Mark D. Dehen, DC, Wayne M. Whalen, DC, Ronald J. Farabaugh, DC,
Cheryl Hawk, DC, PhD
Vice President of Research and Scholarship,
Cleveland Chiropractic Research Center,
Kansas City, Mo, and Los Angeles, Calif
Objective As the chiropractic profession delineates its role in the emerging health care marketplace, it will become increasingly important that the scope of appropriate chiropractic care is clearly defined relative to overall patient case management. Therefore, the Council on Chiropractic Guidelines and Practice Parameters engaged in a multidisciplinary consensus process addressing the terminology related to “levels of care.”
Methods A formal consensus process was conducted in early 2009, following the RAND/UCLA method for rating appropriateness. Panelists were selected to provide a broad representation of the profession in terms of geographic location and organizational affiliation, and an attempt was made to include members of other professions, including representation from third-party payors. The Delphi process was conducted electronically in January-February 2009. A nominal group panel was conducted through an online meeting service using an experienced group facilitator. Twenty-seven panelists were selected; all but 3 were doctors of chiropractic. Six of the panelists had experience as consultants with third-party payors.
Results Fifteen seed statements were circulated to the Delphi panel. Consensus was reached on all statements after 3 Delphi rounds, with further refinements made through the nominal group panel.
Conclusions By using a recognized formal consensus process, the Council on Chiropractic Guidelines and Practice Parameters has endeavored to establish a set of terms that are acceptable to the chiropractic community in order to facilitate their use within the broader health care community.
Key Indexing Terms: Chiropractic, Spinal Manipulative Therapy
From the Full-Text Article:
As the chiropractic profession pursues its role in the emerging health care marketplace, it will become increasingly important that the scope of appropriate chiropractic case management is clearly delineated. To ensure equitable inclusion in the health care arena, it is imperative that the terms used in our interprofessional discussions are common to all health care providers. Therefore, the Council on Chiropractic Guidelines and Practice Parameters (CCGPP), at the behest of the American Chiropractic Association (ACA) Insurance Relations Committee, engaged in a multidisciplinary consensus process to address the terminology related to “levels of care.”
While the chiropractic profession is the third largest doctoral-level health care profession in the United States, behind medicine and dentistry, it is still not fully integrated into mainstream health care. [1 ] This is partly due to the =100-year history of stand-alone chiropractic education and practice. This isolation has tended to engender chiropractic with its own lexicon. As stated by Meeker and Haldeman  in 2002, “Perhaps one of the bigger challenges our profession faces centers on syntax. Clarity in how one uses words is an essential component of good communication. We chiropractors have several words that are unique and perhaps (forgive the pun) “‘out of alignment’ with another’s usage” (p 44).
However, those days of isolationism are fading away. Mainstream health care and governmental organizations such as the World Health Organization, US Department of Health and Human Services and the National Center for Complementary and Alternative Medicine, a division of the National Institutes of Health, consider chiropractic to be complementary and alternative medicine (CAM). However, a 2008 study reported that 31% of surveyed chiropractors categorized chiropractic as CAM, 27% as integrated medicine, and 12% as mainstream medicine.  As one looks over the emerging health care landscape, there are more and more examples of integrated health care arising. New collaborative models are coming to the fore to comprehensively address patient care needs in novel and innovative ways. Pioneers in this area, such as the Texas Back Institute in the early 1990s, did so with an appreciation for the skill sets brought to the table by various practitioner types. [3, 4] Although Texas Back Institute has discontinued that experiment, that trend is now continuing with the integration of chiropractic care into the Veterans Administration hospital system, as well as many other private sector and educational environments, such as the partnership between Northwestern Health Sciences University and the Woodwinds Health Campus in Woodbury, Minn.
