The Report www.chiropracticreport.com Editor: David Chapman-Smith LL.B. (Hons.) March 2009 Vol. 23 No. 2

New Best Practices for Chiropractic Patient-Centered vs. Payer-Centered Care

A. Introduction defined set of best practices to guide and explain quality patient-centered N North America the RE- care – and defend patients and clini- lentless upwards spiral of healthcare I cians against the inappropriate economic costs in the last quarter of the 20th cen- agenda of many third party payers. tury produced the current era of man- aged care. 2. This is the reason why the profession in North America has established the There is no question that the excessive Council on Chiropractic Guidelines cost of American medical care needed and Practice Parameters (CCGPP). The to be reined in. There is also no question Journal of Manipulative and Physiological that third party payers in managed care Therapeutics (JMPT) has now published have been ruthless in establishing rules some first products of this important and procedures based on financial tar- Council, namely: gets rather than reasonable patient care. a) A Best Practices Report on Chiropractic Money that should be going to patient Management of Low-Back Disorders by care is going to a bloated administration Globe, Morris, Whalen, Farabaugh and and managed care owners. In the US the Hawk,5 supported by a new literature ratio of physicians to administrators is review by Lawrence, Meeker, Branson now almost 1 to 1 (1 to 0.95)1. Professional Notes et al. 6 – which is specifically on chiro- LBP – Predictors of Chronic Disability Research is quoted and used selectively. practic management of low-back and Valuable evidence of effectiveness of Low-back pain (LBP) is the most preva- related leg disorders, and is one of three treatments from prospective studies, lent and costly work-related condition, research studies upon which the new from individual randomized controlled and most of the cost relates to the small best practices are based. trials (RCTs) and for subgroups of percentage of workers with acute injuries b) Literature reviews relative to chiro- patients, is excluded or diluted in broad who progress to chronic disability. practic management of: systematic reviews that typically make Accordingly risk factors that are early tentative conclusions only – allowing • Myofascial trigger points and pain syn- predictors of chronic disability – particu- 7 payers to assert there is insufficient evi- dromes – Vernon and Schneider. larly those that can be influenced – are dence. • Fybromyalgia – Schneider, Vernon, Ko, important. However there have been few 8 studies assessing these factors in a large Crucial differences in quality of care are Lawson and Perera. population-based sample. An impres- ignored. In the field of spinal manipula- • Tendinopathy – Pfefer, Cooper and sive new study from Turner, Franklin et tion for example, there are fundamen- Uhl. 9 al. at the University of Washington, does tally different levels of education and These are accompanied by a strong, so and reports that one risk factor/pre- skill for different health professions. This clear and authoritative editorial by John dictor of chronic disability is choice of is apparent from trials such as Meade et Triano, DC PhD, formerly of the Texas 2,3 healthcare provider – and that “workers al., where chiropractors received sig- Back Institute in Dallas, now Dean of whose first health visit for the injury was nificantly superior results for back pain Research, Canadian Memorial Chiro- to a chiropractor had substantially better patients than did physical therapists, practic College, Toronto, and widely outcomes”. 4 and Carey et al., where medical doctors regarded as a leading international 1885 workers back injury claims involv- given postgraduate training in spinal authority on the management of back ing at least four days of lost work time, manipulation proved unable to assess pain. Triano’s editorial is titled What and covered by the State Fund in Wash- and treat back pain patients success- Constitutes Evidence for Best Practice?1 ington from July 2002 through April fully. Yet systematic reviews bundle all and makes many wake up and helpful 2004, were interviewed by telephone the trials together to provide one overall statements such as: three weeks after submitting a lost work assessment of whether spinal manipula- “Under-treatment” is as much of a policy time claim for back injury. Significant tion is an effective treatment. baseline predictors of one year work dis- concern as “over-treatment”, is often ability were subsequently found to be: In this situation it is imperative that caused by economically-driven inter- continued on page 4 the chiropractic profession has its own pretation of evidence and guidelines Main Article continued from page 1 by third parties, and is now “a serious language – for example the differences The Chiropractic Report is an international review problem with evidence of association of between evidence-based and evidence- of professional and research issues published six increasing chronicity and expense”. informed care, between standards and times annually. You are welcome to use extracts guidelines and best practices, etc. from this Report. Kindly acknowledge the source. “Evidence-based” was never intended Subscribers may photocopy the Report or order to mean “evidence-enchained.” As 5. Later in the 1990s the same US additional copies (.80 cents each, plus shipping explained by Dr. David Sackett and other chiropractic organizations, again led – minimum of 20 copies) for personal, non- founders of evidence-based medicine, by COCSA, formed the Council on commercial use in association with their practices. However, neither the complete Report nor the good practice involves a blend of “best Chiropractic Guidelines and Practice majority or whole of the leading