CHAPTER VIII: CONTENT OF PRACTICE

A. Presenting Problems and Diagnoses

Two studies of national scope have tried to describe what chiropractors actually do in practice. The first was a national survey of over 5,000 practicing chiropractors (Christensen, 1993), which asked what conditions patients presented with or had concurrently. The second, using data collected from the office records of a cluster sample of chiropractors, looked at the presenting symptoms the chiropractors recorded in charts and at diagnoses recorded for insurance purposes (Hurwitz, in press). Both studies collected data in the early 1990s. These studies allow for a comparison between what chiropractors indicate they do in response to a survey and what they actually record for specific patients in their office records.

The patient conditions that chiropractors indicated they routinely, often, or sometimes see in their practice are listed in Table 19 (Christensen, 1993). Symptoms for which 1,916 patients sought chiropractic care in the United States and Canada, as recorded in the office record of the initial visit, are listed in Figure 2. About two-thirds of patients were seeking care for low back pain. The diagnoses made by chiropractors (either in the office record or on the claim form) for 477 U.S. patients who sought care for non-low back pain complaints are listed in Table 20. While musculoskeletal conditions dominate all three lists, some obvious discrepancies exist. When asked, chiropractors say they routinely see patients with headaches, often see patients with blood pressure problems, allergies, or obesity, and sometimes see patients with nutritional disorders, menstrual disorders, asthma or emphysema, various infections, diabetes, and a variety of other non-musculoskeletal disorders. Examination of office records for patients’ symptoms and diagnoses, however, reveals a near-absence of non-musculoskeletal conditions. No nonmusculoskeletal symptom accounted for more than 1 percent of patients’ symptoms, and the three most frequently diagnosed nonmusculoskeletal conditions, asthma, otitis media, and migraine headaches, were noted for only about 1 in 200 patients (Hurwitz, in press).

The different messages conveyed by the two sources of data might be accounted for in a variety of ways, including how the information was collected. The conditions patients presented with, or had concurrently reported, in the Christensen survey (1993) may not be the same as the presenting symptoms the chiropractor recorded in the chart or as the diagnoses the chiropractors recorded for insurance purposes. Given reimbursement policies, coding restrictions, and utilization reviews that may occur, some chiropractors may feel an incentive to only report those symptoms and diagnoses that facilitate reimbursement. Reimbursement incentives may strongly influence the records chiropractors keep and the diagnoses that are reported. In many plans, e.g., Medicare, chiropractors are required to report a musculoskeletal diagnosis (and sometimes the diagnosis of "vertebral subluxation" is mandatory) in order to be paid for services.

Table 19. Frequency of Presenting and Concurrent Patient Conditions Chiropractors Indicated They See in Their Practices

Secondly, almost a quarter of the non-low back complaint patients had no diagnosis, and this group might contain some of the "missing" nonmusculoskeletal diagnoses. However, given that few patients presented with nonmusculoskeletal complaints, this is probably not an important factor. Finally, this may reflect vagaries of memory and that the large number of "routine" musculoskeletal pain patients the chiropractor sees recedes somewhat compared to the unusual cases, which seem to stand out.

B. Diagnostic Methods

Chiropractic training and literature approach clinical diagnosis in a similar fashion to that of all health care disciplines in that history, physical and regional examination, special studies, and specialty-specific evaluation procedures are routinely incorporated into patient work-ups (Gatterman, 1990; Haldeman, 1993). All accredited chiropractic teaching institutions incorporate history and physical examination into their curricula. Standard history and physical examination methods are basic chiropractic clinical competencies (Council on Chiropractic Education, 1991). Using standard historical, diagnostic, and assessment procedures, chiropractors attempt to differentiate problems of mechanical versus visceral origin (Souza, 1994a). The chiropractic literature is also paying increased attention to the role pain behavior and psychosocial issues play in conditions such as back pain and to evaluation and management strategies in these areas (Milus, 1994; Skogsbergh, 1994).

