It's time to ask questions about the CCGPP

by Dr. Terry A. Rondberg

The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) has been soliciting contributions from chiropractic organizations to develop "best practices" guidelines. They have recently been approaching state associations for funding. The World Chiropractic Alliance is very concerned about the potential negative impact such guidelines may have on the profession.

As part of its strategy to establish these "best practices" guidelines as the only viable chiropractic guidelines, I believe the CCGPP will probably try to discredit the Council on Chiropractic Practice (CCP), referring to a 2001 JMPT study by a JR Cates. They will probably ignore Dr. Kent's response, which was also published in JMPT. Please read the original articles online to review both items (www2.us.elsevierhealth.com/scripts/om.dll/serve?article=a118987&nav=full)

The CCGPP will undoubtedly claim it isn't the same old "Mercy" group, but a new guidelines group. If that's so, why are so many of the same "scientists" involved? Why are prominent subluxation‑centered teachers, authors, technique developers, and researchers once again absent?

Here are a few of the questions we need to ask:

1. We have excellent guidelines for vertebral subluxation, produced by CCP, which have been accepted for inclusion in the National Guidelines Clearinghouse. These were produced without one cent from any state association. Why should the profession pay CCGPP to develop others? They can't (or shouldn't!) bring up the Cates "study" ‑‑ that "study" was flawed.

2. This appears to be a COCSA/ACA initiative. What provisions have been made to ensure balanced representation of the subluxation‑based community? Why are so many of the people who produced the flawed Mercy guidelines involved?

3. Why isn't this being backed by the Chiropractic Coalition?

4. What safeguards are planned to prevent these guidelines from being used to cut claims by third party payers?

5. Mercy was based on consensus (opinion). Where is their solid, scientific evidence that addresses frequency and duration of care? For example, the Mercy guidelines state that an adequate trial of treatment/care is as follows: "A course of two weeks each of two different types of manual procedures (four weeks total) after which, in the absence of documented improvement, manual procedures are no longer indicated." A nearly identical recommendation may be found in a 1991 RAND Corporation publication.

This is an example of an opinion masquerading as an evidence‑based recommendation. Shekelle acknowledged that "There exists almost no data to support or refute these values for treatment frequency and duration, and they should be regarded as reflecting the personal opinions of these nine particular panelists." Unfortunately, such candor was not evident in the Mercy guidelines.

6. It has been said that there is a "demand" for guidelines for NMS conditions. Who demanded them? Can you name one agency outside of the profession that has made such a demand?

7. Will these guidelines be used by state boards to attack DC's who offer lifetime, subluxation‑based wellness care?

8. Will there be open forums where any interested DC can present evidence?

9. The Mercy conference participants didn't followed their own rules, and rated procedures "established" in the absence of Class I evidence on over 20 occasions. What assurances do we have that this is not just another pricey boondoggle?

10. Will any chiropractor who wishes be permitted to participate in the peer review process?

11. Will the deliberations be open, or subject to secrecy like Mercy?

12. Show us a detailed budget. Can't most of this be accomplished with volunteer help, as was the case with CCP and ICA guidelines?

13. Other than claim cutters, who will benefit from these guidelines?

14. What if the result is not satisfactory to us?

The latest strategy of the medipractor "pied pipers" is the development of practice guidelines. To promulgate such guidelines, they convened the "Mercy Center Conference" and promoted it as adequately representing all factions within the chiropractic profession. Of the 35 participants, the vast majority represented the "disease treatment" paradigm. The ICA had only a few voting participants. The SCASA faction had but one. With such an overwhelming imbalance, how could one hope to produce a document which adequately represented the interests of subluxation‑based chiropractic?

Why wasn't a single ICA radiologist on the panel, when the ACA had many? Why weren't the research directors of the two largest chiropractic colleges in the world present? Why wasn't the ICA researcher of the year invited to participate, when the ACA research arm was more than adequately represented? Why did the ICA and SCASA even agree to participate given such an overwhelming imbalance of votes?

The structure of the conference was designed to suppress dissent. Participants were carefully selected. Observers were prohibited from attending committee meetings, even in a passive, non‑speaking capacity. What did they have to hide?

Recorders were forbidden. Why? Definitions and reviews of literature were not even open to debate. Only recommendations were debated and voted upon, and time was limited. Why? Only official observers and participants were allowed to attend. Why not any DC? And why not let any DC participate in free and open debate? The framers of this debacle may claim the reasons were time and space constraints. But with issues this important, couldn't these concerns have been overcome?

