Chiropractic / Manual Medicine Articles & Podcasts By Dr. Shawn Thistle

This article series by Dr. Shawn Thistle, founder & president of RRS Education (Research Review Service Inc.) is offered in an effort to develop a sensible relationship with research in your day to day practice through open and honest discussion.

Oct. 18/2010

As the 4th anniversary of launching Research Review Service approaches, I have recently taken some time to reflect on our profession and our role in the current healthcare landscape. In the coming days, I hope to reserve a few minutes of your time to discuss this issue. As you read the upcoming series of articles, I want you to take a step back and think about your practice, your future, the future of our discipline, and the rights and expectations of our patients.

You will notice during this discussion, I will continually refer to 'us' because I am just like you - directly involved in patient care, trying to build and maintain my practice, drive referrals, achieve optimal results for my patients, and enjoy life...sound familiar? All the while, I am sorting through the massive amount of research that is published each month and helping modern, evidence-informed clinicians like you and I make some sense of it so we can apply it with our patients - this is the fundamental goal of RRS.

I am passionate about our success as a profession, the continued development of our cultural authority and want what is best for us as a group. I want us to continue to evolve and integrate current knowledge into our patient interactions. I feel that no matter what discipline you are trained in - be it chiropractic, physiotherapy etc. - we are all on the same side.

Our patients rely on us to help them with pain, injuries and many aspects of their health and wellness. That is a big responsibility and a humbling honor. I hope you view it in the same way.

Through this article series, I hope to illuminate the reasons why I started RRS and why I feel it can help every clinician in their practice. But there is a bigger and more important goal...I feel that as a group, we have a strained and dysfunctional relationship with research - a relationship that needs to be discussed and clarified so we can move forward in a realistic and evidence-informed manner.

I have done webcast interviews and presented to various groups on this topic, and in the days to come, I want to get some of these issues out in the open, discuss some misconceptions about research, and stimulate some thought and self-evaluation in all of us. I hope you'll join in and as always, don't hesitate to contact me any time.

What Type of Research Consumer Are You?
Oct. 19/2010

While developing and working on Research Review Service for the last 4 years I have had the privilege of personally interacting with chiropractors, physiotherapists and other manual medicine providers from around the world.  This is something I have truly enjoyed and learned a lot from…our profession certainly attracts caring, passionate and intelligent people. Along the way, it has become apparent to me that we share some valid and consistent concerns; issues that need to be addressed for us to move forward.  I have gained unique insight into the way we as professionals feel about research and think about how it applies to our practices and how we care for our patients.

So let’s talk about this.  It doesn’t surprise me that ‘research’ is an intimidating concept to many people, including most of our colleagues (maybe even you?). Often inaccessible aside from basic abstracts, the sheer volume, complexity and variety are staggering.  So where do you begin? There are a number of issues to consider.

Most of our governing and regulatory bodies just assume that we are all current, while most are not. How many journals do you read each month? How many papers do you analyze and apply to your patient care each year?  Don’t worry, you are definitely not alone if the answers to those questions make you uncomfortable.  This is a growing problem and in a health-care environment where our patients are better educated and more discerning than ever before – it is harming us collectively. To put this in perspective, this is not a problem that is unique to us.

Many professionals would essentially have to stop working just so they could keep up with the volumes of material that are published every month in reputable, peer-reviewed journals! However, that does NOT mean that we don’t have a responsibility to address this issue.

To further complicate matters, there is a distinct disconnect between the researchers and those in the field. I will discuss researchers (also passionate, intelligent and caring people by the way) in an upcoming email but for now, the simple fact is that we generally don’t know the people who generate research and dedicate their lives to it, nor do we know the patients that participate in these studies.  This leaves many wondering - How can it possibly matter to me, my patients, or my practice?