While chiropractors claim to document case progress in standard SOAP (i.e., Subjective, Objective, Assessment, Plan) notation format (Christensen, 1993), several chart abstraction studies have noted that chiropractors often maintain inadequate patient records (Nyiendo, 1991; Hurwitz, in press). Although quality record keeping may be a problem in all health professions, it appears to be a greater problem for chiropractors, who typically practice outside of group clinic and practice settings. It is expected that the increased emphasis on record keeping in the chiropractic literature and, more importantly, the quality assurance processes associated with participation in accredited managed care organizations will lead to improvements in record keeping over time (Mootz, 1994; McElheran, 1994).

Table 20. Most Frequent and Selected Diagnoses of Patients Seeking Care for Non-Low Back Pain Reasons From Chiropractors in the U.S.

Two North American chiropractic practice parameter commissions recently rated history taking as a "necessary" component of a chiropractic patient evaluation (Haldeman, 1993; Henderson, 1994). Exploration of presenting complaint, family history, past health history, psychosocial history, and review of systems were considered necessary components of an adequate history (Haldeman, 1993). Standard procedures have been recommended for history taking that emphasize active listening and directed questioning related to the mechanisms of a problem's onset (Bowers, 1995a). The extent to which practicing chiropractors actually follow these guidelines is unknown. However, a recent survey of more than 6,500 chiropractors by the National Board of Chiropractic Examiners (Christensen, 1993) suggested that case histories are "routinely" performed and that chiropractors place "substantial" importance on the information gleaned from this process.

Performance of a physical examination is considered essential for establishing a diagnosis and determining a treatment plan (Haldeman, 1993; Henderson, 1994; Gatterman, 1990). Chiropractors receive extensive training and appear well prepared to perform orthopedic and neurological assessments (McCarthy, 1994; Evans, 1994) and the Christensen survey (1993) found that chiropractors report that they "routinely" perform these assessments. Assessment of general health status and performance of regional examinations were also considered important by chiropractors but are performed less frequently than physical examinations (Christensen, 1993).

Periodic updating of the physical examination is emphasized in chiropractic education and clinical internships (Gatterman, 1990; Mootz, 1988), and its use is reported by chiropractors to be "frequent" (Christensen, 1993). Reassessment and monitoring of patient progress received special attention by chiropractic practice parameters commissions (Haldeman, 1993; Henderson, 1994). Table 21 lists attributes of chiropractic reassessment considered "necessary" by one of the commissions (Haldeman, 1993). Functional outcomes assessment is increasingly being incorporated into overall clinical strategies for monitoring patient progress (Yeomans, 1996).

In addition to the routine clinical evaluation procedures standard to any patient workup (i.e., history, physical and regional examination, and special studies) chiropractors have developed assessment methods for determination of the mechanical status of a patient. Some mechanical assessment strategies are common to physical medicine procedures (Henninger, 1993, 1994; Hammer, 1991) and others are unique to chiropractic (Haas, 1995; Faye, 1992; Youngquist, 1989). Table 22 provides a listing of mechanical assessment procedures that may be used by chiropractors to identify joint dysfunction.

Table 22. Examples of Mechanical Assessment Procedures Used by Chiropractors to Identify Joint Dysfunction

� Pain provocation

� Static palpation

� Motion palpation

� Range of motion measurement

� Postural symmetry

� Dynamic spinal loading

� Tissue compliance

� Reactive leg length discrepancy

� Gait analysis

� Function capacity and physical performance evaluation

Chiropractors typically approach mechanical assessment in a comprehensive fashion, routinely incorporating a number of hands-on evaluation methods (McMillin, 1995; Henninger, 1994). Osterbauer (1996) reviewed the evidence for reliability and utility of several chiropractic approaches to mechanical assessment procedures for detection of joint dysfunction or subluxation. Procedures with reasonable ("fair to good") reliability included assessments of osseous and soft tissue pain or tenderness (Mootz, 1989; Boline, 1993). Procedures for determining mobility, cutaneous temperature differences, and joint position have not fared well in reliability studies.

3. Special studies

Chiropractic training includes the use of clinical laboratory studies. Details on the application of these tests have long been described in the chiropractic diagnostic literature and in practice parameters (Jaquet, 1971; Adams, 1990; Vear, 1992; Triano, 1992; Haldeman, 1993). However, clinical laboratory testing appears to be only "rarely" or "infrequently" used in chiropractic practice (Hurwitz, in press; Christensen, 1993). For example, blood tests are ordered for fewer than 1 percent of patients (Hurwitz, in press). The infrequent ordering of lab tests may be due to legal restrictions on chiropractors performing phlebotomy in some jurisdictions as well as to the types of patients typically seen by chiropractors.

