Evidence-Based Care vs. Subluxation Care: Are they Mutually Inclusive or Exclusive?
Special Feature
Written by Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M.   
Sunday, 25 November 2012 18:53 Read : 1473 times

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s published by the University of North Carolina at Chapel Hill, "The most common definition of EBP [evidenced-based practice] is taken from Dr. David Sackett, a pioneer in evidence-based practice. EBP 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'" (The University of North Carolina at Chapel Hill, 2010, http://www.hsl.unc.edu/services/tutorials/ebm/whatis.htm).
 
As the University of North Carolina at Chapel Hill goes on to explain, EBP is the integration of:
  1. Clinical expertise: The clinician's cumulated experience, education and clinical skills.
  2. Patient values: The patient's own personal and unique concerns, expectations and values.
  3. The best research evidence into the decision-making process for patient care: The best evidence is usually found in clinically relevant research that has been conducted using sound methodology.
spinereference"The evidence, by itself, does not make a decision for you, but it can help support the patient care process. The full integration of these three components into clinical decisions enhances the opportunity for optimal clinical outcomes and quality of life. The practice of EBP is usually triggered by patient encounters, which generate questions about the effects of therapy, the utility of diagnostic tests, the prognosis of diseases, or the etiology of disorders. Evidence-based practice requires new skills of the clinician, including efficient literature searching, and the application of formal rules of evidence in evaluating the clinical literature" (The University of North Carolina at Chapel Hill, 2010).
 
Wilbeck, Murphy, Heath, and Thomson-Smith (2011) report acute-care nurse practitioners now have metrics to evaluate procedural competencies based upon evidence-based research and care (EBR). Cuellar, Rogers, and Hisghman (2007) report healthcare providers treating sleep disorders in older adults use EBR to provide implications for care. Brady and Smith (2012) report physiotherapists working with high-risk neonatal patients used EBR to achieve a standardized level of competence and enabled the identification of the learning needs required to ensure a certain level of competence. Miller and Skinner (2012) report midwives certify home birth as a less invasive process based upon EBR. These are just a scant few examples in the healthcare industry of how evidence-based research and practice is being used as a tool to improve the quality of care of practitioners along the broad spectrum of healthcare providers.
 
Evidence-based practice is not unique to chiropractic, only to many in concept and practice because as a profession, our culture and history have been based upon results in our individual offices with a poor infrastructure for research and reporting due to lack of funding. This can possibly be traced to "formal medicine's" continued attack on chiropractic and their having control over governmental research dollars. There are also large splinters in the profession moving in different directions, resulting in each faction independently seeking control.
 
Reggars (2011) reported a parallel in Australia: "The 1970's and 1980's saw a dramatic change within the chiropractic profession in Australia. With the advent of government regulation, came government funded teaching institutions, quality research and increased public acceptance and utilization of chiropractic services. However, since that time the profession appears to have taken a backward step, which in the author's opinion, is directly linked to a shift by sections of the profession to the fundamentalist approach to chiropractic and the vertebral subluxation complex. The abandonment, by some groups, of a scientific and evidenced based approach to practice for one founded on ideological dogma is beginning to take its toll" (p. 1). Although Reggars concluded that the root of chiropractic's "backward step" is the ideological dogma of the subluxation practitioners, he is both partially correct and concurrently omitting the other half of the equation.
 
The first step in moving forward and understanding the full spectrum of the issues is to take a stark look at the statistical facts versus beliefs and rhetoric. In 2010 Davis, Sirovich and Weeks reported that chiropractic utilization in the United States remained static at 12.1 million from 2003 until 2006. This represents 4.12% of the population according to the 2003 population reported by the Encyclopedia of the Nations. Davis et al (2010) also reported that in the early 1990s, chiropractic was utilized by 7.7% of the United States adult population, realizing a net loss of utilization of 3.58% in just a decade.
 
While Reggars lays blame on the "subluxation dogmatists," we cannot forget our heritage and history of what got us to caring for 7.7% of the population: Results through nothing more than the chiropractic adjustment. Treating patients with asthma, colitis, eczema, headache, migraine, scoliosis, ADHD and a host of other maladies resulted in both the chiropractors and their patients laying claim that chiropractic care resolved their health issues. I am not referencing or footnoting these claims because I have witnessed them firsthand and am reporting that these types of patients respond to chiropractic care in a repeated, systematized fashion. These types of patients, along with the multitudes of others that have realized pain relief from chiropractic care, have inspired generations to fight for chiropractic to attain our position in mainstream healthcare.

