"Clinical Guidelines for Chiropractic Practice in Canada"
(aka: The Glenerin Treatment Guidelines)
http://www.ccachiro.org/client/cca/cca.nsf/web/Glenerin%20Guidelines?OpenDocument
[ Supportive Care ]
Chapter 8 (Frequency & Duration), section I: "Initiation of a treatment program should be based on clinical need, and must consider the outcome of the condition if no treatment was to be provided, i.e., the natural history of the disorder. The frequency and duration of care should be based on the subjective and objective clinical information gleaned from the case history, the physical and x-ray examination findings, and the clinical impression or diagnosis. The length of time required to achieve clinical objectives may require modification if there has been a delay in seeking treatment, if the pain is severe, if there is a history of several or more previous episodes, or if the injury was superimposed on a preexisting condition. As treatment proceeds, the patient response should be periodically re-assessed by subjective and objective means. A lack of expected improvement necessitates a change in treatment approach or a referral for a second opinion."
Chapter 8, section IV, subsection (i) Acute Care: "After reviewing the available evidence, the 1990 RAND Consensus Panel unanimously agreed upon a definition of adequate therapeutic trial for spinal manipulation (Shekelle et al., 1991). For an uncomplicated case, this multidisciplinary panel recommended two trial courses of two weeks each, using alternative manipulative procedures. Without evidence of demonstrable improvement over this time frame, spinal manipulation was felt to be no longer indicated."
Chapter 8, section IV, subsection (iii) Elective Care: "Growing evidence supports the chiropractic contention that pathomechanics, harmful dysfunction in the neuromusculoskeletal system, often precedes symptoms."
Chapter 8, section V (Treatment / Care protocols): "Patients exhibiting signs of deconditioning or chronicity should be given an exercise program that focuses both on the injured and related areas. Education on body biomechanics and exercises should emphasize the avoidance of pain-related behaviour, flexibility, strength, coordination and endurance. Referral to an appropriate care facility may be desired if specific equipment or expertise is sought. Where prominent psychosocial factors make this appropriate, referral for counselling should be made."
Chapter 8, section VI, subsection A (8.2) (i): "Pain present for greater than 8 days prior to seeking treatment, the presence of severe pain, four or more previous episodes, and pre-existing skeletal anomaly or structural pathology may extend the treatment duration by a factor of 1.5 to 2 times."
Chapter 8, section VI, subsection B (8.3): "In general, more frequent treatment/care (3 to 5 sessions per week for one to two weeks) may be necessary early. Progressively declining frequency is expected until discharge of the patient, or conversion to elective care."
Chapter 8, section VI, subsection D (Complicated Cases): "Subacute and chronic conditions are usually considered to be complicated in that they have exhibited regression [relapse] or retarded recovery in comparison with expectations from the natural history."
Chapter 8, section VI, subsection D (8.7): "Symptom response: after a maximum trial therapy session of manual procedures lasting up to two weeks, and consisting of 3 to 5 treatments per week, reassessment is required if no demonstrable improvement has been noted. An alternative approach [different chiropractic technique] consisting of a maximum of four weeks may be instituted if warranted. Should no demonstrable improvement be forthcoming following this second trial, the patient should be referred or discharged."
Chapter 8, section VI, subsection D (8.9): "Achievement of maximum therapeutic benefit: it is expected that patients will reach their maximum therapeutic benefit within 6 to 16 weeks. To minimize the development of physician/patient dependence, treatment frequency should not exceed two visits per week after the first six weeks. An acute exacerbation may require more frequent care. Should pre-episode status not return, or additional improvement not be forthcoming, maximum therapeutic benefit should be considered to have been reached."
Chapter 14 (Preventitive - Maintenance Care), section II: "Supportive Care: Treatment for patients who have reached maximum therapeutic benefit, but who fail to sustain this benefit and progressively deteriorate when there are periodic trials of withdrawal of treatment. Supportive care follows appropriate application of active and passive care including rehabilitation and lifestyle modifications. It is appropriate when alternative care options, including home-based self-care, have been considered and attempted. Supportive care may be inappropriate when it interferes with other appropriate primary care, or when the risk of supportive care outweighs its benefits, i.e., physician dependence, somatization, illness behaviour, or secondary gain."
Chapter 8, section VI, subsection D (8.10): "Supportive care: supportive care using passive therapy may be necessary if efforts to withdraw treatment/care result in significant deterioration of clinical status. [Rating: Promising Evidence: Class II, III, Consensus level: 1]
Chapter 8, section VI, subsection D (8.11): Cases requiring supportive care: in cases requiring supportive care, the frequency of treatment must be determined on an individual case basis as dictated by therapeutic necessity.
Chapter 8, section VI, subsection F (8.11)(ii): "continued failure to show initial improvement or failure to show additional improvement over any period of six weeks of treatment, should result in patient discharge or appropriate referral, or the patient will be deemed as having achieved maximum therapeutic benefit (MTB). If MTB has been reached, maintenance or supportive care may be considered. Rating: Recommended Evidence: Class II, III, Consensus level: 1"
Chapter 8, section VI, subsection H (8.16): "The frequency of preventive/maintenance care is determined on an individual basis, but generally should not exceed once per month. The frequency of care may vary if the patient's condition changes. In these circumstances there is a reassessment and conversion to appropriate therapeutic intervention, which may include initial and supportive care." Rating: Discretionary,Evidence: Class II, III, Consensus level: 1
Preventative/Maintenance Care: Elective care given at regular intervals designed to maintain maximum health and promote optimal function.
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