Radiology and imaging is used with far greater frequency than laboratory studies. In the NBCE survey (Christensen, 1993), chiropractors indicated that radiographs were "frequently" ordered and special imaging studies such as CT or MR were "sometimes" ordered. In the analysis of office records of patients who sought care for low back pain, 54 percent of patients had lumbosacral radiography, about 2 percent of patients had CT, and 2 percent had MR imaging during their "episode of care" (Hurwitz, in press). Thus, except for plain film radiography, special imaging and other special diagnostic tests are rarely used by chiropractors.

Radiology is a significant component of chiropractic education. A specialty society devoted to radiology, The American Chiropractic College of Radiology, serves in an advisory role for radiology residency programs at chiropractic colleges and certifies specialty-level competency in radiology. Yochum and Rowe (1996), chiropractic radiologists, authored a skeletal radiology text that is used in both chiropractic and medical radiology training. In a study comparing the abilities of chiropractic and medical radiologists, orthopedists, general practitioners, and chiropractic students to interpret radiographs, chiropractic and medical skeletal radiologists scored highest followed by chiropractic students, orthopedists, and general medical and chiropractic practitioners (Taylor, 1995).

Other special studies sometimes used or ordered by chiropractors include nerve conduction studies, bone scans, and electromyography. Appropriate use of these procedures is incorporated into the curriculum of chiropractic colleges and is addressed in chiropractic practice parameters (Haldeman, 1993). Chiropractic utilization of advanced diagnostics is quite low. In the past, chiropractors have been excluded from medical referral loops and have been forced either to care for patients without such studies or to obtain their own equipment and perform the tests themselves. Hence, either by design or circumstance, chiropractors often rely on low tech patient assessment procedures of historytaking, physical, regional, mechanical examinations, and plain film radiography while monitoring progress using a "therapeutic trial" approach to patient management.

C. Treatment Methods

Chiropractic treatments, as well as diagnostic practices, vary by geographic region due to differences in State laws governing scope of practice and due to differences in practitioner philosophy. The therapeutic procedure most closely associated with chiropractic is spinal manipulation. However, chiropractic patient management often includes lifestyle counseling, nutritional management, rehabilitation, various physiotherapeutic modalities, and a variety of other interventions (Gatterman, 1990; Haldeman, 1992, 1993). Physiologic therapeutics, taught in all chiropractic schools, are included in the chiropractic scopes of practice in most jurisdictions. Detailed protocols for the use of physiologic therapeutics have been published in the chiropractic literature (Hooper, 1996; Jascoviak, 1986) and are emphasized in the leading chiropractic research publication, the Journal of Manipulative and Physiologic Therapeutics.

The NBCE survey (Christensen, 1993) reported that chiropractors "routinely" performed chiropractic adjustive techniques. Overall, 96 percent of chiropractors reported having recommended corrective or therapeutic exercise at least once in the 2 years prior to the survey, and 84 percent of doctors recommended nutritional counseling, supportive techniques, or supplements during the same time period. No data are available in the Christensen survey (1993) about the proportion of individual patients who receive specific types of care. The office record data indicated that of 920 patients who presented with low back pain, 84 percent received spinal manipulation (or adjustment), 79 percent received nonthrust manual therapies such as mobilization, massage, and heat packs, 31 percent received education, and 5 percent received other forms of therapy such as acupuncture (Hurwitz, in press).

1. Manual Methods

The syntax surrounding the mechanical intervention of spinal manipulation is the source of some controversy within the chiropractic profession. Most chiropractors prefer the term chiropractic "adjustment" to manipulation because it is believed to imply a more specific or precise maneuver and distinguishes it from other forms of manipulation. There are at least 100 distinct chiropractic, osteopathic, and physical therapy manipulation techniques, a large array of highly specialized adjusting tables and equipment, and a great deal of variation in the specific techniques used by individual practitioners (Haldeman, 1993; Greenman, 1996; Bergmann, 1993).

