Monday, December 16, 2013

Holiday Best Wishes and Some New Work by Palmer People

Dear All: As we head in to the holiday break, I thought I would leave for now with some of the recent work your colleagues have accomplished. Please have a wonderful break, and I will see you in January.

Roecker C, Long CR, Vining R, Lawrence DJ. Attitudes toward evidence-based clinical practice among doctors of chiropractic with diplomate-level training in orthopaedics. Chiropr Man Ther 2013, 21:43 doi:10.1186/2045-709X-21-43

Background: Evidence-based clinical practice (EBCP) is a practice model gaining prominence within healthcare, including the chiropractic profession. The status of EBCP has been evaluated in a variety of healthcare disciplines, but little is known regarding the attitudes doctors of chiropractic (DCs) hold toward this model of healthcare. This project examines the attitudes toward EBCP within a specialty discipline of DCs.

Methods: We identified a survey questionnaire previously used to evaluate EBCP among non-chiropractic complementary and alternative practitioners. We adapted this questionnaire for use among DCs and pretested it in 5 chiropractic college faculty. The final version was administered to DCs with diplomate-level training in orthopedics. The survey was emailed to 299 potential participants; descriptive results were calculated.
Results: 144 surveys were returned, resulting in a 48% response rate. The majority of respondents perceived EBCP as an important aspect of chiropractic practice. Respondents also believed themselves to have an above average skill level in EBCP, reported that training originated from their diplomate education, and based the majority of their practice on clinical research.

Conclusion: Doctors of chiropractic with an orthopedic diplomate appear to have favorable attitudes toward EBCP. Further study will help understand EBCP perceptions among general field DCs. A logical next step includes validation of this questionnaire.

 Mansholt BA, Stites JS, Deerby DC, Boesch RJ, Salsbury SA. Essential literature for the chiropractic profession: a survey of chiropractic research leaders. Chiropr Man Ther 2013, 21:33 doi:10.1186/2045-709X-21-33

Background: Evidence-based clinical practice (EBCP) is an accepted practice for informed clinical decision making in mainstream health care professions. EBCP augments clinical experience and can have far reaching effects in education, policy, reimbursement and clinical management. The proliferation of published research can be overwhelming—finding a mechanism to identify literature that is essential for practitioners and students is desirable. The purpose of this study was to survey leaders in the chiropractic profession on their opinions of essential literature for doctors of chiropractic, faculty, and students to read or reference.

Methods: Deployment of an IRB exempted survey occurred with 68 academic and research leaders using SurveyMonkey®. Individuals were solicited via e-mail in August of 2011; the study closed in October of 2011.Collected data were checked for citation accuracy and compiled to determine multiple responses. A secondary analysis assessed the scholarly impact and Internet accessibility of the recommended literature.
Results: Forty-three (43) individuals consented to participate; seventeen (17) contributed at least one article of importance. A total of 41 unique articles were reported. Of the six articles contributed more than once, one article was reported 6 times, and 5 were reported twice.

Conclusions: A manageable list of relevant literature was created. Shortcomings of methods were identified, and improvements for continued implementation are suggested. A wide variety of articles were reported as “essential” knowledge; annual or bi-annual surveys would be helpful for the profession

Triano JJ, Budgell B, Bagnulo A, Roffey B, Bergmann T, Cooperstein R, Gleberzon B, Good C, Perron J, Tepe R. Review of methods used by chiropractors to determine the site for applying manipulation. Chiropr Man Ther 2013, 21:36 doi:10.1186/2045-709X-21-36

Background: With the development of increasing evidence for the use of manipulation in the management of musculoskeletal conditions, there is growing interest in identifying the appropriate indications for care. Recently, attempts have been made to develop clinical prediction rules, however the validity of these clinical prediction rules remains unclear and their impact on care delivery has yet to be established. The current study was designed to evaluate the literature on the validity and reliability of the more common methods used by doctors of chiropractic to inform the choice of the site at which to apply spinal manipulation.

Methods: Structured searches were conducted in Medline, PubMed, CINAHL and ICL, supported by hand searches of archives, to identify studies of the diagnostic reliability and validity of common methods used to identify the site of treatment application. To be included, studies were to present original data from studies of human subjects and be designed to address the region or location of care delivery. Only English language manuscripts from peer-reviewed journals were included. The quality of evidence was ranked using QUADAS for validity and QAREL for reliability, as appropriate. Data were extracted and synthesized, and were evaluated in terms of strength of evidence and the degree to which the evidence was favourable for clinical use of the method under investigation.
Results: A total of 2594 titles were screened from which 201 articles met all inclusion criteria. The spectrum of manuscript quality was quite broad, as was the degree to which the evidence favoured clinical application of the diagnostic methods reviewed. The most convincing favourable evidence was for methods which confirmed or provoked pain at a specific spinal segmental level or region. There was also high quality evidence supporting the use, with limitations, of static and motion palpation, and measures of leg length inequality. Evidence of mixed quality supported the use, with limitations, of postural evaluation. The evidence was unclear on the applicability of measures of stiffness and the use of spinal x-rays. The evidence was of mixed quality, but unfavourable for the use of manual muscle testing, skin conductance, surface electromyography and skin temperature measurement.

