Who Determines How You Practice Chiropractic?
PRACTICE
MANAGEMENT
Charles L. Blum
If you are like me, you graduated from chiropractic college, passed your licensing examinations, learned different chiropractic techniques to use in practice, and incorporated what you learned in the best way you saw possible to help your patients. As you have practiced, you have learned different assessment and treatment methods that may work better for your patients than what you have utilized previously, and incorporated them into your therapeutic regimen. I foresaw that I could practice this way within the scope of my practice as long as I was helping my patients. However, I have found that things are different from what I had presumed. Practicing chiropractors need to understand how curriculums are developed for our colleges as well as practice guidelines determined by states for scope of practice, insurance agencies for payments, and judicial arenas to determine malpractice.
I recently had the opportunity to participate in a workshop titled, “Toward the Development of a Standardized Chiropractic Technique Program,” at this year’s Association of Chiropractic Colleges’ Research Agenda Joint Conference (ACCRAC) held on March 18-19, 2016 in Orlando, Florida. Part of the process of building a standardized program involves understanding evidence-based practice. Sacket described an “evidence-based practice (EBP) as the conscientious use of current best evidence in making decisions about patient care1.” One aspect of determining best evidence is studying whether chiropractic’s diagnostic and treatment modalities have validity (will what we claim we are finding be supported by the research) and/or reliability (two or more practitioners will have the same finding).
Guiding this workshop was an exhaustive study performed by Triano et al. “designed to evaluate the literature on the validity and reliability of the more common methods used by doctors of chiropractic to inform the choice of the site at which to apply spinal manipulation.2” The study concluded, “A considerable range of methods is in use for determining where in the spine to administer spinal manipulation. The currently published evidence falls across a spectrum ranging from strongly favourable to strongly unfavourable in regard to using these methods. In general, the stronger and more favourable evidence is for those procedures, which take a direct measure of the presumptive site of care-methods involving pain provocation upon palpation or localized tissue examination.2”
Researchers in this study worked diligently to assess all of the data available and a “total of 2,594 titles were screened,
from which 201 articles met all inclusion criteria.2” Interestingly some researchers are questioning the role of EBP, particularly if it does not incorporate the clinician3. If clinical practitioners are not publishing in the scientific literature, how can these doctors in active practice have an adequate voice in guiding the future of chiropractic education and practice?
There is irony in having the future of chiropractic practice determined by researchers and their published literature because all research has some degree of bias. Research will only be performed if there is an entity to pay for that research or if the researcher has an interest in a particular type of study. This means that what is taking place in a doctor’s office may likely not be considered in future practice guidelines or the development of evidence-based practice. If published research will be directing what we teach in the colleges and is used to develop practice guidelines, how can we integrate the wisdom of both the chiropractic researchers and clinic-based factions?
How is it determined what chiropractic clinical diagnostic and treatment methods are taught in our colleges?
Who is developing guidelines for chiropractic care and ultimately the future of chiropractic?
Isaac and Franceschi lament that the gold standard of the EBP “movement, the randomized controlled trial, meets failure in the clinical realm in terms of the value of one patient’s life.3” In certain cases, even the need for validity/reliability
arguments that plague qualitative researchers of the generalizability of an “N of 1” become mute.3 The concept of dualism may be helpful in that it suggests that in order to understand and quantify something we can best do this by separating and comparing. It can be helpful with research when studying “things,” however, this may be limiting when studying phenomena such as a healthcare application and a patient’s response.
It may be important for EBP to incorporate a nondualistic approach for integrating research and clinical experience when developing chiropracticbased EBP4. “Evidence to practice and practice to evidence redefines” EBP “as a circular integration of best research evidence, clinical expertise, and patient values.3 As Merriam claimed, ‘quite a bit can be learned from an N of 1. The impossibility of evidence becomes a matter of practitioner trustworthiness. In this case, a patient’s reality becomes the priority, and where application of statistically based generalizations becomes moot. Yet if clinicians are not performing or guiding research or submitting papers to the peer reviewed literature based on their clinical experience, how can they have a voice in this ‘circular integration’?”
Is it reasonable to presume that researchers have the extensive clinical experience of those working in the chiropractic therapeutic trenches?
Is it reasonable to presume that chiropractors in clinical practice understand evidence-based practice guidelines and use the research literature to improve the care they render?
There have been a few workshops at previous year’s ACC-RAC conferences that attempted to address the relationship between our chiropractic technique systems and the research community. The exchanges during these workshops are usually quite animated and dynamic. One year, I proposed that a good way to study the efficacy or utility of the different chiropractic techniques would be to in-
clude a “hands-on” portion along with discussion and review of the literature. It was fascinating how this suggestion was soundly rejected. Emphasis was solely given to the need of reviewing the published research and chiropractic techniques from that perspective, only.
From my experience, I find that no reading or talking can substitute for what I find through the sense of touch. I wonder if one aspect of the difference between researchers and clinicians may be their preferred learning method. The VARK (visual, auditory, read/ write, kinesthetic) questionnaire is an assessment tool that has been used to study first-year chiropractic students.5
Similar to a study of first-year medical students6, most students in the chiropractic study preferred a multimodal approach to learning, meaning they preferred a mixture of visual, auditory, read/write, and kinesthetic learning. Yet while the majority preferred multimodal learning, approximately a third of those studied had a particular preference for just visual, auditory, or kinesthetic learning.7 8
Is it possible that learning preferences influence a chiropractor’s choice to become a clinician, an academician, or a researcher?
