2. Algorithm for the Chiropractic Treatment of Spine Related Pain

3. Source Documents A LGORITHMS FOR THE C HIROPRACTIC M ANAGEMENT OF A CUTE AND C HRONIC S PINE -R ELATED P AIN, G REGORY A. B AKER, DC, R ONALD J. F ARABAUGH, DC, T HOMAS J. A UGAT, DC, MS, CCSP, FASA, C HERYL H AWK, DC, P H D; TOPICS IN INTEGRATIVE HEALTH CARE [ISSN 2158-4222] – VOL 3(4), D EC 2012. C HIROPRACTIC M ANAGEMENT OF L OW B ACK D ISORDERS : R EPORT FROM A C ONSENSUS P ROCESS, G. Globe, MBA, DC, PhD, C. Morris, DC, W. Whalen, DC, R Farabaugh, DC, and C. Hawk, DC, PhD; JMPT, November/December 2008 M ANAGEMENT OF C HRONIC S PINE -R ELATED C ONDITIONS : C ONSENSUS R ECOMMENDATIONS OF A M ULTIDISCIPLINARY P ANEL, R. Farabaugh, DC, M. Dehen, DC, and C. Hawk, DC, PhD; JMPT, Volume 33, Number 7, Sept. 2010.

4. Algorithm for the Chiropractic Treatment of Spine Related Pain Dictate or recommend the modality of treatment Guide the management of non-painful functional or structural spinal care (subluxation correction, posture correction, scoliosis management, etc) Apply to wellness care/health promotion The scope of this algorithm is for the chiropractic management of spine related pain. It does not:

5. This is a new patient Patient presents with spine related pain This is an established patient with a new condition or a moderate- severe exacerbation of a pre- existing condition This is an established patient with a mild episode of a previously treated (usually chronic) condition. Perform New Patient Evaluation Perform Established Patient Evaluation Perform Evaluation 1 (Often Condition Focused) Go to Acute Care Algorithm Go to Chronic Care Algorithm 1 23 456

6. This is a new patient Patient presents with spine related pain This is an established patient with a new condition or a moderate- severe exacerbation of a pre- existing condition This is an established patient with a mild episode of a previously treated (usually chronic) condition. Perform New Patient Evaluation Perform Established Patient Evaluation Perform Evaluation 1 (Often Condition Focused) Go to Acute Care Algorithm Go to Chronic Care Algorithm 1 23 456

7. This is a new patient Patient presents with spine related pain This is an established patient with a new condition or a moderate- severe exacerbation of a pre- existing condition This is an established patient with a mild episode of a previously treated (usually chronic) condition. Perform New Patient Evaluation Perform Established Patient Evaluation Perform Evaluation 1 (Often Condition Focused) Go to Acute Care Algorithm Go to Chronic Care Algorithm 1 23 456

8. This is a new patient Patient presents with spine related pain This is an established patient with a new condition or a moderate- severe exacerbation of a pre- existing condition This is an established patient with a mild episode of a previously treated (usually chronic) condition. Perform New Patient Evaluation Perform Established Patient Evaluation Perform Evaluation 1 (Often Condition Focused) Go to Acute Care Algorithm Go to Chronic Care Algorithm 1 23 456

9. Patient presents with acute spine related pain. Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Is co-management required? Refer to appropriate provider/facility YesNoYes Yes or No Begin therapeutic trial of up to 12 visits within 4 weeks. Assess for improvement at mid- point of trial using any of the accepted measurement tools Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Refer to appropriate provider/facility Continue Trial Symptoms Resolved? Perform Reassessment Evaluation Yes No Acute Care Algorithm 1 2 3 4 5 6 7 8 9 10 11 12

10. Patient presents with acute spine related pain. Is Condition Outside of Scope of Practice or Skill Set Refer to appropriate provider/ facility Is co-management required? Refer to appropriate provider/facility YesNoYes Yes or No Begin therapeutic trial of up to 12 visits within 4 weeks. Assess for improvement at mid- point of trial using any of the accepted measurement tools Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Refer to appropriate provider/facility Continue Trial Symptoms Resolved? Perform Reassessment Evaluation Yes No Acute Care Algorithm 1 2 3 4 5 6 7 8 9 10 11 12