Conclusions: A considerable range of methods is in use for determining where in the spine to administer spinal manipulation. The currently published evidence falls across a spectrum ranging from strongly favourable to strongly unfavourable in regard to using these methods. In general, the stronger and more favourable evidence is for those procedures which take a direct measure of the presumptive site of care– methods involving pain provocation upon palpation or localized tissue examination. Procedures which involve some indirect assessment for identifying the manipulable lesion of the spine–such as skin conductance or thermography–tend not to be supported by the available evidence.

Monday, December 9, 2013

Books for the Evidence-Based Practitioner

A number of excellent books are now published which provide strong grounding in evidence-based care. I thought I would list several here as a resource for you. They are in no particular order.

1.       Howlett B, Rogo EJ, Shelton TG. Evidence-based Practice for Health professionals: An Interprofessional Approach.  Burlington, MA; Jones and Bartlett, 2014

2.       Blessing JD, Forister JG. Introduction to Research and Medical Literature for Health professionals, 3rd Edition. Burlington, MA; Jones and Bartlett, 2013

3.       Rosser WW, Slawson DC, Shaughnessy AF. Information Mastery: Evidence-Based Family Medicine.  Hamilton, ON; BC Decker Inc, 2004

4.       Brownson RC, Baker EA, Leet TL, Gillespie KN. Evidence-Based Public Health. New York, NY; Oxford Press, 2003

5.       Haneline M. Evidence-Based Chiropractic Practice.  Sudbury, MA; Jones and Bartlett, 2007

6.       Guyatt G, Rennie D, Meade MO, Cook DJ. JAMA Evidence: Users’ Guides to the Medical Literature. A Manual for Evidence-Based Clinical Practice, 2nd edition.  New York, NY; McGraw Hill, 2008

7.       Howick J. The Philosophy of evidence-Based Medicine. Oxford, UK; BMJ Books, 2011

8.       Srauss SE, Richardson WS, Glasziou P, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM, 3rd edition. Edinburgh, UK; Elsevier, 2008

9.       Nordenstrom J. Evidence-Based Medicine in Sherlock Holmes’ Footsteps. Malden, MA; Blackwell Publishing, 2007

10.   Crombie IK. The Pocket Guide to Critical Appraisal. Oxford, UK; BMJ Books, 1996

11.   Dagenais S, Haldeman S. Evidence-Based management of Low Back Pain. St. Louis, MO; Elsevier, 2012

Monday, December 2, 2013

Regression Analysis

In a recent issue of the “Newsletter of the International Society for Evidence-Based Health Care,” (Newsletter 13, October 2013), Benkhadra et al (1) provide an interesting discussion of how to make sense of regression analysis. They position this as using an analogy from third-grade math. In their article, they note that for novices to evidence-based practice, the words “regression analysis” or “regression model” can put people off from reading further for simple fear they will not be able to understand what is being said. To help such readers, they provide an example based on simple math. I would like to use their example: they look at using results from a young middle-aged man looking to see if he qualifies for life insurance. In his case, he has elevated cholesterol. And he wonders if this might be due to his drinking alcohol. A study is found (2) that looks at the association between alcohol and cholesterol level, and this study is a regression analysis reporting results as regression coefficients. The value reported is 0.298, with p<0 .05="" confidence="" interval="" no="" o:p="" reported="">

To try to see what this means, the authors ask you to consider a simple “input/output” table, and they ask you to predict what values would come next:
Input=3, output=8
Input=4, output=10
Input=5, output=?
Input=6, output=?

 A moment’s thought shows you that the relation here is that output is equal to ( input x2)+2.  You could now develop a linear regression graph for several different people and show that (y=A*x+B) as the line best fitting this relationship. In the case of the paper we found, the actual measure is (cholesterol= 160+0.2998 x alcohol consumption per week).  This has some implications; for example, when alcohol consumption is 0, cholesterol would be 160, and as alcohol consumption increases, so does cholesterol levels at a predictable rate. This is a linear regression, and is a simple model. Of course, it gets more complex as we increase variables…

1.       Benkhadra K, Asi N, Haydour Q, Murad MH. Making sense of a study using regression analysis: analogy from third grade math. International Society of Health Care for Evidence-Based Health Care, October 2013: 4-6
2.       Porrini M, Simonettim P, Testolin G, Roggi C, Laddomada MS, Tencone MT. Relation between diet composition and coronary disease risk factors. J Epidemiol Community Health 1991;45:148-151

 Links for Further Explanation