using ccgpp to build a strong and profitable practice

Using CCGPP to Build a Strong and Using CCGPP to Build a Strong and Profitable PracticeProfitable Practice

“The Commission”The Commission”

• The Commission is the scientific arm of the organization (i.e. the researchers)

• Products: Literature syntheses, guidelines, inclusion in the National Guideline Clearinghouse.

““The Clinical The Clinical Compass”Compass”

• Is the “process” for translating evidence into knowledge.

• Includes the various strategies of the DIER process (Dissemination, Implementation, Evaluation, Revision).

• Products: Seminars, products, webinars, articles, websites, various versions of the literature syntheses recommendations.

““WHAT is CCGPP?”WHAT is CCGPP?”

““WHY CCGPP?”WHY CCGPP?”

The CCGPP's missionThe CCGPP's mission is to provide is to provide consistent and widely adopted consistent and widely adopted chiropractic chiropractic practice informationpractice information, to perpetually , to perpetually distribute and update this data as is distribute and update this data as is necessary, so that necessary, so that consumers and others consumers and others have reliable information on which to base have reliable information on which to base informed health care decisions.informed health care decisions.

““Council on Chiropractic Guidelines and Practice Council on Chiropractic Guidelines and Practice Parameters (CCGPP)”Parameters (CCGPP)”

CCGPP was also delegated to examine all CCGPP was also delegated to examine all existing existing guidelines, parameters, protocols guidelines, parameters, protocols and best practices and best practices in the United States and in the United States and other nations with a chiropractic lens. other nations with a chiropractic lens.

Participation and process have been as Participation and process have been as transparent as possible and a major goal is transparent as possible and a major goal is to represent a diverse cross-section of the to represent a diverse cross-section of the profession on the projects that CCGPP has profession on the projects that CCGPP has been involved in.been involved in.


CCGPP was charged with CCGPP was charged with developing guidelines developing guidelines regarding the most common regarding the most common conditionsconditions treated by treated by chiropractic physicians.chiropractic physicians.

Condition-based care is consistent with that found Condition-based care is consistent with that found throughout the healthcare industry today, thus the throughout the healthcare industry today, thus the focus of CCGPP’s efforts.focus of CCGPP’s efforts.


Since its inception, CCGPP has had tremendous success fulfilling its mission. In addition to over 12 Chapters/Literature Syntheses produced, CCGPP has also completed and published multiple guidelines which now appear in the National Guideline Clearinghouse.


Step 1: Step 1: Be Aware of Available Be Aware of Available

ResourcesResources

1. A wealth of information is available on the CCGPP website at www.ccgpp.org.

2. All completed literature syntheses and consensus guidelines have been published in www.jmptonline.orgwww.jmptonline.org, , and

3. submitted for inclusion in the National Guideline Clearinghouse at www.guideline.gov.

CCGPP Website Informationhttp://www.ccgpp.org


1. Acute Low Back Pain

2. Chronic Spine Pain

3. Terminology4. Lumbar5. Lower Extremity6. Nonmusculoskelet

al7. Fibromyalgia8. Methodology

9. Myofascial Trigger Points

10. Tendinopathy11. Wellness12. What Constitutes

Evidence.

13. Thoracic and 14. Upper extremity

chapters Completed: In Process


15.Cervical and16.Diagnostic Imaging reports have

been issued.

Be Aware of Available ResourcesBe Aware of Available Resources

Top Four PapersTop Four Papers

PlusPlus

Published ChaptersPublished Chapters

Delphi AcuteAcute Low Back Guideline:

CHIROPRACTIC MANAGEMENT OF LOW CHIROPRACTIC MANAGEMENT OF LOW BACK DISORDERS: REPORT FROM A BACK DISORDERS: REPORT FROM A CONSENSUS PROCESSCONSENSUS PROCESS, JMPT Oct 2008, Globe, Morris, Whalen, Farabaugh, Hawk, DC,


Delphi ChronicChronic Care Guideline:

Management of Chronic Spine-Related Management of Chronic Spine-Related Conditions: Consensus Conditions: Consensus Recommendations of a Recommendations of a Multidisciplinary Panel:Multidisciplinary Panel: JMPT September 2010, Farabaugh, Dehen, Hawk.


