Evidence-based practice

Codes and guidelines

Evidence-based practice

The role of the Chiropractic Board of Australia (the Board) is to protect the public consistent with the Health Practitioner Regulation National Law, as in force in each state and territory (the National Law). It does this through its work in the National Registration and Accreditation Scheme (the National Scheme) in partnership with the Australian Health Practitioner Regulation Agency (Ahpra).

The core role of the Board and Ahpra is to protect the public. All chiropractors have a duty to make safe and effective patient care their primary concern.

Overview

Best practice approaches to providing chiropractic care are published in peer reviewed literature. This evidence should be used to guide clinical practice and ensure chiropractors provide safe care. The Board expects chiropractors to make sure their clinical practice is consistent with current evidence and/or best practice approaches.

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What is evidence-based practice?

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Evidence-based practice is an approach to care that integrates the best available research evidence with clinical expertise and patient values.¹

Integrating evidence to clinical based practice is necessary for all health professionals.

Evidence-based practice as it relates to a practitioner’s clinical decision making relies on the integration of three critical elements:

the current best available evidence
the clinical expertise of the practitioner
the patient’s values and expectations.

Clinical decision making is a complex process that involves gathering and interpreting data from a number of sources and collaborating with the patient in order to choose a course of treatment. Evidence-based practice involves the practitioner considering the available research, other sources of information including clinical experience and the patient’s values during their clinical decision-making process.

¹Sackett D et al. 2000 ‘Evidence-based medicine: How to practice and Teach’ EBM, 2nd edition. Churchill Livingstone, Edinburgh, p1.

Why should I use evidence-based practice?

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The Board’s Code of Conduct states that chiropractors should practise safely, effectively and in partnership with patients and colleagues using patient-centred approaches and be informed by the best available evidence to achieve the best possible patient outcomes. Chiropractors should recognise the vital role of ethical and evidence-based research to inform quality health care.

By incorporating the best research evidence into their clinical decision-making, chiropractors can ensure that patients receive the highest possible standard of care.

What is current best evidence?

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Current best evidence is up-to-date information from relevant, valid research about the effects of different forms of health care.

There is a wide range of evidence about chiropractic healthcare. This evidence includes randomised controlled trials, non-randomised controlled studies, descriptive studies, qualitative research and other evidence. Not all evidence is equally convincing. Some types of evidence are considered more reliable than others. There is a hierarchy of evidence that rates different types of evidence for reliability.

Hierarchy of evidence

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Evidence is rated from most reliable to least reliable. The National Health and Medical Research Council (NHMRC) in Australia uses a scale from Level I, being most reliable, to Level IV, being least reliable.

Table A - Hierarchy of evidence

Level I	Evidence is considered to be the best quality evidence. It includes the systematic review or meta-analysis of Level II studies. A systematic review aims to provide an exhaustive summary of current literature relevant to a particular research question.
Level II	Evidence takes the form of a randomised controlled trial (RCT). RCT’s are often used to test the effectiveness of health interventions. The subjects in an RCT are randomly allocated to one or more blinded treatment groups and the results of these groups are usually compared to a control group of subjects who received no or placebo treatment.
Level III-1	Evidence includes pseudorandomised controlled studies that assign subjects to a treatment method based on location, days of the week or other non-randomised methods and compare the outcomes from each group.
Level III-2	Evidence includes studies that compare outcomes for subjects who have undergone a particular treatment with subjects who have not. The study may be designed as a prospective or retrospective study.
Level III-3	Evidence includes studies that compare the outcomes from two or more studies or analyse trends in outcome that are measured over multiple time points. A comparative study without concurrent controls.
Level IV	Evidence consists of case series with either post-test or pre-test outcomes and includes case studies of single or small numbers of subjects.

Evidence based on clinical experience and/or case studies is not considered valid or reliable as it is based on a small sample size and is not blinded or randomised making it subject to practitioner and patient bias.

It’s important to note when the research was undertaken to ensure that evidence used for clinical decision making is current.

Does evidence-based practice mean that I can only use treatments with high level evidence?

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Evidence-based practice means that chiropractors should make decisions about the care of the individual patient by integrating their individual clinical expertise with the best available clinical evidence. Relevant evidence is not always available to help with decision-making about every condition.

However, clinical experience on its own is rarely sufficient to justify a clinical decision. A chiropractor is entitled to use their clinical experience to help in their decisions regarding patient care. In cases where there is only low-level evidence to support a particular treatment choice, they should inform the patient of this fact and that it is their clinical experience that the treatment may be effective for the presenting condition. Without this information and understanding of the benefits and risks involved, the patient is unable to make an adequately informed decision about their health care.

More importantly where there is evidence that a form of care is inappropriate or unsafe, a practitioners’ clinical experience or patient’s preference should not be used to override the evidence.

What does it mean in practice?

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The Board’s Code of conduct states that good practice includes ensuring services provided are appropriate, necessary, and likely to benefit the patient. It requires practitioners to understand and apply public health principles and use the best available evidence in making clinical decisions. A chiropractors role is to be an advisor who empowers informed patient decisions. Relying only on those studies that support your views and/or practice style does not constitute evidence-based practice. Good practice includes encouraging and supporting patients to be well-informed about their health, and to use this information wisely when they are making decisions.

Chiropractors should recognise that their clinical experience cannot be used to justify treatment that is contradictory to other treatment modalities that have good evidence for their efficacy.

Additional resources

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