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Council on Chiropractic Guidelines and Practice Parameters

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Council on Chiro. Guidelines and Practice Parameters
Logo
Foundation 1987
Location Lexington, SC (USA)
Country Flag usa.gif United States
President Thomas J. Augat, DC, MS, CCSP, FASA Flag usa.gif United States
Website CCGPP

The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) researches and rates evidence for the chiropractic profession, and compiles it into a summary document containing a literature synthesis.[1]

History

The Council on Chiropractic Guidelines and Practice Parameters (CCGPP), was formed in 1995 at the behest of the Congress of Chiropractic State Associations (COCSA), and with assistance from the American Chiropractic Association, Association of Chiropractic Colleges, Council on Chiropractic Education, Federation of Chiropractic Licensing Boards, Foundation for the Advancement of Chiropractic Sciences, Foundation for Chiropractic Education and Research, International Chiropractors Association, National Association of Chiropractic Attorneys and the National Institute for Chiropractic Research

Mission

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.

Structure

Six members were appointed to represent the Congress of Chiropractic State Associations (COCSA). Other members were appointed by the organizations that created CCGPP. The CCGPP is a steering organization comprised of 21 individuals. 16 are chiropractors with one in education, one in research and 14 in full-time private practice. There is a vendor representative, a representative from chiropractic colleges and attorneys representing the National Association of Chiropractic Attorneys, as well as a public member. A research commission with several dozen members reports to and is supervised by CCGPP.

Resource Center

Guidelines

In 2008 the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) embarked upon an ambitious project to help clarify treatment guidelines related to low back disorders. Although a number of guidelines addressing manipulation exist, none to that point in time had incorporated a broad-based consensus of chiropractic research and clinical experts representing mainstream chiropractic practice into a practical document designed to provide standardized parameters of care. Following a RAND/UCLA methodology for consensus development, this broad-based panel of experienced chiropractors was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for patients with low back pain, based on both the scientific evidence and their clinical experience. In general, if the patient is improving up to two rounds of up to 12 visits per round were deemed appropriate. [2]

In 2010 CCGPP researchers conducted another Delphi panel again following the RAND/UCLA protocol for consensus development, and sought to address the issue of proper treatment related to the management of chronic spine-related conditions. Chronic spine-related conditions are very problematic in terms of treatment and indemnity costs, diagnostic complexity, and appropriate case management. The purpose of this project was to develop a broad-based multidisciplinary consensus of medical and chiropractic clinical experts representing mainstream medical and chiropractic practice to produce a document designed to provide standardized parameters of care and documentation. After a very tedious process, a multidisciplinary panel of experienced practitioners was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for complex patients with chronic spine-related conditions, based on both the scientific evidence and their clinical experience. In general this panel concluded that conservative management of chronic spine-related disorders could include "episodic" treatment (ex. 1-6 visits for a mild episode of chronic pain flare-up), to "scheduled" chronic pain management, which could include up to 1-4 treatments per month, to be re-evaluated at a minimum every 12 visits. [3]

Research / vetted papers

Physiotherapy

(see:) Low level laser

Non-Musculoskeletal conditions

Cervicogenic vertigo

  • A 2010 systematic review indicates that SMT is effective for cervicogenic vertigo. [4]

Premenstrual syndrome and dysmenorrhea

  • A 2010 review found that SMT is not effective for dysmenorrhea, compared to a sham manipulation, and that the evidence for premenstrual syndrome is inconclusive. [4]

Respiratory disease

  • A 2013 systematic review of manual therapy for pediatric respiratory disease indicated that it appears to be beneficial; the most commonly used manual therapies for this population are chiropractic and osteopathic manipulation and massage. [5]
  • A 2007 systematic review stated, “Evidence was promising for potential benefit of manual procedures for elderly patients with pneumonia,” [6] while a 2010 systematic review said the evidence was inconclusive. [4]

Safety of Spinal Manipulative Therapy/Chiropractic Care

The 2007 clinical practice guidelines on low back pain (LBP) from the American College of Physicians and the American Pain Society found that serious adverse events related to spinal manipulative therapy (SMT) for LBP are apparently rare but that the data on adverse events were poorly reported in the literature. [7]

A 2008 population-based, case-control and case-crossover study found no evidence of increased risk of vertebrobasilar artery (VBA) stroke related to chiropractic care, compared to primary medical care. [8] This comprehensive study, published in Spine, involved evaluation of nine years of medical records in the Canadian province of Ontario (covering 100 million patient years).