article may be external evidence” and “individual clini- Parameters (CCGPP), as an independent reproduced in any other form without written cal expertise” – and as Sackett has said organization with an elected Council permission. “neither alone is enough”.11 and appointed Research Commission, The opinions and statements in this publication are those of the individual authors alone, not the In this issue of the Report we look at and representative panels of expert and Editorial Board, World Federation of Chiropractic or these new publications and their impor- clinically experienced doctors of chiro- any other organization. tance in clinical practice – but first some practic asked to produce best practices Subscription: for rates and order form, see page 8. brief history of the CCGPP. reports for different fields of chiropractic • Visit www.chiropracticreport.com practice. The papers now discussed are • Call 416.484.9601 • Email us at [email protected] B. CCGPP - Background the first published best practices of the CCGPP, and related research reviews. Editorial Board 3. In January 1992 all the major chiro- Other evidence reviews and best prac- Alan Breen DC, PhD, England Raul Cadagan DC, PT, Argentina practic organizations in the US, led by tices are being developed for other areas Ricardo Fujikawa DC, MD, Brazil the Congress of Chiropractic State Asso- of practice – preventive and wellness Scott Haldeman DC, MD, PhD, United States ciations (COCSA) because it was seen care, extremities, the cervical spine and Donald Henderson DC, Canada Nari Hong DC, South Korea as the most representative of the profes- non-musuculoskeletal disorder. Gary Jacob DC, MPH, LAc, United States sion, held a conference at the Mercy The overall goal of the CCGPP is to Dana Lawrence DC, United States Center, San Francisco to agree upon the establish a fair basis for the provision Charlotte Leboeuf-Yde DC, PhD, Denmark profession’s first ever evidence-based Craig Morris DC, United States of chiropractic healthcare services, and Lindsay Rowe DC, MD, DACBR, Australia consensus guidelines for practice. This judgement of them by others – one Hossein Sabbagh DC, Iran led to the Guidelines for Chiropractic based upon credible evidence and Louis Sportelli DC, United States Quality Assurance and Practice Param- Aubrey Swartz MD, United States patient-centered care and not driven by Yasunobu Takeyachi DC, MD, Japan eters (thereafter known as theMercy selective evidence and other agendas. Changes of mailing instructions should be sent to Center Guidelines) published by Aspen They are a shield for patients and pro- 12 The Chiropractic Report, 203–1246 Yonge Street, in 1993. viders for appropriate care – but also a Toronto, Ontario, Canada M4T 1W5, These Guidelines represented a major sword for inappropriate and undocu- telephone 416.484.9601, fax 416.484.9665. Printed by Harmony Printing Limited, 416.232.1472. step forward, demonstrating a matu- mented care. Copyright © 2009 Chiropractic Report Inc. rity that gave the profession new cred- ISBN 0836-144 ibility in many circles. One result was C. Triano Editorial appointment of two representatives of the profession, Dr. Scott Haldeman and 4. Dr. Triano is a recognized leader in b) Because of the policies of managed Dr. John Triano, to the US government’s spine care because of a prominent career care “under-treatment is a serious prob- AHCPR Panel that produced the first in both research and clinical practice. lem with evidence of associated increas- US national guidelines on management His doctoral degree is in spinal biome- ing chronicity and expense.” While of back pain in 1994. Another result was chanics. Following his participation on over-treatment is also a legitimate health that there was evidence-based support the US AHCPR Clinical Practice Panel policy concern, “the social and economic for many aspects of chiropractic practice, he, with Richard Deyo, MD MPH from impact of under-treated pain is a prob- including management of patients with Washington, was one of the two featured lem to patients and to society which is conditions sometimes labelled as contra- experts on the Time Life Medical video often ignored in deference to concerns of indications to chiropractic care by others Back Pain designed for public education. over-treatment.” His editorial is important because of his – such as DJD, osteoarthritis, spondy- c) In 43% of US households at least one lolysis and spondylolisthesis. reputation and the important and well- referenced conclusions he makes. member experiences chronic pain. For However, these guidelines were promul- 1 out of 2 (48%) this is skeletal pain. gated at a time when the whole process Triano starts by confirming that in the Patients with low-back pain “are less of guidelines development and dis- US “the system for delivery of health- likely to be under care than those with semination was not well understood and care services is broken”, and that this other disorders.” (Although this editorial developed. They were not user friendly, specifically includes the management of describes the situation in the US, there and were misinterpreted and used inap- patients with spinal pain. Points are: are clearly similarities in many other propriately by many third party payers. a) Healthcare costs continue to rise. countries). 4. Over the last 15 years much has been Administration/bureaucracy, meant to d) “The American Pain Society and the learnt about the process of developing contain costs, is now part of this prob- World Health Organization have called and disseminating and gaining accep- lem. It is also increasing distrust among attention to both under-treatment of tance of practice guidelines. One aspect all parties in healthcare, including pain and the need for acceptable stan- of this has been more sensitive use of between patient and provider. dards of care.”

