Being evidence-based, patient-centric and ethical: uniting around the evidence, part 2

As I did in Part 1, (Canadian Chiropractor April 2020) let me once again begin with what I believe should be the guiding clinical principle for all chiropractors (and all other healthcare practitioners) and should be part of the Chiropractic Oath: “The guiding principle behind evidence-informed management is that practitioners should be aware of and use research evidence when available, make personal recommendations based on clinical experience when it is not available, and be transparent [and patient-centric] about the process used to reach their conclusion.” ¹

I define evidence-based, ethical, patient-centric care as that care which, based on the available evidence, has the best statistical chance to provide the best benefit:harm ratio for any given patient. Should any two interventions have similar benefit:harm ratios, then whichever intervention is the most cost-effective or has the best benefit:cost ratio should be recommended first.

Whatever care fits this description, provided from whatever practitioner, is, ethically, care that must be universally advocated. Simply being integrative or collaborative is not synonymous with being evidence-based or patient-centric or ethical. Integrating with, collaborating with, or referring to practitioners who utilize interventions that lack evidence of effectiveness, cost-effectiveness, and/or safety, is neither evidence-based, nor patient-centric, nor ethical.

Being an evidence-based practitioner can only be validly defined as a practitioner that is aware of, and implements the evidence; in other words, a practitioner that utilizes the most evidence-based interventions available within their scope of practice and/or that refers for the most evidence-based interventions available.

I have spent the last 20 years trying to bring chiropractors together around the available evidence and the ethical principle of practicing according to it. I have been, and remain, an uncompromising advocate of evidence-based care as I see this as synonymous with both being ethical and patient-centric.

In the words of Sherlock Holmes, the “obvious fact” is that there are, with respect to non-traumatic instability, non-infectious, and non-cancerous neuromusculoskeletal and spinal health issues, few interventions within the scope of practice of chiropractic, or any healthcare profession for that matter, which qualify as evidence-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.

What, other than chiropractic SMT/adjustment, general spinal and overall fitness exercise, and healthy lifestyle advice, is taught as part of the core curriculum at chiropractic college, is within the scope of chiropractic practice, and is, or could validly be labelled as evidence-based? Not soft-tissue techniques. Not passive modalities. Not “specialized” spinal exercise programs. “Study care patients were also advised to avoid guideline-discordant treatments, including muscle relaxant and opioid-class medications, passive physiotherapy modalities, bed rest, and ‘‘special’’ back exercise programs (eg, ‘‘core stability’’ or extension exercises).”²

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 (including A.R.T. and Graston), no passive modalities, and no “specialized” spinal exercise programs (including McKenzie Method and McGill Stabilization Exercises) are included. In other words, none of these interventions have met the standard of evidence-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 irony is that the loudest, most vitriolic, self-proclaimed “evidence-based” faction (one of the gangrenous arms in the profession I identified in part 1) within chiropractic is the one advocating for more clinical implementation of interventions that are not evidence-based and, perplexingly, less utilization of chiropractic adjustment/SMT.

The silent majority (what I identified as the ethical, reasonable torso of the profession in part 1) simply does what they learned at chiropractic college (chiropractic SMT/adjustment (and hopefully exercise and healthy lifestyle advice). This has always been identified as the clinical focus of the chiropractic profession and what represents our unique value, and what represents our unique level of expertise compared to other practitioners. It also represents the most evidence-based option within our scope of practice.

I have often heard the vitriolic self-proclaimed “evidence-based” faction criticize chiropractic SMT/adjustment-centric practitioners for lacking evidence or clinical expertise or clinical excellence but when asked what evidence-based interventions they use or recommend for clinical practice other than chiropractic SMT/adjustment and general exercise and healthy lifestyle advice the members of this faction either list interventions which they BELIEVE are evidence-based which are not, or they hide behind the veil of patient-preference as they disallow the same answer from those who are chiropractic SMT/adjustment-centric.  I don’t mind loud calls for evidence-based or evidence-informed care, in fact I applaud them, I just demand that they advocate and utilize evidence-based care.

The ability to point out that SMT is not perfect, or that more research is needed, should NEVER be interpreted as being synonymous with having a more evidence-based intervention to offer or recommend. Criticizing the use of chiropractic SMT/adjustment for lack of evidence is highly hypocritical when placed in the context of offering a solution which involves interventions based on less valid and reliable diagnostic criteria and with less evidence of effectiveness, cost-effectiveness, and/or safety.

How is advertising a “specialized exercise program or protocol”, “special” soft-tissue technique or taping technique that has no valid placebo-controlled research evidence, and is not listed as an evidence-based intervention in any published systematic review or practice guideline, acceptable or, validly labelled as evidence-based? Or how is self-identifying as a “soft-tissue specialist” (which, as far as I know, is not a recognized specialty within chiropractic or any other healthcare field),  any different that self-identifying as a “visceral or pregnancy specialist”. If your first response is biological plausibility you are not only ignorant of the neurophysiology of nociception and proprioception and their potential autonomic effects, you are also ignorant of the allostatic load literature; your argument is simply without any logical or scientific merit.

To be clear, I am not suggesting that biological plausibility is valid evidence of effectiveness or benefit, however, it is hypocritical to use it to your advantage when convenient while you use it against those you disagree with. Biological plausibility is justification for research, it is not justification for false claims; regardless of whether that false claim is about neuro-MSK or non-neuro-MSK benefits.

Applying non evidence-based interventions to celebrities or athletes and writing a testimonial should NEVER be interpreted as more scientific or logical or ethical or evidence-based than applying SMT to a patient with a non-neuro-MSK condition and writing a testimonial. A documentary or book or Facebook post, blog or website with testimonials involving non evidence-based “specialized” exercise or rehab protocols, soft tissue, and/or taping and/or modality interventions is no different with respect to quality of evidence or ethics than those with testimonials involving chiropractic SMT/adjustment provided to patients with non-MSK health issues. The truth is all false claims should be universally unacceptable regardless of what practitioner makes them or what health issues they pertain to.

The problem is, the other gangrenous arm (identified in Part 1 as those making false claims regarding the benefits of SMT/adjustment), rather than implementing, marketing, and communicating chiropractic SMT/adjustment in an evidence-based way, too often take the evidence for chiropractic SMT/adjustment from low back pain, neck pain, and headache studies, or testimonials, or basic science regarding biological plausibility, and make claims of benefit regarding conditions where no such evidence exists.  This is equally disturbing and professionally harmful. Ethics and integrity require applying the same standards to every intervention and every practitioner – period.

Perhaps we should start by equally applying the principles of evidence-based/informed care to what is allowed to be sold in the stores at chiropractic colleges, what seminars are approved for continuing education credit, which vendors are allowed at chiropractic seminars, and which interventions are allowed to be advertised by individual practitioners.

The right question is not whether chiropractic SMT/adjustment is perfect or if the need for more research is indicated, the valid question is, among available interventions which meet the standard of evidence-based, which of these have the highest level of evidence regarding effectiveness, cost-effectiveness and safety? There is a very strong scientific and logical case that the answer, at least with respect to back pain and other non-traumatic, non-infectious, non-cancerous spinal health issues, is chiropractic SMT/adjustment and general exercise and healthy lifestyle advice. This becomes even truer when variables such as dose of care, interval between end of care and data collection, and thrust vs non-thrust SMT/adjustment are taken into consideration when comparing SMT to placebo or other interventions.

References:

1. Haldeman, S. & Dagenais, S. What have we learned about the evidence-informed management of chronic low back pain? Spine J Jan-Feb;8 (1) 266-277
2. Bishop, et al. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. The Spine Journal 10 (2010): 1055-64

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).