17.4 Patient Care: Case Management and Contraindications

17.4 Patient Care: Case Management and Contraindications

Quick Answer: Part II case-management items test whether you can manage a patient over time—not just perform one adjustment. Know when to treat, when to modify, when to refer, how to document, and how absolute vs. relative contraindications change the plan.

Case Management Framework

Case management is the ongoing process of planning, delivering, monitoring, and modifying care to achieve defined outcomes. On the NBCE, it intersects Chiropractic Practice (17%) and broader clinical-science Patient Care content (~27% when combined with related domains). A competent case-management sequence includes:

1. Initial evaluation — History, examination, clinical impression, prognosis.
2. Care plan — Short- and long-term goals (pain reduction, ROM restoration, return to work/sport), proposed interventions (adjustive, soft tissue, rehab, lifestyle), visit frequency.
3. Informed consent — Risks, benefits, alternatives discussed and documented.
4. Trial of care — Time-limited course with objective milestones (e.g., 50% pain reduction in 2 weeks, improved SLR angle).
5. Re-evaluation — Scheduled intervals (often 30 days or sooner if worsening) comparing current status to baseline.
6. Modification or referral — If goals are not met, change technique, add co-management, order imaging, or refer—not indefinite passive care without progress.
7. Discharge or maintenance — Discharge when goals are met; maintenance care only with documented functional rationale where jurisdiction allows.

Vignettes often ask the next best step after six visits without improvement—correct answers favor re-evaluation, imaging consideration, or referral over continued identical treatment.

Absolute vs. Relative Contraindications

Understanding this distinction is one of the highest-yield Part II skills.

Absolute Contraindications

No manipulation (or no manipulation at the affected region) until the condition is resolved or specialist clearance is documented:

When any absolute contraindication is present, the correct board action is stop manipulation and refer—not a gentler thrust, not the same technique with less force.

Relative Contraindications

Manipulation may proceed with modification, co-management, or after additional workup:

Relative contraindications require clinical judgment—the exam rewards the safest reasonable option, not aggressive defaults.

Indications for Chiropractic Care

Indications center on mechanical neuromusculoskeletal disorders amenable to manual care:

• Segmental dysfunction with restricted motion and pain
• Mechanical low back and neck pain without red flags
• Sacroiliac and extremity joint fixations after appropriate screening
• Headache subtypes with cervical component (after vascular red-flag exclusion)
• Supportive care during rehabilitation from resolved acute injury

Non-indications include primary treatment of systemic disease, unmanaged psychosocial crisis driving pain alone, or conditions requiring medical/surgical priority (e.g., acute appendicitis presenting as abdominal pain—refer, do not adjust).

Referral and Co-Management

Refer when:

• Red flags appear at any visit
• Diagnosis is uncertain after reasonable workup
• Progress plateaus beyond expected timeline
• Patient requires pharmacologic, surgical, or specialty care beyond DC scope
• Legal or ethical boundaries require another provider (OB for high-risk pregnancy, cardiologist for unexplained chest pain)

Document referral communication—to whom, when, and what information was sent. Part II frequently tests whether referral should occur before the next adjustment.

Informed Consent

Valid informed consent includes:

• Nature of treatment proposed (regions, technique types)
• Material risks — including rare cervical manipulation complications (stroke/dissection), disc aggravation, rib fracture in osteoporosis, post-treatment soreness
• Benefits and reasonable alternatives (medication, PT, surgery, no treatment)
• Patient questions answered; voluntary agreement documented

Consent is ongoing—new techniques or regions require updated discussion. A patient who develops new neurologic symptoms mid-course must be re-consented only after re-evaluation and possible referral, not merely asked to continue.

Documentation Standards for Case Management

Complete records support board answers and malpractice defense:

• Every visit: Subjective change, objective re-check of key findings, assessment update, plan for today and forward.
• Care plan updates: When frequency or goals change, document why.
• Contraindication screen: Especially cervical vascular history, osteoporosis, anticoagulation—note negative screens when relevant.
• Outcome measures: Pain scales, disability indexes (Oswestry, NDI), ROM degrees.
• Discharge summary: Goals met or reason for termination/referral.

Avoid cookie-cutter notes identical visit to visit; they signal poor case management on audits and board-style chart-review questions.

Integrating Technique with Management

The NBCE links analysis, technique, and management in single case stems. A typical flow:

Evaluate → identify segmental dysfunction → screen contraindications → obtain consent → select appropriate technique → reassess response → adjust plan or refer.

If step two or three fails (red flag found, absolute contraindication), steps four through six do not proceed as originally planned. Choosing referral over adjustment in that moment is almost always the scored answer.

Patient Care Domain Weighting Reminder

While this section sits in Chiropractic Practice, Patient Care themes (~27%) recur across Part II—ethics, boundaries, scope, communication, and safety. Treat every contraindication and documentation question as both a clinical-science and practice-operation item. The doctor who adjusts well but manages poorly fails the board and risks patients in practice.