Lord Edward Herbert is known for saying "God's mill grinds slow but sure." This quote is quite apropos to the events revolving around the development and acceptance of chiropractic guidelines which support subluxation-centered practice.

On March 11, 1999 the Washington State Chiropractic Quality Assurance Commission (CQAC) voted in favor of issuing an interpretative statement in support of the Council on Chiropractic Practice's (CCP's) "Clinical Guideline #1: Vertebral Subluxation in Chiropractic Practice." The CQAC felt that the "Guideline" outlined an acceptable standard of care for the practice of chiropractic in Washington.

The crux of the matter in that state is that the CQAC was not interpreting the adoption of the CCP "Guideline" to mean that this was the only way to practice, just that it was an acceptable way to practice.

It seems the tables had been turned on the Mercy crowd and any thought that they would have to abide by a subluxation-based document sent chills up their spines. Remarkably, the questions and concerns revolved around issues that had nothing to do with quality of patient care but had to do with third party concerns, IMEs, worker's compensation, etc.

I had the opportunity to represent the CCP at this CQAC meeting to discuss any questions and/or concerns they had about the document. I was particularly intrigued by the two dissenting votes that were cast.

In an example of sandbox politics one of the dissenting votes had to do with a Board member's opinion that the "author" of the document is not liked. I wanted to tell him to take his pail and shovel and go home but instead pointed out that the document has more than one author.

The other dissenter openly acknowledged that he performed IMEs and was concerned about how the document would affect him and others of his ilk should it be adopted. His concerns didn't get much air time from the rest of the Board. So, despite these concerns by just two members, the CQAC voted in favor of the CCP document.

However, it didn't end there.

The Washington State Chiropractic Association started receiving calls with "concerns" about the CCP document. The CQAC also received a few phone calls from various IME doctors who were worried about the impact this would have on their livelihood.

There were three main concerns that the Association received regarding the adoption of the CCP "Guideline." Even a cursory reading of them reveals that they could only be the concerns of those who make a living cutting other chiropractors' claims. Clearly, they were not the concerns of the average practicing chiropractor in the state of Washington.

It was interesting to see an e-mail spread around that discussed these concerns since many of the names on it were chiropractors who routinely perform insurance exams.

One worry was that there were no limitations on care in the CCP "Guideline." Besides the obvious fact that one doesn't routinely see chiropractors begging to have more limitations and restrictions placed between them and their patients, let's discuss reality.

The CCP "Guideline" clearly outlines that signs and indicators of subluxation are the way to measure accountability. The CCP document's basis is that patients who exhibit signs and indicators of subluxation, regardless of their condition, are entitled to care directed at reducing those subluxations.

The need for an adjustment or for ongoing care is based on objective signs of functional and structural improvement, as well as changes in the indicators for subluxation.

The most important difference between the conclusions in documents such as Mercy, the AHCPR low back guides and what is contained in the CCP document is the CCP "Guideline's" allowance for the care of an asymptomatic/symptomatic patient as long as he or she is showing signs of subluxation.

There was also an allegation that there weren't any controlled studies in the CCP document. This is patently untrue. There are recommendations/conclusions in the document which are indeed based on controlled studies.

I need only point to the section concerning "Surface Electromyography." But more important, the idea that controlled studies are necessary in the first place to make recommendations is in direct conflict with the dictates of the AHCPR and researchers like Sackett et al.

Pertinent AHCPR literature which is used to create guideline documents was reviewed and utilized in the development of the CCP document and the discussion of the "best available evidence" is contained in those documents. Apparently, the AHCPR was not concerned about the number of controlled studies since the CCP "Guideline" has been accepted by them.

The last concern had to do with the CCP's recommendations regarding duration of care and that, since the duration of care is based on the reduction of subluxation and not the treatment of symptoms or syndromes, this would somehow lead to third parties restricting care.

Huh?

This amounts to doublespeak and as stated, the CCP document features subluxation guidelines. If a patient exhibits signs of a subluxation and the chiropractor documents those signs, then an adjustment is justified. The need for chiropractic intervention is not based on symptoms alone, but rather on the presence of a subluxation on that particular day, in that particular patient.

In addition the CCP "Guideline" states:

"Treatment protocols and duration of care for these conditions are addressed in other guidelines, which may be appropriate for any practitioner whose clinical interests include alleviation of such conditions."

I want to make something very clear to everyone. The CCP "Guideline" is a consumer-based and practitioner-based document which protects the individual relationship between a patient and his or her chiropractor. This is inherent in the mission statement of the CCP. It is NOT an insurance-based document.

The concerns expressed by the few who contacted the Washington Association and the CQAC are clearly not concerns of the average practicing chiropractor but are concerns with what third parties will say and, thus, can only be the concerns of those working for or within the insurance industry.

One of the CQAC Board members made the comment that chiropractors have basically been carrying on in an impotent fashion and letting the insurance industry and IME doctors determine the standard of care for them. She remarked that this is an opportunity to take back our autonomy.

Amen!