Page  5. The two fundamental questions reviews of the evidence, making these Force Report13,14 indicates that both and issues for both quality of care and research summaries unreliable. Reflect- medication such as NSAIDs and manual patient-centered care, explains Triano, ing a growing concern in the research treatments such as spinal manipulation are first “do patients get the care they world, Triano emphasizes the real limita- are supported by research as safe, effec- need” and second “is the care effective tions of randomized controlled trials, tive and appropriate for most patients when they get it.” Clinical guidelines and namely that: with neck pain (Grades I and II), that pathways are commonly implemented • They ignore context and the skill of the patients should be advised of both by payers to answer different questions provider of treatment options (and others), and that the treat- based on economics. The end result is ment given should be based on patient • They only minimally acknowledge the the broken system – the level of adminis- preference. Many patients prefer a more important and confounding effects of tration and costs go up, health outcomes natural treatment that does not rely on placebo healing properties deteriorate, and everyone is frustrated. medication, others are uncomfortable • They ignore patient actions, prefer- Payers and policy makers will continue with a manual approach and prefer a pill. ences, and beliefs, which may influence to substitute their own guidelines unless Respecting those preferences will pro- outcome professions establish their own patient- duce the best results in individual cases. centered, evidence-informed best prac- • Poorly performed RCTs are more 7. Natural History. Many guidelines tices. That is what Triano is explaining, misleading than well-performed cohort that provide benchmarks for appropriate that is what the chiropractic profession is studies. care as based upon the presumed natu- doing through the CCGPP. For these reasons, both the limitations ral history for patients with back pain. 6. Rigid Guidelines vs Best Practice of the research and the need to acknowl- This sounds reasonable but, as Triano Recommendation – and Individual edge that clinical decisions must be explains, “natural history is widely mis- Context. Triano presents an expert made giving primary consideration to understood”. The literature in the 1980s analysis of why rigid guidelines and the needs of the individual patient, the was misleading. Data now show more cookbook rules, often used by payers and term ‘evidence-informed’ is now pre- extensive chronicity than previously focusing on fixed frequency and dura- ferred by Triano and many other experts, understood. Therefore for example: tion of care, are inadequate and therefore rather than ‘evidence-based’. a) Early evidence indicated that 40- inappropriate. The bottom line is that b) Case Complexity. This refers to the 50% of patients with back pain were they do not acknowledge the individual many personal, biomechanical and improved in one week, 85-90% in 6- context for each patient and clinician psychosocial risk factors that may com- 12 weeks, and that as many as 90% of and clinical decision. For reasonable plicate and delay recovery. Those estab- patients had problems that resolved and effective care, rigid guidelines or lished in the literature and mentioned by without intervention. However this is templates must be replaced by “evidence- Triano are shown in Table 1. The obliga- now known to present an incomplete informed best practice recommenda- tion of the clinician is to discover and picture. Many patients with acute low- tions”. That is why the new CCGPP rec- document these risk factors, the obliga- back pain have persistent pain if fol- ommendations are called best practices, tion for those developing or interpreting lowed for 1-2 years – as many as 62% and not guidelines or stadards. All guide- guidelines/best practices is to acknowl- will have one or more relapses during lines/best practices must acknowledge edge the appropriateness of individual one year follow-up, and 40% report con- the primacy of the individual context of treatment plans reflecting them. tinuing back pain at six months. each case. Elements of this context are: c) The Provider’s Expertise and Experi- b) With respect to workers’ compensa- a) Limitations in the Best Available ence. The importance of this should be tion injuries, many agencies use reports Evidence. 85% of current healthcare self-evident to anyone who has been a of return to work experience at one practices remain scientifically unfound- patient – in other words everyone. An month but, says Triano, these are prob- ed. Even where there is good research interesting parallel can be made with lematical and “do not capture the chron- evidence on the effectiveness of given the legal system. Appeal court judges are ic episodic nature of back problems.” In assessments or treatment protocols, these very reluctant to overturn a finding of recent work such back pain patients were methods are ineffective for many patients fact (as opposed to a finding of law) by tracked for one year and, although 50% in the trials in which they were studied. a lower court judge. It is the lower court experienced no work time loss in the Conversely, treatment methods found judge who saw the witnesses, heard first month after injury, 30% of them had ineffective in other trials are effective the lawyers, had the best opportunity work absence on account of this injury for many of the individual subjects or to make an appropriate decision. Over by the end of one year. Further, among patients. Finally much valuable research and again appeal judges say “I may have those who did have work absences with- (e.g. well-designed prospective studies) come to a different conclusion myself, in the first month but had returned, 19% is frequently omitted from systematic but the lower court judge had a bet- had absence later in the year. Assuming ter opportunity to assess the evidence an individual doctor of chiropractic has – appeal denied.” There should be similar a typical case mix “the presence of symp- Full text – www.ccgpp.org respect for and bias towards acceptance toms and impairment beyond 12 weeks For the full text of the literature syntheses of the clinician’s opinion in health care. may be as high as 31% to 40%, not the and the low-back disorders best practices d) The Patient’s Preferences and typical 10% often quoted.” document referred to in this Report, and 8. Process of Care. Main factors deter- much other information on the Council on Beliefs. These are known to influence Chiropractic Guidelines and Practice Param- care given and results. Therefore, for mining how a case progresses include eters, go to the above website. example, the recent BJD Neck Pain Task timely and appropriate care, case com-

