CCCHHHIIIRRROOOPPPRRRAAACCCTTTIIICCC BBBEEESSSTTT PPPRRRAAACCCTTTIIICCCEEESSS::: AAA SSSyyysssttteeemmmaaatttiiiccc RRReeevvviiieeewww bbbyyy ttthhheee RRReeessseeeaaarrrccchhh CCCooommmmmmiiissssssiiiooonnn ooofff ttthhheee CCCooouuunnnccciiilll ooonnn CCChhhiiirrroooppprrraaaccctttiiiccc GGGuuuiiidddeeellliiinnneeess aaannnddd PPPrrraaaccctttiiiccceee PPPaaarrraaammmeeettteeerrrsss - DRAFT FOR STAKEHOLDER REVIEW AND COMMENTARY - Quality health care delivery enhances satisfaction and value for patients, caregivers and society. [Note to reader: This stakeholder review draft holds several formats for references that occurred as source documents were consolidated. The final draft may include additional references submitted by stakeholders. Thus, final formatting and listing of references will be deferred until the stakeholder comments have been received.] - 1 – Stakeholder review draft. Not for distribution otherwise or for attribution. TTTaaabbbllleee ooofff CCCooonnnttteeennntttsss Page CHIIROPRACTIC BEST PRACTICES: What Constitutes Evidence for 1 Best Practice? Table of contents 2 What Constitutes Evidence for Best Practice? 4 Best practices: Chiropractic management of low back pain and low 22 back related leg complaints – draft for stakeholder critique Primary reference 24 source Primary conclusion Rated literature summary 26 summary Process description 30 Criteria and process for topic selection 30 CCGPP process flow chart 31 Team selection and orientation training of 33 team leaders Identifying searching and selecting the 34 evidence Forming conclusions from the evidence 34 Minimally clinically important change 35 Evidence rating 35 Definitions for evidence ratings 37 Use of evidence tables 39 Use of consensus 39 Considered judgment (after 39 stakeholders) Stakeholder review and implementation 39 Audit and review 41 Literature Summary: 42 - The approach of this work 42 Rated Literature 43 - Treatment 43 - 68 Assurance and advice 43 Adjustment /manipulation /mobilization 44 - 55 Acute low back pain 46 – 48 Sick list comparisons 46 Backschool programs 46 Physiological therapeutics 46 and exercise Sham and alternate 47 manual methods Medication comparison 47 Subacute back pain 48 - 49 - 2 – Stakeholder review draft. Not for distribution otherwise or for attribution. Staying active comparisons 48 Physiological therapeutics 48 And exercise Sham and alternate 49 manual methods Medication comparison 49 Chronic low back pain 49 - 52 Staying active comparisons 49 Physician consult / 49 medical care / education Backschool programs 50 Physiological therapeutics 50 Modality comparison Exercise modalities 51 Sham and alternate 52 manual methods Medication comparisons 52 Sciatica /radicular /radiating pain 53 - 54 Staying active / 53 Bed rest comparisons Physician consult / medical care 53 / education comparison Physiological therapeutics 53 Modality comparison Exercise modalities 54 Sham and alternate 54 manual methods Medication comparisons 54 Disc herniation 54 Massage 55 Backschool 56 Lumbar supports/corsets 56 Physiological & therapeutic modalities 56 – 58 Traditional traction 57 Diathermy 57 Ultrasound 57 Electrical stimulation 58 Exercise 58 – 61 Referral / comanagement 61 Treatment literature as 61 - 63 yet unrated Diagnostics 63 - 68 History, Physical and Laboratory 63 - 65 Examination - 3 – Stakeholder review draft. Not for distribution otherwise or for attribution. Computerized range of motion 65 Plain film radiography 65 Specialized imaging 66 Spinal ultrasound 66 Surface EMG 67 Videofluoroscopy 67 Diagnostic literature as 67 – 68 yet unrated Tally of rated sources Number of sources rated by the 68 interdisciplinary team of reviewers and used in formulating conclusions of chiropractic best practices. Natural & treatment (Not yet edited for format) 69 - 70 history Common markers, (Not yet edited for format) 70 - 75 rating complexity & outcomes Reference lists (Not yet edited for format. Will be completed 76 with input from the stakeholder review.) Appendix: 129 – 156 Table A1: Applicable ICD codes 129 Table A2: Urgent/emergent “red flags” 130 Table A3: Suspicious “yellow flags” 131 Table A4: Interpretation bias in the 132 literature Table A5: Bronfort RCT scoring system 133 Table A6: SIGN RCT scoring system 135 Table A7. AGREE score rating of 136 guidelines. Table A8. MOOSE score rating of 140 systematic reviews/meta-analyses Table A9: Quality scores for RCTs. 142 Table A10: AGREE scores rating of 143 guidelines Table A11: MOOSE scores of systematic 143 reviews/meta-analyses Table A12: Evidence tables 144 - 152 Table A13:Literature search strategy 153 Best practices: Chiropractic management of neck pain and neck related leg complaints – draft for stakeholder critique – Release to be determined. Best practices: Chiropractic management of low back pain and low back related leg complaints – draft for stakeholder critique – Release to be determined - 4 – Stakeholder review draft. Not for distribution otherwise or for attribution. Best practices: Chiropractic management of thoracic pain and costovertebral disorders – draft for stakeholder critique –Release to be determined Best practices: Chiropractic management of upper extremity disorders – draft for stakeholder critique – Release to be determined Best practices: Chiropractic management of lower extremity disorders – draft for stakeholder critique – Release to be determined Best practices: Chiropractic management for soft tissue disorders and fibromyalgia – draft for stakeholder critique –Release to be determined Best practices: Chiropractic management for prevention, wellness, nonmusculoskeletal disorders and special populations– draft for stakeholder critique –Release to be determined What Constitutes Evidence for Best Practice? John J. Triano, DC, PhD, FCCS(C) Co-Chair, Research Commission, CCGPP Integrated - multidisciplinary practice Texas Back Institute, Plano, Texas Introduction Health care in the United States is broken. The Institute of Medicine published its report, Crossing the Quality Chasm 1in 2001 noting the critical need to address organizational support process, evidence-based practice infrastructure, effective use of information technology, and alignment of payment incentives to support quality. None of the stakeholders in the health care system are satisfied with today’s bureaucratic and adversarial system. Although the American system is number one in emergency care, it ranks number 37 in overall quality of care. Appropriateness of treatment is being questioned on all fronts and for all disciplines. As much as 85% of current health care practices remain scientifically invalid despite the jurisdictional claims of medicine to scientific supremacy 2. The perception of over-utilization and inappropriate utilization of care have been widely discussed and the importance of under-treatment has been acknowledged but with lesser emphasis. The unsuitable conduct of a minority of professionals; health care providers and attorneys has been used by policy makers and payers to leverage clinical decision making from the confidential realm of the doctor-patient relationship through the interjection of third-party case managers. Although the imposition of third party payers into the directing of key aspects of clinical decision-making helped slow the health cost increases during the 1990’s, savings came primarily from reduction of reimbursements and some administrative efficiencies. In fact, the additional administrative oversight has increased overhead costs for doctors and reduced the face-to-face time the can - 5 – Stakeholder review draft. Not for distribution otherwise or for attribution. spend with patients and read the literature. The cost of additional bureaucracy now is a factor. Health care costs have begun to increase again. This has slowed the advancement of new knowledge through research, and increased distrust between patient and provider. It has fostered suspicion among all members of the health care infrastructure and a loss of faith in the idea of a durable and adequate social safety net for patients. Undertreatment, especially in the management of pain, is a serious problem. Some suggest that there is evidence of increasing chronicity and expense associated with under-treatment. The American Pain Society and World Health Organization have called attention to both under-treatment of pain and acceptable standards of care. In 43% of households in the United States at least one member experiences chronic pain. Of these, 84% have medical insurance (42% indemnity, 20% Medicare and supplemental, 6% Medicare only). Skeletal pain accounts for 48% (back pain 35%, L BP 23%, disc 9%, upper/mid back 4%, knee 5%, neck 4%, shoulder/arm 3%, ankle/foot 2%, joints 2%, bones 2%, hip 2%, chronic bursitis 1%). Those with LBP are less likely to be under care (p=0.0002) than other disorders. A total of 40% of interviewees suffer constant pain while 60% are intermittent in their symptoms. As reported by Lazarus and Neumann (2001) 3, the majority do not consider their current treatment adequate. Seventy-six percent have tried alternative therapies including chiropractic with results rated somewhat successful (50%), very successful (19%), and extremely successful (8%). Pain effects on the quality of life have been documented: Nineteen percent say it affects their employment (6.2 hours per month per patient). Severe pain patients lose 8.2 hrs per month. Pain interferes with normal activities of daily living as well as preventive health efforts - Exercise 46%; Sports 43%; Sleep