EVIDENCE-BASED PRACTICE PAGE
 
   

The Evidence-based Practice Page

This section was compiled by Frank M. Painter, D.C.
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Evidence-based Articles
 
   


  
The Problem with Randomized Controlled Trials and Meta Analyses Page


  
A Comprehensive Review of Chiropractic Research
           Anthony Rosner, PhD, Research Director of FCER

           “Evidence-based medicine” [EBM] was introduced as a term to denote the application of treatment that has been proven and tested “in a rigorous manner to the point of its becoming 'state of the art.'” [12] Its intention has been to ensure that the information upon which doctors and patients make their choices is of the highest possible standard. [13] To reach a clinical decision based upon the soundest scientific principles, EBM proposes five steps for the clinician to follow as shown in TABLE 2. [14]


  
The Obstacles and Barriers to CAM Research
           Anthony Rosner, PhD, Research Director of FCER

The efforts to launch and develop a National Center for Complementary and Alternative Medicine within the framework of the NIH are indeed admirable, taking the Center from a humble $2M annual budget in 1991 to one that approaches $70M today. This has taken place despite the comments of highly visible and influential individuals within the medical community to discredit alternative medicine in virtually any shape or form. Following are what I believe to be the most significant barriers to research efforts in alternative medicine, the barriers having either remained in place or only recently having been removed.


  
The Trials of Evidence:
Interpreting Research and the Case for Chiropractic

The Chiropractic Report ~ July 2011 ~ FULL TEXT

For the great majority of patients with both acute and chronic low-back pain, namely those without diagnostic red flags, spinal manipulation is recommended by evidence-informed guidelines from many authoritative sources – whether chiropractic (the UK Evidence Report from Bronfort, Haas et al. [1]), medical (the 2007 Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society [2]) or interdisciplinary (the European Back Pain Guidelines [3]).


  
The Mythology Of Science-Based Medicine
           The Huffington Post ~ 2-25-2011

           One side, mainstream medicine, promotes the notion that it alone should be considered "real" medicine, but more and more this claim is being exposed as an officially sanctioned myth. When scientific minds turn to tackling the complex business of healing the sick, they simultaneously warn us that it's dangerous and foolish to look at integrative medicine, complementary and alternative medicine, or God forbid, indigenous medicine for answers. Because these other modalities are enormously popular, mainstream medicine has made a few grudging concessions to the placebo effect, natural herbal remedies, and acupuncture over the years. But M.D.s are still taught that other approaches are risky and inferior to their own training; they insist, year after year, that all we need are science-based procedures and the huge spectrum of drugs upon which modern medicine depends.


  
The Shifting Sands of EBM (Evidence-Based Medicine)
           Anthony L. Rosner, PhD, Research Director at Parker College of Chiropractic

           Cracks in the foundation of the conventional wisdom of randomized clinical trials (RCTs) began to appear in the 1980s when the quality of observational (cohort, case series) studies was found to improve such that their predictive value in clinical situations could now be compared to that seen in the more rigorous RCTs. [1,2] At the same time, RCTs began to be seriously challenged due to their limited applicability in clinical situations. [3,4] Among other problems, RCTs were found to lack insight into lifestyles, nutritional interventions and long-latency deficiency diseases. [5] Quirks have even surfaced which demonstrate how the exalted meta-analysis is subject to human error and bias. [6]


  
Evidence-Based Medicine:
Best Practices and Practice Guidelines

J Manipulative Physiol Ther 2007 (Nov);   30 (9):   615–616 ~ FULL TEXT

Any thoughtful physician would want to provide the best services for his or her patients, and as far as we know, this has been a precept that has been accepted since the beginning of recorded history as it relates to the practice of healing. This position is one of simple ethical behavior and is part of any vow taken by doctors who practice in one of the branches of medicine. This ethic is characterized by the old and often repeated principle “primum non nocere,” which, interpreted means “first do no harm.”


  
When Evidence and Practice Collide
           J Manipulative Physiol Ther 2005 (Oct);   28 (8):   551–553 ~ FULL TEXT

           “Until now, we believed that the best way to transmit knowledge from its source to its use in patient care was to first load the knowledge into human minds… and then expect those minds, at great expense, to apply the knowledge to those who need it. However, there are enormous ‘voltage drops’ along this transmission line for medical knowledge.”


  
Fostering Critical Thinking Skills:
A Strategy for Enhancing Evidence Based Wellness Care

Chiropractic & Osteopathy 2005 (Sep 8)   Volume 13 (1): 19 ~ FULL TEXT

Chiropractic has traditionally regarded itself a wellness profession. As wellness care is postulated to play a central role in the future growth of chiropractic, the development of a wellness ethos acceptable within conventional health care is desirable. This paper describes a unit which prepares chiropractic students for the role of "wellness coaches". Emphasis is placed on providing students with exercises in critical thinking in an effort to prepare them for the challenge of interfacing with an increasingly evidence based health care system.


