The diagnostic and therapeutic procedures considered are:
I. Diagnostic Procedures
A. History and Physical Examination
B. Routine Roentgenographic Evaluation
C. Laboratory Tests
E. Computed Tomography (CT)
F. Magnetic Resonance Imaging (MRI)
H. Intravenous-Enhanced CT
I. Gadolinium-Enhanced (Gadolinium Gadopentate)MRI
K. Radionuclide (Technetium, Indium, and Gallium) Scanning
L. Electrodiagnostic Studies
M. Diagnostic Selective Injection Procedures
N. Physical Capacity Evaluations
O. Personality/Psychological Evaluations
II. Therapeutic Procedures
A. Phase 1: Nonoperative Care
- Thermal Treatment
- Endorphin-Mediated Analgesic Therapy (Acupuncturoid Treatment)
- Restriction of Activity
- Back Education
- Therapeutic Exercise
- Manual Therapy (including chiropractic adjustments)
- Spinal Braces and Other Movement-Restricting Appliances
B. Phase II: Nonoperative Care
10. ReactivationC. Surgical Procedures
12. Work Simulation
13. Psychosocial Intervention
14. Vocational Rehabilitation
15. Interdisciplinary Team Approach
- Percutaneous Discectomy (Nuclectomy)
- Spinal Fusion
- Internal Fixation Systems
- Spinal Osteotomy
- Therapeutic Injections
- Neuroablative Procedures
- Surgical Fusion of the Sacroiliac (SI) Joint
Each procedure was rated as to its established use and acceptance. These are the categories the NASS used:
I. Generally accepted, well established, and widely used.
II. Generally accepted and well established, but of limited application.
III. Accepted, but considered developmental.
IV. Of limited clinical history.
V. Under investigation.
VI. Of no proven value.
Chiropractic adjustments are included under the term "manual therapy." This is the guideline:
Procedure Category: I (Generally accepted, well established, and widely used.)
Joint manipulation, soft tissue and joint mobilization, therapeutic massage, and chiropractic adjustments are modalities included in this category. Mechanical adjustments are performed by applying external pressure, or from trunk movements the patient performs.
a. Minimum time for treatment response: 1 or 2 treatments.
b. Treatment frequency: 2-5 supervised treatments per week for the first 2 weeks, decreasing to 1-2 treatments per week.
c. Optimum treatment duration: 1 month.
d. Maximum treatment duration: 2-4 months.
In an exclusive interview with Committee Chairman Casey K. Lee, M.D., Dr. Lee explained how the guidelines were developed:
"DC": Can you tell us briefly how the guidelines were developed for the North American Spine Society's report?
Dr. Lee: It was approximately five years ago. The leaders of the North American Spine Society felt that this was very important. The committee was made up of six members which included non-surgeons, surgeons, and a consultation with a radiologist. Dr. Scott Haldeman was called in on a couple of occasions and he had an opportunity to have some input. We had many meetings together.
"DC": In your opinion, what are the implications of these guidelines? How do you feel they will be used and how far-reaching will they be?
Dr. Lee: I think they are very important. I don't know how it will affect others, but what is hoped is that we review what is going on in North America in terms of diagnostic and therapeutic procedures for the patient who is suffering with low back pain problems. Hopefully, this will give some directions and quides to practitioners. By doing this we will provide a better way of managing our patients with a back pain problem in terms of better medical care, better effectiveness and decisions, both in medical care as well as economic situations. As you know, the health care economics are of very much concern to all of us, and we are hoping we can be cost effective as well as effective in medical care; that is the first thing as we all know. This is what we are hoping for.
"DC": Do you anticipate these guidelines being updated in the near future?
Dr. Lee: I believe our new chairman Dr. Steven Garfin is planning to start working on an update. I think every three to five years it will be updated, maybe sooner if necessary.
Scott Haldeman, D.C., M.D., Ph.D., was the NASS president during the time that the guidelines were being developed. We asked Dr. Haldeman to comment on how the guidelines would affect health care.