The highly biased, incomplete reviews of literature concerning subluxation‑based instrumentation, such as surface EMG and thermocouple instruments, could not be challenged. Yet many participants relied on these reviews, and the biases of their authors, to form decisions.

The most ridiculous part of the conference dealt with complications. Participants voted on the probability of complications arising from given conditions. How can the incidence of adverse reactions be voted upon? Either you have the data or you don't! Guessing at numbers based upon conjecture and an occasional case report is absurd. The very people who discount favorable case reports seemed more than willing to draw sweeping conclusions from negative case reports.

The profession has been sold yet another "bill of goods" by a group of individuals who expect their document to be accepted without question. There are no provisions for revising it. The field is expected to embrace it without question. If the profession does accept the jurisdiction of this document, subluxation‑based chiropractic will suffer.

Coincidence or Conspiracy?

Are these events mere coincidence, or is there an organized conspiracy to make chiropractic a subset of allopathic medicine? You the reader must decide.

Sociologist Walter Wardwell in his chapter, "Present and future role of The Chiropractor" in Haldeman's "Modern Developments in the Principles and Practice of Chiropractic," argues for chiropractors becoming "limited medical practitioners." He mentions such professions as dentistry, optometry, podiatry, and psychology, observing that "they do not challenge medicine's basic theories of disease and therapy." Why should chiropractic follow suit? Wardwell lists the following:

1. Chiropractors in fact devote most of their time to the alleviation of neuromusculoskeletal symptoms.

2. These conditions are the kinds that the public believes that chiropractors can treat best.

3. It is for such conditions that physicians and other providers are most likely to refer patients to chiropractors.

4. Third party payers are most willing to reimburse chiropractors for treating such conditions.

5. There is a more obvious and direct relationship between chiropractic adjustments and such conditions.

6. If a chiropractor is especially cautious or concerned about his image, it is no doubt safer for him to restrict his practice to neuromusculoskeletal conditions than to attempt to treat systemic conditions or those involving internal organs.

In short, if we sell out our principle, and reinforce the inaccurate and limited perspective we have allowed to develop in the minds of the public, it will be easier to milk the insurance cow!

What price would we pay for taking such a course? Rather than consider the loss to the chiropractor, consider the loss to humanity.

How many infants will die needlessly from SIDS because of atlantooccipital subluxations? How many children will develop chronic diseases because of subluxations? How many unnecessary antibiotics will be prescribed, and what will be the ecological impact of such indiscriminate therapy? How many surgeries will be performed that could be avoided? How many families will remain childless because a parent has a subluxation preventing conception?

How many people will be unable to fully express their genetic potential because of subluxation? And how will this interference affect them on a psychological and emotional level? How will it affect their relationships with others? How will it affect society as a whole?

Principles or politics?

The fundamental issues are simple. Are we a profession with a clearly defined mission, or are we a profession simply seeking some niche which offers access to a slice of the health care pie? Are we driven by principles or politics?

In discussing the diversity of individuals in the profession, B.J. Palmer stated, "When it comes to Chiropractic we are agreed upon Innate, subluxation, and adjustment. Chiropractic overshadows dissolution and procedures union." He was aware that unity would occur when chiropractors were driven by principles.

He was equally aware of the other faction. B.J. explained, "They had no one agreed understanding on philosophy, science, and art. They had one dollar god before them, regardless of what damage was done the sick who were searching health. This heterogeneous mass had no goal. There was no fundamental upon which they could join hands. Posterity was measured in terms of dollars to them today. They agree upon two things: money and disgrace!"

The solutions to our situation are simple. We must realize that our hard‑won political victories were achieved because our forebears were driven by a desire to bring chiropractic to the people. Despite their political differences, they were one in their zeal to get chiropractic's unique contribution to humanity as widely disseminated as possible. They may have differed on scope of practice issues, but were united by a common denominator ‑‑ correction of vertebral subluxations.

They also embraced a vision of chiropractic care influencing the entire body. They did not confine their services to patients with musculoskeletal problems. Differences between the allopathic approach and the chiropractic approach to health problems were accentuated. Yes, our predecessors knew that chiropractic offered something medicine did not ‑‑ a separate, distinct, non‑duplicating health service.

The big question for them: Are you driven by principles or politics?

I discourage any organization or individual from supporting CCGPP efforts to create "Best Practices/Mercy II."