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The Evidence-Based Case Report: a Resource Pack for Chiropractors

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The Evidence-Based Case Report: a Resource Pack for Chiropractors Clinical Chiropractic (2003) 6, 73—84 RESOURCE DOCUMENT The evidence-based case report: a resource pack for chiropractors Amanda R. Jones-Harris* Active Chiropractic Clinic, The Orchard Surgery, Baldock Road, Buntingford, Hertfordshire SG9 9DL, UK Received 3 February 2003; accepted 27 February 2003 Introduction a disparity develops between diagnostic skills and clinical judgement that increases with experience What is evidence-based medicine? and dating of academic knowledge resulting in a decline in clinical performance over time. EBM was Evidence-based medicine (EBM) is described as developed to help bridge this gap between research ‘‘...the conscientious, explicit and judicious use and practice. Recent advances in database search- of current best evidence in making decisions about ing and secondary sources of evidence, as well as the care of individual patients. The practice of improved access to them, have made the practice evidence-based medicine requires the integration of EBM a more viable option.2 of individual clinical expertise with the best avail- able external clinical evidence from systematic research.’’1 More recently, this definition has been Limitations of evidence-based medicine updated to incorporate patient values in the deci- sion process.2,3 These key elements of evidence- Three limitations are universal to medicine and based clinical decisions are depicted in Fig. 1. The science: the shortage of coherent, consistent evi- overall aim of EBM is to provide the best possible dence; the difficulty of applying evidence to indi- care for the individual patient. vidual patients and external barriers to the practice The integration of best research evidence, clin- of high quality medicine. In addition, EBM has some ical expertise and patient values, allows clinicians further specific limitations. and patients to form a ‘‘diagnostic and therapeutic Practitioners often lack the required skills in alliance’’ to optimise clinical outcomes and quality identifying and formulating clinical questions5 and of life.2 As professionals, we should constantly in finding, assessing, interpreting and applying cur- question clinical practice how and why we practice rent best evidence.5—7 Time limitations have also in the way we do and whether we are providing been reported as a major barrier that prohibits the most effective care for our patients. To do evidence-based practice.5,7—9 less is to practice as a technician and not as a Concern has also been expressed about the professional.4 potential conflict between best evidence and per- The need for evidence-based practice has arisen ceived patients’ wishes9,10 and fears that the way from the rapid advances in medical knowledge and evidence is presented could unduly influence a the large number of clinical papers being published. patient’s decision.10 Traditional sources of information such as text- The evidence in evidence-based practice has books rapidly become out of date. Consequently, been criticised because it is produced by research- ers not practising medics.11 EBM is considered of ÃTel.: þ44-1763-274646. greatest value when undertaken by practising clin- E-mail address: [email protected] icians as they are in the best position to balance (A.R. Jones-Harris). research evidence with clinical evidence for a 1479-2354/03/$30.00 ß 2003 the College of Chiropractors. Published by Elsevier Science Ltd. All rights reserved. doi:10.1016/S1479-2354(03)00022-1 74 A.R. Jones-Harris shift towards outcomes-based research19,20 and a growing acceptance of the importance of qualita- tive research.2,17,21,22 Yet, despite this, qualitative methods are still absent from hierarchies of evi- dence.2 If the qualitative values, preferences and perspectives of patients are to be incorporated into the definition of evidence-based practice, then it can be argued that evidence-based approaches must be able to cope with such data.17 Ultimately, it should be the research question itself that should determine the most appropriate research metho- dology and methods.23 Complementary and alternative medicine (CAM) and evidence-based practice The call for complementary medicine to become Figure 1 An updated model for evidence-based clinical research led and evidence-based has become 3 decisions. Reproduced with permission from the American increasingly voiced.24 However, EBM has also been College of Physicians. seen as a threat to complementary and alternative medicines (CAM). It has been suggested that CAM particular case.6,12 Therefore, this criticism could not supported by reliable scientific evidence should actually be viewed as a reason why practising phy- be viewed with suspicion25 and complementary