TerminologyTerminology Paper:

Consensus Terminology for Stages of Consensus Terminology for Stages of Care: Acute, Chronic Recurrent and Care: Acute, Chronic Recurrent and WellnessWellness, JMPT August 2010, Dehen, Whalen, Farabaugh, Hawk. (Published July/August 2010)


NEW CHAPTER:NEW CHAPTER:

Effort spearheaded by Drs. Carl Cleveland III and Jay Triano. Principle investigator(s): Brian Budgell, DC, PhD

COST: $60,000COST: $60,000


RENAMED to: RENAMED to: ““Determining the Site of Care: What is the Evidence Determining the Site of Care: What is the Evidence

Regarding the Primary Methods Used to Locate the Regarding the Primary Methods Used to Locate the Site of Treatment Used by Chiropractors: a Site of Treatment Used by Chiropractors: a

Proposed Formal Literature Systhesis.Proposed Formal Literature Systhesis.””

Project Goal:Project Goal:

• This chapter will provide the evidence related to the rationale basis of performing spinal manipulation on a particular spine site.

New Chapter: New Chapter: Formerly the “Subluxation Chapter”Formerly the “Subluxation Chapter”


Step 2: Step 2: Highlights of the Chronic Highlights of the Chronic

Pain GuidelinePain Guideline

““Chronic Care Recommendations”Chronic Care Recommendations”

Comment: Not every patient who suffers a flare-up of their symptoms needs ongoing care for an extended period of time. The consensus panel recommend up to four visits after TW, followed by re-evaluation to determine the need for care or ability to discontinue care and transition that patient to home/self care. If further care is indicated If further care is indicated based upon TW and re-evaluation, the panel based upon TW and re-evaluation, the panel recommended up to 4 visits per month, to be recommended up to 4 visits per month, to be re-evaluated minimally every 12 visits. re-evaluated minimally every 12 visits. See Table 5 for more information on dosaging.

“Patient recovery patterns vary depending on degrees of exacerbations. Mild exacerbation episodes may be manageable with 1-6 office visits within a chronic care treatment plan. There is not a linear effect between the intensity of exacerbation and time to recovery.25 Moderate and severe exacerbation episodes within a chronic care treatment plan require acute care recommendations and case management.” (Page 6-7 Scheduled ongoing chronic pain management treatment planning. See Table 5)

Comment: It is important to recognize the difference between those patients who need ongoing “scheduled” care versus those patients who suffer acute exacerbations of their chronic pain. Acute exacerbations often require increase care as described in Table 5.

Chronic care goals are to:

1. Minimize lost time on the job2. Support patient's current level of function/ADL3. Pain control/relief to tolerance4. Minimize further disability5. Minimize exacerbation frequency and severity6. Maximize patient satisfaction7. Reduce and/or minimize reliance on medication

(Page 7. Chronic Care Goals)

Comment: Remember that once a case has progressed to a state of maximal medical improvement with the patient unable to return to a pre-accident state, no advancement or improvement in visual analog (VAS) or outcome assessment (OAT) scores is expected, and ongoing care may be necessary. The goals of ongoing care are significantly different than that of acute care where one could expect an improvement VAS or OAT scores.

“The management for chronic pain patients ranges from home-directed self-care to episodic care to scheduled ongoing care.” (Page 3 Definition of “Chronic Pain Patients”)

Comment: Chronic pain management includes a population of patients who require “scheduled ongoing care”, which represents a deviation from historically limiting recommendations which supported chronic spine care (spinal manipulation) rendered only in episodes.

“…these patients may be expected to progressively deteriorate as demonstrated by previous treatment withdrawals.” (Page 3 Definition of “Chronic Pain Patients”. Also see Page 5 Clinical Re-evaluation)

Comment: Therapeutic withdrawal (TW) is included as part of proper case management. Without a TW there is no way to determine the stability of the spine and whether or not a patient requires ongoing care. HOWEVER, TW can include HOWEVER, TW can include an abrupt discontinuation of care, OR a gradual an abrupt discontinuation of care, OR a gradual withdrawal. AND, there is no defined time frame for withdrawal. AND, there is no defined time frame for TW. TW. One cannot pre-determine when the patient’s condition will decline, or how long it will remain stable, therefore it would be improper to require a defined time from for TW.

