Council on Chiropractic Guidelines and Practice Parameters Best Practice: The Chiropractic Clinical Compass

Mark Dehen, D.C.

The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) is currently in the process of developing the new Chiropractic Clinical Compass. This is a best practices document designed to direct the doctor of chiropractic toward a comprehensive health solution for the patient, rather than providing only a cookbook recipe for a particular condition. The Chiropractic Clinical Compass will accomplish this by providing the field practitioner with the latest, most comprehensive compilation of relevant research available, while also incorporating the doctor’s experience, the patient’s preferences, and available resources.

Best practices are “patient centered,” and are designed to ensure quality health care with a focus on patient preference. Best practices are also guided by and dependent upon the hands-on experience of the practitioner and the best available external evidence, such as prognostic markers/outcome measures and therapeutic regimens for an appropriate trial of care.

In an article on evidence-based patient care in the 1997 publication “Seminars in Perinatology,” Dr. DL Sackett from the Oxford University writes “Evidence-based (care) means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that we individual clinicians acquire through clinical experience and clinical practice. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient-centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens.

“Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by external evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best external evidence, practice risks becoming rapidly out of date, to the detriment of patients.”

Therefore, the first responsibility of the doctor of chiropractic is to develop an understanding of the patient’s health care needs, associated with their presentation, prior to developing a plan for intervention. The central core of clinical practice should and does focus around the needs of the patient. Clinical practice is “patient-centered care” delivered with integrity and that determines what, why and how we practice.

This approach is in keeping with the traditional chiropractic values of attaining good health through structural balance, lifestyle interventions and patient activity. This combination has resulted in the chiropractic profession’s successes, particularly the profession’s high patient satisfaction ratings.

Today, health-care research is exploding in volume and the typical practicing DC has difficulty staying abreast of the information. The Chiropractic Clinical Compass will consolidate that information into a readily accessible database for the doctor’s use. More importantly, this information will be viewed from a chiropractic perspective. By centralizing the relevant research and rating its strength, the CCGPP hopes to create a paradigm shift in the practicing DC by providing a convenient, powerful tool for use in patient care. Also, by rating the evidence, the CCGPP will identify chiropractic’s efficacy to chiropractors, patients, other health care professionals and third party payers.

This compilation will also recognize those areas where the evidence is not very strong. When this is the result of a lack of credible evidence, it can serve as an indication for further research. In instances where the evidence for care is sparse or absent, especially where the evidence doesn’t indicate clear contraindications to care, the strength of provider experience in conjunction with patient preference may warrant support for individual treatment options. The Compass will support these care choices through specific consensus processes that have been deemed acceptable scientific methods for “filling in the gaps” where external evidence is lacking. The Chiropractic Clinical Compass will provide doctors with the supporting information to make reasonable, informed health-care decisions. The document will assist the doctor’s explanation of the rationale for treatment to the patient, case managers and third party payers. In addition, the Compass will be able to provide that initial second opinion the doctor occasionally needs. The Chiropractic Clinical Compass also recognizes the individuality of patients and helps to balance their preferences with reasonable treatment options, allowing for tailored care.

It is this balanced approach that drew the CCGPP to the best practices format. The chiropractic profession is in the forefront of health-care provider groups to gravitate toward evidence-based practice, and the Compass efforts will bring that effort to the next level. One important reason for moving to a best practice approach and away from a “Guidelines” approach is the unfortunate tendency for guidelines to be used as care end points rather than as suggestions for typical cases. Best practices documents like the Compass recognize the individuality of the patient, his or her physician and the circumstances of care.

The CCGPP was formed in 1995 at the behest of the Congress of Chiropractic State Associations (COCSA) to address ongoing guidelines development and refinement. Eventually the committee decided upon a “best practice” initiative. The CCGPP’s goal was to represent a diverse cross-section of our profession, offering differing points of view. While not all have chosen to participate, every legitimate national chiropractic organization has been invited to take part.

Members were appointed by the professional organizations that formed CCGPP in 1995, including the American Chiropractic Association (ACA), Association of Chiropractic Colleges (ACC), Council on Chiropractic Education (CCE), Federation of Chiropractic Licensing Boards (FCLB), Consortium for Chiropractic Research (CCR), Foundation for Chiropractic Education and Research (FCER), International Chiropractors Association (ICA), National Association of Chiropractic Attorneys (NACA), Foundation for the Advancement of Chiropractic Tenets and Science (FACTS), and the National Institute for Chiropractic Research (NICR). In addition, six members of CCGPP were appointed by COCSA. ICA, FACTS and CCE have since left CCGPP. The CCR no longer exists.

