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September 2006

What other organizations have said about the CCGPP document

The following are excerpts from position papers, responses sent to COCSA about the document, press releases and official statements. Some states made comments but have not made an official determination to reject the document.

Federation of Straight Chiropractors and Organizations

We respectfully submit that the document, in its entirety, does not reflect the position of the FSCO or the practices of our membership in any way ... It is clear that the document and the opinions it contains address only the "condition‑centered" model of practice. The practice of straight chiropractic is not condition‑centered, but rather, it is vertebral subluxation centered. The CCGPP draft does not attempt to gather and include information representing this key constituent of the profession. Since input from this segment of the profession has been ignored, the outcome is invalid.

International Chiropractors Association

The Board of Directors of the International Chiropractors Association (ICA) has called for the withdrawal of the current "Best Practices" document of The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) draft "Low Back" document." At their meeting of July 11, 2006, the ICA Board adopted an emphatic position of opposition to this divisive and highly charged issue out of a strong sense of responsibility to the doctor in the field, and out of deep sense of concern over the methodological and procedural flaws in the CCGPP process. "In order to fulfill our responsibilities to our membership and to the future of the chiropractic profession, ICA's Board of Directors had no choice but to act to oppose this latest CCGPP initiative," President Dr. John K. Maltby.

Alabama State Chiropractic Association

Format is extremely difficult to use in any practical, clinical way... This committee feels that extensive work and re‑emphasis be placed on the preface of the document so that the insurance industries and TPP's do not abuse a progressive but confusing document. We also believe that the document does not lend itself to ease of use as presently written, and would hope that with the comments already made, some re‑organization in format be undertaken before its final iteration....

Georgia Chiropractic Association

We fear the use of The American College of Radiology Guidelines on plain film radiographs for low back pain diagnostics may lead to some tremendous misunderstanding by insurers and providers as to what constitutes 'uncomplicated low back pain... The American College of Radiology guidelines are written for the medical profession, whose initial care of low back pain consist of pain pills, muscle relaxors and/or NSAIDS. Chiropractic care, although considered conservative, begins with manipulation of the spine, which does have risks along with tremendous benefit. To provide that service without properly screening the patient is unwise

Georgia Chiropractic Council

This document is symptom focused rather than condition focused. One of the underlying causes of the poor state of health of U.S. citizens is its myopic focus on eliminating symptoms rather than restoring normal function...The document seems to be more useful as a tool to substantiate third party pay for some procedures i.e. SMT, rather than a tool useful to the practicing chiropractor to help in day‑to‑day clinical decision making. There is no question that having a document that summarizes (although incompletely) available research is useful, but that doesn't make it a "best practices" document. The CCGPP Document Review Committee therefore recommends that this document be rejected until the above concerns are addressed.

Illinois Chiropractic Society

Concern was raised with the low rating of physiologic therapeutics and at times what appeared to be inconsistent interpretation of the evidence. As one respondent remarked "how can manipulation and specific exercise both be listed as 'A' " when one is "supported by good evidence from relevant studies" and one is "not supported by fair evidence from relevant studies"? The majority of the CCGPP committee was concerned with the possible use or abuse of the CCGPP summary conclusions by the insurance industry to limit coverage to only those evidence based methods that received a high rating.... We feel the document should not have been released outside of the profession prior to review.

Iowa Chiropractic Society

While this draft shows long hours and hard work by its presenters, there are many areas of concern by the doctors.... Hard work on completing a project does not mean the project is sufficient, accurate, or done. From the conclusions by the three doctors, content, organization of information, lack of field doctor's contribution, this draft is not acceptable as presented, and still needs work.

Kentucky Association of Chiropractors

While we recognize the intent of this document is to establish evidence of best practice methodologies, we fear that insurers, state governments, et. al. will use this document as guidelines. If used as guidelines, many of the commonly utilized treatment/diagnostic methods in chiropractic offices that have been given "low grades" may seriously affect many of our chiropractors' ability to provide care to their patients as they were taught in accredited chiropractic colleges as well as their ability to earn a living... We are concerned that the chiropractic profession, the major stakeholders of this document, was not afforded the opportunity to review and comment on the document prior to it being released for comment by others in the health care industry. Furthermore, the commenting process did not allow for accurate identification of the submitter allowing for non‑chiropractors to possibly identify themselves as chiropractors. ... The National Association of Chiropractic Attorneys have expressed that this document will make it more difficult for them to represent chiropractors.

Chiropractic Association of Louisiana

Based upon the committee's assessment, the Board of Directors of the Chiropractic Association of Louisiana voted unanimously to request that the document be withdrawn until the flaws contained in the document have been corrected to the satisfaction of the chiropractic profession.... The committee believes that a major shortcoming of the CCGPP document is that it cannot be applied to the specific patient. As such, it does not help with clinical decision making or establishing the need for care.

