‘PICO-D Management’; a decision-aid for evidence-based chiropractic education and clinical practice

Chiropractors in common with all other health professionals have an obligation to provide patients sufficient information to allow them to determine what is for them the best course of management [50‐52]. Patients, in the end, not health professionals, determine the actions they will take with respect to their own health and illness, including when, how, and from whom they seek care, and how they pursue the recommendations of their various care providers [51]. Leask [53] emphasises information should match people’s conceptual pathways, explain choices and their implications, demonstrate balance, communicate risk in understandable formats and help patients clarify what is important.

This is our decision-aid that can be used in both a teaching and clinical context that facilitates a comparison of evidence and other factors to assist in clinical decision-making. Figure 1 is a schematic representation of the contextual implementation of the classical EBP process of weighing up information that needs to be converted into answerable questions, finding the best evidence with which to answer those questions, critically appraising the evidence for its validity and usefulness, applying the results of the appraisal into clinical practice, and finally, evaluating performance [54].

This decision-aid involves the clinician applying four simple steps; describing the patient and their problem, comparing the proposed intervention with feasible options for this patient in terms of best available evidence, risk vs. benefit, cost, feasibility / availability, deciding the appropriate way to measure the outcome and quantifying the time-frame [55, 56]. The variables are effectively weighed much like a set of scales [57].

For example, a likely question for a chiropractor may be framed like this;

“For a patient with non-specific, acute [or subacute/chronic] low back pain [P], is usual chiropractic care (UCC) composed of active care (discouraging bed rest, providing education, reassurance, addressing fear avoidance, advising activity), and passive care (CSMT and maybe other adjunctive manual methods) [I], at least as effective with comparable risk and cost compared to usual medical care (UMC) and superior to natural history (NH) [C], in reducing pain and improving function [O] over a specific time-frame (ie;12 weeks) [D] ?”

Now the question has been framed, how does one consult the evidence in answering the question? This is a process of starting at the higher levels of the evidentiary hierarchy and working through until the best available evidence is found to apply in the context of the framed question. For the example, with respect to the example of non-specific acute and subacute low back pain, there are readily accessible contemporary clinical practice guidelines that have direct relevance for chiropractors [58].

The quantitative hierarchy of evidence for interventions is well articulated in the literature, the levels of evidence in this space being relevant to informing clinical interventions [59]. Then there is the increasing recognition of the value of qualitative and mixed methods studies; methodologies that ensure the voices of consumers and practitioners are heard, considered and contextualised [60, 61]. A useful table for recording these variables and options is offered in Fig. 2.

Massage, Acupuncture, Yoga, and Cognitive-Behavioural Therapy are recommended as an option for subacute and chronic LBP [63]. However electro-therapeutics such as ultrasound, TENS and short-wave diathermy are not recommended due to their unknown effectiveness [65].

(*We have extracted relevant specific citations from clinical practice guidelines for risk, cost, feasibility, measures and duration).

Using our hypothetical patient as an example, the chiropractor is able to cite moderate level evidence and strong recommendations for all the active and passive components of the clinical encounter. If usual medical care is considered as the comparator option, (and assuming it is guideline concordant) one finds moderate evidence and weak recommendations for the medication component [68, 95]. It should be pointed out that no intervention for spinal pain has greater than a moderate level of evidence; moderate evidence is thus the best available [62].

We are of the view that being overly critical of field practitioners for low adoption of EBP is not productive and thus propose an approach that entails education via demonstrating that EBP is actually in everyone’s best interest, including practitioners. We recognise there is continuing debate over whether EBM is markedly better than standard teaching methodologies; although some evidence for the effectiveness of EBM has accumulated, there is still only emerging evidence on what are the most effective methods of teaching it [98‐100]. There is also still an ongoing robust debate as to whether practitioners of EBM actually provide better health care [101] than those who do not [102‐107]. Just as clinicians recognise that chastising risky behaviour by patients will not alter it, so with field clinicians. Tying desired changes to existing norms helps people understand and adopt practices, as does how messages are framed [12].

