1. Evidence-based Chiropractic II
Michael T. Haneline, DC, MPH
PP presentations
Articles and checklists for class workshops
Sample test questions
Syllabus, etc.
Evidence-based Chiropractic

2. Evidence-based Chiropractic II
Required text:
Evidence-based Chiropractic Practice. Haneline M. Jones & Bartlett Publishers
Read chapters before pertinent class sessions
Exam questions are taken from the text
Evidence-based Chiropractic

3. Evidence-based Chiropractic
Syllabus
Topics
Elementary biostatistics
Research design
Literature searching strategies
Outcome measures and the importance of their use in a chiropractic practice
Class workshops appraising several articles
Literature searching workshop in the library
Evidence-based Chiropractic

4. Evidence-based Chiropractic
Course Goals
To assist students in becoming critical thinkers in chiropractic practice
To teach students to find, acquire, read, critically appraise, understand and apply information published in scholarly periodicals
To relate research to clinical practice and clinical practice to scholarship
Evidence-based Chiropractic

5. Evidence-based Chiropractic
Projects
Case Report Critical Appraisal
Literature Review Critical Appraisal
Reliability of Outcome Measures Critical Appraisal
Randomized Clinical Trial Critical Appraisal
EBC 5-step project
Evidence-based Chiropractic

6. Evidence-based Chiropractic Practice
The best available research evidence, combined with clinical expertise and patient values.

7. What is Evidence-based Chiropractic (EBC)?
EBC developed out of a movement started by a group of medical educators at McMaster’s University during the 1980s
These physicians observed that a gap had developed between what occurred in clinical practice and what was obtainable in reports of clinical research
Evidence-based Chiropractic

8. Evidence-based Chiropractic
What is EBC? (cont.)
Essentially, clinicians could not stay abreast with new research because it was being produced so fast; consequently they were not putting into practice the most current information
Evidence-based methods were designed to bridge this gap
Evidence-based Chiropractic

9. Evidence-based Chiropractic
What is EBC? (cont.)
Originally known as evidence-based medicine (EBM)
The concept has been embraced by the chiropractic profession (and others)
Evidence-based Chiropractic

10. EBC is unique in several ways
Chiropractic interventions (manipulation) are difficult to investigate by experimental methods
Difficulty in designing an effective placebo
It is difficult to blind both doctors and patients
As a result, there are fewer chiropractic articles that use a placebo control group than other disciplines
Evidence-based Chiropractic

11. Evidence-based Chiropractic
EBC is unique (cont.)
Chiropractors commonly utilize multiple treatment modalities
A variety of manipulations, exercises, ergonomic advice, physiotherapy, etc.
In contrast, clinical trials often utilize only one modality
In order to isolate it and compare it with a placebo or an alternative therapy
Evidence-based Chiropractic

12. Evidence-based Chiropractic
EBC is unique (cont.)
Finances were very limited for chiropractic research in the past which hampered progress
High-quality research is very expensive
Things have changed in recent years
Federal funds are increasingly becoming available
Numerous elegant chiropractic studies have resulted
Evidence-based Chiropractic

13. Evidence-based Chiropractic
A unique evidence base
The uniqueness of chiropractic research has produced a correspondingly unique evidence base of chiropractic information
Studies may appear to be less rigorous than for other forms of treatment
Nonetheless, many studies are available to support and help direct chiropractic patient care
Evidence-based Chiropractic

14. Evidence-based practice (EBP) is
“. . . the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”
David Sackett, MD
Evidence-based Chiropractic

15. EBP incorporates the skills of the doctor
The practitioner’s clinical expertise is integrated with the best available external clinical evidence from systematic research
Clinical expertise: the skills and knowledge gained by clinicians through clinical experience and practice
EBP relies heavily upon the practitioner’s past clinical experience
Evidence-based Chiropractic

16. EBP is not a “cookbook” method of practice
It is the integration of the best evidence with the past training and expertise of the clinician, which results in better care for the patients
Evidence is added to patient care to replace outdated information
Best evidence is that which is most current, valid, and as high in the hierarchy of evidence as possible.
Evidence-based Chiropractic

