When did chiropractors first take an interest in adjunctive therapies, and how strong has that attachment been over the years? To answer those questions, we literally need to start "before the beginning":
1886-1896: D.D.
1914-1918: The application of physiological therapeutics in chiropractic was firmly established at the National College of Chiropractic in 1914.2 Physical therapy and the many modalities we know today did not become generally accepted by the allopathic medical community at large until 1914-1918, when their use was demanded by the armed services during World War I.
1937: Production of intersegmental traction tables by the Spinalator Company for the chiropractic profession have been documented as early as 1937.3 Logan College of Chiropractic utilized early versions of today's electrotherapy equipment, including the "Polysine Generator" and the "Lightning Electro-Therapy Kit."2
1945: Photographs of the B.J. Palmer Clinic in 1945 revealed a large rehabilitation department that was extensively equipped with all the various active high-tech exercise equipment of the day.3 This included the use of various cycles, stretching mats, parallel bars, proprioception systems and variable resistance exercise devices for all parts of the body (Palmer College of Chiropractic today sponsors a three-year residency program in rehabilitation which is patterned after the popular radiology residency programs throughout the profession).
1975: In the June edition of the ACA Journal of Chiropractic for that year, the ACA Council on Physiological Therapeutics published perhaps the first "Physiotherapy Guidelines for the Chiropractic Profession."4
1995: In February 1995, the ACA guidelines first presented in 1975 were revisited. The ACA Council on Chiropractic Physiological Therapeutics and Rehabilitation invited all Chiropractic Council on Education (CCE) college physiotherapy departments to attend a conference which was hosted at Western States Chiropractic College. Each college was given the opportunity to send one representative. Additionally, a private practice chiropractor and a physical therapist were invited to attend.
The conference participants reviewed current Agency for Health Care Policy and Research (AHCPR) positions relative to physical modalities, transcutaneous electrical nerve stimulation, shoe insoles/lifts, lumbar corsets/belts, traction and biofeedback.5 Prior to the conference attendees, concurring with the AHCPR positions relative to acute low back pain, felt that there was the necessity of a complete review of the same journal studies and articles. However, it was felt that conference participants could develop a consensus on the stage and time usage of the most common adjunctive therapies, if chosen to be utilized by a clinician.
Achieving a consensus was important: to use physiological therapeutics on a rational basis, the practitioner must have knowledge of the actions and an understanding of their predictable effects on the tissues and pathophysiologic processes involved. Adjunctive therapy applications could then be provided according to the stages of episode.
Conference participants developed an initial agreement on the treatment stages of the commonly utilized modalities and procedures. The treatment time range (low-high) of each modality-procedure was agreed upon, based on effective clinical application. This was followed by a review by each CCE chiropractic college physiotherapy department with a recommendation back to the council. Each CCE college had the opportunity for a final review and comment on the treatment stage and treatment time given to each modality-procedure. The final consensus, based upon Frymoyer,6 is outlined in Table 1.
The utilization of these physiotherapy guidelines (Table 2) has been helpful in clinical applications. However, it was not and is not the intent of these guidelines to recommend the use of any specific modality/procedure. Clinicians must depend upon their own knowledge of chiropractic and expertise in the use or modification of these materials and information. Generally, passive care is time limited, progressing to active care and patient functional recovery.
1996: The practicing clinician, faced with making daily treatment decisions, also had the difficulty of assigning the correct CPT code to the treatment rendered.7 The 1996 CPT codes appropriate to adjunctive therapies (Table 3) were "matched up" to the Physiotherapy-Rehab Guidelines (Table 4). Under certain circumstances, a service or procedure was partially reduced at the clinician's discretion. Under these circumstances, the service provided could be identified by its usual procedure number and the addition of the modifier, -52, signifying that the service had been reduced. This provided a means of reporting reduced services without disturbing the identification of the basic service.
Today: Further research appears necessary to obtain a consensus of the clinical guidelines of the application of specific physiotherapy/rehabilitative procedures, concerning the restoration of function and prevention of disability following disease, injury or loss of a body part. The question to be debated in this regard is whether only randomized controlled clinical trials (RCT) should be used to evaluate the efficacy of clinical regimes. It is certainly the most persuasive design for considering treatment efficacy. However, it would be a grave error to disregard all studies that did not incorporate this design.
The effects of insulin on diabetic hyperglycemia, of penicillin on pneumococcal pneumonia, or of vitamin B12 on pernicious anemia have been accepted without demands for randomized trials. Although dramatic treatment effects such as these are not the rule, they clearly show the fallacy of assuming that only RCTs can demonstrate treatment feasibility.
References
- ACA Council on Physiological Therapeutics. Physiotherapy guidelines for the chiropractic profession. ACA Journal of Chiropractic June, 1975; 9:S-66.
