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October 2006, Vol. 16, No. 4
Table of Contents
Do 90% of Acute Low Back Pain Episodes Resolve Within Two Months Regardless of Treatment Rendered? • Blues Already Using CCGPP to Cut Claims! • CBP® Annual Awards • Chiropractic, Disease, Adjustments and Other Voodoo! • Effective Initial Exam • It's Don's Opinion • Letters to the Editor • Neurosurgeon Heralds Posture Pump® MRI Study • New PCCRP X-ray Guidelines Will Protect Your Rights • Association of NJ Chiropractors OPEN LETTER to the CCGPP • PosturePrint® Head Manuscript Accepted by JMPT • Research Corner • The Benefits of Short Duration Whole Body Vibration • Triano and CCGPPs Will Give You Six Visits Part II • PostureRay™: Digital X-ray Digitization and Analysis has Finally Arrived
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Association of NJ Chiropractors' OPEN LETTER to the CCGPP
by Thomas J. Sidoti, DC
Dear Members of the CCGPP Board,
The Association of New Jersey Chiropractors (ANJC) notes that many questions concerning the development, review process, and distribution of the Council on Chiropractic Guidelines and Practice Parameters’ (CCGPP) Low Back document have been raised by the chiropractic profession. In an effort to clarify the many issues that have been raised, the ANJC respectfully requests that CCGPP formally address each of the following points:
1.) The profession has raised serious concerns about the evidence utilized by CCGPP. It has been noted that the United States Department of Health and Human Services, Oxford Centre for Evidence-based Medicine, and the Department of Public Health Sciences King’s College London all define “Levels of Evidence” for ranking the validity of evidence for use in evidence-based research. The highest levels of evidence (Level 1) are always Randomized Controlled Trials (RCT’s) and Systematic Reviews of the Literature (SR’s), followed by Cohort Studies, Case Studies, and Case Series (Levels 2, 3, and 4). In all instances, Expert Opinion is ranked the lowest possible form of evidence (Level 5) and should only be used when other evidence does not exist.
It is well known that hundreds of published peer-reviewed studies that support numerous chiropractic diagnostic and treatment methods exist that are rated Levels 2, 3, and 4. Despite the abundance of such evidence, CCGPP appears to have refused to consider these studies and instead relied only on certain Level 1 evidence and the remainder on their own Level 5 personal opinion.
Please explain CCGPP’s rationale for utilizing the Level 5 opinion of its panel members in drafting the Low Back document and its failure to consider the wealth of evidence that supports chiropractic diagnostic and treatment methods that are far more highly rated as Level 2, 3, and 4.
2.) CCGPP classifies the Low Back Document as “Chiropractic Best Practices.” A Best Practice is defined as “a technique or methodology that, through experience and research, has proven to reliably lead to a desired result.” There has been expectation that a Chiropractic Low Back Best Practices document would therefore provide Chiropractic methodology that would provide Doctors of Chiropractic with the Best Practices to achieve the best outcome for Low Back Conditions. The profession has noted that the CCGPP Low Back document does not provide this guidance, and question has been raised as to its utility for Doctors of Chiropractic.
Please explain how the CCGPP Low Back document can be used by Doctors of Chiropractic to better care for specific Low Back conditions.
Please explain why specific chiropractic techniques for specific low back conditions are not addressed.
3.) The profession has raised concerns about possible conflicts of interest between CCGPP and the Work Loss Data Institute (WLDI) (http://www.worklossdata.com/). WLDI is a small independent database development company with one office in San Diego, CA and one in Corpus Christi, TX. WLDI sells evidence-based treatment guidelines primarily relating to workers compensation and disability. These guidelines are sold to the insurance industry and various state and local disability agencies for use in the review of claims. The WLDI website indicates that CCGPP will make its Chiropractic Low Back document available to them by late 2006.
Please explain the method by which CCGPP selected WLDI, a small company that primarily sells workers compensation and disability guidelines to the Insurance Industry, to sell and distribute the CCGPP Chiropractic Low Back document.
Please explain how much WLDI stands to profit, if any, from the sale of the CCGPP Low Back document.
Please explain if CCGPP will derive any financial benefit from providing any chiropractic document to WLDI, or if it will share in any WLDI profits, if any, from the sale of the CCGPP Low Back document.
