Using CCGPP to Build a Strong and Profitable Practice

1. Using CCGPP to Build a Strong and Profitable Practice

2. “WHAT is CCGPP?” “The Clinical 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. “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.

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

4. “Council on Chiropractic Guidelines and Practice Parameters (CCGPP)” CCGPP was also delegated to examine all existing guidelines, parameters, protocols and best practices in the United States and other nations with a chiropractic lens. Participation and process have been as transparent as possible and a major goal is to represent a diverse cross-section of the profession on the projects that CCGPP has been involved in.

5. “Council on Chiropractic Guidelines and Practice Parameters (CCGPP)” CCGPP was charged with developing guidelines regarding the most common conditions treated by chiropractic physicians. Condition-based care is consistent with that found throughout the healthcare industry today, thus the focus of CCGPP’s efforts.

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

7. “Council on Chiropractic Guidelines and Practice Parameters (CCGPP)” Step 1: Be Aware of Available Resources

8. CCGPP Website Information http://www.ccgpp.org A wealth of information is available on the CCGPP website at www.ccgpp.org. All completed literature syntheses and consensus guidelines have been published in www.jmptonline.org, and submitted for inclusion in the National Guideline Clearinghouse at www.guideline.gov.

9. “Council on Chiropractic Guidelines and Practice Parameters (CCGPP)” • Acute Low Back Pain • Chronic Spine Pain • Terminology • Lumbar • Lower Extremity • Nonmusculoskeletal • Fibromyalgia • Methodology • Myofascial Trigger Points • Tendinopathy • Wellness • What Constitutes Evidence. • Thoracic and • Upper extremity chapters Completed: In Process

10. “Council on Chiropractic Guidelines and Practice Parameters (CCGPP)” • Cervical and • Diagnostic Imaging reports have been issued.

11. Be Aware of Available Resources Top Four Papers Plus Published Chapters

12. CCGPP Website Information http://www.ccgpp.org Delphi Acute Low Back Guideline: CHIROPRACTIC MANAGEMENT OF LOW BACK DISORDERS: REPORT FROM A CONSENSUS PROCESS, JMPT Oct 2008, Globe, Morris, Whalen, Farabaugh, Hawk, DC,

13. CCGPP Website Information http://www.ccgpp.org Delphi Chronic Care Guideline: Management of Chronic Spine-Related Conditions: Consensus Recommendations of a Multidisciplinary Panel: JMPT September2010, Farabaugh, Dehen, Hawk.

14. CCGPP Website Information http://www.ccgpp.org Terminology Paper: Consensus Terminology for Stages of Care: Acute, Chronic Recurrent and Wellness, JMPT August 2010, Dehen, Whalen, Farabaugh, Hawk. (Published July/August 2010)

15. CCGPP Website Information http://www.ccgpp.org NEW CHAPTER: Effort spearheaded by Drs. Carl Cleveland III and Jay Triano. Principle investigator(s): Brian Budgell, DC, PhD COST: $60,000

16. New Chapter: Formerly the “Subluxation Chapter” RENAMED to: “Determining the Site of Care: What is the Evidence Regarding the Primary Methods Used to Locate the Site of Treatment Used by Chiropractors: a Proposed Formal Literature Systhesis.” Project Goal: • This chapter will provide the evidence related to the rationale basis of performing spinal manipulation on a particular spine site.

17. “Council on Chiropractic Guidelines and Practice Parameters (CCGPP)” Step 2: Highlights of the Chronic Pain Guideline

18. “Chronic Care Recommendations”

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

20. Chronic pain management treatment planning/dosaging • 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 based upon TW and re-evaluation, the panel recommended up to 4 visits per month, to be re-evaluated minimally every 12 visits. See Table 5 for more information on dosaging.

21. Exacerbations • “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.

22. Chronic Care Goals • Chronic care goals are to: • Minimize lost time on the job • Support patient's current level of function/ADL • Pain control/relief to tolerance • Minimize further disability • Minimize exacerbation frequency and severity • Maximize patient satisfaction • Reduce and/or minimize reliance on medication • (Page 7. Chronic Care Goals)

23. 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.

24. Scheduled Ongoing Care • “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.

25. Therapeutic Withdrawal • “…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 an abrupt discontinuation of care, OR a gradual withdrawal. AND, there is no defined time frame for 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.

26. Benefits of Ongoing Care • “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, when the benefits outweigh the risks, ongoing care may 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 manipulation and other types of care rendered by chiropractic physicians often outweighs the risk commonly associated with standard medical management.

27. Categorized as “Complicated” • “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.

28. Prognostic Factors • “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.

29. Comorbidities • “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.

30. Complicating Factors • “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.

31. Multidisciplinary Care • “…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.

32. Multimodal Care • “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.

33. Risk Factors-Yellow Flags • “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.

34. Diagnosis • “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.

35. Clinical Information • “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.

36. Chronic pain management components • “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)

37. Chronic pain management components • 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.

38. Chronic pain management treatment planning/dosaging • “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)

39. Use of Guidelines: Discussion • “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)

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

41. “Council on Chiropractic Guidelines and Practice Parameters (CCGPP)” Step 3: Contents of Published Guidelines…Examples

42. 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

43. American College of Physicians Recommendation 7: For patients who do not improve with self-careoptions, clinicians should consider the addition of nonpharmacologictherapy with proven benefits—for acute low back pain,spinal manipulation; for chronic or subacute low back pain,intensive interdisciplinary rehabilitation, exercise therapy,acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioraltherapy, or progressive relaxation (weak recommendation, moderate-quality)

44. CCGPP Website Information http://www.ccgpp.org Delphi Acute Low Back Guideline: CHIROPRACTIC MANAGEMENT OF LOW BACK DISORDERS: REPORT FROM A CONSENSUS PROCESS, JMPT Oct 2008, Globe, Morris, Whalen, Farabaugh, Hawk, DC,

45. Summary of the Evidence for Chiropractic Management for Low Back Disorders Strong evidence supports the use of spinal manipulation to reduce symptoms and improve function in patients with acute and subacute low back pain. There is good evidence that the use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence.

46. Summary of the Evidence for Chiropractic Management for Low Back Disorders There is fair evidence for the use of manipulation for patients with low back pain and radiating leg pain, sciatica or radiculopathy, however, manipulation in combination with other common forms of therapy may be of clinical value. Cases with high severity of symptoms may benefit by referral for co-management of symptoms with medication. Strong evidence supports the use of spinal manipulation /mobilization to reduce symptoms and improve function in patients with chronic low back pain.

47. Initial Course of Treatment

48. Frequency and Duration for Continuing Courses of Treatments

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

50. CHIROPRACTIC MANAGEMENT OF UPPER EXTREMITY PAIN Team Lead Thomas Souza, DC Dean of Academic Affairs Palmer Chiropractic College San Jose, CA 95134