October 2005

Strange bedfellows

by Dr. Christopher Kent

An article in the online journal Chiropractic & Osteopathy should be required reading for every chiropractor. If you are unfamiliar with this publication, visit http://www.chiroandosteo.com. If the mere title of the journal gives you pause, wait until you start reading the contents.

The eight authors of "Chiropractic as Spine Care: A Model for the Profession" have mapped their vision of your future. Before discussing the paper, let's look at the affiliations of the eight authors. Three are academics at chiropractic colleges. One is the Commission Chair of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP), Dr. John J. Triano. The other four are associated with American Specialty Health. [1]

American Specialty Health

According to the American Specialty Health (ASH) website, their mission is "To empower individuals to live healthier, longer lives." [2]  In practice, ASH has been severely criticized by chiropractors for policies which impose strict limitations on chiropractic care. A poll published in Dynamic Chiropractic reported that ASH led the pack in response to the question, "Which managed care organizations do you think are the most abusive to patients?" gathering more votes than all the others combined. [3]  Not surprisingly, ASH nearly tied Landmark in responses to the question, "Which managed care organization do you think is most abusive to doctors of chiropractic?" [4]

Those who have dealt with ASH know that in the credentialing process, chiropractors who use objective assessments such as SEMG, thermography, x‑ray analysis for biomechanical analysis, etc. may be screened out. Ditto those who provide long‑term wellness care. If ASH doesn't like what you're doing, you'll be given a "corrective" plan. Scary sounding terms such as "non‑compliance" and "violation" will be used to get your adrenals stimulated. If you fail to respond, or get dropped, ASH threatens to report you to regulatory agencies, including licensing boards. They even want to control how you handle non‑ASH patients. ASH appears to be focused on limiting chiropractic to short‑term, episodic care for musculoskeletal pain syndromes ‑‑ a far cry from their stated mission "To empower individuals to live healthier, longer lives."

All of this is done using ASH's concept of "professionally recognized standards." Right now, they use their own. As some providers have discovered, no amount of contrary literature seems to sway them. Ah, but wouldn't it be easier for ASH to impose its myopic view of chiropractic if it had "best practices" guidelines that were "independently" produced?

CCGPP

The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) is seeking financial support to promulgate a set of "best practices" for the profession. It has been nearly 14 years since the folks at the Congress of Chiropractic State Associations (COCSA) engineered the Mercy debacle. Those unfamiliar with Mercy are strongly encouraged to read the relevant materials on the WCA website, and the article published in the Journal of Vertebral Subluxation Research. [5,6,7]  Interestingly, more than 50% of the profession has been in practice 15 years or less. [8]  So, the same folks who brought you Mercy are re‑framing their efforts under the new moniker "best practices." Those who have not been around long enough to remember the devastating effect of Mercy may readily follow the pied pipers of CCGPP, and those who recall Mercy might believe that the old dogs have learned new tricks.

Don't be fooled by the name change. The game is the same. According to an article in Clinical Chiropractic, Dr. Eugene Lewis, CCGPP chairman, stated at the Federation of Chiropractic Licensing Boards 2004 meeting that  the CCGPP documents would be helpful for state boards to determine "overutilization." [9]

There are two ways to develop guidelines or "best practices." One is to assemble a group of experts and have them come to a consensus on how practitioners should care for patients. The other is to conduct systematic reviews and meta‑analyses of all available scientific evidence and to develop a set of recommendations based on that evidence.

The first method, consensus, is merely a way of formalizing the opinions and biases of the members of the panel. The second method is evidence‑based. It involves conducting systematic reviews and analyses of all available evidence, and to develop a set of recommendations based on that evidence.

Which method will CCGPP be using? Their web site Q and A section tells us how they plan to handle subluxation and wellness care:

"Q: What if there isn't enough evidence on a topic?

A: Consensus will dictate the conclusion.

Q: What will CCGPP say about wellness care?

