Evidence-based practice, research utilization, and knowledge translation in chiropractic: a scoping review

The research question that guided this scoping review was: What is known about EBP, RU, and KT in chiropractic practice? [22].

A health sciences librarian (JB) conducted searches in EMBASE, CINAHL, MEDLINE, Index to Chiropractic Literature (ICL), PubMed publisher content, AMED and the Cochrane Library from the earliest date available in each database to May 28^th 2015 using a combination of keywords and MeSH terms. The search strategy was developed for MEDLINE and a modification of this strategy was used to search the other databases [see Additional files 1. MEDLINE search strategy used to identify research articles]. The search strategy was peer reviewed by another health sciences librarian using the Peer Review of Electronic Search Strategies checklist [24]. We further refined the search strategy iteratively with input from investigators and collaborators, and in consultation with an experienced librarian. The reference lists of all included articles were reviewed to ensure that no relevant articles were missed. The grey literature (organization websites, theses/dissertations, conference proceedings) was also searched by hand, electronically, and by contacting specific authors. The team librarian executed all final searches, exported the results into EndNote and removed all duplicates from the search results.

A pre-defined data charting form recorded the following information for each study: author, year of publication, country, study design, purpose of the study/research question, clinical setting, population characteristics (e.g., years in practice, type of practice), methodology, whether the study dealt with EBP and/or RU and/or KT, intervention, outcome measures, results, implications for practice, limitations, and directions for future research. The charting form was tested independently by two RAs on a random sample of 10 articles and revised iteratively by the study team while the search was completed. Differences in data charting were resolved by discussion or with the involvement of a third reviewer (AB). The three reviewers met to determine whether their approach to data extraction was consistent with the research question and purpose. No formal quality assessment of included studies was performed as the aim of this scoping review was to identify the breadth of the literature and the major areas of research activity with corresponding resulting themes [See Additional files 2. Data Abstraction Table].

We synthesized the data according to three distinct steps: (1) Analysing the data (descriptive numerical and qualitative thematic analyses), (2) reporting the findings, and (3) discussing results implication [22].

The search conducted up until May 28^th 2015 yielded 4443 citations, including 5 articles from hand searches of key articles and 3 articles from conference abstracts. A total of 4011 articles remained after removing duplicates. Initial screening of titles and abstracts resulted in the rejection of 3878 articles that did not meet the inclusion criteria. Articles on theoretical models (n = 87), tool development (n = 76) and undergraduate education (n = 66) were excluded at this stage. The remaining 133 full-text articles were assessed for eligibility by the first author and a group of four review authors who underwent an inter-rater reliability process to ensure agreement. The level of agreement between the authors was 75 %. Sixty-two full-text articles were excluded at this stage. A PRISMA flow chart was used to track the number of studies at each stage of the review (Fig. 1).

Sixty-seven studies reported in 69 articles were included in the review. Sixty-five studies (94 %) were published between 2001 and May 2015. The number of studies increased steadily each year with the exception of 2009 and 2012 (Fig. 2). Over a third (n = 24) of articles were published in the years 2013 and 2014 alone. Canada produced the most studies (n = 20), followed by the US (n = 15), Australia (n = 11) and the UK (n = 10) (Fig. 3). Most of the studies used self-administered survey questionnaires (n = 39) or interviews (n = 9), descriptive analysis or mixed methods (n = 9). The remaining ten studies used quantitative methods, including longitudinal studies (n = 7), randomized controlled trials (RCTs) (n = 2), and one audit of clinical practice (Fig. 4). Based on area of clinical practice, the studies focused on: general chiropractic practice (n = 17), research beliefs and skills (n = 18), low back pain (n = 12), neck pain (n = 8), spinal imaging (n = 7), nutrition (n = 2) and immunization (n = 1) (Fig. 5). Authors affiliation with chiropractic educational institutions were as follows (represented by at least one author): CMCC (n = 9 articles), Palmer (n = 7), Anglo-European (n = 5), Murdoch (n = 5), UQTR (n = 4), other institutions (n = 1) including: NYCC, Welsh Institute of Chiropractic College, IFEC (Paris), University of Southern Denmark, Logan, Parker, University of Western States, Northwestern, Cleveland, RMIT, Swiss Institute, National). Of interest, the top three journals where included articles were published were Chiropractic and Manual Therapy (CMT, n = 11), closely followed by the Journal of Manipulative Physiological Therapeutics (JMPT, n = 10), and the Journal of the Canadian Chiropractic Association (JCCA, n = 7) (Fig. 6).

