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Canadian Chiropractic Guideline Initiative (CCGI) progress and future directions: December 2017.

Introduction

Cultural shift takes time...

In 1994, the AHCPR guidance (1), (now AHRQ in the United States) on Acute Low Back Problems in Adults met with strong opposition from physicians when recommending 'Relief of discomfort can be accomplished most safely with nonprescription medication and/or spinal manipulatio '. Similarly, the Clinical Guidelines for Chiropractic Practice in Canada, or "Glenerin Guidelines" (2), released only a year before, encountered huge resistance from the chiropractic profession who feared this was prescriptive in nature, instead of being what it intended to be, a tool to inform clinical decision making (3). In an interview in Dynamic Chiropractic in 1994, Dr. Silvano A. Mior stated at the time: "As with the Mercy document, the Glenerin document is but the first step in the climb to establishing and implementing guidelines for the practice of chiropractic in Canada - a climb that I trust all chiropractors will take." (4) Now a quarter of a century later, it appears that the cultural shift toward an evidence-informed chiropractic profession is well underway.

Helping transform the landscape of the chiropractic profession in Canada

Since the launch of the Canadian Chiropractic Guideline Initiative (CCGI) in 2013, and with the invaluable support of national and provincial associations and CCGI stakeholders, much progress has been made towards the uptake of evidence-informed practice and the use of best practices. Today, the Canadian Chiropractic Association (CCA) and almost all provincial associations and regulatory boards have adopted the evidence-informed practice statement. This statement signifies that clinicians make clinical decisions based on the most recent evidence, their clinical expertise and patient's preferences and values.

An international leader in the development and dissemination of clinical practice guidelines and in the creation of best practice tools for clinicians and patients

The CCGI website went live in September 2014 helping inform Canadian chiropractors of the latest evidence. The CCGI has shown itself to be an innovative leader in creating best practices and resources, ready to collaborate, and eager to build for the future. Some of the initiatives released by the CCGI include the popular exercise videos and handouts for patients based on the latest recommendation, interactive online educational modules for clinicians, the opinion leader and best practice collaborator program advocating locally for CCGI resources, practice-based research networks evaluating evidence-informed practices, and new ideas for data collection and international collaborations.

Progress to date

Clinical practice guidelines

The recently published CCGI guideline on "The Treatment of Whiplash and Neck Pain Associated Disorders" (2016) (5) is now posted on the National Guideline ClearingHouse website. In August 2017, the Guideline Development Group (GDG) submitted their scientific manuscript on Spinal Manipulation Therapy for the Treatment of Low Back Pain for publication. Accompanying knowledge translation strategies including a new series of exercise videos are ready for release. We anticipate this guideline to be published in early 2018. We expect to develop guidance on the conservative management of spinal stenosis in the first half of 2018 and are currently conducting a structured search to identify pertinent studies. The guideline panel will be composed of a multidisciplinary team, including several chiropractic experts and researchers on spinal stenosis.

Easy-to-use videos based on the most recent evidence

We have enjoyed productive collaborations in the creation of best practice tools for clinicians and patients. Following the successful launch of the first CCGI exercise video series for neck pain, created in collaboration with l'Universite du Quebec a Trois Rivieres (UQTR) faculty member, Dr. Caroline Poulin DC, MSc and Dr. Nadia Richer DC, MSc, and the UQTR IT department, a new series of exercises videos and patient handouts on low back pain is planned to be released in early 2018 (Figure 1). The CCGI will also release a new series of yoga exercise videos for low back pain, in collaboration with Dr. David Whitty, CCGI opinion leader and certified yoga instructor. These easy-to-use videos are based on the most recent evidenc -based recommendations for low back pain, and are designed to help clinicians and patients who may be new to this approach. We are also very pleased to be working with the Ontario Chiropractic Association (OCA) to create a new patient handout on self-management and educatio. Plain-language patient versions of the Neck Pain and Whiplash Guidelines are now posted on the CCGI websit, and a plain-language patient version of the Low Back Pain Guideline is in preparation. All of our new tools will be posted online.

Promoting CCGI work internationally

We continue to promote the work of CCGI and our related research projects at the national and international level. A strong representation of CCGI researchers and collaborators at the WFC DC 2017 conference demonstrated the influence of our team at the international level. As part of our promotion of CCGI guidelines and resources to a wider audience, Dr. Joel Weisberg DC and Dr. Michele Maiers DC, PhD presented a webinar on the treatment of neck pain and whiplash disorders in collaboration with the American Chiropractic Association and ChiroCredit in May 2017. We continue to build bridges with chiropractic schools and researchers in Europe and Australasia, and look forward to developing new practice-based research collaborations in the next few years.

Best Practice Collaborators and Opinion Leaders Initiative

Over 100 CCGI Best Practice Collaborators and Opinion Leaders are advocating for best practices to their colleagues across Canada. These dedicated individuals are using knowledge translation strategies adapted to their provincial and regional context. This includes making presentations to colleagues at provincial meetings, sharing CCGI best practice resources with the multidisciplinary team in their clinic, posting about evidence-informed practice on social media or in their local newspaper, and meeting up online to brainstorm on how best to support the implementation of best practices in their area. We are excited about the potential of these collaborators to effect change across the country. Their efforts to reach colleagues are now supported by our two knowledge brokers, Dr. Kent Stuber and Dr. Gaelan Connell, who are helping CCGI create tools such as the new podcast series, designed to help clinicians put clinical practice guidelines into practice.