“Ongoing care may be inappropriate when it interferes with other appropriate care or when the risk of supportive care outweighs its benefits, that is, physician dependence, somatization, illness behavior, or secondary gain. However, However, when the benefits outweigh the risks, ongoing care may when the benefits outweigh the risks, ongoing care may be both medically necessary and appropriate.” be both medically necessary and appropriate.” (Page 3 Application of Chronic Pain Management)

Comment: In the past treatment was often denied due to concerns over physician dependency resulting in over reliance on less effective, less safe, and more invasive medical care. This guideline emphasizes that the benefits of spinal This guideline emphasizes that the benefits of spinal manipulation and other types of care rendered by manipulation and other types of care rendered by chiropractic physicians often outweighs the risk chiropractic physicians often outweighs the risk commonly associated with standard medical commonly associated with standard medical management.management.

“Once documented as persistent or recurrent, these chronic presentations should not be categorized as “acute” or uncomplicated.” (Page 3 Application of Chronic Pain Management)

Comment: In the past care was often denied based upon guidelines that were based on “uncomplicated” patients, which is simply not the case with the chronic pain population of patients.

“Prognostic factors that may provide a partial basis for the necessity for chronic pain management of spine-related conditions after MTI has been achieved include:” (Page 3-4 Prognostic Factors.)

Comment: Documentation should include prognostic factors which may help explain the presence or potential for chronic pain.

“Other factors or comorbidities not listed above may adversely affect a given patient's prognosis and management. These should be documented in the clinical record and considered on a case-by-case basis. Each of the following factors may complicate the patient's condition, extend recovery time, and result in the necessity of ongoing care: (Page 4 Prognostic Factors.)

Comment: Documentation should include comorbidities which may help explain the presence or potential for chronic pain.

“Individual factors from this list may adequately explain the condition chronicity, complexity and instability in some cases. However, most chronic cases that require ongoing care are characterized by multiple complicating factors.” (Page 5 Complicating Factor. See table 2.)

Comment: Documentation should include comorbidities which may help explain the presence or potential for chronic pain.

“…the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) conducted a formal consensus process with a multidisciplinary panel of experts…” (Page 2 Chiropractic Management)

Comment: This guideline includes input from not only chiropractic physicians, but also MDs, PT, MT, psychologist, and LAc.

“Those recommendations also held true for the management of chronic LBP, with the judicious addition of one or more interventions, such as back exercises, behavioral therapy, acupuncture, yoga, massage therapy, multidisciplinary rehabilitation, and adjunctive or strong opioid analgesics.4,9” (Page 2 Chiropractic Management)

Comment: Current guidelines, including CCGPP and ODG, include a multimodal approach to the treatment of spine pain, which includes spinal manipulation.

“A number of prognostic variables have been identified as increasing the risk of transition from acute/subacute to chronic nonspecific spine-related pain.” (Page 5 Risk Factors)

Comment: Documentation should include risk factors which may help explain the presence or potential for chronic pain.

“The diagnosis should never be used exclusively to determine need for care (or lack thereof). The diagnosis must be considered with the remainder of case documentation to assist the physician or reviewer in developing a comprehensive clinical picture of the condition/patient under treatment.” (Page 5 Diagnosis)

Comment: Too often ongoing care is denied due to the diagnosis. For example, the diagnosis of “sprain/strain” alone does not portray the potential complexities of a case that need to be considered when determining medical necessity or causation. In addition to prognostic factors, comorbidities, complicating factors, and risk factors, the neurological principles (receptive field enlargement, neuroplasticity, and neurologicl wind-up) related to chronic pain help explain the development of chronic pain even when the diagnosis is as seemingly simple as sprain/strain.