Page  The Chiropractic World

LBP – Predictors of Chronic Disability In Sao Paulo the CREFITO has sought to have the interim injunc- continued from page 1 tion removed. However on March 3, just as this Report is going to print, Federal Judge Diana Brunstein has not only confirmed the injunction, but has offered powerful and helpful reasons in • injury severity – rated from medical records support. Based on evidence and arguments presented by the • “specialty of the first healthcare provider seen for the injury” ABQ she has ruled that chiropractic, although not recognized – obtained from administrative data by law in Brazil, is established internationally as a profession, not • worker reported physical disability – Roland Morris Disability a technique, and that it is not competent for physiotherapy to Questionnaire declare chiropractic a specialty. Judge Brunstein acknowledges • number of pain sites that a proposal for legislation for chiropractic has been present- • “very hectic” job ed to the legislature, and that this is where this dispute should • no offer of job accommodation (e.g. light work) be resolved. • previous injury involving a month or more off work The ABQ’s fight for the appropriate recognition of chiropractic The single strongest predictor of one year work disability was in Brazil is important not only in that country, but throughout self report of functional limitations on the Roland Morris Disabil- Latin America and internationally. That is why it has been sup- ity Questionnaire. Here is further evidence that use of validated ported by generous donations from chiropractic associations patient questionnaires is of key importance. and individuals from around the world. Legal and legislative Workers whose first healthcare visit for the injury was to a chi- costs remain high for the ABQ, most of whose members have ropractor “had substantially better outcomes”. The percentage graduated during the past five years from Brazil’s two, new, of those workers disabled at one year was 5% - this compares university-based chiropractic programs. Please consider giving with primary care (12%), occupational medicine (26%) and other financial support yourself. For more information, donation forms (23%). Additionally, for those disabled at one year, the average and list of donors to date, go to the Newsroom at www.wfc.org. number of work disability days compensated during the year See there also Judge Brunstein’s March 3 decision. were: United Arab Emirates: The World Federation of Chiropractic’s Provider Average number of days off 4th Annual Eastern Mediterranean Region Seminar was held in Chiropractor 14 Dubai, United Arab Emirates, February 27-28. It was hosted by Primary care 14 the Emirates Chiropractic Association (ECA) which represents Occupational medicine 70 the 20 doctors of chiropractic practising in the UAE. Other 30 Chiropractic practice is recognized and regulated by legislation The study did not look into details of care given after the first in the UAE and most doctors work in interdisciplinary clinics. visit. Turner, Franklin et al. offer two possibilities for the better The majority, such as Dr. Travis Mitchell from South Africa, ECA outcomes for those consulting a chiropractor – “. . . it is possible President and Dr. Peter Jensen from Denmark, who has been at that workers who saw chiropractors differed in prognostically the Zayed Military Hospital in Abu Dhabi for 10 years, are expa- favourable ways . . . it is also possible that chiropractic care was triates. Others, such as Dr. Tarek Tawil, ECA Vice-President and a more effective in improving pain and disability and/or promot- graduate of Cleveland College in Los Angeles, are from the UAE ing return to work.” They simply conclude that “further research and elsewhere in the Middle East. Dr. Tawil is Chief of Staff of the is needed to investigate the effects of early care on work dis- Spine and Joint Unit of the Elaj Medical Centres, 20 large medi- ability.” cal centres throughout the Gulf region. (Turner JA, Franklin G et al. (2008) ISSLS Prize Winner: Early Predic- The Dubai meeting was attended by DCs representing 10 coun- tors of Chronic Work Disability: A Prospective, Population-Based tries – Cyprus, Egypt, Iran, Lebanon, Libya, Qatar, Saudi Arabia, Study of Workers with Back Injuries, Spine, 33(25):2809-2818). Syria, Turkey and the UAE. The two countries in the region with World Notes (Source: World Federation of Chiropractic) legislation to regulate the practice of chiropractic, other than the UAE, are Cyprus and Iran. Dr. Gamal Giroush of Tripoli reported Brazil: Last November we explained that, in response to that Libya is about to enact chiropractic legislation. efforts by the Brazilian Chiropractors’ Association (ABQ) to have the government pass legislation to regulate the practice of Next year’s WFC Eastern Mediterranean Region Seminar is to chiropractic, the physiotherapy profession had mounted an be held April 8-9 or 15-16 in Shiraz, Iran, hosted by the Iranian aggressive campaign to have chiropractic declared a specialty Chiropractors’ Association. This will be a two day meeting and of physiotherapy. Brazil has under 400 duly qualified chiroprac- confirmed speakers are Dr. Scott Haldeman and Dr. John Triano. tors, there are over 90,000 physiotherapists. The PT campaign is For further details after April 30 see www.wfc.org/Events. being led by the CREFITO, the branch of the national regulatory Dr. Travis Mitchell body, COFFITO, for Brazil’s most powerful and populous state of (left) and Dr. Tarek Sao Paulo. Tawil, President Since August PT investigators had been visiting DC clinics, and Vice-President sometimes accompanied by the federal police, trying to pres- of the Emirates sure DCs to sign declarations acknowledging the illegal practice Chiropractic of PT and to cease practice. The ABQ and its lawyers were suc- Association. cessful in getting an interim injunction to stop such harassment. In the months since there has been similar PT activity in other Brazilian states.