... There are no comments in the CCGPP document to clarify that the document should not be used in all cases of low back pain. There are conditions, complicating factors, age of the patient and/or patient preferences that have not been addressed. There are also no clear recommendations with regard to the need to modify care for a specific patient's complicating conditions and the likelihood that care will be extended as a result of the modified treatment procedures.

Maryland Chiropractic Association

The Maryland Chiropractic Association (MCA) formed a nine‑member committee to review and critique CCGPP Best Practices Lower Back Draft. The committee met over a number of weeks, and thoroughly reviewed and discussed the low back draft document and presented a recommendation that was unanimously passed by the MCA board calling for the withdrawal of the document....

The committee felt that the CCGPP draft document was designed and executed so poorly that it failed completely in its intended purpose. Standard guideline writing criteria (were) ignored or not addressed. Our greatest concerns were that this document will not help the patient or the clinician to improve clinical outcomes and there is a strong potential that it will be abused by third party payers, plaintiff attorneys in malpractice cases and defense attorneys in injury cases as well as by state and federal regulators....

The committee was generally disturbed by the excessive use of jargon, overly technical prose, poor organization of ideas, awkward and poor use of language. The document was almost unreadable. We felt that a document of this importance should not have been released in such shabby shape. Page and table references are inaccurate and made review difficult. Frankly, we are embarrassed for the profession at the job CCGPP did regardless of our criticisms of the design and approach taken here.

Association of New Jersey Chiropractors

It is impossible to adequately review this document in the 60 days allotted. The CCGPP document took years to produce yet contains serious flaws and omissions. The ANJC opines that it would be irresponsible to release the document prematurely as it will set precedent with insurers and regulators. ... The ANJC rejects the draft CCGPP document on best practices for low back as presented

New York Chiropractic Council

The New York Chiropractic Council has determined that the CCGPP Low Back Draft document does not reflect the manner in which our members practice, and if followed, would result in sub standard care for the patients we serve. In fact, according to national and international surveys, the document does not reflect the way most chiropractors practice in all other jurisdictions.

After careful review the New York Chiropractic Council has determined that the Low Back Draft is at best a review of the literature concerning Spinal Manipulative Therapy for lower back pain. The document does not discern whether the SMT is performed by a chiropractor and additionally does not differentiate between SMT performed by other providers and a spinal adjustment performed by a doctor of chiropractic. This Low Back draft is simply not a chiropractic document.

We, the Board of the New York Chiropractic Council take the position of NO SUPPORT in the matter of the CCGPP's recent publishing of the Low Back Draft document, as currently written. We feel for the reasons listed above that this document is unfairly critical of a large segment of the profession and will be detrimental to the practicing chiropractor and the patients we serve. We do concur with the International Chiropractors Association's Critique of the Low Back Draft along with all of their referenced data. The New York Chiropractic Council recommends that the Low Back Draft be withdrawn at this time.

Regardless of your practice style, you are at risk of being injured by the CCGPP Low Back draft.

Virginia

Was written and reviewed with team members with potential financial conflicts of interest. A hospital administrator, IMEs, even a Medical doctor worked in placing guidelines for us and our patients. Could they understand our paradigm of ADIO, let alone subluxation‑based practices which most of us manage....?

Confusion about what is "Levels of Evidence" and a complete lack of definition between this and "grades of recommendations". The authors refer to the American College of Physicians PIER program. This medical doctor ratings system is nothing like the CCGPP's rating, which is some kind of new no other researchers are aware of. The Dept. of Health and Human Services has a commonly accepted model that should be use...

Has no latitude for specific adjustment techniques. "Therapeutical practices and interventions" listed mention only HVLA manipulation. What about Cox, Thompson, CBP, Grostic, Logan, etc? This document may be used against you and your patient's care cut if you don't use the "therapeutical interventions" approved.

Wisconsin Chiropractic Association

The WCA understands the need for practice guidelines and we would enthusiastically support a document that is developed without bias and fairly represents the practice of chiropractic. However, we are very troubled by these guidelines because it appears as if the guidelines have a fatal flaw in their construction and have been co‑opted by the insurance industry and medical professions. While there may also be clinical criticisms of the guidelines, we believe the document fails the initial test of credibility and should be withdrawn....

The most damaging result will likely be the gradual elimination of reimbursement for any service that does not receive an "A" or "B" grade. After all, why should an insurer pay for something that received a "C" or "D" in a "best practices" document"? To the biased reader, the fact there is "no good evidence from relevant studies" supporting the use of modalities will be viewed as a deficiency of the chiropractic profession. In other words, the biased presumption will be that the chiropractic profession could have done this research but did not do so because it knew the results would show these services were ineffective.

The reality is far different. The vast sums of research money are directed at diseases that kill people. Cancer, heart disease, AIDS, MS, and diabetes are favorite recipients of research dollars. Philanthropic organizations are funded primarily from families of individuals who have died from these diseases. Because individuals do not die from low back pain, there is little incentive to develop supporting philanthropic organizations and even less incentive for the government to fund chiropractic research.