Patient-centered chiropractic care and emerging treatments call for your own evidence-informed inquiry when evidence-based research falls short
For these chiropractors, pre-authorization processes are then required by Medicare before patients can receive treatment. Doctors who are required to submit more thorough documentation before adjusting their patients must submit their recommended treatment plans for approval.
Every modern health care practitioner is surely familiar with David Sackett’s 1996 description of evidence-based medicine as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”1 The intent of evidence-based practice (EBP) was to marry the best and most current quantitative scientific research evidence with the clinical experience of the practitioner, earned through clinical practice with patients, to create optimal decision-making for the treatment of a problem.
Over the years, however, critics of EBP have argued that this approach turns clinicians into technicians who follow a recipe, with individual patient and practitioner values, as well as the circumstances of each patient, being lost in the mix.2 The majority of providers, left to their own devices, would probably not express this tendency. However, the adoption of evidence-based practice guidelines such as the American College of Occupational and Environmental Medicine or Official Disability Guidelines that dominate the third-party pay structure has certainly contributed to the idea that the research component of EBP is what really matters and the other factors are less important. One could make the argument that, over time, EBP became research-focused rather than patient-focused.
Any chiropractor who has been told they have six visits to make significant changes with a patient with low back pain or else their care is the wrong option, for example, understands the frustration that can come with EBP guidelines. It is easy to see how practitioners can have a negative outlook on the evidence when it is used to guide care (or the lack thereof) for patients who depend on third-party pay structures.
Also inherent to evidence-based practice is the type of research that is considered. Practice guidelines like the ACOEM or ODG mentioned previously, systematic reviews and meta-analyses get the highest ranking. However, as with any type of research these can have their own inherent biases and are not without problems, especially when being applied to a patient whose circumstances may not exactly match the research inquiry. In practice, EBP tends to put the highest value on these types of research, assessment and diagnosis, and factors like prevalence.2 Rarely, however, does a patient’s presentation exactly match the inquiries of EBP and the evidence, and so, how does a provider use all of the available research to better serve the patient at hand?
In more recent years the term “evidence-informed practice” (EIP) has found its way into the lexicon of health care providers. While it may seem like mincing words, there is a significant difference between what has become evidence-based practice and this newer approach. Proponents of EIP suggest that the goal of collecting evidence to help inform a provider on a particular case should go further than the singular goal of reducing bias and that a wider range of research information should be used. Estabrooks advocated that providers add “some of our own conventional wisdom and common sense” and give higher value to qualitative studies, case reports, scientific principles and expert opinions.3 Miles and Loughlin have promoted the use of evidence-informed practice to mean the process is person-centered rather than research and evidence-focused4 and this is, perhaps, the most important distinction between evidence-informed and evidence-based practice styles.
To better illustrate the differences in evidence-based and evidence-informed practices, let us consider two therapies gaining popularity among manual therapists and chiropractors: cupping and compression “flossing.” Cupping gained wide popularity in the United States during the 2016 Olympics when U.S. swimmer Michael Phelps was seen with the now-familiar cupping marks on his shoulder and back. The media exploded with curiosity about cupping therapy. Of course, the endless debates about “if it works” or not came with it.
Cupping and compression-band flossing
Cupping has been used for more than 3,000 years throughout Asia, Greece, Egypt and the Saharan region, Iran, and throughout the Muslim world. A medical textbook published in Europe in 1694 shows an illustration of a man having cupping performed on his buttocks. Yet, a 2014 systematic review of cupping concluded that, “because of the unreasonable design and poor research quality, the clinical evidence of cupping is very low,” and a 2011 review found that, “the effectiveness of cupping is currently not well-documented for most conditions.”
Compression-band flossing, aka “voodoo flossing,” has quite a fuzzy history; however, there is clear evidence of it being utilized in powerlifting gyms before gaining popularity in the CrossFit community through the book and videos of physical therapist Kelly Starrett. Today it is rare to not see it being practiced by laypeople in these settings.
