You may want to explore the shift away from Guidelines (usually containing numbers/suggested treatment time frames, that are often mistakenly applied as arbitrary limits) to “Best Practices” (clinical judgments regarding patient care that are informed by the best evidence and balanced by patient complexity and provider experience to improve the quality and reduce the costs of care).
Evidence-based Practice
This page provides information about interpreting the various statistical tests utilized in journal articles, and contains other information regarding Evidence-based Practice.
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Best Practice Initiative
Explore the shift from Guidelines, often containing numbers/ suggested treatment time frames, to “Best Practices”, which are clinical decisions informed by the best evidence available, and balanced by patient complexity and provider experience.
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Guidelines Page
Our original Guidelines section contains a compendium of Guidelines from around the World, as well as a selection of articles about the need for, and frequent misuse of these Guidelines.
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Best Practices for Chiropractic Management of Adult
Patients With Mechanical Low Back Pain:
A Clinical Practice Guideline for
Chiropractors in the United States
J Manipulative Physiol Ther 2023 (Jun 20); S0161-4754 ~ FULL TEXT
This paper updates the best-practice guideline on chiropractic management of mechanical LBP in adults in the US from the prior iterations. [4, 82] This guideline provides evidence-informed guidance to DCs related to both initial care management and the progression of care throughout an episode of the condition to reduce practice variability among providers while improving outcomes. We identified benchmarks and decision points in care management and provided information related to each issue. Providers can use this document as a reference point for the care they provide their patients. This updated Clinical Practice Guideline (CPG) condensed the number of recommendations from 51 to 38 while providing more evidence-informed insight into the diagnostic considerations for LBP, including the history and examination and diagnostic imaging. This document provides a more comprehensive description of the conservative management approaches to LBP, including chiropractic approaches and co-management considerations for multidisciplinary care.
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Best-Practice Recommendations for Chiropractic Care for
Pregnant and Postpartum Patients:
Results of a Consensus Process
J Manipulative Physiol Ther 2022 (Sep); 45 (7): 469–489 ~ FULL TEXT
This best-practice recommendations article is a synthesis of the current evidence and collective expert opinion about a reasonable clinical approach for chiropractic care and management of pregnant and postpartum populations. This article provides an initial framework for chiropractors who wish to manage these populations and to help chiropractic researchers determine and examine the gaps in the literature to implement a robust research program that informs future clinical guidelines. As the first best-practices recommendations document for pregnant and postpartum patients, it is expected to evolve as new evidence emerges.
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Best Practices for Chiropractic Management of Patients
with Chronic Musculoskeletal Pain:
A Clinical Practice Guideline
J Altern Complement Med 2020 (Jul 30) ~ FULL TEXT
The Delphi process was conducted January-February 2020. The 62-member Delphi panel reached consensus on chiropractic management of five common chronic MSK pain conditions: low-back pain (LBP), neck pain, tension headache, osteoarthritis (knee and hip), and fibromyalgia. Recommendations were made for nonpharmacological treatments, including acupuncture, spinal manipulation/mobilization, and other manual therapy; modalities such as low-level laser and interferential current; exercise, including yoga; mind-body interventions, including mindfulness meditation and cognitive behavior therapy; and lifestyle modifications such as diet and tobacco cessation. Recommendations covered many aspects of the clinical encounter, from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral. Appropriate referral and comanagement were emphasized.
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What Does Best Practice Care for Musculoskeletal Pain
Look Like? Eleven Consistent Recommendations From
High-quality Clinical Practice Guidelines:
Systematic Review
Br J Sports Med 2020 (Jan); 54 (2): 79–86 ~ FULL TEXT
Variation in the quality of care is a barrier to providing high value musculoskeletal pain (MSK) care. Clinical practice guidelines (CPGs) are an important tool to address MSK pain care quality. We identified 11 consistent recommendations (Box 2) for the management of MSK conditions. These recommendations can be used by consumers, clinicians and at health services and policy levels to improve the quality of MSK pain care. Optimising the implementation of these recommendations comprises the next challenge.
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Best-Practice Recommendations for Chiropractic
Management of Patients With Neck Pain
J Manipulative Physiol Ther. 2019 (Nov); 42 (9): 635–650 ~ FULL TEXT
A set of best-practice recommendations for chiropractic management of patients with neck pain based on the best available evidence reached a high level of consensus by a large group of experienced chiropractors. The recommendations indicate that manipulation and mobilization as part of a multimodal approach are front-line approaches to patients with uncomplicated neck pain.
