International Chiropractors Association Position
on the CCGPP “Best Practices” Draft

This section is maintained by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

Executive Summary

The International Chiropractors Association (ICA) formed a Presidential Commission during the Annual Board of Directors meeting in May 2006 to review, comment and make recommendations to the Board of the ICA on a position regarding The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) “Draft Low Back Best Practices Document.” The committee met numerous times via conference calls and developed drafts that were widely circulated among our membership for additional comments. A final draft was submitted to our Board of Directors for approval as the official response to the Draft Low Back Document from CCGPP.

The ICA, after a careful, deliberate and objective review and analysis of the introduction and the 1st chapter of “Chiropractic Best Practices” developed by the research commission of the Council on Chiropractic Guidelines and Practice Parameters, has determined that this document does not meet the most basic needs of the chiropractic patient or the doctor of chiropractic. The ICA finds that the proposed chapter is no more than a current review and rating of the scientific literature with all emphasis placed on the highest level of evidence available “randomized clinical trials” (RCTs) to support the general use of physical medicine modalities not unique to the chiropractic profession in response to non-specific patient conditions associated with the general patient complaint/symptom of low back pain.

The ICA holds that the major clinical concern of the doctor of chiropractic, in respect to his or her realm of specialized health care, is the detection, location, analysis, control, reduction and correction of the vertebral subluxation. While we recognize that low back pain and related symptoms are a significant economic burden to the United States and that many patients seek our service in order to alleviate symptoms, we hold that the doctor of chiropractic is concerned with correcting the cause of our patient’s problems rather than only treating the symptoms.

It is the position of the ICA that, because of the unique and non-duplicative nature of the science, art and philosophy of chiropractic, the development of any clinical guidelines, including “Best Practices”, intended for utilization within the chiropractic profession must be based upon the best available and most current research of chiropractic procedures performed by qualified doctors of chiropractic and must address the principal areas of clinical concern of chiropractors as defined and recognized world-wide.

The ICA finds that although the CCGPP limited review of the literature addresses the general use of physical medicine modalities in the treatment of general conditions frequently associated with low back pain, it does not adequately address those specific interventions that are unique to the chiropractic profession or the specific conditions most frequently seen by doctors of chiropractic, and it should be rejected in its entirety.


Summary of ICA Concerns

•   Complete Lack of “Levels of Evidence”

It is the position of the ICA that the most fundamental step in developing “Best Practices” is to follow all internationally accepted protocols for guideline development.

The Center for Evidenced Based Medicine (CEBM) describes “Levels of Evidence” as having essentially originated when Suzanne Fletcher and Dave Sackett were working for the Canadian Task Force on the Periodic Health Examination in the late 1970’s. They introduced "levels of evidence" for ranking the validity of “evidence” concerning the merit of medical procedures. They then submitted "grades of recommendations" to the advice given in the report, based upon the extent of evidence reviewed.

It is the position of the ICA that all references used for the development of chiropractic guidelines, including “Best Practices" should be reviewed for their validity as “evidence” for the merit of specific, unique chiropractic procedures and their associated outcomes. The research committee appears to have neglected this necessary step of determining levels of evidence prior to the process of rating the evidence.


•   Expert Opinion is Used as “Evidence”, But Not Case Studies

The ICA holds that the case study is extremely important in establishing Chiropractic “Best Practices”, in that a preponderance of the evidence in support of chiropractic for conditions exists at this level. It is inappropriate to omit a review of this level of evidence in the development of any form of chiropractic clinical guideline, including best practices. It is an obvious shortcoming that the lowest level of evidence, Expert Opinion (Level 5) is used by CCGPP, but they did not include higher levels of evidence, Non-randomized Control Trials or Observational Studies with and without controls. (Levels 2-4)


•   Inadequate Review of Natural History of LBP

The CCGPP draft still references the flawed study by Dixon to support a conclusion that most low back pain is self limiting and self resolving within a matter of a few weeks. The ICA holds that the resulting implication that the principle objective of chiropractic intervention is pain relief pending self resolution is fundamentally flawed and is inconsistent with all generally accepted definitions of chiropractic and its clinical focus. (WHO, WFC, ACC, ICA etc.)


