Chiropractic Practice Guidelines

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

You may also want to explore the shift away from Guidelines (usually containing numbers/suggested treatment time frames, that are often mistakenly applied as arbitrary limits) to “Best Practices” (clinical judgments regarding patient care that are informed by the best evidence and balanced by patient complexity and provider experience to improve the quality and reduce the costs of care). Please refer to our Outcome Assessment and the Documentation sections for more helpful information.

You may want to explore the shift away from Guidelines (usually containing numbers/suggested treatment time frames, that are often mistakenly applied as arbitrary limits) to “Best Practices” (clinical judgments regarding patient care that are informed by the best evidence and balanced by patient complexity and provider experience to improve the quality and reduce the costs of care).

Evidence-based Practice This page provides information about interpreting the various statistical tests utilized in journal articles, and contains other information regarding Evidence-based Practice.

Best Practice Initiative Explore the shift from Guidelines, often containing numbers/ suggested treatment time frames, to “Best Practices”, which are clinical decisions informed by the best evidence available, and balanced by patient complexity and provider experience.

Guidelines Page Our original Guidelines section contains a compendium of Guidelines from around the World, as well as a selection of articles about the need for, and frequent misuse of these Guidelines.

Guidelines From Around The World

	Alternative Medicine Guidelines A Chiro.Org collection Britain's Department of Health, in collaboration with the Foundation for Integrated Medicine has published Complementary Medicine, a document that explains the benefits of the top six complementary therapies provided by Britain's National Health Service (NHS).
	The “Best Practice” Initiative A Chiro.Org collection The Council on Chiropractic Guidelines and Practice Parameters (CCGPP), was formed in 1995 at the behest of the Congress of Chiropractic State Associations (COCSA) and with assistance from numerous national associations to create an equitable chiropractic practice document. CCGPP was delegated to examine all existing guidelines, parameters, protocols and best practices in the United States and other nations in the construction of this document. Come review all the CCGPP literature syntheses on low back, upper and lower extremities, non-musculoskeletal conditions, prevention and health promotion, and soft tissue conditions. You may also enjoy the Evidence-based Practice Page.
	Diagnostic Imaging Guidelines for Musculoskeletal Complaints in Adults A Chiro.Org collection These evidence-based diagnostic imaging practice guidelines are intended to assist primary care providers and students in decision making regarding the appropriate use of diagnostic imaging for specific clinical presentations. The guidelines are intended to be used in conjunction with sound clinical judgment and experience.
	Headache Guidelines (Canada) A Chiro.Org collection This material was developed by the Guidelines Development Committee (GDC) under the auspices of the Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory and Education Accrediting Boards, Clinical Practice Guidelines Project (The CCA·CFCREAB-CPG)
	Insurance Industry Guidelines A Chiro.Org collection This section defines terminology, outlines "accepted (and unaccepted) diagnostic tests" in Personal Injury, and offers you access to Allstate's "confidential" Employee Training Manual.
	Low Back Pain Guidelines from Around the World A Chiro.Org collection A new addition is the Danish Institute's Low Back Pain Guidelines, available in HTML or Adobe Acrobat. This section also includes recommendations from the California Industrial Medical Council, the Royal College of General Practitioners, the 1994 AHCPR guides, the "Mercy Conference Document", and the New Zealand "Psychosocial Yellow Flags" Page
	Musculoskeletal Pain Guidelines A Chiro.Org collection Review these recent guidelines.
	Neck Disorder Guidelines from Around the World A Chiro.Org collection This newly updated page includes all the combined guidelines for Neck Disorders (including both Whiplash-associated Disorders AND Neck Disorders not due to whiplash) into a single unified source page.   This page also includes 6 tables, generously donated by Arthur Croft, D.C., from his text Whiplash Injuries: The Cervical Acceleration/ Deceleration Syndrome.   It also includes guidelines from the California Industrial Medical Council. You may also want to visit our Whiplash Page and our Chronic Neck Pain Page
	Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update Comparative Effectiveness Review Number 227 Rockville (MD): Agency for Healthcare Research and Quality (2020) Trials identified subsequent to the earlier report largely support previous findings, namely that exercise, multidisciplinary rehabilitation, acupuncture, CBT, mindfulness practices, massage, and mind-body practices most consistently improve function and/or pain beyond the course of therapy for specific chronic pain conditions. Additional research, including comparisons with pharmacological and other active controls, on effects beyond the immediate post-treatment period is needed, particularly for conditions other than low back pain.
	Pediatric Care Guidelines A Chiro.Org collection This new page contains all the collected pediatric guidelines for the care of children.
	Physiotherapy and Rehabilitation Guidelines for the Chiropractic Profession A Chiro.Org collection From the Council on Chiropractic Physiological Therapeutics and Rehabilitation
	Radiology Guidelines A Chiro.Org collection Review this selection of articles and guidelines from our Radiology Section
	State and National Guidelines for Chiropractic Practice A Chiro.Org collection Review the International Chiropractors Association (ICA) and Canadian guides for care, documentation, and outcome assessments.
	Subluxation–based Guidelines A Chiro.Org collection Includes Guidelines from the International Chiropractors Association (ICA) and the Council on Chiropractic Practice (CCP) regarding Instrumentation, Radiographic and other Imaging, Clinical Impression and Assessment, Reassessment and Outcome Assessment, Modes of Adjustive Care, Duration of Care for Correction of Vertebral Subluxation, and Chiropractic Care for Children.
	Workers Compensation Guidelines (California) A Chiro.Org collection This section defines California's recommendations for Neuromusculoskeletal, Low Back, Neck and Shoulder complaints.
	AHCPR/AHRQ Guidelines Access The original Agency for Health Care Policy and Research (AHCPR) has now evolved into Agency for Healthcare Quality and Research (AHRQ).
	Chiro.Org's Documentation Section A Chiro.Org collection This section contains documentation recommendations from State and National associations. Documentation Recommendations for:    Clinical Impression and Diagnosis    Initial Exam    Outcome Assessment    Record Keeping

