FEATURE PROFESSION UNITING AROUND THE EVIDENCE, PART 2 Being evidence-based, patient-centric and ethical BY DR. JAMES L. CHESTNUT T he guiding principle be-hind evidence-informed management is that prac-titioners should be aware of and use research evi-dence when available, make personal recommen-dations based on clinical experience when it is not available, and be transpar-ent [and patient-centric] about the process used to reach their conclusion.” (Haldeman, S. & Dagenais, S. What have we learned about the evidence-in-formed management of chronic low back pain?) Evidence-based, ethical, patient-cen-tric care is care that, based on the avail-able evidence, has the best statistical chance to provide the best benefit:harm ratio for any given patient. Should any two interventions have similar bene-fit:harm ratios, then whichever interven-tion is the most cost-effective or has the best benefit:cost ratio should be recom-mended first. Collaborating with prac-titioners who utilize interventions that lack evidence of effectiveness, cost-ef-fectiveness, and/or safety, is neither evi-dence-based, patient-centric, nor ethi-cal. Being an evidence-based practitioner can only be validly defined as a practitioner that utilizes the most evi-dence-based interventions available within their scope of practice and/or that refers for the most evidence-based in-terventions available. With respect to non-traumatic insta-bility, non-infectious, and non-cancer-ous neuromusculoskeletal and spinal health issues, there are few interventions within the scope of practice of chiro-practic, or any healthcare profession for that matter, which qualify as evi-dence-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/adjust-ment, general spinal and overall fitness exercise, and healthy lifestyle advice, what is taught as part of the core curric-ulum at chiropractic college, is within the scope of chiropractic practice, and is, or could validly be labelled as evi-dence-based? Not soft-tissue tech-niques. Not passive modalities. Not “specialized” spinal exercise programs. “Study care patients were also advised 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). 18 Chiropractic and Naturopathic Doctor May 2020 to avoid guideline-discordant treat-ments, including muscle relaxant and opioid-class medications, passive phys-iotherapy modalities, bed rest, and ‘special’ back exercise programs (eg, ‘core stability’ or extension exercises).” [Bishop, et al. The Chiropractic Hospi-tal-based Interventions Research Out-comes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medi-cal 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 interven-tions have met the standard of evi-dence-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 cndoctor.ca
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