- Jaskoviak PA and Schafer RC. Applied Physiotherapy. Arlington: The American Chiropractic Association, 1993:1-3.
- Thomas CL (ed.). Taber's Cyclopedic Medical Dictionary, 14th edition. Philadelphia: F.A. Davis, 1981:1098.
- Peterson D and Wiese G. Chiropractic: An Illustrated History. St. Louis: Mosby Year Book, Inc., 1985.
- Bigos S et al. Acute low back problems in adults. Clinical Practice Guideline No. 14. AHCPR Publication no. 95-0642. Rockville: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, December 1994.
- Frymoyer JW. Back pain and sciatica. New England Journal of Medicine 1988; 318:291-300.
- American Medical Association. Physicians' Current Procedural Terminology -- CPT 96. Chicago: American Medical Association, 1995.
Kim Christensen, DC, DACRB, CCSP
Ridgefield, Washington
| Table 1 -- Treatment Stages and Times of Modality-Procedures | |
| Stages of Episode* | Time Course |
| Acute | 0-6 weeks |
| Stage 1 -- Acute Inflammation | 2-3 days |
| Stage 2 -- Repair-Regeneration day | 4-6 weeks |
| Subacute | |
| Stage 3 -- Remodeling-Rehab | week 7-week 12 Chronic |
| Stage 4 -- Chronic | over 12 weeks |
Chronic recurrent episodes are treated as acute.
- The above stages assume no complications including: obesity; systemic disorders; multiple injuries; increased age; non-compliance to care; re-injury or aggravation; patient self-treating or in treatment with others; pre-existence of structural or degenerative dysfunction; psychological disorder/dysfunction; medications.6
| Table 2 -- Physiotherapy-Rehab Guidelines | ||
| Modality-Procedure | Treatment Stage | Treatment Time Range (Low-High) |
| Cryotherapy | 1,2,3,4 | 5-20 minutes |
| ice massage | 1,2,3,4 | 2-5 minutes |
| Heat -- superficial infrared heat light | 2*,3,4 | 10-20 minutes |
| hot packs | 2*,3,4 | 10-20 minutes |
| paraffin | 2*,3,4 | 7-10 dips/10-20 minutes |
| hydrotherapy | 2*,3,4 | 10-30 minutes |
| Heat -- deep continuous ultrasound | 2,3,4 | 5-10 minutes |
| pulsed ultrasound | 2,3,4 | 2-8 minutes |
| microwave diathermy | 2,3,4 | 5-30 minutes |
| shortwave diathermy | 2,3,4 | 10-30 minutes |
| EMS | ||
| subsensory stimulation | 1,2,3,4 | none established |
| sensory stimulation | 1,2,3,4 | 10-30 minutes |
| TENS | 1,2,3,4 | variable |
| muscle stimulator | 1,2,3,4 | 10-30 minutes |
| motor stimulation | 2*,3,4 | 10-30 minutes |
| trigger point | 2,3,4 | 2-5 minutes |
| Mechanical Vibration | 2*,3,4 | 2-10 minutes |
| Traction (in-office) continuous | 1*,2,3,4 | 1-20 minutes |
| intermittent | 1*,2,3,4 | 1-20 minutes |
| ambulatory | 1*,2,3,4 | 1-30 minutes |
| intersegmental | 1*,2,3,4 | 1-10 minutes |
| flexion-distraction | 1*,2,3,4 | by technique |
| extension compression | 1*,2,3,4 | by technique |
| Massage | 1*,2,3,4 | 5-15 minutes* |
| Myofascial Release | 1*,2,3,4 | by technique |
| Trigger Point Therapy | 1*,2,3,4 | by technique |
| Exercise (in-office) passive | 1*,2,3,4 | 5-30 minutes |
| active | 1*,2,3,4 | 15-90 minutes |
| work hardening | 4 | 2-8 hours |
| activities of daily living (i.e., back school) | 1,2,3,4 | 15-60 minutes |
| Bedrest | 1 | 0-2 days |
| Biofeedback (in-office) | ||
| muscle re-education | 3,4 | 5-10 minutes |
| relaxation/pain reduct | 4 | 20-30 minutes |
| Bracing | 1,2,3,4 | none established |
| *physician discretion |
| Table 3 -- Physical Medicine and Rehabilitation | |
| Modalities | |
| Any physical agent applied to produce therapeutic changes to biologic tissue; includes but is not limited to thermal, acoustic, light, mechanical or electric energy. | |
| Supervised The application of a modality that does not require direct (one-on-one) patient contact by the provider. | |
| 97010 | application of a modality to one or more areas; hot or cold packs |
| 97012 | traction, mechanical |
| 97014 | electrical stimulation (unattended) |
| 97016 | vasopneumatic devices |
| 97018 | paraffin bath |
| 97020 | microwave |
| 97022 | whirlpool |
| 97024 | diathermy |
| 97026 | infrared |
| 97028 | ultraviolet |
| Constant Attendance | |
| The application of a modality that requires direct (one-on-one) patient contact by the provider. | |
| 97032 | application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes |
| 97033 | iontophoresis, each 15 minutes |
| 97034 | contrast baths, each 15 minutes |
| 97035 | ultrasound, each 15 minutes |
| 97036 | Hubbard tank, each 15 minutes |
| 97039 | unlisted modality (specify type and time if constant attendance) |
| Therapeutic Procedures | |
| A manner of effecting change through the application of clinical skills and/or services that attempt to improve function. Physician or therapist is required to have direct (one-on-one) patient contact. | |
| 97110 | therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility |
| 97112 | neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture and proprioception |
| 97113 | aquatic therapy with therapeutic exercises |
| 97116 | gait training (includes stair-climbing) |
| 97122 | traction, manual |
| 97124 | massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) |
| 97139 | unlisted therapeutic procedure (specify) |
| 97150 | therapeutic procedure(s), group (2 or more individuals) |
| 97250 | myofascial release/soft tissue mobilization, one or more regions |
| 97265 | joint mobilization, one or more areas (peripheral or spinal) |
| 97500 | orthotics training (dynamic bracing, splinting), upper and/or lower extremities; initial 30 minutes, each visit |
| 97501 | each additional 15 minutes |
| 97520 | prosthetic training; initial 30 minutes, each visit |
| 97521 | each additional 15 minutes |
| 97530 | therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes |
| 97535 | self-care/home management training (e.g., activities of daily living [ADL] and compensatory training, meal preparation, safety procedures and instructions on use of adaptive equipment), direct one-on-one contact by provider, each 15 minutes |
| 97537 | community/work re-integration training (e.g., shopping, transportation, money management, vocational activities and/or work environment/modification analysis, work-task analysis), direct one-on-one contact by provider, each 15 minutes |
| 97542 | wheelchair management/propulsion training, each 15 minutes |
| 97545 | work hardening/conditioning; initial 2 hours |
| 97546 | each additional hour Tests and Measurements |
| 97703 | checkout for orthotic/prosthetic use, established patient, each 15 minutes |
| 97750 | physical performance test or measurement (e.g., musculoskeletal functional capacity), with written report, each 15 minutes |
| Other Procedures | |
| 97770 | development of cognitive skills to improve attention, memory, problem solving; includes compensatory training and/or sensory integrative activities, direct (one-on-one) patient contact by the provider, each 15 minutes |
| 97799 | unlisted physical medicine/rehabilitation service or procedure |
| Biofeedback | |
| 90900 | biofeedback training; by electromyogram application (e.g., in tension headache, muscle spasm) |
| 90915 | other |
| Table 4 -- CPT Codes | ||
| Modality-Procedure | CPT Code | |
| Cryotherapy | 97010 | |
| ice massage | 97010, | 97124 |
| Heat--superficial | ||
| infrared heat light | 97035 | |
| hot packs | 97010 | |
| paraffin | 97018 | |
| hydrotherapy | 97024 | |
| Heat--deep | ||
| ultrasound | 97035 | |
| continuous | 97035 | |
| pulsed ultrasound | 97035 | |
| diathermy | 97024 | |
| microwave diathermy | 97020 | |
| shortwave diathermy | 97024 | |
| EMS | (unattended) | (attended) |
| subsensory stimulation | 97014 | 97032 |
| sensory stimulation TENS | 97014 | 97032 |
| muscle stimulator | 97014 | 97032 |
| muscle stimulation | 97014 | 97032 |
| trigger point | 97014 | 97032 |
| Mechanical Vibration | 97124 | 97039 |
| Traction (in-office) | (mechanical) | (manual) |
| continuous | 97012 | 97122 |
| intermittent | 97012 | 97122 |
| intersegmental | 97012 | 97122 |
| flexion-distraction | 97122 | |
| extension compression | 97012 | |
| ambulatory | 97012, 97110 | 97530, 97112 |
| Massage | 97124 | |
| Myofascial Release | 97250 | |
| Trigger Point Therapy | 97139 | |
| Exercise (in-office) | ||
| passive | 97110 | |
| active | 97110, 97530 | |
| work hardening | 97545 | |
| daily activities | 97535 | |
| Biofeedback (in-office) | ||
| muscle re-education | 90900, 90915 | |
| relaxation/pain red. | 90900, 90915 | |
| Bracing | 99070 |
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