Articles about Guidelines

	Best Practices for Chiropractic Management of Adult Patients With Mechanical Low Back Pain: A Clinical Practice Guideline for Chiropractors in the United States J Manipulative Physiol Ther 2023 (Jun 20); S0161-4754 ~ FULL TEXT This paper updates the best-practice guideline on chiropractic management of mechanical LBP in adults in the US from the prior iterations. [4, 82] This guideline provides evidence-informed guidance to DCs related to both initial care management and the progression of care throughout an episode of the condition to reduce practice variability among providers while improving outcomes. We identified benchmarks and decision points in care management and provided information related to each issue. Providers can use this document as a reference point for the care they provide their patients. This updated Clinical Practice Guideline (CPG) condensed the number of recommendations from 51 to 38 while providing more evidence-informed insight into the diagnostic considerations for LBP, including the history and examination and diagnostic imaging. This document provides a more comprehensive description of the conservative management approaches to LBP, including chiropractic approaches and co-management considerations for multidisciplinary care.
	Best-Practice Recommendations for Chiropractic Care for Pregnant and Postpartum Patients: Results of a Consensus Process J Manipulative Physiol Ther 2021 (Nov 23); S0161 ~ FULL TEXT This best-practice recommendations article is a synthesis of the current evidence and collective expert opinion about a reasonable clinical approach for chiropractic care and management of pregnant and postpartum populations. This article provides an initial framework for chiropractors who wish to manage these populations and to help chiropractic researchers determine and examine the gaps in the literature to implement a robust research program that informs future clinical guidelines. As the first best-practices recommendations document for pregnant and postpartum patients, it is expected to evolve as new evidence emerges.
	Best Practices for Chiropractic Management of Patients with Chronic Musculoskeletal Pain: A Clinical Practice Guideline J Altern Complement Med 2020 (Jul 30) ~ FULL TEXT The Delphi process was conducted January-February 2020. The 62-member Delphi panel reached consensus on chiropractic management of five common chronic MSK pain conditions: low-back pain (LBP), neck pain, tension headache, osteoarthritis (knee and hip), and fibromyalgia. Recommendations were made for nonpharmacological treatments, including acupuncture, spinal manipulation/mobilization, and other manual therapy; modalities such as low-level laser and interferential current; exercise, including yoga; mind-body interventions, including mindfulness meditation and cognitive behavior therapy; and lifestyle modifications such as diet and tobacco cessation. Recommendations covered many aspects of the clinical encounter, from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral. Appropriate referral and comanagement were emphasized.
	Best-Practice Recommendations for Chiropractic Management of Patients With Neck Pain J Manipulative Physiol Ther. 2019 (Nov); 42 (9): 635–650 ~ FULL TEXT A set of best-practice recommendations for chiropractic management of patients with neck pain based on the best available evidence reached a high level of consensus by a large group of experienced chiropractors. The recommendations indicate that manipulation and mobilization as part of a multimodal approach are front-line approaches to patients with uncomplicated neck pain.
	Best Practices for Chiropractic Care for Older Adults: A Systematic Review and Consensus Update J Manipulative Physiol Ther 2017 (May); 40 (4): 217–229 ~ FULL TEXT A total of 199 articles were found; after exclusion criteria were applied, 6 articles about effectiveness or efficacy and 6 on safety were added. The Delphi process was conducted from April to June 2016. Of the 37 Delphi panelists, 31 were DCs and 6 were other health care professionals. Three Delphi rounds were conducted to reach consensus on all 45 statements. As a result, statements regarding the safety of manipulation were strengthened and additional statements were added recommending that DCs advise patients on exercise and that manipulation and mobilization contribute to general positive outcomes beyond pain reduction only. This is an update of the 2010 Consensus Document titled: Recommendations for Chiropractic Care for Older Adults: Results of a Consensus Process
