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Evidence-based chiropractic (EBC) in everyday practice

Evidence-based chiropractic (EBC) in everyday practice. Implementation of EBC. EBC has many uses. The steps of EBC were intended for use in solving clinical questions They are also useful to help practitioners answer many other types of questions

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Evidence-based chiropractic (EBC) in everyday practice

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  1. Evidence-based chiropractic (EBC) in everyday practice Implementation of EBC

  2. EBC has many uses • The steps of EBC were intended for use in solving clinical questions • They are also useful to help practitioners answer many other types of questions • e.g., which continuing education seminars to attend, educational materials to purchase, or equipment to purchase Evidence-based Chiropractic

  3. A 23-year-old female patient with neck pain & headache • Headache • Frequency 3-4 per week, lasting 3 to 4 hours • Extends from behind the right eye to the occiput • No aura • Reclining in a darkened room at the onset limits the pain to 4 on the 11-point NRS; if not, may become 8 or 9 with nausea and vomiting • Headache Disability Inventory score is 55 Evidence-based Chiropractic

  4. Neck pain & headache patient (cont.) • Neck pain • Constant • Intensity varies from 2 to 9 on the NRS • Trigger points with grade 2 tenderness are present in the upper cervical region • Cervical ROM restricted and painful on extension and lateral bending bilaterally • Characteristic Pain Intensity score is 6 Evidence-based Chiropractic

  5. Neck pain & headache patient (cont.) • Medication does not really help, so she wants to try chiropractic • How should one proceed in this case? • Is chiropractic care for migraine headache evidence-based? • Are there adjunctive therapies that may be beneficial? • Does the patient have migraine versus cervicogenic headache? Evidence-based Chiropractic

  6. Create a clinical question • Background question • What is migraine and how is it different from cervicogenic headache? • Headache that lasts 4 to 72 hours, is throbbing, is moderate to severe in intensity, is unilateral, becomes worse with exertion, and is associated with nausea, vomiting, or sensitivity to light, sound, or smell • Clinical question • What diagnostic tests can differentiate migraine from cervicogenic headache? Evidence-based Chiropractic

  7. Create a clinical question (cont.) • Foreground question • Is spinal manipulation effective at reducing headache in a young adult female patient? • Patient or Problem:ayoung adult female headache patient (P) • Intervention: manipulation(I) • Comparison: tests that can differentiate migraine from cervicogenic headache (C) • Outcome: reduced pain (O) Evidence-based Chiropractic

  8. Select search terms • Choose several key words from the clinical question • e.g., migraine or cervicogenic headache • Search the MeSH Database for migraine to find MeSH terms • Migraine without aura is most appropriate • There are no MeSH terms for cervicogenic headache Evidence-based Chiropractic

  9. Search MeSH from PubMed Or search from the MeSH Database Evidence-based Chiropractic

  10. Search the databases • PubMed is searched using Cervicogenic headache as a text word • The final search terms are as follows migraine without aura AND cervicogenic headache [tw] • 19 items result, with an article by Antonaci et al. being particularly relevant • But it does not discuss treatment Evidence-based Chiropractic

  11. Search (cont.) • A text word search is performed using cervicogenic headache without the MeSH term and limits set to “Meta-analysis” • An article by Bronfort et al points to a positive effect with manipulation equivalent to commonly used prescriptions and better than massage • The other article is on electrotherapy, but does not point to effectiveness Evidence-based Chiropractic

  12. PubMed text word search Limits are set to meta-analysis Evidence-based Chiropractic

  13. Search the databases • A search of the MANTIS database using the same search terms with the “High Clinical Relevancy” option checked produces 21 citations • A systematic review by Astin and Ernst conflicts with Bronfort et al. • However, numerous errors and omissions were pointed out in a Letter to the Editor • Thus, the Bronfort meta-analysis is chosen Evidence-based Chiropractic

  14. MANTIS search terms High Clinical Relevancy checked Evidence-based Chiropractic

  15. Search (cont.) • Another study points to a dose-response relationship between chiropractic care and cervicogenic headache • Larger doses (9 to 12 chiropractic treatments) were more beneficial than lower doses * Haas, M., et al., Dose response for chiropractic care of chronic cervicogenic headache and associated neck pain: a randomized pilot study. J Manipulative Physiol Ther, 2004. 27(9): p. 547-53. Evidence-based Chiropractic

