EvidenceBased Chiropractic: An Introduction Richard Strunk, DC, MS

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Evidence-Based Chiropractic An
IntroductionRichard Strunk, DC, MS
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• Who is this guy?
• PROFESSIONAL EXPERIENCE
• Faculty at CCCKC-Health Center and Research
  department, since 2006
• Private practice
• Connecticut and New York
• Chiropractic Physician, 1996-2004
• University of Bridgeport College of
  Chiropractic
• Bridgeport, Connecticut, Instructor/ Assistant
  Professor, 2001-2004
• EDUCATION
• Palmer College of Chiropractic
• Davenport, Iowa
• Master of Science, Clinical Research, 2006
• New York Chiropractic College
• Seneca Falls, New York

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Definition Actively seeking support for and
improvement of chiropractic clinical practices
through the integration of the 1) best available
research evidence, combined with 2) clinical
expertise and 3)patient preferences (values).
(Haneline MT)
Evidence-Based Chiropractic (EBC)
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• A method that facilitates the process of
  practitioners finding solutions to their
  patients clinical problems.

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Best available research evidence Finding and
implementing the most current and pertinent
information possible from the highest level of
evidence.
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Clinical expertise consists of the skills and
knowledge that clinicians acquire through
clinical experience and practice. This is vital
to EBC.

• Relies heavily on past experience
• Clinical experience will help the clinician
  decide whether to incorporate or discard a new
  studys results.

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Patient preferences are related to the personal
values, concerns, and expectations that patients
have as they receive care or contemplate
receiving care. They can directly influence your
outcomes.

• Values beliefs about care (ex.
  philosophical/religious)
• Concerns (ex. financial issues, time
  constraints)
• Expectations degree of acceptance of doctors
  recommendations.
• Management treatment procedures need to be
  aligned with patient preferences/values/concerns.
  

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EBC was derived from Evidence-Based Medicine
(EBM). EBM was developed because of the observed
gap between what occurred in clinical practice
and vast amount of new information that was being
produced from clinical research.EBM practice was
designed to educate clinicians on how to
integrate research findings into clinical
practice.
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Why EBC Sources of information from textbooks,
field experts, respected colleagues are either
outdated, not available or not likely to generate
best information possible when each is used by
itself.

• Patients and public want unbiased, current,
  information.
• Expected from Insurance companies and other
  payers.
• Best care possible/patient centered care
• Justification of care and charges.

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When to use EBC patient-specific issues,
condition- specific issues and doctor
self-education are instances when EBC is
warranted.

• Is further testing needed to confirm or rule out
  a diagnosis?
• Is the patient a likely candidate for
  chiropractic care?
• Are there any contraindictions to spinal
  manipulation?
• What are the best management approaches for
  carpal tunnel syndrome, chronic neck pain, or
  lumbar spinal stenosis?
• What are reliable outcome instruments for
  assessing pain or patient disability?

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5 Steps of EBC 1. Ask a clinically relevant
question. 2. Search the literature to find the
best available evidence to 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 the
first 4 steps if necessary.
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• Step 1 Develop a clinical question. A good
  clinical question should consist of the following
  components
• 1. Patient(s) and/or problem (a 57 year old
  female with neck pain).
• 2. Intervention/exposure (spinal manipulation).
  
• 3. Comparison intervention (if applicable
  exercise)
• 4. Outcome(s) of interest (preferably patient
  oriented such as pain and/or disability in
  comparison to disease oriented evidence
  (example x-ray findings or range of
  motion)
• The above components form the mnemonic PICO.

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Depending on your focus, a clinically relevant
question might contain either or both of the
following types of information Background
questions (anatomical and pathophysiogical
mechanisms). Foreground questions (diagnostic
and treatment related strategies).
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• A 78 yr old female enters your office with low
  back pain and diffuse bilateral leg pain which
  travels below the knees. The leg pain is made
  worse with walking and relieved by resting for 15
  or 20 minutes or maintaining a flexed posture.
  The patient has only mild decreased reflexes of
  S1 bilat (1). From X-rays and an old CT scan,
  moderate Lsp spinal stenosis is present.
• You consider accepting this patient for a trial
  manual therapy and wonder if there is evidence
  that supports this type of management and if
  there are any alternative therapies that might be
  superior.
• How would you formulate a question about the
  above mentioned patient?

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• Step 2 Search the literature for the best
  available evidence.
• need to know how to find the highest quality
  journals as well as the hierarchy of evidence.
• In order to find the highest quality journals,
  one must know the best biomedical databases. In
  these databases, selected journals are indexed
  (listed). The highest quality journals are
  usually indexed together because of they contain
  similar criteria (ex. peer reviewed).

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• Examples of good and pertinent databases to DCs
  are
• Pubmed/MEDLINE
• MANTIS (Manual Alternative and Natural Therapy
  Index System)
• ICL (Index to Chiropractic literature)
• CINAHL (Cumulative Index to Nursing and Allied
  Health Literature)
• Cochrane data base.
• To date, Pubmed is probably the most extensive
  database but it still doesnt have a few
  chiropractic journals. If not found in Pubmed,
  try MANTIS, ICL or CINAHL.

