In the past five years, I have reviewed 350 cases and testified on 70 occasions, mostly on behalf of plaintiffs. I have seen every conceivable attack on chiropractic that the insurance companies could hurl.

One of the best weapons available to blunt these attacks is the Council on Chiropractic Practice's (CCP) "Clinical Guideline Number One Vertebral Subluxation in Chiropractic Practice."

Yet few doctors actually cite these guidelines when they explain why the care they rendered was reasonable and necessary.

Researchers many years ago found that doctors in different parts of the country practiced in widely differing ways. For example, the chance of getting a particular medical procedure in Los Angeles might be far greater than in Boston.

Experts concluded that either Los Angeles patients were being overtreated or Boston patients were being undertreated. They felt there was a need for nationwide guidelines so that patients would receive the right amount of care.

When doctors practice according to guidelines, it is far more difficult for insurers to claim that chiropractic care was excessive. No longer must you solely rely upon: "It is my clinical judgment that the patient needed X number of adjustments." You now can cite a professional guideline to support your position.

In court, insurers almost inevitably will declare that the CCP guidelines are neither "recognized" nor reliable.

The first objection is easily overcome by explaining that the CCP guidelines have been accepted by the National Guideline Clearinghouse (NGC) found on the Internet at http://www.guideline.gov/index.asp. In fact, the CCP Guideline is the only such document listed by NGC.

The NGC is "a public resource for evidence-based clinical practice guidelines. NGC is sponsored by the Agency for Healthcare Research and Quality (AHRQ) (formerly the Agency for Health Care Policy and Research [AHCPR]) in partnership with the American Medical Association and the American Association of Health Plans."

While the NCG does not state that the listed guidelines are scientifically perfect, inclusion of the CCP guidelines on the list means they deserve the same recognition as other included guidelines which address nearly every system in the body.

The accusation that the CCP Guideline is unreliable can be just as easily refuted. A review of the list of contributors, and their credentials, will convince any objective, unbiased person (such as a juror) that the guidelines are reliable and reflect modern chiropractic practice.

Most states license chiropractors primarily to correct spinal subluxations with spinal adjustments. Therefore, doctors should focus on subluxations in their reports. The CCP Guideline states: "Since the duration of care for correction of vertebral subluxation is patient specific, frequency of visits should be based upon the reduction and eventual resolution of indicators of vertebral subluxation." (P. 83)

The CCP Guideline does not solely address frequency of spinal adjustments. It also addresses examination procedures such as postural analysis, inclinometry, and surface EMG. You should carefully review a summary of the Guideline on the NCG website under the section "Musculoskeletal Diseases," or download a free copy of the entire guideline from the World Chiropractic Alliance website at www.worldchiropracticalliance.org (listed under "Quick Links" on the left hand navigation bar)

The CCP Guideline covers numerous procedures used to check for vertebral subluxation, including palpation, range of motion, postural analysis muscle strength testing, orthopedic/neurological tests, quality of life assessment instruments. If the case history and the chiropractic analysis reveal the presence of indicators of subluxation, it is both reasonable and necessary for you to provide an adjustment, according to the Guideline.

A typical argument made by a medical doctor regarding the CCP Guideline is that the Guideline was drafted exclusively by chiropractors and for chiropractors.

An effective response is: "Who do you think should write guidelines for medical doctors? If chiropractors cannot write their own professional guidelines then neither can medical doctors."

However, it is useful to also explain that the CCP Guideline was written by a multidisciplinary team, not just chiropractors.

Another defensive tactic I employ is to go on the offense. "Did you know, doctor, that according to the New England Journal of Medicine, non-steroidal anti-inflammatory medications killed almost as many Americans in 1997 as did AIDS (16,500 versus 16,686)? If deaths from NSAIDs were tabulated separately in National Vital Statistics reports, NSAIDs would be the 15th most common cause of death in the U.S. Yet these toxic effects remain largely a 'silent epidemic,' with many physicians and most patients unaware of the magnitude of the problem." (NEJM, June 17, 1999, pp. 1888-1899.)

Given these facts, it is the rare juror who will not agree that safety considerations require that chiropractic be used before NSAIDs are considered.

Armed with the CCP Guidelines, you are ready to fight those who would say that your spinal adjustments were excessive or unnecessary.

The CCP Guideline states that a chiropractor must adjust a subluxation until all indicators of subluxation are gone.

Recognition of the Guideline by the NCG, coupled with the impressive credentials of the contributors make for powerful arguments.

It is not necessary to capitulate to those who harshly criticize chiropractic care that you know was reasonable and necessary. If you use all of the weapons in your arsenal -- including the CCP Guideline -- you can win.