Uniting around the evidence, part 1

Haldeman and Degenais elegantly describe what being an evidence-based/informed practitioner entails in their 2008 article in <i>The Spine Journal</i>. “The guiding principle behind evidence-informed management is that practitioners should be aware of and use research evidence when available, make personal recommendations based on clinical experience when it is not available, and be transparent about the process used to reach their conclusion.” ¹ 

I would add that this principle applies not only to care directly provided by any given practitioner, but also to care provided via integration and collaboration with, and/or referrals to, other practitioners. I’m not sure how any ethical healthcare practitioner could disagree with this guiding principle.

I contend that only when we, as a profession, ethically and objectively apply this guiding principle will we unite, express our potential, and earn the cultural authority, interprofessional respect, referrals, inclusivity, and reimbursement that the evidence clearly indicates we deserve.

The evidence-based care movement is the best thing to ever happen to chiropractic; it has created an even playing field and, finally, a demand that care be based on evidence not unearned cultural authority and monopoly, credentials, or lobbying power.

The evidence is on our side. The problem is, we have refused to allow the available evidence to unite us and, instead, have allowed two small, vocal, and too often vitriolic extreme factions within our profession to biasedly and misleadingly apply the guiding principles of evidence-based care in order to divide us.

Both these factions represent “gangrenous arms” that need to be removed. Both factions are guilty of bias and dogma based on ignorance of the literature and/or a refusal to ethically and  objectively apply the guiding principles of evidence-informed care.

One extreme tends to exaggerate the evidence and blindly accept virtually any claim regarding the need and benefit of chiropractic SMT/adjustment. This group also often blindly denies the benefits of other interventions based on a misguided “principle” that chiropractic practice must always reflect the vision of its founders and only include “straight” chiropractic adjustments and not any other “mixing” interventions – even if they are evidence-based. Clearly this is an unscientific, illogical, dogmatic stance; chiropractic is not a religion or a cult, we do not follow a founder to guide our clinical encounters, we follow basic science, clinical evidence, and clinical experience.

Certainly the chiropractic paradigm of addressing the cause, restoring function rather than treating symptoms of dysfunction, and understanding the relationship between segmental motion, spinal health, neuromusculoskeletal health, and overall health and quality of life are important in guiding our research and clinical decisions, but we must never use paradigm or philosophy as evidence for the need for care, or as evidence of benefit from care.

The other extreme tends to exaggerate and blindly accept the validity of unproven soft-tissue therapies, “specialized” exercise programs, and/or disproven passive physical therapy modalities and virtually any other non-chiropractic SMT/adjustment interventions while too often rejecting and/or downplaying the evidence regarding the effectiveness, cost-effectiveness, and safety of chiropractic SMT/adjustment.

Obviously it is neither scientifically valid nor logical nor ethical to reject SMT due to a “lack of evidence” while accepting, promoting, and utilizing other interventions with less evidence than SMT. The standard of evidence regarding effectiveness, cost-effectiveness, and safety must be equally applied to all interventions.  If it is not, then the terms “evidence-based” and “evidence-informed” simply turn into marketing terms, or a way to disguise personal bias or opinion, rather than unbiased movements to improve healthcare.

I ask the reader to honestly self-critique whether your own stance is scientific and evidence-based or biased and dogmatic.  Ask yourself if you use the same standards to evaluate the clinical protocols you and your professional peer group use as you do to evaluate those who practice differently. Are you “aware of and [do you] use research evidence when available, [do you] make personal recommendations based on clinical experience when it is not available, and [are you] transparent about the process used to reach [your] conclusion[s].” ¹

As, or more importantly, do you accept the different clinical experience and different clinical decisions of other chiropractors as equal to your own and your peers, or do you have a dogmatic bias in favour of your own experience and opinions and against those whose experience and opinions differ from your own? Do you have any valid evidence that your clinical protocols based on your experience and opinions elicit greater patient outcomes? Of course you don’t, if you did, then your clinical protocols would be classified as evidence-based in the peer-reviewed literature.

Do you criticize the use of testimonials and/or case reports as evidence when others use them and then use them as evidence for what you do in practice? Do you criticize others for making false claims based on testimonials and/or case reports while you do the same? Do you judge unsubstantiated claims of benefit or clinical superiority for soft-tissue techniques, taping techniques, “specialized” exercise programs, or modalities more harshly than such claims regarding SMT/adjustment? Do you judge a testimonial from an athlete as more or less scientifically valid than one from a child, mother, or father?