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Effect of Intensive Patient Education vs Placebo
Patient Education on Outcomes in Patients With
Acute Low Back Pain: A Randomized Clinical Trial 12612001180808
JAMA Neurol 2019 (Feb 1); 76 (2): 161–169 ~ FULL TEXT
Adding 2 hours of patient education to recommended first-line care for patients with acute low back pain did not improve pain outcomes. Clinical guideline recommendations to provide complex and intensive support to high-risk patients with acute low back pain may have been premature.
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Best Practices for Chiropractic Care for Older Adults:
A Systematic Review and Consensus Update
J Manipulative Physiol Ther 2017 (May); 40 (4): 217–229 ~ FULL TEXT
A total of 199 articles were found; after exclusion criteria were applied, 6 articles about effectiveness or efficacy and 6 on safety were added. The Delphi process was conducted from April to June 2016. Of the 37 Delphi panelists, 31 were DCs and 6 were other health care professionals. Three Delphi rounds were conducted to reach consensus on all 45 statements. As a result, statements regarding the safety of manipulation were strengthened and additional statements were added recommending that DCs advise patients on exercise and that manipulation and mobilization contribute to general positive outcomes beyond pain reduction only.
This is an update of the 2010 Consensus Document titled:
Recommendations for Chiropractic Care for Older Adults:
Results of a Consensus Process
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Best Practices for Chiropractic Care of Children:
Consensus Update
J Manipulative Physiol Ther. 2016 (Mar); 39 (3): 158–168 ~ FULL TEXT
Chiropractic is a health care profession concerned with the diagnosis, treatment, and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health. [1] Chiropractic care is the most common complementary and integrative medicine practice used by children in the United States. [2] A recent Gallup survey found that approximately 14% of US adults reported that they had used chiropractic care in the prior 12 months, that more than 50% had ever used a doctor of chiropractic (DC) for health care, and that more than 25% would choose chiropractic care as a first treatment for neck or back pain. [3] The findings from this survey also were consistent with a previous study that found that patients use chiropractic services in different ways, sometimes for treatment and sometimes for health promotion. [4]
This is an update of the 2009 Consensus Document titled:
Best Practices Recommendations for Chiropractic Care
for Infants, Children, and Adolescents
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Clinical Practice Guideline: Chiropractic Care
for Low Back Pain
J Manipulative Physiol Ther. 2016 (Jan); 39 (1): 1–22 ~ FULL TEXT
To facilitate best practices specific to the chiropractic management of patients with common, primarily musculoskeletal disorders, the profession established the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) in 1995. [6] The organization sponsored and/or participated in the development of a number of “best practices” recommendations on various conditions. [21–32] With respect to chiropractic management of LBP, a CCGPP team produced a literature synthesis [8] which formed the basis of the first iteration of this guideline in 2008. [9] In 2010, a new guideline focused on chronic spine-related pain was published, [12] with a companion publication to both the 2008 and 2010 guidelines published in 2012, providing algorithms for chiropractic management of both acute and chronic pain. [10] Guidelines should be updated regularly. [33, 34] Therefore, this article provides the clinical practice guideline (CPG) based on an updated systematic literature review and extensive and robust consensus process. [9–12]
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Algorithms for the Chiropractic Management of Acute
and Chronic Spine-Related Pain
Topics in Integrative Health Care 2012 (Dec 31); 3 (4) ID: 3.4007 ~ FULL TEXT
The complexity of clinical documentation and case management for health care providers has increased along with the rise of managed care. Keeping up with the policies of different insurers and third party administrators can be a daunting task. To address these issues for doctors of chiropractic (DCs) and policymakers, the Council for Chiropractic Guidelines and Practice Parameters (CCGPP) developed three consensus documents. Each of these documents was the outcome of a formal consensus process in which a multidisciplinary Delphi panel consisting of experts in chiropractic and low back pain treatment came to agreement on terminology and treatment parameters for the chiropractic management of spine-related musculoskeletal pain. [1–3]
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Consensus Process to Develop a Best-Practice Document on
the Role of Chiropractic Care in Health Promotion,
Disease Prevention, and Wellness
J Manipulative Physiol Ther. 2012 (Sep); 35 (7): 556–567 ~ FULL TEXT
Chiropractic wellness care (sometimes referred to as maintenance care [MC]) is accepted by the profession as an integral part of chiropractic practice. [1–6] The theory of MC suggests that ongoing chiropractic care may have value in maintaining and promoting health, as well as preventing disease. [7]
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Consensus Terminology for Stages of Care:
Acute, Chronic, Recurrent, and Wellness
J Manipulative Physiol Ther 2010 (Jul); 33 (6): 458–463 ~ FULL TEXT
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.”
