Best Practices in Chiropractic This section was compiled by Frank M. Painter, D.C.
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The Council on Chiropractic Guidelines and Practice Parameters (CCGPP), was formed in 1995 at the behest of the Congress of Chiropractic State Associations (COCSA) and with assistance from numerous national associations to create an equitable chiropractic practice document. CCGPP was delegated to examine all existing guidelines, parameters, protocols and best practices in the United States and other nations in the construction of this document. Their first mission was to describe the difference between “Guideline” and “Best Practice”.
This Page was previously located in the Evidence-based Practice Page
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
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]
Acute, Chronic, Recurrent, and Wellness
J Manipulative Physiol Ther 2010 (Jul); 33 (6): 458–463
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
The Chiropractic Report ~ March 2009
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.
Preface ~ August 13, 2007
Background and Methodology
J Manipulative Physiol Ther 2008 (Nov); 31 (9): 637–643
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:
and Practice Parameters: Methodology
J Manipulative Physiol Ther 2008 (Nov); 31 (9): 645–650
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;
CCGPP Literature Syntheses
Acute, Chronic, Recurrent, and Wellness
J Manipulative Physiol Ther 2010 (Jul); 33 (6): 458–463
As the chiropractic profession delineates its role in the emerging health care marketplace, it will become increasingly important that the scope of appropriate chiropractic care is clearly defined relative to overall patient case management. Therefore, the Council on Chiropractic Guidelines and Practice Parameters engaged in a multidisciplinary consensus process addressing the terminology related to “levels of care.”
Chronic Spinal Pain
Consensus Recommendations of a Multidisciplinary Panel
J Manipulative Physiol Ther 2010 (Sep); 33 (7): 484–492
A multidisciplinary panel of experienced practitioners was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for complex patients with chronic spine-related conditions, based on both the scientific evidence and their clinical experience.
Low Back and Leg Complaints
Leg Complaints: A Literature Synthesis
J Manipulative Physiol Ther 2008 (Nov); 31 (9): 659–674
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.
Report From a Consensus Process
J Manipulative Physiol Ther 2008 (Nov); 31 (9): 651–658
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.
Nonmuscuoloskeletal Conditions
A Systematic Review With Implications for Whole Systems Research
J Alternative and Complementary Medicine 2007 (Jun); 13 (5): 491–512 ~ FULL TEXT
Objectives: (1) To evaluate the evidence on the effect of chiropractic care, rather than spinal manipulation only, on patients with nonmusculoskeletal conditions; and (2) to identify shortcomings in the evidence base on this topic, from a Whole Systems Research perspective.
Myofascial Trigger Points/Myofascial Pain Syndrome
A Systematic Review of the Literature
J Manipulative Physiol Ther 2009 (Jan); 32 (1): 25–40
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.
Summary of Clinical Practice
Recommendations from the Commission of the Council on Chiropractic Guidelines and Practice Parameters
Our search yielded the following results: 8 systematic reviews, 3 meta-analyses, 5 published guidelines, 1 consensus document. Our direct search of the databases for additional randomized trials did not find any chiropractic RCTs that were not already included in one or more of the systematic reviews/guidelines. The review of the MANTIS and ICL databases yielded an additional 38 articles regarding various non-pharmacological therapies such as chiropractic, acupuncture, nutritional/herbal supplements, massage, etc. Review of these articles resulted in the following clinical practice recommendations regarding non-pharmaceutical treatments of FMS. Strong evidence supports aerobic exercise and cognitive behavioral therapy. Moderate evidence supports massage, muscle strength training, acupuncture, and spa therapy (balneotherapy). Limited evidence supports spinal manipulation, movement/body awareness, and vitamins, herbs, and dietary modification.
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.
Lower Extremity Conditions
Expansion of Literature Review
J Manipulative Physiol Ther 2009 (Jan); 32 (1): 53–71
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.
Summary of Clinical Practice
Recommendations from the Commission of the Council on Chiropractic Guidelines and Practice Parameters
Of the total 389 citations captured, 39 were determined to be relevant. Review of these articles resulted in the following clinical practice recommendations for manipulative therapy of lower extremity conditions. 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.