A Pubmed search performed by this author found only two peer-reviewed articles on flossing. The first had to do with ankle range of motion, jumping and sprinting performance, and the second was a follow-up to that study. Compression flossing is widely used, yet there is essentially no evidence for or against it in the literature.
Strict adherents to EBP would likely pass over both cupping and flossing as options for patients with neuromusculoskeletal problems. Flossing has no apparent high-quality research for or against it at all, and the systematic reviews of cupping are not favorable. Comparatively, the evidence-informed approach would look at more types of evidence. Cupping has been used in a variety of cultures for thousands of years and flossing, while much newer, is commonly used in athletic circles. An evidence-informed practitioner would take this anecdotal evidence and use into account.
Furthermore, an EIP approach takes into higher account the principles underlying these therapies. Both therapies engage the skin and underlying tissues like fascia and muscle. Cupping creates decompression of tissues while flossing creates compression. Providers can manipulate the cups or floss once they are placed, creating shear patterns in the tissues; and it is known that certain receptors (Ruffini endings) in tissues respond favorably to shear and compression and can create local and global tissue tone changes.5
Cupping and flossing create increased sensory input into the areas they are applied to. Given that acute and chronic pain has been shown to “smudge” the sensory cortex’s representation of affected body parts6 and have a negative effect on tactile acuity,7,8 could adding stimulation to these areas via cups or floss have a beneficial effect for patients? Cupping and flossing both allow for the addition of active movement, creating different types of strain, shear and the potential for haptic feedback that allows patients to use cups as targets for movement patterns — or, when coupled with compression bands, to maintain body positions during movements in tasks that make them maintain a certain amount of tension in a band through a movement.5
There is no evidence, for or against, the use of cupping or compression flossing when coupled with meaningful movement; however, there is certainly biological plausibility and foundational science that supports the potential of these therapies. An evidence-informed approach would combine anecdotal evidence, the potential underlying mechanisms, risk and reward analysis, and would balance these against EBP guidelines that suggest that an intervention for low back pain, for example, should yield significant objective changes within a trial of six visits.
Such an approach does not throw the evidence that is available out the window, nor does it so rigidly adhere to a certain type of study that it stifles the potential for outcomes in an intervention with the patient. This type of approach is patient-focused and outcome-focused and has the best potential for putting the needs of the patient first before all else.
Steve Agocs, DC, is assistant dean of chiropractic education at Cleveland University-Kansas City as well as a course instructor on chiropractic history and technique. Agocs is a post-graduate educator sponsored by RockTape with an interest in movement, instrument assisted soft tissue manipulation, kinesiology taping, functional cupping, flossing and pain science. He can be contacted at
1 Sackett DL, et al. Evidence-based medicine: what it is and what it isn’t. BMJ. 1996;312:71-72.
2 Woodbury GM and Kuhnke JL. Evidence-based practice vs. evidence-informed practice: What’s the difference? Wound Care Canada. 2014;12(1):18-21.
3 Estabrooks CA. Will evidence-based nursing practice make practice perfect? Canadian Journal of Nursing Research. 1998;30(1):15-36.
4 Miles A and Loughlin M. Models in the balance: evidence-based medicine versus evidence-informed individualized care. Journal of Evaluation in Clinical Practice. 2011;17:531-536.
5 Capobianco S. FMT RockPods and FMT RockFloss. Seminar presented at the meeting of RockTape Instructors, Cancun, Mexico. January 2019.
6 Schabrun SM et al. Smudging of the motor cortex is related to the severity of low back pain. Spine. 2017 Aug 1;42(15):1172-1178.
7 Harvie DS. Tactile acuity is reduced in people with chronic neck pain. Musculoskelet Sci Pract. 2018 Feb;33:61-66.
8 Adamczyk W et al. Lumbar tactile acuity in patients with low back pain and healthy controls: systematic review and meta-analysis. Clin J Pain. 2018 Jan;34(1):82-94.