Characterization of risk for adverse events related to SMT and comparison to adverse events from medications used for the same conditions:

  • Serious adverse events 5-6 per 100,000 cervical spine manipulations.
  • Serious adverse events no more than 1 per million patient visits for lumbar spine manipulation. [9]
  • In the trials included in a 2010 systematic review, the relative risk (RR) for high velocity manipulation causing minor/moderate adverse events was significantly less than the RR of the comparison medication (usually NSAIDs). [10]
  • Risk of death from NSAIDs for osteoarthritis has been estimated to be 100–400 times the risk of death from cervical manipulation. [10] [11]

Concerning adverse events related to chiropractic care/SMT for children, 2 systematic reviews, one covering databases from inception through 2004 [12] and the other 2004-2010, [13] found 9 severe adverse events and 20 indirect adverse events (effects due to delayed diagnosis or inappropriate use of SMT for certain conditions). [12] [13]

In summary, adverse events from spinal manipulation occur rarely, and the safety profile of SMT compares favorably to that of medications used for similar musculoskeletal conditions.

Soft Tissue

Trigger points and myofascial pain syndrome

  • Evidence level B (moderately strong evidence) – manual therapies provide immediate pain relief for trigger points (TrPs) [14]
  • Evidence level C (limited evidence) – supporting manual therapies for long term use in management of TrPs and myofascial pain syndrome (MPS) [14]
  • Level A (substantial evidence) – laser therapy is effective for TrPs and MPS [14]
  • Level B – TENS may be effective for immediate relief for TrPs [14]
  • Level C – (frequency modulated neural stimulation) FREMS, (high-voltage galvanic stimulation) HVGS, (electrical muscle stimulation) EMS and Interfential current (IFC) [14]
  • Level C – ultrasound no more effective than placebo [14]
  • Level B - magnets may be effective for TrPs and MPS [14]
  • Level B – deep acupuncture for TrPs for up to 3 months [14]

Tendinopathy

  • Clinically important benefit - therapeutic US for calcific shoulder tendinopathy [15]
  • Lack of evidence – “thermotherapy, therapeutic exercise, massage, transcutaneous electrical stimulation and other forms of electrical stimulation, mechanical traction, combined rehabilitation approaches” [15]
  • No recommendations – manipulation/mobilization alone or in combination with other interventions [15]

Fibromyalgia

  • Fibromyalgia syndrome “is not a peripheral disorder of the soft tissues, but rather a disorder of aberrant pain processing and central sensitization” [16]
  • Strong evidence – low-dose antidepressants; light aerobic exercise and Cognitive Behavioral Treatment (CBT) [16]
  • Moderate evidence – massage, muscle strength training, acupuncture and spa therapy (balneotherapy) [16]
  • Limited evidence – spinal manipulation; movement/body awareness; and vitamins, herbs and dietary modifications [16]
  • “No single therapy or intervention that can be considered a cure” [16]
  • Combination of therapies is most helpful [16]
  • More research is necessary [16]