Page  News and Views

WFC’s 10th Biennial Congress

Some of the delegates at the 4th WFC Eastern Mediterranean Seminar in Dubai Hosted by USA: Dr. Paul Dougherty (right) of New Canadian Chiropractic Association York Chiropractic College is featured in an article on the importance of bone and Incorporating joint health and the prevention of mus- WFC’s and FCER’s International Conference on Chiropractic Research culoskeletal disorders in the March 2009 FICS Symposium issue of The Nation, the influential monthly Tom Hyde Dinner publication of the American Public Health Association that is widely read by health policy-makers in the US and internation- Celebrating Chiropractic ally. The article is about the work of the in the 21st Century US Bone and Joint Decade to raise awareness of the burden of bone and joint disorders – the leading reason for people seeking Keynote Addresses: David Eisenberg from Harvard on integration medical care, and affecting 107 million adults, in the US in 2005 of chiropractic services at Harvard; Jack Taunton, Chief Medical – and to the need to develop preventive programs. Officer and Robert Armitage, Coordinator, Chiropractic Services “One of the things we need to do is make public health practi- on the Vancouver Olympics. Technique: Overviews of all and choice of workshops – Ted Carrick (neurology), Mark Charrette tioners more aware of musculoskeletal issues,” says Dougherty in (lower extremities), Chris Colloca (instrument adjusting), Tom the Nation. “Because (chiropractors) are musculoskeletal special- Hyde (Graston), Jeanne Ohm (pediatrics), Gary Jacob (McKenzie ists, it really makes sense we would be the ones talking to the Methods), Kirkwood and Kazemi (rehab exercises, Leahy (ART), public and educating them about these issues.” Walker (NET), etc. Clinical Sciences: Scott Haldeman, Jay Triano, The reason Dougherty is being quoted is his leadership in com- David Cassidy, Greg Kawchuk, Alan Breen, etc. Philosophy and munity and public health work – he is a member of the Board Motivation: Guy Riekeman, Gerard Clum, Serge Robert, Gilles of Directors of the US Bone and Joint Decade, representing Lamarche, etc. Integrated Care: e.g. Amy Freedman, MD and the American Chiropractic Association, and Chair Elect of the Brian Gleberson, DC on diet, fall prevention and collaborative Chiropractic Healthcare Section of the American Public Health care for seniors; Heiner Biederman, MD and Jeanne Ohm, DC on assessment and management infants. Association. Specific projects he and NYCC have been involved in recently include: Dates: April 29 to May 2, 2009 • An education program for nursing home residents in Rochester Venue: Hilton Bonaventure Hotel, Montreal, Quebec, Canada on back pain, its prevention and management and the impor- CE Credits: 18 hours – Canadian provinces/US states/Europe – see tance of remaining physically, mentally and socially active. website. • In a joint project with the State University of New York, deliver- All information: Program, registration, accommodations, social ing a geriatric course for social work students in an assisted-liv- events and tours: ing facility, educating both students and resident seniors about • Visit www.wfc.org/Congress2009 fall prevention and other related geriatric issues. (For FICS Symposium and Tom Hyde Dinner visit Dr. Dougherty serves on other multidisciplinary committees www.fics-sport.org). in his community and his NYCC colleague Dr. Jonathan Egan • Contact: Linda Sicoli at the WFC at 416-484-9978, serves on the Seneca Falls Public Health Board. He explains that fax 416-484-9665 or [email protected]. “the exciting thing about serving on each of these boards is that there is no discrimination against us as chiropractors – everyone Outstanding academic and social program – join 1000 DCs from is there for the same reason, the good of the public”. over 30 countries in a city famed for its music, restaurants and nightlife – exciting Montreal. Dougherty believes that the profession has much to gain from public service and speaking out for public health as opposed to specific chiropractic issues. In the APHA he would like to see the Chiropractic Healthcare Section be the leaders in introducing increased awareness of the importance of musculoskeletal dis- ease and its treatment and prevention.

