The document, Clinical Guidelines for Chiropractic Practice in Canada, aka Canadian Guidelines or "Glenerin Guidelines" after the Glenerin Inn conference site, culminated three years of work involving over 23 organizations in a two stage process: research and development of draft guidelines; and review and final agreement on clinical guideline statements.
The document has benefited significantly from early drafts of the Mercy Guidelines which were made available when the Canadian process first began.
Because of the unique reimbursement structure chiropractic enjoys in Canada, there was very little chance that drafts of the guidelines would be used to the detriment of reimbursement, thus allowing drafts of the guidelines to be widely disseminated before the final conference.
Each chapter of the document was developed by two different committees. Literature review committees created the initial drafts of each chapter. Consensus committees finalized each chapter. During the entire process, each draft was available for review by Canadian DCs at large, one of the benefits of having a single national association.
The conference was facilitated by three former Mercy panel members:
- Donald J. Henderson, DC, BSc, FCCS(C), DBCBR, FCCR(C), FICC vice president, Canadian Chiropractic Assoc., chairman, CCA Standards of Practice Committee: currently in practice;
- Silvano Mior, DC, FCCS(C), associate editor, Journal of the Canadian Chiropractic Assoc., assoc. dean, graduate studies in research, Canadian Memorial College of Chiropractic: currently in practice;
- Howard Vernon, DC, FCCS(C), Director of Research, Canadian Memorial College of Chiropractic: currently in practice; and
The 35 panel members were almost exclusively practitioners, with one attorney acting as a representative of the public. In addition, David Chapman-Smith, LLB(Hons), contributed legal consultation to the conference.
From the outset, one question was asked:
Will the Canadian Conference, using mostly practitioners, produce a guidelines document that is substantially different from the Mercy Guidelines that were created by a panel weighted evenly by practitioners, academicians and researchers?The conference began with opening remarks from Mercy veterans Marion McGregor, DC, FCCS(C), MSc, Donald M. Petersen Jr., and Louis Sportelli, DC. Dr. McGregor and Mr. Petersen were observers to the conference and acted as resources.
The Canadian Guidelines consist of 20 chapters:
Informed Consent
Initial Clinical Examination
Initial Documentation
Diagnostic Imaging
Guidelines for Laboratory Procedures
Therapeutic and Diagnostic Instrumentation
Analysis, Diagnosis and Clinical Impression
Record Keeping
Frequency and Duration of Care
Re-Assessment
Modes of Care and Management
Outcome Assessment
Contraindications and Complications
Maintenance/Preventive/Support Care
- Continuing Education
- The Role of Associations and Licensing Boards in Developing and Insuring Standards
- Guidelines for Research in Quality Care
- Practice Advertising
- Chiropractic Terminology/Glossary
- indicates chapters unique to the Canadian Guidelines, i.e., not included in Mercy Guidelines
The Canadian Guidelines use the Mercy rating system without the "strength of evidence" factor. This provided a very good opportunity for comparison of the two documents. The conference format and consensus structure are also very similar to that of the Mercy Conference. Ultimately, the Canadian Conference achieved greater consensus overall, with no minority opinions.
While the Canadians Guidelines are not yet published, some interesting insights can be gained by the Glenerin Conference facilitators who will also be editing the guidelines document:
David Chapman-Smith, LLB, who acted as legal counsel and editor for both the Mercy and Glenerin conferences stated:
"The Glenerin, the Canadian equivalent to the Mercy Center Conference, was equally important to the U.S. and Canada. Why? Because practice guidelines are based on two bodies of knowledge -- the published research and the clinical experience. One would expect this information to be interpreted in broadly the same way in the U.S. and Canada. If Canadian DCs disagree with U.S. DCs for example on frequency and duration and modes of care, both sets of guidelines lose credibility.As an observer to the conference, Dr. McGregor stated:"Fortunately, following another bruising but inspiring residential conference with 16 hour days, Canadian chiropractors have produced guidelines consistent with the Mercy Center Guidelines.