You may also enjoy this ACA Press release titled:
Chiropractic Reaches Consensus
On Terminology For Stages Of Care
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Best Practices Recommendations for Chiropractic Care for
Older Adults: Results of a Consensus Process
J Manipulative Physiol Ther 2010 (Jul); 33 (6): 464–473 ~ FULL TEXT
By 2030, nearly 1 in 5 US residents is expected to be 65 years or older. [1] Chiropractors commonly provide care to older adults in the United States, with approximately 14% of chiropractic patients being 65 years or older. [2] With musculoskeletal conditions cited as a leading cause of disability in this population, [3] it is important that the large body of evidence for the effectiveness of chiropractic care be examined for relevance to the geriatric population. This is particularly important given the statements made by the American Geriatric Society (AGS) in their clinical practice guidelines for the management of chronic pain in older adults. The 1998 AGS report made the following recommendation on chiropractic (based on the single study available at that time): [4]
These recommendations have been updated by the 2017 article:
Best Practices for Chiropractic Care for Older Adults:
A Systematic Review and Consensus Update
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Best Practices Recommendations for Chiropractic Care for
Infants, Children, and Adolescents:
Results of a Consensus Process
J Manipulative Physiol Ther. 2009 (Oct); 32 (8): 639–647 ~ FULL TEXT
The National Center for Health Statistics found that manipulation by chiropractors or osteopathic physicians was the most commonly used provider-based complementary and alternative (CAM) therapy among US children under age 18 in 2007. [1] The most frequent complaint causing children to seek CAM care, in general, was back or neck pain (7%). Because the prevalence of low back pain (LBP) in children has been estimated to be as high as 40%, with recurrent LBP occurring in 20% of older adolescents, this is not surprising. [2] However, children also sought CAM care for a number of other complaints, both musculoskeletal and nonmusculoskeletal, as shown in Table 1. Approximately 12% of US children used some type of CAM therapy in 2007; about 3% used manipulation (chiropractic or osteopathic). Adolescents used CAM more than younger children, and it was more commonly used among children with more health problems and doctor visits. [1]
These recommendations have been updated by the 2016 article:
Best Practices for Chiropractic Care of Children:
A Consensus Update
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A Review of the CCGPP Process
The Chiropractic Report (March 2009) ~ FULL TEXT
In North America the relentless upwards spiral of healthcare costs in the last quarter of the 20th century produced the current era of managed care. There is no question that the excessive cost of American medical care needed to be reined in. There is also no question that third party payers in managed care have been ruthless in establishing rules and procedures based on financial targets rather than reasonable patient care. Money that should be going to patient care is going to a bloated administration and managed care owners. In the US the ratio of physicians to administrators is now almost 1 to 1 (1 to 0.95) Research is quoted and used selectively. Valuable evidence of effectiveness of treatments from prospective studies, from individual randomized controlled trials (RCTs) and for subgroups of patients, is excluded or diluted in broad systematic reviews that typically make tentative conclusions only – allowing payers to assert there is insufficient evidence. Crucial differences in quality of care are ignored. In the field of spinal manipulation for example, there are fundamentally different levels of education and skill for different health professions. This is apparent from trials such as Meade et al., where chiropractors received significantly superior results for back pain patients than did physical therapists, and Carey et al., where medical doctors given postgraduate training in spinal manipulation proved unable to assess and treat back pain patients successfully.
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Background and Methodology
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What Constitutes Evidence for Best Practice?
J Manipulative Physiol Ther 2008 (Nov); 31 (9): 637–643 ~ FULL TEXT
As much as 85% of current health care practices remain scientifically unfounded despite the claims of western medicine to scientific supremacy. [15] The CCGPP recognizes the humanitarian charge to doctors to alleviate patient condition, the social responsibility for managing resources responsibly, and the occasional ethical conflict that may arise between these 2 priorities in a given case. As a result, the CCGPP adopts the positions of Sackett [16, 18] and of Sox [56] in recommendations for provider considerations when strong evidence is absent. The following steps are suggested for the care giver:
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Literature Syntheses for the Council on Chiropractic
Guidelines and Practice Parameters: Methodology
J Manipulative Physiol Ther 2008 (Nov); 31 (9): 645–650 ~ FULL TEXT
The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence-based values for chiropractic care. Content and process–experienced team leaders were selected to manage 8 domains based on regional disorders: low back and related lower extremity conditions; neck pain, headache, and related upper extremity conditions;
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CCGPP Literature Syntheses
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Low Back and Leg Complaints
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Chiropractic Management of Low Back Pain and Low Back-
Related Leg Complaints: A Literature Synthesis
J Manipulative Physiol Ther 2008 (Nov); 31 (9): 659–674 ~ FULL TEXT
As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence. There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.