sicians should become conversant in the relevant health care practitioners have been urged to EBM skills, so that they can appraise the primary embrace empiricism or risk extinction.26 sources of evidence for themselves. Others argue that EBM is more likely to empower Through debate, many of the other suggested rather than disadvantage CAM practitioners27,28 as, ‘‘limitations’’ of EBM have been clarified. Claims without it, the future of CAM would be decided by that EBM degrades clinical expertise, is limited to medical tradition, power and influence. Moreover, clinical research, ignores patients’ values and pre- EBM should promote higher quality CAM research, ferences and promotes a ‘cookbook’ approach to which should translate into better patient care.28 medicine7 have been dismissed as they are contrary It has also been suggested that EBM could help to the more recent definition of EBM.13 EBM has also bridge the gap between allopathic and CAM been accused of being a cost cutting exercise insti- providers,28—31 but the difference in the philoso- gated by economists.7,11 However, in reality, it phies of health care between allopathic medicine would probably increase, rather than decrease, and CAM is a major barrier to realising EBM in the the cost of health care.14 CAM community.31,32 What counts as ‘‘external’’ evidence Evidence-based chiropractic practice Until recently, sound evidence has been interpreted The chiropractic profession in the United Kingdom by many as being synonymous with randomised has already come a long way by gaining regulation controlled trials (RCTs).15 Because the RCT is gen- and setting standards for practice through the Gen- erally considered the gold standard of research eral Chiropractic Council. The profession overall design, the supposition has been that only evidence has greatly benefited from research33 and has been from RCTs should be considered in evidence-based held up as an example within CAM because of its medicine. However, this view is now being chal- research and guideline development.34 The profes- lenged.1,16,17 Amoreflexible approach to the hier- sion is being urged to embrace evidence-based archy of evidence has been suggested whereby RCTs practice.35—39 However, the lack of high-quality and observational studies have complementary evidence about many therapies, diagnostic tests roles. There are times when RCTs are unethical or and procedures used in chiropractic practice,37 impractical and a good quality observational study and manual medicine generally,40 is an impediment is more appropriate.18 There has also been a general to further implementation of the evidence-based The evidence-based case report: a resource pack for chiropractors 75 approach. Therefore, to advance within the EBM The EBM approach can be summarised in five ethos, the profession needs to increase the quality steps:7,58 asking answerable clinical questions; and quantity of research and researchers,39,41—43 as searching for the evidence; critically appraising well as educate chiropractors in the skills and prin- the evidence for its validity and relevance; making ciples of evidence-based practice.38,39,44 Whilst not a decision, by integrating the evidence with your all clinicians need to be proficient in advanced clinical expertise and the patients’ values and eval- appraisal, it is argued that all need some evi- uating your performance. An evidence-based case dence-based practice skills to be able to understand report should illustrate each step of this process.54 secondary sources of preappraised evidence, as well as to use the original literature when no preappraised synopsis exists.45 Asking the question Teaching critical appraisal skills to practitioners does not, however, inevitably translate into their Clinical questions occur frequently through daily application in clinical practice and improved clinical practice. They may arise through cognitive patient outcomes.29,46,47 Although aspects of evi- dissonance, reflective practice and the desire to dence-based health care and critical appraisal are ensure maintenance of up to date knowledge. Ask- being incorporated into the curriculum at many ing the clinical question initially means defining the chiropractic colleges,46,48 these skills are not being patient and determining the patient’s problem. applied to any great extent by the student interns in There may be, at any one time, a number of cases the college clinics.46 that generate questions. To ensure that cases are It is agreed that, in order for evidence-based considered in order of priority and of significance to practice to be implemented, the information needs practice, the following criteria can be considered: to be useful, manageable and accessible36 and be the frequency of the problem; the magnitude of its taught in a way which makes it relevant to real consequences; the availability
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