Special Populations

Geriatrics

  • Strength training and balance exercises improve function and reduces impairment
  • Strong evidence to support[17]
  • Counseling for physical activity and exercise[17]
  • Counseling for general health[17]
  • Counseling for fall prevention[17]
  • Screen for fall risks factors
  • Medication use (including polypharmacy)[17]
  • Blood pressure[17]
  • Balance and gait[17]
  • Heart health[17]
  • Home safety[17]
  • Tables included in the article
  • Outlines geriatric red flags for immediate referral and those requiring co-management or appropriate referral[17]
  • “Agency for Healthcare Research and Quality (AHRQ) recommendations for screening and counseling for adults aged 65 and older”[17]
  • Hawk et al. provides “a general framework for what constitutes an evidence-based and reasonable approach to the chiropractic management of older adults”[17]
  • Dougherty et al. article focuses on SMT, acupuncture, physical activity/exercise, nutritional counseling and fall prevention[18]
  • Observational studies and RCTs “have reported improvement of spinal pain (acute, sub-acute and chronic) among seniors using SMT, BioEnergetic Synchronization Technique and Cox Flexion-Distraction technique”[18]
  • 2010 UK Report of Manual therapies:
  • “SMT is effective in adults for: acute, subacute and chronic LBP; migraine and cervicogenic headache; cervicogenic dizziness”[18]
  • “Manipulation/mobilization is effective for several extremity joint conditions”[18]
  • “Thoracic manipulation/mobilization is effective for acute/subcute neck pain”[18]
  • Limited evidence for SMT for “COPD, constipation, depression (associated with back pain), Parkinson’s disease, MS, pneumonia, spinal stenosis, urinary incontinence, and OA pain and dysfunction, especially of the knee”[18]
  • Acupuncture and chronic MSK pain:
  • Insufficient experimental evidence showing it benefit over other modalities[18]
  • Limited evidence for supplement use impacting health outcomes
  • Most beneficial: Vitamin D and calcium as an “adjunct to pharmacologic regimen in treatment of osteoporosis and in the prevention of hip fractures and other non-vertebral fractures”[18]
  • Recommended 1,200 mg calcium; 1,000 IU of Vitamin D[18]
  • Other supplements have “inadequate evidence or evidence of significant side effects”[18]
  • Positive effects of aerobic exercise and strength training (strength, balance and physical functioning)[18]
  • Modest beneficial effect of resistive training on strength outcomes[18]
  • Strong evidence for improving gait speed and chair stands[18]
  • Decreased levels of arthritic knee pain with resistive training[18]
  • “DCs should collect falls history information, and provide treatment and exercises for musculoskeletal conditions”[18]

Pediatrics

A 2012 systematic reviewed stated, “studies that monitored both subjective and objective outcome measures of relevance to both patients and parents tended to report the most favorable response to SMT, especially among children with asthma.” [19]

  • ADHD
  • Evidence is insufficient to support chiropractic care for ADHD in children. [20] [21]
  • Autism spectrum disorders
  • Limited literature regarding chiropractic care and autism.4 Preliminary studies suggest some benefit from chiropractic care. [22]
  • “Given the ineffectiveness of pharmaceutical agents, a trial of chiropractic care for sufferers of autism is prudent and warranted.”[22]
  • Asthma
  • A 2010 systematic review states that SMT is not effective for asthma, compared to sham manipulation. [23] However, a 2007 review indicates that the entire clinical encounter of chiropractic care, including SMT, is beneficial to patients with asthma. [24]
  • Another 2010 systematic review states that “chiropractic care showed improvements in subjective measures and, to a lesser degree objective measures, none of which were statistically significant. Some asthmatic patients may benefit from this treatment approach; however, at this time, the evidence suggests chiropractic care should be used as an adjunct, not a replacement, to traditional medical therapy.” [25]
  • Best practices recommendations
  • Figure included in article listing “Red Flags” that require emergent treatment or referral and co-management (Figure 2) [26]
  • Standards for pediatric education should be developed in chiropractic college curriculum including post graduate education [26]
  • Chiropractic treatment for infants, children and adolescents include, but are not limited to spinal manipulation, vitamins, dietary interventions, therapeutic exercise, posture correction, and physical agents. Patient preference is important. [26]
  • Adult research may not be generalizable to pediatric population [26]
  • Colic
  • “Chiropractic care is a viable alternative to the care of infantile colic and congruent with evidence-based practice, particularly when one considers that medical care options are no better than placebo or have associated adverse events.” [27]
  • Cochrane database systematic review and a 2010 review found that evidence was insufficient to make conclusions about the effectiveness of SMT.[21] [28]
  • Musculoskeletal conditions
  • Evidence is insufficient for manual therapy for spinal disorders in the pediatric population specifically. There was one RCT for TMJ disorders. [29]
  • Nocturnal enuresis
  • Evidence is insufficient for SMT. [21]
  • Otitis media
  • Evidence is insufficient to support or refute SMT for OM3,12 but there is no evidence of serious adverse events from SMT for children with OM. [30]
  • Respiratory disease
  • Study looked at osteopathic manipulation, massage and chiropractic and found that the literature is insufficient. [31]

