Taking an Evidence-Based Approach to Patient Care

By Christine Goertz posted 06-20-2017 09:14

  

By now you are no doubt familiar with the concept of evidence-based clinical practice (EBCP). But what does that really mean for the doctor of chiropractic? How does one actually implement the “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of an individual patient”1 when that individual patient is on the adjusting table? It is not that easy, for a number of reasons. 

For one thing, historically, an evidence-based approach to clinical practice was not always emphasized in chiropractic colleges. It’s important to note that this has been changing for some time. For example, the National Center for Complementary and Integrative Health at the National Institutes of Health awarded a grant several years ago to a group of chiropractic education institutions—including Palmer College of Chiropractic, University of Western States, Northwestern Health Sciences University and National University of Health Sciences--to incorporate evidence-based clinical practice into their curriculum. In addition, most chiropractic colleges today are members of the Consortium of Evidence-informed Practice Educators. 

Evidence Not Always Available...or Straightforward

When it comes to chiropractic clinical practice, however, there is simply no evidence available yet regarding key components of what we do, such as the effectiveness of some adjusting techniques, the reliability/validity of some examination procedures, what patient populations might benefit the most, and the effects of chiropractic treatment on viscero-somatic conditions. In addition, reading and critically evaluating the scientific literature is not always that straightforward. How do you apply the findings from a randomized clinical trial on the effects of spinal manipulation for headache to the specific patient sitting in your office right now (the one who would have never gotten into that study because he or she also has severe low back pain, is obese, drinks way too much alcohol and suffers from diabetes)? 

As difficult as it can be to sort all of this out, it is extremely important for us to make a concerted effort to do so. Why? Because, overall, it will lead to higher quality patient care. Let me give you an example: On May 1, 2017, Aaron E Carroll, MD, a professor in pediatrics at Indiana University School of Medicine, wrote an article in The New York Times column The Upshot titled, “For Bad Backs, It’s Time to Rethink Biases about Chiropractors2.” In the article, Dr. Carroll shares that, during the course of his career, he has referred patients for various low back pain treatments, however, spinal manipulation was not something that he had ever considered. He is considering it now, and encouraging other physicians to think about doing the same. What changed? He read several studies recently published in the scientific literature3,4,5 that concluded that spinal manipulation delivered by a doctor of chiropractic (or physical therapist) can be effective, safe and is no more expensive than other commonly used therapies. Because Dr. Carroll is taking an evidence-based approach to patient care, it is possible--even likely--that he and perhaps his colleagues who read The New York Times, will begin referring patients who otherwise would not have gone to chiropractors. As a result, some of those patients might have less low back pain after six weeks or avoid suffering from the side effects of NSAIDS, opioids or unnecessary surgery. Clearly, this is something to celebrate; however, there is a caveat…. 

Challenge Your Clinical Beliefs 

Taking an evidence-based approach to healthcare delivery does not mean only accepting those research findings that agree with your current beliefs! Thus, today’s blog challenge is to take four action steps.  

  1. The first is to read at least one of the articles that Dr. Carroll did3,4,5  on low back pain. What is your opinion of the quality of these studies? Do you think the author’s conclusions are correct? 
  2. The second is to also read the articles he used to reach the conclusion that spinal manipulation is not effective for dysmenorrhea or infantile colic.6,7  What is your opinion of the quality of these studies? Do you think the author’s conclusions are correct? 
  3. As you complete these first two action steps, do you find yourself agreeing with the studies that support the use of chiropractic care more than the ones that don’t? The third action step is to think about what level of scientific evidence it would take for you to switch to a chiropractic technique that the literature says works better than the technique you normally use, in the same way that Dr. Carroll changed his practice to consider referral of his low back pain patients for spinal manipulation. I know firsthand what a difficult exercise this can be. During my 25 years as a scientist, the findings of some studies, even studies that I have been involved in conducting, have been different than I had originally hypothesized. For example, I came out of chiropractic school absolutely convinced that HVLA side posture adjusting was by far the more effective chiropractic technique for chronic low back pain, a belief that I held for 25 years. It was a surprise to learn recently that flexion distraction works at least as well.8
  4. The fourth is to first learn a little bit more about evidence-based practice in general, and how you might be able to implement some aspects of it into your practice, by visiting the Palmer Center for Chiropractic Research's new evidence toolkit for clinicians. Another great EBP resource is the Clinical Compass, created by the Council on Chiropractic Guidelines and Practice Parameters. The University of Minnesota also offers a free online series (act now, a small charge for each module will begin in August!) in evidence-based clinical practice that serves as a good primer. 
  5. The fifth action step is to comment on this blog post below and let me know what you think! 

Dr. Goertz is senior scientific advisor for the ACA. She also serves as vice chancellor for research and health policy at Palmer College of Chiropractic and CEO of the Spine Institute for Quality (Spine IQ).

References 

  1. Sackett DL. Evidence-based Medicine. Spine, 1998;23(10):1085-1086.  
  2. For Bad Backs, It May Be Time to Rethink Biases About Chiropractors,” The New York Times, published online May 1, 2017.  
  3. Chou R et al. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med,  2017;166(7):493-505.  DOI: 10.7326/M16-2459  
  4. Paige N et al. Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain Systematic Review and Meta-analysis. JAMA, 2017;317(14):1451-1460. doi:10.1001/jama.2017.3086   
  5. Martin, B. et al. The Association of Complementary and Alternative Medicine Use and Health Care Expenditures for Back and Neck Problems. Medical Care, 2012. 50 (12); 1029–1036. doi:10.1097/MLR.0b013e318269e0b2.   
  6. Procter M et al. Spinal manipulation for dysmenorrhoea. Cochrane Library, published July, 19, 2006.
  7. Dobson D et al. Manipulative Therapies for Infantile Colic. Cochrane Library, published Dec. 12, 2012.
  8. Xia T et al.  Similar Effects of Thrust and Nonthrust Spinal Manipulation Found in Adults with Subacute and Chronic Low Back Pain: A Controlled Trial with Adaptive AllocationSpine 2016;41(12):E702-E709.
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08-20-2017 10:44

Dr. Goertz, thank you for your continued efforts on our behalf, collectively. We try to teach the concept of "endless improvement" to our young associates, because the volume of info to assimilate and be responsible for is humbling. I don't do nearly as good a job as I would like and am re-committing myself to reading just a bit more every day, as a result of your article. Thanks again!