If you will indulge me, I will leave you today with some homework. One thing I have noticed since I started Research Review Service is that most of us have an often dysfunctional, love-hate sort of relationship with research. I feel all of us should be research ‘consumers’ – integrating this essential knowledge into our practice to the best of our ability. If you will allow me to generalize for a moment, I have noticed that most of us fall into one of the following patterns of research consumption:
  1. Those who have not updated their knowledge since graduation and do not consult the literature for any reason. They rely on their own experience to guide their patient care.
  2. Those who I call ‘fair-weather research consumers’: they often inappropriately trumpet positive results of mediocre quality research to serve their beliefs or interests, while turning a blind eye to higher level evidence just because they don’t like the results.
  3. Those who integrate current research, to the best of their ability, into their patient interactions while keeping in mind that the two other crucial pillars of evidence-based medicine (or what I like to refer to as evidence-informed practice) are patient preferences and clinical experience.
  4. Those who forget that patient preference and clinical experience are also important, relying solely on stringent research findings to dictate their treatment approaches.
So, your homework is simply to answer this question: If you had to identify yourself with one of these groups, which one would it be? There is no risk in being honest here and this discussion will continue.

Excuses, Excuses
Oct. 28/2010

To quickly review, last time I described four patterns of research consumption in our profession:
  1. Those who have not updated their knowledge since graduation and do not consult the literature for any reason.  They rely on personal experience to guide their patient care.
  2. Those who I call ‘fair-weather research consumers’: they often inappropriately trumpet positive results of mediocre quality research to serve their beliefs or interests, while turning a blind eye to higher level evidence just because they don’t like the results.
  3. Those who integrate current research, to the best of their ability, into their patient interactions while keeping in mind that the two other crucial pillars of evidence-based medicine (or what I like to refer to as evidence-informed practice) are patient preferences and clinical experience.
  4. Those who forget that patient preference and clinical experience are also important, relying solely on stringent research findings to dictate their treatment approaches.
I asked you to identify with one of these groups…I hope you were candid with yourself and I realize these options certainly exist on a continuum…

In my opinion, the most concerning groups are the first and the last, but we will focus primarily on the first group today. As for the ‘fair-weather’ folks in the second group – they normally have good intentions, but unfortunately the way they communicate with their patients can be misleading, and the way they communicate with other health professionals can be downright embarrassing. Subsequent parts of this article series will discuss how to shift your habits closer to those in the third group, and how to sensibly avoid the downfalls of the fourth.

Now for the first group…it is time for ALL OF US to stop tip-toeing around this. It is sad but true: Too many of our colleagues fall into this category! This should concern us all. I’m trying to figure out why this is and I may offend some people along the way. For the sake of our profession, WE need to start taking a long hard look at ourselves and focus a critical eye toward the future of how we will evolve as evidence-informed professionals and of course, how we deal with our patients.

There are many potential reasons for people to neglect their duty to stay current by ignoring research and the list below is likely not exhaustive, just my ideas and observations.   

Please be open and honest with yourself as you read through these.  Even if you fall somewhere between groups 1 and 3, ask yourself: Do any of these reasons for completely ignoring research or not staying current hold true for me? These are listed in no particular order:
  1. flat out stubbornness, arrogance, or ignorance…
  2. a subjective (and sometimes false) sense that what you have been doing thus far has worked, so why fix what's not broken?
  3. laziness or unwillingness to take the time to search, read, evaluate and integrate new research findings, techniques or practices to a point of proficiency and confidence
  4. lack of research appraisal skills and/or access to relevant literature
  5. reluctance to admit that you have been treating less than optimally – and the fear associated with that
  6. absolutely, positively no time
  7. loyalty to one school of thought or treatment approach that biases you against all others, or closes your mind to new ideas
  8. the ease of falling back on what's comfortable, familiar, and what's been taught in school (no matter how long ago that was)
  9. attitudes gained due to the influence of mentors, some of which are fiercely independent "gurus", practice consultants etc.
  10. a lack of understanding of how emerging research can enhance your patient care and benefit your practice
This list could go on but I’ll stop there.  I’ll leave you with one more thought: What level of current research/knowledge integration would you expect and deserve from your family doctor? Or your lawyer? Your accountant?  You get the idea…

That is enough to ponder for now – next time we will discuss why many cannot approach research with confidence and clarity, and dispel some common misconceptions about research in our discipline (group 3 here we come!).

Breaking Down Barriers
Nov. 4/2010

My intent for this article series is to demystify research and discuss how we relate to this aspect of our profession…so what do I mean by that?  Well, the end goal of these articles, and the overarching goal of RRS is to promote critical review and integration of pertinent research findings into our patient care in a manner that is sensible, affordable, convenient and time-efficient for both practicing clinicians and students.

