DR. JAMES L. CHESTNUT 2020-04-27 20:32:12
PROFESSION
Being evidence-based, patient-centric and ethical
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 [and patient-centric] about the process used to reach their conclusion.” (Haldeman, S. & Dagenais, S. What have we learned about the evidence-informed management of chronic low back pain?)
Evidence-based, ethical, patient-centric care is care that, based on the available evidence, has the best statistical chance to provide the best benefit:harm ratio for any given patient. Should any two interventions have similar benefit: harm ratios, then whichever intervention is the most cost-effective or has the best benefit:cost ratio should be recommended first. Collaborating with practitioners who utilize interventions that lack evidence of effectiveness, cost-effectiveness, and/or safety, is neither evidence- based, patient-centric, nor ethical. Being an evidence-based practitioner can only be validly defined as a practitioner that utilizes the most evidence- based interventions available within their scope of practice and/or that refers for the most evidence-based interventions available.
With respect to non-traumatic instability, non-infectious, and non-cancerous neuromusculoskeletal and spinal health issues, there are few interventions within the scope of practice of chiropractic, or any healthcare profession for that matter, which qualify as evidence- based. The “inconvenient truth” is that much of healthcare with respect to spinal health issues is most accurately described as evidence-informed and/or based on clinical experience at best, and based on dogma, personal bias, and maximizing financial compensation at worst.
Other than chiropractic SMT/adjustment, general spinal and overall fitness exercise, and healthy lifestyle advice, what is taught as part of the core curriculum at chiropractic college, is within the scope of chiropractic practice, and is, or could validly be labelled as evidence- based? Not soft-tissue techniques. Not passive modalities. Not “specialized” spinal exercise programs.
“Study care patients were also advised to avoid guideline-discordant treatments, including muscle relaxant and opioid-class medications, passive physiotherapy modalities, bed rest, and ‘special’ back exercise programs (eg, ‘core stability’ or extension exercises).” [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.]
Just pick up one of the plethora of recent systematic reviews or clinical practice guidelines relating to spinal healthcare or low back pain and you will see that no soft-tissue techniques, no passive modalities, and no “specialized” spinal exercise programs are included. In other words, none of these interventions have met the standard of evidence- based because they lack valid clinical evidence of effectiveness from valid clinical intervention studies.
So, what is all the infighting about? It can’t be about evidence because the only evidence-based interventions we are taught at chiropractic college and that are within our scope of practice, are SMT/adjustment and general exercise and healthy lifestyle advice. The silent majority group if chiropractors simply does what they learned at chiropractic college. This has always been identified as the clinical focus of the chiropractic profession and what represents our unique value and expertise compared to other practitioners. The irony is that the self-proclaimed “evidence-based” faction within chiropractic is the one advocating for more clinical implementation of interventions that are not evidence- based and less utilization of chiropractic adjustment/SMT. I have often heard this “evidence-based” faction criticize chiropractic SMT/adjustment- centric practitioners for lacking evidence or clinical expertise or clinical excellence but when asked what evidence- based interventions they use or recommend for clinical practice other than chiropractic SMT/adjustment and general exercise and healthy lifestyle advice, the members of this faction either list interventions they believe are evidence-based (which are not), or they hide behind the veil of patient-preference as they disallow the same answer from those who are chiropractic SMT/ adjustment-centric. I don’t mind loud calls for evidence-based or evidence-informed care, in fact I applaud them.
The ability to point out that SMT is not perfect, or that more research is needed, should never be interpreted as being synonymous with having a more evidence-based intervention to offer or recommend. Criticizing the use of chiropractic SMT/adjustment for lack of evidence is highly hypocritical when placed in the context of offering a solution that involves interventions based on less valid and reliable diagnostic criteria and with less evidence of effectiveness, cost-effectiveness, and/or safety.
How is advertising a “specialized exercise program or protocol” for example, that has no valid placebo-controlled research evidence, and is not listed as an evidence-based intervention in any published systematic review or practice guideline, acceptable or, validly labelled as evidence-based? Or how is self-identifying as a “soft-tissue specialist” (which, as far as I know, is not a recognized specialty within chiropractic or any other healthcare field), any different than self-identifying as a “visceral or pregnancy specialist?” If your first response is biological plausibility you are not only ignorant of the neurophysiology of nociception and proprioception and their potential autonomic effects, you are also ignorant of the allostatic load literature; your argument is simply without any logical or scientific merit.
I am not suggesting that biological plausibility is valid evidence of effectiveness or benefit. However, it is hypocritical to use it to your advantage when convenient, while you use it against those you disagree with. Biological plausibility is justification for research, it is not justification for false claims; regardless of whether that claim is about neuro-MSK or non-neuro-MSK benefits.
The problem is, those making false claims regarding the benefits of SMT/ adjustment, rather than implementing, marketing, and communicating chiropractic SMT/adjustment in an evidence- based way, too often take the evidence for chiropractic SMT/adjustment from low back pain, neck pain, and headache studies, testimonials, or basic science regarding biological plausibility, and make claims of benefit regarding conditions where no such evidence exists. Ethics and integrity require applying the same standards to every intervention and every practitioner.
Perhaps we should start by equally applying the principles of evidence- based/informed care to what is allowed to be sold in the stores at chiropractic colleges, what seminars are approved for continuing education credit, which vendors are allowed at chiropractic seminars, and which interventions are allowed to be advertised by individual practitioners.
The right question is not whether chiropractic SMT/adjustment is perfect or if the need for more research is indicated, the valid question is, among available interventions which meet the standard of evidence-based, which of these have the highest level of evidence regarding effectiveness, cost-effectiveness and safety?
There is a very strong scientific and logical case that the answer, at least with respect to back pain and other non-traumatic, non-infectious, non-cancerous spinal health issues, is chiropractic SMT/adjustment and general exercise and healthy lifestyle advice. This becomes even truer when variables such as dose of care, interval between end of care and data collection, and thrust vs non-thrust SMT/adjustment are taken into consideration when comparing SMT to placebo or other interventions.
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. He 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).
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