  16. Critique the articles found in the literature search • Appraise the Bronfort et al. systematic review using an appropriate checklist • The review appears to be valid • Its methodology was sound • A thorough search was carried out • Articles were accurately appraised and synthesized in an unbiased manner Evidence-based Chiropractic

  17. Apply the evidence from the articles • Apply the information to the management of the patient’s condition • Consider the practitioner’s clinical expertise and the patient’s values • Chiropractic adjustments are recommended • Visit frequency is 3 times per week • OMs will be re-administered at 2 and 4 weeks Evidence-based Chiropractic

  18. Patient values • The patient is hesitant to accept cervical manipulation because of the stroke risk • However, she ultimately accepts the treatment recommendations • When informed that the risk is 1 per 1,000,000 cervical manipulations or less • And that these types of strokes have been reported following many other activities involving neck movement Evidence-based Chiropractic

  19. Review the efficiency of the first 4 steps of EBC • The PubMed search may have been too limited because so few citations were retrieved • The statement about the incidence of stroke following cervical manipulation was not evidence-based • Another investigation should be done to verify the statement’s accuracy Evidence-based Chiropractic

  20. Cervical manipulation and stroke search • PubMed search strategy chiropractic manipulation AND (stroke OR dissection) AND incidence • 16 citations result • Mostly case reports and review articles • Incidence estimates show the rate of stroke reports to range from 1:400,000 to 1:5,846,381 cervical manipulations • Hence, the 1:1,000,000 estimate is probably correct Evidence-based Chiropractic

  21. Selecting postgraduate education • Countless seminars, conferences, and meetings are available • Some are very high-quality, some are very poor-quality • Which ones are likely to be useful? • Evidence-based methods are the best way to evaluate them Evidence-based Chiropractic

  22. Factors to consider about postgraduate education • Is it affiliated with a trustworthy sponsoring organization like a chiropractic college or association? • Affiliation is not a guarantee that the material is valid and worthwhile, but it is more likely since basic requirements must be met • Lecture notes and other material should be critiqued using strategies similar to those used to evaluate journal articles Evidence-based Chiropractic

  23. Factors to consider about postgraduate education (cont.) • Instructors should have legitimate credentials and specialties in the topic • Beware of inflated or falsified credentials • Diplomate status should be from a recognized and credible specialty organization • Do a literature search see if the speaker has been published • Were the journals peer-reviewed? Evidence-based Chiropractic

  24. Factors to consider about postgraduate education (cont.) • Unconventional terms should be adequately defined • The use of nonstandard terminology is a red flag for untrustworthy information • Consider another seminar if these criteria are not met • Evidence-based methods can also be used to evaluate seminars after attending them Evidence-based Chiropractic

  25. Green’s criteria to evaluate chiropractic techniques • Is there a reasonable anatomic and physiological basis for the procedures involved? • Is research available on the treatment and/or diagnostic methods? • Is literature available that covers indications and contraindications to the procedure? Evidence-based Chiropractic

  26. Green’s criteria to evaluate chiropractic techniques (cont.) • Is a reliable test available to measure clinical change? • Is the procedure’s response reproducible? • Is the procedure cost effective? • Learning experiences are better when interactive, with adequate time for Q&As Evidence-based Chiropractic

  27. Evidence-based Chiropractic

  28. Evidence-based Chiropractic

  29. Dr. DA Versendaal has been developing and researching CRA for over 40 years . . . Evidence-based Chiropractic

  30. Evidence-based Chiropractic

  31. The American Chiropractor Evidence-based Chiropractic

  32. 1998 Evidence-based Chiropractic

  33. Scientifically and clinically proven. Evidence-based Chiropractic

  34. Evidence-based Chiropractic

  35. 1998 Evidence-based Chiropractic

  36. Equipment purchases • There are many possible choices • Wrong choices waste money and may be useless or even potentially harmful to patients • Sometimes manufacturers claims are misleading • Examples • “Clinically proven” • “96% success rate” • “Established reliability” Evidence-based Chiropractic