	Guideline for Reporting Interventions on Spinal Manipulative Therapy: Consensus on Interventions Reporting Criteria List for Spinal Manipulative Therapy (CIRCLe SMT) J Manipulative Physiol Ther 2017 (Feb); 40 (2): 61–70 ~ FULL TEXT This is the first effort to develop a criteria list designed to improve the reporting of trials of SMT, and this list should be used in conjunction with the CONSORT Statement and its extension for nonpharmaceutical trials. This initiative represents an important step toward improving the quality of reporting SMT and will help clinicians to interpret the results of trials and effectively apply them to clinical practice.
	The Treatment of Neck Pain-Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline J Manipulative Physiol Ther. 2016 (Oct); 39 (8): 523–564 ~ FULL TEXT The objective was to develop a clinical practice guideline on the management of neck pain-associated disorders (NADs) and whiplash-associated disorders (WADs). This guideline replaces 2 prior chiropractic guidelines on NADs and WADs.
	Management of Neck Pain and Associated Disorders: A Clinical Practice Guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration European Spine Journal 2016 (Jul); 25 (7): 2000–2022 ~ FULL TEXT This guideline is based on recent systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences (obtained from qualitative research) when formulating recommendations. Target audience includes clinicians; target population is adults with grades I-III NAD <6 months duration.
	Best Practices for Chiropractic Care of Children: A Consensus Update J Manipulative Physiol Ther. 2016 (Mar); 39 (3): 158–168 ~ FULL TEXT Chiropractic is a health care profession concerned with the diagnosis, treatment, and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health. [1] Chiropractic care is the most common complementary and integrative medicine practice used by children in the United States. [2] A recent Gallup survey found that approximately 14% of US adults reported that they had used chiropractic care in the prior 12 months, that more than 50% had ever used a doctor of chiropractic (DC) for health care, and that more than 25% would choose chiropractic care as a first treatment for neck or back pain. [3] The findings from this survey also were consistent with a previous study that found that patients use chiropractic services in different ways, sometimes for treatment and sometimes for health promotion. [4] This is an update of the 2009 Consensus Document titled: Best Practices Recommendations for Chiropractic Care for Infants, Children, and Adolescents
	Clinical Practice Guideline: Chiropractic Care for Low Back Pain J Manipulative Physiol Ther. 2016 (Jan); 39 (1): 1–22 ~ FULL TEXT To facilitate best practices specific to the chiropractic management of patients with common, primarily musculoskeletal disorders, the profession established the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) in 1995. [6] The organization sponsored and/or participated in the development of a number of “best practices” recommendations on various conditions. [21–32] With respect to chiropractic management of LBP, a CCGPP team produced a literature synthesis [8] which formed the basis of the first iteration of this guideline in 2008. [9] In 2010, a new guideline focused on chronic spine-related pain was published, [12] with a companion publication to both the 2008 and 2010 guidelines published in 2012, providing algorithms for chiropractic management of both acute and chronic pain. [10] Guidelines should be updated regularly. [33, 34] Therefore, this article provides the clinical practice guideline (CPG) based on an updated systematic literature review and extensive and robust consensus process. [9–12]
	Adherence to Clinical Practice Guidelines Among Three Primary Contact Professions: A Best Evidence Synthesis of the Literature for the Management of Acute and Subacute Low Back Pain J Can Chiropr Assoc 2014 (Sept); 58(3): 220–237 ~ FULL TEXT To determine adherence to clinical practice guidelines in the medical, physiotherapy and chiropractic professions for acute and subacute mechanical low back pain through best-evidence synthesis of the healthcare literature. Of the three professions examined, 73% of chiropractors adhered to current clinical practice guidelines, followed by physiotherapists (62%) and then medical practitioners (52%).
	The Clinical Practice Guideline Initiative: A Joint Collaboration Designed to Improve the Quality of Care Delivered by Doctors of Chiropractic J Can Chiropr Assoc 2013 (Dec); 57 (4): 279–284 ~ FULL TEXT The overall purpose is to develop evidence-based Clinical Practice Guidelines and to facilitate the utilization of these and existing guidelines among chiropractors. Further, it aims to enhance academic, clinical and research partnerships to help close the gap between research knowledge and its implementation in clinical practice in order to improve health outcomes.