•   Use of Medical Studies Applied to Chiropractic Care

The ICA recognizes that there are very few high quality, level 1 studies available to support the most common interventions traditionally used by chiropractors; while there are a plethora of level 2-4 studies detailing these interventions. It is the position of the ICA that it is inappropriate to use a preponderance of medical studies of non-chiropractic interventions to formulate best practices for chiropractic interventions.

•   Limited “Practices and Interventions Considered”

The term Spinal Manipulative Therapy, as defined by the World Health Organization “includes all procedures where the hands or mechanical devices are used to mobilize, adjust, manipulate, apply traction, massage, stimulate or otherwise influence the spine and paraspinal tissues with the aim of influencing the patient’s health.”

The ICA holds that the general description “Spinal Manipulative Therapy”, which includes a host of various and different specific interventions which may result in clinically different outcomes, is not an appropriate, clinically significant entity on which to base any set of chiropractic practice guidelines or best practices.


•   CCGPP’s X-ray Utilization Rating is Flawed

The ICA holds that the use of x-rays by the doctor of chiropractic, when clinically indicated, is common practice, used by a majority of chiropractors, necessary in diagnosis, analysis, prognostic evaluation and in the evaluation of subluxation location, correction, reduction and total spinal evaluation.

The ICA refutes the CCGPP claim that “There is insufficient evidence of clinical utility in diagnosing spinal pain syndromes in routine practice settings at this time”. The CCGPP has put forth an extremely selective and limited review of the literature on this topic. The ICA committee has referenced a large body of evidence, neglected by the CCGPP, which directly contradicts the CCGPP’s rating of X-ray.


•   CCGPP Should Not Have Been Released Until All Ratings Are Completed

The ICA strongly objects to the decision to limit consideration in this first iteration to guidelines, systematic reviews, meta-analysis, randomized controlled trials (RCT’s) and cohort studies, and to then draw conclusions from only the RCT’s, guidelines and systematic reviews The ICA strongly objects to the omission of level 2-4 evidence and the reliance on non-chiropractic studies of non-chiropractic interventions.


•   CCGPP Rated Several Procedures Incorrectly ( e.g. Surface EMG and Traction)

Despite the existence of a Meta-Analysis with favorable results for SEMG, CCGPP seems to rely on the 1993 Mercy Document as a basis for an incorrect rating. The procedure identified as “Traction”, failed to differentiate between Flexion-Distraction, Extension Traction or Axial/longitudinal Traction, also resulting in a rating that does not seem to be consistent with an objective review of the most current literature. The ICA refutes the CCGPP’s ratings for many of the procedures reviewed. The ICA committee has referenced a large body of evidence, neglected by the CCGPP, which directly contradicts many of the CCGPP ratings.


•   The First Chapter of the CCGPP Chiropractic Best Practices Should Be Rejected

The ICA stands ready to participate in a broad-based, nationwide campaign on the part of the chiropractic profession, in cooperation with any or all state chiropractic associations, to reject the recently proposed “Chiropractic Best Practices” as not representative of the nature of chiropractic as practiced in the United States.

The International Chiropractors Association is the oldest continuously existing international chiropractic organization in the world. Established in 1926 by B.J. Palmer (son of D.D. Palmer, the founder of chiropractic), the ICA represents thousands of practitioners, educators, students and lay persons dedicated to the chiropractic profession. The ICA has traditionally been an continues to be recognized as representing the moderate voice of the chiropractic profession. The ICA represents and promotes the interest of chiropractic, chiropractors and the patients they serve through advocacy, research, and education.

Throughout its long history, the ICA has sought to educate and inform the public, health care professions and health policymakers on the principles and definitions of chiropractic in order to foster a broader understanding and acceptance of theprofession. The ICA has also established standards of ethical, technical and professional excellence as guideposts for the Doctor of Chiropractic.

For More Information Contact: ICA / 1110 North Glebe Road Ste 650 / Arlington, VA USA / www.chiropractic.org / 800-423-4690

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Since 7-15-2007