There are four terms with distinct definitions that are frequently used to characterize manual manipulative methods (Haldeman, 1993). The general umbrella term of spinal manipulative therapy is often used to encompass all types of manual techniques regardless of their precise anatomic and physiologic focus or their discipline of origin. Mobilization is defined as passive movement of a joint within its physiologic range of motion. This roughly equates to the range of motion a joint can typically be taken through by its intrinsic musculature. Manipulation is passive joint movement, which takes the joint beyond its physiologic range into the paraphysiologic space. Intrinsic muscle contraction alone does not usually move joints this far. When a joint is moved into this "para-physiologic" range, cavitation can occur, which, in a synovial joint, is typified by an audible release or "pop." A gaseous bubble may appear within the synovial fluid for several minutes after manipulation (Greenman, 1996).

Both mobilization and manipulation are used to facilitate joint motion. When applied in manual medicine and physical therapy, assessment and manipulative treatment tend to focus exclusively on joint pain and restriction. However, even though the execution of high velocity manipulative thrusts by chiropractors and nonchiropractors may appear similar, chiropractic techniques focus on a more global clinical picture to characterize and apply adjustments. Chiropractors typically consider the nature and mode of condition onset, muscle spasm, pain radiation patterns, static and dynamic postures, and/or gaits as well as joint pain in determining whether or not a mechanical intervention should be applied (Mootz, 1995a). For example, the spinal areas manipulated using typical manual medicine and physical therapy assessment approaches are often based on which joints or regions have restricted motion. In contrast, the decision as to which area to manipulate using various chiropractic techniques may be based upon pain radiation patterns, which paraspinal muscle regions are taut and how they are enervated, the biomechanical function of affected joints compared to that of adjacent areas, and the mechanics involved in initial onset (Grice, 1992; Gitelman, 1992). Thus the regions manipulated by chiropractors may not directly correspond to the symptomatic region or to the area that a nonchiropractor may feel is the site of the manipulable lesion.

In addition, there are many unique features associated with chiropractic techniques including patient positioning, equipment, characteristics of prestressing joints, and thrust. Decisions about the frequency and duration of chiropractic manipulative treatment may not be much influenced by its effect on range of motion. Rather, progress indicators such as function, coordination, and endurance often influence when and how chiropractic manipulation is provided. Some of the syntax in chiropractic reflects this with many drawing a distinction between the terms manipulation and adjusting. Table 23 provides definitions for manipulation, mobilization, and adjusting that illustrate these conceptual differences (Haldeman, 1993).

Bartol (1991) categorized chiropractic adjustive techniques according to their mechanical characteristics. Table 24 lists a classification scheme used by American and Canadian chiropractic practice parameter commissions to categorize types of chiropractic manual interventions. Table 25 provides examples of some better known chiropractic adjustive techniques. The Christensen survey (1993) reported that chiropractors "routinely" perform specific chiropractic adjustive techniques, "frequently" employ supportive or other non-adjustive techniques, but only "sometimes" use instruments (e.g., Activator) in the application of adjustments.

Regarding specific forms of manipulation and adjusting used by chiropractors, the job analysis by Christensen (1993) reported that Diversified, Gonstead, Flexion-Distraction, Activator, and Thompson techniques were the most frequently used procedures. All other techniques were used by fewer than 43 percent of practitioners. Over 93 percent of chiropractors reported using such full-spine adjusting procedures as their primary approach to patient care. Fewer than 2 percent indicated a primary emphasis on upper cervical procedures. Although roughly one-third of chiropractors indicated that they used other techniques (such as cranial work), the number reporting them as a primary emphasis was too small to warrant an individual listing in the Christensen job analysis (1993).

2. Exercise and Rehabilitation

According to Christensen (1993), 96 percent of chiropractors reported that they used corrective and therapeutic exercises. Evidence-based guidelines published by AHCPR stress the importance of early activation of acute low back pain patients in order to optimize recovery (Bigos, 1994). Chiropractors have incorporated patient activation and exercise into their management strategies since the early part of the 20th century (Cook, 1994; Liebenson, 1995). Chiropractors have also become involved in the treatment of athletes, gaining substantial recognition in the sports medicine specialties. The American College of Sports Medicine was one of the first multidisciplinary organizations to allow chiropractors membership status. Chiropractors also have been included by many countries as Olympic team physicians and leading chiropractic colleges have recently sponsored postgraduate certification programs in sports chiropractic and rehabilitation. A clinical journal devoted to sports chiropractic and rehabilitation has been published for the better part of a decade and chiropractic authors have increasingly emphasized rehabilitation and activation strategies (Liebenson, 1995; Cook, 1994; Nelson, 1994; Souza, 1994b).