“Clinical information obtained during re-evaluation that may be used to document the necessity of chronic pain management for persistent or recurrent spine-related conditions includes, but is not limited to:” (Page 5 Clinical Re-evaluation Information. See Table 3)

Comment: Documentation should include clinical information which may help explain the presence or potential for chronic pain.

“A variety of functional and physiological changes may occur in chronic conditions. Therefore, a variety of treatment procedures, modalities, and recommendations may be applied to benefit the patient. These include but are not limited to the items indicated in Table 4.” (Page 6 Chronic Pain Management Components. See Table 4)

Comment: Due to the complexities associated with chronic pain, a variety of treatments may be necessary, including passive and active therapies and recommendations. In more complicated cases a multimodal treatment regimen is preferred. In less complicated chronic cases home exercise alone may be all that is necessary to control pain. Other cases may require spinal manipulation only, or NSAIDs only. Remember, each case is unique and patient preferences must be considered as well as the response to care and the other issues mentioned throughout this paper.

“Although the visit frequency and duration of supervised treatment vary, and are influenced by the rate of recovery toward MTI values and the individual's ability to self-manage the recurrence of complaints, a reasonable therapeutic trial for managing patients requiring ongoing care is up to 4 visits after a therapeutic withdrawal. See Table 5 for a summary of dosaging and reevaluation recommendations.” (Page 6. Chronic pain management treatment planning/dosaging. See table 5)

“It is important for the reader to recognize that these guidelines are intended to be flexible and may need to be modified. They are not standards of care. Adherence to them is voluntary. Alternative practices are possible and may be preferable under certain clinical conditions. The ultimate judgment regarding the propriety of any specific procedure must be made by the practitioner in light of individual circumstances presented by each patient.” (Page 7. Discusssion)

Comment: It is important to again emphasize that every case is unique, and each physician must recommend treatment based upon those individual circumstances. It It would be improper for the treating physician or any would be improper for the treating physician or any consultant to recommend denial of treatment based consultant to recommend denial of treatment based upon sole diagnostic test/findings, or based upon upon sole diagnostic test/findings, or based upon research alone. research alone.

In an evidence-based, condition-based, value-based healthcare environment, it remains very critical to recognize the importance of guidelines, in combinations with research, clinical decision-making, and patient values, in addition to the process and progress of care and all the issues mentioned in this paper.


Step 3: Step 3: Contents of Published Contents of Published Guidelines…ExamplesGuidelines…Examples

American College of Physicians

Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline

from the American College of Physicians and the American Pain

Society

2 October 2007 | Volume 147 Issue 7 | Pages 478-491

American College of Physicians

Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic

therapy with proven benefits—for acuteacute low back pain, spinal manipulationspinal manipulation; for chronic or chronic or subacute subacute low back pain, intensive interdisciplinary rehabilitation, exercise interdisciplinary rehabilitation, exercise therapy,therapy, acupuncture, massage therapy, acupuncture, massage therapy, spinal spinal manipulationmanipulation, yoga, cognitive-behavioral, yoga, cognitive-behavioral

therapy, or progressive relaxation therapy, or progressive relaxation (weak recommendation, moderate-quality)

Delphi AcuteAcute Low Back Guideline:

CHIROPRACTIC MANAGEMENT OF LOW CHIROPRACTIC MANAGEMENT OF LOW BACK DISORDERS: REPORT FROM A BACK DISORDERS: REPORT FROM A CONSENSUS PROCESSCONSENSUS PROCESS, JMPT Oct 2008, Globe, Morris, Whalen, Farabaugh, Hawk, DC,


1.Strong evidence supports the use of spinal spinal

manipulation manipulation to reduce symptoms and improve function in patients with acute and acute and subacute low back pain.subacute low back pain.

2.There is good evidence that the use of exerciseexercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence.

3. There is fair evidence for the use of manipulation manipulation for

patients with low back pain and radiating leg pain, low back pain and radiating leg pain, sciatica or radiculopathysciatica or radiculopathy, however, manipulation in combination with other common forms of therapy may be of clinical value.

4. Cases with high severity of symptoms may benefit by referral for co-management of symptoms with referral for co-management of symptoms with medicationmedication.