Knowledge Transfer Within the Canadian Chiropractic Community Part 1: Understanding Evidence-Practice Gaps J Can Chiropr Assoc. 2013 (Jun); 57 (2): 111–115 ~ FULL TEXT This two-part commentary aims to provide a basic understanding of knowledge translation (KT), how KT is currently integrated in the chiropractic community and our view of how to improve KT in our profession. Part 1 presents an overview of KT and discusses some of the common barriers to successful KT within the chiropractic profession. Part 2 will suggest strategies to mitigate these barriers and reduce the evidence-practice gap for both the profession at large and for practicing clinicians. Part 2: Narrowing the Evidence-Practice Gap J Can Chiropr Assoc. 2014 (Sep); 58 (3): 206–214 ~ FULL TEXT This two-part commentary aims to provide clinicians with a basic understanding of knowledge translation (KT), a term that is often used interchangeably with phrases such as knowledge transfer, translational research, knowledge mobilization, and knowledge exchange. [1] Knowledge translation, also known as the science of implementation, is increasingly recognized as a critical element in improving healthcare delivery and aligning the use of research knowledge with clinical practice. [2] The focus of our commentary relates to how these KT processes link with evidence-based chiropractic care.

	Consensus Process to Develop a Best-Practice Document on the Role of Chiropractic Care in Health Promotion, Disease Prevention, and Wellness J Manipulative Physiol Ther. 2012 (Sep); 35 (7): 556–567 ~ FULL TEXT Chiropractic wellness care (sometimes referred to as maintenance care [MC]) is accepted by the profession as an integral part of chiropractic practice. [1–6] The theory of MC suggests that ongoing chiropractic care may have value in maintaining and promoting health, as well as preventing disease. [7]
	Developing Clinical Practice Guidelines: Reviewing, Reporting, and Publishing Guidelines; Updating Guidelines; and the Emerging Issues of Enhancing Guideline Implementability and Accounting for Comorbid Conditions in Guideline Development Implementation Science 2012 (Jul 4); 7: 62 ~ FULL TEXT Clinical practice guidelines are one of the foundations of efforts to improve health care. In 1999, we authored a paper about methods to develop guidelines. Since it was published, the methods of guideline development have progressed both in terms of methods and necessary procedures and the context for guideline development has changed with the emergence of guideline clearing houses and large scale guideline production organisations (such as the UK National Institute for Health and Clinical Excellence). It therefore seems timely to, in a series of three articles, update and extend our earlier paper. In this third paper we discuss the issues of: reviewing, reporting, and publishing guidelines; updating guidelines; and the two emerging issues of enhancing guideline implementability and how guideline developers should approach dealing with the issue of patients who will be the subject of guidelines having co-morbid conditions.
	An Updated Overview of Clinical Guidelines for the Management of Non-specific Low Back Pain in Primary Care European Spine Journal 2010 (Dec); 19 (12): 2075–2094 ~ FULL TEXT This updated review includes national clinical guidelines from 13 countries and 2 international clinical guidelines from Europe published from 2000 until 2008. The content of the guidelines appeared to be quite similar regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions. Consistent features for acute low back pain were the early and gradual activation of patients, the discouragement of prescribed bed rest and the recognition of psychosocial factors as risk factors for chronicity.
	Best Practices Recommendations for Chiropractic Care for Older Adults: Results of a Consensus Process J Manipulative Physiol Ther 2010 (Jul); 33 (6): 464–473 ~ FULL TEXT A multidisciplinary panel of experienced chiropractors was able to reach a high level (80%) of consensus on evidence-informed best practices for the chiropractic approach to evaluation, management, and manual treatment for older adult patients. These recommendations have been updated by the 2017 article: Best Practices for Chiropractic Care for Older Adults: A Systematic Review and Consensus Update
	Rigorous Development Does Not Ensure That Guidelines are Acceptable to a Panel of Knowledgeable Providers J Gen Intern Med. 2008 (Jan); 23 (1): 37–44 Despite very rigorous development methods compared with guidelines assessed in prior studies, experts felt that these guidelines omitted common clinical situations and contained much content of uncertain validity. Guideline acceptability should be independently and formally evaluated before dissemination.
