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Chiropractic Journal of Australia : CJA June 2013
Chiropractic Journal of Australia Volume 43 Number 2 June 2013 63 of other forms of health care. Acupuncture has been accepted based on 1000's of years of anecdotal evidence -- an interesting precedent. Other questions have been raised as to the suitability of a formal evidence base for medicine. It would be critically unfair to expect a totally RCT studies-based chiropractic practice to meet this particular level, when the established gatekeeper profession has apparently not met such a standard. To expect more of chiropractors would amount to a double standard. This does not mean that chiropractic should not strive for the higher standard; indeed it should seek to frmly establish such a base. Current reports note contradictions in the medical feld concerning some drugs and surgical procedures,despite claims of that profession being based on EBPs over the years.18,19 REVIEW The view that clinical care must be evidence based, raises the question of what form that evidence should take. Tonelli states clearly that: " The knowledge gained from clinical research does not directly answer the primary clinical question of what is best for the patient at hand. Proponents of evidence-based medicine have made a conceptual error by grouping knowledge derived from clinical experience and physiologic rationale under the heading of "evidence" and then have compounded the error by developing hierarchies of "evidence" that relegate these forms of medical knowledge to the lowest rungs." 11 Currently, much of the evidence recommended for EBP is based on RCTs, meta-analyses and systematic reviews that are centred on medical evidence. Indeed a great deal of the ‘medical evidence’ seems to go out of its way to avoid citing refereed chiropractic literature, even that from chiropractic journals listed on PubMed. This evidence can be of limited use to chiropractors, as assessments and management of cases are subject to 'alternative' models. Therefore at times, it is not appropriate to substantiate a care program other than on anecdotal or empirical evidence and experience based on undergraduate education. Some Grounds for Considering Change As doubts are now being expressed in the literature about the suitability of the previous ‘gold standard’20 of evidence being necessarily appropriate as the primary guide for clinical sciences greater emphasis should be placed on other forms of evidence. This is not to say that RCTs and similar studies should be down-graded at all, but a broader range of evidence could apply to a given situation. The selected range of evidence levels should then also vary for differing conditions. Given the vagaries of clinical practice, it may well be that anecdotal and empirical evidence deserves a much greater justifcation, particularly in view of the rising recognition of patient satisfaction becoming a factor – in conjunction with the more formal traditional studies.9-11 There have been some reservations expressed over anecdotal evidence in the health feld. However doubts have now been levelled at that criticism. Indeed the wealth of anecdotal studies in chiropractic is somewhat impressive, not only in relation to orthopaedic conditions, but other conditions as well as published textbooks. Gatterman, Haldeman, Leach, Davies, Cramer & Darby, Rowe & Yockum, Wyatt and Croft are but a few of the published chiropractic authors. In further support of anecdotal evidence, Campo avers that "Our patients' stories too, if only we could listen to them less critically and cynically, might similarly inspire us to the more practically important discoveries of what truly ails them." "Whether we choose to admit it or not, the anecdote continues to be an important engine of novel ideas in medicine."21 Anecdotal evidence probably would have gained more recognition if it had been labelled under a heading of empirical evidence which is defned in the Miriam Webster22 Online Dictionary as:- 1 : originating in or based on observation or experience 2 : relying on experience or observation alone often without due regard for system and theory 3 : capable of being verifed or disproved by observation or experiment "Anecdotal evidence can have varying degrees of formality. For instance, in medicine, published anecdotal evidence by a trained observer (a doctor) is called a case report, and is subjected to formal peer review. Although such evidence is not seen as conclusive, it is sometimes regarded as an invitation to more rigorous scientifc study of the phenomenon in question. For instance, one study found that 35 of 47 anecdotal reports of side effects were later sustained as "clearly correct."http://en.wikipedia.org/ wiki/ - cite_note-Venning-13 23 One questions whether there has ever been a study comparing the RCT-type studies with the patient-derived results of approval. After all, RCTs have been almost imposed onto clinical practitioners and appear to be based on a model that it is still essentially a theory. It assumes that it is more satisfying to patients, but their opinion has generally not been sought. The philosophy behind RCT theory has not been formerly challenged to my knowledge. According to Kent, Haneline attests that, "It should be noted that the process of EBP itself has not been rigorously tested, so we do not know for sure if it actually results in improved health. No RCTs that have compared EBP with standard methods of practice have been carried out in any of the health care professions because of the methodological diffculties and exorbitantly high costs that would be associated with attempting to execute such studies." 24 Others have claimed that the more formal evidence can be biased,25,26 inappropriate,27 inconsistent,28 amongst other problems and controversies.29-31 Schultz and colleagues concluded that their study provided "...empirical evidence that inadequate methodological approaches in controlled trials, particularly those representing poor allocation concealment, are associated with bias."26 Begley from the University of Bern found distinct inconsistencies on medical practices in referring to the "treatments they offer and which ones (were) supported by solid empirical evidence,"28 PATIENT-ORIENTED EBP ROME
CJA March 2013
CJA September 2013