Being evidence-based, patient-centric and ethical: Uniting around the evidence, Part 3

Regarding what is taught at chiropractic college and what is within the scope of chiropractic practice, when we move away from the spine and/or away from chiropractic SMT and general spinal and overall fitness exercises, we move away from evidence-based care and we move toward evidence-informed intervention protocols based on individual subjective clinical experience and/or patient preference.

Subjective clinical experience and patient preference are inherently biased; they are highly prone to self-fulfilling prophecy based on confirmation bias. However, the guiding principle of evidence-informed care includes a tacit acceptance of the validity of clinical judgement and patient preference and such tacit acceptance is universal in all healthcare fields.

Still, it must be remembered that NO protocol based on clinical experience or patient preference, nor any testimonial or case study describing any such protocol, represents valid evidence of a cause and effect relationship between intervention and outcome. Thus, scientifically, logically, and ethically, we must never claim that our clinical experience/judgement is better, more evidence-based, more scientific, or more valid than anyone else’s. If we do, we become hypocritical, dogmatic, and dishonest; we announce to the world that we lack both sound scientific judgement and ethics.

For the above reasons, I focus on evidence-based interventions for patients with non-cancerous, non-infectious, non-traumatic instability neuromusculospinal health issues [uncomplicated spinal health issues] for “unifying around the evidence”.

Of all the available interventions for uncomplicated spinal health issues, which is/are the most evidence-based with respect to effectiveness, cost-effectiveness, and safety? This very question was asked and answered by Professor Pran Manga in the infamous 1993 Manga Report which evaluated, compared, and contrasted the level of evidence regarding effectiveness, cost-effectiveness, and safety of chiropractic SMT/adjustment, usual medical care, physical therapy, and surgical interventions for patients with low back pain.

Manga’s conclusions were earth shaking to say the least. “On the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments [drugs, surgery, physical therapy] for low back pain. Many medical therapies are of questionable validity or are clearly inadequate.” “What the literature revealed to us is the much greater need for clinical evidence of the validity of medical management of low back pain.” “Our reading of the literature suggests that chiropractic manipulation is safer than medical management of low back pain.” “Taking a global view of the evidence in this and the previous chapters, there seems to be a comprehensive body of evidence, which can fairly be described as overwhelming, for the cost-effectiveness of chiropractic over medical management of patients with low-back pain.”(1)

Why would I choose to cite a report written almost 30 years ago? To make the point that so little has changed in terms of available evidence-based interventions for uncomplicated spinal health issues, or, sadly, the blatant bias for usual medical care and against chiropractic SMT/adjustment.

What new, evidence-based interventions have been added to usual medical care education or practice since 1993? None that are evidence-based. In fact, for decades the gold standard usual medical care intervention in virtually all medical clinical guidelines for the treatment of low back pain was paracetamol/acetaminophen/Tylenol.

A study by Davies et al. in 2008 found that there had never been a single placebo-controlled trial showing effectiveness of this “gold standard” medical treatment.(2) Finally, after decades of being considered the gold standard, in 2017 the Chou et al. systematic review for the American College of Physicians Clinical Practice guideline declared acetaminophen ineffective.(3) There had never been a shred of valid evidence for the clinical guidelines “gold standard” first line usual medical care intervention for low back pain!

NSAIDS have also been ubiquitously recommended as first-line usual medical care treatment for uncomplicated spinal health issues for decades. The latest Cochrane Review published in 2020 concluded that, though there was evidence of small effects for (short term only) pain relief (7.29 points on the 100 point VAS scale) and small effects for functional improvement (2 points on the 24 point Roland Morris Disability Scale), that, “The magnitude of these effects is small and probably not clinically relevant.”(4)

Muscle relaxants are also commonly prescribed. No valid evidence of clinically relevant benefit. Antidepressants are now commonly prescribed. No valid evidence of clinically relevant benefit.

Usual medical care has also added glucocorticoid joint injections. No valid evidence of clinically relevant benefit, considered “off label,” yet, despite this, increasing in prevalence.(5)

New cage fusion surgeries have also been added– no valid evidence of benefit, ample evidence of harm, yet these too are increasing in prevalence and back surgeries now outnumber hip replacement surgeries.(6-10)

I would be remiss not to mention Vioxx and opioids, which have also been added to usual medical care since the Manga Report. I think we are all aware of the devastating effects of these interventions.