Included studies were classified into three major categories, namely evidence-based practice (EBP), research utilization (RU), and knowledge translation (KT). Each category was further sub-classified into major themes as follows: two themes under EBP (attitudes and beliefs of chiropractors and implementation of EBP), two under RU (guideline adherence; frequency and sources of information accessed) and three under KT (knowledge practice gaps; barriers and facilitators to knowledge use; and selection, tailoring, and implementation of KT interventions) (Fig. 7).

Twenty of the 67 studies (30 %) were related to EBP and reflected two major themes: I) Attitudes and beliefs towards EBP (n = 17 articles) and II) Implementation of EBP (n = 3).

The notion of two basic groups in chiropractic: “orthodox” and “unorthodox” through the early half of the 20th century has changed. A minority of clinicians (approximately 18 %) continue to hold a more traditional perspective [18, 92, 93]. Traditional views of chiropractic appear to negatively influence practice behaviour (e.g., anti-vaccination, non-guidelines-based x-ray use, and low adherence to patient education, work and activity recommendations) [18, 32‐34] and adherence to professional associations [27]. In other words, 1 in 5 chiropractors may be delivering care that is not evidenced-based, potentially putting patients at risk of harm from communicable diseases and unnecessary radiation exposure and/or giving advice that delays patient recovery. While it is estimated that fewer than 5 % of initial patient consultations to chiropractors are for non-musculoskeletal disorders [94‐96], there is currently minimal evidence to support chiropractic treatment for these conditions [97, 98]. Despite this, a recent review of websites of major chiropractic associations, colleges (n = 11) and commercial clinics (n = 80) across Canada suggests that over 30 % of included practices presented chiropractic as both an evidence-based profession in line with science and an alternative option for treating and addressing health concerns such as allergies, attention deficit disorder, bedwetting and premenstrual syndrome [99]. Such discourse and dissonance, and the high degree of variability in scope of practice across US states [100] and in other countries [101] are sources of confusion among members of the public, other health disciplines and policy makers [102].

Leaders in the profession and clinicians alike need to be aware of a moderate to strong association between HCPs’ attitudes and beliefs and their influence on the attitudes and beliefs, clinical management, and outcomes of patients with low back pain [34]. This is important in light of efforts in Canada and elsewhere to support health system reform that encourages prevention, inter-professional collaboration, evidence-based practice, patient-choice, and protection of the public interest [http://​www.​chiropractic.​ca/​about-cca/​position-statements/​]. Multilevel strategies involving professional chiropractic leaders, teaching institutions, researchers and other stakeholders are needed to help transform the culture of chiropractic toward one that is guided by EBP principles [103].

Studies included in the current review found that chiropractors generally held positive attitudes towards EBP, and were interested in improving their EBP skills [36‐40]. However, the use of evidence-based information sources is suboptimal [32, 39, 55, 56]. Recent studies in Canada [104] and in the US [81] support these findings. Positive relationships have been noted between research utilization and nurses’ beliefs and attitudes toward research and the different kinds of research utilization [9]. Further research is needed to establish if similar determinants apply in chiropractic.

