October 2006

More states join CCGPP protest

30 state groups demand withdrawal of low‑back document

Organizations from more than 30 states have called for the withdrawal of the low‑back document developed by the Council on Chiropractic Guidelines and Practice Parameters (CCGPP). No chiropractic group has yet come out in favor of the guideline draft although a few are still in the process of reviewing it and deciding on the stance they should take.

Opposition to the document has arisen across the entire spectrum of chiropractic practice, from broad‑scope to subluxation‑based. Perhaps the most troublesome flaw in the CCGPP document is the selection of research literature upon which the guidelines were supposed to be based. Instead of reviewing all available literature, the evidence reviewed was cherry picked to include just those areas of interest to the developers.

As described in an article published in the Review of General Psychology: "Selectivity in a literature review can take several forms. At worst, the author may be operating as an 'intuitive lawyer' rather than in a scientist mode, in the sense of trying to make a case for one particular position or conclusion... This could lead him or her to cover only material that fits that view and ignore the rest. The reader is therefore left unaware of material that would weaken or contradict the argument. Such an approach is at best unfortunate and sloppy, at worst intellectually dishonest." ("Writing Narrative Literature Reviews," by Roy F. Baumeister and Mark R. Leary, Review of General Psychology 1997, Vol. 1, No. 3, 311‑320)

In the case of the low‑back draft, it's clear that the selection of evidence was primarily left up to the CCGPP's Research Commission Chair, John Triano, DC, and the Work Loss Data Institute (WLDI).

The WLDI is a private, for‑profit company that markets disability guidelines and data to a variety of clients, including the insurance industry. Although the CCGPP now states that it retained the WLDI only to "publish and distribute" its documents, the WLDI's own explanation reflects a far deeper involvement. It states (http://www.disabilitydurations.com/ODG%20Treatment%20in%20Workers.htm): "In late 2002, the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) approached Work Loss Data Institute about researching and authoring treatment guidelines for the chiropractic profession." (NOTE: the WLDI has reportedly pulled several Internet documents since the beginning of the controversy concerning its involvement in the CCGPP process.)

Who picked the evidence?

In an article published in Dynamic Chiropractic,, Preston Fitzgerald, DC, called the relationship between WLDI and CCGPP a "joint development chiropractic guidelines effort" and noted that the WLDI "has previous extensive expertise with evidence‑based guidelines publications and its editorial review board expertise (sic) will research available evidence." ("The Need for Chiropractic Practice Guidelines: A Forensic Analysis," by Preston Fitzgerald, DC, Dynamic Chiropractic, May 6, 2004, emphasis added.)

Clearly, the WLDI had the job of selecting evidence to review. Dr. Fitzgerald is president and founder of the National Board of Forensic Chiropractors and served on the editorial review board of the WLDI's Official Disability Guidelines. It is assumed, therefore, that Fitzgerald was involved in the development of the ODG's exciting chiropractic guidelines, which specified the following "therapeutic" use of chiropractic:

Mild: 6 visits over 2 weeks

Severe: Trial of 6 visits over 2 weeks

Severe: With evidence of objective functional improvement, total of up to 18 visits (12 additional) over 6‑8 weeks, avoid chronicity of care

Elective care: As needed

Although lauding the WLDI's expertise in guideline issues, Fitzgerald's article contained information on chiropractic guidelines that was either deliberately misleading or demonstrated shocking ignorance of the professional guidelines.

He stated: "The only national guidelines for the chiropractic profession, the 'Mercy Guidelines,' were published in 1992 and are no longer current, and they do not have full support from many chiropractors."

While his characterization of the Mercy guidelines as obsolete and lacking support is correct, his statement that they are the only guidelines for the chiropractic profession is totally inaccurate. In fact, the Council on Chiropractic Practice's "Clinical Guideline Number 1: Vertebral Subluxation in Chiropractic Practice," first published in 1998, were accepted for inclusion in the National Guideline Clearinghouse, a comprehensive electronic database administered by the Agency for Policy and Health Care Research (AHCPR) which allows access to accepted guidelines from various health care disciplines. The Mercy Guidelines were pulled from the NGC list, leaving the CCP guidelines as the only comprehensive chiropractic document in the database.

Fitzgerald also appeared unfamiliar with existing research on chiropractic and contended that "Since 2000, I have provided editorial guidance and reviewed hundreds of scientific articles for the WLDI projects, and can categorically state that there is a paucity of scientific articles for some elements of the essential functions of the chiropractic professional's job analysis. It is my firm conviction that the collaborative efforts between the WLDI and the Council on Chiropractic Guidelines & Practice Parameters (CCGPP) will set new standards for the chiropractic profession by presenting and summarizing the highest quality, most up‑to‑date scientific studies."

Overlooking evidence

Yet, the "collaborative efforts" of the WLDI and CCGPP failed ‑‑ or refused ‑‑ to consider a substantial amount of existing evidence. Many organizations point to this basic flaw in the CCGPP development process. The Michigan Chiropractic Association, for instance, notes that "This document has used a selective database of studies which conveniently eliminated most of the chiropractic studies with visit regimes of 20 or more. Care over a few visits per condition is overutilization."

The International Chiropractors Association (ICA) took particular exception to the selective review of literature in regard to X‑ray. "The ICA refutes the CCGPP claim that 'There is insufficient evidence of clinical utility in diagnosing spinal pain syndromes in routine practice settings at this time.' The CCGPP has put forth an extremely selective and limited review of the literature on this topic. The ICA committee has referenced a large body of evidence, neglected by the CCGPP, which directly contradicts the CCGPP's rating of X‑ray." It added that "The ICA committee has referenced a large body of evidence, neglected by the CCGPP, which directly contradicts many of the CCGPP ratings."

Similarly, the World Chiropractic Alliance's position paper on the CCGPP document notes that "In one subject where a detailed review was undertaken, SEMG, CCGPP erroneously claimed that there was no new research of consequence since 1993. Our review showed this statement to be grossly in error. Similarly, the section on x‑ray is incomplete, flawed, and biased based upon our committee review. Therefore, the conclusions and recommendations are in error. If the rest of the document used incomplete, obsolete, biased literature reviews, the entire document and process is suspect."

Donald D. Harrison, PhD, DC, originator of CBP technique and publisher added his complaints to the growing criticism. In an article posted online he stated: "CBP ... 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. ... Since CBP 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 continued: "Also, 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."

Yet, the rising chorus of protests about the CCGPP may not prevent the document from being published and distributed to the insurance industry. WLDI brochures have already announced the coming availability of the document and the CCGPP has stated openly that distribution of its work is not dependent upon approval by the Congress of Chiropractic State Organizations, which initiated the effort.

Future issues of The Chiropractic Journal will examine how the CCGPP relied far more on personal opinion than on scientific evidence, criticisms about the grading system used to rate evidence, the condition‑centered paradigm reflected by the document, possible conflicts of interest among CCGPP leaders, potential misuse of the document by insurance companies and state boards, and the CCGPP's perceived arrogance as demonstrated by its refusal to listen to or be guided by input from the profession.