November 2006

CCGPP: Personal opinion trumps scientific evidence

A firestorm continues to rage around the release of the low‑back document developed by the Council on Chiropractic Guidelines and Practice Parameters (CCGPP). More than 30 state and national organizations have demanded the withdrawal of the "best practices" draft, with many groups working hard to mobilize their members in a massive protest. So far, the CCGPP has issued no official statement about its willingness to abide by the obvious wishes of the profession and appears determined to have the document published by the Work Loss Data Institute (WLDI), a private company which markets guidelines to the insurance industry and other clients.

The controversial relationship between the CCGPP and the WLDI ‑‑ and the potential conflicts of interest arising from that relationship ‑‑ were examined in last month's Chiropractic Journal (www.worldchiropracticalliance.org/tcj/2006/oct/a.htm), where the spotlight was on the equally disturbing issue of the CCGPP's use of personal opinion and "consensus" to develop the guidelines.

In contrast to the Mercy guidelines, the CCGPP document was touted as being evidence‑based rather than the result of a consensus of personal opinions. Yet, this proved to be misleading, since CCGPP members were given the power to rely on consensus rather than evidence if they deemed the evidence insufficient. Asked what would happen if "there isn't enough evidence on a topic?" Eugene A. Lewis, DC, CCGPP chairman, stated, "Consensus will dictate the conclusion."

A close review of the document, however, shows that personal opinion and consensus took precedence even when ample scientific evidence was available.

X‑rays, traction evidence ignored

Thomas Sidoti, DC, chairman of the Association of New Jersey Chiropractors (ANJC) Literature Search Committee, pointed out several specific instances where personal opinion appeared to trump existing evidence. In a letter to CCGPP Board member Ronald J. Farabaugh, DC, he noted that the "CCGPP has not adequately responded to concerns that it utilized the lowest possible form of evidence, the Level 5 opinion of the CCGPP panel, while not considering evidence that is more highly rated as Level 2 (nonrandomized Clinical Control Trials), Level 3 (observational studies with controls), and Level 4 (observational studies without controls). Can you please explain why the opinion of the panel members was used when scientifically superior levels of evidence that are rated higher were not considered?"

Dr. Sidoti raised similar concerns in regard to the CCGPP's ratings on X‑ray and traction, stating that the "CCGPP has determined that there is no evidence to suggest there is a benefit to taking an x‑ray of an area of the spine in which, at a minimum, there is no pain or decreased range of motion. This would appear to create an obstacle for chiropractors that may have a patient present with organic or other non‑musculoskeletal dysfunctions which commonly respond well under chiropractic care. It could also pose barriers to those who wish to x‑ray asymptomatic spinal regions which may be associated with the low back problem. Chiropractors have been presented with these types of cases for over 100 years and commonly find it prudent to x‑ray the lumbar spine to determine the existence/extent of any subluxation or to rule out pathology before introducing an adjustive force into the spine. It appears from the Low Back document that this is an unsupported use of x‑ray. Can you please comment?"

On the issue of traction, he noted: "CCGPP has specifically singled out Traction as 'Not Supported by Fair Evidence from Relevant Studies.' No distinction is made between the various forms of traction such as Flexion‑Distraction, Axial/Longitudinal Traction and Extension Traction. Concern has been raised that the draft document's conclusion will therefore be utilized by third‑party payers as a basis to justify non‑payment of all traction services including decompression procedures (DRX 9000, etc.), intersegmental traction procedures (Anatamotors, etc.), manual distraction flexion/extension procedures (Cox, etc.), and various traction devices (Posture Pumps, etc.). Can you please explain why distinctions between the various forms of Traction were not made, and why numerous studies supporting these procedures were not considered in the rating?"

Donald D. Harrison, PhD, DC, MSE Originator of CBP Technique, also expressed shock that the CCGPP ignored valid research in favor of their own personal opinions. "I, personally, can question CCGPP's statement, 'delegated to examine all existing guidelines, parameters, protocols and best practices in the United States and other nations.' CBP Nonprofit has 80 published/in‑press Index Medicus research articles, but the CCGPP committee members had ZERO of these on their consideration list until I sent copies of these to Drs. Lewis and Triano in August 2004. I believe their statement should read, 'delegated to SELECTIVELY examine all existing...' Since CBP NP has 6 published Clinical Control Trials, how did they miss all 6? I can only think of one possible answer: they have a preconceived agenda of short term frequency and duration (to restrict chiropractic care) and do not want to consider any data that represents necessity for long term care."

