© 2006 evidence-based chiropractic 1 evidence-based chiropractic ii michael t. haneline, dc, mph...

Evidence-based Chiropractic 1 © 2006

Evidence-based Chiropractic II

• Michael T. Haneline, DC, MPH

• [email protected]

• http://w3.palmer.edu/michael.haneline– PP presentations– Articles and checklists for class workshops– Sample test questions– Syllabus, etc.


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


• 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

Syllabus


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


Projects

• Case Report Critical Appraisal

• Literature Review Critical Appraisal

• Reliability of Outcome Measures Critical Appraisal

• Randomized Clinical Trial Critical Appraisal

• EBC 5-step project

© 2006

Evidence-based Chiropractic Practice

The best available research evidence, combined with clinical

expertise and patient values.


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


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


What is EBC? (cont.)

• Originally known as evidence-based medicine (EBM)– The concept has been

embraced by thechiropractic profession (and others)


EBC is unique in several ways

1. 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


EBC is unique (cont.)

2. 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


EBC is unique (cont.)

3. 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


• 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

A unique evidence base


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


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


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


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


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


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


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.


EBC is . . .


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


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


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


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?


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


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


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


The five steps of EBP

1. Ask a clinically relevant question 2. Search the literature to find the best available

evidence to answer your question 3. Appraise the evidence for validity and

applicability to the clinical circumstances 4. Apply the relevant evidence to the clinical

situation 5. Evaluate your effectiveness in carrying out

steps 1 through 4 and revise if necessary


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


Two types of questions

1. 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)• http://www.merckmedicus.com


Types of questions (cont.)

2. 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)


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)


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?

P. A middle aged female patient with lumbar spinal stenosis and concomitant radicular pain

Q. Manipulation

R. Any alternative method that might be superior to manipulation

O. A reduction of lower back and leg pain


Patient-Oriented Evidence that Matters (POEMs)

1. The outcome in a study should be something patients care about

– Like morbidity or quality of life

2. The problem should be widespread and the intervention should be feasible

3. The information should have the potential to change the practice of many practitioners


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


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


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


Hierarchy of research evidence

Systematic reviews of RCTs are considered by

most to be the “gold standard” for determining if

a treatment is effective

Progressively fewer studies are available

as one advances from the lowest to the

highest levels of the evidence pyramid

Use the highest level of evidence possible to make clinical decisions


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


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 in EBP is founded on science

• Science is . . .– The observation, identification,

description, experimental investigation, and theoretical explanation of phenomena


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


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 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)


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


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


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


SIGN levels of evidence (cont.)

• 3 – Non-analytic studies (e.g., case reports, case series)

• 4 – Expert opinion


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


SIGN grades of recommendations

• A – At least one meta analysis, 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


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+



• C – 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++



• D– Evidence level 3 or 4 or– Extrapolated evidence from studies rated as

2+


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 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


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


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


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


Philosophy definition

1. The love and pursuit of wisdom by intellectual means and moral self-discipline

2. Investigation of the nature, causes, or principles of reality, knowledge, or values, based on logical reasoning rather than empirical methods

3. The critical analysis of fundamental assumptions or beliefs

4. A set of ideas or beliefs relating to a particular field or activity; an underlying theory

5. A system of values by which one lives


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


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


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


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

© 2006 evidence-based chiropractic 1 evidence-based chiropractic ii michael t. haneline, dc, mph...

Documents

chiropractic research

chiropractic profession

evidencebased medicine

fewer chiropractic articles

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