FEATURE PROFESSION SMT/ADJUSTMENT-CENTRIC PRACTICE Uniting around the evidence, part 4 BY DR. JAMES L. CHESTNUT I 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). 16 Chiropractic and Naturopathic Doctor July/August 2020 www.Cndoctor.ca © Have a nice day / Adobe Stock n the previous parts of this article series, I have argued that, based on a fair interpretation of the peer-reviewed clinical evidence, and of all the possible interven-tions for non-cancerous, non-in-fectious, non-traumatic instabil-ity, neuro-musculospinal health issues (uncomplicated spinal health issues), the most evidence-based with respect to effectiveness, cost-effectiveness, and safety, is chiropractic thrust SMT/ adjustment (and general spinal and overall fitness exercises and healthy lifestyle advice). This is true for inter-ventions within and outsie chiropractic education and scope of practice. I realize that this is not always the conclusion of systematic reviews and/ or clinical guidelines, which often rate the evidence for SMT as similar, or inferior to, other interventions. I con-tend that this is due to a bias against SMT in clinical studies, in systematic reviews, and in the evidence rating scales such as the JADAD scale, due to a failure to take into account varia-bles which can significantly affect outcomes such as dose of care, timing of outcome measures in relation to end of active care, and differentiation between thrust SMT and non-thrust mobilizations. Most clinicians simply rely on the conclusions of systematic reviews as they lack the familiarity with the litera-ture, scientific methodological exper-tise, or time to properly critique such reviews by reading each individual study reviewed, assess its methodolog-ical validity, and/or recognize which studies have been excluded based on biased selection criteria. Most clini-cians are also unaware that the JADAD and other study quality rating scales do not differentiate between studies that include two or three SMT sessions vs studies that include 8-12 SMT sessions, studies that measure outcomes weeks or months after the last SMT session vs immediately after the last SMT session, or studies that include only non-thrust mobilizations vs thrust SMT. As Bronfort et al. pointed out in their 2008 review in The Spine Journal re-garding the lack of standardization of dose of care and timing of outcome measures in the published studies, “The number of SMT treatments var-ied from 1 to 24 and follow-up from immediate posttreatment to three years.” 1 Inexplicably, and pathetically, Most clinicians rely on the conclusions of reviews because of lack of familiarity. little has changed since 2008; the lack of standardization in SMT study meth-odology makes lumping all these stud-ies together into a single systematic review invalid and using the JADAD scale or any other study quality rating scale cannot correct for this issue. This lack of standardization of dose of care and follow-up time also creates large heterogeneity of results, which is used to justify downgrading the level of evidence for SMT in systematic reviews. As an example from the re-cent 2017 Paige et al. systematic re-view in JAMA, “The quality of evi-dence was judged as moderate that treatment with SMT was associated with improved pain and function in patients with acute low back pain, which was downgraded from high due
Chiropractic + Naturopathic Doctor July/August 2020: Page 16