"DC": Dr. Haldeman, could you tell us briefly how you feel these guidelines developed by the North American Spine Society will be applied in the general field of health care?
Dr. Haldeman: The North American Spine Society today is probably the most prestigious scientific spine society in North America, in that its entire meeting is research oriented. It has liaison with multiple specialist societies, including neurosurgery, neurology, orthopedic surgery, and physical medicine. It has, as its members, almost all clinical groups who research spinal conditions and practice in the field of the spine.
You don't have to be a researcher to be a member as in the international societies of the lumbar spine, but you do have to attend the meetings regularly. Chiropractors are not excluded, but it requires four years of postprofessional, full-time training to be a member, so chiropractors have to have a Ph.D. in order to be a member. There are, apart from myself, four other chiropractic members: John Triano, David Cassidy, and Reed Phillips.
Close to 250-300 papers are submitted every year and about 60-70 papers are presented or accepted and then there are another 50-100 posters. There have been a number of symposia on manipulation and a number of papers both in presentation and as posters by chiropractors submitted and accepted at the meeting. So, it doesn't exclude chiropractors, as such.
The (guidelines) committee was formulated about five years ago in response to the same pressures that are forcing the chiropractors now to convene their meeting in January -- the Mercy Center Conference (Quality Assurance Conference). The same pressures were evident then to the surgeons, radiologist, and physiatrist, that they would have to establish standards. So, they convened this meeting. It was convened by the president of the society. Later, I became president of the society. During my presidency many of these meetings were held and the initial document was submitted.
The initial guidelines went through a number of revisions and it was sent out to all members of the society for their input. It was then brought back and is now being ratified by council and published. It is going to be a document like all the other documents -- like the RAND Corporation document, and like multiple consensus documents that are being presented. It is going to be used as a guideline by which the practice or authorization of certain practices can be judged.
Chiropractic input on these guidelines was relatively small because the interest in chiropractic was relatively small. They came up with treatment numbers which were not that much different than the RAND Corporation numbers, as to frequency and duration of care. Chiropractic was given as high a procedure rating as any other treatment for back pain. So, to that extent, the guidelines have endorsed the effectiveness of manipulation in chiropractic treatment.
"DC": Do you see this affecting chiropractic manipulation in the future as we move towards a national health care system?
Dr. Haldeman: Yes, I think it is an endorsement of the validity of chiropractic adjustments and manipulation. It is an attempt to put it into some degree of perspective, but it is an endorsement that chiropractic adjustments have now been accepted as a valid method for the treatment of back pain by the most prestigious scientific organization in the country.
"DC": What does the chiropractic profession need to do to effectively follow up on the North American Spine Society guidelines and the Quality Assurance Conference?
Dr. Haldeman: What the profession is going to have to do is basically learn about them. When you have endorsed a treatment approach as the RAND Corporation and the North American Spine Society have done, then you have to establish exactly when, where, and how often the treatment should be valid and presented, because most of these are opinions. To vary from these opinions you then have to do present research arguments in disagreement. Many of these opinions will not be the way, and will not give chiropractors everything they want; they don't endorse prolonged treatment, in effect they don't endorse preventive treatment and things like this.
But chiropractors are going to have to do the research to change the exceptions and the narrow acceptance that these documents are presenting. Then, what's going to have to happen is that chiropractors are going to have to learn about these things -- they are going to have to be widely disseminated, widely debated and discussed, and then used as an emphasis or as a pointer to where research resources have to go.
Based on the NASS guidelines, it appears that chiropractic adjustments have reached a new level of being considered "generally accepted, well established and widely used." But this is within a narrow framework developed by an organization outside of the profession. As Dr. Haldeman stated, the job now is to dedicate significant resources towards high quality research that will further clarify and expand the role of chiropractic care in the health care arena.
This is clearly an opportunity for this profession to take the ball and run. But this will only occur with credible research by the best the profession has to offer.