A: This is an important area for our profession and will be addressed. Since there is virtually no research in this area, consensus will also be the rule." [10]

The 'Spine Care' model

Why is this a problem? See what the authors of "Chiropractic as Spine Care," including CCGPP Commission Chair Dr. Triano, have to say about subluxation‑based health care:  "A number of models are impractical, implausible, or even indefensible from a purely scientific point of view (e.g. subluxation‑based healthcare)..." As to preventive care, it is dismissed as "unproven and unlikely to be true..." They further state, "[U]ntil we can demonstrate that we are effective where others are not, the proposition of chiropractic as the 'wellness profession' is not defensible." The authors claim that, "The vast majority of human health problems that require an intervention do not fall within the chiropractic therapeutic spectrum." [1]

Other DCs are in the cross‑hairs of these zealots: "The profession is further encumbered by questionable institutionalized practices. For example, some practice consultants promote the policy of withholding treatment on the first visit, preferring to reschedule the patient for a report of findings on a subsequent visit...Others promote the use of x‑rays on nearly every patient in order to determine biomechanical deviations from a theoretical 'model' of a normal spine implying that this information is so essential to treatment that the benefit outweighs the very real risk of radiation exposure." [1]

This article is more than 50 pages long, and it would take at least as many pages to adequately address the misconceptions, misinformation, leaps of faith, and contradictions contained therein. CCGPP will likely disclaim this article, dismissing it as the personal opinions of the authors. It could be bad for business. Yet, if it expresses the opinions of the CCGPP Commission chair, who vets the evidence, the profession has cause for concern.

The position of the "Spine Care" authors is completely at odds with the mainstream of the chiropractic profession and represents the most radical medical fringe elements. According to a 2003 study on "How Chiropractors Think and Practice: The Survey of North American Chiropractors," published by the Institute for Social Research at Ohio Northern University, "For all practical purposes, there is no debate on the vertebral subluxation complex. Nearly 90% want to retain the VSC as a term. Similarly, almost 90% do not want the adjustment limited to musculoskeletal conditions. The profession ‑‑ as a whole ‑‑ presents a united front regarding the subluxation and the adjustment." [11]

Who is CCGPP accountable to?

Hold on to your hat. The short answer is "no one." The truth is skillfully buried in a list of questions and answers on the CCGPP website:

"Q: Will COCSA or some other group 'sign off' on this?"

A: No, COCSA and all of the other organizations to whom CCGPP members report have already appointed the existing representatives to find the resources to write and publish this document." [10]

What can I do?

The right thing. Decline supporting any effort involving guidelines or "best practices" until you have an opportunity to see and evaluate the product. Lend your support to the Council on Chiropractic Practice (CCP) whose guidelines development and peer‑review process was open to any interested DC. You can find out more about CCP, and download both the original document and update at no cost. [12]

References

1. http://www.chiroandosteo.com/content/13/1/9

2. http://www.ashcompanies.com/AboutUs/ASHMission.aspx

3. http://www.chiroweb.com/chiropoll/03archive/2_18_03.html

4. http://www.chiroweb.com/chiropoll/02archive/9_16_02.html

5. http://www.worldchiropracticalliance.org/positions/mercy.htm

6. http://www.worldchiropracticalliance.org/positions/mercy2.htm

7. http://www.jvsr.com/abstracts/index.asp?id=53

8. Job Analysis of Chiropractic 2005. National Board of Chiropractic Examiners. Greely, CO. 2005.

9. Harrison D: "Don's opinion." American Journal of Clinical Chiropractic 2005;15(1).

Available online at http://www.idealspine.com

10. http://www.ccgpp.org/archives/Common%20Questions%20&%20Answers.pdf

11. McDonald W, Durkin K, Iseman S, et al: "How Chiropractors Think and Practice." Institute for Social Research. Ohio Northern University. Ada, OH. 2003.

12. http://www.ccp‑guidelines.org

(Dr. Christopher Kent, president of the Council on Chiropractic Practice, is a 1973 graduate of Palmer College of Chiropractic. The WCA's  "Chiropractic Researcher of the Year" in 1994, and recipient of that honor from the ICA in 1991, he was also named ICA  "Chiropractor of the Year" in 1998. He is director of research and a co‑founder of Chiropractic Leadership Alliance. With Dr. Patrick Gentempo, Jr., Dr. Kent produces a monthly audio series,  "On Purpose," covering current events in science, politics and philosophy of vital interest to the practicing chiropractor. For subscription information call 800‑892‑6463.)