A positive, evidence-informed relationship with research should begin during our undergraduate or graduate education, and continue throughout our practice careers. Unfortunately, this is simply not the case for many of our colleagues. In the first three parts of this series, we have discussed some common patterns of ‘research consumption’ as well as some of the reasons why many of us don’t stay as current as we should. I hope my last article made you think critically about your reasons for ‘consuming’ research the way you do (if you ‘consume’ it at all).

Today my goal is to break down some of the perceived barriers between the growing body of published research and those who can benefit from it – you, me and our patients! There are some prevalent misconceptions out there, and it appears that we as a profession have allowed our relationship with research to become quite dysfunctional.Fear, misunderstanding and misinterpretation seem to predominate, when what we really need is some time, common sense, understanding and application. There is a better road ahead and a bright future for our profession, but we must continue to adapt our approach to patient care, and one critical component of this is consistent review and integration of emerging research. It is our responsibility.

I would like to discuss a few issues. The statements below are some common misconceptions about research I have discussed with people just like you since I started Research Review Service…they are generalizations and starting points for discussion. Similar to the last article, these are presented in no particular order and this is likely not a comprehensive list.

“If we only adhere to treatment approaches that have high-level evidence to support them, we wouldn’t be able to do much to our patients!”

This is true to some degree, but it is changing more rapidly than ever before. New research is emerging each month that can help us apply our unique skills and manage our patients more effectively and efficiently. However, relying on research alone is not a practical or prudent option (remember, I said those in this group were as concerning as those who completely ignore research). There is a very important factor to consider here: The theory and practice of evidence-based medicine contains three equally-important components, not just one. The 3 components are: 1) Pertinent research; 2) experience of the treating clinician; and 3) patient preference. I mention this because many forget that being ‘evidence-based’ requires all three. This means, of course, that #1 cannot be neglected!

“Studies don’t reflect how I treat my patients…”

Generating high-level manual therapy research is challenging. Our research capacity is growing and we must keep in mind that research on manual medicine techniques is in its infancy compared to medical research in general. We face some unique obstacles that we need to consider when attempting to interpret our body of literature. For example, studying what we do to our patients isn’t as simple as administering drug ‘X’ for disease ‘Y’ and comparing it to a placebo pill. There are other factors to consider which have made our research challenging to conduct on some levels.

We touch our patients, listen to them, and interact with them during each treatment. We develop supportive relationships with them. The effects of these sorts of things are difficult to quantify, but they can certainly have a positive effect on treatment outcome. Further, manual therapy (hands-on) interventions are hard to standardize. Let’s use spinal manipulation as an example: We are all different sizes and have different skills – the size of our hands, our touch, speed, force development, set-up techniques, patient instructions etc. are widely variable among clinicians…not to mention the variability in our patients! Newer research models are attempting to account for these differences and progress is certainly being made on many fronts. It is important to remember that general concepts, clinical ‘pearls’ and techniques can all be gleaned from many types of research – when it is appraised critically and explained in a way that makes sense.

“Research could discredit what we do… so let’s only focus on studies that have positive results”

Since I launched RRS, I have been asked numerous times whether we review the literature that "supports chiropractic" or "supports physical therapy"…by digging a bit deeper into these generic requests it became apparent that those who were asking about this research were interested ONLY in studies that have positive outcomes, rather than the literature as a whole.

Hmmm…this is a problematic, unbalanced approach, isn’t it? One of the roles of research is to evaluate the efficacy of our current methods of assessment and treatment. The outcomes of these studies, whether positive or negative, provide learning opportunities that can change how we approach patient care.  We need to know what does work AND what doesn’t.  We must understand the mechanisms behind what we do, the basic science principles, biomechanical and psychosocial aspects. We must embrace new ideas and abandon older ideologies as new research clarifies what we do.  All forms of research, from case studies to meta-analyses can contribute to our body of knowledge, refresh us on topics some of us learned about years ago, assimilate a multidisciplinary ‘state of the literature’ that we need to be a part of…this list could go on.  Knowledge evolves and changes over time, and we need to stay current to do the same. 

“Researchers don’t understand what we do and do not want to support our profession…they just want to further their own careers.”

There is a problematic disconnect here and it goes two ways.  Practicing clinicians often express concern that those conducting our research are out of touch with the realities of clinical practice. I have the privilege of knowing many researchers personally and I can assure you that this is far from the truth.  In general, most researchers were, or still are, involved in patient care.  Many will say that their clinical experience spawned their interest and pursuit of research.