Table 23. Distinctions Between Adjustment, Manipulation, and Mobilization

Chiropractic Adjustment: This term refers to a wide variety of manual and mechanical interventions that may be high or low velocity; short or long lever; high or low amplitude; with or without recoil. Procedures are usually directed at specific joints or anatomic regions. An adjustment may or may not involve the cavitation or gapping of a joint (opening of a joint within its paraphysiologic zone usually producing a characteristic audible "click" or "pop"). The common denominator for the various adjustive interventions is the concept of removing structural dysfunctions of joints and muscles that are associated with neurologic alterations. The chiropractic profession refers to this concept as a "subluxation." This use of the word subluxation should not be confused with the term’s precise anatomic usage, which considers only the anatomical relationships.

Manipulation and Mobilization: During joint motion, three barriers or end ranges to movement can be identified. The first is the active end range, which occurs when the patient has maximally contracted muscles controlling a joint in a particular directional vector. At this point, the clinician can passively move the joint toward a second barrier called the passive end range. Movement up to this barrier is termed physiologic joint space. Beyond this point, the practitioner can move the joint into its paraphysiologic space. The third barrier encountered is the anatomic end range. Movement beyond this will result in rupture of the joint’s ligaments.

Manipulation: Passive movement of short amplitude and high velocity, which moves the joint into the paraphysiologic range. This is accompanied by cavitation or gapping of the joint, which results in an intrasynovial, vacuum phenomenon thought to involve gas separating from fluid. Usually accompanied by an audible pop or click, manipulation has been shown to result in increased joint motion compared to mobilization alone. This increase in motion lasts for a 20 to 30 minute refractory period during which an additional cavitation of the same joint will not occur. Manipulation is a passive dynamic thrust that causes cavitation and attempts to increase the manipulated joint’s range of motion.

Mobilization: Passive movement within the physiologic joint space administered by a clinician for the purpose of increasing overall range of joint motion.

ACUTE / CHRONIC PROBLEM CARE	Yes	No	N/A	Comments
Problem/#Title _____________
1. Was the subjective data adequate?	____	____	____	_______________
2. Was the objective data adequate?	____	____	____	_______________
3. Was the assessment adequate?	____	____	____	_______________
4. Were the diagnostic procedures adequate?	____	____	____	_______________
5. Was recommended therapy indicated and appropriate for the stated condition?	____	____	____	_______________
6. Does the plan contain appropriate initial short and long term goals?	____	____	____	_______________
7. Are treatment goals reviewed/revised according to their expiration dates?	____	____	____	_______________
8. Was a consultation requested if indicated?	____	____	____	_______________
9. Was the patient referred to the nutritionist if indicated?	____	____	____	_______________
10. Was the patient referred to rehabilitation if indicated?	____	____	____	_______________
11. Was the patient referred to electrodiagnosis if indicated?	____	____	____	_______________
12. Was the patient referred to ergonomics if indicated?	____	____	____	_______________
13. Was the patient referred to orthopedics if indicated?	____	____	____	_______________
14. Was the patient referred to family practice if indicated?	____	____	____	_______________
15. If appropriate, was the patient placed on elective care?	____	____	____	_______________
16. Does a progress note indicate the patient received patient education, including explanation of diagnosis?	____	____	____	_______________
17. If the patient received a new therapy, does SOAP note indicate specific pt. ed. was given about therapy?	____	____	____	_______________
18. MECHANICAL LOW BACK PAIN: Has the initial treatment goal been achieved within 3 weeks?	____	____	____	_______________
19. MECHANICAL NECK PAIN: Has the initial treatment goal been achieved within 3 weeks?	____	____	____	_______________
20. SHOULDER IMPINGEMENT: Has the initial treatment goal been achieved within 6 weeks?	____	____	____	_______________