Tendinopathy
A Literature Synthesis
J Manipulative Physiol Ther 2009 (Jan); 32 (1): 41–52
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.
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 practice recommendations for chiropractic management of tendinopathy. 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 and orthotics and cryotherapy in the treatment of tendinopathy.
Projects in Process
Articles About Guideline Development
International Chiropractors Association's
Best Practices and Practice Guidelines
Chiropractors Association members, contained herein, are evidence-based suggestions for appropriate care of patients seeking chiropractic care. While no guideline can replace the clinical decisions made by a chiropractic practitioner in the course of caring for an individual patient’s health problem, the suggestions contain herein, are based on the best available published evidence. Any approach, by a practitioner, that is different from these ICA-BPPG Guidelines, does not necessarily mean that the approach in question was below the standard of care. However, any chiropractic practitioner, who adopts a course of action different from these ICA-BPPG Guidelines, is advised to keep sufficient patient records to explain why such an action was undertaken.
Dr. Mark D. Dehen ~ Vice Chair of the CCGPP ~ April 26, 2007
The Introductory Chapter has been reviewed and revised, per our discussion with COCSA. This was done to improve its clarity and readability without amending the existing research or conclusions, as necessitated maintaining the editorial independence of the project. Currently, the CCGPP is in the process of hiring a healthcare editor to further revise the "evidence synthesis" to make it more user-friendly to the profession at large. Dr. Bill Meeker and Dr. Dana Lawrence, team leads for the low back evidence synthesis chapter, are completing the review and synthesis of the commentary received. Once that commentary has been collated, it will be reviewed by the team for consideration as part of the expert opinion process. That commentary and the team response will then be included in the final version of the low back evidence synthesis.
J Manipulative Physiol Ther 2004 (May); 28 (4): 215-216 ~ FULL TEXT
Like most social trends, evidence-based care, originally conceived as a method to inform clinicians and improve patient outcomes, has been propelled beyond its original intent. It has now become evidence-based policy making. In debate, the vanguard of its proponents and its opponents often use stereotypical descriptions that further polarize as they express their views.
Ronald J. Farabaugh, D.C. ~ CCGPP Board Member
A rumor has it that the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) is developing a new guideline. I say rumor, because like all rumors the information released so far has been filled with a combination of fact, fiction, and at times outright misinformation. I intend on producing a series of short articles over the next six months explaining the facts in an effort to help the Chiropractic profession understand the process, and the difference between a “Best Practice” initiative and a “Guideline”. Did you know there is a major difference?
Eugene A. Lewis, DC, MPH, CCGPP Chairman
The best practice initiative undertaken by the Chiropractic Guidelines and Practice Parameters is progressing at a steady pace, with the Introduction and first completed chapter of the document (lumbar spine disorders) scheduled for release in early 2005.
Jeffrey R. Cates, DC, MS, DABCO, DABCC
So, how can DCs use the new CCGPP best practice document to their advantage? Read it! Understand it! It tells you how to document the necessity of supportive care, how to document exacerbations and so much more. If we as a profession don’t adopt the CCGPP’s fair and valid best practice guide, the insurance companies will use their own guidelines to assess our work, and it is very unlikely that they will be as balanced and fair as those put forth by our own scholars.
John J. Triano, DC, PhD
The pace at which information is being published is almost too intensive to conceive. Critical appraisal of the literature is a skill unto itself. It has been estimated that if an individual attempted to keep up with all the literature related to his or her own discipline by reading one article per day, by the end of one year, they would be 99 years behind. The AHCPR guidelines, the first governmentally sanctioned review leading to the recognition of the value of high-velocity, low-amplitude procedures for acute, adult low back pain, located over 10,317 articles. When articles relevant for the task were culled, 3,918 were left.
Mark Dehen, D.C.
One important reason for moving to a best practice approach and away from a “guidelines” approach is the unfortunate tendency for guidelines to be used as care end points rather than as suggestions for typical cases. Best practices documents like the Compass recognize the individuality of the patient, his or her physician and the circumstances of care.
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