Uptake of best practices and resources

To evaluate the uptake of best practices and resources, a new national survey to assess evidence-informed beliefs and implementation among chiropractors across Canada will be launched in early 2018. This will help us evaluate the impact of our programs over the past 3 years. In additio, we are moving into the implementation phase of a research study (Phase 2) in collaboration with a team at CMCC and universities of McGill, Minnesota and Pittsburg. This study is looking at implementing an intervention for self-management, known as 'Brief Action Plannin ', for patients with spine disorders. So far this year, CMCC patients, interns, clinicians and decision-makers have already completed questionnaires, interviews and focus groups looking at the barriers and facilitators to using self-management strategies. We are now tailoring the intervention, based on the results of Phase 1 (focus groups and interviews), and will be ready to launch a pilot cluster randomized-controlled trial at CMCC in late 2017. We anticipate that this important study will help us to better understand the feasibility of conducting these types of studies within teaching institutions and how to equip future clinicians with the skills they need to provide self-management advice in a sustainable manner. We are especially grateful for the outstanding collaboration of the CMCC staff and interns in this study, and for the enthusiastic participation of patients at the CMCC clinics.

We continue to look for new ways to encourage the uptake of evidence-informed resources. A CCGI mobile application would make it easier for clinicians and patients to access tools for decision-making and self-management. We are currently completing a needs assessment for a CCGI mobile application with clinicians and chiropractic students and looking into the feasibility of developing a prototype for testing more widely in 2018. Stayed tuned for more news on this exciting new development.

Practice-based research networks (PBRNs)

The ongoing work of the practice-based research networks (PBRNs) is helping clinicians get involved in research and in the establishment of best practices, thanks to seed funding provided by CCGI. Two new projects based in Quebec and Nova Scotia were funded by CCGI for the 2017-18 period. There are now at least 160 chiropractors participating in our PBRNs in Canada. A new call for applications was announced in mid-September for the 2018-19 funding round. CCGI is proud to be able to offer funding for PBRNs for a total of $45,000 for this round. The aim is to encourage implementation and collection of similar patient reported outcome measures (e.g., disabilit, pain, quality of life, satisfaction with care questionnaire) across the Canadian PBRNs and eventually in the chiropractic profession.

Where next?

After nearly 6 years of dedicated work, CCGI Project Lead and CCRF Professor, Dr. Andre Bussieres will complete his mandate on April 30 th 2018, and a new CCGI project lead will be hired in early 2018. A new part-time CCGI knowledge translation (KT) lead will also be recruited in 2018. As we move ahead, we are looking forward to continuing to develop, adopt, and adapt high quality clinical practice guidelines, create new innovative tools for clinicians and patients, monitor uptake and patient health outcomes, and build international collaborations. Above all, CCGI is committed to improving patient care by encouraging the use of evidence-informed practice in clinical practice. We wish to thank the large number of collaborators and supporters including CCGI stakeholder, scientists, clinicians, and patient advocates who have helped make this initiative a true success and an example for colleagues around the world.

References

(1.) Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, 1994.

(2.) Henderson D, Chapman-Smith D, Mior S, Vernon H. Clinical guidelines for chiropractic practice in Canada. J Can Chiropr Assoc. 1994;38(suppl): 1-203.

(3.) Gatterman MI, Dobson TP, LeFevbre R. Chiropractic quality assurance: standards and guidelines. J Can Chiropr Assoc. 2001;45(1): 11-17.

(4.) Editorial Staff. Glenerin conference produces Canadian guidelines. Mercy conference provides the model. Dynamic Chiropractic. 1993;11(10), available at: http://www.dynamicchiropractic.ca/mpacms/dc/article.php?id=42268

(5.) Bussieres AE, Stewart G, Al-Zoubi F, Decina P, Descarreaux M, Hayden J, et al. The Treatment of Neck Pain-Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline. J Manipulative Physiol Ther. 2016;39(8):523-564.e27.

(JCCA. 2017;61(3):186-189)

Andre Bussieres, DC, PhD (1,2)

(1) School of Physical and Occupational Therapy, Faculty of Medicine, McGill University

(2) Departement chiropratique, Universite du Quebec a Trois-Rivieres

Corresponding author: Andre Bussieres

Assistant Professor, CCRF Professorship in Rehabilitation Epidemiology, School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, 3630 Promenade Sir-William-Osler (Drummond), Hosmer House, Room 205 Montreal, Quebec, Canada H3G 1Y5 Professeur, Departement chiropratique, Universite du Quebec a Trois-Rivieres 3351, boul. Des Forges, C. P. 500, Trois-Rivieres (Quebec) Canada G9A 5H7 Tel: (819) 376-5011 (3972)

E-mail : andre.bussieres@mcgill.ca, andre.bussieres@uqtr.ca
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Title Annotation:Commentary
Author:Bussieres, Andre
Publication:Journal of the Canadian Chiropractic Association
Article Type:Report
Date:Dec 1, 2017
Words:1844
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