Having "predetermined protocols" is a "standard of care" with a diagnostic or treatment regimen to follow. That standard of care is in the public interest to ensure the safety of our patients. Every health care profession has a regimen of diagnosis and care: predetermined protocols.
Standards of Care in Other Professions
Based on personal experience, orthopedic surgeons will rarely evaluate you before an X-ray is taken of the body part in question. That is currently one standard in orthopedics. Although a baseline protocol is a reasonable approach to care based on an initial evaluation, many providers differ depending upon experience.
An ophthalmologist, faced with a clinical finding of macular degeneration, would consider as a treatment, fluorescein angiography (FA)-guided reduced-fluence photodynamic therapy (PDT) as an accepted protocol.1
If a patient presents to the emergency room with an occlusive stroke, the protocol is a tissue plasminogenic activator (r-tPA) within four hours.2
A patient with worsening symptoms of gait abnormalities, weakness, sensory changes, and diagnosed with cervical spondylitic myelopathy with minimal symptoms – without hard evidence of gait disturbance or pathologic reflexes – warrants nonoperative treatment; but patients with demonstrable myelopathy and spinal cord compression are candidates for operative intervention.3 This is accepted protocol depending upon 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.4
Chiropractic Recommendations for Immediate Care
The example protocols above are in different medical specialties, and each specialty has its protocol. Chiropractic is no different. Based on the literature, there are three recommendations for immediate care:
- Based on the evidence, there are three steps recommended, diagnosis, treatment, and reassessment that includes both idiopathic and identified causes. Dosage is based upon "best-practice," and the selection should respect recommendation #2.5
- Based on all the evidence, recommendations for initial care to include multimodal care inclusive of manipulation [chiropractic spinal adjustment], mobilization, ischemic pressure, clinic and home-based exercise, supervised graded strengthening exercises, traction, patient education, low-power laser, massage, transcutaneous electrical nerve stimulation (TENS), pillows, pulsed electromagnetic therapy, or ultrasound – for patients with acute or chronic pain, where the origin of the pain is known or unknown, to improve pain and some ROM – in dosages and methods based on the practitioner's experience and the patient's specific situation.6
- Based on all the evidence, in the absence of objective findings with neck pain not due to whiplash (e.g., ROM, muscle hypertonicity), we do not recommend that treatment be initiated. If, after a complete examination, all findings except for pain are normal, we recommend discharge of the patient from chiropractic care and, possibly, referral based on the practitioner's experience.7
X-Ray as a Predetermined Protocol to Ensure Public Safety
After a thorough history and examination, a prognosis and treatment plan must be concluded. If your goals include structural care and correction, an accurate, reproducible analysis must be determined. X-ray as a predetermined protocol is a reasonable approach to ensure public safety.
Seffinger, et al., reported, "Given that the majority of palpatory tests studied, regardless of the study conditions, demonstrated low reliability, one has to question whether the palpatory tests are indeed measuring what they are intending to measure. That is to say, is there content validity of these tests? Indeed, there is a paucity of research studies addressing the content validity of these procedures. If spinal palpatory procedures do not have content validity, it is unlikely they will be reproducible (reliable). Obviously, those spinal palpatory procedures that are invalid or unreliable should not be used to arrive at a diagnosis, plan treatment, or assess progress." (E419).8
It was determined that X-ray is reliable in morphology, measurement and biomechanics, inclusive of accuracy and reproducibility.9-10 Therefore, for concluding an accurate biomechanical diagnosis, X-ray is a reasonable approach.
The issue of safety must also be considered for X-ray. Tubiana, et al. (2009), reported, "Among humans, there is no evidence of a carcinogenic effect for acute irradiation at doses less than 100 mSv and for protracted irradiation at doses less than 500 mSv." (pg. 17)11
The American College of Radiology, in its February 2020 ACR Appropriateness Criteria, reported, "Adverse health outcomes for radiation doses below 100 mSv are not shown by the evidence."12
A lumbar X-ray is 1.4 Msv for the cervical spine based on osseous density. Therefore, a doctor would need to take 71 lumbar X-rays to be considered any risk of harm. I will go "on the limb" (without evidence) and report that doctors of chiropractic do not shoot 71 lumbar X-rays in one session.
