Chiropractic + Naturopathic Doctor

Bias is omnipresent

By Dr. Joe Ghorayeb   

Features Clinical Education Opinion Patient Care

A response to “Uniting around the evidence, part 1”

In review of Dr. James Chestnut’s highly rhetorical and presumptive opinion piece on how best to unite the chiropractic profession around research evidence, I feel compelled to opine on Dr. Chestnut’s various personal beliefs, disguised as facts, and to reiterate a logical approach to establishing professional unity.

Dr. Chestnut begins by referencing a principle of evidence-informed management for chronic low back pain as described in an editorial (Haldeman and Dagenais 2008) and proclaims that only when chiropractors “ethically and objectively apply this guiding principle will we unite, express our potential, and earn the cultural authority, interprofessional respect, referrals, inclusivity, and reimbursement that the evidence clearly indicates we deserve.”


What is meant by the term “cultural authority”? Gaining public trust and acceptance through full integration as part of mainstream medicine? Or to remain peripheral and part of CAM, thereby imposing public trust and acceptance? The notion of inclusivity, again, is a rather vague and abstract idea. Without clarification, I will take the liberty to assume that he means for chiropractic to be included in mainstream healthcare. In order for this to occur, a precondition stipulates that the profession, as a whole, assimilates with the greater scientific community to better demonstrate that its members are evidence-based practitioners.

Dr. Chestnut appropriately highlights a key impediment in chiropractic progress when describing the beliefs and attitudes of vitalistic chiropractors, but mistakenly paints evidence-based DCs with the same brush, noting: “The other extreme tends to exaggerate and blindly accept the validity of unproven soft-tissue therapies, ‘specialized’ exercise programs…while too often rejecting and/or downplaying the evidence regarding the effectiveness, cost-effectiveness, and safety of chiropractic SMT/adjustment.”

Simply referring to oneself as an “evidence-based chiropractor” does not make one so. Evidence-based chiropractors, in the truest sense, do not blindly accept or advocate for any “specialized” exercise programs, as it is well understood that all forms of exercise and physical activity are beneficial to health (Warburton et al. 2006). Evidence-based chiropractors also reject the false narratives that may be attached to all forms of manual and passive therapies with the same level of enthusiasm. So much so, that chiropractic students have recently made a call to action against unsubstantiated claims (Plener et al. 2020).

Bias is omnipresent, and we would do well to acknowledge this and take appropriate steps to debias ourselves when faced with dilemmas. At the same time, effective communication, updated knowledge acquisition and dissemination, and joint collaboration are tried-and-true methods of evoking positive change. Conversely, Dr. Chestnut’s proposal: to amputate the “gangrenous arms that need to be removed,” is a rather unique and illogical approach to promote unity. In my view, in order to unite the profession moving forward, we must first think about how we deliver healthcare and what care we deliver.

Throughout the opinion piece, the author mistakenly uses the terms evidence-based practice (EBP) and evidence-informed practice (EIP) interchangeably. For clarity, the concept of EIP encourages practitioners “to be knowledgeable about findings coming from all types of studies and to use them in their work in an integrative manner, taking into consideration clinical experience and judgment, clients’ preferences and values, and context of the intervention.” 1

EBP was initially defined as “the conscientious, explicit and judicious use of current evidence in making decisions about care of individual patients,”2 and later broadened to include a life-long problem-solving approach to the delivery of care that integrates the best evidence from well-designed studies and evidence-based theories with a clinician’s expertise, which includes internal evidence gathered from a thorough patient assessment and patient data, and a patient’s preferences and values.3

Dr. Chestnut’s misinterpretation continues as he misconstrues both what it means to be “evidence-based” (Djulbegovic et al. 2009) and the utility of “biological plausibility” (Fedak et al. 2015). As a result, he slides down a slippery slope, committing several other common logical fallacies along the way.

If Dr. Chestnut is truly interested in promoting unity within the chiropractic profession, all he has to do is consult the literature, as it appears that the majority of chiropractors hold favourable attitudes and beliefs toward EBP (Bussières et al. 2016).

[1] Nevo, I., & Slonim-Nevo, V. (2011). The myth of evidence-based practice: Towards evidence-informed practice. British Journal of Social Work, 41(1), 1–22.

[2] Sackett, D. L., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (1997). Evidence-based medicine: How to practice and teach EBM. New York, NY: Churchill Livingstone.

[3] Melnyk, B. M., & Fineout-Overholt, E. (2014). Evidence-based practice in nursing & healthcare: A guide to best practice (3rd ed.). Philadelphia, PA: Wolters Kluwer/Lippincott, Williams & Wilkins.

Joe Ghorayeb DC, MHA has been in clinical practice since 2003 with a special interest in physical rehabilitation.

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