  
Applying Evidence-Based Health Care to Musculoskeletal Patients
as an Educational Strategy for Chiropractic Interns
(A One-Group Pretest-Posttest Study)

J Manipulative Physiol Ther 2004 (May);   27 (4):   253–261

The results of this study suggest that having chiropractic interns apply EBHC to actual musculoskeletal patients along with attending EBHC workshops had a positive impact on interns' perceived ability to practice EBHC.


  
Fables or Foibles: Inherent Problems with RCTs
           J Manipulative Physiol Ther 2003 (Sept);   26 (7):   460 ~ FULL TEXT

           The 7 case studies reviewed in this report combined with an emerging concept in the medical literature both suggest that reviews of clinical research should accommodate our increased recognition of the values of cohort studies and case series. The alternative would have been to assume categorically that observational studies rather than RCTs (Randomized Controlled Trials) provide inferior guidance to clinical decision-making. From this discussion, it is apparent that a well-crafted cohort study or case series may be of greater informative value than a flawed or corrupted RCT. To assume that the entire range of clinical treatment for any modality has been successfully captured by the precision of analytical methods in the scientific literature, indicates Horwitz, would be tantamount to claiming that a medical librarian who has access to systematic reviews, meta-analyses, Medline, and practice guidelines provides the same quality of health care as an experienced physician.


  
Effect of Interpretive Bias on Research Evidence
           British Medical Journal 2003 (Jun 28);   326 (7404):   1453–1455 ~ FULL TEXT

           Doctors are being encouraged to improve their critical appraisal skills to make better use of medical research. But when using these skills, it is important to remember that interpretation of data is inevitably subjective and can itself result in bias. Facts do not accumulate on the blank slates of researchers' minds and data simply do not speak for themselves. (1) Good science inevitably embodies a tension between the empiricism of concrete data and the rationalism of deeply held convictions. Unbiased interpretation of data is as important as performing rigorous experiments. This evaluative process is never totally objective or completely independent of scientists' convictions or theoretical apparatus. This article elaborates on an insight of Vandenbroucke, who noted that "facts and theories remain inextricably linked... At the cutting edge of scientific progress, where new ideas develop, we will never escape subjectivity." (2) Interpretation can produce sound judgments or systematic error. Only hindsight will enable us to tell which has occurred. Nevertheless, awareness of the systematic errors that can occur in evaluative processes may facilitate the self regulating forces of science and help produce reliable knowledge sooner rather than later.


   Evidence-based Chiropractic Care: Cochrane Systematic
Reviews of Health Care Interventions

J Canadian Chiropractic Assoc 2003 (Mar);   47 (1):   8–16 ~ FULL TEXT

This Adobe Acrobat article (292 KB) states: As a chiropracvtor, you want whats best for your patients. In order to make well-informed clinical decisions, you and your patients require high-quality, up-to-date, trustworthy healthcare information. Such information is available in the Cochrane Library of systematic reviews of healthcare interventions.


  
Is Chiropractic Evidence Based? A Pilot Study
           J Manipulative Physiol Ther 2003 (Jan);   26 (1):   47 ~ FULL TEXT

           When patients were used as the denominator, the majority of cases in a chiropractic practice were cared for with interventions based on evidence from good-quality, randomized clinical trials. When compared to the many other studies of similar design that have evaluated the extent to which different medical specialties are evidence based, chiropractic practice was found to have the highest proportion of care (68.3%) supported by good-quality experimental evidence.


  
Placebo Surgery
           Chiropractic Journal 2002; September

           Many scientists and clinicians consider the placebo-controlled trial the "gold standard" for evidence-based practice. Interestingly, surgical procedures are often exempt from such scrutiny. Ethical considerations are considered barriers to the use of placebo-controlled investigations for surgical procedures. [3,4] Interestingly, there have been five studies where placebo surgery was used as a control. The placebo group generally did as well or better than the group receiving the real operation. Read more about the difficulties of designing a "neutral" sham in a chiropractic (or CAM) trial.


   Evidence-Based Chiropractic Care Part I:
Contribution of Cochrane Collaboration and the Canadian
Cochrane Network and Centre

J Canadian Chiropractic Assoc 2002 (Sep);   4 (3): 137-143 ~ FULL TEXT

This Adobe Acrobat article states: Chiropractors are busy health professionals. Like all other health pratitioners today, you do not have the time to read all the literature you ought to review to keep current with new research and the reports of best practices in your profession. Fortunately, there are relaible sources of up-to-date summarized literature available to help you.


