C., Mullen, E. J., Newhouse, R. P., Walker, B. B., & Whitlock, E. (2009). Toward a transdisciplinary model of evidence-based practice. Milbank Quarterly, 87, 368–390

[4] Cierpiałkowska, Lidia, et al. "Evidence-based assessment in a transtheoretical and paradigmatic approach." Current Issues in Personality Psychology 5.3 (2017): 153-162.

[5] https://www.mass.gov/doc/233-cmr-4-standards-of-practice-and-professional-conduct/download

[6] https://op.nysed.gov/professions/chiropractic/laws-rules-regulations/article-132

[7] https://www.boneandjointburden.org/fourth-edition/iia0/low-back-and-neck-pain

[8] Eklund, Andreas, et al. "Expectations influence treatment outcomes in patients with low back pain. A secondary analysis of data from a randomized clinical trial." European Journal of Pain 23.7 (2019): 1378-1389.

[9] Ndetan, H., et al. "Chiropractic Care for Spine Conditions: Analysis of National Health Interview Survey." Journal of Health Care and Research 2020.2 (2020): 105

[10] Koytak, A., Bayraktar, H., & Ozdemir, H. (2020). Fluorescein angiography as a primary guide for reduced-fluence photodynamic therapy for the treatment of chronic central serous chorioretinopathy. International Ophthalmology, 1-7.

[11] Ying, A., Cheng, Y., Lin, Y., Yu, J., Wu, X., & Lin, Y. (2020). Dynamic increase in neutrophil levels predicts parenchymal hemorrhage and function outcome of ischemic stroke with r-tPA thrombolysis. Neurological Sciences, 1-9

[12]Emery, S. E. (2001). Cervical spondylotic myelopathy: diagnosis and treatment. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 9(6), 376-388

[13] Planning, O. T. (2001). Congenitally missing maxillary lateral incisors and orthodontic treatment considerations for the single-tooth implant. J can dent assoc, 67, 25-8

[14] https://acsearch.acr.org/docs/69483/Narrative/

[15] Whalen, Wayne, et al. "Best-practice recommendations for chiropractic management of patients with neck pain." Journal of Manipulative and Physiological Therapeutics 42.9 (2019): 635-650.

[16] Globe, G., Farabaugh, R. J., Hawk, C., Morris, C. E., Baker, G., Whalen, W. M., ... & Augat, T. (2016). Clinical practice guideline: chiropractic care for low back pain. Journal of manipulative and physiological therapeutics, 39(1), 1-22.