Monday, January 12, 2009

Evidence-Based Chiropractic

Over the past few weeks, I’ve engaged in several discussion and meeting where the concept of evidence-based chiropractic (EBC) has been discussed. The administration at Palmer College has committed to the inclusion of EBC in our DC curriculum, and the ninth trimester research course is largely devoted to a thorough presentation of its concepts. Yet still some confusion remains, and I thought I would take time here to discuss some general concepts involved with EBC.

One the challenges members of the chiropractic profession face is how to respond to a patient that stands outside of the normal day-to-day patient management protocols. What do we do when a patient walks in, say, and says that they have a condition such as brucellosis? Certainly, we’ve likely received little training on the management of brucellosis in our clinical education, yet our patient hopes there is something we can do for him. Likely, we will attempt in some fashion to locate information about the chiropractic management of brucellosis, and using that information attempt to move forward with the treatment. But there is a great deal embodied in what I just said. First, we need to recognize that we are essentially trying to construct a clinical question. That is the first skill we need to develop. Once the question is developed, we need to locate information. That is a second skill. Once we have located good information, we need to appraise it to determine what literature, out of all that we find, is germane to answering our question, and that is yet another skill. We need to understand the data in the reports we read, which is still another skill. And then we need to apply the information and monitor what happens, potentially leading to a new question and a new cycle of information gathering, etc. In a nutshell, EBC is the means to do just that.

All too often, EBC is seen as nothing more than using the results of clinical trials to inform clinical practice. As a result, many people fear that doing so will lead to managed care corporations limiting what chiropractors can do in practice. There is, of course, some merit to this fear, but I would remind readers that chiropractic is not simply whatever 65,000 chiropractors say it is (some use crystal waving, for example, but I ask, is that really chiropractic?). And we are all aware that clinical guidelines are often developed using clinical trial results; that is, after all, the entire reason for the Cochrane Collaboration. But this is not what EBC is.

David Sackett described evidence-based medicine as “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 form systematic research.” (1) To this has been added the need to take into account patient values as well.

There are a number of points to note here: (1) Clinical expertise is an important part of EBC. In chiropractic, often what we have is significant clinical expertise, but little evidence from clinical trials. (2) Best evidence. This does not necessarily mean “clinical trials.” Often, such information does not exist, but other forms of information, perhaps from lower on the evidence hierarchy, exists. We can use that information in EBC. (3) Patient values come to the fore, and are respected. Why do patients seek chiropractic care and what do they expect from that care? This is taken into account in EBC.

All EBC really is, is a set of tools. These tools help a clinician develop a clinical question, perhaps using a PICO format (patient, intervention, comparison, outcome), develop a literature search, locate and appraise literature, and then apply the information. These tools can be sophisticated, but in the end, they can be easily be learned. As we move forward with implementing our R25 grant, we are working to help provide the skills necessary to use these tools.


1. Sackett DL Rosenburg WMC, Muir Gray JM, Haynes RB, Richardson WS. Evidence-based medicine: what it is and what it isn’t. Br Med J 1996;312:71-72

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