17. Evidence-based Chiropractic
Patient preferences
The personal values, concerns, and expectations that patients have about their care
Taking patient preferences into consideration is an essential step in the EBP process
Evidence-based Chiropractic

18. Patient preferences (cont.)
Personal values
The beliefs patients have about the care that is being offered to them
May be related to philosophical or even religious issues
Patient concerns
e.g., financial issues, time constraints, and office location
Evidence-based Chiropractic

19. Patient preferences (cont.)
Patient expectations
The degree that patients accept a doctor’s recommendations
Often wide-ranging and can have a significant impact on clinical results
Evidence-based Chiropractic

20. Evidence-based Chiropractic
EBC is . . .
Actively seeking support for and improvement of chiropractic clinical practice through the integration of the best available research evidence, combined with clinical expertise and patient values.
Evidence-based Chiropractic

21. Evidence-based Chiropractic
EBC is . . .
Evidence-based Chiropractic

22. Evidence-based Chiropractic
Why EBP?
Practitioners may not have enough information to answer clinical questions
Complicated cases
Patients sometimes ask difficult questions
The need to stay current in light of an overwhelming amount of new research
Must be able to distinguish the good from the bad
Evidence-based Chiropractic

23. Evidence-based Chiropractic
Why EBP? (cont.)
Best practices
Use of the most valid clinical tools available
Established through research
To determine the most effective form of treatment
Is there any associated harm?
Utilize valid and reliable diagnostic tests
Evidence-based Chiropractic

24. Evidence-based Chiropractic
Why EBP? (cont.)
Better reimbursement
Insurance companies often pay for services when provided with an explanation grounded in credible evidence that justifies the clinical procedures
Evidence-based Chiropractic

25. Evidence-based Chiropractic
When EBP?
Patient-specific
Patients who present for care with unusual conditions that are unknown to the practitioner
Is the patient a good candidate for chiropractic care?
What are the best case management options?
Are there contraindications to manipulation?
Should the patient be referred elsewhere?
Evidence-based Chiropractic

26. Evidence-based Chiropractic
When EBP? (cont.)
Condition-specific
Practitioners become familiar with unknown conditions
After the patient presents for care
Reactive learning
Before the patient presents for care
Proactive learning
Achieved by consistently reading current evidence
Evidence-based Chiropractic

27. Evidence-based Chiropractic
When EBP? (cont.)
Self education
Attending seminars and conferences
How informed is the speaker and how accurate and current is the material?
Practitioners gathering the best available evidence on their own
Journal articles are the most dependable source
Textbooks and prior knowledge become obsolete rapidly as new information becomes available
Evidence-based Chiropractic

28. It takes time and practice to learn EBP methods
Some elements of EBP are difficult to master (e.g., research methods and biostatistics)
Make time to read journal articles
Peruse abstracts, then read the entire articles of those that are of interest
Set aside time to search for answers to clinical questions
Evidence-based Chiropractic

29. Evidence-based Chiropractic
The five steps of EBP
Ask a clinically relevant question
Search the literature to find the best available evidence to answer your question
Appraise the evidence for validity and applicability to the clinical circumstances
Apply the relevant evidence to the clinical situation
Evaluate your effectiveness in carrying out steps 1 through 4 and revise if necessary
Evidence-based Chiropractic

30. Asking clinical questions
Question should be clinically relevant
The answer will help with the management of a particular patient or patients with a similar condition
A good question will help guide the search for evidence toward relevant material
Can save a great deal of time
Evidence-based Chiropractic

31. Evidence-based Chiropractic
Two types of questions
Background questions
Simple two-part questions that address the basic facts about a patient’s health problem
Do not fully address issues about the best diagnostic or treatment options
This type of information can be acquired from current textbooks and peer-reviewed and referenced electronic publications (e.g., Harrison’s Online)
Evidence-based Chiropractic

32. Types of questions (cont.)
Foreground questions
More complex than background questions
Apply to decisions about the most favorable treatment or diagnostic strategies
Derived from
Primary sources (journal articles of clinical studies)
Secondary sources (expert reviews of all available original articles on a given topic)
Evidence-based Chiropractic

