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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. How to print PP slides. Course Objectives.

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evidence based chiropractic 1
Michael Haneline, DC, MPH



PowerPoint slides of the lectures are downloadable at the course website

Evidence-Based Chiropractic 1
course objectives
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
course objectives cont
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

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

due next thursday 4 13 06
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
what is ebc
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)

Best clinically relevant

research evidence

Clinical expertise

Patient values

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
sackett one of the originators of ebp
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.
sackett cont
Sackett cont.
  • Without current best evidence, practice risks become rapidly out of date, to the detriment of patients.”
why ebc
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
when ebc
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
how to practice ebc
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
how to practice ebc cont
Howto practice EBC? cont.
  • Evaluate your effectiveness and efficiency in executing the preceding steps and seek ways to improve them for next time
why chiropractic research
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
why critical appraisal
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
study the study
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
case in point
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.

  • Should we draw conclusions from this small sample?
  • Should we change our practice based on these findings?
  • Should we ignore this practice-based evidence?
what does evidence based practice really mean
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.

what is evidence
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
what is the best evidence
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
quantitative vs qualitative research
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
quantitative vs qualitative research cont
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)
quantitative research
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
qualitative research
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”
quant qual cont
Quant/Qual cont.
  • Quantitative
    • Experiments
    • Test hypotheses
    • Deductive
  • Qualitative
    • Descriptive, unable to test hypotheses
    • Holistic concept about social or human problems
    • Inductive
de vs in ductive reasoning
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
de vs in ductive cont
De vs In - ductive cont.






inductive deductive reasoning
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)
inductive deductive reasoning1
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)
inductive deductive reasoning2
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
inductive deductive cont
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
inductive deductive cont1
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
evidence based clinical practice
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
ebp cont
  • 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
another definition
Another definition. . .

“… the conscientious use of current best evidence in making decisions about the care of individual patients…”

(O’Rourke, 1997)

another another definition
Another, another definition
  • Information—facts!
    • Not opinions
    • Not beliefs
    • Not theories or philosophy
the steps of ebp sackett 1996
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
the steps of ebc cont
The steps of EBC cont.
  • Apply the results of the appraisal in our clinical practice; and
  • Evaluate our performance
five steps of ebc sackett 2000
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

five steps of ebc 2000 cont
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

  • 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?
back to example
Back to Example

PICO structure

writing proper questions
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
background vs foreground questions cont
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
background vs foreground questions cont1
Background vs. foreground questions cont.
  • Example background questions
    • What is de Quervain’s disease?
    • What causes migraine headaches?
background vs foreground questions cont2
Background vs. foreground questions cont.
  • Foreground questions provide information about the best diagnostic test for a specific disease, or the best treatment strategy for a specific patient
  • Foreground questions pertain to foreground knowledge
  • Are more complex than background questions
  • Answers to these types of questions are found in reports of clinical research or systematic reviews
background vs foreground questions cont3
Background vs. foreground questions cont.
  • Foreground information answers specific questions regarding a specific patient
  • Foreground resources can be divided into primary sources such as original research articles published in journals; and secondary sources such as systematic reviews of the topic
foreground questions are made up of 4 components
Foreground questions are made up of 4 components:
  • The patient or problem at issue (P)
  • The intervention or exposure under consideration (I)
  • Comparison intervention or exposure (C)
    • When appropriate
  • The clinical outcomes of interest (O)
pico analysis of a foreground question
PICO analysis of a foreground question
  • Is exercise effective at reducing pain in a chiropractic patient with RA?
    • Patient or Problem:
      • Who is affected? Describe the specific patient population and/or problem context
      • Chiropractic patient with RA
    • Intervention(s):
      • What is being done? Define the interventions
      • Exercise
pico analysis of a foreground question cont
PICO analysis of a foreground question cont.
  • Comparison (if there is one):
    • Exercise could be compared with passive modalities?
  • Outcomes
    • Define the outcomes, focusing on outcomes that are important to patients like less pain or better mobility rather than intermediate endpoints like better ROM
types of questions
Types of questions

Each question type may require different kinds

of information for evidence and, possibly,

different types of resources

assignment due 4 20 06
Assignment due 4/20/06
  • Write three background and three corresponding foreground questions
  • Use hypothetical clinical problems that may be encountered in chiropractic practice
  • Include the 4 PICO elements (if applicable) and list them:
    • Patient/Population or Problem
    • The Intervention
    • The Comparison
    • Outcomes