Evidence-Based Chiropractic 1

1. Michael Haneline, DC, MPH michael.haneline@palmer.edu http://w3.palmer.edu/michael.haneline PowerPoint slides of the lectures are downloadable at the course website Evidence-Based Chiropractic 1

2. How to print PP slides

3. Course Objectives • At the conclusion of this course students will be able to: • demonstrate knowledge of the steps of evidence based practice • define selected scientific method and epidemiological terms • retrieve relevant information given a clinical question • search an online database using key words and search strategies

4. Course Objectives cont. • categorize articles retrieved based on their research design and level of evidence • evaluate the credibility of a given paper/article and understand value of peer-review • describe and demonstrate strategies for when there is little or no evidence • demonstrate knowledge of major historical developments in chiropractic research

5. Grading IEBC* assignment 5 points Literature searching/reviewing 5 points Write an answerable question 5 points Midterm Exam 40 points Final Exam 50 points TOTAL 100 points *Institute for Evidence-Based Chiropractic

6. Due next Thursday 4/13/06 • Visit the website for the Institute for Evidence-Based Chiropractic (IEBC): http://www.chiroevidence.com/EBC.html • Access and read the article: “Evidence-Based Chiropractic: The Responsibility of Our Profession” • Write a short synopsis of the article (100+ words). Conclude with your own thoughts about the article’s message (50+ words) • (100+) + (50+) = 150+ words total

7. What is EBC? • Evidence-based chiropractic (EBC) is the integration of • Best clinically relevant research evidence combined with • Clinical expertise and • Patient values (The unique preferences, concerns, and expectations each patient brings to a clinical encounter)

8. Best clinically relevant research evidence Clinical expertise Patient values

10. EBP EBC • Evidence-based practice is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients • It means integrating individual clinical expertise with the best available external clinical evidence from research

11. Sackett – one of the originators of EBP • “Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. • Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient.

12. Sackett cont. • Without current best evidence, practice risks become rapidly out of date, to the detriment of patients.”

13. Why EBC? • The need for valid information about diagnosis, prognosis, treatment, and prevention • Textbooks are often out-of-date, experts are frequently wrong, journals are overwhelming in volume and applicability for practical clinical use • Limited time to find & assimilate evidence

14. When EBC? • The practice of EBC is usually triggered by patient encounters that generate questions • About the effects of therapy • The usefulness of diagnostic tests • The prognosis of diseases • The etiology of disorders

15. Howto practice EBC? • Convert the need for information into an answerable question • Find the best evidence available to answer your question • Critically appraise the evidence for validity, impact, and applicability to your practice • Integrate the critical appraisal with your clinical expertise and with your patient

16. Howto practice EBC? cont. • Evaluate your effectiveness and efficiency in executing the preceding steps and seek ways to improve them for next time

17. Why Chiropractic Research? • To improve the science of chiropractic • To improve the chiropractic profession • To add to mankind’s store of knowledge • And above all • To improve the quality of chiropractic patient care

18. Why critical appraisal? • Each study contributes to the Evidence Base • Rarely is one study considered definitive • All studies have limitations • Some studies are seriously flawed • Therefore • Do not draw over-expansive conclusions from one piece of evidence

19. Study the Study • Consider possible methodological flaws • Consider other explanations, confounders • Appropriate use and interpretation of statistics • Study design appropriate for answering the research question • Authors conclusions in line with the evidence presented

20. Case in point • Hubka et al found that in 8 patients with cervical radiculopathy, all of whom received a HVLA manipulation, the outcome depended on direction of thrust • 6/8 adjusted on side of arm symptoms got well • 2/8 adjusted on side opposite arm symptoms went on to surgery Hubka MJ, Phelan SP, Delaney PM, Robertson VL. Rotary manipulation for cervical radiculopathy: observations on the importance of the direction of the thrust. J Manipulative Physiol Ther 1997;20(9):622-7.

21. Questions • Should we draw conclusions from this small sample? • Should we change our practice based on these findings? • Should we ignore this practice-based evidence?

22. What does evidence-based practice really mean? Do I really have to change the procedures I use? Practitioners don’t like changing practices, and tend toignore guidelines. They want research more to prove chiropractic than to improve clinical interventions.