When one does a query in PubMed on "vertebral subluxation (VS)," there should be 100,000+ hits ...

 
In spite of the rhetoric from subluxation-based practitioners, when we look in PubMed and other scientific search engines, there is significant commentary but minimal reporting of evidence-based scientific conclusions. There is a growing body of low-value research in case reports, but the publishers have decided to hide that behind a curtain of profiteering, preventing the scientific community and the profession from accessing that information.  In spite of the greed or lack of accepted evidence-based research, there is one underlying fact: Results. It doesn't take research to help patients get better—it only takes chiropractic care.
 
The other side of the argument is clear and powerful. Without the evidence, chiropractic will not evolve past 1895, and that is the second part of the core of the problem. When one does a query in PubMed on "vertebral subluxation (VS)," there should be 100,000+ hits on VS and asthma, colitis, eczema, etcetera, that show the evidence-based research in an accepted scientific format; i.e., how 800 patients in a controlled study showed evidence of a malady resolving with nothing but chiropractic care. We can say with a great degree of certainty that the pharmaceutical companies and many medical specialties will fight funding of any research that can lower their bottom line. These types of studies, without hospital populations of illnesses or teaching institutions associated with hospitals to funnel these populations of illnesses to a study, offer greater challenges for the chiropractic profession. In addition, the costs are significant, and chiropractic does not have the political leverage to garner governmental grants at that level. Therefore, without the evidence-based research and evidence-based practice, we will be stuck with ideology based upon empirical results in our offices: a practice designed for failure over time.
 
CONCLUSION: In spite of the loud rhetoric from the conservative far right fighting for subluxation only in the "1895 model" and the liberal far left fighting for severe expansion of scope in an evidence-based model only, those factions have to realize they are collectively responsible for the 4.12% of the population we now care for. The chiropractic message is so muddled that a confused public has already emigrated to alternative treatments.
 
PLAN: The only plan that is reasonable and that will move the profession to grow is for the evidence-based practitioners to stay the course and embrace the subluxation ideology until research catches up. Patients get well in spite of the research not being there. In addition, the subluxation practitioners must embrace the evidence-based providers and fight for and support financially real research, not just that designed to further the ideological causes, but the broad spectrum of research that will eventually conclude the truth of the true scope of what chiropractic has to offer. We must also support research by embracing our colleges and universities because, inherently, that is where the DCs, DC PhDs and others qualified to do research lend their careers. It is our only way up.

Author's concluding note: The only way to remove the splinters and impediments for success is to have a single chiropractic organization in the United States with 50 chapters—no multiple national organizations and no state organizations. Combined, we are a political force with leverage. Splintered, we will continue to get more of the same: less and less every year.

References:
  1. The University of North Carolina at Chapel Hill (2010, July). What is evidence-based practice (EBP)? Retrieved from http://www.hsl.unc.edu/services/tutorials/ebm/whatis.htm
  2. Wilbeck, J., Murphy, M., Heath, J., & Thomson-Smith, C. (2011). Evaluation methods for the assessment of acute care nurse practitioner inserted central lines: Evidence-based strategies for practice. Journal of the Association for Vascular Access, 16(4), 226-33.
  3. Cuellar, N. G., Rogers A., E., & Hisghman, V. (2007). Geriatric Nursing, 28(1), 46-52.
  4. Brady, A., & Smith, P. (2012). A competence framework and evidenced-based practice guidance for the physiotherapist working in the neonatal intensive care and special care unit in the United Kingdom. Journal of Neonatal Nursing, 18(1), 8-12.
  5. Miller, S., & Skinner, J. (2012). Are first-time mothers who plan home birth more likely to receive evidence-based care? A comparative study of home and hospital care provided by the same midwives. Birth, 39(2), 135-44.
  6. Reggars, J. (2011). Chiropractic at the crossroads or are we just going around in circles? Chiropractic & Manual Therapies, 19(11), 1-9.
  7. Davis, M., Sirovich, B., & Weeks, W. (2010). Utilization and expenditures on chiropractic care in the United States from 1997 to 2006. Health Research and Education Trust, 45(3),748-761.
Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M. -

Dr. Mark Studin is just one voice, a chiropractor seeking to attain 95% of the entire population under chiropractic care in his lifetime. He can be reached at or 631-786-4253.

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