Please explain why CCGPP did not select the Congress of Chiropractic State Associations (COCSA) to sell and distribute the CCGPP Best Practice documents directly, with proceeds going to the chiropractic profession.
4.) It has been noted by the profession that the WLDI website highlights the Chiropractic Treatment Guideline for a diagnosis of Low Back Pain (ICD 724.2) as follows: (http://www.odg-disability.com/bp/724.htm#724.2)
Chiropractic Guidelines:
Therapeutic care —
Mild: 6 visits over 2 weeks
Severe: Trial of 6 visits over 2 weeks
Severe: With evidence of objective functional improvement, total of up to 18 visits (12 additional) over 6-8 weeks, avoid chronicity of care
Elective care — As needed
The Question has been raised as to why CCGPP would utilize WLDI as a distribution company when it already markets, in our opinion, extremely restrictive chiropractic treatment guidelines of six (6) visits for two weeks, and up to 18 visits over 6-8 weeks (only for severe cases with objective functional improvement) for low back pain.
Please explain CCGPP’s rationale for selecting a guideline distribution company that already markets, what is in our opinion, excessively restrictive Chiropractic Treatment Guidelines to the Insurance Industry.
Please explain if the CCGPP Low Back Guideline can be used to refute the above referenced six-visit Chiropractic Treatment Guideline marketed by WLDI.
• If yes, please explain how.
• -If yes, please also explain if CCGPP has arranged with WLDI to stop marketing the six-visit guideline in exchange for providing its company with the CCGPP Low Back document.
Please explain the Frequency and Duration protocols that the CCGPP panel feels the evidence in the Low Back document can support.
If the CCGPP Low Back document cannot be used to refute the above noted six-visit guidelines, please explain the benefit to the profession of publishing the CCGPP Low Back document.
5.) The profession has raised potential conflict-of-interest concerns that John Triano, D.C., CCGPP Research Commission Chair, is (or was) a member of the WLDI Board of Advisors. This concern is based on the fact that Dr. Triano was listed as such a member on the WLDI website as recently a few months ago. When questions were raised about this relationship, Dr. Triano’s name was abruptly removed from the website. Internet Archives of WLDI’s web pages confirm that Dr. Triano was listed as a member of the WLDI Board of Advisors for more than three years prior to his name being removed.
Please explain Dr. Triano’s role with WLDI during the three years he was a member of WLDI’s Board of Advisors and why this position was not a conflict of interest.
Please explain if Dr. Triano’s personal relationship with WLDI played a role in CCGPP’s decision to contract with WLDI to distribute the CCGPP Low Back document.
Please clarify what role Dr. Triano played in the development of the six-visit Chiropractic Treatment Guidelines currently marketed by WLDI to the Insurance Industry.
6.) The profession has noted that CCGPP has repeatedly asserted that the Low Back document is NOT a guideline. Question has been raised as to why WLDI’s website is specifically marketing CCGPP’s product to the Insurance Industry as a Chiropractic Guideline. The exact language used on the WLDI website is as a follows: “the new chiropractic guidelines will be the official guidelines of another major medical specialty group, the chiropractic professionals.”
Please explain why CCGPP refuses to classify its Low Back document as a “Guideline” to the Chiropractic Profession, but permits WLDI to specifically market the document as a “Guideline” to the Insurance Industry.
7.) The profession has raised concerns that the Low Back document is for all practical purposes a de-facto guideline, and will be used as such by the Insurance Industry. CCGPP has asserted that “Best Practices” differ from “Guidelines” in that guidelines have frequency and duration limits, and best practices do not. A review of the other chiropractic guidelines calls into question this assumption. For example, the Council on Chiropractic Practice (CPP) Clinical Practice Guideline on Vertebral Subluxation does not have frequency and duration limits, but was accepted for inclusion in the National Guideline Clearinghouse (NGC) as well as Healthcare Standards Official Directory. Michelle Tregear, PhD, NGC Project Manager, specifically addressed this issue in a letter dated March 17, 2006 as follows:
The phrases ‘best practice’, ‘clinical guideline’, ‘standard of care’, etc, are used in many different contexts and some terms are more defined than others. Please note the NGC inclusion criteria which rely on the Institute of Medicine (IOM) definition:
“Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. [Institute of Medicine. (1990). Clinical Practice Guidelines: Directions for a New Program, M.J. Field and K.N. Lohr (eds.) Washington, DC: National Academy Press. page 38].”