From a necessity and safety issue, X-rays are a reasonable "predetermined" approach to care. They are a patient-centered approach and avoid any "guessing." The goal is to have an accurate diagnosis, and you cannot reliably determine if the axis is left or right based upon palpation. Your clinical evaluation creates the necessity for an X-ray, and it is here that you need to document the need for a biomechanical conclusion, if that is your goal.
The Power of the Predetermined Initial Protocol
When creating treatment plans, an initial predetermined protocol is essential to ensuring public safety. As chiropractors, although we are primary health care providers, a portal of entry into the health care system, practicing within our scope is predominantly spine. There are five regions, 24 movable vertebrae, and muscle and ligaments attached, so our treatment plans and diagnosis are typically confirmed to those body parts.
A reasonable initial "predetermined treatment plan" is to adjust the spine, utilize modalities as adjunctive therapy, and then introduce stabilizing treatment in the form of exercise therapy. This is no different than the four disparate professions listed above – chiropractic also must have predetermined protocols to ensure public safety.
Since no crystal balls are handed out with our diplomas, we will not know how each patient will react to care initially. In a "patient-centered" approach, the doctor's experience is part of the equation; however, each patient is unique and will respond accordingly. It is unreasonable for a doctor to know how that will occur with the initial evaluation and management visit.
For that reason, a re-evaluation should be performed a minimum of every 30 days while under active care to allow the body time to react so the doctor can customize a treatment plan after each re-evaluation as clinically indicated.
These are reasonable and predetermined initial treatment protocols taught in every chiropractic college worldwide. They exist to ensure public safety and start the pathway to positive outcomes under chiropractic care.
Take-Home Points
Carrier algorithms, political ideologies or personal biases cannot negate the evidence in the literature or a doctor's clinical decision-making at the expense of public safety. Predetermined treatment plans are the only way to ensure public safety once a diagnosis and prognosis have been concluded with a thorough evaluation and management encounter.
X-ray is a reasonable, safe choice for an accurate biomechanical diagnosis, even in the absence of "red flags." Adjusting, adjunctive therapy and exercise rehabilitation are also reasonable predetermined treatment plans until the first re-evaluation.
References
- Koytak A, et al. Fluorescein angiography as a primary guide for reduced-fluence photodynamic therapy for the treatment of chronic central serous chorioretinopathy. Int Ophthalmol, Jul 2020;40(7):1807-1813.
- Ying A, et al. Dynamic increase in neutrophil levels predicts parenchymal hemorrhage and function outcome of ischemic stroke with r-tPA thrombolysis. Neuro Sci, 2020 Aug;41(8):2215-2223.
- Emery SE. Cervical spondylotic myelopathy: diagnosis and treatment. J Am Acad Orthop Surg, 2001;9(6):376-388.
- Planning, OT. Congenitally missing maxillary lateral incisors and orthodontic treatment considerations for the single-tooth implant. J Can Dent Assoc, 2001;67:25-8.
- Canadian Chiropractic Association, Canadian Federation of Chiropractic Regulatory Boards, Clinical Practice Guidelines Development Initiative, & Guidelines Development Committee. Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash. J Can Chiro Assoc, 2005;49(3):158.
- Bussieres AE, et al. The treatment of neck pain–associated disorders and whiplash-associated disorders: a clinical practice guideline. JMPT, 2016;39(8):523-564.
- Ibid.
- Seffinger MA, et al. Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature. Spine, 2004;29(19):E413-E425.
- Fedorak C, et al. Reliability of the visual assessment of cervical and lumbar lordosis: how good are we? Spine, 2003;28(16):1857-1859.
- Marques C, et al. Accuracy and reliability of X-ray measurements in the cervical spine. Asian Spine J, 2020;14(2):169.
- Tubiana M, et al. The linear no-threshold relationship is inconsistent with radiation biologic and experimental data. Radiology, 2009;251(1):13-22.
- Wang J, et al. ACR Appropriateness Criteria Radiation Dose Assessment Introduction. Revised February 2020.
Dr. Mark Studin is an adjunct associate professor at the University of Bridgeport School for Chiropractic, teaching advanced imaging and triaging chronic and acute patients; and an adjunct postdoctoral professor at Cleveland University-Kansas City College of Chiropractic. He is also a clinical instructor for the State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Office of Continuing Medical Education. Dr. Studin consults for doctors of chiropractic, medical primary care providers and specialists, and teaching hospitals nationally. He can be reached at
or 631-786-4253.