Evidence-Based Chiropractic

:dropcap_open:I:dropcap_close:n 2011, Spine published an article that bears reading by every chiropractor. The study, entitled “The Pros and Cons of Evidence-Based Medicine” (Croft et al.), takes a look at the continuing debate within the medical profession as to the proper role of “evidence-based medicine.” The authors’ comments should be food for thought for chiropractors interested in keeping their practices on sound scientific footing. As you will see, the value of EBM is a subject that may be viewed quite differently by “researchers, clinicians, and policy makers.”
The Facts:
  • spinesEvidence-based medicine is the idea that current scientific evidence can be combined with the clinician’s expertise, as well as the patient’s preferences and expectations, to obtain the best outcomes.
  • The “evidence” usually comes in the form of original research and systematic reviews of current scientific literature on a given subject. 
  • Some argue that evidence could also mean observations and the clinical experience of the practitioner, even if there isn’t published data to back up those observations. In that case, the term “evidence-based” may more rightfully be called “experience-based” medicine.
  • Often the “evidence” eventually ends up in published clinical guidelines. The authors note that “much of the evidence in any clinical guideline is likely to come from expert opinion.”
  • Guidelines often combine expert consensus, scientific research, clinical practice, observation, and clinical judgment to produce their recommendations.
  • Unfortunately, there is a significant risk of bias among “experts” and the term “evidence-based medicine” may not be entirely appropriate.
  • The authors note that EBM can help make clinical practice more transparent, reduce random variables in treatment protocols across the professions, and even help reduce or eliminate harmful/ineffective treatment methods.
  • They also state that EBM has been accused of refusing to give credence to valid information unless it is derived from randomized controlled trials. This can be very limiting because the ability to assess treatment using the rigid structures of clinical trials can often be confounded for “practical or ethical” reasons. For this reason, many common forms of treatment currently are accepted as standard practice even though there is little or no evidence in the form of clinical trials. 
  • In reality, the daily decisions that doctors and patients must make are much more complex than the structured design of clinical trials. 
  • Furthermore, too many sources of information or too many highly detailed clinical guidelines may result in practitioners choosing to simply ignore all or part of the recommended care for a given condition.
Of particular relevance to chiropractors is this comment made by the authors: “In the field of low back pain, EBM rarely provides the basis for action in a primary care consultation.” For example, most clinical trials evaluate only a single-treatment intervention. In real life, though, chiropractors often use multiple interventions (adjustments, ice, muscle stimulation, etc.) simultaneously. The use of multiple interventions may result in improved outcomes regardless of whether or not the treatment methods have ever been studied together in concert. Limiting our treatment only to those methods that have been thoroughly researched may easily hamstring our best efforts to treat patients.
As the chiropractic profession continues to move toward evidence-based practice guidelines, it’s also good to remember the ever-present potential for bias. Research by chiropractors, for example, might tend to be biased in favor of spinal manipulation as a treatment while other studies by MDs or PTs might easily be less favorable. It’s also worth remembering that treatment guidelines are to “skew toward select areas where evidence has been gathered, and away from interventions for which research is lacking, regardless of efficacy.” In the same vein, it should also be understood that the constant demand for more evidence before particular treatment methods are allowed is likely to retard progress and stifle creativity.
Finally, clinical practice guidelines are increasingly being used as far more than recommendations for treatment. Insurers frequently cite lack of evidence as justification for denial of payment. Failure to follow published treatment guidelines may too easily become the basis for a lawsuit. It’s worth remembering that a lack of good data on a particular therapy or treatment tells us absolutely nothing as to the efficacy, or lack thereof, of the method (a fact many insurers conveniently seem to overlook). 
Take Home
Taken too far, overreliance on EBM can serve to stifle professional judgment and negate the value of hard won experience. So what to do? Should we just ignore all the “evidence” and proceed to randomly do whatever we like in our clinics? Not at all, but neither should we proceed as if we’re totally blinded by the presence (or lack) of evidence. The debate about the value of EBM will likely continue. Established standards of professionalism demand we stay current as to the best available evidence. However, being the doctor has always required practitioners to think, evaluate, and temper that knowledge with professional experience and judgment. Special thanks to our chiropractic sciences contributor Roger Coleman, DC for this thought-provoking article. 

Croft P, Malmivaara A, van Tulder M. The pros and cons of evidence-based medicine. Spine. 2011;36:1121-5.
Dr. Mark R Payne, Phenix City, AL is Editor of ScienceInBrief.com, a scientific literature review for busy chiropractors. He is also President of Matlin Mfg Inc. a manufacturer of postural rehabilitation products since 1988. Subscription to ScienceInBrief.com is FREE to doctors of chiropractic and chiropractic students. Reviews of relevant scientific articles are emailed weekly to subscribers.

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