	Best Practices Recommendations for Chiropractic Care for Infants, Children, and Adolescents: Results of a Consensus Process J Manipulative Physiol Ther. 2009 (Oct); 32 (8): 639–647 ~ FULL TEXT There has been much discussion about the role of chiropractic care in the evaluation, management, and treatment of pediatric patients. To date, no specific guidelines have been adopted that address this issue from an evidence based perspective. Previous systematic reviews of the chiropractic literature concluded that there is not yet a substantial body of high quality evidence from which to develop standard clinical guidelines. The purpose of this project was to develop recommendations on "best practices" related primarily to the evaluation and spinal manipulation aspects of pediatric chiropractic care; nonmanipulative therapies were not addressed in detail. These recommendations have been updated by the 2016 article: Best Practices for Chiropractic Care of Children: A Consensus Update
	Chiropractic Clinical Practice Guideline: Evidence-based Treatment of Adult Neck Pain Not Due to Whiplash J Canadian Chiro Assoc 2005 (Sep); 49 (3): 158–209 ~ FULL TEXT Researchers worked with the Canadian Chiropractic Association, the Canadian Federation of Chiropractic Regulatory Boards, the Clinical Practice Guidelines Development Initiative, and the Guidelines Development Committee (GDC) to provide an evidence-based clinical practice guideline for the chiropractic cervical treatment of adults with acute or chronic neck pain not due to whiplash.
	Evidence-Based Guidelines for the Chiropractic Treatment of Adults With Headache J Manipulative Physiol Ther. 2011 (Jun); 34 (5): 274–289 ~ FULL TEXT Evidence suggests that chiropractic care, including spinal manipulation, improves migraine and cervicogenic headaches. The type, frequency, dosage, and duration of treatment(s) should be based on guideline recommendations, clinical experience, and findings. Evidence for the use of spinal manipulation as an isolated intervention for patients with tension-type headache remains equivocal.
	GRADE: An Emerging Consensus on Rating Quality of Evidence and Strength of Recommendations British Medical Journal 2008 (Apr 26); 336 (7650): 924–926 ~ FULL TEXT Guidelines are inconsistent in how they rate the quality of evidence and the strength of recommendations. This article explores the advantages of the GRADE system, which is increasingly being adopted by organisations worldwide
	Evaluation of Clinical Practice Guidelines in Chiropractic Care: A Comparison of North American Guideline Reports Journal of the Canadian Chiropractic Assoc 2001 (Sep); 45 (3): 141–153 ~ FULL TEXT In the past two decades, clinical guidelines have become practical tools that assist clinicians, policy makers and insurers make informed decisions about the clinical and administrative management of patients. The popularity of these tools has increased so rapidly that clinicians now face the dilemma of having to choose from a plethora of documents of varying quality that were developed by various scientific, professional, political and commercial parties. In this context, a key challenge for the users of clinical practice guidelines is to determine whether their recommendations are valid, useful, based on the best available evidence and developed with sound scientific methodology.
	Evidence-based Clinical Guidelines Submitted to the Australian National Health and Medical Research Council for the Management of Acute Low Back Pain: A Critical Review J Manipulative Physiol Ther 2001 (Feb); 24 (2): 131–139 ~ FULL TEXT Moves are afoot in Australia to publish Evidence-Based Clinical Guidelines for the Management of Acute Low Back Pain.1 A draft has been prepared by Professor Nikolai Bogduk of the University of Newcastle and the Newcastle Bone and Joint Institute, New South Wales. Bogduk has made a gallant attempt to address the issue of acute low back pain, but the document is seriously flawed in many respects. This is surprising and alarming, given the author's prominence in the international spine community.   You will also enjoy this response from Anthony L. Rosner, PhD, research director for FCER.
	Developing Clinical Guidelines British Medical Journal 1999 (Feb 27); 318: 593–596 ~ FULL TEXT The methods of guideline development should ensure that treating patients according to the guidelines will achieve the outcomes that are desired. This article presents a combination of the literature about guideline development and the results of our combined experience in guideline development in North America and Britain. It considers the five steps in the initial development of an evidence based guideline
	Chiropractic Care for Common Industrial Low Back Conditions Chiropractic Technique 1993 (Aug); 5 (3): 119–125 ~ FULL TEXT This is the first guideline I have seen which actually states the number of visits which may be appropriate for a variety of common low back conditions.   I have used these "care plans" for years, presenting them to third party's as a "working diagnosis" care plan, which need ongoing "fine tuning" during patient care. Check out this Chiropractic Technique article, and the attached care plans, which have been released exclusively to Chiro.Org by the National College of Chiropractic. Thanks, Dana!

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