The World Chiropractic Alliance
Position Paper on
CCGPP "Low Back Best Practices" Document

The World Chiropractic Alliance (WCA), after careful review of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) “Low Back Best Practices” draft, has adopted the following position statement:
 
This document does not reflect the position of the WCA concerning the practice of chiropractic.  The WCA embraces the Chiropractic Paradigm promulgated by the Association of Chiropractic Colleges (ACC) which holds that:

Chiropractic is Concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.

A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.

A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available rational and empirical evidence.

We question the appropriateness of the CCGPP process for determining chiropractic “best practices.”  The CCGPP approach defines “best practices” in terms of diagnostic and treatment protocols for musculoskeletal pain syndromes.  It does not address the analysis and adjustment of vertebral subluxations as a practice objective distinct from the treatment of a medical condition.

WCA has other concerns regarding this document:

1. Chiropractic practice focuses on the unique needs and characteristics of individual patients, and acknowledges the diversity of chiropractic techniques.  Randomized Clinical Trials (RCTs) look at groups of patients with certain common characteristics.  They cannot predict how a given clinical approach will affect an individual patient.   The CCGPP document exhibits over reliance on RCTs to the exclusion of case studies and other valuable evidence.  Furthermore, consensus is used as a substitute for evidence.  The WCA holds that in the absence of evidence, and one must resort to opinion, the opinion that should prevail is the opinion of the attending chiropractor.

2. It is impossible to adequately review this document in the 60 days provided.  This document took years to produce, yet has serious flaws.  It would be irresponsible to release it prematurely.  It will set precedent with insurers and regulators.

3. The section on diagnostics is incomplete, dated, and biased.  In one subject where a detailed review was undertaken, SEMG, CCGPP erroneously claimed that there was no new research of consequence since 1993.  Our review showed this statement to be grossly in error.  Similarly, the section on x-ray is incomplete, flawed, and biased based upon our committee review.  Therefore, the conclusions and recommendations are in error.  If the rest of the document used incomplete, obsolete, biased literature reviews, the entire document and process is suspect.

 4. The document relies heavily on Mercy, a flawed document 13 years old, and generally rejected by the practitioner community.

5. All “manipulative” procedures are lumped together.  There is no distinction made between manipulation and chiropractic adjustment.  Adjusting techniques vary widely.  To suggest that Diversified, Logan Basic, Activator, CMRT, SOT blocking, etc. can be homogenized under the term “manipulation” is ridiculous.  Any review purporting to assess an adjusting method must carefully describe and detail each method, or it is meaningless. 

6. The document uses the term subluxation, but includes no operational definition.

An evidence-based alternative to the CCGPP approach is using objective clinical outcomes assessments to determine the appropriateness of care.  As others have noted, a clinician can document improvement in function and quality-of-life.  How one achieves such improvement varies from individual to individual.  We have all had cases where a patient who failed to respond to one technique enjoyed a favorable outcome when a different technique was employed. 

In addition, there are conflict-of-interest issues with CCGPP which are of grave concern.  It is obvious that CCGPP wishes to get third party payors and regulatory agencies to use this document.  This could affect the very culture of the profession and have a chilling effect on practice and income.

WCA feels that the CCGPP Low Back Best Practices draft is methodologically flawed and poorly executed. It is does not reflect the practice objectives of analysis, adjustment, and management of vertebral subluxation.  The literature reviews are dated, biased, and incomplete.  WCA urges individual chiropractors and chiropractic organizations to reject this document, and request that CCGPP terminate their “best practices” project. 

WCA enthusiastically supports the development of evidence-based clinical practice guidelines that are congruent with the practice objective of analysis and adjustment of vertebral subluxations to achieve optimum function and quality-of-life.

-- unanimously passed by the WCA Board of Directors, July 2006