Please explain CCGPP’s rationale for distinguishing between a “Guideline” and “Best Practice” document.
Please explain CCGPP’s rationale for distinguishing the Low Back document as a Best Practice as opposed to a Guideline.
8.) The profession has raised concerns that the CCGPP Low Back document does not include Frequency and Duration approximations for specific conditions. The primary concern is that the lack of such approximations will allow the insurance industry to interpret the evidence to devise their own Frequency and Duration approximations that will severely limit chiropractic care.
Please explain why chiropractic Frequency and Duration approximations have been omitted from the Low Back document.
9.) The profession has raised concerns that the CCGPP Chiropractic Low Back document is in fact a joint effort between CCGPP and WLDI. There is greater concern that WLDI and CCGPP are developing a joint protocol for Frequency and Duration of effective chiropractic treatment. This is particularly concerning in light of WLDI’s long standing adherence to six-visit Chiropractic Treatment Guidelines. Internet Archives of web pages removed from the WLDI website confirm that such a joint effort with CCGPP was underway. The following paragraph is taken directly from archived pages of the WLDI website:
• CCGPP Chiropractic Practice Guidelines — Development by WLDI and the Council on Chiropractic Guidelines and Practice Parameters is underway, and this joint protocol for frequency and duration of effective chiropractic treatment is expected later in the year.
Please explain any collaboration between CCGPP and WLDI as it pertains to the above statement.
Please also explain and provide any Frequency and Duration protocols for effective chiropractic treatment as described in the above statement.
10.) The profession has raised questions regarding the CCGPP “Rapid Response Team.” In a recent public E-mail, Ronald J. Farabaugh, D.C., CCGPP Secretary, offered the following:
Our enemy includes those who would use this or any other document incorrectly to line their own pockets.....primarily the consultants, not all consultants, but bad consultants. This remains the primary reason why CCGPP is forming a Rapid Response Team to address issues of document misuse. We will not sit idly by and allow bad consultants to negatively affect patient care with their own self-serving misinterpretation of this document/process.
Please explain the protocols for the CCGPP Rapid Response Team.
Please provide the names of the members of the CCGPP Rapid Response Team. If the team is not already formed, please advise if the team will be in place at or before the time the CCGPP Low Back document is released.
Please advise how many members will be on the CCGPP Rapid Response Team and explain how they will be chosen.
Please explain the CCGPP plan to defend practicing chiropractors from misuse of the document.
As an example, please explain how the CCGPP Rapid Response Team will defend chiropractors that treat patients with radiculopathy if their claims are denied because the CCGPP Low Back document does not include chiropractic indications for radiculopathy.
Please provide examples of what the CCGPP considers “good” versus “bad” consultants. Please explain the methodology used in this determination.
11.) The profession has noted that the CCGPP relies heavily on the Guidelines for Chiropractic Quality Assurance and Practice Parameters (Mercy Guidelines). The Mercy Guidelines is, in our opinion, a flawed 13-year-old document that has been de-listed from the National Guideline Clearinghouse and has been generally rejected by the chiropractic practitioner community.
Please explain why CCGPP relied on the flawed Mercy Guidelines for this document.
12.) The profession has noted that CCGPP has lumped together all manipulative procedures as “manipulation” despite the fact that adjusting techniques vary widely. Techniques such as Diversified, Logan Basic, Activator, CMRT, SOT blocking, etc., utilize different protocols and may result in different outcomes.
Inasmuch as the Low Back document is designed to assess manipulative treatment for the benefit of the chiropractic profession, please explain why specific types of adjusting techniques and/or other treatment utilized is not described in detail so as to be of value to the treating chiropractor. Please also explain why experts in the various chiropractic techniques were not appointed to the CCGPP panel to aid in the development of the Low Back document.
13.) The profession has noted that the CCGPP has specifically singled out Traction as “Not Supported by Fair Evidence from Relevant Studies.” No distinction is made between the various forms of traction such as Flexion-Distraction, Axial/Longitudinal Traction and Extension Traction. Concern has been raised that the draft document’s conclusion will therefore be utilized by third-party payers as a basis to justify non-payment of all traction services including decompression procedures (DRX 9000, etc.), intersegmental traction procedures (Anatamotors, etc.), manual distraction flexion/extension procedures (Cox, etc.), and various traction devices (Posture Pumps, etc.).
