The CCGPP Best- Practices Chiropractic Clinical Compass takes the best research and makes it scientifically credible and useable by field doctors

Let’s begin by assessing where we currently are as a profession, because for us to grow and flourish, we must first examine where we stand, both internally and externally. Our interminable internecine battles have divided us for most of our history. We certainly don’t expect the Best Practices Chiropractic Clinical Compass from the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) to solve that problem. But we do have other problems.

In an era of explosive proliferation of scientific literature, including evidence about chiropractic care, most doctors don’t know where to begin to find answers to the questions of how best to treat patients. We have a plethora of techniques, but little means of ascertaining which ones produce the best results. We have incredibly variable treatment regimens, ranging from a “find it, fix it, and leave it alone” approach to multimonth, multivisit regimens. What works for some patients fails to produce similar results in similar patients.

The external perceptions of our inconsistent and variable care is perplexing to our patients, third-party payors, and regulators who all want answers to what is reasonable or appropriate. Visiting a new chiropractor is much like a box of chocolates: You never know what you’re going to get.

The results are sadly predictable: Distrust exists from those we serve and those who pay the bills. Battles over reimbursement for our services are on the rise, and devaluation of our services is increasing.

Tools To Fight Back
Several years ago, the Congress of Chiropractic State Associations, (COCSA), representing state associations of all stripes, along with nearly every other major US chiropractic organization, commissioned the CCCGPP to address this problem. We were asked to begin to develop tools the profession could use to collect and interpret the relevant evidence for what we most commonly do, and find a way to make it scientifically credible, defensible, and readily useable by field doctors. It had to be able to overcome already-existing guidelines developed by nonchiropractors to curb care, but not significantly limit typical mainstream care.

This is a tall order to fill, indeed, and one that will take great effort and a significant investment in time, talent, and money.

Best Practices: The Process
That process, the development of the chiropractic “Best Practices,” has been under way for several years now, and the very first plank in the bridge to that reality has been laid. The CCGPP Research Commission determined that the first step was to survey the profession to determine what most of us do and how. That has been accomplished. The next step is to collect the available scientific evidence, filter it through a chiropractic perspective, and organize it in a meaningful way. The first chapter in that effort, a review of the literature on low back-related conditions, was recently issued in draft form.

To fulfill the requirement for external validity, and to avoid the appearance of a self-serving tract, it was necessary to follow previously established, scientifically rigorous, and defensible guidelines. The international community has relied on a collection of such requirements, termed the AGREE document (Appraisal of Guidelines for Research and Evaluation), to guide just this sort of effort. CCGPP is making every effort to comply with those criteria, and other guidelines inside and outside the profession that have failed to adhere to them have lost credibility and validity as a result.

We determined to look at the most common conditions seen by chiropractors as enumerated in the professionwide survey we previously undertook. Those include low-back pain and related conditions, neck pain, thoracic spine conditions, upper- and lower-extremity conditions, soft-tissue complaints, wellness and maintenance, and the care of pediatric and geriatric populations. The list is not exhaustive; we intend to visit other conditions, treatments, and approaches in the future. For now, this is where we start.

We Want Feedback
The low-back draft, as noted, was recently released, and we asked the profession and its many organizations to review the work we had done—not to ask for an endorsement, but to determine whether we had complied with the process we laid out and whether we had missed any relevant research.

It must be understood that while there is a significant body of research validating many of our most common approaches—particularly manipulation, advice, and exercise—research is often contradictory, equivocal, or simply missing. Some research isn’t worth the paper it is written on, while other research is excellent and compelling. To make sense of it, one must apply criteria to the research, in terms of both the type of study and the quality. That means ranking the research, in this case using an A-B-C-D scale. Where the research is unclear, widely used consensus methodology was adopted to fill in the blanks with a chiropractic orientation.

The remaining chapters will follow a similar course, but represent only the first step in the process. The library of information must then be transformed into tools that the average DC can use in his or her office. That will involve developing seminars, online interactive tools, search strategies, and more. You will be able to go online and search for a specific condition, collect relevant literature to support your treatment for a specific patient, review options with patients, and set realistic goals.

A New Vision
Consider the following scenario: You have a patient with a low-back condition to which you have applied your usual treatment strategies, without resolution. Rather than simply referring him out, or continuing to do what is clearly not working, imagine being able to log on to the Chiropractic Compass to look for help. Information you can rely on will indicate which treatment approaches have the most evidence of success. Which combinations of approaches work best? What sort of benchmarks should you expect to see in your care? Imagine patients being able to access similar information to see what they should expect—this is another intent of this document.

Remember your chiropractic college days in the clinic? A patient with a particular condition would present, and you might have no idea how to proceed. What exams should you do? What co-morbid factors should be considered? What treatment approaches should you try first, and when should you expect to see some improvement? If that doesn’t work, what next? Wouldn’t it be useful to have some consistency in training for chiropractic students, and some measure of uniformity in what the public could expect when seeking our services?

Imagine a scenario in which most chiropractors approached similar problems with similar interventions, and that over time we as a profession could refine those approaches to provide our patients with the most clinical and cost-effective care? That is the process we have begun.

Only the Beginning
This is simply a beginning. CCGPP is committed, as a permanent organization, to reviewing each chapter every 2 years to capture new research or to refine consensus.  We are also pledged to aggressively fight abuses of the document by others who might seek to use it to curtail care. If we discover insurance carriers inappropriately using guidelines to deny care, we expect to have the tools to fight them on your behalf, with the credibility and resources to stand up to them.

Accomplishing this goal will take time, effort, support, and money. It will mean adhering to standards for what is considered “good” quality research, and at times that will mean that popular but less rigorous research may not be included. Some of our sacred cows may be gored. But it will also mean that the playing field will be leveled.  Insurance companies that use private treatment guidelines to cut care can be challenged with more rigorous research. Auto carriers will no longer be able to deny reasonable treatment approaches for our patients with real “soft-tissue” injuries.

How Will This Work?
The intent of the Compass is to provide doctors and others with a hierarchy of evidence for the conditions we commonly see. Where good evidence exists, we start there and try to use what works. However, this is no cookbook approach. Readers won’t find “chiropractic by the numbers” in our document. Each patient is unique and deserves unique consideration. You will find help in deciding what exams work best and how to identify and document co-morbid and complicating factors. Those findings may influence treatment choices that may vary from the more typical approach, but with a rationale.

Evidence and Value-Based Care
With traditional guidelines, variances from the norm are usually denied. We have all experienced this. Traditional guidelines rely on scientific evidence to the exclusion of most other factors. That’s why the rest of the provider world has been moving away from “guidelines” toward a three-pronged approach: the synthesis of evidence with physician experience and knowledge, and the preferences and goals of the patient. That approach is termed “evidence-based care” or “evidence-informed practice.”

CCGPP is incorporating these concepts in our Best Practices Chiropractic Clinical Compass. As noted, when traditional guidelines are imposed, research alone usually dictates care. With evidence-based care, and the CCGPP Chiropractic Clinical Compass, when evidence is lacking or inconclusive, physician knowledge and patient preference trump other information. And that can only benefit our patients and our profession.

For more information on contributing to this historic chiropractic initiative, please visit www.ccgpp.org.

Wayne M. Whalen, DC, DACAN, is chair of the Council on Chiropractic Guidelines & Practice Parameters (CCGPP). Contact him at DrWWhalen@aol.com or (619) 258-1144.