  
Informatics Skills:
Weakness in the Foundation of Research

Proceedings of the 2002 International Conference on Spinal Manipulation (OCT)

One of the challenges facing today’s health care professionals is the difficulty in keeping current despite the proliferation of medical literature. This need is compounded with the increasing advocacy for evidence-based medicine. Current estimates suggest that clinicians would need to read 19 articles per day, every day of the year to keep abreast of relevant clinical developments. [1] Other than consulting colleagues in the field or experts, health care professionals can peruse literature reviews for a concise, qualitative or quantitative meta-analysis of pertinent information. However, expert bias and errors in the literature review process has been shown to be a reason for caution. 2 It is often impossible to separate fact from opinion or to decipher the authors’ methods for selecting material. [3]


   The Evidence House: How to Build an Inclusive Base
for Complementary Medicine

West J Med 2001 (Aug);   175 (2):   79-80

We all want good evidence available when making medical decisions. Evidence, however, comes in a variety of forms and purposes, and what may be good for one purpose may not be good for another. The term "evidence-based medicine" (EBM) has become almost a cliché in recent years, being used as a synonym for "good" or "scientific," both to support and refute the value of complementary medicine practices. But EBM takes a narrow view of what constitutes "good" evidence, and it excludes important qualitative and observational information about the use and benefits of complementary medicine.


   The Evidence In Evidence-based Practice:
What Counts And What Doesn't Count?

J Manipulative Physiol Ther 2001 (Jun);   24 (5):   362–366 ~ FULL TEXT

For those who are prepared to buy in to EBP, there is a question that is only now being debated in the chiropractic literature.   This question, which is being vigorously debated elsewhere in EBP, is one of exactly what does and what does not count as evidence in EBP.   In the working definition of EBP, the "evidence" is characterized as being "sound" and generated from "well-conducted research".   But what exactly does this mean? For many, the terms sound and well-conducted research are instinctively interpreted as referring to randomized controlled trials (RCTs).   The RCT has been designated – in many cases accurately – the gold standard of research designs.   Accordingly, the intuitive assumption that only evidence from RCTs counts in EBP is understandable.   However, this position is now being challenged, and other designs, such as observational and qualitative research, are being considered legitimate providers of the evidence in EBP.   It might be time to look at how these moves will affect chiropractic research in the future.


   Evidence-based Clinical Guidelines for the Management of
Acute Low Back Pain: Response to the Guidelines Prepared for
the Australian Medical Health and Research Council

J Manipulative Physiol Ther 2001 (Jun);   24 (3):   214–220 ~ FULL TEXT

In Bogduk's opinion, the major reason for justifying these guidelines in preference to previous multidisciplinary efforts in both the United States1 and the United Kingdom2 is that consensus or expert opinion is no longer to be accepted as a form of evidence. Bogduk claims that all of his conclusions are preferably based on hard evidence from the published clinical trials, yet nowhere in his treatise is there any indication that his own review of the evidence is either systematic or impartial. As I will make clear in what follows, his analysis of the literature pertaining to spinal manipulation in particular is both flawed and incomplete, seriously undermining the credibility of the entire report.


  
Evaluating the Quality of Clinical Practice Guidelines
           J Manipulative Physiol Ther 2001 (Mar);   24 (3):   170–176

           The literature reviewed suggests that professional organizations or groups should undertake a critical review of guidelines using available critical guideline appraisal tools. Guideline validity appraisal should be done before acceptance by the chiropractic profession. To avoid unwarranted utilization of poorly constructed guidelines, it is strongly recommended that all future guidelines be reviewed for validity and scientific accuracy with the findings published in a medically indexed journal before they are adopted by the chiropractic community.


   Interpreting The Evidence: Choosing Between Randomised
And Non-randomised Studies

British Medical Journal 1999 (Jul 31);   319:   312–315 ~ FULL TEXT

Evaluations of healthcare interventions can either randomise subjects to comparison groups, or not.   In both designs there are potential threats to validity, which can be external (the extent to which they are generalisable to all potential recipients) or internal (whether differences in observed effects can be attributed to differences in the intervention).   Randomisation should ensure that comparison groups of sufficient size differ only in their exposure to the intervention concerned.   However, some investigators have argued that randomised controlled trials (RCTs) tend to exclude, consciously or otherwise, some types of patient to whom results will subsequently be applied.


   Applying Research Evidence to Individual Patients
            British Medical Journal 1998 (May 30);   316 (7139):   1621–1622 ~ FULL TEXT

           At the heart of clinical medicine is an unresolved conflict between the essentially case based nature of clinical practice and the mainly population based nature of the research evidence. While clinicians are exhorted to use up to date research evidence to give patients the best possible care, actually doing so in individual patients is difficult.


