© 2006 Evidence-based Chiropractic 1 Evidence-Based Chiropractic 1 Michael Haneline, DC, MPH [email protected] .

1 © 2006Evidence-based Chiropractic

Evidence-Based Chiropractic 1

Michael Haneline, DC, [email protected]

http://w3.palmer.edu/michael.haneline

• PowerPoint slides of the lectures are downloadable at the course website

• Recommended text– Evidence-based Chiropractic Practice.

Haneline M. Jones & Bartlett Publishers


How to print PP slides


Course Objectives

• At the conclusion of this course students will be able to:1. demonstrate knowledge of the steps of

evidence based practice2. define selected scientific method and

epidemiological terms3. retrieve relevant information given a clinical

question4. search an online database using key words

and search strategies


Course Objectives (cont.)

5. categorize articles retrieved based on their research design and level of evidence

6. evaluate the credibility of a given paper/article and understand the value of peer-review

7. describe and demonstrate strategies for when there is little or no evidence

8. demonstrate knowledge of major historical developments in chiropractic research


Grading

IEBC* assignment 5 pointsLiterature searching/reviewing 5 points Write an answerable question 5 points Midterm Exam 40 pointsFinal Exam 50 points

*Institute for Evidence-Based Chiropractic


Due next Thursday 10/9/08

• Read the article: “Evidence-Based Chiropractic: The Responsibility of Our Profession”– Available on the EBC 1 web page

• 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?

• 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 Best clinically relevant research evidenceresearch evidence Clinical expertiseClinical expertise

Patient valuesPatient 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

• “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.)

• Without current best evidence, practice risks become rapidly out of date, to the detriment of patients.”


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?

• 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?

1. Convert the need for information into an answerable question

2. Find the best evidence available to answer your question

3. Critically appraise the evidence for validity, impact, and applicability to your practice

4. Integrate the critical appraisal with your clinical expertise and with your patient


How to practice EBC? (cont.)

5. Evaluate your effectiveness and efficiency in executing the preceding steps and seek ways to improve them for next time


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?

• 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

• 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

• 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.


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?


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?

• 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 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.)

• 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

• 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

• 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.)

• Quantitative– Experiments– Test hypotheses– Deductive

• Qualitative– Descriptive, unable to test hypotheses – Holistic concept about social or human

problems– Inductive


Qualitative Quantitative

A complete, detailed description.Classify features, count them, and construct statistical models in an attempt to explain what is observed.

Recommended during earlier phases of research projects.

Recommended during latter phases of research projects.

Researcher may only know roughly in advance what he/she is looking for.

Researcher knows clearly in advance what he/she is looking for.

The design emerges as the study unfolds. All aspects of the study are carefully designed before data is collected.

Researcher is the data gathering instrument.

Researcher uses tools, such as questionnaires or equipment to collect numerical data.

Data is in the form of words, pictures or objects.

Data is in the form of numbers and statistics.

Qualitative data is more 'rich', time consuming, and less able to be generalized.

Quantitative data is more efficient, able to test hypotheses, but may miss contextual detail.

Researcher tends to become subjectively immersed in the subject matter.

Researcher tends to remain objectively separated from the subject matter.


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.)

Deductive reasoning

Inductive reasoning

(Maybe)


• 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 where balls were observed kicked up and coming back down)

– General (the prediction that a similar event will result in a similar outcome in the future)



• 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)– Specific (this particular kick)



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 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


• 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 vs. a placebo would be?– Deductive

Inductive/deductive (cont.)


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


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.)

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


Example

• You are 3 months in practice and your CA informs you that a patient with de Quervain's disease made an appointment for tomorrow

• What is de Quervain's disease?

• Does it respond to chiro?• What’s the best treatment

method?


Components of good clinical questions

Patient or Problem Description of the patient or the target disorder of interest

Intervention Could include: –Exposure –Diagnostic test –Prognostic factor –Therapy –Patient perception etc.

Comparison Intervention Relevant most often when looking at therapy questions

Outcome Clinical outcome of interest to you and your patient


Back to Example

Patient or Problem de Quervain's disease

Intervention Manipulation of MP joint

Comparison Intervention PT

Outcome Less pain

PICO structure


Writing proper clinical questions

• Background vs. foreground questions

• Background questions – Are simple two-part questions about the basic

facts of a disease

• Foreground questions – Provide information about the best diagnostic

test for a specific disease, or the best treatment strategy for a specific patient


Background questions

• They have two components: – A question root (who, what, etc.) with a verb – A disease, or an aspect of a disease

• 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


• Clinical questions may require general background knowledge about a disease or disease process

• 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

http://www.merckmedicus.com

Background questions (cont.)


Example background questions

• What is de Quervain’s disease?

• What causes migraine headaches?

• Who gets rheumatoid arthritis?

• What tissues are most commonly strained in whiplash injuries?


Foreground questions

• Pertain to foreground knowledge

• Are more complex than background questions

• Answers to foreground questions are found in reports of clinical research or systematic reviews – These resources provide specific information

about diagnosis and treatment


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– Secondary sources such as systematic

reviews of the topic


Foreground questions are made up of 4 components:

1. The patient or problem at issue (P)

2. The intervention or exposure under consideration (I)

3. Comparison intervention or exposure (C)

– When appropriate

4. The clinical outcomes of interest (O)


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.)

– 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


Your patient has a question

P Patient orproblem

Describes patient (age, sex, race, past medical history, etc.)

A 50 year old woman witha family history of breast cancer

I Intervention What happens or is to be done;treatment, diagnostic test, exposure, screening

Hormone replacementtherapy

C Comparison Compared to what? Nothing, placebo, gold standard, anotherintervention

Nothing

O Outcomes What is the effect of theintervention? (Mortality after aparticular time period, hospitalizations)

Prevention of Alzheimer'sDisease


Types of questions

Clinical Findings Manifestations of Disease

Prevention Prognosis

Cause/Etiology Cost-effectiveness

Differential Diagnosis Education

Quality of Life Harm/Risk

Diagnostic Tests Therapy

Each question type may require different kinds of information for evidence and, possibly, different types of resources


Assignment due 10/16/08

• Write 3 background and 3 corresponding foreground questions

• Use hypothetical clinical problems that may be encountered in chiropractic practice

• Include the 4 PICO elements and list them: – Patient/Population or Problem– The Intervention– The Comparison (if applicable) – Outcomes

© 2006 Evidence-based Chiropractic 1 Evidence-Based Chiropractic 1 Michael Haneline, DC, MPH [email protected] .

Documents

level of evidence

steps of evidence

chiropractic research

excellent external evidence

clinical encounter slide

words total slide

individual clinical

search strategies slide