Pregnancy

  • A 2009 systematic review indicates that, although the body of evidence is limited, it supports the use of SMT for back pain and related symptoms during pregnancy. [32]
  • RCT conducted by George et al. concluded, “A multimodal approach to low back and pelvic pain in mid pregnancy benefits patients more than standard obstetric care.” [33]

Spinal Decompression

  • A 2006 systematic review indicated that the evidence was insufficient to prove the efficacy of motorized spinal decompression for chronic discogenic low back pain. [34]

A 2007 review stated, “only limited evidence is available to warrant the routine use of non-surgical spinal decompression, particularly when many other well investigated, less expensive alternatives are available.” [35]

Spinal Manipulative Therapy (SMT)

References

  1. "Who is CCGPP and how was it formed?". Council on Chiropractic Guidelines and Practice Parameters. 2008. http://ccgpp.org/. Retrieved 2008-07-08. 
  2. Globe, G; Morris, CE; Whalen, WM; Farabaugh, RJ; Hawk, C (2008 Nov-Dec). "Chiropractic management of low back disorders: report from a consensus process". JMPT 31 (9): 651-8. http://www.ncbi.nlm.nih.gov/pubmed/?term=Chiropractic+Management+of+Low+Back+Disorders%3A+Report+from+a+Consensus+Process. Retrieved 3/09/2013. 
  3. Farabaugh, RJ; Dehen, MD; Hawk, C (2010 Sept). "Management of chronic spine-related conditions: consensus recommendations of a multidisciplinary panel.". JMPT 33 (7): 484-92. http://www.ncbi.nlm.nih.gov/pubmed/?term=Farabaugh%3A+Chronic+Spine+Pain%3A. Retrieved 3/09/2013. 
  4. Cite error: Invalid <ref> tag; no text was provided for refs named Asthma
  5. Pepino, VC et al (Jan 2013). "Manual therapy for childhood respiratory disease: a systematic review". J Manipulative Physiol Ther 36 (1): 57-65. http://www.ncbi.nlm.nih.gov/pubmed/23380215. Retrieved 12-7-2013. 
  6. Cite error: Invalid <ref> tag; no text was provided for refs named Asthma-Hawk
  7. Chou, R et al (Oct 2 2007). "Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society". Ann Intern Med 147 (7): 478-491. http://www.ncbi.nlm.nih.gov/pubmed/17909209. Retrieved 12-7-2013. 
  8. Cassidy, JD et al (Feb 15 2008). "Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study". Spine 33 (4): S176-183. http://www.ncbi.nlm.nih.gov/pubmed/18204390. Retrieved 12-7-2013. 
  9. Bronfort, G et al (2010 Feb 25). "Effectiveness of manual therapies: the UK evidence report.". Chiropr Osteopat 18 (3). http://www.ncbi.nlm.nih.gov/pubmed/20184717. Retrieved 12-7-2013. 
  10. 10.0 10.1 Carnes, D et al (Aug 2010). "Adverse events and manual therapy: a systematic review". Man Ther 15 (4): 355-363. http://www.ncbi.nlm.nih.gov/pubmed/20097115. Retrieved 12-7-2013. 
  11. Dabbs, V et al (Oct 1995). "A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain". J Manipulative Physiol Ther 18 (8): 530-536. http://www.ncbi.nlm.nih.gov/pubmed/8583176. Retrieved 12-7-2013. 
  12. 12.0 12.1 Vohra, S et al (Jan 2007). "Adverse events associated with pediatric spinal manipulation: a systematic review". Pediatrics 119 (1): 275-283. http://www.ncbi.nlm.nih.gov/pubmed/17178922. Retrieved 12-7-2013. 
  13. 13.0 13.1 Humphreys, BK (2010 Jun 2). "Possible adverse events in children treated by manual therapy: a review". Chiropr Osteopat 18 (12). http://www.ncbi.nlm.nih.gov/pubmed/?term=Possible+adverse+events+in+children+treated+by+manual+therapy%3A+a+review. Retrieved 12-7-2013. 