   Qualitative Research and Evidence Based Medicine
            British Medical Journal 1998 (Apr 18);   316 (7139):   1230–1232 ~ FULL TEXT

           Qualitative research may seem unscientific and anecdotal to many medical scientists. However, as the critics of evidence based medicine are quick to point out, medicine itself is more than the application of scientific rules. Clinical experience, based on personal observation, reflection, and judgment, is also needed to translate scientific results into treatment of individual patients.


  
Evidence-Based Medicine:   What It Is and What It Isn't
          British Medical Journal 1996 (Jan 13);   312:   71–72 ~ FULL TEXT

          Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgement that individual clinicians acquire through clinical experience and clinical practice.


  
Proposal for Establishing Structure and Process in the Development
of Implicit Chiropractic Standards of Care and Practice Guidelines

J Manipulative Physiol Ther 1992 (Sep);   15 (7):   430–438

This proposal offers a preliminary definition of the structure and process, including a "seed" policy statement and decision flow chart, specific to guideline development. Once the structure and process of guideline development for chiropractic are defined, the profession can then present this product to federal and state agencies, private sector health care purchasers, patient advocacy groups and other stakeholders of chiropractic care.


  
Accuracy of Data in Medical Abstracts of Published Research Articles
           Researchers randomly selected 44 articles from each of five medical journals, including Lancet and The New England Journal of Medicine. The results, published in JAMA 1999 (Mar 24);   281 (12):   1110—1111, showed that between 18 and 68 percent of the 264 abstracts evaluated were inaccurate, meaning there were omissions or inconsistencies between the data in the abstract and the data in the body, tables and figures of the main article. The results are especially troubling because abstracts are widely used, often separate from their text, as in MEDLINE and other databases, and data taken from the abstracts may be reported and disseminated in other works, in other formats and in the media. You may also enjoy the Editorial ~ JAMA 1999 (Mar 24);   281 (12):   1129—1130 on this topic.


   "Evidence-Based Care":   From Guidelines to Practice
          Specialists of the neuromusculoskeletal (NMS) system have seen tremendous changes in the last decade. "Medicalization" has led to excesses in diagnostic testing and surgery, while chiropractic and psychological approaches have been underutilized. Evidence pointing out that ineffective approaches were overutilized and effective approaches underutilized has been summarized and published in guidelines throughout the world.


   Behavioral and Physical Treatments for Tension-type
and Cervicogenic Headache

Duke University Evidence-based Practice Center Report

In 1996, the Agency for Health Care Policy and Research (AHCPR) was scheduled to produce a set of clinical practice guidelines on available treatment alternatives for headache. This headache project was based on the systematic evaluation of the literature by a multidisciplinary panel of experts. Due to largely political circumstances, however, their efforts never came to fruition. The work was never released as guidelines, but was instead transformed with modifications and budget cuts into a set of evidence reports on only migraine headache. Thanks to FCER funding, the evidence reports have now been updated on both cervicogenic and tension-type headaches.   You may also download the full 10-page Duke University Report in Adobe Acrobat format.   You might also enjoy Dr. Anthony Rosner's recent article on this topic.

 
   

Evidence-based Introduction
 
   

Thanks to Michael T. Haneline, DC, MPH for providing the following materials to help our profession utilize evidence-based articles! He teaches classes on Evidence-based chiropractic at Palmer West.

“Don't have a clue how to interpret the various statistical tests utilized in many of the journal articles in order to practice evidence-based chiropractic? Then read these two brief articles that provide an overview of some important statistical concepts, required to understand the methods involved in research. You may want to read the "Descriptive Statistics" article first.”



   Descriptive Statistics
           Descriptive statistics (DS) characterize the shape, central tendency, and variability of a set of data. When referring to a population, these characteristics are known as parameters; with sample data, they are referred to as statistics.
Word document (285 KB)      OR      Acrobat file (80 KB)


   Common Statistical Tests
           The purpose of this brief discourse on statistical tests is to enable chiropractors to better understand the mechanisms used by researchers as they evaluate and then draw conclusions from data in scientific articles. The emphasis is on understanding the concepts, so mathematics is purposefully deemphasized.
Word document (275 KB)      OR      Acrobat file (164 KB)


   Evidence-based Chiropractic
           This is the syllabus and Powerpoint notes for an Evidence-based class being taught to chiropractic students by Michael T. Haneline, DC, MPH, FICR at Palmer College of Chiropractic West.


[acrobat]   Download The Adobe Acrobat Reader for Free

 
   

Helpful Tools
 
   

   National Guideline Clearinghouse
           Agency for Healthcare Research and Quality (AHRQ)

           AHRQ's National Guideline Clearinghouse is an an Internet repository of evidence-based clinical practice guidelines launched in 1998.


   Patient Safety Network
           Agency for Healthcare Research and Quality (AHRQ)

           This site is a valuable gateway to resources for improving patient safety and preventing medical errors and is the first comprehensive effort to help healthcare providers, administrators, and consumers learn about all aspects of patient safety.



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