5. Strong evidence supports the use of spinal spinal manipulation manipulation /mobilization to reduce symptoms and improve function in patients with chronic low back chronic low back painpain.

Stage of Condition

Frequency Duration Re-evaluate after:

Acute 3x weekly 2-4 weeks 2-4 weeks

Sub-acute 3x weekly 2-4 weeks 2-4 weeks

Chronic 2-3 x weekly 2-4 weeks 2-4 weeks

Recurrent/Flare-up

1-3x weekly 1-2 weeks 1-2 weeks

Stage of Condition

Frequency Duration Re-evaluate after:

Acute 2-3x weekly 2-4 weeks 4-12 treatments

Sub-acute 2-3x weekly 2-4 weeks 4-12 treatments

Chronic 1-3 x weekly 2-4 weeks 2-12 treatments

Recurrent/Flare-up

1-3x weekly 1-2 weeks 1-6 treatments

“ROM is commonly used by practitioners for a variety of reasons. It has not been shown to be a It has not been shown to be a valid functional outcome valid functional outcome measuremeasure; however, it may be used as part of determining an impairment rating, or to determine whether a to determine whether a patient responded positively to a patient responded positively to a single treatment sessionsingle treatment session.”

CHIROPRACTIC CHIROPRACTIC MANAGEMENT OFMANAGEMENT OF

UPPER EXTREMITY PAINUPPER EXTREMITY PAIN

Team LeadThomas Souza, DC

Dean of Academic AffairsPalmer Chiropractic College

San Jose, CA 95134

Upper extremity pain, shoulder pain, elbow pain, and wrist pain

Chronicity range: acute, subacute, chronic and recurrent

Evaluation:Rating A: Evaluation: Questionnaires, physical examinations (rotator cuff-full/partial tears, instability, ROM)

Manipulation/MobilizationRating B: MobilizationRating D: Manipulation/HVLA

Conservative Non-Manipulation: Rating: B - for exercise for roator cuff disorders and

impingement syndrome Rating: A - for ultrasound for calcific tendinitis

Recommendation: Chiropractors should consider mobilization approaches to the glenohumeral joinst or cervical spine for patients with shoulder pain. Although, Although, there is no literature support for or there is no literature support for or against high-velocity, low-amplitude against high-velocity, low-amplitude adjusting of the shoulder, based on adjusting of the shoulder, based on expert opinionexpert opinion, we recommend its use with the cautions stated in the main text of the document.

Brantingham JW, Globe G, Pollard H, Hicks M, Korporaal C, Hoskins W. Manipulative therapy for lower Manipulative therapy for lower extremity conditions: expansion of literature review.extremity conditions: expansion of literature review. J Manipulative Physiol Ther. 2009 Jan;32(1):53-71.

Manipulative therapy of lower extremity conditions: Summary of Clinical Practice Recommendations from the Commission of the Council on Chiropractic Guidelines and Practice Parameters

NGC: Summary of Clinical Practice Recommendations

Rating B: Fair evidence for manipulative therapymanipulative therapy of the knee and/or full kinetic chain combined with multimodal or exercise therapy for knee knee osteoarthritis. osteoarthritis.

Rating B: Fair evidence for manipulative therapy manipulative therapy

of the knee and/or full kinetic chain combined with multimodal or exercise therapy for Patellofemoral Patellofemoral Pain Syndrome. Pain Syndrome.


Rating B: Fair evidence for manipulative manipulative

therapy therapy of the ankle and/or foot combined with multimodal or exercise therapy for Ankle Ankle Inversion Sprain. Inversion Sprain.

1.Myofascial trigger points and myofascial pain syndrome

2.Fibromyalgia3.Tendinopathy

Vernon H, Schneider M. Chiropractic management of myofascial trigger points myofascial trigger points and myofascial pain and myofascial pain syndrome:syndrome: a systematic review of the literature. J Manipulative Physiol Ther. 2009 Jan;32(1):14-24.

NGC: Chiropractic management of myofascial trigger points and myofascial pain syndrome: Summary of Clinical Practice Recommendations Recommendations from CCGPP


Conclusion and strength of evidence rating: Conservative non-manipulationConservative non-manipulation

Rating A: laser therapieslaser therapies. There is strong evidence that laser therapy (various types of lasers) is effective in the treatment of MTrPs and MPS.