"The Glenerin Conference is the voice of the chiropractic profession in Canada. Canada ... is a multicultural patchwork, held together by an affinity for tolerance and comfort with difference. The Glenerin Conference reflects this Canadian approach within an already diverse profession. All of the 35 panel members came together to produce a document reflecting the current wisdom and practice of the profession amidst the many factors unique to its background. As an observer who was part of the Mercy Conference, it was reassuring to note that the discussion of guidelines at the Glenerin Conference was substantially similar to the conference that went before it. Differences reflected the subtle weighing of concerns which naturally vary between our two countries. It was a momentous experience, and I was very grateful to the Canadian Chiropractic Association for the opportunity to observe it."During the summer, the CCA's executive committee will prepare a resolution for the organization's board of governors concerning the dissemination of the guidelines, and the membership for the new guideline's review committee. It is expected that this resolution will be presented to the CCA board of governors during the November semi-annual meeting. The board of governors will also canvass their member divisions for endorsement of the document. In the future, the public and other professions will be invited to share their opinions of the guidelines, for revision purposes.
The Glenerin/Mercy Center Conference participants offered their comments on the consensus process of the Canadian Guidelines:
Dr. Donald J. Henderson:
"It was less than one week ago that the four-day Glenerin Consensus Conference, Mississauga, Canada was convened to decide on clinical practice guideline recommendations for Canadian chiropractors; as part of a major CCA project initiated more than three years ago.
"More than three hundred recommendations were discussed and voted upon using rules of procedure established at the Mercy Center Conference. Many of the Mercy Guidelines along with guidelines developed by two independent groups of 35 chiropractors representing all provincial and national organizations in Canada as well as members from the field -- were drafted and supported by evidence available in the literature.
"There were no minority opinions debated on any of the clinical issues raised; a surprising accomplishment when one considers the diversity of opinion present in many of the pre-conference proposals. Further, there was no hint of political or self-interest posturing during the conference. Given that all organizations had the opportunity to comment on earlier drafts, I expect that the Canadian chiropractic community will be generally supportive of the work of their colleagues. The conference proceedings should be published and available by fall of 1993."
Dr. Howard Vernon:
"The 35 practicing Canadian chiropractors who assembled in Toronto on April 4-7/93 forged just such a consensus on mainstream practice of chiropractic in Canada. While the debate was often heated, and while opinions and experience were certainly diverse, in the end, our similarities, or rather, our commonality was far greater than our differences.
"This conference built upon the strong foundation provided by the Mercy Center Conference. In this way the outcome of the Glenerin process validated the Mercy Guidelines. This occurred in a manner that is important to acknowledge. The Mercy Center Guidelines were formulated largely by a group who were recognized to be scholars and clinical experts. Guidelines which arise in this sort of context can suffer from a "credibility gap" with the average clinician, as perhaps being too rigorous, or relying on too small and too critical a base of evidence from valid scientific studies. If this were the case with the Mercy Center Guidelines, then a group composed more substantially of average practitioners, such as at the Glenerin Conference, might diverge and disagree to a significant degree with the content and ratings of the "experts" guidelines. In the vast majority of cases where similar guidelines were considered at Glenerin, this was, happily, not the case.
"Finally, the Glenerin project was not merely a replication of the Mercy Center process. Several new areas, deemed to be particularly important in the Canadian context, including practice advertising, the role of associations in developing and implementing guidelines, and a research agenda were examined. ...
"The challenge faced by Canadian chiropractors is the same as that which was faced after publication of the Mercy Center Guidelines -- review, modification, adoption, dissemination, and implementation within the field. Anyone who thought the hard work was over is greatly mistaken!"
Dr. Silvano A. Mior:
"The Canadian experience in establishing practice guidelines recently culminated with the Glenerin consensus conference. This conference brought together 34 chiropractors associated with different provincial, national, and governing bodies and all were active in full time practice. The remaining member was a lawyer, who represented the public interest. The group discussed and rated recommendations from 18 chapters. Each chapter had been previously circulated to all interested parties across the country for greater input, but was also heavily influenced by the strength of the Mercy document. ... As at Mercy, the process slowly took shape as the group learned the dynamics of reaching consensus. However, after the first day it was 'doubtful' that the document would be completed. By the end of the second day, the process was in full swing and sleepless nights were inevitable if the conference was to succeed. My rating for completion was now raised to 'equivocal.' By the end of the third day, negotiations increased and it now appeared 'promising.' By the afternoon of the fourth day, it was 'established' that the document was completed and consensus reached on all recommendations with no minority report. The success of the Glenerin conference was in part due to the previous experiences at Mercy, but more so to the dedication and contribution of all those involved from the panel members to the secretarial help and each and every chiropractor who offered opinions along the arduous course of completing the document. 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."
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