Page  Main Article continued from page 3 plexity, and confounding events outside the control of the ment because it is related to spinal function.” The authors provider and/or patient. These obviously cannot be assessed by conclude the evidence supports use of ROM “as a means to simple benchmark numbers on frequency and duration of care. monitoring improvement in function over time and, therefore, What they require is consideration of “the documented care improvement as it relates to the use of SMT.” Readers must con- process.” On this important concept of process of care Triano sult the paper itself at www.ccgpp.org for many other specific explains that the management of a patient has only three alter- findings. natives: • The patient progresses favourably and in reasonable similarity E. Low-Back Disorders – Best Practices to relevant benchmarks Report • Progress is below expectations but the provider has acted 11. This brings us to the consensus report from Gary Globe, appropriately with diagnostic or therapeutic modifications 5 MBA DC PhD, Craig Morris, DC, Wayne Whalen, DC, et al. pre- • Progress is below expectations but appropriate action has not senting best practices in chiropractic for the management of been taken patients with low-back disorders. Although this also says noth- As Triano concludes “where the process of care is reasonable it ing very new or surprising, it will be most important for all cli- is counterproductive for third party intercession to hinder, stop nicians in the profession – both as a shield to defend reasonable or alter care.” If due process has been followed, then provider patient-centered practice that goes beyond cookbook templates decision-making should not be questioned. for care, but also as a sword in the hands of third parties to cut Here, then, are many expert and referenced facts, concepts and down extended patient care not supported by patient improve- findings from Triano. We now turn to consider the new evi- ments, timely re-examinations and sound documentation. dence synthesis supporting the CCGPP’s new best practices on Points are: low-back disorders. a) This report is from a representative panel of 40 clinically experienced doctors of chiropractic in the United States. D. Low-Back Disorders – Evidence b) The core background documents on research evidence, or Synthesis the ‘seed documents’, given to them were the CCGPP literature synthesis just discussed, the Clinical Practice Guidelines on 9. The thorough new literature review relative to chiropractic Low-back Pain from the American College of Physicians and 6 management of low-back and related leg complaints is by American Pain Society,15 and the expert review titled Evidence a representative group of leading US chiropractic scientists Informed Management of Chronic Low-Back Pain with Spinal (e.g. Dana Lawrence, DC MMedEd, William Meeker, DC MPH, Manipulation and Mobilization by Bronfort, Haas et al. recently Gert Bronfort, DC PhD) and clinicians (e.g. Richard Branson, published in The Spine Journal. 16 DC and Jeff Cates, DC MS, respectively in private practice in Minnesota and Oregon) and Mark Micozzi, MD PhD from the Georgetown University School of Medicine, Washington, DC. Points are: Table 1. Risk Factors commonly attributed to the occurrence or persistence of low back-related musculoskeletal disorders a) Literature was reviewed according to the process adopted by Adapted from Triano, JMPT 20081 the Cochrane Working Group for Low-Back Pain – with the Category Factor notable exception that cohort studies were included as well as Personal Age (older) RCTs, systematic reviews and guidelines. Sex (female) b) Each study was not only given an overall grade for strength Severity of symptoms of evidence - Grade A (good); Grade B (fair); or Grade C Leg pain > back pain (limited) - but also a specific quality score based on set crite- Increased spine flexibility Reduced muscle endurance ria. Therefore, most helpfully, a specific quality score or QS is Prior recent injury (<6 mo) including surgery given when a study is mentioned in the text. Prior surgery c) There are pagesof specific research conclusions, first relative Asymptomatic atrophy of multifidus up to 5 y later to ‘assurance and advice’ and ‘adjustment/manipulation/mobi- Abnormal joint motion with or without abnormal elec- tromyogram function of medial spine extensors lization’ and then for various treatment approaches under each Poor body mechanics of acute, sub-acute and chronic low-back pain, and sciatica/ Falling as mechanism of prior injury radicular/radiating leg pain. There is nothing suddenly new or Biomechanical Prolonged static posture >20o (offs radio, 5.9) surprising but summary main points are: Poor spinal motor control • There is fair evidence that high-velocity, low-amplitude pro- Vehicle operation >2 h per day cedures (HVLA – a term that includes both adjustment and Sustained (frequent/continuous trunk load >20 lb Materials (handling (static work postures, frequent manipulation) have “better short-term efficacy than mobiliza- bending and twisting, lifting demands, pushing, pulling tion or diathermy.” and repetitive exertion) • For chronic low-back pain, there is fair evidence that HVLA Psychosocial Condition chronicity is better than physical therapy and home exercises, and better Employment history (<5 y, same employer) than general medical care or placebo in the short term. Results Employment satisfaction are improved when exercises are added. Lower wage employment Family/relationship stress 10. Significantly, there is a positive assessment of range-of- Attorney retention motion testing (ROM) – described as an examination proce- Expectations of recovery dure “used by nearly every chiropractor . . . to assess impair-

