Evidence-Based Practice:
Should We or Shouldn't We?
By Henry Pollard, Simon French and Bruce Walker on behalf of the COCA Executive

Evidence based practice (EBP) is a term that carries considerable weight in today’s competitive healthcare environment. It is also a term that is misunderstood and feared by practitioners from many professions, including chiropractic and osteopathy. But what does this term EBP mean, what are the benefits of EBP and what does it require of practitioners? The following article will be the first of a series of opinion pieces and discussions on this and related topics. These articles will focus on the use and application of EBP in clinical practice, and also the use of EBP in the formulation of COCA policy on a particular issue. This discussion will also tackle the issues and difficulties of how EBP can best be used to embrace the less well established practices of our art.

The recent national conference and COCA national executive meeting included a number of vigorous debates regarding EBP and “type O” disorders. It was decided at the executive meeting that COCA wishes to dispel the myths associated with EBP, and at the same time acknowledge the growing movement of vitalistic healthcare in chiropractic, osteopathy and healthcare in general. The executive all agreed that it is important to have a balanced perspective about untested therapies.

The oft quoted “the absence of evidence is not evidence of absence” is a cry from practitioners and researchers alike. Therapies that have strong support in the literature for the management of most non-specific spinal pain include, only some medications, giving advice to patients such as remaining active, and some cognitive and behavioural therapy. According to the most recent research, most of the therapies that we use for the “type M” conditions (musculoskeletal) are probably little different in outcome to the use of analgesics, exercise and reassurance! However, we do not advocate giving away the manual procedures used in the treatment of these conditions.

Let us explain. Evidence-based practice is summed up best by the following equation:

EBP = 1. Best available evidence AND 2. Clinical experience AND 3. Patient values

1. Best available evidence is advancing at a rapid rate, but it still has a long way to go in fields of chiropractic and osteopathy. However, when we do have good evidence we should review our methods of practice accordingly.
2. Clinical experience. It is this area where there is so much diversity of opinion. This is quite understandable given the lack of experimental trials and the breadth of techniques and modalities we use. It is in the clinical experience area where we find ourselves every day in practice and by and large doing a good job. There are generally no absolute rules, but recognition of our limitations, logic and previous experience should be the mainstay. Importantly, it is an area where we can practice comfortably within the bounds of societal restraint but we cannot be dogmatic about what we do or claim.
3. Patient values. The health care values of patients are an important part of practice. We are all trained to take this into account. If we do not the outcomes suffer.

When reading the above equation for evidence based practice it is clear that most of what we do each day fits into the EBP model.

Although the treatment and diagnostic procedures utilised in chiropractic and osteopathic practices are commonly not supported by current evidence, we are not obliged to abandon them unless there is unequivocal evidence that ‘proves’ they are worthless. Equally, a therapy should not be presented as ‘proven’ when its outcomes are not predictable or even guaranteed. Unreasonable use of some therapies in the absence of any real reason to do so will increasingly attract the ire of regulatory bodies, and that ire is now becoming manifest.

For this and other reasons, that we hope will become apparent in future COCA News pieces, COCA feels strongly that practitioners should be embracing EBP now. The main benefit being that we can embrace change by keeping abreast of new science and we can continue to practice using our clinical experience and the values of patients.

COCA believes it is contributing to EBP by continuing to adopt best practice in research reporting (in COCA News and the ACO journal), in conducting continuing education activities and in developing policies. But how can a practitioner in the field be ‘evidence-based’? As described above, EBP embraces the best available evidence, clinical experience and patient values. The following attributes are often described as being essential for the evidenced based practitioner. How do you score with them?

1. Constantly questioning
   The practitioner is alert to questions that arise from observations and problems in daily practice and in communication with colleagues and patients.
   
   
2. Sceptical of current practice
   The practitioner has a healthy scepticism of his/her own standards and effectiveness, of accepted practice and of received wisdom.
   
   
3. Open to other points of view
   The practitioner listens to and values other people’s perspectives - patients, colleagues, students, etc.
   
   
4. Aware of the validity and limitations of knowledge
   The practitioner appropriately applies knowledge whether it derives from research or from personal experience.
   
   
5. Acquires knowledge of EBP
   The practitioner possesses a level of knowledge of EBP appropriate to his/her situation.
   
   
6. Capable of applying EBP in his/her situation
   The practitioner applies the knowledge of EBP appropriate to his/her situation.
   
   
7. Continuously learning
   The practitioner partakes in active learning to keep up to date. The practitioner adopts the mantra of ‘life long learning’.
   
   
8. Able to practice where uncertainty is apparent
   Evidence is frequently unable to provide answers to meet the requirements of every day practice. The practitioner is able to utilise clinical experience and patient values to make rational diagnostic and management decisions.
   
   

We hope this stimulates a little interest in this debate. What do YOU think? All opinions are welcome in this discussion.

Where should we go from here?