And does this learning preference influence the type of research that is performed by the chiropractic research community?
At the 2016 ACC-RAC workshop “Building Chiropractic Research Capacity: 2016 Research Agenda Update,” there was a section discussing clinical related research. The predominant theme from those present in this section was that colleges need to create a culture of research, which supports teaching and integrating research concepts into the curriculum. In addition, support should be given to research projects (including those by instructors and students) and the creation of PhD research tracts for chiropractic students and instructors wanting to move in that direction. While I feel all of these suggestions are very important
for the future of chiropractic research, my concern is where does the doctor in clinical practice9 fit within this solution?
One answer may be to develop a mentorship between research faculty and doctors in clinical practice10 that have a desire to share their findings in the research arena but are not skilled or are intimidated to do so. Another possible option could be the development of a free online research certification course that could instruct a doctor in clinical practice in the understanding, performing, and publishing of their research. For example, the National Institute of Health Office of Extramural Research has a free certification service to guide doctors wanting to learn about “Protecting Human Research Participants11.” This could represent a beginning step toward something created by an international chiropractic college academic and research consortium.
Next year’s ACC-RAC conference (March 15-18, 2017) is expected to be a monumental joint conference bringing together the ACC-RAC and the World Federation of Chiropractic’s 14th Biennial Congress and National Chiropractic Leadership Conference (NCLC), hosted by the American Chiropractic Association. This will be an important place for
all researchers and clinicians to meet and collaborate.
Sacro Occipital Technique Organization (SOTO) - USA is a technique-based research and teaching organization that includes an SOT Research Conference as a part of its
annual clinical symposium. This year, May 13-14, 2016, will mark its eighth annual research event. In this arena, doctors in clinical practice have a venue to share their research in a welcoming environment, which follows the guidelines of the ACC-RAC platform presentations. The SOT Research Conference is one avenue for doctors in clinical practice to engage in the research arena and help build a future for the chiropractic profession that integrates both research and clinical practice in a nondualistic manner.
^From my experience, I find that no reading or talking can substitute for what I find through the sense of touch 5 J
Who determines how you will practice chiropractic? By default, the researchers will determine the guidelines of how to practice and what future students learn, and thus the future of chiropractic.13 However, it is hoped that doctors in clinical practice can also help direct the future of chiropractic. This can be a reality if programs can be developed to help them step up and become more involved in the chiropractic research process. Also, the college-based research programs should be
encouraged to involve and incorporate field doctors’ thoughts and experiences in the development and direction of future chiropractic research.
References:
1. Sackett D, Strauss S, Richardson W, et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh: Churchill Livingstone; 2000.
2. Triano JJ, Budgell B, Bagnulo A, Roffey B, Bergmann T, Cooperstein R, Gleberzon B, Good C, Perron J, Tepe R. Review of methods used by chiropractors to determine the site for applying manipulation. Chiropr Man Therap. 2013 Oct 21;21(1):36.
3. Isaac C A, Franceschi A. EBM: Evidence to practice and practice to evidence. Journal of Evaluation in Clinical Practice. 2008; 14(5): 656-659.
4. Merriam S. What can you tell from an N of 1?: issues of validity and reliability in qualitative research. PAACE Journal of Lifelong Learning. 1995;4:51-60.
5. Williams JL. The behavioral and the mystical: reflections on behaviorism and eastern thought. The Behavior Analyst. 1986;9(2):167-173.
6. Burnham K. Learning preferences of 1 st-year chiropractic students. The Journal of Chiropractic Education. 2014;28(1):5582.
7. Kharb PI, Samanta PP, Jindal M, Singh V. The learning styles and the preferred teaching-learning strategies of first year medical students. J Clin Diagn Res. 2013 Jun;7(6): 1089-92.
8. Liew SC, Sidhu J, Barua A. The relationship between learning preferences (styles and approaches) and learning outcomes among pre-clinical undergraduate medical students. BMC Med Educ. 2015 Mar 11; 15:44.
9. Lisle AM. Assessing learning styles of adults with intellectual difficulties. J Intellect Disabil. 2007 Mar;ll(l):23-45.
10. Walker BF, Stomski NJ, Hebert JJ, French SD. A survey of Australian chiropractors’ attitudes and beliefs about evidence-based practice and their use of research literature and clinical practice guidelines. Chiropr Man Therap. 2013 Dec 17;21(1):44.
11. DeCastro R, Sambuco D, Übel PA, Stewart A, Jagsi R. Mentor networks in academic medicine: moving beyond a dyadic conception of mentoring for junior faculty researchers. Acad Med. 2013 Apr;88(4):488-96.
12. NIH Office of Extramural Research. Protecting Human Research Participants, https://phrp.nihtraining.com/ [Last Accessed 3-23-16],
13. Bussières AE, Al Zoubi F, Stüber K, French SD, Boruff J, Corrigan J, Thomas A. Evidence-based practice, research utilization, and knowledge translation in chiropractic: a scoping review. BMC Complement Altern Med. 2016 Jul 13 ; 16( 1):216.
Charles L. Blum, DC is in private practice Santa Monica, California, director of research for Sacro Occipital Technique Organization - USA, adjunct research faculty at Cleveland Chiropractic College and teaches the Sacro Occipital Technique (SOT) elective class at Palmer College of Chiropractic - West and Southern California University of Health Sciences. Contact Dr. Blum at 310-392-9795 /www.drcharlesblum.com
