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Using CCGPP to Build a Strong and Profitable Practice. “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).

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slide2

“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.
slide3

“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.

slide4

“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.

slide5

“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.

slide6

“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.

slide7

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

Step 1:

Be Aware of Available Resources

slide8

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.

slide9

“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
slide10

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

  • Cervical and
  • Diagnostic Imaging reports have been issued.
slide11

Be Aware of Available Resources

Top Four Papers

Plus

Published Chapters

slide12

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,

slide13

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.

slide14

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)

slide15

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

slide16

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.
slide17

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

Step 2:

Highlights of the Chronic Pain Guideline

chronic pain management treatment planning dosaging
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.
exacerbations
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.
chronic care goals
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)
chronic care goals1
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.
scheduled ongoing care
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.
therapeutic withdrawal
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.
benefits of ongoing care
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.
categorized as complicated
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.
prognostic factors
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.
comorbidities
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.
complicating factors
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.
multidisciplinary care
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.
multimodal care
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.
risk factors yellow flags
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.
diagnosis
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.
clinical information
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.
chronic pain management components
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)
chronic pain management components1
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.
chronic pain management treatment planning dosaging1
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)
use of guidelines discussion
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)
use of guidelines discussion1
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.
slide41

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

Step 3:

Contents of Published Guidelines…Examples

slide42

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

slide43

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)

slide44

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,

summary of the evidence for chiropractic management for low back disorders
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.

summary of the evidence for chiropractic management for low back disorders1
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.

spinal rom assessment
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.”

slide50

CHIROPRACTIC MANAGEMENT OF

UPPER EXTREMITY PAIN

Team Lead

Thomas Souza, DC

Dean of Academic Affairs

Palmer Chiropractic College

San Jose, CA 95134

best practices chiiropractic management of upper extremity pain
BEST PRACTICES: CHIIROPRACTIC MANAGEMENT OF UPPER EXTREMITY PAIN

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

Chronicity range: acute, subacute, chronic and recurrent

example upper extremity shoulder
ExampleUpper Extremity-Shoulder

Evaluation:

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

Manipulation/Mobilization

Rating B: Mobilization

Rating D: Manipulation/HVLA

Conservative Non-Manipulation:

Rating: B - for exercise for roator cuff disorders and

impingement syndrome

Rating: A - for ultrasound for calcific tendinitis

upper extremity shoulder
Upper Extremity-Shoulder

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

lower extremity team lead stephen perle dc ms
Lower ExtremityTeam Lead: Stephen Perle, DC, MS
  • Brantingham JW, Globe G, Pollard H, Hicks M, Korporaal C, Hoskins W. Manipulative therapy for lower extremity conditions: expansion of literature review. J Manipulative PhysiolTher. 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
example lower extremity conditions
Example: Lower extremity conditions

NGC: Summary of Clinical Practice Recommendations

  • Rating B: Fair evidence for manipulative therapy of the knee and/or full kinetic chain combined with multimodal or exercise therapy for knee osteoarthritis.
  • Rating B: Fair evidence for manipulative therapy of the knee and/or full kinetic chain combined with multimodal or exercise therapy for Patellofemoral Pain Syndrome.
example lower extremity conditions1
Example: Lower extremity conditions

NGC: Summary of Clinical Practice Recommendations

  • Rating B: Fair evidence for manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for Ankle Inversion Sprain.
soft tissue chapter team lead gordon lawson dc ms
Soft Tissue ChapterTeam Lead: Gordon Lawson, DC, MS

Myofascial trigger points and myofascial pain syndrome

Fibromyalgia

Tendinopathy

myofascial trigger points and myofascial pain syndrome
Myofascial trigger points and myofascial pain syndrome
  • Vernon H, Schneider M. Chiropractic management of myofascial trigger points and myofascial pain

syndrome: a systematic review of the literature.

J Manipulative PhysiolTher. 2009 Jan;32(1):14-24.

  • NGC: Chiropractic management of myofascial trigger points and myofascial pain syndrome: Summary of Clinical Practice Recommendations from CCGPP
example myofascial trigger points and myofascial pain syndrome
Example:Myofascial trigger points andmyofascial pain syndrome

NGC: Summary of Clinical Practice Recommendations

  • Conclusion and strength of evidence rating: Conservative non-manipulation
  • Rating A: laser therapies. There is strong evidence that laser therapy (various types of lasers) is effective in the treatment of MTrPs and MPS.
example myofascial trigger points and myofascial pain syndrome1
Example:Myofascial trigger points andmyofascial pain syndrome

NGC: Summary of Clinical Practice Recommendations

  • Rating B: TENS, 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.
example myofascial trigger points and myofascial pain syndrome2
Example:Myofascial trigger points and myofascial pain syndrome

Conclusion and strength of evidence rating: Manipulation/ mobilization

  • Rating B: short-term relief. There is moderately strong evidence to support the use of some manual therapies (manipulation, ischemic pressure) 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.
fibromyalgia
Fibromyalgia