MEDICAL RECORDS
21. Does the Problem List contain all significant clinical impressions?	____	____	____	_______________
22. Does the Problem List accurately indicate if problems are active or resolved?	____	____	____	_______________
23. Were all entries in the record legible?	____	____	____	_______________
24. Does the progress note follow SOAP format?	____	____	____	_______________
25. Do all therapy/plan orders bear the clinician’s signature and date?	____	____	____	_______________

CONTINUITY OF CAR
26. If ordered, was consultation/referral carried out?	____	____	____	_______________
27. Are all abnormal laboratory, imaging, and specialty procedure results adequately followed up?	____	____	____	_______________
28. Are test results available for tests ordered on previous visit? (NA if 1 wk since last visit)	____	____	____	_______________
29. Was the patient seen by the same provider/group on 8 out of the 10 most recent visits (within 6 months)?	____	____	____	_______________

Figure 3. Practitioner performance audit form

Source: Iannelli GC. Principles of quality management in chiropractic practice. In Lawrence D, et al. (eds). Advances in Chiropractic, Vol. 2. St. Louis, MO: Mosby, 1995. Reprinted with permission.

from Canada revealed that between January 1986 and December 1990, there were a total of 159 claims made against chiropractors with the most common complaints being for lumbar spine injury, rib fracture, soft tissue injury, and cervical spine injury. Cerebrovascular accidents accounted for 8 percent of the claims (Henderson, 1994). According to claims data from the National Chiropractic Mutual Insurance Company for 1990, the most common causes of malpractice claims were for disc problems, failure to diagnose, fracture, and soft tissue injury. Cerebrovascular accidents accounted for 6 percent of claims made (Haldeman, 1993). Estimates of the risk of specific complications from lumbar and cervical spine manipulation are presented in Chapter XI.

In part due to concerns about the risk of adverse events and malpractice claims, guidelines for clinical management, minimization of risks, and informed consent have been published in the chiropractic literature (Haldeman, 1993; Henderson, 1994). Table 27 lists some conditions identified in the Guidelines for Chiropractic Quality Assurance and Practice Parameters that may require modification of high velocity thrust procedures due to possible risks of complications (Haldeman, 1993). Because of the limitations in data quality and availability, the type of evidence available for making these ratings was primarily expert opinion of participating panelists and/or case reports.

GUIDELINES FOR CHART RECORD CONTENT

Chiropractors have the legal and ethical responsibility to maintain complete and accurate records for each patient. Patient files should be stored neatly and organized to facilitate tracking and retrieval, with a system in place to maintain patient confidentiality. The following guidelines are adapted from the 1994 NCQA Guidelines for Medical Record Review.

To be considered complete, chiropractic chart records should include the following features:

Medical Record Overview

• 1. Chart documentation is organized.

• 2. The record is legible.

• 3. If any non-standard abbreviations, codes, or scales are used, a key should be included to allow easy interpretation by any reviewing person.

• 4. The patient name is prominent on each and every page.

• 5. The date is noted for each provider contact / office visit / phone call / record review.

• 6. Entries contain author identification when anyone other than the primary treating doctor makes any entry in the chart record.

• 7. When there is significant risk of injury from a procedure, there is documentation of informed consent by the patient.

Exam / Intake Records

• 8. The patient's name / address / age / family status are noted.

• 9. Past medical / health history are recorded.

• 10. The list of patient's major problems / diagnosis is prominent, and revised as the patient's condition warrants.

• 11. Documented examination findings include adequate and appropriate testing for the patient problem.

Daily Chart Records

• 12. Relevant history / subjective findings of the presenting problem noted for each visit.

• 13. Pertinent objective findings noted when there is significant change.

• 14. Assessment / diagnosis noted in encounter entries, corresponding to subjective / objective findings.

• 15. Treatment plan / recommendations noted, corresponding to the patient problem / diagnosis. Return time is noted as weeks, months, or PRN.

• 16. Notation of care prescribed or provided, corresponding to the problem being treated.

• 17. The care provided appears to be "medically" appropriate.

