“Evidence-based” means you are following what science has reported. Evidence-based practice is widely recognized as the key to improving healthcare quality and patient outcomes. Although the purposes of research (conducting research to generate new knowledge) and evidence-based practice (utilizing best evidence) seem quite different, an increasing number of research studies have been conducted with the goal of translating evidence effectively into practice.
Clearly, evidence from research (effective innovation) must be accompanied by effective implementation and an enabling context to achieve significant outcomes.1 This is derived from using the following three components:
- Best available evidence in the literature
- Clinician’s knowledge
- Patient feedback
When I was in chiropractic college in the 1970s, there was little to no credible scientific published research on what a subluxation was, or how the chiropractic spinal adjustment worked from a mechanistic perspective. However, after interviewing hundreds of chiropractic patients and hearing their stories, I chose to help people get well without drugs and entered our profession with one goal in mind: to first help people and then validate what we do with results in the scientific community, as I felt it was the only pathway to significantly increase utilization.
DD and BJ Palmer’s “vitalistic approach to disease” was the bone-on-nerve root theory, and based on the technology of the times, it was a brilliant hypothesis that proved “almost correct.” There is bone on the nerve; however, it is at the facet level due to a meniscoid displacement.3 Where the facets buckle, then approximate affecting the nociceptors on the facet surface.4 It is this level of evidence, understanding and ability to communicate that fosters relationships between medical doctors and doctors of chiropractic. Most MD specialists and many primary care providers know there can be no bone on the nerve at the root level, and when having a collegial conversation, a philosophical answer will destroy the reputation of the individual doctor. This false information perpetuates the further degradation of our profession’s reputation from the referral community, placing us somewhere below a physical therapist but slightly above a massage therapist. And chiropractic as a profession comes into question. The comment I get from MD specialists on this misinformation is, “How can a doctor in today’s healthcare community be so misinformed about what you do every day?” It is a statement I agree with.
Being an evidence-based provider means staying current with the “science,” no matter the industry. Being considered an expert means being well-read and current.
The evidence discusses a biomechanical pathology, which is also colloquially considered a vertebral subluxation, creates maladaptive changes in the central nervous system, which affects the thalamus, primary and secondary somatosensory regions, cingulate, insular cortices and the limbic system.5,6 The thalamus controls sensory and motor relaying signals as well as the regulation of consciousness and alertness. The somatosensory region interprets sensations, including touch, pressure, vibration, temperature, itch, tickle and pain. The insular region controls sensorimotor processing, risk-reward behavior, autonomics, pain pathways and auditory and vestibular function. The limbic system is the part of the brain involved in our behavioral and emotional responses, especially when it comes to behaviors we need for survival: feeding, reproduction, caring for our young and fight-or-flight responses.
These are the neural mechanisms explaining why a biomechanical lesion can create adverse health issues. The evidence also discusses when delivering a chiropractic spinal adjustment, you can affect each one of the aforementioned regions by creating homeostasis in the central nervous system by causing central segmental motor control through a chiropractic spinal adjustment.6 Please note the absence of using the term “manipulation.” Spinal manipulation does not change central segmental motor control, which separates chiropractic from physical therapy, massage therapy, exercise physiology and all other types of physical medicine modalities.6
The above evidence in the literature must be the basis for communication with referral sources in the healthcare community. We no longer need to talk about philosophy, as we have evolved in the scientific arena, giving evidence to why chiropractic works.
Technology has also given demonstrative evidence of where the primary biomechanical lesions of the spine are located. This quells the mantra of today’s medicine in their “non-specific back pain” claims. Even with advanced technology, every DC graduating from a CCE-accredited college knows how to analyze a pelvis that has gone 2X PIEX or an axis that has gone spinous right. That is spinal biomechanics and easy to determine. The advanced technology allows us, in graphic format, based on X-ray, which has been proven reliable in intra- and inter-operator reproducibility, 100% safe in chiropractic offices, to make a diagnosis more accurate and demonstrable.