While guideline compliance for managing acute whiplash [50] and low back pain [51] was deemed acceptable, the application of EBP and adherence to imaging guidelines [40, 45, 83] and best practice [55, 56] appears suboptimal. Identified barriers and facilitators to using EBP and guidelines in chiropractic are similar to those reported in reviews of physicians and allied care providers [5, 105, 106]. Lack of time, perceived lack of clinical evidence, lack of incentives, motivation and agreement with CPGs, having graduated over 10 years ago, insufficient skills or confidence in locating, interpreting, critically appraising, and applying research findings to clinical practice are believed to be important barriers [36, 40, 71, 74‐76]. In contrast, having a favourable attitude toward EBP [36], free online databases at work, online educational materials, and access to critical reviews and full-text articles [40, 55, 56] were perceived as facilitators of RU. Recently, the World Federation of Chiropractic (WFC) put forth such a reading list (http://​www.​wfcsuggestedread​inglist.​com/​#download). Other important resources on EBP can be found on the Canadian Chiropractic Guideline Initiative (CCGI) website with links to Cochrane reviews relevant to the scope of practice (www.​chiroguidelines.​org).

Although effect sizes were small to moderate, included studies evaluating the effect of educational interventions on process of care [83‐87] and professional behaviour change [88‐90] generally found that these strategies favourably shifted chiropractors’ beliefs and attitudes toward CPGs and increased guideline adherence. However, the research to support this is limited. Well-designed evaluation studies targeting chiropractors with larger sample sizes, longer follow-up, use of a control group and validated outcome measures are needed. Furthermore, the lack of consistency of effect in these studies may be related to the intervention strategies used. There is general agreement that implementation strategies are more effective if they address identified barriers to change [107], and that the effectiveness of strategies depends on the organizational context in which they are implemented [108]. Examples of theory-based KT interventions in chiropractic are those aiming to reduce spine imaging [109] or to increase use of multimodal care for neck pain [72] (Trial Registration: https://​clinicaltrials.​gov/​, NCT02483091, registered 17 June 2015). Future dissemination and implementation efforts should aim to address knowledge-practice gaps identified in our review, including risk factors for scoliosis progression [62], establishing prognosis for whiplash [63], routinely using validated outcomes measures and patient-reported health outcomes (other than pain and disability scales) [30, 64, 65], the ongoing use of passive therapy to manage acute whiplash [50] and patient care concerned with public health issues [67‐69].

Knowledge gained from this review provides a deeper insight on ways in which we can help end users engage in group discussions. For clinicians, strategies aimed at closing the evidence-practice gap can reduce inappropriate practice variations and improve process of care and patient outcomes. Chiropractors recognize the important of research to raise the credibility of the profession [37, 39] and are willing to support research efforts, mostly as participants (e.g., completing surveys) or by providing patient data [37]. Chiropractic Practice-Based Research Networks (PBRNs) in Canada [110], Europe [111], USA [112] and Australia [113] offer the opportunity for clinicians and patients to engage in meaningful clinical research to enhance the management of musculoskeletal care. PBRNs can facilitate recruitment and help retain participants, two essential but challenging aspects of clinical research [114, 115]. Furthermore, PBRNs may be ideal environments to increase understanding of barriers to professional behaviour change and to pilot test implementation of CPGs and best practices prior to scaling up interventions [110]. Details on projects from chiropractic PBRNs in Canada and Australia can be found elsewhere (http://​www.​chiroguideines.​org and http://​www.​acorn-arccim.​com/​).

Interprofessional collaboration is an essential component for moving toward integrated health care [116, 117]. Findings from this scoping review indicate that chiropractic is actively engaged in interprofessional primary care research in the area of musculoskeletal disorders. As research capacity continues to grow in the chiropractic profession, it is envisioned that health service and KT research will increasingly influence practice, programmes and policy.