33. Elements of a good clinical question (PICO)
Patient or problem
Intervention
Comparison intervention (optional)
Outcome(s) of interest
Should be of interest to patients (e.g., less pain or disability)
Evidence-based Chiropractic

34. Evidence-based Chiropractic
PICO example
Is manipulation effective at reducing back and leg pain in a middle aged female patient with lumbar spinal stenosis and concomitant radicular pain, or are any alternative methods more favorable?
A middle aged female patient with lumbar spinal stenosis and concomitant radicular pain
Manipulation
Any alternative method that might be superior to manipulation
A reduction of lower back and leg pain
Evidence-based Chiropractic

35. Patient-Oriented Evidence that Matters (POEMs)
The outcome in a study should be something patients care about
Like morbidity or quality of life
The problem should be widespread and the intervention should be feasible
The information should have the potential to change the practice of many practitioners
Evidence-based Chiropractic

36. Disease Oriented Evidence (DOE)
Studies that involve outcomes that may be of interest to researchers and practitioners, but are of little interest to patients
Surrogate end points are used as a substitute for clinically meaningful POEMs
Examples: range of motion, leg length
Evidence-based Chiropractic

37. Evidence-based Chiropractic
Example of a POEM
A RCT showing that exercise along with manipulation leads to less low back pain and disability than manipulation alone
Why?
Problem is encountered frequently in practice
The article considers pain, and disability as the primary outcomes (patient oriented)
This should be a “practice-changer” for chiropractors who use manipulation only
Evidence-based Chiropractic

38. Evidence-based Chiropractic
What is evidence?
Something that is helpful in forming a conclusion or judgment
Found primarily in journal articles that deal with:
The effectiveness and safety of treatments
The validity and reliability of diagnostic tests
The incidence and prevalence of diseases in populations
Evidence-based Chiropractic

39. Hierarchy of research evidence
Progressively fewer studies are available as one advances from the lowest to the highest levels of the evidence pyramid
Systematic reviews of RCTs are considered by most to be the “gold standard” for determining if a treatment is effective
Use the highest level of evidence possible to make clinical decisions
Evidence-based Chiropractic

40. Progression of clinical investigation
Clinical investigation typically begins with case reports/series, then advances to observational studies, and then to RCTs
The final step is a systematic review after a few RCTs have been reported
Evidence-based Chiropractic

41. A lower-level study may be better evidence
Studies that rank higher on the hierarchy of evidence pyramid are not always better
For instance, a single RCT that involved few subjects is not necessarily more credible than reliable results from a high-quality non-randomized trail
Sometimes RCTs are of little value because of design flaws
Evidence-based Chiropractic

42. Evidence in EBP is founded on science
Science is . . .
The observation, identification, description, experimental investigation, and theoretical explanation of phenomena
Evidence-based Chiropractic

43. Founded on science (cont.)
The scientific method
The principles and empirical processes of discovery and demonstration considered characteristic of or necessary for scientific investigation, generally involving the observation of phenomena, the formulation of a hypothesis concerning the phenomena, experimentation to demonstrate the truth or falseness of the hypothesis, and a conclusion that validates or modifies the hypothesis
Evidence-based Chiropractic

44. Practitioners should be able to interpret scientific reports
Must be able to discriminate good- from poor-quality evidence
Unfortunately, many do not understand basic research methods
This state of affairs is changing
Continuing education for practitioners
Chiropractic students are now taught to interpret scientific reports
Evidence-based Chiropractic

45. Evidence rating systems
Used to rate the quality and class structure of evidence
Examples
Scottish Intercollegiate Guidelines Network (SIGN)
Agency for Healthcare Research (AHRQ)
Oxford Centre for Evidence-based Medicine (CEBM)
Evidence-based Chiropractic

46. Evidence-based Chiropractic
Rating systems (cont.)
The relative strength of evidence depends on:
Position in the hierarchy of study designs
The study’s validity
Refers to the degree that a study design is able to produce dependable results
Evidence-based Chiropractic

47. SIGN levels of evidence
1++
High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias 1+
Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias 1−
Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
Evidence-based Chiropractic

48. SIGN levels of evidence (cont.)
2++
High quality systematic reviews of case-control or cohort studies or High quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal 2+
Well conducted case-control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal 2−
Case-control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal
Evidence-based Chiropractic

