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Chiropractic Journal of Australia : CJA June 2013
66 Chiropractic Journal of Australia Volume 43 Number 2 June 2013 • Much of practice is professional judgement and therefore not subject to set EBP 'formulas.' • In a practical sense, if EBP is to be enforced, patients with conditions for which there is insuffcient evidence about chiropractic's effectiveness could be denied care. If we were to practise strict evidence-based chiropractic, the only patients we could treat would be those with a limited number of conditions for which we have a large body of evidence of our effectiveness (e.g., acute low back pain). • Evidence may be poorly backed up by relevant literature – especially given the questions now being raised of bias in sponsored research. An example of this is provided by pharmacology research where Aldhous states: "I'm an advocate of controlled trials but we have an overblown estimate of how useful they can be. Clinical trials are done mostly by the industry. Only half of the trials are published and of those that are, ghost writers for the industry polish a negative trial so that it's glowingly positive." 46 In a serious challenge to standard EBP protocols, a recent paper in the British Medical Journal analysed the dominance and appropriateness of ‘high-level’ evidence. Over the past 20 years, evidence based medicine has had a substantial infuence on clinical decision making throughout the developed world. It now underpins healthcare policy and the burgeoning industry of clinical guideline development. Two problems have resulted. Firstly, so called high level evidence is increasingly equated with strong recommendations; and Secondly, evidence other than that derived from randomised controlled trials (RCTs) is seen as intrinsically less valuable or reliable." 2 Further evidence questions the reliability of RCTs and other formal studies. A paper in the New England Journal of Medicine which assessed a report from the US National Research Council titled “The Prevention and Treatment of Missing Data in Clinical Trials,” questions the selectivity of published research data. It states that "Substantial instances of missing data are a serious problem that undermines the scientifc credibility of causal conclusions from clinical trials." Other papers have address the NRC report, including one that reported missing data in orthopaedic research fndings.47 Another area is the inconsistency of guidelines and their interpretation. For instance, in relation to angiography it was found that "There's been considerable variation across the United States in how operators interpret the current guidelines." 48 While these shortcomings reveal ‘holes’ in the system, they do not obviate the need for evidence - it is just that an EB system needs to be critically reviewed and other criteria developed so that the implementation of that system is a fexible and appropriate evidence base. Given the limitations in the current model of EBP, patient self-assessed input appears to be a most satisfactory candidate for inclusion as a part of an evidence base – a signifcant strengthening of the current clinical evidence model. Models have been reviewed for such conditions as urinary problems, diabetes, cancer49 and scoliosis.50 Precedents Both medicine and chiropractic are based on theories or hypotheses. Both professions comprise basic physiological and scientifc facts supported by empirical and researched observations as evidence to support these hypotheses. It has been reported that the scientifc evidence base for medical care stands between 15-20%.18,19 Haneline defines EBP for chiropractors as "Actively seeking support for and improvement of chiropractic clinical practice through the integration of the best available research evidence, combined with clinical expertise a nd patient preferences." 51 This is an ideal defnition, but the case is put here to extend it to include more personalised patient involvement. Has Medicine Followed an EB Practice? It could also be said that some of the evidence in medicine has been questioned from within its own profession. If such reservations exist, one would ask if it is possible to attain or even expect a higher standard of an evidence base for chiropractic than there is of medicine. One would not expect a double-standard, although in the clinical sciences, one would not anticipate a level of evidence that theoreticians advocate in idealistic circumstances. It could be noted that medicine has given the impression that 'it' has practised evidence based care for some time, yet many medical drugs are withdrawn due to adverse effects or lack of effcacy after they have been in circulation. In October 2012, arthroscopic knee surgery, which had been frequently employed, was declared an ineffective procedure for common degenerative knee conditions.52 One wonders how a procedure could become widely accepted, when it is supposed to be based on evidence. It has been established that there is a confict of interest with Cochrane Collaboration research as "Only 16 of the 151 Cochrane reviews (11%, 7% to 17%) provided any information on trial author-industry fnancial ties or trial author-industry employment. Information on trial funding and trial author-industry ties was reported in one to seven locations within each review, with no consistent reporting location observed." 53 It is recalled that some medical doctors adopted acupuncture treatments well before the previously mentioned gold standard of researched studies assessed it. Some studies were established later, but not at the time when medicine frst incorporated acupuncture. Most acupuncture evidence is anecdotal or at most, empirical. As recently as 2006, it was stated '...that only 15% of what doctors did was backed by hard evidence. A great many doctors and health-care quality experts have come to endorse [this] critique. And while there has been progress in recent years, most of these physicians say the portion of medicine that has been proven effective is still outrageously low -- in the range of 20% to 25%. "We don't have the evidence [that treatments work], and we are not investing very much in getting the evidence," says Dr. Stephen C. Schoenbaum.' 54 PATIENT-ORIENTED EBP ROME
CJA March 2013
CJA September 2013