  37. Equipment purchases (cont.) • The validity and reliability of diagnostic equipment can be assessed by searching the literature to find studies that have tested the equipment • Although the specific brand name may not be mentioned, but the underlying theory has been tested • A comparable version of a previously validated instrument may not need testing Evidence-based Chiropractic

  38. Sometimes studies disagree • For instance, the Scoliometer • Several studies have investigated its reliability and validity, but conclusions have been conflicting • Cote et al. reported that the interexaminer measurement error of the Scoliometer was high • They felt that the Adam’s forward bending test was more sensitive than the Scoliometer Evidence-based Chiropractic

  39. Studies disagree (cont.) • The authors concluded that the Scoliometer is not appropriate for independent use as a diagnosis or patient management tool because of its poor validity • However, another study showed it to be suitable for screening purposes • One may need to read several articles, or a good systematic review, to discover the worth of a diagnostic device Evidence-based Chiropractic

  40. Thermocouple devices • Used to measure side-to-side paraspinal temperature differences • When temperature variation occurs over a spinal segment, it is thought to represent neurophysiologic dysfunction caused by vertebral subluxation • However, their validity has been questioned and little research exists to support their use Evidence-based Chiropractic

  41. Thermocouple devices (cont.) • Clinical question • Is the assessment of paraspinal temperature via thermocouple devices valid and reliable? • Search terms for use on the PubMed and ICL databases • Thermocouple, nervoscope, and neurocalometer • Thermocouple produces nearly 800 citations using PubMed (too broad) Evidence-based Chiropractic

  42. Thermocouple devices (cont.) • Only 11 citations are produced when the term is combined with spine using the AND operator • Neurocalometer retrieves only one article that discusses the instrument from a historical perspective • Searching ICL for thermocouple returns one article, neurocalometer three, and nervoscope zero Evidence-based Chiropractic

  43. Thermocouple devices (cont.) • 3 articles were retrieved that might be helpful • They must be evaluated for quality and to determine if they contain relevant information • A literature review reported that the reliability of thermocouple devices was supported by a study by Plaugher et al. • Its methodology should be critiqued using an appropriate checklist Evidence-based Chiropractic

  44. Plaugher et al. • Compared the findings of Nervoscope scans of the cervical-thoracic, mid-thoracic, and lower lumbar regions for intraexaminer and interexaminer reliability • Data from the lumbar spine were not analyzable and cervical-thoracic interexaminer reliability was weak • However, good interexaminer agreement was reported in the mid-thoracic spine Evidence-based Chiropractic

  45. Plaugher et al. (cont.) • Examiners were considered to agree when both recorded a positive finding anywhere within the 5 mid-thoracic vertebrae • Yet, most chiropractors apply spinal adjustments to specific levels • It is questionable as to how relevant these findings are to clinical practice • A later review indicated that there were many unresolved questions about these devices Evidence-based Chiropractic

  46. Plaugher et al. (cont.) • Several other problems with this study • The study sample consisted of healthy chiropractic students that were selected out of convenience • Good validity/reliability studies are selected from a defined population that has the same spectrum of disease severity as is seen in clinical practice • No demographic data were presented • Needed to assess the makeup of the sample Evidence-based Chiropractic

  47. Plaugher et al. (cont.) • A funding source was the Gonstead Clinical Studies of Society, which promotes the use of this device • A possible conflict of interest • Based on this evidence, should a practitioner purchase one of these devices? Evidence-based Chiropractic

  48. Thermocouple devices (cont.) • Armed with the knowledge obtained from this evidence-based process, one can now make an educated decision • Very little evidence supports its validity or reliability • Few studies have dealt with the topic and those that have are unconvincing • Practitioners should therefore choose other established diagnostic methods Evidence-based Chiropractic

  49. Thermocouple devices are used by many practitioners • Their use is part of an adjustive technique system that is utilized by more than 50% of chiropractors in the United States • In the face of ambiguous evidence, one could still opt to use a thermocouple device as an aid to spinal analysis • However, it should be used alongside other valid tests Evidence-based Chiropractic

  50. When evidence is lacking for your topic • Unsystematic observations or a generalization from a physiological study will be available for any topic • But this type of evidence is extremely weak • Practice guidelines may help, but are not always available and may be inconsistent • Therefore, other methods are required to help guide decisions about patient care Evidence-based Chiropractic

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