It must be highlighted that usual care by any health professional, including chiropractic, is a package not one treatment in isolation; chiropractic is a profession, not a technique. Management of patients entails a complex combination of variables that make each and every person unique, a so called random sample of n = 1 [108]. Discussions regarding clinical management must take account of the entire clinical encounter rather than focussing on one isolated aspect [109]. However stakeholders including third party payers and administrators usually require that clinical decision making by health care providers should rely as far as is possible on evidence deriving from research, which may be practice-based [110]. ‘PICO-D Man’ directs attention to the clinical application in a way that is relevant to chiropractors including possibly in the context of conducting practice-based research [111]. Some chiropractors, in our experience are fond of the saying; “Chiropractic works; it gets results and that’s what counts”; but it may reasonably be countered with “compared to what and by how much and for whom”? ‘PICO-D Man’ represents how that question may be addressed and EBP sensibly applied in a clinical context. While this paper presents the example of a person with acute or subacute spinal pain the model may find application for other clinical scenarios [112].

It is important to point out the clinician has a responsibility to develop a management plan that is defendable, not one that is necessarily agreed to by all other health care professionals. Adherence to CPGs while relatively higher among chiropractors, is a challenge for all primary care professions in the spinal care sector [113]. Patients generally have realistic expectations, although some may consider their prognosis to be different from that which would be expected from known prognostic factors [114]. Accordingly, clinicians should pay attention to previous experience in patients with low expectations rather than focusing on psychological factors such as depressive symptoms and fear avoidance beliefs [114]. It should also be remembered there may also be a genetic predisposition to LBP [115] which highlights the importance of obtaining a family history about back pain.

Triano [116] provided a helpful guide based on the positions of Sackett [117, 118] and Sox [119] in recommendations for provider considerations when strong evidence is absent; i.e. Review available evidence, is it physiologically plausible? Is the thinking is based on valid evidence? Consider costs to the patient, when in doubt, take special care to avoid actions that might cause harm, whether it is physical, emotional, or economic. Above all, talk to the patient, explaining the ambiguity in the evidence and the steps proposed [116]. In clinical circumstances where there is low or absent evidence, a three question ‘Traffic Light System’ can also be useful as a simple framework to help chiropractors make clinical decisions in a simple and lucid manner; Are there objectively tested facts to support the concept? Are the concepts that form the basis for this clinical act or decision based on other scientifically acceptable concepts? and Is the concept based on long-term and widely accepted experience [120]?

The simplest approach to a problem can usually be defended. Chiropractic is in essence a straightforward system of clinical management; rule out serious causes, educate the patient regarding spinal health and self-care, promote healthy lifestyle choices (diet, rest, physical activity, positive mental attitude) and provide manual care as appropriate.

The extent to which this decision-aid may assist in clinical practice still needs to be tested; thus it is presently used in the educational domain where anecdotally it appears useful. The field of ‘translational research’ which explores the implementation of EBP in healthcare is complex. As Kessler and others highlight; “complex problems of complex patients embedded in complex healthcare systems in complex and changing communities require complex interventions” [121‐124]. In the scenario offered here, we have presented the illustration of acute/subacute spinal pain and provided the reader with one answer in this context; this application of the algorithm leads to one answer, and because of its flexibility allows for the cultural, social and other perspectives (of both patients and providers) to lead to individualised decision-making. While we feel this is the strength of the decision-aid, it does not replace the specific needs of all practitioners who will invariably have unique cultural and social overlays respecting their patients in their own clinics. Another limitation that should be mentioned is the changing nature of the evidence and the need and challenge for practitioners to stay up-to-date. Information contained in guidelines may be out-dated by the time they are published. Responsible clinicians have to be cognizant of this and thus cannot blindly follow guidelines without question. Translating a culture of EBP into everyday clinical practice is a challenge and while we feel our approach is simpler and more intuitive than other more complex Critical Appraisal Skills Programme (CASP) sheets [125] such as the Graphic Appraisal Tool for Epidemiologic Studies (GATE Frame) [126], this position would need to be established via a formal reliability/validity study. Evaluation studies have shown that decision aids improve decision making in many ways including increasing patient participation in decision making without adversely affecting anxiety [127, 128]. We feel an ideal platform to investigate the feasibility of the tool would be using a established Australian Practice-Based Research Network (ACORN) in collaboration with experienced ACORN methodologists [129]. Field practitioners may possibly be more likely to use a decision-aid if it can be shown to streamline their clinical practice and facilitate (for example) third party payments possibly via an online or mobile device ‘PICO-D Man’ ‘app’.