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Evidence Based Practice: A Responsibility for both Clinicians and Researchers

11 May 2016
Randall Cooper
Many people around the world recently viewed the footage of a Melbourne based chiropractor adjusting the spine of a 4 day old baby for colic. Debate has raged since, primarily about whether infants should be adjusted. Is it safe? Is it effective? Is it necessary?

Some people argue that such techniques lack scientific evidence in the form of high quality studies. Fair enough. Evidence based practice is, and needs to be the cornerstone of healthcare. However the chiropractor involved was interviewed on television, and although not very convincing or articulate, argued that he had been successfully doing these techniques for 20 years with no issues, and that the baby involved made a significant improvement after his treatment.

I don't want to comment specifically on this case, however it did get me thinking about who is responsible for evidence based practice and the progression of the healthcare – clinicians or researchers? Should clinicians be telling researchers what to study, or should researchers be telling clinicians how to practice?

In my own practice, it’s a dilemma I frequently encounter. As a sports physiotherapist with experience and higher qualification, I’m often referred patients/athletes that aren’t responding to routine treatment. Many of my referring practitioners are very competent, and when I go through the patient’s history it’s clear that they’ve exhausted all evidence based treatments and routine care. So what do I do? Do I say “I’m sorry, I can’t help you as you’ve already tried everything that we know works”? Of course I don’t.

When you have a desperate patient, who has been on the medical roundabout for a considerable amount of time, you have to do something - something different. You need to use a combination of detailed assessment, clinical reasoning, experience, evidence, but also a degree of pushing the boundary with something new. It’s at these moments, that you truly get to experience where things can change for the better. Improvement in one patient isn’t enough, but if you have 9/10 it’s noteworthy and a clinician should take it further. I took that daunting plunge earlier in my career.

At the time I was working with the Australian Aerial Ski Team, and we had a disastrous run of knee injuries with seven out of eight athletes rupturing their ACL in a 2-year window. We followed routine/best practice with surgery and rehabilitation, but when a number of them sustained graft ruptures, we needed to do something different.

I devised a return to sport testing protocol in conjunction with Orthopaedic Surgeon Hayden Morris (then revised and updated in with Physiotherapist Mick Hughes). The protocol was run at the end of their rehabilitation, and it worked on our small sample size. We noticed errors at the end of rehab that we normally would have overlooked, corrected them, and sent the athletes back into sport in better shape. We significantly reduced the number ACL injuries and re-injuries in this group.

Importantly, we took it a level further by collecting and analyzing the data on more patients, and presented results at a few orthopaedic and physiotherapy conferences. It was intimidating to put your work up infront of peers, however I expected and accepted constructive feedback. The protocol has since been used and adapted in clinical practice and research circles. I’m glad that I not only tried something different, but also presented the information to the clinical and academic community. I’d encourage others to do the same.

On the other side of the equation I did a Masters degree by research nearly 15 years ago. By doing a systematic review into rehabilitation following ACL reconstruction it was easy to identify holes in evidence, and I conducted a few studies that plugged small knowledge gaps. I’m glad I did that too, and knew that this work also made a contribution to clinical practice.

Researchers and clinicians have different, but equally important roles to play in the progression of healthcare. Clinicians are at the coalface and need to try different approaches at different times. It’s when these different approaches seem to work, it’s important for clinicians to put their ideas up for testing and scrutiny. It takes courage to do this, but it must be done. Researchers can look at things from a different angle, analyzing the literature and looking to test clinically relevant gaps in the evidence.

Getting back to the issue regarding the chiropractic adjustment of the newborn baby it’s unfortunately a failing on both fronts. Clinical chiropractors who teach and/or perform these techniques would have benefited from having their ideas put up for peer review. Researchers of chiropractic science should have been aware of this controversial clinical practice and it’s lack of evidence, and set out to answer the question with good research. At the moment, nobody can answer whether these techniques are safe or effective.

It’s a situation all health professionals can learn from.

 

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You can also check out my ACL Masterclass with Mick Hughes at Learn.Physio, or download your copy of the Melbourne ACL Rehabilitation Guide 2.0 here.




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