11. Patient presents with acute spine related pain. Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Is co-management required? Refer to appropriate provider/facility YesNoYes Yes or No Begin therapeutic trial of up to 12 visits within 4 weeks. Assess for improvement at mid- point of trial using any of the accepted measurement tools Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Refer to appropriate provider/facility Continue Trial Symptoms Resolved? Perform Reassessment Evaluation Yes No Acute Care Algorithm 1 2 3 4 5 6 7 8 9 10 11 12

12. Patient presents with acute spine related pain. Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Is co-management required? Refer to appropriate provider/facility YesNoYes Yes or No Begin therapeutic trial of up to 12 visits within 4 weeks. Assess for improvement at mid- point of trial using any of the accepted measurement tools Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Refer to appropriate provider/facility Continue Trial Symptoms Resolved? Perform Reassessment Evaluation Yes No Acute Care Algorithm 1 2 3 4 5 6 7 8 9 10 11 12

13. Patient presents with acute spine related pain. Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Is co-management required? Refer to appropriate provider/facility YesNoYes Yes or No Begin therapeutic trial of up to 12 visits within 4 weeks. Assess for improvement at mid- point of trial using any of the accepted measurement tools Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Refer to appropriate provider/facility Continue Trial Symptoms Resolved? Perform Reassessment Evaluation Yes No Acute Care Algorithm 1 2 3 4 5 6 7 8 9 10 11 12

14. Patient presents with acute spine related pain. Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Is co-management required? Refer to appropriate provider/facility YesNoYes Yes or No Begin therapeutic trial of up to 12 visits within 4 weeks. Assess for improvement at mid- point of trial using any of the accepted measurement tools Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Refer to appropriate provider/facility Continue Trial Symptoms Resolved? Perform Reassessment Evaluation Yes No Acute Care Algorithm 1 2 3 4 5 6 7 8 9 10 11 12

15. Patient presents with acute spine related pain. Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Is co-management required? Refer to appropriate provider/facility YesNoYes Yes or No Begin therapeutic trial of up to 12 visits within 4 weeks. Assess for improvement at mid- point of trial using any of the accepted measurement tools Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Refer to appropriate provider/facility Continue Trial Symptoms Resolved? Perform Reassessment Evaluation Yes No Acute Care Algorithm 1 2 3 4 5 6 7 8 9 10 11 12

16. Patient presents with acute spine related pain. Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Is co-management required? Refer to appropriate provider/facility YesNoYes Yes or No Begin therapeutic trial of up to 12 visits within 4 weeks. Assess for improvement at mid- point of trial using any of the accepted measurement tools Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Refer to appropriate provider/facility Continue Trial Symptoms Resolved? Perform Reassessment Evaluation Yes No Acute Care Algorithm 1 2 3 4 5 6 7 8 9 10 11 12

17. Patient presents with acute spine related pain. Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Is co-management required? Refer to appropriate provider/facility YesNoYes Yes or No Begin therapeutic trial of up to 12 visits within 4 weeks. Assess for improvement at mid- point of trial using any of the accepted measurement tools Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Refer to appropriate provider/facility Continue Trial Symptoms Resolved? Perform Reassessment Evaluation Yes No Acute Care Algorithm 1 2 3 4 5 6 7 8 9 10 11 12

18. Patient presents with acute spine related pain. Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Is co-management required? Refer to appropriate provider/facility YesNoYes Yes or No Begin therapeutic trial of up to 12 visits within 4 weeks. Assess for improvement at mid- point of trial using any of the accepted measurement tools Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Refer to appropriate provider/facility Continue Trial Symptoms Resolved? Perform Reassessment Evaluation Yes No Acute Care Algorithm 1 2 3 4 5 6 7 8 9 10 11 12

19. Patient presents with acute spine related pain. Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Is co-management required? Refer to appropriate provider/facility YesNoYes Yes or No Begin therapeutic trial of up to 12 visits within 4 weeks. Assess for improvement at mid- point of trial using any of the accepted measurement tools Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Refer to appropriate provider/facility Continue Trial Symptoms Resolved? Perform Reassessment Evaluation Yes No Acute Care Algorithm 1 2 3 4 5 6 7 8 9 10 11 12