Dr. Harrison added that "Dr. Triano refused to send my normal spinal model papers to CCGPP Committee members, stating in a letter to Dr. Lewis that these papers were 'Theoretical Foundation' papers. However, my spinal models are of two types, theoretical models AND averages of normal subjects. If one uses averages for normal blood pressure, why not averages for normal spinal position? It is obvious that the committee chairman (Triano) is selectively screening papers BEFORE any such might be given to CCGPP members."

Dr. Triano's opinion well known

The personal opinions, and agendas, of John J. Triano, DC, are well known in the profession. In an article for Chiropractic & Osteopathy (2005, 13:9), Dr. Triano stated: "A number of models are impractical, implausible or even indefensible from a purely scientific point of view (e.g., subluxation‑based healthcare), from a professional practice perspective (e.g., the primary care model), or simply from common sense (e.g. Innate Intelligence as an operational system for influencing health)."

Sidoti was one of many chiropractic leaders to point out the fact that Triano and other CCGPP members held views on chiropractic that were out of the mainstream. In his letter to Dr. Farabaugh, he stated: "Four members of the CCGPP Research Commission (Drs. John Triano, Dana Lawrence, Gert Bronfort, and Stephen Perle) along with four employees of ASH (American Specialty Health) co‑authored a paper published in 2005 entitled 'Chiropractic as spine care: a model for the profession.' This paper strikes down the basis of chiropractic as it is commonly taught and practiced by a majority of the chiropractic profession. The paper is also highly critical of various aspects of chiropractic care including x‑ray and certain models of chiropractic. The paper appears supportive of the insurance industry stance that does not support the use of various chiropractic x‑rays or chiropractic treatment for anything other than musculoskeletal conditions. It is further noted that the paper was written during the same time‑frame as the CCGPP Low Back document."

Farabaugh responded that "Simply co‑authoring an editorial paper does not constitute a conflict of interest. While the timing of the release of that paper was certainly unfortunate, it had nothing to do with CCGPP, and nothing to do with literature, ratings, or recommendations... We recognize that we may continue to disagree on this topic since there are those in our profession who feel that anyone who questions the subluxation principle is often labeled as a chiropractic heretic, unworthy of participating in anything to do with this profession. We continue to believe that a healthy debate on sensitive issues is possible, in fact probably healthy for Chiropractic. We do not feel that merely co‑authoring an editorial paper constitutes a conflict of interest."

The response did nothing to dispel doubts about Triano's ability to fairly weigh the evidence. As Sidoti noted in his reply, "CCGPP is entitled to its above stated position that, 'We [CCGPP] do not feel that merely co‑authoring an editorial paper constitutes a conflict of interest.' A large segment of the profession may, however, strongly disagree that the published paper co‑authored by Dr. Triano and members of the insurance industry is simply an 'editorial paper.' Many may believe that the Research Commission Chairman and Editor for a Low Back document that will affect all chiropractors should at the very least be an impartial individual. They may also believe that there is a conflict of interest when the Chairman and Editor has a publicly declared chiropractic viewpoint that subsequently appears in the Low Back document."

Still, regardless of whose opinions are used, the fact remains that consensus is not evidence. The National Health and Medical Research Council has made this clear, noting that "The current levels (of evidence) exclude expert opinion and consensus from an expert committee as they do not arise directly from scientific investigation."

The World Chiropractic Alliance's position paper on the CCGPP low‑back‑pain draft specifically pointed to this flaw in the CCGPP protocol, noting: "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."

Despite its willingness to discard evidence in favor of personal opinions, the CCGPP tried hard to position its guidelines as evidence‑based documents, seldom referring to its self‑granted authority to ignore evidence and substitute opinion in its place.

In an effort to distance itself from the widely rejected Mercy Guidelines, it even tried to characterize its results as "best practices" documents rather than guidelines. That pretense was made transparent, however, when its partner, the WLDI, announced its future sale of "the new chiropractic guidelines (that) will be the official guidelines of another major medical specialty group, the chiropractic professionals."

The use of personal opinions ‑‑ particularly those of a group of chiropractors so vocal in their opposition to the traditional, conservative and subluxation‑centered view of most chiropractors ‑‑ is only one of many reasons organizations are almost universally lining up to oppose the CCGPP. In future issues, The Chiropractic Journal will continue to examine other flaws and to report on the many groups joining the effort to stop the publication and marketing of the CCGPP documents.