The common language spoken in these environments is the language of “best practices,” and it is a language in which practicing doctors of chiropractic (DCs) need to become fluent.  Chiropractic colleges need to properly prepare students to thrive in the emerging evidenced-based practice environment. In this environment, DCs will regularly be faced with challenging diagnostic and treatment situations. As we become more fully integrated into mainstream health care, chiropractors will have to communicate effectively with other practitioners, using a common language of best practices. [ 5, 6] This will require enhanced critical thinking and research interpretation skills, an appreciation of the importance research has in improving clinical practice, and increased practical clinical experience and facility with common interdisciplinary terminology. 
These integrated exposures, along with the applicable literature syntheses of the CCGPP, [8-13] are serving to further expose other health care stakeholders to the effectiveness of chiropractic case management in the continuum of patient presentations from acute to chronic neuromusculoskeletal conditions.  This premise is endorsed in a 2007 article in the Annals of Internal Medicine, which recommends, “For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or sub acute low back pain, intensive interdisciplinary rehabilitation, exercise, therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation.”  This position is also reiterated by Bronfort et al who state, “For chronic low back pain, there is moderate evidence that spinal manipulative therapy (SMT) with strengthening exercise is similar to that of prescription nonsteroidal anti-inflammatory drugs with exercise in both short and long-term…there is moderate evidence that SMT is superior to general practice medical care and similar to physical therapy in both the short and long term. There is limited evidence of short- and long-term superiority of SMT over hospital outpatient care for pain and disability.” 
The practice of chiropractic includes establishing a diagnosis, facilitating neurological and biomechanical integrity through appropriate chiropractic case management, and promoting health.  Chiropractic practice includes examinations, diagnostic imaging, as well as extremity manipulation, physiotherapy modalities, therapeutic exercises, diet/nutritional counseling, and ergonomics consultation. Chiropractic case management is not solely spinal manipulative therapy, although that is the DC’s most commonly recognized mode of intervention.
To clarify how chiropractic care applies in the various stages of typical patient presentation, the ACA Insurance Relations Committee revised the terminology related to levels of care of appropriate chiropractic case management for all levels of care. Once internal consensus was obtained on these terms, the ACA Insurance Relations Committee then wanted to further refine this terminology among a broader, more diverse group of experts in order to facilitate its use in the external marketplace. Therefore, the ACA forwarded those terms to the CCGPP, and a formal consensus panel was convened. This panel consisted of a wide geographic representation of active chiropractic practitioners, other disciplines, and third-party payers. The process and results are described below.
This formal consensus process to clarify the terminology used by chiropractors related to common areas of patient care is important as such care becomes increasingly integrated into the mainstream. The chiropractic profession’s history of developing outside mainstream medicine has fostered colloquialism and confusion, often to the detriment of our shared patients. Terms such as preventative/maintenance care,  defined as care to reduce the incidence or prevalence of illness, impairment, and risk factors and to promote optimal function, and supportive care, defined as treatment/care for patients having reached maximum therapeutic benefit, in whom periodic trials of therapeutic withdrawal fail to sustain previous therapeutic gains that would otherwise progressively deteriorate,  are chiropractic specific and not commonly used by other health care disciplines.
Therefore, for the purposes of this project, chiropractic care as it applies to the typical patient presentation was to be described using conventionally recognized terminology across the accepted continuum of care, from acute to chronic/recurrent on to wellness. Acute conditions were those having a relatively short but possibly severe course, for example, acute cervical torticollis. Chronic/recurrent conditions were those persisting over a long period, for example, lumbar degenerative disc disease with associated osteoarthritis and occasional sciatic leg referral. Wellness care was considered more related to enhancement of function and ability to perform daily activities. Our panelists were charged with identifying the common characteristics of each of these 3 primary levels of care. Medically necessary care refers to care that is generally reimbursable by third party carriers, for example, acute and/or chronic/recurrent care. Ongoing care in the chronic/recurrent population was discussed as potentially contraindicated, for example, if it delayed appropriate psychological care in the dependent personality patient.