20. Patient presents with acute spine related pain. Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Is co-management required? Refer to appropriate provider/facility YesNoYes Yes or No Begin therapeutic trial of up to 12 visits within 4 weeks. Assess for improvement at mid- point of trial using any of the accepted measurement tools Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Refer to appropriate provider/facility Continue Trial Symptoms Resolved? Perform Reassessment Evaluation Yes No Acute Care Algorithm 1 2 3 4 5 6 7 8 9 10 11 12

21. Patient presents with acute spine related pain. Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Is co-management required? Refer to appropriate provider/facility YesNoYes Yes or No Begin therapeutic trial of up to 12 visits within 4 weeks. Assess for improvement at mid- point of trial using any of the accepted measurement tools Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Refer to appropriate provider/facility Continue Trial Symptoms Resolved? Perform Reassessment Evaluation Yes No Acute Care Algorithm 1 2 3 4 5 6 7 8 9 10 11 12

22. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

23. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

24. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

25. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

26. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

27. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

28. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

29. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

30. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

31. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

32. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

33. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

34. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

35. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

36. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

37. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

38. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

39. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

40. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

41. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

42. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

43. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

44. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

45. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

46. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

47. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

48. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

49. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

50. MTB Achieved? Continue up to 12 visits within 4 weeks Yes No Acute Care Algorithm Do Significant Symptoms and/or Functional deficits Remain? Is condition Stable or resolved? Release with home care instructions or transition to wellness care Trial withdrawal desired? Functional/symptom improvements? Has condition deteriorated Consider co- management Provide home care instructions and initiate trial withdrawal. Reassess condition status Refer Yes Go to Chronic Care Algorithm Other Treatment Options available In this facility? Additional improvement likely? Refer Yes No Yes 13 14 17 15 16 19 18 20 21 22 23 24 25 26 27 Yes NoYes No/Not SureYes No/Not Sure

51. Chronic Care Algorithm Minimize lost time on the job Support patient’s current level of function/ADL Pain control/relief to tolerance Minimize further disability Minimize exacerbation frequency and severity Maximize patient satisfaction Chronic Care Goals

52. Patient presents with chronic/recurrent spine related pain. Do the benefits of chronic pain management outweigh the risks? Refer to appropriate provider/facility or provide home management instructions. Red flags present? Refer to appropriate provider/facility This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms This is a symptom flare for a known chronic condition or recurrence of acute condition This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. Traumatic cause of exacerbation? Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. Consider imaging Mild Exacerbation? Moderate to severe exacerbations follow Acute Care Algorithm. Continue NoYes No or yes but appropriately managed. Yes No Yes Chronic Care Algorithm 1 2 3 4 7 6 5 8 9 10 11 12

53. Patient presents with chronic/recurrent spine related pain. Do the benefits of chronic pain management outweigh the risks? Refer to appropriate provider/facility or provide home management instructions. Red flags present? Refer to appropriate provider/facility This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms This is a symptom flare for a known chronic condition or recurrence of acute condition This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. Traumatic cause of exacerbation? Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. Consider imaging Mild Exacerbation? Moderate to severe exacerbations follow Acute Care Algorithm. Continue NoYes No or yes but appropriately managed. Yes No Yes Chronic Care Algorithm 1 2 3 4 7 6 5 8 9 10 11 12

54. Patient presents with chronic/recurrent spine related pain. Do the benefits of chronic pain management outweigh the risks? Refer to appropriate provider/facility or provide home management instructions. Red flags present? Refer to appropriate provider/facility This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms This is a symptom flare for a known chronic condition or recurrence of acute condition This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. Traumatic cause of exacerbation? Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. Consider imaging Mild Exacerbation? Moderate to severe exacerbations follow Acute Care Algorithm. Continue NoYes No or yes but appropriately managed. Yes No Yes Chronic Care Algorithm 1 2 3 4 7 6 5 8 9 10 11 12

55. Patient presents with chronic/recurrent spine related pain. Do the benefits of chronic pain management outweigh the risks? Refer to appropriate provider/facility or provide home management instructions. Red flags present? Refer to appropriate provider/facility This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms This is a symptom flare for a known chronic condition or recurrence of acute condition This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. Traumatic cause of exacerbation? Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. Consider imaging Mild Exacerbation? Moderate to severe exacerbations follow Acute Care Algorithm. Continue NoYes No or yes but appropriately managed. Yes No Yes Chronic Care Algorithm 1 2 3 4 7 6 5 8 9 10 11 12