Please explain why distinctions between the various forms of Traction were not made.
Please explain why CCGPP used Level 5 personal opinion to determine that Traction was not supported by evidence despite the availability of numerous studies supporting these procedures with evidence rankings of Level 2, 3, or 4.
Please explain how the CCGPP Rapid Response Team will defend Doctors of Chiropractic with traction claims denied based on the CCGPP rating.
14.) The profession has noted its opinion that the CCGPP section on diagnostics appears incomplete, dated, and biased. X-ray and Surface EMG (SEMG) are but two procedures in which CCGPP erroneously claimed that there was no new or recent research of consequence when in fact numerous studies have been shown to be published that were ranked as Level 2, 3, and/or 4.
Please explain why CCGPP used Level 5 personal opinion to determine that various X-ray and Surface EMG procedures only be approved for limited use despite the availability of numerous recent studies supporting the use of X-ray and SEMG for numerous chiropractic applications with evidence rankings of Level 2, 3, and/or 4.
15.) The profession has noted that the CCGPP has omitted procedures such as Manipulation under Anesthesia and others that are used in a significant number of chiropractic practices. Concern has been raised that these omissions may result in a lack of insurance reimbursement for these services.
Please explain why Manipulation under Anesthesia and other common chiropractic procedures have been omitted, potentially giving the Insurance Industry a rationale for denying reimbursement for these procedures.
16.) The profession has noted that the CCGPP uses the term “subluxation,” but includes no operational definition. As a document designed for the chiropractic profession, the omission of such a definition is problematic.
Please explain why the term “subluxation” is not defined.
17.) The profession has noted that the CCGPP document fails to adequately consider causes of the subluxation and attendant low back problems, and how etiology may affect treatment choices. The document also fails to recognize the effectiveness of chiropractic treatment for complex cases such as those involving radiculopathy.
Please explain why the causes of subluxation and attendant low back problems, and how etiology may affect treatment choices, are not adequately addressed.
Please also explain why the document fails to recognize the effectiveness of chiropractic treatment for complex cases such as those involving radiculopathy, etc.
18.) The profession has raised concerns that the CCGPP document does not properly represent the practice methods of the chiropractic profession. It has been noted that the Low Back document has not been endorsed by any major national chiropractic organization, with most publicly calling for its withdrawal. In addition, approximately 30 state chiropractic organizations have so far also called for its withdrawal. Question has been raised as to how CCGPP will address this issue.
Please advise if CCGPP will allow the chiropractic profession to review and approve or disapprove the final version of the Chiropractic Best Practices Low Back document before it is released to WLDI or other parties.
Please explain CCGPP’s procedure if the Low Back document is rejected by the majority of the profession.
Please advise if the CCGPP will withdraw the Low Back document if the majority of the chiropractic profession requests this action.
The ANJC looks forward to an open professional dialog between the CCGPP and chiropractic profession on this important matter. We ask that the above noted concerns be promptly and respectfully addressed.
Thank You,
Thomas J. Sidoti, D.C., Chairman
ANJC Literature Search Committee
Dr. Tom Sidoti is a 1984 graduate of Life Chiropractic College and maintains a family practice in Passaic, NJ. He currently serves on the Board of Directors of both the regional Council of NJ Chiropractors (CNJC) and statewide Association of NJ Chiropractors (ANJC). Dr. Sidoti also serves as Chairman of the ANJC Literature Search Committee which recently produced and submitted a comprehensive 36-page comment to the CCGPP Low Back draft. The comment outlined numerous faults with the document and recommended that it be withdrawn.
Dr. Sidoti is a former Vice President of the NJ State Board of Chiropractic Examiners, and served as chairman of its Rules and Regulations Committee. During his term he was selected as one of NJ’s representatives to the Federation of Chiropractic Licensing Boards (FCLB), and was also selected by the National Board of Chiropractic Examiners (NBCE) to help write one of its Part III National Board Examinations. Some of Dr. Sidoti’s accomplishments include Life University “Alumnus of the Year” and CNJC “Chiropractor of the Year.”
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