Rating B: TENS, magnets, and acupunctureTENS, magnets, and acupuncture. There is moderately strong evidence that TENS is effective in the short-term relief of pain at MTrPs. There is moderately strong evidence that magnet therapy is effective in the relief of pain at MTrP and in MPS. There is moderately strong evidence that a course of deep acupuncture to MTrPs is effective in the treatment of MTrPs and MPS for up to 3 mo.

Conclusion and strength of evidence rating: Manipulation/ Manipulation/ mobilizationmobilization

Rating B: short-term relief. There is moderately strong evidence to support the use of some manual therapies (manipulation, ischemic manual therapies (manipulation, ischemic pressurepressure) in providing immediate relief of pain at MTrPs.

Rating C: long-term relief. There is limited evidence to support the use of some manual therapies in providing long-term relief of pain at MTrPs.

Schneider M, Vernon H, Ko G, Lawson G, Perera J. Chiropractic management of fibromyalgia syndromefibromyalgia syndrome: a systematic review of the literature. J Manipulative Physiol Ther. 2009 Jan;32(1):25-40.

NGC: Chiropractic management of fibromyalgia syndrome: Summary of Clinical Practice Recommendations from the Commission of the Council on Chiropractic Guidelines and Practice Parameters


Strong evidence supports aerobic exercise and aerobic exercise and cognitive behavioral therapy. cognitive behavioral therapy.

Moderate evidence supports massage, muscle massage, muscle strength training, acupuncture, and spa strength training, acupuncture, and spa therapy (balneotherapy). therapy (balneotherapy).

Limited evidence supports spinal spinal manipulation, movement/body awareness, manipulation, movement/body awareness, and vitamins, herbs, and dietary modification. and vitamins, herbs, and dietary modification.


Conclusions: Presently there is no single therapy no single therapy or intervention that can be considered a cure for FMS.

Combinations of therapies appear to be most helpfulCombinations of therapies appear to be most helpful, and future research seems to be looking toward strategies by which to find sub-groups of FMS patients who might respond better to certain therapies.

Current literature (since 2006) provide evidence that FMS is not a peripheral disorder of the soft tissues, but rather a disorder of aberrant pain disorder of aberrant pain processing and central sensitization.processing and central sensitization.

Pfefer MT, Cooper SR, Uhl NL. Chiropractic Management of tendinopathytendinopathy: a literature synthesis.J Manipulative Physiol Ther. 2009 Jan;32(1):41-52.

NGC: Chiropractic management of tendinopathy: Summary of Clinical Practice Recommendations from the Commission of the Council on Chiropractic Guidelines and Practice Parameters


Rating A: nothingnothing

Rating B: Ultasound, Eccentric exerciseUltasound, Eccentric exercise

Rating C: Manipulation/mobilization, Manipulation/mobilization, friction friction

massage, acupuncture, surgery, massage, acupuncture, surgery, topicaltopical

NSAIDs.NSAIDs.

BEST PRACTICES: CHIROPRACTIC BEST PRACTICES: CHIROPRACTIC MANAGEMENT OF MANAGEMENT OF

PREVENTION AND HEALTH PROMOTION; PREVENTION AND HEALTH PROMOTION; NONMUSCULOSKELETAL CONDITIONS; AND NONMUSCULOSKELETAL CONDITIONS; AND

CONDITIONS OF CONDITIONS OF THE ELDERLY, CHILDREN AND PREGNANT THE ELDERLY, CHILDREN AND PREGNANT

WOMENWOMEN

Team LeadCheryl Hawk, DC, PhD, CHES

Vice President of Research and ScholarshipCleveland Chiropractic CollegeKansas City and Los Angeles

1. Chiropractic Care for Non-musculoskeletal Conditions

2. Wellness, Health Promotion and Disease Prevention

3. Special Populations: Children

4. Special Populations: Pregnant Women

5. Special Populations: Older Adults

Rating C: Asthma, infantile colic, Otitis media, cervicogenic vertigo, dysmenorrhea

Rating I: other non-musculoskeletal conditions

Rating A: Counseling tobaccousers to quit

Rating A: Counseling sedentary patients to engage in physical activity

Rating I: Spinal manipulation for health promotion


Step 4: Step 4: Fighting BackFighting Back

““Proper Use of Guideline”Proper Use of Guideline”

All guidelines serve merely as background information to assist doctors in the clinical decision-making process.