Page  c) Panelists were given not only these seed documents but also • Additional care. This is subsequent care in cases of “exacerba- ‘seed statements’ developed by a separate expert committee tion/flare-up”, or “when withdrawal of care results in substantial appointed by the CCGPP. These 27 seed statements related to measurable decline in functional or work status.” various different aspects of care. g) Outcome Measurement. “For a trial of care to be consid- d) The panel then used a Delphi process to refine and agree on ered beneficial it must be substantive, meaning that a definite the appropriateness of the seed statements. ‘Appropriateness’ improvement in the patient’s functional capacity has occurred.” was rated using the RAND/UCLA process. This involved a scale Examples of acceptable outcome measures are then given and a 1 to 9 (highly inappropriate to highly appropriate) and agree- include: ment on appropriateness was considered to be present when at i) Pain scales, such as the visual analog scale and the numeri least 80% of panelists marked 7, 8 or 9 and the median response rating scale score was 7 to 9. ii) Pain diagrams that allow the patients to demonstrate the 5 e) The publication by Globe, Morris et al. describes the process, location and character of their symptoms then comprises the agreed statements and some supporting iii) Validated activities of daily living measures, such as the comment under the subheadings of: Oswestry Back Disability Index and the Roland Morris Back • General Consideration Disability Index, RAND 36, Bournemouth Disability Question- • Informed Consent naire. • Examination Procedures • Severity and Duration of Conditions iv) Increases in home and leisure activities, in addition to • Treatment Frequency and Duration increases in exercise capacity. • Initial Course of Treatments for Low Back Disorders v) Increases in work capacity or decreases in prior work restric- • Reevaluation and Reexamination tions. • Continuing Course of Treatments vi) Improvement in validated functional capacity testing, such • Additional Care as lifting capacity, strength, flexibility and endurance. • Outcome Measurement • Spinal Range of Motion Assessment This presents a clear requirement of objective documentation in contemporary chiropractic practice. Note that ROM test • Caution and Contraindications - • Conditions Contraindicating certain Chiropractic-Directed ing, while approved for the purposes of determining patient Treatments such as Spinal Manipulation and Passive Therapy response to a single treatment session, is not regarded as an • Conditions Requiring Co-Management overall valuable functional outcome measure. • Conditions Requiring Referral h) Contraindications. These are given under the subheadings f) Treatment Frequency and Duration. Core concepts and osseous conditions, neurologic conditions, inflammatory condi- terms used in all discussion of initial and continuing treatment tions, bleeding disorders and other. Under ‘other’, note that con- are: traindications for the use of high-velocity manipulation include – importantly - “inadequate manipulative training and skills”. • A therapeutic trial of treatment or care. For new patients with a low-back disorder, whether acute or chronic, “a typi- cal initial therapeutic trial of chiropractic care consists of 6-12 F. Other Evidence Syntheses visits over a 2-4 week period, with the doctor monitoring the 12. Myofascial Trigger Points (TrPs)and Myofascial Pain patient’s progress with each visit to ensure that acceptable clini- Syndrome (MPS). Comments on this expert review by How- cal gains are realized.” ard Vernon, DC PhD, Canadian Memorial Chiropractic Col- • Reevaluation/reexamination. “A detailed or focused reevalu- lege, Toronto and Michael Schneider, DC, School of Health ation designed to determine the patient’s progress and response and Rehabilitation Sciences, University of Pittsburgh, of the 7 to treatment should be conducted at the end of each trial of research evidence supporting chiropractic management are: treatment.”. However the patient’s condition “should be moni- a) The same methodology is used as for the low-back disorders tored for progress with each visit”, and “near the midway point and other CCGPP reviews. of a trial of care the practitioner should reassess whether the b) Vernon and Schneider explain that ever since the work of current course of care is continuing to produce satisfactory Travell and Rinzler in 1952 the role of TrPs and MPS “has clinical gains using commonly accepted outcomes assessment become an accepted part of musculoskeletal clinical practice.” methods.” However, “interest in myofascial tenderness extends through- The purpose of the reevaluation at the end of the trial of treat- out the ” and “Nimmo’s explanations in ment is to determine “the necessity for additional treatment” the 1950s of the pathophysiology of TrPs are still regarded as – which should be based on the response to the trial of care and accurate and highly sophisticated.” There are then references “the likelihood that additional gains can be achieved.” to works by other chiropractic authors – including Schneider, • Maximal therapeutic benefit.This is the point where, even if Perle, Hains and, of course, Hammer. there has only been partial resolution of the patient’s problem, c) The helpful conclusion of the literature review is that “man- measurable response has ended following all reasonable treat- ual type therapies and some physiologic therapeutic modalities ment and diagnostic studies. have acceptable evidentiary support in the treatment of MPS • Continuing course of treatments. This follows the initial trial and TrPs.”. With respect to modalities: of care, is given where there are “substantive, measurable func- • There is substantial evidence supporting laser therapy for TrPs tional gains” but “remaining functional deficits”, and the patient and MPS (Level A). is continuing to improve. Continuing care is different from and • There is moderately strong evidence forTE NS for TrPs (Level B). can be compared with:

Page  • There is limited evidence for other forms of electrotherapy • There is good evidence that ultrasound therapy provides ben- and ultrasound (Level C). efit for calcific tendonitis. • There is moderate evidence for acupuncture for TrPs and • There is an overall lack of evidence for all treatments for ten- magnets for TrPs and MPS (Level B). dinopathy, including commonly used medical treatments such 13. Fibromyalgia Syndrome. From eight systematic reviews of as NSAIDs and corticosteroid injections. the trials, three meta analyses, five published guidelines and one consensus document, Schneider, Vernon et al. 8 conclude that F. Conclusion there is: 16. Here then, in research reviews and a best practices docu- • Strong evidence supporting aerobic exercise and cognitive ment, is the evidence base for current chiropractic management behavioural therapy (Level A) for low-back and leg-related disorders. Clinicians clearly owe • Moderate evidence supporting massage, muscle strength train- a large debt of gratitude to the CCGPP, its volunteers and sup- ing, acupuncture and spa therapy (balneotherapy) (Level B). porters for producing this and ongoing work. Here also, in Tri- • Limited evidence supporting spinal manipulation, movement/ ano’s editorial, is expert advice on how to use the evidence base. body awareness and vitamins, herbs and dietary modification Where care is paid for by a third party there must be respect (Level C). for three viewpoints, those of the patient, provider and payer. This requires respect for a reasonable but properly documented The authors conclude that all these treatments “have acceptable course of patient-centered care – a course of care in which the evidentiary support in the treatment of fibromyalgia syndrome.” individual context requires at least as much consideration as the 14. Tendinopathy. The evidence review is by Mark Pfefer, RN evidence base. TCR MS DC, Stefan Cooper, DC and Nathan Uhl, DC, all affiliated with 9 Cleveland Chiropractic College, Kansas City. They note that References chronic tendon pathology, a soft-tissue condition commonly seen in chiropractic practice, is often known as tendonitis. They 1. Triano, JJ (2008) What Constitutes Evidence for Best Practice? J Manip- ulative Physiol Ther 31:637-643 prefer the term tendinopathy because the condition has not 2. Meade TW, Dyer S et al. (1990) Low‑Back Pain of Mechanical Origin: been association with inflammation. Their conclusions relative Randomised Comparison of Chiropractic and Hospital Outpatient Treat- to chiropractic management are: ment, Br Med J 300:1431‑37. • There is limited evidence that manipulation and mobilization 3. Meade TS, Dyer S et al (1995) Randomised Comparison of Chiropractic are beneficial for tendinopathy (Level C) and more research and Hospital Outpatient Management for Low-Back Pain: Results from is needed on the combinations of manipulation, mobilization, Extended Follow Up, Br Med J 311:349-351. facilitated stretching and other interventions most commonly 4. Curtis P, Carey TS et al. (2000), Training Primary Care Physicians to Give Limited for Low Back Pain, Spine; 25(22):2954- used in chiropractic practice. 2960. 5. Globe GA, Morris CE, Whalen WM et al. (2008) Chiropractic Manage- ment of Low Back Disorders: Report from A Consensus Process, J Manipu- lative Physiol Ther 31:651-658. SUBSCRIPTION AND ORDER FORM 6. Lawrence DJ, Meeker W, Branson R et al. (2008) Chiropractic Manage- (6 bi-monthly issues) Year commences January ment of Low Back Pain and Low Back-Related Leg Complaints: A Litera- Check one ture Synthesis. J Manipulative Physiol Ther 31:659-674 US and Canada 1 year $115.00 7. Vernon H, Schneider M (2009) Chiropractic Management of Myofascial (your currency) 2 years $210.00 Trigger Points and Myofascial Pain Syndrome: A Systematic Review of the Literature, J Manipulative Physiol Ther 32(1):14-24 Australia 1 year A$130.00 8. Schneider M, Vernon H et al. (2009) Chiropractic Management of 2 years A$245.00 Fibromyalgia Syndrome: A Systematic Review of the Literature, J Manipu- Europe/elsewhere 1 year US$120.00 lative Physiol Ther 32(1):25-40 2 years US$220.00 9. Pfefer MT, Cooper SR, Uhl NL (2009) Chiropractic Management of Tendinopathy: A Literature Synthesis, J Manipulative Physiol Ther Name 32(1):41-52 11. Sackett DL (1997) Evidence-Based Medicine, Semin Perinatol 21:3-5. Address 12. Haldeman S, Chapman-Smith D, Petersen DM (1993) Guidelines for City Province/State Chiropractic Quality Assurance and Practice Parameters: Proceedings of Country Postal Code/Zip the Mercy Center Consensus Conference, Aspen Publishers, Gaithersburg, Maryland. Telephone ( ) 13. Haldeman S, Carroll L et al. (2008) The Bone and Joint Decade 2000- PLEASE CHECK ONE 2010 Task Force on Neck Pain and Its Associated Disorders; Executive Visa Card number Summary, Spine 33(4S):S5-S7 MasterCard Expiration date 14. Haldeman S, Carroll LJ, Cassidy JD et al. (2008) The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Cheque/Check enclosed Euro Spine J 17 (Suppl.1):S1-S220 Payable to: The Chiropractic Report 15. Chou R, Qaseem A et al. (2007) Diagnosis and Treatment of Low- 203–1246 Yonge Street Back Pain: A Joint Clinical Practice Guideline from the American College Toronto, Ontario, Canada M4T 1W5 of Physicians and the American Pain Society, Annals Int Med 147 (7): Tel: 416.484.9601 Fax: 416.484.9665 478-491. E-mail: [email protected] 16. Bronfort G, Haas M et al. Evidence-Informed Management of Chronic Website: www.chiropracticreport.com Low Back Pain with Spinal Manipulation and Mobilization, The Spine Journal, (2008) 8::213-245.

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