In addition, providing context for chiropractic care in chronic/recurrent cases, as supported by contemporary research previously identified in the CCGPP’s literature syntheses, [8-13] is important in establishing a chiropractic alternative for this expanding patient population. Concomitantly, while the definition of wellness care remains fluid, the historical chiropractic health care model of improving function, good nutrition and exercise endorsement are consistent with basic wellness tenets. Refining these terms with a chiropractic lens was felt to be important in order to standardize the delivery of such care.
In the face of the evolving health care market, with its demands for effective collaborative outcome-oriented patient management, there is a role for chiropractic integration. However, this historic lack of standardized common language is a handicap that needs to be addressed. Therefore, this consensus project is an initial step to close that gap. Currently, the CCGPP is involved in a new multidisciplinary consensus project to better outline documentation and parameters for chronic/recurrent care. Future research will also be necessary in the area of wellness care as that area of patient focus matures.
The chief limitation of this project was the lack of diversity in the consensus panel, which included only 3 non-DCs (one of whom was an RN) and only 2 International Chiropractors Association members. The CCGPP had hoped to attract a broader, more multidisciplinary panel. Our inability to do so may reflect the longstanding isolation of the profession, as well as the factionalism within it. Another limitation may be related to the number of source documents available to provide to the panel as background on terminology in use throughout the medical and research communities. Additional sources may have been useful for the panel to gain a broader understanding of common medical lexicon. We reviewed only a limited number of terms and perspectives centered on “levels of care.” There may be other terminology, definitions, or perspectives which were not considered, although efforts were made to include those most commonly used in the health care arena. Limitations imposed by the Delphi process, as well as the limited diversity of the panel members, may also have contributed to a bias in consideration of other definitions or terminology.
Achieving consensus on this terminology related to the spectrum of patient presentations is expected to facilitate their use within the profession of chiropractic, which, in time, may facilitate better integration of chiropractic care within the health care mainstream.
Funding Sources and Potential Conflicts of Interest
The American Chiropractic Association provided partial funding for this project, as well as donating the services of their staff in conducting the Delphi rounds. All authors and panelists participated without compensation from any organization. Cleveland Chiropractic College made an in-kind contribution to the project by allowing Dr Hawk to devote a portion of her work time to this project. There were no conflicts of interest reported by the authors.
- It will become increasingly important in the emerging health care system that the scope of appropriate chiropractic care is clearly defined relative to overall patient case management.
The CCGPP would like to thank Kara Murray for her efficient management of the consensus project, Cathy Evans for her advice in developing the process for communicating with panelists and tracking responses, and Sue Baptiste, OT, MS, for her expert facilitation of the nominal group panel. The following individuals generously donated their time and expertise in participating as Delphi panelists: Greg Baker, DC; Wayne Carr, DC; John Curtin, DC; Lawrence Davis, DC; Phil Denniston, MBA; John Donofrio, DC; Paul Dougherty, DC; Jason Evans, DC; Rich Guttschow, DC; Marcy Halterman-Cox, DC, JD, MsPH; Lawrence Humberstone, DC; Christopher John Klaes, DC; Howard Levinson, DC; Donald Littlejohn, DC; Laney Nelson, DC; Eugene Packer, DC; Mike Powell DC; Joe Schneller, DC; Steven Schram, PhD, DC, LAc; Jeff Smith, Michael Swank, DC; Joseph Unger, DC; Nathan Unruh, DC; Robert Walsh, DC; and Jim Wyllie, DC.
The following individuals generously donated their time and expertise in participating as nominal group panelists: Greg Baker, DC; Marcy Halterman-Cox, DC, JD, MsPH; Lawrence Humberstone, DC; George McClelland, DC; Laney Nelson, DC; Eugene Packer, DC; M Chris Ringle, RN, CPC, CPC-P; Steven Schram, PhD, DC, LAc; Michael Swank, DC; Joseph Unger, DC; and Nathan Unruh, DC.