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Chiropractic Management of Low Back Disorders:
Report From a Consensus Process
J Manipulative Physiol Ther 2008 (Nov); 31 (9): 651–658 ~ FULL TEXT
The findings of the CCGPP literature synthesis particularly support, although clinical practice is not limited to, the use of manual therapeutic techniques (such as manipulation and mobilization procedures), patient education regarding reassurance, staying active and avoiding illness behavior, and also rehabilitative exercise as the therapeutic basis for care for low back conditions. It is also important to note that the CCGPP recommendations in support of manipulation for both acute and chronic low back pain closely mirror many other systematic reviews of the literature. For example, Bronfort et al6 have also recently concluded that manual therapeutic methods, such as spinal manipulation and mobilization methods, combined with active care/exercises have been shown to be effective in the management of chronic back pain.
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Nonmuscuoloskeletal Conditions
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Chiropractic Management of Fibromyalgia Syndrome:
A Systematic Review of the Literature
J Manipulative Physiol Ther 2009 (Jan); 32 (1): 25–40 ~ FULL TEXT
Our search yielded the following results: 8 systematic reviews, 3 meta-analyses, 5 published guidelines, and 1 consensus document. Our direct search of the databases for additional randomized trials did not find any chiropractic randomized clinical trials that were not already included in one or more of the systematic reviews/guidelines. The review of the Manual, Alternative, and Natural Therapy Index System and Index to Chiropractic Literature databases yielded an additional 38 articles regarding various nonpharmacologic therapies such as chiropractic, acupuncture, nutritional/herbal supplements, massage, etc.
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Myofascial Trigger Points/Myofascial Pain Syndrome
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Chiropractic Management of Myofascial Trigger Points and
Myofascial Pain Syndrome: Summary of Clinical Practice
J Manipulative Physiol Ther. 2009 (Jan); 32 (1): 14–24
The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. PubMed, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, and databases for systematic reviews and clinical guidelines were searched. Separate searches were conducted for (1) manual palpation and algometry, (2) chiropractic and other manual therapies, and (3) other conservative and complementary/alternative therapies. Studies were screened for relevance and rated using the Oxford Scale and Scottish Intercollegiate Guidelines Network rating system.
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Chiropractic Management of Myofascial Trigger Points and
Myofascial Pain Syndrome: Summary of Clinical Practice
Recommendations from the Commission of the Council
on Chiropractic Guidelines and Practice Parameters
Review of these articles resulted in the following clinical recommendations regarding treatment:
Moderately strong evidence supports manipulation and ischemic pressure for immediate pain
relief at MTrPs, but only limited evidence exists for long-term pain relief at MTrPs. Evidence
supports laser therapy (strong), transcutaneous electrical nerve stimulation, acupuncture, and
magnet therapy (all moderate) for MTrPs and MPS, although the duration of relief varies among
therapies. Limited evidence supports electrical muscle stimulation, highvoltage galvanic
stimulation, interferential current, and frequency modulated neural stimulation in the treatment
of MTrPs and MPS. Evidence is weak for ultrasound therapy.
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Lower Extremity Conditions
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Manipulative Therapy for Lower Extremity Conditions:
Expansion of Literature Review
J Manipulative Physiol Ther 2009 (Jan); 32 (1): 53–71 ~ FULL TEXT
Of the total 389 citations captured, 39 were determined to be relevant. There is a level of C or limited evidence for manipulative therapy combined with multimodal or exercise therapy for hip osteoarthritis. There is a level of B or fair evidence for manipulative therapy of the knee and/or full kinetic chain, and of the ankle and/or foot, combined with multimodal or exercise therapy for knee osteoarthritis, patellofemoral pain syndrome, and ankle inversion sprain.
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Chiropractic Management of Tendinopathy:
A Literature Synthesis
J Manipulative Physiol Ther 2009 (Jan); 32 (1): 41–52 ~ FULL TEXT
There is evidence that ultrasound therapy provides clinically important improvement in the treatment of calcific tendonitis. There is limited evidence of the benefit of manipulation and mobilization in the treatment of tendinopathy. Limited evidence exists to support the use of supervised exercise, eccentric exercise, friction massage, acupuncture, laser therapy, use of bracing, orthotics, and cryotherapy in the treatment of tendinopathy.
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