Evidence-Based Practice Skills
Although all 4 institutions have followed different approaches to implementation, the overall strategies share some common principles. (a) Course work should incorporate journal club formats, checklist reviews of current studies, and student construction of critical appraised topics. (b) Informational literacy assignments should span all 4 years, be relevant, and relate to other course content. (c) The language and concepts of evidence-based practice must permeate all diagnosis and management courses and, where feasible, basic science courses as well. (d) Focused and ongoing training must target a large proportion of classroom and clinical faculty across the entire school curriculum. (e) Application of these skills must be patient based and become part of the clinic culture as opposed to an endeavor segregated to a journal club activity.
Effectiveness of Manual Therapies
The goal of evidence-based practice is to incorporate the best-quality evidence into the clinical decision-making process to provide timely, appropriate care.11,12 The results of randomized controlled trials (RCTs) on manual therapies have been published in more than 200 peer-reviewed articles, and many of these have been synthesized in systematic reviews and evidence-based guidelines.13
Below we present a brief evidence synthesis based predominantly on the United Kingdom Evidence Report by Bronfort et al,13 currently the most comprehensive review of the evidence for the efficacy of manual therapies.14 The report was commissioned by the UK General Chiropractic Council in response to media concerns about scope of practice and claims of effectiveness in advertising. The report summarized the scientific evidence regarding the effectiveness of manual treatment as a therapeutic option of the management of 26 musculoskeletal and nonmusculoskeletal conditions. The authors based their conclusions on the results of systematic reviews of randomized controlled trials, widely accepted evidence-based guidelines, and randomized controlled trials not yet included in the former.
Low Back Pain
Spinal manipulation is an effective care option for acute, subacute, and chronic low back pain. Massage was also found to be effective for chronic low back pain.13 Notably, these finding were based, in part, on the clinical practice guidelines developed for the American Pain Society and the American College of Physicians. Chou et al15,16 recommended these treatments in addition to medical care. The most recent meta-analysis was supportive in finding clinically meaningful differences in aggregate between manipulation and other treatment alternatives.17 A 2010 Cochrane review suggested that there is moderate evidence that exercise can prevent recurrences of back pain, although there was conflicting evidence as to its effectiveness as a primary treatment.18 Based on fewer studies than on exercise or manipulation, a Cochrane systematic review found benefit of massage for patients with subacute and chronic nonspecific low back pain, especially when combined with exercise and education.19 Research on most conservative treatments for low back pain, including drug therapy, have reported only modest benefits.20 It remains to be seen whether this is due to the limited effectiveness of the interventions or the heterogeneity of patient populations. Research continues in an attempt to identify potential responder and nonresponder subgroups currently under the generic label of nonspecific low back pain. Potentially better results can also be linked to combination therapies and interdisciplinary approaches.
Neck Pain
Spinal manipulation was found to be effective for acute and subacute neck pain. Effectiveness was also found for acute whiplash when spinal manipulation is combined with exercise. Spinal manipulation was shown to be effective for chronic neck pain when combined with exercise.13 However, a new study suggests the efficacy of spinal manipulation alone in patients with associated cervicogenic headache.21Massage is also effective for chronic neck pain. An influential systematic review on this topic was conducted by the Bone and Joint Decade 2000–2010 Task Force on Neck Pain.22
Mid Back Pain
The evidence to date is inconclusive in a favorable direction for the use of thoracic spinal manipulation for mid back pain. This is because there has been only 1 small placebo-controlled trial to date. On the other hand, thoracic spinal manipulation has been shown to be efficacious for the care of neck pain.13 The trends in the data thus suggest spinal manipulation for mid back pain is a promising therapy requiring further trials.
Headaches
Extremity Conditions
Manipulation of extremity joints is used for a variety of conditions. However, there are fewer trials than for back pain, neck pain, and headaches. Effectiveness was found for shoulder girdle pain, adhesive capsulitis, lateral epicondylitis, hip and knee osteoarthritis, patellofemoral pain syndrome, and plantar fasciitis. Inconclusive evidence in a favorable direction was observed for rotator cuff pain, shoulder pain, carpal tunnel syndrome, ankle sprains, Morton’s neuroma, hallux limitus, and hallux abductor valgus. The only definitive negative finding was for ankle fracture rehabilitation, while several other forms of post surgical rehabilitation had inconclusive evidence leaning in the negative direction.13
Nonmusculoskeletal Conditions
There was positive evidence for spinal manipulation for only 1 nonmusculoskeletal condition, cervicogenic dizziness. The evidence for the effectiveness of spinal manipulation was negative for asthma and dysmenorrhea; the addition of spinal manipulation to diet was also ineffective for hypertension. Evidence was inconclusive for pneumonia, stage 1 hypertension, pre-menstrual syndrome, nocturnal enuresis, and otitis media.13
Safety
Manual therapies including spinal manipulation are generally safe. Side effects tend to be benign: minor and self-limiting with short duration (eg, mild postmanipulation soreness).24–26 Severe complications have been associated with spinal manipulation but are extremely rare.25 For example, cauda equina syndrome can be as rare as 1 in 100 million following lumbar manipulations.27 Cassidy et al28 reviewed approximately 100 million person-years of records to evaluate stroke risk associated with cervical spinal manipulation and medical care. The authors concluded that the risk was extremely small and there was no excess risk from chiropractic care compared with medical care for neck pain and headaches. They hypothesized that the equivalent risk for chiropractic and medical care suggests that a stroke prodrome can lead to care seeking for these conditions. It is unlikely that manipulation of the neck is causally related to stroke.
Other Interventions
Other interventions commonly employed by the chiropractic profession have a similar evidenced-based foundation. A 2010 Cochrane review suggested that there is moderate evidence that exercise can help prevent recurrences of back pain, although there was conflicting evidence as to its effectiveness as a primary treatment.18 Based on fewer studies than on exercise or manipulation, a Cochrane systematic review found benefit of massage for patients with subacute and chronic nonspecific low back pain, especially when combined with exercise and education.19
Research on most conservative treatments for low back pain, including drug therapy, have reported only modest benefits.20 It remains to be seen whether this is due to the limited effectiveness of the interventions or the heterogeneity of patient populations. Research continues in an attempt to identify potential responder and nonresponder subgroups currently under the generic label of nonspecific low back pain. Potentially better results can also be linked to combination therapies and interdisciplinary approaches.
Conclusion
Evidence-based practice has made significant inroads into the chiropractic profession by expanding clinical research into interventions commonly employed by chiropractors and by graduating more Evidence-based practice savvy practitioners. The most common conditions treated by chiropractors are back pain, neck pain, and headaches.9 The best available evidence supports manipulative therapy as a reasonable option for many of these complaints. Manipulative therapy also holds potential value for the treatment of a variety of extremity conditions. Chiropractic practice is far broader than spinal manipulation alone, typically including other evidenced-based interventions such as massage, exercise therapy, and activity modification advice. Chiropractic education, with the help of federal grants and partners in established medical schools, is aggressively addressing the need to create more Evidence-based practice savvy graduates. These efforts will hopefully lead to improved patient outcomes and offer a common language and perspective to facilitate greater interprofessional cooperation.
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