Chiropractic teaching institutions play a crucial role in promoting EBP/RU/KT with their students and alumni [118, 119]. To do so, academic programs should incorporate EBP content early in a program of study and “weave” it throughout the 4–5 years of professional education. Curricula [120] should be designed to foster the attributes known to support an EBP approach (i.e., attitudes, reflection, skills, knowledge, confidence, etc.) [15, 121]. EBP content should be situated in authentic contexts and using real life scenarios that resemble the types of cases graduates are most likely to encounter in their future clinical practice [120, 122]. Importantly, students should be scaffolded towards higher levels of performance of EBP and autonomy in applying EBP. This may be achieved by first expanding students’ knowledge base, then by focusing on the application of EBP for different and increasingly complex cases and finally, by fostering students’ ability to reflect upon and assess the outcomes of the EBP process. Faculty could promote EBP competencies by working closely with clinicians; together they can provide a more holistic view of EBP (i.e. from the classroom to its real life application) [123, 124]. Moreover, clinician “role models” and EBP “champions” are ideally positioned to influence the design and delivery of the EBP content in the classroom.

To increase the likelihood of successful change however, faculty members could benefit from continuing professional development; not only on the EBP process itself, but on how to teach and evaluate EBP (i.e., content knowledge and pedagogical content knowledge). The Consortium for Evidence-Informed Practice Educators (http://​www.​cameducatorsfore​ip.​org/​) and the Academic Collaborative for Integrative Health (http://​www.​accahc.​org/​) are examples of initiatives respectively aimed at providing leadership, training, and support to CAM educators in the principles, practice and teaching of Evidence-Informed Practice (EIP) and in cultivating partnerships and advancing interprofessional education and collaborative practice. Other important initiatives to promote the application of EBP include the development and dissemination of clinical practice guidelines and related tools by the Council on Chiropractic Guidelines and Practice Parameters (http://​clinicalcompass.​org/​) and the CCGI (http://​www.​chiroguidelines.​org). Together, these initiatives should facilitate the shift of the chiropractic profession toward EBP, which ultimately may translate in the delivery of safer and more effective patient centered care [125].

This review complies with key steps outlined in the Joanna Briggs Institute manual for conducting scoping reviews, [126] including using an a-priori protocol, a search of several databases, consulting an experienced health sciences librarian to ensure our strategy was appropriate, keeping the search strategy unrestricted to study design, screening titles and abstracts followed by full-text screening for relevance using at least two independent reviewers, and using a standardized data abstraction form adapted to the focus of the review. Nonetheless, this review also has some limitations. The quality of included articles was not assessed as part of this scoping review. Further research is required into effective EBP training programmes for chiropractors to improve attitudes, skills and uptake of EBP. Research is also needed on whether specific elements of post-graduate (and undergraduate) training that can be identified as effective across the spectrum of chiropractors’ attitudes and beliefs about EBP to sustainably improve EBP knowledge, skills, attitudes and behaviours. There is a need for robust dissemination and implementation research to increase guideline adherence and improve patient health outcomes. Large integrated clinical and administrative databases can better our understanding of practice patterns and variations, incident reporting and safety measures in chiropractic, knowledge-practice gaps, and provide additional compelling evidence from chiropractic outcomes. One important barrier to conducting clinical research is recruitment. Despite an increased evidence base for methods to improve the response rates to postal questionnaires [127], there has been a steady downward trend in clinician’s response rates to surveys [128]. We estimated the response rate for 31 cross-sectional (survey) studies at less than 50 % (range 2-100 %), with greater participation from northern European countries compared to North America or Australia. However, this figure should be interpreted with caution considering several of the studies could not determine the number of invited subjects who actually opened the invitation letter or e-mail for surveys. Planned targeted dissemination strategies of the review findings include: presentations at key national conferences, partnerships with relevant stakeholders in the chiropractic community to identify strategies for information exchange, use of chiropractic opinion leaders to help disseminate findings and recommendations, creation of briefing notes highlighting key messages, recommendations, and action items, and posting on the Canadian Chiropractic Guideline Initiative (CCGI) website designed to share findings with end-users.