  14. 14.0 14.1 14.2 14.3 14.4 14.5 14.6 14.7 Vernon, H et al (Jan 2009). "Chiropractic management of myofascial trigger points and myofascial pain syndrome: a systematic review of the literature". J Manipulative Physiol Ther 32 (1): 14-24. http://www.ncbi.nlm.nih.gov/pubmed/?term=Chiropractic+management+of+myofascial+trigger+points+and+myofascial+pain+syndrome%3A+a+systematic+review+of+the+literature. Retrieved 12-8-2013. 
  15. 15.0 15.1 15.2 Pfefer, MT et al (Jan 2009). "Chiropractic management of tendinopathy: a literature synthesis". J Manipulative Physiol Ther 32 (1): 41-52. http://www.ncbi.nlm.nih.gov/pubmed/?term=Chiropractic+management+of+tendinopathy%3A+a+literature+synthesis. Retrieved 12-8-2013. 
  16. 16.0 16.1 16.2 16.3 16.4 16.5 16.6 Schneider, M et al (Jan 2009). "Chiropractic management of fibromyalgia syndrome: a systematic review of the literature". J Manipulative Physiol Ther 32 (1): 25-40. http://www.ncbi.nlm.nih.gov/pubmed/19121462. Retrieved 12-8-2013. 
  17. 17.00 17.01 17.02 17.03 17.04 17.05 17.06 17.07 17.08 17.09 17.10 17.11 Hawk, C et al (Jul-Aug 2010). "Best practices recommendations for chiropractic care for older adults: results of a consensus process". J Manipulative Physiol Ther 33 (6): 464-473. http://www.ncbi.nlm.nih.gov/pubmed/?term=Best+practices+recommendations+for+chiropractic+care+for+older+adults%3A+results+of+a+consensus+process. Retrieved 12-22-2013. 
  18. 18.00 18.01 18.02 18.03 18.04 18.05 18.06 18.07 18.08 18.09 18.10 18.11 18.12 18.13 18.14 Dougherty, PE et al (Feb 21, 2012). "The role of chiropractic care in older adults". Chiropr Man Therap 20 (1): 3. http://www.ncbi.nlm.nih.gov/pubmed/22348431. Retrieved 12-22-2013. 
  19. Gleberzon, BJ et al (Jun 2012). "The use of spinal manipulative therapy for pediatric health conditions: a systematic review of the literature". The Journal of the Canadian Chiropractic Association 56 (2): 128-141. http://www.ncbi.nlm.nih.gov/pubmed/?term=The+use+of+spinal+manipulative+therapy+for+pediatric+health+conditions%3A+a+systematic+review+of+the+literature. Retrieved 1-9-2014. 
  20. Karpouzis, F et al (Jun 2010). "Chiropractic care for paediatric and adolescent Attention-Deficit/Hyperactivity Disorder: A systematic review". Chiropr Osteopat 18 (13). http://www.ncbi.nlm.nih.gov/pubmed/20525195. Retrieved 1-9-2014. 
  21. 21.0 21.1 21.2 Ferrance, RJ et al (Jun 2010). "Chiropractic diagnosis and management of non-musculoskeletal conditions in children and adolescents". Chiropr Osteopat 18 (14). http://www.ncbi.nlm.nih.gov/pubmed/?term=Chiropractic+diagnosis+and+management+of+non-musculoskeletal+conditions+in+children+and+adolescents. Retrieved 1-9-2014. 
  22. 22.0 22.1 Alcantara, J et al (Nov-Dec 2011). "A systematic review of the literature on the chiropractic care of patients with autism spectrum disorder". Explore (NY) 7 (6): 384-390. http://www.ncbi.nlm.nih.gov/pubmed/?term=A+systematic+review+of+the+literature+on+the+chiropractic+care+of+patients+with+autism+spectrum+disorder. Retrieved 1-9-2014. 
  23. Bronfort, G et al (Feb 2010). "Effectiveness of manual therapies: the UK evidence report". Chiropr Osteopat 18 (3). http://www.ncbi.nlm.nih.gov/pubmed/20184717. Retrieved 1-9-2014. 
  24. Hawk, C et al (Jun 2007). "Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research". J Altern Complement Med 13 (5): 491-512. http://www.ncbi.nlm.nih.gov/pubmed/?term=Chiropractic+care+for+nonmusculoskeletal+conditions%3A+a+systematic+review+with+implications+for+whole+systems+research. Retrieved 1-9-2014. 
