By Austin Bergquist, PhD
It is a wonderful time to be a chiropractor in Canada. The profession has witnessed a gradual increase in utilization since the 1980s, women and diverse populations represent a greater proportion of the profession than ever before, and research activity designed to understand how chiropractic works and how to make it better has never been more productive.
However, low trust from the public and allied medical professions remains a major barrier to widespread chiropractic consumption. To address this issue, among other concerns, the Canadian Chiropractic Association now strongly encourages chiropractors to adopt an evidence-based practice model in their patient care.
From its inception in the early 1990s, the phrase “evidence-based practice” has meant that clinical decision-making should be guided ultimately by a balance between the implicit knowledge that accumulates through clinical experience, the personalized preferences of the patient, and knowledge gleaned from outcomes of high-quality scientific research studies. However, in Canada, the balance has shifted in recent years. A disproportionate emphasis has been placed on the importance of high-quality scientific research evidence.
Specifically, if a clinical decision lacks demonstrated value in the form of a randomized controlled trial, the gold standard in scientific research design, then that clinical decision is considered unsupported and falls outside the boundaries of evidence-based practice, regardless of the “lesser quality by design” literature base that may exist, as well as the personalized clinical reasoning or patient preferences that may have informed the decision.
The move toward such a research-focused practice is done with the best of intentions. The scientific research process is viewed as our most reliable method of generating knowledge unencumbered by confounding variables, such as the many forms of bias that can systematically hijack the truth. However, the problem with relying so heavily on research evidence when guiding clinical decision-making is that most research evidence lacks the ultimate objectivity it is designed to provide and carries a number of limitations often overlooked by its advocates.
Let us consider a limitation generalizable to all research. An important step in the scientific research process involves the confirmation or “replication” of research findings by others within the scientific community. Until the research finding is replicated, it is unclear whether the finding represents the truth, or whether it is a result of something unique to the scientists who conducted the experiments. Unfortunately, replication is rarely undertaken because it is not incentivized within the current research climate. Funding agencies, journals that publish research, and university or college faculties that determine which scientists are hired and which receive tenure, are only interested in who made the initial research “discovery,” not in who reproduced it.
However, when replication studies are undertaken, more often than any scientist would like to admit, published research findings are unsupported or even refuted by subsequent research evidence. The pressure to find something in academia is immense, and whether done intentionally or unintentionally, research outcomes are often subjected to the needs and desires of the scientists conducting the experiments. This widespread phenomenon, known as the replication crisis, describes how only a fraction of published literature can be reproduced, calling into question the utility of research findings in clinical practice. When replication studies become incentivized and integrated more deeply into research culture, scientists will be held more accountable for their findings, and subsequently, the reliability of their findings will carry more utility in clinical decision-making.
Research funding in Canada
Let us now consider a more nuanced limitation specific to chiropractic research in Canada, a portion of provincial licensing fees collected from every chiropractor is directed to the Canadian Chiropractic Association’s research foundation, the Canadian Chiropractic Research Foundation. The mission statement of the Foundation is to “fund research to improve the lives of people living with musculoskeletal pain and disability.” Accordingly, much of the high-quality chiropractic research coming out of Canada has taken a musculoskeletal pain-based approach. It is thanks to this work that chiropractors in Canada are becoming known to the public as back pain, neck pain and headache “experts.”
Arguably, the effects of chiropractic are broader in scope than the musculoskeletal pain-based mission of the Canadian Chiropractic Research Foundation. Patients regularly report relief of non-musculoskeletal pain, and even seek preventive chiropractic care to stay healthy. However, the burden of proof falls on the vitalistic chiropractor to generate research evidence. Unfortunately, research proposals investigating such vitalistic-based health outcomes are unlikely to be funded by the Canadian Chiropractic Research Foundation, a funding body that receives funding from both mechanistic and vitalistic chiropractors.
A Catch-22 for Vitalism
The vitalistic chiropractor is caught in a Catch-22. Their association pushes for them to align with evidence-based practice that relies heavily on research evidence but tends not to fund research that represents their full experience in practice. The kicker is that the vitalistic chiropractor has no say how their licensing money is used and is beholden to support the mechanistic agenda of the Canadian Chiropractic Research Foundation; the epitome of circular logic.
The problem is compounded further by the association acknowledging only research evidence generated by randomized controlled trials in the development of their clinical practice guidelines. Since there has been little research funding directed toward vitalistic-based health outcomes, there are very few randomized controlled trials investigating these outcomes. Importantly, we should remain aware that a properly conducted and objective research study of “lesser quality by design” is far more valuable than a compromised “gold standard.” At present, there is considerable opportunity to improve upon research in this area and to expand the chiropractic evidence-based scope of practice. We must remain cognizant that research funds are limited and that we owe it to our patients to be responsible shepherds of the funds available.
Informing the ‘gold standard’
Evidence-based practice has not solved what it has intended, in large part due to the disproportionate emphasis that has been placed on the importance of only “gold standard” research evidence. Rather than do away with evidence-based practice, I support the growing movement to re-adjust the balance placed on the original tenants of evidence-based practice.
In its ideal form, evidence-based practice is an iterative process, whereby clinical experience and patient preferences inform research inquiry while research outcomes inform clinical reasoning, and so on. If done compassionately with our patient’s best interests at heart, research evidence can be a valuable addition to clinical decision-making.
About Austin Bergquist
Austin Bergquist, PhD, earned his doctorate degree in Neuroscience at the University of Alberta (funded by Alberta Paraplegic Foundation). He has completed a post-doctoral fellowship at the Toronto Rehabilitation Institute (funded by the Canadian Institutes of Health Research). He has researched novel methods of generating fatigue-resistant muscle contractions through spinal reflex pathways in people who experience paralysis due to spinal cord injury, and he is currently studying at Life Chiropractic College West to become a fourth-generation chiropractor.