Recently, in meetings with a neurosurgeon and medical primary care provider, they acknowledged skepticism about referring to chiropractic based on their belief, backed by the evidence in the literature of non-specific back pain. Sharing a few recent scientific articles and showing them the graphics derived from digitizing technology centered on segmental pathology (not alteration of motion segment integrity), they both immediately changed their referral pattern from drugs and physical therapy to chiropractic. Based on the feedback from their patients and the evidence in the literature, the surgeon now sends all mildly acute patients for chiropractic clearance and images before he sees them. The primary care provider refers, on average, 20-25 back-related patients weekly. Previously, he would normally treat with analgesics as a first-line treatment followed by either an orthopedic surgeon or physical therapy. Now, he sends all of them to chiropractic first for case management because he wants a drugless option with superior outcomes.
The above scenarios are based on the evidence in the literature as a starting point to change referral habits and have been “played out” successfully on the national platform. The paradigm shift from the perspective of the referrers (MDs predominantly) is not pandering to the medical community; it is learning how to communicate while speaking a language they can understand: biomechanical pathology. Then, the evidence in the literature, which is based on the scientific principles of publication, will be used to validate the results that have been realized in the chiropractic profession for 128 years. No longer do we, as a profession, lean on theory, philosophy, beliefs or rhetoric. The evidence is all there to learn, implement and share.
The above examples of the evidence in the literature are a small sampling. Connective tissue, such as joint capsules and deep paraspinal muscles, also must be considered, learned and taught. There’s significant involvement with the dorsal and ventral roots, spinal thalamic tracts and other afferent and efferent impulses that come into play when understanding why a chiropractic spinal adjustment works. A deeper understanding of the evidence makes you a better doctor and part of the healthcare system that treats 99% of the population, while the chiropractic profession is mired in a cycle that consistently brings us back to 7% utilization.
Final thoughts
Many can “dig their heels in” and say, I am not pandering to the MDs or interested in learning more because I am complacent and content. For those, you possibly will forever sit in your offices while the masses are subjected to needless drugs and surgery. Also, the current trend in chiropractic is for those recently out of school and many others who are now embracing how chiropractic is evolving in the scientific community and putting it into action. It is those who embrace the evidence who stand the best chance of success with the greatest opportunity for growth based on using the evidence in the literature by teaching others in the healthcare community and being part of it vs. fighting it. All are welcome.
MARK STUDIN, DC, FPSC, FASBE(C), DAAPM, is an adjunct assistant professor at the University of Bridgeport, School of Chiropractic and an adjunct post-doctoral professor at Cleveland University-Kansas City, College of Chiropractic. He is a clinical instructor at The State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Office of Continuing Medical Education. He also earned his Fellowship in Primary Spine Care certified in joint providership from The State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Office of Continuing Medical Education, and Cleveland University Kansas City, College of Chiropractic. He also runs the Academy of Chiropractic’s Personal Injury Program. He can be reached at 631-786-4253 or DrMark@AcademyOfChiropractic.com.
References
- Chien LY. Evidence-based practice and nursing research. J Nurs Res. 2019;27(4):e29. PubMed. https://pubmed.ncbi.nlm.nih.gov/31313747/. Accessed Jan. 9, 2024.
- Sackett D L et al. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71-72. PubMed. https://pubmed.ncbi.nlm.nih.gov/8555924/. Accessed Jan. 9, 2024.
- Farrell SF, et al. Cervical spine meniscoids: an update on their morphological characteristics and potential clinical significance. Eur Spine J. 2017;26(4):939-947. PubMed. https://pubmed.ncbi.nlm.nih.gov/27995341/. Accessed Jan. 9, 2024.
- Evans DW. Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: previous theories. J Manipulative Physiol Ther. 2022;25(4):251-262. PubMed. https://pubmed.ncbi.nlm.nih.gov/12021744/. Accessed Jan. 9, 2024.
- Gay CW, et al. Immediate changes after manual therapy in resting-state functional connectivity as measured by functional magnetic resonance imaging in participants with induced low back pain. J Manipulative Physiol Ther. 2014;37(9):614-627. PubMed. https://pubmed.ncbi.nlm.nih.gov/25284739/. Accessed Jan. 9, 2024.
- Haavik H, et al. The contemporary model of vertebral column joint dysfunction and impact of high-velocity, low-amplitude controlled vertebral thrusts on neuromuscular function. Eur J Appl Physiol. 2021;121(10):2675-2720. PubMed. https://pubmed.ncbi.nlm.nih.gov/34164712/. Accessed Jan. 9, 2024.