  25. Kaminskyj, A et al (March 2010). "Chiropractic care for patients with asthma: A systematic review of the literature". The Journal of the Canadian Chiropractic Association 54 (1): 24-32. http://www.ncbi.nlm.nih.gov/pubmed/20195423. Retrieved 1-9-2014. 
  26. 26.0 26.1 26.2 26.3 Hawk, C et al (Oct 2009). "Best practices recommendations for chiropractic care for infants, children, and adolescents: results of a consensus process". J Manipulative Physiol Ther 32 (8): 639-647. http://www.ncbi.nlm.nih.gov/pubmed/?term=Best+practices+recommendations+for+chiropractic+care+for+infants%2C+children%2C+and+adolescents%3A+results+of+a+consensus+process. Retrieved 1-9-2014. 
  27. Alcantara, J et al (May-Jun 2011). "The chiropractic care of infants with colic: a systematic review of the literature". Explore (NY) 7 (3): 168-174. http://www.ncbi.nlm.nih.gov/pubmed/21571236. Retrieved 1-9-2014. 
  28. Dobson, D et al (Dec 2012). "Manipulative therapies for infantile colic". Cochrane Database Syst Rev 12 (CD004796). http://www.ncbi.nlm.nih.gov/pubmed/23235617. Retrieved 1-9-2014. 
  29. Hestbaek, L et al (June 2010). "The evidence base for chiropractic treatment of musculoskeletal conditions in children and adolescents: The emperor's new suit?". Chiropr Osteopat 18 (15). http://www.ncbi.nlm.nih.gov/pubmed/?term=The+evidence+base+for+chiropractic+treatment+of+musculoskeletal+conditions+in+children+and+adolescents%3A+The+emperor's+new+suit%3F. Retrieved 1-9-2014. 
  30. Pohlman, KA et al (Sep 2012). "Otitis media and spinal manipulative therapy: a literature review". J Chiropr Med 11 (3): 160-169. http://www.ncbi.nlm.nih.gov/pubmed/23449823. Retrieved 1-9-2014. 
  31. Pepino, VC et al (Jan 2013). "Manual therapy for childhood respiratory disease: a systematic review". J Manipulative Physiol Ther 36 (1): 57-65. http://www.ncbi.nlm.nih.gov/pubmed/23380215. Retrieved 1-9-2014. 
  32. Khorsan, R et al (Jun 2009). "Manipulative therapy for pregnancy and related conditions: a systematic review". Obstet Gynecol Surv 64 (6): 416-427. http://www.ncbi.nlm.nih.gov/pubmed/19445815. Retrieved 1/11/2014. 
  33. George, JW et al (Apr 2013). "A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy". Am J Obstet Gynecol 208 (4): 295 e291-297. http://www.ncbi.nlm.nih.gov/pubmed/?term=A+randomized+controlled+trial+comparing+a+multimodal+intervention+and+standard+obstetrics+care+for+low+back+and+pelvic+pain+in+pregnancy. Retrieved 1/11/2014. 
  34. Macario, A et al (Sep 2006). "Systematic literature review of spinal decompression via motorized traction for chronic discogenic low back pain". Pain practice : the official journal of World Institute of Pain 6 (3): 171-178. http://www.ncbi.nlm.nih.gov/pubmed/?term=Systematic+literature+review+of+spinal+decompression+via+motorized+traction+for+chronic+discogenic+low+back+pain. Retrieved 1/11/2014. 
  35. Daniel, DM (May 2007). "Non-surgical spinal decompression therapy: does the scientific literature support efficacy claims made in the advertising media?". Chiropr Osteopat 15 (7). http://www.ncbi.nlm.nih.gov/pubmed/?term=Non-surgical+spinal+decompression+therapy%3A+does+the+scientific+literature+support+efficacy+claims+made+in+the+advertising+media%3F. Retrieved 1/11/2014. 

External Links

CCGPP Website