One of the several problems with the CCGPP low-back document is that it will restrict cases you may treat

The “Best Practices: Chiropractic Management of Low Back Pain and Low Back Related Leg Complaints” guidelines from the research commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) will be used by third parties to reduce, restrict, and deny services to chiropractic patients and place them into a no-win situation.

Our concerns mirror the concerns of the International Chiropractors Association. After carefully reviewing the document, the Michigan Chiropractic Association (MCA) has voted to reject the draft for several reasons.

A List of Concerns
1) This document was written and reviewed by team members with potential financial conflicts of interest. A hospital administrator, independent medical examiners, and even a medical doctor worked in placing guidelines for us and our patients. Could they understand our inside-out paradigm, let alone subluxation-based practices that most of us manage?

2) There is confusion about what “levels of evidence” are, and the document completely lacks a definition between this and “grades of recommendations.” The authors refer to the American College of Physicians PIER program. This medical doctor ratings system is nothing like the CCGPP’s rating, which is some kind of new system no other researchers are aware of. The US Department of Health and Human Services has a commonly accepted model that should be used.

3) The document does not rate case studies as evidence. This means 90% of chiropractic evidence is not even considered. We are not privy to the billions given to the National Institutes of Health or pharmaceutical conglomerates, so anecdotal and case-study research should be used.

4) The document contains no suggestion of frequency and duration of care. We must assume that a “per condition” (pain) spinal adjustment is only necessary subjectively. This document has used a selective database of studies with visit regimes of 20 or more. Care plans that are more than six to 10 visits may be considered overutilization.

5) This document has a flawed understanding of low back pain’s natural history. Research cited from a 1973 study by Dixon used a retrospective study of one doctor’s records to label patients who did not return for care as 90% recovery of acute low back pain. What an assumption!

6) This document has medical studies applied to chiropractic care. Does pharmacological and surgical care have the same outcome goal as our spinal rehabilitation adjustments?

7) This document has targeted an audience of seven groups: four are chiropractic groups, one is patients, and the other two are third-party payors and government agencies. What are insurance companies and bureaucrats doing helping to form clinical guidelines?

8) This document has no latitude for specific adjustment techniques. “Therapeutical practices and interventions” listed mention only high-velocity, low-amplitude (HVLA) manipulation. What about techniques such as Cox, Thompson, chiropractic biophysics, Grostic, and Logan? This document may be used against you and your patient’s care plan if you don’t use the “therapeutical interventions” approved.

9) This document will restrict cases you may treat. Do all of our patients fit the low back pain or leg pain model? What if you are faced with pelvic or abdomen dysfunction in a patient from subluxation of the sacrum? You may now have to answer to a board review or a judge for malpractice.

Perpetuating a Bias?
10) This document states, “Full spine plain film X-ray, plain film X-ray, and video fluoroscopy is not supported for routine screening or diagnosis of pathological conditions” or “not supported for initial screening of uncomplicated low back pain.” Is that what chiropractic colleges now teach?

We believe an ill-advised agenda is at work. Some of these “researchers” may be perpetuating a bias for insurance companies and government agencies that don’t want to pay for exams and x-rays. We have fought for years to get x-ray privileges in all states and provinces, and it should always rest on the attending doctor as to what diagnostics are appropriate. CCGPP is using selective literature review for its evidence. A superficial review from PubMed, Mantis, and Cinahl found plenty of utility for full-spine x-ray, plain-film x-ray, and video fluoroscopy—157 references, in fact.

Again, no case studies are reviewed by this document, and the opinions of the “researchers” of clinical utility stand alone as evidence. They also say radiographic measurements of leg-length inequality (LLI) have not been studied for validity. In fact, PubMed lists more than 30 studies. One study shows x-ray evaluation of LLI is the most accurate method. Another shows the correction of LLI with correctly sized heel lifts will prevent future lumbar degeneration, stress fractures, and, naturally, low back pain.

11) The quality and the interpretations of studies quoted in the guidelines are suspect.

12) This document has surface electromyography (SEMG) and traction incorrectly rated according to studies recently published. Again they cite Mercy, 1993 and another 1994 study. Plenty of new peer-reviewed work is available and is of higher quality than any quoted in this document.

13) This document has a treatment method of “referral/co-management.” How many more people will fail from inappropriate medical spinal care in these cases? Of course, if we identify something out of our scope we will refer—but is that treatment?

Sam Caruso, DC, is president of the Michigan Chiropractic Asso­ciation. Contact him at (248) 693-4800 or chirosam@sbcglobal.net.