Introduction Introduction and Methodology
The Council on Chiropractic PracticeIn the summer of 1995, chiropractic history was made in Phoenix, Arizona with the formation of the Council on Chiropractic Practice (CCP). The meeting was attended by an interdisciplinary assembly of distinguished chiropractors, medical physicians, basic scientists, attorneys, and consumer representatives.
The CCP is an apolitical, non-profit organization. It is not affiliated with any other chiropractic association. The CCP represents a grass-roots movement to produce practice guidelines which serve the needs of the consumer, and are consistent with "real world" chiropractic practice.
The mission of the CCP is "To develop evidence-based guidelines, conduct research and perform other functions that will enhance the practice of chiropractic for the benefit of the consumer."
Evidence-Based PracticeEvidence-based clinical practice is defined as "The conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients... (it) is not restricted to randomized trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions." (1)
This concept was embraced by the Association of Chiropractic Colleges in its first position paper. This paper stated:
Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.
A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.
A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available rational and empirical evidence. (2)
The CCP has developed practice guidelines for vertebral subluxation with the active participation of field doctors, consultants, seminar leaders, and technique experts. In addition, the Council has utilized the services of interdisciplinary experts in the Agency for Health Care Policy and Research (AHCPR) guidelines development, research design, literature review, law, clinical assessment, and clinical chiropractic.
Guidelines Development ProcessIn harmony with these general principles, the CCP has created a multidisciplinary panel, supported by staff, and led by a project director. The guidelines were produced with input from methodologists familiar with guidelines development.
The first endeavor of the panel was to analyze available scientific evidence revolving around a model which depicts the safest and most efficacious delivery of chiropractic care to the consumer. A contingent of panelists, chosen for their respective skills, directed the critical review of numerous studies and other evidence.
Since the guidelines process is one of continuing evolution, new evidence will be considered at periodic meetings to update the model of care defined by the guidelines.
The panel gathered in a second meeting to interview technique developers to ascertain the degree to which their procedures can be expressed in an evidence-based format. Individuals representing over thirty-five named techniques participated. Others made written submissions to the panel. The technique developers presented the best available evidence they had to substantiate their protocols and assessment methods.
A primary goal of the panel is to stimulate and encourage field practitioners to adapt their practices to improve patient outcomes. To achieve this objective, it was necessary to involve as many practitioners as possible in the development of workable guidelines.
Consistent with the recommendations of AHCPR, an "open forum" was held where any interested individual could participate. Practitioners offered their opinions and insights in regard to the progress of the panel. Field practitioners who were unable to attend the "open forum" session were encouraged to make written submissions. Consumer and attorney participants offered their input. A meeting was held with chiropractic consultants to secure their participation.
After sorting and evaluating the evidence gathered in the literature review, technique forum, written comments, and open forum, the initial draft of the guidelines was prepared. It was distributed to the panel for review and criticism. A revised draft was prepared based upon this input.
International input from the field was obtained when the working draft guidelines documents was submitted to 195 peer reviewers in 12 countries.
After incorporation of the suggestions of the reviewers, a final draft was presented to the panel for approval. This document was then submitted for proofreading and typesetting.
The purpose of these guidelines is to provide the doctor of chiropractic with a "user friendly" compendium of recommendations based upon the best available evidence. It is designed to facilitate, not replace, clinical judgment.
As Sackett wrote, "External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision. Similarly, any external guideline must be integrated with individual clinical expertise in deciding whether and how it matches the patient's clinical state, predicament, and preferences, and thereby whether it should be applied." (1)
The most compelling reason for creating, disseminating, and utilizing clinical practice guidelines is to improve the quality of health care.
1. Sackett DL. Editorial: Evidence-based medicine. Spine 1998; 23(10):1085.
2. Position paper #1. Association of Chiropractic Colleges. July 1996.
Ratings and Categories of Evidence
RatingsEstablished. Accepted as appropriate for use in chiropractic practice for the indications and applications stated.
Investigational. Further study is warranted. Evidence is equivocal, or insufficient to justify a rating of "established."
Inappropriate. Insufficient favorable evidence exists to support the use of this procedure in chiropractic practice.
Categories of EvidenceE: Expert opinion based on clinical experience, basic science rationale, and/or individual case studies. Where appropriate, this category includes legal opinions.
L: Literature support in the form of reliability and validity studies, observational studies, "pre-post" studies, and/or multiple case studies. Where appropriate, this category includes case law.
C: Controlled studies, including randomized and non-randomized clinical trials of acceptable quality.
DisclaimerThese guidelines are for informational purposes. Utilization of these guidelines is voluntary. They are not intended to replace the clinical judgement of the chiropractor. It is acknowledged that alternative practices are possible and may be preferable under certain clinical conditions. The appropriateness of a given procedure must be determined by the judgement of the practitioner and the needs and preferences of the individual patient.
It is not the purpose or intent of these guidelines to provide legal advice, or to supplant any statutes, rules, and regulations of a government body having jurisdiction over the practice of chiropractic.
These guidelines address vertebral subluxation in chiropractic practice, and do not purport to include all procedures which are permitted by law in the practice of chiropractic. Lack of inclusion of a procedure in these guidelines does not necessarily mean that the procedure is inappropriate for use in the practice of chiropractic.
Participation in the guidelines development process does not necessarily imply agreement with the final product. This includes persons who participated in the technique conference, leadership conference, open forum, and peer review process. Listing of names acknowledge participation only, not necessarily approval or endorsement.
The guidelines reflect the consensus of the panel, which gave final approval to the recommendations.