23. What is evidence? • A product of scholarly inquiry • Published works from research • Teaching • Writing • Practicing (clinician-scientist) • Research: the process of gathering, evaluating & interpreting information to answer a question or solve a problem • Research can be original or bibliographic

24. What is the best evidence? • Valid basic science or clinical research (patient-centered) • Clinically relevant • Regarding accuracy and precision of diagnostic and prognostic procedures • (technical assessment) • Regarding efficacy and safety of therapeutic, rehabilitative, and preventive protocols

25. Quantitative vs. qualitative research • Quantitative research • Results of quantitative research are numbers • Utilizes statistical techniques that can be used to analyze the numbers (data) and draw conclusions • Statistically tests a specific hypothesis

26. Quantitative vs. qualitative research cont. • Qualitative research • Involves analysis of data derived from words (e.g., surveys and questionnaires) • Investigates naturally occurring phenomena without trying to manipulate them • Phenomena are studied as a whole (holistic) rather than focusing on narrow aspects • Observations are typically assigned to categories (M–F; Mild–Moderate–Severe; Yes–No)

27. Quantitative Research • Strengths • Strong scientific basis • Rigorous methodology • Weaknesses • Uses a very rigid approach and attempts to control all of the variables • Often dissimilar to actual practice

28. Qualitative Research • Strengths • Orientated toward understanding human nature • Findings can often be used to prompt quantitative research studies • Weaknesses • Perceived as a non-scientific approach • Often dismissed as being “subjective”

29. Quant/Qual cont. • Quantitative • Experiments • Test hypotheses • Deductive • Qualitative • Descriptive, unable to test hypotheses • Holistic concept about social or human problems • Inductive

31. De vs. In – ductive reasoning • Deductive • Reasoning that proceeds from the general to the specific • Concerned with testing or confirming hypotheses • Inferences from general principles • Inductive • Reasoning that proceeds from particular facts to a general conclusion

32. De vs In - ductive cont. Deductive reasoning (Maybe) Inductive reasoning

33. Inductive/deductive reasoning • INDUCTION: moves from the specific to general • “I've noticed that every time I kick a ball up, it comes back down, so I guess this next time I kick it up, it will come back down too.” • Specific (each instance in which balls were observed kicked up and coming back down) • To general (the prediction that a similar event will result in a similar outcome in the future)

34. Inductive/deductive reasoning • DEDUCTION: moves from general to specific • “That's Newton's Law. Everything that goes up must come down. And so, if you kick the ball up, it must come down.” • General (the law of gravity) • To specific (this kick)

35. Inductive/deductive reasoning • It is important to recognize whether the form of an argument is inductive or deductive, because each requires different types of support • In the preceding ball example: • The inductive argument is supported by previous observations • The deductive argument is supported by reference to the law of gravity

36. Inductive/deductive cont. • Inductive reasoning is arguing from observation • Arguments based on experience or observation are best expressed inductively • Deductive reasoning is arguing from laws (like gravity) • Arguments based on laws, rules, or other widely accepted principles are best expressed deductively

37. Inductive/deductive cont. • A study that surveyed chiropractic patients to see how they felt after receiving care for lower back pain would be? • Inductive • A study that compared two groups of lower back pain patients receiving chiropractic care versus a placebo would be? • Deductive

38. Evidence-based clinical practice • EBP • An approach to clinical decision making that integrates the best available evidence, clinical expertise, and patient values to decide upon health care options which suit each patient best(Sackett, 2000) • Evidence-based decision making vs. opinion-based decision making

39. EBPcont. • EBP is Not • Cookbook health care • e.g., Chiropractic technique systems • Simply applying findings of research publications • Each case, each patient, is unique • Simply adhering to guidelines • Guidelines may be used and abused

40. Another definition. . . “… the conscientious use of current best evidence in making decisions about the care of individual patients…” (O’Rourke, 1997)

41. Another, another definition • Information—facts! • Not opinions • Not beliefs • Not theories or philosophy

42. The steps of EBP (Sackett 1996) • In the EBP process, we • Ask clinically important questions • Track down, with maximum efficiency, the best evidence with which to answer these questions • Critically appraise that evidence for its truth and clinical applicability

43. The steps of EBC cont. • Apply the results of the appraisal in our clinical practice; and • Evaluate our performance

44. Five steps of EBC(Sackett, 2000) 1. Create an answerable question (hypothesis) about the healthcare problem confronting you 2. Find the best evidence to answer the particular question 3. Critically appraise the evidence for quality

45. Five steps of EBC 2000 cont. 4. Integrate critical appraisal with clinical expertise, patient’s needs & circumstances, and apply the integration to the case 5. Evaluate the effectiveness of your decision and look for ways to improve

46. Example • You are 3 months in practice and your CA informs you that a patient with de Quervain's disease made anappointment for tomorrow • What is de Quervain's disease? • Does it respond to chiro? • What’s the best treatment method?

47. Components of good clinical questions

48. Back to Example PICO structure

49. Writing proper questions • Background vs. foreground questions • Background questions are simple two-part questions about the basic facts of a disease • They have two components: • A question root (who, what, when, etc.) with a verb • A disease, or an aspect of a disease • Clinical questions may require general background knowledge about a disease or disease process

50. Background vs. foreground questions cont. • Background information is sought to answer general clinical questions such as what is the disorder, what causes it, how does it present, what are some treatment options  • These questions can be answered by using “background” resources such as textbooks and narrative reviews in journals which give a general overview of the topic • e.g., The Merck Manual of Diagnosis and Therapyhttp://www.merck.com/mrkshared/mmanual/home.jsp