56. Patient presents with chronic/recurrent spine related pain. Do the benefits of chronic pain management outweigh the risks? Refer to appropriate provider/facility or provide home management instructions. Red flags present? Refer to appropriate provider/facility This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms This is a symptom flare for a known chronic condition or recurrence of acute condition This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. Traumatic cause of exacerbation? Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. Consider imaging Mild Exacerbation? Moderate to severe exacerbations follow Acute Care Algorithm. Continue NoYes No or yes but appropriately managed. Yes No Yes Chronic Care Algorithm 1 2 3 4 7 6 5 8 9 10 11 12

57. Patient presents with chronic/recurrent spine related pain. Do the benefits of chronic pain management outweigh the risks? Refer to appropriate provider/facility or provide home management instructions. Red flags present? Refer to appropriate provider/facility This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms This is a symptom flare for a known chronic condition or recurrence of acute condition This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. Traumatic cause of exacerbation? Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. Consider imaging Mild Exacerbation? Moderate to severe exacerbations follow Acute Care Algorithm. Continue NoYes No or yes but appropriately managed. Yes No Yes Chronic Care Algorithm 1 2 3 4 7 6 5 8 9 10 11 12

58. Patient presents with chronic/recurrent spine related pain. Do the benefits of chronic pain management outweigh the risks? Refer to appropriate provider/facility or provide home management instructions. Red flags present? Refer to appropriate provider/facility This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms This is a symptom flare for a known chronic condition or recurrence of acute condition This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. Traumatic cause of exacerbation? Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. Consider imaging Mild Exacerbation? Moderate to severe exacerbations follow Acute Care Algorithm. Continue NoYes No or yes but appropriately managed. Yes No Yes Chronic Care Algorithm 1 2 3 4 7 6 5 8 9 10 11 12

59. Patient presents with chronic/recurrent spine related pain. Do the benefits of chronic pain management outweigh the risks? Refer to appropriate provider/facility or provide home management instructions. Red flags present? Refer to appropriate provider/facility This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms This is a symptom flare for a known chronic condition or recurrence of acute condition This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. Traumatic cause of exacerbation? Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. Consider imaging Mild Exacerbation? Moderate to severe exacerbations follow Acute Care Algorithm. Continue NoYes No or yes but appropriately managed. Yes No Yes Chronic Care Algorithm 1 2 3 4 7 6 5 8 9 10 11 12

60. Patient presents with chronic/recurrent spine related pain. Do the benefits of chronic pain management outweigh the risks? Refer to appropriate provider/facility or provide home management instructions. Red flags present? Refer to appropriate provider/facility This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms This is a symptom flare for a known chronic condition or recurrence of acute condition This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. Traumatic cause of exacerbation? Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. Consider imaging Mild Exacerbation? Moderate to severe exacerbations follow Acute Care Algorithm. Continue NoYes No or yes but appropriately managed. Yes No Yes Chronic Care Algorithm 1 2 3 4 7 6 5 8 9 10 11 12

61. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

62. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

63. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

64. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

65. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

66. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

67. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

68. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

69. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

70. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

71. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

72. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

73. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

74. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

75. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

76. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

77. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

78. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

79. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

80. Treat for up to 6 visits. Has patient returned to pre- episode status? Consider further diagnostic testing Does Condition Worsen upon repeated attempts to withdraw care? NoYes Release patient Provide home management recommendations if appropriate Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. Red Flags present or other conditions outside of scope or skill set? Refer to appropriate provider/facility Symptoms Improved?/Are Chronic Care goals being Met? MTB/Pre-Episode Status Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management Treat for up to 6 visits. Consider multimodal, multidisciplinary care. Chronic Care Algorithm No Yes No Yes No 13 14 15 16 17 18 19 20 21 22 2523 24

81. In Summary Spine related pain All decisions should take into account provider experience and patient preference. Care is appropriate provided improvement is demonstrated and/or expected.

82. Two Items of interest Thera-band System Appeal Letters * Thank you North Carolina Chiropractic Association (NCCA) 81 www.ccgpp.org