• 18. Reports (lab, imaging, second opinion, etc) and correspondence are signed or initialed as reviewed by the provider, significant findings are noted in the record.

• 19. Notation of patient's response to care.

• 20. Notation of home exercises /activities / ADLs given.

• 21. Appropriate diagnostic testing or referral is noted.

• 22. Notation of review / discussion of specialist findings and further recommendations.

• 23. All S.O.A.P. areas are updated for each PRN follow-up visit.

Figure 4. Chart record content guideline

Source: McElheran L, Sollecito P. Delivering quality chiropractic care in a managed care setting. Top Clin Chiropr 1994;1(4):78.

Table 27. Examples of Conditions (or Concurrent Conditions) That May Necessitate Modification of High Velocity Thrust Procedures on a Patient

Absolute contraindication to high velocity thrust procedures

� region with acute episode of rheumatoid arthropathy
� acute fracture/dislocation
� osodontoideum
� active juvenile avascular necrosis
� area with malignancy
� bone or joint infection
� acute myelopathy or cauda equina syndrome

Relative to absolute contraindication to high-velocity thrust procedures

� joint instability
� benign bone tumors
� clinical manifestations of vertebrobasilar arteriole insufficiency (to cervical manipulation)
� congenital or acquired skeletal deformities

Relative contraindication to high-velocity thrust procedures

� spondylolisthesis with progressive slippage
� articular hypermobility
� bone demineralization
� patient with bleeding disorders

No contraindication

� uncomplicated degenerative joint disease
� subacute or chronic ankylosing spondylitis
� nonprogressive spondylolysis or spondylolisthesis
� scoliosis
� acute soft tissue injury

ROUTINELY SEEN	Spinal subluxation/joint dysfunction Headaches
OFTEN SEEN	Muscular strain/tear Osteoarthritis/degenerative joint disease Peripheral neuritis or neuralgia Tendonitis/tenosynovitis Radiculitis or radiculopathy Vertebral facet syndrome Intervertebral disc syndrome Sprain or dislocation of any joint Extremity subluxation/joint dysfunction Hyperlordosis of cervical or lumbar spine Scoliosis Bursitis or synovitis High or low blood pressure Allergies Obesity
SOMETIMES SEEN	Kyphosis of thoracic spine Osteoporosis/osteomalacia Carpal or tarsal tunnel syndrome Skeletal congenital/developmental anomaly Articular joint congenital/developmental anomaly TMJ syndrome Thoracic outlet syndrome Systemic rheumatoid arthritis or gout Occupational or environmental disorder Muscular atrophy Nutritional disorders Menstrual disorders Asthma, emphysema, or COPD Upper respiratory or ear infection Pregnancy Respiratory viral or bacterial infection Acne, dermatitis, or psoriasis Loss of equilibrium Diabetes Psychological disorders Eating disorders Ear or hearing disorders Eye or vision disorders Hiatus or inguinal hernia Gastrointestinal bacterial or viral infection Infection of kidney or urinary tract Colitis or diverticulitis Thyroid or parathyroid disorder Hemorrhoids

ICD CODE	DESCRIPTION	% of all non-LBP Diagnoses (N=477)
•••	Missing	23.7
847.0	Sprains and strains, neck	13.7
847.1	Sprains and strains, thoracic	5.4
723.1	Cervicalgia	3.7
839.0	Dislocation, cervical vertebra	3.7
729.1	Myalgia and myositis, unspecified	3.4
739.1	Nonallopathic lesion, cervical region	3.2
784.0	Headache	2.7
723.2	Cervicocranial syndrome	2.1
723.3	Cervicobrachial syndrome (diffuse)	1.8
346.0	Migraine	0.5
382.9	Unspecified otitis media	0.3
493.9	Asthma, unspecified	0.2
•••	(130 other diagnoses)	(35.6)
		100%

Full-spine high velocity techniques Diversified Gonstead Thompson Terminal Point Pierce-Stillwagon Pettibon Chiropractic Biophysics	Lumbo pelvic techniques Cox Flexion-distraction Logan Basic
Upper cervical techniques Upper Cervical Specific NUCCA Grostic Orthogonal	Miscellaneous/Instrument Adjusting Sacro-Occipital Technique Applied Kinesiology Activator Toftness