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• Examples of quality journals that are of interest
  to DCs include
• JMPT
• Spine Journal
• Chiropractic and Osteopathy (on-line, free)
• Journal of Chiropractic Medicine
• Chiropractic Journal of Australia
• Clinical Chiropractic Journal
• Links to articles are usually available through
  most databases search results (in some type of
  format ex. PDF). Articles are usually more
  accessible through a chiropractic colleges
  library website where colleges have subscriptions
  to various journals or databases.

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It is best to gather the highest level of
evidence that is available on a subject (as seen
on the top parts of pyramid). The higher the
level of evidence, the more confidence one can
have in applying a studys results to your
patient.
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• Step 3 Appraising the evidence
• General red flags for untrustworthy information
  when appraising the evidence.
• Journal is not peer-reviewed.
• Article has an advertising tone.
• Article format is incorrect (should include an
  Abstract, Introduction, Methods, Results and
  Discussion).
• References are insufficient or outdated.
• Journal is not indexed.
• Article has a testimonial function.
• Conflicts of interest exist.

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• Appraising the evidence General recommendations
• Abstract the purpose and results of the study
  should be correctly and adequately described.
• Introduction should include a literature review
  of the topic including deficiencies and the
  purpose of study.

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• Methods Should include a detailed description of
  the study design and data analysis.

• Description of sample patients, data collection
  methods (ex. outcome disability questionnaires)
• descriptive statistics (ex. mean/median, or mode)
  
• appropriate inferential statistics (ex.
  confidence intervals or P values)

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• Results a detailed report of data (with
  appropriate descriptive and inferential
  statistics) so the results can be effectively
  interpreted and if needed replicated.

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• Discussion an accurate discussion of the results
  including any deficiencies with study. There
  should not be any unreasonable and unsupported
  statements that diverge from what the data truly
  reveals. A comparison of the data (results) with
  the discussion/ conclusion is recommended.

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• References should mostly be of high quality and
  peer-reviewed types, should accurately support
  the given statements in the text and there should
  be an adequate number of them supporting the most
  important statements.

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• Appraising the evidence
• The Food and Nutrition Science Alliances 10 red
  flags of junk science
• Recommendations that promise a quick fix
• Dire warnings of danger from a single product or
  regimen
• Claims that sound to good to be true
• Simplistic conclusions drawn from a complex study
• Recommendations based on a single study

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Appraising the evidenceThe Food and Nutrition
Science Alliances 10 red flags of junk science

• Dramatic statements that are refuted by reputable
  scientific organizations
• Lists of good and bad foods
• Recommendations made to help sell a product
• Recommendations based on studies published
  without peer review
• Recommendations from studies that ignore
  differences among individuals or groups
• Source Food and Nutrition Science Alliance. Junk
  science Scientists issue 10 red flags for
  consumers News release. 1995. Chicago Author.

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• Step 4 Apply the relevant evidence to the
  clinical situation. When applying the relevant
  evidence to your clinical situation, one needs to
  ask if the studys patients characteristics are
  similar to your patients characteristics.
• 1) Are the demographics (age, gender)
  similar?
• 2) Is the type of condition and intensity of the
  condition (acute vs. chronic) similar?
• 3) Is the type of intervention or diagnostic test
  similar to what you utilize?
• The more similar the studys characteristics are
  to your patient(s), the greater the chance of
  success when applying the evidence to your
  patient(s) (assuming the studys methodology is
  of sufficient quality).

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• After evaluating the study, we can apply a rating
  to the study in question Acceptable to Not
  Acceptable
• Learning curve in this process.
• Dont be afraid to ask for help. EBC/EBM is a
  complex process.

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• FCER has a new service for the chiropractic
  profession called the Evidence-Based Resource
  Center and DCConsultSM
• DC ConsultSM is a new web site designed to meet
  the needs of the chiropractic profession. It
  provides doctors with timely and accurate
  information that will minimize risk and foster
  the best possible patient care. The content will
  include
• Reviews of the scientific literature related to
  the prevention, diagnosis and treatment of
  common clinical conditions.
• Patient handouts
• Articles from experts in the field
• Pre-defined Manual, Alternative and Natural
  Therapy Index SystemTM (MANTIS) searches
• Critical product reviews
• Coding and billing information.

http//www.dcconsult.com Username ccckc,
password ruthrose76
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• Case 2
• You have been treating a 45 year old male patient
  with neck pain using manipulation for the past 2
  weeks. After doing a re-evaluation of his neck
  pain, you realize the patient has responded very
  little to your care.
• You suspect the patient might be depressed and is
  the reason for his lack of progress. You want to
  see if the patients depression might be
  preventing his recovery and would like to know if
  there is a valid and reliable questionnaire for
  depression.