Chiropractic care has recently been added to the Joint Commission Standard on pain management.
About the Joint Commission
The Joint Commission is a not-for-profit and independent organization that is responsible for accrediting and certifying “nearly 21,000 health care organizations and programs in the United States”. Certain standards must be met in order to be certified and accredited.1 Joint Commission resources include accreditation for organizations such as nursing homes, office-based surgery centers, hospitals, doctors’ offices, home healthcare providers, and behavioral health treatment facilities. Ambulatory and behavioral healthcare, hospital and laboratory services, and nursing care centers can all become accredited.2 In terms of certification, the programs included are disease-specific care, palliative care, health care staffing, integrated care, prenatal care, and primary care medicine.3 For interested parties, “Joint Commission Connect is a secure website intended only for the Joint Commission accredited or certified organizations”.4 With regard to pain management, the Joint Commission’s website notes that “more than 76 million people suffer from pain”, including acute, chronic, and post-surgical pain. To meet the Joint Commission standards, healthcare organizations need to “recognize the right of patients…to appropriate assessment of management of pain”. In addition, patients must be screened and periodically reassessed. It is also important to “educate patients…and their families, about pain management”. While some medical services, such as X-rays, do not require asking patients about pain, it is important to recognize if a patient is in pain and provide appropriate care. This could mean that a patient may be treated or referred for further assessment. Of course, patients need to “report pain and to cooperate with the prescribed treatment”.5
Chiropractic and the Joint Commission
Recently, the Joint Commission standards on pain management were clarified to “include pharmacologic and nonpharmacologic approaches”. This was important in that, along with the healthcare provider’s professional and clinical judgment, patients should also be evaluated in terms of the “potential risk of dependency, addiction, and abuse”. Pharmacologic strategies include opioid, nonopioid, and “adjuvant analgesics”. In this clarification, Standard PC.01.02.07 now states that “physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy” can now be included as nonpharmacologic strategies.6 In the past, nonpharmalogic approaches were not even considered in the Standard. The Joint Commission recognized Doctors of Chiropractic as “physicians” since 2009. Although the guidelines do not constitute a mandate, Karen Erickson, DC, FACC noted, “What’s important is that it changes the culture of health care…the new map’s contours now have two categories for pain management” and that “providers will become educated about…chiropractic and acupuncture”. Erickson also found it significant that the Joint Commission used the terms “osteopathy” and “chiropractic” instead of “manipulation”. The request to review the pain management Standard was initiated in April 2013 by Arya Nielsen, PhD, Marsha J. Handel, MLS, and Ben Kligler, MD of Mount Sinai Beth Israel Department of Integrative Medicine.7
Pain Management Comparison
Patients are prescribed medications for acute and chronic pain. Some of the medicines prescribed include antidepressants, calcium channel ligands (pregabalin and gabapentin), topical lidocaine and capsaicin, opioids, muscle relaxants, nonopioid anagesics (NSAIDs and COX-2 agents), and antiepileptic medications. For patients with chronic pain, it is “one of the most prevalent, costly and disabling conditions in both clinical practice and the workplace”. Chronic pain leads to sleep disturbances, depression, and anxiety disorders. Neuropathic pain, in particular, is “challenging”. Neuropathic pain is “pain arising as a direct consequence of a lesion or disease affecting the somatosensory system”. Because medications carry risks and side effects, patients need to be educated about these issues, including the addiction possible with opioids. To combat abuse of such prescriptions, doctors can specify “the frequency of obtaining medications, providing timely refills but no early replacement for lost or stolen prescriptions”. In addition, patients need to be aware of “safe storage, no sharing, single-source prescribing, monitoring through urine screens, and adhering to monitored visits”. There are several nonpharmacologic options to medications, however, that do not have the side-effects and other risks, including “interventional pain management, physiotherapy, psychotherapy, and pain rehabilitation”.8 Chiropractic may treat chronic pain. After an examination and diagnosis, the chiropractor can work with the patient for an individualized treatment plan, which might include manual therapies, manipulation, and therapeutic exercises.9 Chiropractors can also treat neck pain and, according to a study in the Annals of Internal Medicine, chiropractic care was more effective than medications for this condition. In the 12 week study of 272 patients with neck pain, those who utilized exercise or chiropractic “were more than twice as likely to be pain free compared to those who took medication”. In fact, “32 percent who received chiropractic care” were “pain free” compared to “13% of those treated with medication”. Home exercises were also found to be essential for pain management and prevention of future problems. Patients need to be educated about proper posture and ergonomics, as well as repetitive stress injuries. Exercise strengthens muscles and improves flexibility. Chiropractors can instruct patients in ergonomics, posture, and exercises.10