December 2005

The next step in becoming an evidence‑based

by Dr. David A. Jackson

A great deal has been said recently about evidence‑based practice and there can be little doubt that the chiropractic profession will move toward that paradigm along with all other health care disciplines.

The most frequently quoted definition of evidence‑based care is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research." (Sackett, D. Evidence‑based Medicine: How to Practice and Teach EBM. 2nd edition. Churchill Livingtone, 2000.)

Sounds good, but ‑‑ as one recent Clinical Chiropractic article by Jennifer E. Bolton, PhD, points out ‑‑ "the practicality of integrating clinical research evidence into clinical practice arguably remains today's biggest challenge." (Bolton, J. "Time to (evidence‑base) practice what we preach." Clinical Chiropractic 2005, 8, 1‑4).

The real challenge for chiropractors may not be the implementation of evidence‑based practice as much as the accumulation of the actual evidence upon which to base that practice. Right now, nearly every major chiropractic researcher agrees that there is a serious deficiency of the type of clinical research we need to validate and support our practice.

As William Meeker, DC, director of the Palmer Center for Chiropractic Research, stated: ""The research has not been done. Let's face it. We have a massive fact deficit in chiropractic."

Donald R. Murphy, DC, went so far as to claim: "Scientific literature has failed to demonstrate the very existence of the subluxation."

This summer, during the World Federation of Chiropractic's "Identity Consultation," that group's Assembly declared: "There is little existing research or scientific evidence to support chiropractic's role in overall health improvement"

Outsiders have taken up the refrain as well.

The British Medical Association warned, "There is a lack of sufficient evidence to support many of the claims of efficacy (for chiropractic and CAM). ... Without evidence, it is impossible for the public and the medical profession to make informed decisions on the risks and benefits of different therapies."

The refusal to fund a chiropractic college as part of Florida State University was based, in part, on a consultant's report that claimed any beneficial physiological response by the body to chiropractic is "largely speculative."

And the now‑famous analysis of chiropractic in Newsweek magazine concluded that it suffered from a "Dearth of good research to prove efficacy."

Why, then, are we adjusting anyone? Where is the evidence that chiropractic helps anyone except some adults with low‑back pain?

Until recently, few DCs cared much about chiropractic research. They "knew" chiropractic worked because they saw the results in their offices every day. Most of them had been on the receiving end of chiropractic care at one time in their lives and the experience convinced them of the far‑reaching benefits of spinal adjustments. "We don't need research to 'prove' chiropractic works. We already know it does," was a common refrain.

But, in this day and age of evidence‑based practice, it isn't enough to 'know' chiropractic works. We have to be able to prove it with clinical, scientific evidence that will convince those who have never gotten an adjustment in their lives.

As Dr. Bolton said, "Up to now, research evidence may have been something of a luxury that clinicians chose to use when it suited, and then put aside while they go on with the routine of everyday practice. However, the world is rapidly changing to one where evidence is becoming increasingly important..."

Obviously, the first step to establishing chiropractic as an evidence‑based profession is to amass the evidence.

There are two ways to do this. The first is to sit back and wait for our colleges and research organizations to produce the needed research. This is what we have traditionally done but after more than a century, we still haven't filled the information void. As Dr. Meeker noted in the Spring/Summer 2005 issue of the FCER publication Advance, "there are not many more people doing chiropractic research now than there were 10 years ago."

The second is for research to become a professional priority. Dr. Bolton was absolutely right when she stated "clinicians do not get off that lightly simply by leaving evidence‑based practice to the researchers. From its definition, evidence‑based practice is about the use of research evidence, not for, or by, external stakeholders, but by individual practitioners treating individual patients.... For chiropractic practice to become evidence‑based, as espoused by the champions of evidence‑based practice, clinicians need to be able to act both as 'research‑users' and as 'research‑providers.'"

To do so, she maintained, "clinicians will need to attain the skills to undertake research that answers meaningful clinical questions that arise in everyday practice, and then to be able and willing to disseminate that evidence in a publishable format."

Yet, there can be no doubt that being a clinical investigator isn't something you can easily do in between seeing patients and managing a busy chiropractic office. How many of you can simply decide to "do some research" in your office and get the results published? Where do you even start?

One place to start is with RCS (Research & Clinical Science), the private sector research firm that is developing a global network of field doctors interested in becoming clinical investigators as well as research‑users.

To begin with, RCS authorized clinical investigators receive specialized training, including the National Institutes of Health "Human Participant Protections Education for Research Teams" and RCS's own health outcomes research training program. In addition, every RCS doctor is individually assessed by an independent Institutional Review Board and must be IRB‑approved before participating in RCS. The RCS project is itself IRB‑approved and backed by a world class International Scientific Advisory Panel made up of MDs, DCs, and PhDs who are active in scientific research.

To make the actual research gathering experience trouble‑free, RCS doctors may opt to utilize RCS supplied electronic equipment, including a Tablet PC loaded with proprietary research software or web based technology that uploads patient data to the main RCS data warehouse, where it will be analyzed by the Panel.

Thousands of doctors around the world will be gathering uniform data on hundreds of thousands of volunteers and patients, including "before and after" data on those who receive chiropractic care over a period of time. This data will serve to help provide scientific evidence on chiropractic's impact on all aspects of health, wellness and quality of life.

The RCS program, in effect, eliminates one of the biggest hurdles faced by our profession: apathy. As Dr. Bolton noted, "From our own experiences of putting on workshops and seminars in evidence‑based practice for chiropractors in the field, the interest is dramatically disappointing to say the least." Because of its unique structure, RCS is able to generate excitement in the data‑gathering process. RCS makes research not only easy but exciting. With it, doctors are able to contribute valuable data while having the opportunity to introduce thousands of people to the basic chiropractic concepts.

In exchange for their participation fee (currently as low as $149 a month), RCS doctors place themselves at the forefront of the evidence‑based trend, showing to their patients and their communities that they are active in research and cutting edge practice.

(Dr. David A. Jackson is chief executive officer of Research and Clinical Science ‑‑ RCS ‑‑ a private sector research program exploring issues of subluxation correction and chiropractic care as they relate to health and wellness. Previously, he served as president of the Chiropractic Leadership Alliance and Creating Wellness Alliance and was owner/operator of several private practice offices in California and Idaho that specialized in high‑volume, family wellness‑based care. For more information on RCS, call 800‑909‑1354 or 480‑303‑1694, or visit the RCS website at www.rcsprogram.com. Doctors of chiropractic may log on to a special limited‑access area of the site by using the username DC1 and password RESEARCH.)