49. SIGN levels of evidence (cont.)3
Non-analytic studies (e.g., case reports, case series) 4
Expert opinion
Evidence-based Chiropractic

50. Grades of recommendations
Utilized by guidelines developers to make comments about the appropriateness of various treatment and diagnostic procedures
Recommendations are based on the quantity and quality of evidence that is available
Evidence-based Chiropractic

51. SIGN grades of recommendations
At least one meta­analysis, systematic review, or RCT rated as 1++ and directly applicable to the target population or
A systematic review of RCTs or a body of evidence consisting principally of studies rated as 1+ directly applicable to the target population and demonstrating overall consistency of results
Evidence-based Chiropractic

52. SIGN grades of recommendations (cont.)B
A body of evidence including studies rated as 2++ directly applicable to the target population and demonstrating overall consistency of results or
Extrapolated evidence from studies rated as 1++ or 1+
Evidence-based Chiropractic

53. SIGN grades of recommendations (cont.)
A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results or
Extrapolated evidence from studies rated as 2++
Evidence-based Chiropractic

54. SIGN grades of recommendations (cont.)
Evidence level 3 or 4 or
Extrapolated evidence from studies rated as 2+
Evidence-based Chiropractic

55. Evidence-based Chiropractic
Critical appraisal
Articles should be critically appraised to determine whether or not the information should be applied to the clinical circumstances
If valid and applicable, the information can be utilized to make clinical decisions
If not, either reject the information or utilize only those portions that are valid and applicable
Evidence-based Chiropractic

56. Evidence is rarely definitive
Especially true when considering only a single study
The degree of confidence that one may have in evidence depends on
The strength (hierarchy/validity) of the research and
How the various pieces of research on that topic blend together
Evidence-based Chiropractic

57. When there is little or no evidence
The practitioner must decide whether or not to render treatment
Perhaps on a time and improvement dependant trial basis or
Refer to an appropriate specialist for autonomous or co-management of the case
Bear in mind
No evidence of effect is not the same as evidence of no effect
Evidence-based Chiropractic

58. Chiropractic philosophy and EBC
“The foundation of chiropractic includes philosophy, science, art, knowledge, and clinical experience.” The Chiropractic Paradigm The Association of Chiropractic Colleges
However, many chiropractors have a limited understanding of the concepts of philosophy
Evidence-based Chiropractic

59. Philosophy and EBC (cont.)
Many chiropractors think of philosophy as it relates to their fundamental beliefs and underlying principles about the profession
Thus, one is said to have a philosophy of chiropractic
This perception only comprises a small part of the word’s complete definition
Evidence-based Chiropractic

60. Philosophy definition
The love and pursuit of wisdom by intellectual means and moral self-discipline
Investigation of the nature, causes, or principles of reality, knowledge, or values, based on logical reasoning rather than empirical methods
The critical analysis of fundamental assumptions or beliefs
A set of ideas or beliefs relating to a particular field or activity; an underlying theory
A system of values by which one lives
Evidence-based Chiropractic

61. Evidence-based Chiropractic
Philosophy and dogma
A belief system taken to an extreme becomes dogma; defined as
An authoritative principle, belief, or statement of ideas or opinion, especially one considered to be absolutely true
Dogmatic practitioners may be reluctant to acknowledge new information and change their practices in response
Evidence-based Chiropractic

62. Evidence-based Chiropractic
Dogmatism
The chiropractic profession at large is plagued with dogmatism that affects both sides of the political fence Seaman
Dogmatism is the principle barrier to a rational and unifying depiction of the role of chiropractors, as well as the furtherance of chiropractic science Keating
Evidence-based Chiropractic

63. The solution for dogmatism
When used effectively, philosophy leads to a willingness to critically examine one’s beliefs
Rather than being dogmatic, one should welcome new (better) evidence and try to incorporate it into patient care
Evidence-based Chiropractic

64. EBC and philosophy are complementary
There are no sacrosanct truths in chiropractic that should never be questioned
Any conceivable chiropractic-related topic should be open for discussion
Evidence-based Chiropractic