A guideline serves as a “compass” for care, not a cookbook for care.

Guidelines should never be used punitively, or as prescriptions for care.

Each patient is unique and treatment recommendations must be based on the specific factors pertaining to the individual case.

Guidelines are only one piece of evidence to consider when considering the medical necessity of care. Other pieces of evidence include: 1. research, 2. clinical experience/decision-making, 3. patient values, 4. risk stratification, 5. process of care, 6. response to care, 7. documentation, etc.

Guidelines are not cookbooks with rigid dosages for Guidelines are not cookbooks with rigid dosages for treatment. treatment.

Most, if not all, guidelines like Mercy, ACOEM, ODG, Milliman and Roberston, etc., are based upon the acute, non-complicated patient.

Each case is unique and may present with many complications that should be reported and considered to help clarify why treatment may help clarify why treatment may have extended beyond the natural healing have extended beyond the natural healing time, time, or expected recovery time, compared to a non-complicated, mild, acute case.

Any reviewer/consultant who recommends a denial based upon his/her belief that a guideline was exceeded should volunteer his/her rationale, and/or be challenged to produce the page, produce the page, paragraph, and sentence paragraph, and sentence in the guideline being referenced indicating were the POR/DC exceeded the guideline.

Additionally, exceeding the guideline is NOT the issue in chronic pain management.

“WhyWhy were expected treatment parameters exceeded” IS the question.

Reviewer: Must consider complicating factors, versus the generic “treating non-allowed conditions”.

Pain versus Pathology

Numerous studies suggest that one CANNOT accurately rely upon diagnostic tests to determine the presence or absence of pain.

Therefore, how can a consultant viewing nothing more than a radiology report conclude that pain is generated from non-allowed diagnoses?

State the reason for the appeal Stick to the facts Avoid emotion/Keep it professional! Do not attached the reviewer, but do

attack his/her inaccurate statements.1. “I wish to file an appeal to the denial for the

following reasons:”2. “Consulted stated…..”3. “Response:……”4. End with a brief case summary

We need funding, from both the field doctors and corporate sponsors, in order to fund the Clinical Compass, the Rapid Response Team and future research projects.

Our mission is to generate a pool of funds which can be granted to the colleges to fund research projects and “fill in the gaps” which have been identified through the CCGPP process thus far.

Many thanks to our corporate supporters:

ChiroCode Institute, ChiroCode Institute, Lamont Leavitt, and late D. Henry Leavitt

Core ProductsCore Products and President Philip Mattison who recently committed up to $10,000 in the form of a matching donation. He will donate $1 for every dollar donated by the profession, up to $10,000!

Core Products will provide a free pillowfree pillow per $100 donated to the CCGPP. This “product rebate” will be capped at a total of 500 pillows and will equate to a potential of $50,000 raised by the profession. Doctors pay only freight on pillows earned.

Core Products will provide a 10% discount10% discount on ALL products available through the Core Website for anyone who signs up for a recurring $84/mo for 12 month “membership” to CCGPP.

ACA:

“The profession and ACA are is indebted to CCGPP for its invaluable assistance in gathering the information we have needed to approach insurance companies and regulators to effectively advocate for the profession. In our work with insurers, in this In our work with insurers, in this time when there is an increased focus on time when there is an increased focus on quality care based upon evidence, we find quality care based upon evidence, we find that the message we share must be that the message we share must be undergirded by research.undergirded by research. It is the yardstick used to drive policy change, so to facilitate change that results in favorable adjudication, we must wield the sword of evidence skillfully.”