Today, the CCGPP is a steering organization comprised of one educator, one researcher, one vendor, one consumer, two attorney representatives and 16 full time practicing chiropractors. Their mission is to oversee the best practices development project, procure funding and support and work on the dissemination, implementation, evaluation and revision (DIER) process.

This DIER process initially began in 2000 with a baseline survey to assess the chiropractic profession. As the document sections are released in 2006, there will 25 be a 60-day comment period open to stakeholders. The CCGPP is encouraging considerable involvement in this phase. The document will then be revised accordingly. The Chiropractic Clinical Compass will then be formally released in totality and training will begin in the colleges and with practicing chiropractic doctors to create uniformity in its implementation across the profession.

The actual document is being developed by the CCGPP Research Commission. This commission, composed of a group of scientists and academicians who are well-known within our profession and have had experience in this area or have necessary skillsets. Many of come from chiropractic colleges and serve at the request of CCGPP. This body is gathering, rating, and summarizing the research and producing the final best practice document. Currently, over 50 individuals are on the research commission.

The Best Practices document has been divided up into the following areas:

  1. Low Back and related lower extremity conditions
  2. Neck and related upper extremity conditions
  3. Thoracic and costovertebral disorders
  4. Upper Extremity condition, not related to neck
  5. Lower Extremity conditions, not related to low back
  6. Myofascial and soft tissue disorders
  7. Non-musculoskeletal, prevention, wellness and special populations

The Compass, with its extensive research net, editorial independence and autonomous DIER process, intends to avoid the pitfalls that have befallen previous chiropractic guideline-development efforts. Over the last decade a significant body of science has emerged to ensure the validity and veracity of best practices development. These recommendations and tools are being implemented by the CCGP Research Commission to safeguard the integrity of the Compass. Most importantly, by utilizing the chiropractic colleges and state associations to educate doctors and students, as well as third party payers, governmental regulators and others in the proper use and interpretation of the Compass, the CCGPP intends to limit rumors, misconceptions and inappropriate application.

As part of the DIER process, the CCGPP will be developing a variety of vehicles to distribute the information. The goal is to provide a dynamic database that will change with the addition of new research and other information. The CCGPP is mandated to regularly revise the document on a biannual basis to capture fresh advancements in the literature. The CCGPP also recognizes that different people comprehend information in different ways. Thus, the CCGPP intends to provide access to the Compass in a variety of formats. The Chiropractic Clinical Compass also intends to respect the spectrum of philosophical orientations in our profession. Therefore, the CCGPP has adopted the Pyradigm concept. Chiropractic, like all other health care professions, has a theory of how things work, a way of looking into that theory and a way of applying that theory. We often refer to these as the philosophy, science and art of chiropractic.

The Pyradigm is a way of looking at a system of relationships. In this case, the Pyradigm is composed of four components: philosophy, science, art and the Chiropractic Compass and their relationships to one another. This systems-view allows each chiropractor to see themselves within it. Philosophy proposes theories in order to add meaning to what we do, but some doctors are more attracted to the practical results that come from practice. Others are more drawn to the science side where ferreting out the “truth” is of paramount importance. Some chiropractors focus on patient care with the patient’s satisfaction as the primary goal. Every doctor, despite a preference for one perspective, relies on all three components for a meaningful, effective and satisfying practice. This systems-view incorporates and honors all of these perspectives.

The lack of this systems-perspective, in addition to our inability to have constructive dialogue within the profession, continues to pose great problems. The chiropractic profession is at a point in history where it will either do the hard work or run the risk of other professions doing it; leaving us in the dust to our in fighting.

Despite this spectrum of philosophies and experience within the chiropractic profession, there is one constant: the basic tenet of “Primum non nocere” -“First, do no harm” — or do what is best for each patient. This is the goal of the Chiropractic with its balanced approach of incorporating relevant clinical research, the clinical experience of the treating doctor and patient preferences and values.

To date this great undertaking has been solely underwritten by your profession and its related organizations and friends. Although applications are in for federal funding, we are in great need of additional funding to make this project successful. We ask that you show your support for your profession by sending contributions to the CCGPP at PO Box 2054, Lexington, SC 29071 or 13 ccgpp@sc.rr.com.

Finally, as Thomas Edison said, “the Doctor of the future will give no medicine, but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease”. Let the Chiropractic Compass point the way!

About the Author

Dr. Mark D. Dehen is a second generation Doctor of Chiropractic practicing in North Mankato, MN. He 20 does ergonomic consulting and injury prevention for local industries. Dr. Dehen is a past president of the 21 MN Chiropractic Association and recipient of the MN Chiropractor of the Year award. Currently, he serves as Treasurer of the CCGPP.