Do you judge a case report on chiropractic adjustment/SMT as more or less scientifically valid than a case report on a soft-tissue technique? Do you judge a case report about pain as implicitly more or less valid than a case report regarding a non-neuromusculoskeletal complaint? Do you judge “special” back exercise programs or athletic taping protocols that lack valid evidence of effectiveness from randomized placebo-controlled trials as more or less evidence-based or scientific just because such interventions do or do not match your clinical preference?

Do you interpret the fact that preventative, wellness, and/or salutogenenic paradigms of healthcare make perfect biological and clinical sense as synonymous with the idea that there is valid clinical evidence that chiropractic adjustment/SMT prevents illness, increases wellness, or improves health?

Is an unsubstantiated, never tested claim that chiropractic adjustment/SMT takes pressure off a nerve to an organ less troubling to you than an unsubstantiated never tested claim that a soft-tissue technique breaks up scar tissue or that an athletic taping technique improves athletic performance or prevents injury?

You can see why I get attacked from both extremes – nobody who is dogmatic and lacks evidence likes to have to answer questions regarding evidence for what they do, they only like to pose such questions regarding what others do. To me this is the litmus test for unscientific dogma and unethical bias. The truth is, if we are honest, we all have our confirmation biases regarding our own clinical results based on the biases of our chiropractic college, our professional peer group, and our clinical experience. This is exactly what the evidence-based movement was intended to address!

The peer-reviewed literature clearly points out that all healthcare professionals suffer from a lack of knowledge regarding which interventions are evidence-based, and clinicians in all professions often differ amongst themselves in how they manage patients. “Multiple studies have demonstrated a poor correlation between what primary health-care providers think is an effective treatment and what has actually been shown to be an effective treatment.” ²

What all professions don’t suffer from, is public vitriolic infighting and accusations of malfeasance based on different clinical experience and opinion masked as differences in levels of evidence. It’s time we grew up and started acting professionally. It’s time we stopped allowing dogmatic, extreme factions to define and divide us. It’s time we started adhering to the guiding principles of evidence-based/informed care in an atmosphere of dignity and respect regarding our differences while we continue to conduct research. It’s time we stopped interpreting differences in clinical experience and opinion as differences in ethics, intellect, clinical effectiveness, and patient satisfaction when so such evidence exists.

It’s time all of us in the middle, those of us willing to apply these principles in an unbiased, fair, and ethical manner, and who insist on using evidence when it is available and acknowledge that it is possible for two ethical clinicians to differ on their experience and thus how they would use that experience to manage patients, to come together in the ethical, reasonable, professional “torso” and remove both unethical, unreasonable, unprofessional gangrenous “arms.”

In the end, the only ethical goal is to provide the best possible care that elicits the best possible benefit:harm ratio, for the least possible expense, for any given patient.

We must do our best to remove all unethical, false claims, but we must do this in an ethical, unbiased, evidence-based way; we must never demand a higher level of evidence from others than we demand from ourselves.  Again, this is the litmus test for ethics.

When there is clear evidence available then this can and should be used to create standards of practice. When there is no clear evidence available, which is more often the case than not in all aspects of healthcare, then ethics demand that we don’t allow the vocal, vitriolic, biased, dogmatic voices from either extreme to influence standards of practice or regulatory decision-making.

In part 2 of this article I will discuss further evidence-based commonalities amongst chiropractors that can serve to unite us and help us to better serve both our professional interests, and, most importantly, those of the public.

REFERENCES:

1. Haldeman, S. & Dagenais, S. What have we learned about the evidence-informed management of chronic low back pain? Spine J Jan-Feb;8 (1) 266-277
2. Bishop, et al. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. The Spine Journal 10 (2010): 1055-64

Dr. James Chesnut B.Ed, M.Sc, DC, C.C.W.P., recently developed the Evidence-Based Chiropractic and Lifestyle Clinical Protocols which include evidence-based spinal health exams, reports, and patient education; these protocols are in use in chiropractic offices around the world. Dr. Chestnut also developed, wrote the texts, and still teaches the Evidence-Based Chiropractic and Lifestyle post-graduate certification program accredited through the International Chiropractors Association (ICA). Dr. Chestnut also wrote the book ‘Live Right for Your Species Type’, explaining the relationship between lifestyle, stressors, epigenetics, metabolic adaptation, and states of sickness and health.