Schneider M, Vernon H, Ko G, Lawson G, Perera J. Chiropractic management of fibromyalgia syndrome: a systematic review of the literature. J Manipulative PhysiolTher. 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

example fibromyalgia
Example:Fibromyalgia

NGC: Summary of Clinical Practice Recommendations

  • Strong evidence supports aerobic exercise and cognitive behavioral therapy.
  • Moderate evidence supports massage, muscle strength training, acupuncture, and spa therapy (balneotherapy).
  • Limited evidence supports spinal manipulation, movement/body awareness, and vitamins, herbs, and dietary modification.
fibromyalgia1
Fibromyalgia

NGC: Summary of Clinical Practice Recommendations

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

Combinations 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 processing and central sensitization.
tendinopathy
Tendinopathy

Pfefer MT, Cooper SR, Uhl NL. Chiropractic Management of tendinopathy: a literature synthesis.J Manipulative PhysiolTher. 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

tendinopathy1
Tendinopathy

NGC: Summary of Clinical Practice Recommendations

  • Rating A: nothing
  • Rating B: Ultasound, Eccentric exercise
  • Rating C:Manipulation/mobilization, friction

massage, acupuncture, surgery, topical

NSAIDs.

wellness
Wellness

BEST PRACTICES: CHIROPRACTIC MANAGEMENT OF

PREVENTION AND HEALTH PROMOTION;

NONMUSCULOSKELETAL CONDITIONS; AND CONDITIONS OF

THE ELDERLY, CHILDREN AND PREGNANT WOMEN

Team Lead

Cheryl Hawk, DC, PhD, CHES

Vice President of Research and Scholarship

Cleveland Chiropractic College

Kansas City and Los Angeles

wellness1
Wellness

Chiropractic Care for Non-musculoskeletal Conditions

Wellness, Health Promotion and Disease Prevention

Special Populations: Children

Special Populations: Pregnant Women

Special Populations: Older Adults

example chiropractic care for non musculoskeletal conditions
Example:Chiropractic Care for Non-musculoskeletal Conditions

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

Rating I: other non-musculoskeletal conditions

wellness health promotion and disease prevention
Wellness, Health Promotion and Disease Prevention
  • Rating A: Counseling tobacco

users to quit

  • Rating A: Counseling sedentary patients to

engage in physical activity

  • Rating I: Spinal manipulation for health

promotion

slide71

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

Step 4:

Fighting Back

“Proper Use of Guideline”

proper use of guidelines
Proper use of Guidelines
  • 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.
proper use of guidelines1
Proper use of Guidelines
  • Guidelines are only one piece of evidence to consider when considering the medical necessity of care. Other pieces of evidence include:
    • research,
    • clinical experience/decision-making,
    • patient values,
    • risk stratification,
    • process of care,
    • response to care,
    • documentation, etc.

Guidelines are not cookbooks with rigid dosages for treatment.

proper use of guidelines2
Proper use of Guidelines
  • 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 have extended beyond the natural healing time, or expected recovery time, compared to a non-complicated, mild, acute case.
proper use of guidelines3
Proper use of Guidelines
  • 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, paragraph, and sentence in the guideline being referenced indicating were the POR/DC exceeded the guideline.
proper use of guidelines4
Proper use of Guidelines
  • Additionally, exceeding the guideline is NOT the issue in chronic pain management.
  • “Why were expected treatment parameters exceeded” IS the question.
  • Reviewer: Must consider complicating factors, versus the generic “treating non-allowed conditions”.
proper use of guidelines5
Proper use of Guidelines
  • 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?
filing the appeal
Filing the Appeal
  • 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.
      • “I wish to file an appeal to the denial for the following reasons:”
      • “Consulted stated…..”
      • “Response:……”
      • End with a brief case summary
empowerment contribution opportunities
Empowerment Contribution Opportunities
  • 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.
corporate supporters
Corporate Supporters
  • Many thanks to our corporate supporters:
    • ChiroCode Institute, Lamont Leavitt, and late D. Henry Leavitt
    • Core 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!
the core products challenge gift
The Core Products challenge/gift!

Core Products will provide a free 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% 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.

what others are saying
What others are saying…..
  • 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 time when there is an increased focus on quality care based upon evidence, we find that the message we share must be 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.” 
what others are saying1
What others are saying…..
  • ACA:
  • “The responses from CCGPP have shown that the profession is ready to boldly defend itself with the evidence and are framed in a tone 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.”
www neck911usa com
www.neck911usa.com
  • Is now a positive chiropractic information website!
  • Special thanks to Dr. Rob Sheely and the ACA
ccgp resources
CCGP Resources

Addendum Resources

slide86

Topic:

Background and Methodology

  • 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.
slide87

Topic:

Low back and leg complaints

  • 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.
slide88

Topic:

Lower 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 on
  • Chiropractic Guidelines and Practice Parameters
slide89

Topic:

Tendinopathy

  • 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 on
    • Chiropractic Guidelines and Practice Parameters
slide90

Topic:

Fibromyalgia

  • 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
    • Recommendations from the Commission of the Council on
    • Chiropractic Guidelines and Practice Parameters
slide91

Topic:

Myofascial trigger points and myofascial 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. 2009
    • Jan;32(1):14-24.
  • Chiropractic management of myofascial trigger points and myofascial pain syndrome: Summary of Clinical Practice
    • Recommendations from the Commission of the Council on
    • Chiropractic Guidelines and Practice Parameters
slide92

Topic:

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.
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