Physical therapy has added no new evidence-based interventions since 1993 (other than SMT) that I am aware of and the passive modalities considered standard of care for decades are now considered guideline discordant.11

So, where does all this leave us? It leaves us exactly where Manga left us in 1993. It leaves us, I hope, with the knowledge that, with respect to uncomplicated spinal health issues, there are no other professions, or healthcare professionals (HCPs), with a more evidence-based intervention than chiropractic SMT/adjustment and that the decades of claims to the contrary have been based on deliberate lies intended to monopolize cultural authority and re-imbursement, or ignorance of the literature, or both.

The idea that chiropractors should seek approval from, or defer to, any other practitioner or profession for expertise, evidence-based interventions, ethics regarding false claims, or safety with respect to uncomplicated spinal health issues, is scientifically absurd, illogical, and unethical. Certainly, there are many health issues for which we should refer to other HCPs. Uncomplicated spinal health issues for patients of any age, just isn’t one of them. From pediatric to geriatric patients with uncomplicated spinal health issues, chiropractors represent the most highly trained, most skilled, and most competent healthcare professionals with the most evidence-based intervention.

We need to hold our heads high and demand the cultural authority, the fairness of re-imbursement, the interprofessional respect, and the public recognition we have earned with our documented record of effectiveness, safety, cost-effectiveness, and patient satisfaction. We must unite around the irrefutable principle that all false claims are unacceptable regardless of whether they pertain to SMT/adjustment, soft-tissue techniques, taping techniques, modalities, “special” back exercise protocols, drugs, injections, or surgeries, or whether they pertain to athletes, children, the elderly, or adults, or whether they pertain to pain, function, performance, chronic illness, or wellness.

I hope this leaves us unified around some evidence-based pride tempered with some humility regarding the fact that, though we may be the best available choice for most patients, we are by no means the perfect choice or the only choice. We just should, reasonably, as Manga concluded, and as the literature since has confirmed, be considered the best first choice for patients with uncomplicated spinal health issues.

Let’s once and for all unite around evidence-based interventions, respect each other’s clinical experience and judgment regarding the application of evidence-informed interventions, refrain from all false claims, cut off both gangrenous, vitriolic arms of our profession, and unite aound the ethical, patient-centric, evidence-based, chiropractic SMT/adjustment-centric spine.

In part 4 I will provide an evidence-based argument that in the peer-reviewed literature, including systematic reviews and clinical guidelines, the effectiveness of chiropractic SMT/adjustment is often rated lower than it should be due to clinical trials that include very low doses of care, large gaps between active care delivery and outcome assessment, and a lack of distinction between thrust manipulation and mobilization.

References:

1. Manga, et al. (1993). The Manga Report: The effectiveness and cost-effectiveness of chiropractic management of low-back pain. Richmond Hill, Ontario, CANADA. Kenilworth Publishing (an Independent Report Commissioned by the Ontario Provincial Government).
2. Davies et al. (2008). A systematic review of paracetamol [acetaminophen] for non-specific low back pain. Eur Spine Journal 17(11): 1423-1430
3. Chou et al. (2017). Systemic Pharmacological Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Annals of Internal Medicine 166: 480-492
4. Van der Gaag et al. (2020) Non-steroidal anti-inflammatory drugs for acute low back pain (review). Cochrane Database of Systematic Reviews Issue 4. Art. No.:CDO13581.
5. Deyo, R.A, and Mirza, K. (2016) Herniated Lumbar Intervertebral Disk – Clinical Practice. N Engl J Med; 374:1763-72
6. Nguyen, et al. (2011). Long-term Outcomes of Lumbar Fusion Among Workers’ Compensation Subjects: A Historical Cohort Study. Spine 36(4): 320-331
7. Magout et al. 2006 Lumbar fusion outcomes in Washington State workers’ compensation. Spine 31 (23) pp2715-23
8. Don & Carragee. 2008 Evidence-informed management of chronic low back pain with surgery . The Spine Journal 8 (1) 258-265
9. Don, Carragee al. (2011). A critical review of recombinant human bone morphogenetic protein-2 trials in spinal surgery: emerging safety concerns and lessons learned. The Spine Journal 11(6): 471-491

10. Harris, Ian. Surgery, the Ultimate Placebo: A Surgeon Cuts Through the Evidence. 2016. University of New South Wales Press.
11. 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).