The Need for Chiropractice Practice Guidelines: A Forensic Analysis - Part 3 of 3

Keeping current with the medical literature is an arduous proposition. The piles of unread journals that collect on desks and in boxes during chiropractic school and postgraduate training only grow larger. The number of chiropractic and medical textbooks, guidelines, newsletters and specialty journals grows, while the time to read them is in short supply. Yet we are pressed to keep current from several sides. Most of us are taught early in chiropractic training that to be a good chiropractic clinician, one must keep abreast of the latest in common conditions; examination procedures; special diagnostic procedures; emerging clinical syndromes; orthopedic, neurological and chiropractic tests; and innovative manipulative/adjustive and adjunctive modalities.¹

We need to learn which manual therapies to avoid or administer, and how to improve our understanding of the causes of subluxation and disease. Specialty boards and chiropractic societies reinforce this concept by requiring documentation of continuing education for certification and society membership. Some recertification boards specifically call for examination based on information from the current evidence-based literature.

Patients also expect informed chiropractic health care professionals. Like their chiropractic providers, they are overloaded with medical facts and fiction from radio, television, Internet and the popular press. Whether they read The Wall Street Journal or a supermarket tabloid, they are likely to be getting information that is at least in part based on reports from the medical literature. Patients want to know about their risk of developing spinal disc disease when they injure their spines; whether their spinal injuries deserve a CAT scan, MRI with contrast, EMG or plain film X-ray imaging; or if the latest manipulative thrust really works.

Even though we desire to review all the current evidence-based literature, the eyes grow tired, and the job of sorting through the stacks of published material seems a losing proposition. Some relief can come from often-overlooked chiropractic college librarians, who will graciously assist by narrowing the focus of your search from the many literature sources that are available.

It is also very expensive to purchase every abstract on the requested subject matter. Medical textbooks, special review journals, newsletters, Internet-based guidelines, teleconferences, and videotapes and audiotapes supply condensed abstracts on emerging clinical trends. We can read the expert opinions about everything from ankylosing spondylitis to anatomical short leg from one of several chiropractic textbooks, or listen to a content author discuss musculoskeletal examination while driving to work, thanks to technology.

Secondary sources are an efficient way to gather information and circumvent the painful process of trying to master the complicated presentation of data in primary sources. Health care researchers have problems like the rest of our profession. Sometimes, their personal opinions get the upper hand and cast controversy into fact. Opinions and biased reading can become standard knowledge. That should not surprise us, since many systematic reviews of trials are open to differing interpretation.² It does mean, however, that while texts, abstracts, studies and reviews are helpful, we cannot depend primarily on secondary sources for evidence-based practice guideline development to improve the professional chiropractic practice. The challenge is to be able to evaluate a primary evidence-based research article ourselves and judge its evidence, value, content, objective, study selection, data extraction, references, and data synthesis.

David L. Sackett, professor at the NHS Research and Development Centre for Evidence-Based Medicine, Oxford, has summarized the practice of evidence-based health care in detail:

"Evidence-based medicine (EBM) means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise, we mean the proficiency and judgment that we individual clinicians acquire through clinical experience and clinical practice. By the best available external clinical evidence, we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient-centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough [emphasis added. Without clinical expertise, practice risks becoming [sic] tyrannized by external evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best external evidence, practice risks becoming [sic] rapidly out of date, to the detriment of patients."³

Finding time to do this reading is not the only challenge. Extensive literature searches revealing articles describing clinical studies have become increasingly sophisticated. Not only has the complexity of the information presented increased, so have the methods used to obtain and interpret data. Clinical studies of the medical literature are now rated by the type of evidence, such as systematic review/meta-analysis, stratified sampling techniques, randomized double-blind clinical trials (RCTs), conference proceedings, state treatment guidelines, or presentation slides/independent study, to list merely a few.

The ranking within the type of evidence is further differentiated as high, medium and low, and is also evaluated from the index and peer-reviewed literature (e.g., Index Medicos, CINAHL. MANTIS, Cochrane, published guidelines) using standardized, widely accepted instruments that determine the quality of the evidence. Instruments are available to address RCTs (CONSORT), diagnostic studies (STARD), meta-analyses (Sackett/AGREE/ QUORUM), epidemiology studies (MOOSE) and cost analyses (Sackett).⁴

The Work Loss Data Institute (WLDI) has previous extensive expertise with evidence-based guidelines publications^{5, 6} and its editorial review board expertise will research available evidence. That research will be used by the editorial team of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) in providing up-to-date evidence. The overall task is to provide the stakeholders (patients, chiropractors, associations, colleges and policy-makers) with a condition-based review of the literature that focuses on treatment of common complaints attended within chiropractic practice.

Our profession will be well-served, with the focus on attempting to improve quality of care, through the ongoing collaborative WLDI/CCGPP efforts that guide and identify best practices in chiropractic practice. Of course, guidelines cannot and do not determine the bounds of clinical expertise or the elements of individual clinical presentations. Plain and simple - this is a lofty, difficult, expensive methodical path we work toward, and there are no magic bullets! My point of this three-part series is to give the average practicing chiropractic professional a glimpse of the complex task confronting the "best practice" guidelines clinical content experts, publishers and the editorial review boards.

Many of you have asked or have offered to contribute to this guidelines project; I suggest that you make a direct financial contribution to chiropractic research. For organizations and individuals that wish to contribute their resources in the form of grants or individual monetary contributions, contact the Foundation for Chiropractic Education and research (FCER)⁷ and the CCGPP.⁸ If you wish to further your dedication, advancement and understanding of evidence-based chiropractic health care principles and practice, there are products, journals and text available through the WLDI and the Journal for Manipulative and Physiological Therapeutics.⁹

References

1. Christensen MG, Kerkoff D, Kollasch MW. Job Analysis of Chiropractic 2000. National Board of Chiropractic Examiners.
2. Oxman AD, Thomson MA, Davis DA, Haynes RB. "No magic bullets: a systematic review of 102 trials of interventions to improve professional practice." Canadian Medical Association Journal 1995;153:1423-1431. http://mdm.ca/cpgsnew/cpgs/CPGworkshop1994/1423e.html.
3. Dr. Jay Triano. "Re: FW: CCGPP - From Dr. Triano." E-mail to Phil Denniston. (Mar 5, 2004).
4. Dr. Jay Triano. "Re: FW: CCGPP - From Dr. Triano." E-mail to Phil Denniston. (Mar 5, 2004).
5. Whelen P, publisher. Official Disability Guidelines Treatment in Workers' Comp 2004, second edition, Work Loss Data Institute, Encinitas, Calif.
6. Occupational Medicine Practice Guidelines, Evaluation and Management of Common Health Problems and Functional Recovery in Workers, second edition. ACOEM Guidelines.com. www.disabilitydurations.com/acoem.htm.
7. The Foundation for Chiropractic Education and Research (FCER), P.O. Box 400, Norwalk, IA 50211-0400 Phone: 800-622-6309 or 515-981-9888; fax: 515-981-9427; E-mail: fcer@fcer.org.
8. Council on Chiropractic Guidelines and Practice Parameters, P.O. Box 2054, Lexington, South Carolina 29071. Phone: 803-356-6809; fax: 803-356-6826.
9. Journal of Manipulative and Physiological Therapeutics. Subscriptions through Mosby: elspcs@elsevier.com. Phone: 800-654-2452 or 407-345-4299 (outside the U.S.); fax: 800-225-6030 or 407-363-9661 (outside the U.S.).

(Editor's note: Parts 1 and 2 of this series appeared in the Jan. 1 and Feb. 26 issues, respectively.)