ACA:

““The responses from CCGPP have shown that The responses from CCGPP have shown that the profession is ready to boldly defend itself the profession is ready to boldly defend itself with the evidence and are framed in a tone with the evidence and are framed in a tone that encourages collaborative dialog.that encourages collaborative dialog. In addition, the resources provided have not only assisted our current battles, but have gone on to prove helpful in many other similar situations. As for service, we have found CCGPP to exceed our expectations with regard to timely response, comprehensiveness of the objective data, and professionalism of reporting. CCGPP is playing a vital role in helping the chiropractic profession and we hope it will for a very long time to come.”

Is now a positive Is now a positive chiropractic chiropractic information website!information website!

Special thanks to Special thanks to Dr. Rob Sheely Dr. Rob Sheely and and the ACAthe ACA

Addendum Resources

What constitutes evidence for best practice? Triano JJ.

J Manipulative Physiol Ther. 2008 Nov-Dec;31(9):637-43.

Literature syntheses for the Council on Chiropractic Guidelines and Practice Parameters: methodology. Triano JJ.

J Manipulative Physiol Ther. 2008 Nov-Dec;31(9):645-50.

Topic: Topic: Background and MethodologyBackground and Methodology

Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis. Lawrence DJ, Meeker W, Branson R, Bronfort G, Cates JR, Haas

M, Haneline M, Micozzi M, Updyke W, Mootz R, Triano JJ, Hawk C. J Manipulative Physiol Ther. 2008 Nov-Dec;31(9):659-74.

Chiropractic management of low back disorders: report from a consensus process. Globe GA, Morris CE, Whalen WM, Farabaugh RJ, Hawk C;

Council on Chiropractic Guidelines and Practice Parameter. J Manipulative Physiol Ther. 2008 Nov-Dec;31(9):651-8.

Topic: Topic: Low back and leg complaintsLow back and leg complaints

Topic: Topic: Lower Extremity ConditionsLower Extremity Conditions

• Manipulative therapy for lower extremity conditions: expansion of literature review.

Brantingham JW, Globe G, Pollard H, Hicks M, Korporaal C,Hoskins W. J Manipulative Physiol Ther. 2009 Jan;32(1):53-

71. • Manipulative therapy of lower extremity conditions: Summary of Clinical Practice

Recommendations from the Commission of the Council onChiropractic Guidelines and Practice Parameters

Topic: Topic:

TendinopathyTendinopathy

Chiropractic management of tendinopathy: a literature synthesis.

Pfefer MT, Cooper SR, Uhl NL. J Manipulative Physiol Ther. 2009 Jan;32(1):41-52.

Chiropractic management of tendinopathy: Summary of Clinical Practice

Recommendations from the Commission of the Council onChiropractic Guidelines and Practice

Parameters

Topic: Topic: FibromyalgiaFibromyalgia

Chiropractic management of fibromyalgia syndrome: a systematic review of the literature.

Schneider M, Vernon H, Ko G, Lawson G, Perera J. J Manipulative Physiol Ther. 2009 Jan;32(1):25-40.

Chiropractic management of fibromyalgia syndrome: Summary of Clinical Practice


Parameters

Topic: Topic: Myofascial trigger points and myofascial Myofascial trigger points and myofascial

pain syndrome pain syndrome

Chiropractic management of myofascial trigger points and myofascial pain syndrome: a systematic review of the literature.

Vernon H, Schneider M J Manipulative Physiol Ther. 2009Jan;32(1):14-24.

Chiropractic management of myofascial trigger points and myofascial pain syndrome: Summary of Clinical Practice


Parameters

Topic: Topic: Nonmusculoskeletal conditions/Wellness Nonmusculoskeletal conditions/Wellness

Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research.

Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW.

J Altern Complement Med. 2007 Jun;13(5):491-512.

Please visit our web site at: www.ccgpp.org

Thank you for your ongoing support!

If we can do anything to help you, please let us know.

CCGPPP.O. Box 2542

Lexington, SC 29071803-356-6809

[email protected]

using ccgpp to build a strong and profitable practice

Documents

chiropractic guidelines

process slide

practice parameters

profitable practice

consensus guidelines

developing guidelines

chiropractic physicians

existing guidelines