They have relevant questions related to daily practice and they want to generate answers to benefit all of us.They are passionate, intelligent people who want us all to succeed and advance. However, I will point out that researchers often make one flawed assumption and it goes something like this: “If I publish my research, everyone in the field will read it, understand it and apply it.” In most cases, this is entirely inaccurate.  It also doesn’t help that most of our governing bodies and professional associations echo this sentiment and assume that research dissemination just ‘happens’. This is where the knowledge gap exists, which is why I launched RRS.

“Most research does not apply to chiropractic…”

With apologies to my chiropractic colleagues, this seems to be a unique concern for us. The simple fact is that there aren’t many journals dedicated to strictly ‘chiropractic research’. However, there are many journals dedicated to manual therapy techniques (including chiropractic), biomechanics, spinal conditions, sports injuries, exercise and rehabilitation, pain…this list could go on. My point is that the knowledge we integrate into everyday practice comes to us from many biomedical disciplines so we need to look at the literature in a broader sense.

There is one more important barrier we must address - in the final installment in this series, I will tackle the pragmatic aspects of research dissemination and explain how Research Review Service can help bridge the gap.

Research Doesn’t Have to be Intimidating … Embracing a Sensible Approach
Nov. 11/10

I know you are all busy and I truly appreciate the time you have taken to read these articles. I hope that on some level they have enhanced your understanding of research as a tool and how it can impact your patient care. This is the final installment of this series, and it comes to you with a special offer. But first, let’s attempt to wrap up this discussion.

Last time I alluded to one more area representing a significant barrier to increasing the uptake of research by those in practice. This area is broad, and its components are the fundamental issues facing numerous professions when discussing dissemination and integration of current research into practice patterns.

The following set of questions represents, by far, the most intimidating barrier facing individuals and our profession collectively …

“The volume of literature is so large I can’t possibly keep up … Should I bother? I haven’t read any research in years? Where do I start? Can even a bit of reading help me?”

There are some significant barriers to efficient dissemination of research to practitioners in the field. The sheer volume of published literature is certainly intimidating, but forms only part of the story. There are issues with locating, interpreting, assessing and accessing most forms of research.

The simple truth is that key research findings which can change the way we treat our patients are not reaching the majority of our colleagues. Acquisition, appraisal and application of research is, understandably, not a skill set that most apply with confidence. It’s OK to need some help. Most practitioners consult a very limited number of journals (if any), read only the abstracts, and have unpolished literature-searching skills to answer specific clinical questions. They possess inadequate research appraisal skills if and when they find appropriate studies, and to top it all off most people lack of access to full-text papers.

Further, we currently have no central mechanism for the distribution and integration of current research into our practices. Therefore the responsibility falls on individual practitioners, who often work by themselves with little opportunity to discuss patient care with colleagues. This is why I created RRS…in the last 4 years it has developed into a good place to start, or a great addition to your existing research regimen.

Why I created Research Review Service Inc.

I am just like most of you – involved directly in patient care and in need of timely, efficient and pertinent clinical information. I designed the RRS model of information delivery to make an impact without being overwhelming. It fits into your busy schedule.

We review about 60 papers per year on a variety of clinical topics – far more than most would read on their own, but not so many that it becomes too onerous and time consuming. I firmly believe that when it comes to ‘consuming’ research, some is ALWAYS better than none! Along with our team of contributing writers, I select interesting, timely and relevant studies to review. We at RRS keep our eyes on the literature for you! We obtain the studies, assess their quality and write concise reviews emphasizing the clinical application of research.

Now let me be clear. I am well aware that one newsletter, blog or service like RRS cannot possibly review every study or every relevant piece of literature. However, we have to start somewhere and those who have subscribed would tell you that it certainly helps to read what your colleagues say about RRS (FEEDBACK). Cost effective exposure to ~60 pertinent papers per year is a great start, and don’t forget that subscribers have full access to our keyword-searchable database which now contains nearly 300 reviews written in the last 5 years! We take input and suggestions very seriously, and do our best to adapt our content and cover material that you want to learn about!

RRS provides all of this for less than the cost of any weekend seminar!

Thank you for reading and many thanks to those who have been in touch with questions and feedback.

As always, if you have any questions about this article series or anything related to RRS Education, contact me anytime. Also, although our communication typically occurs via email, I always appreciate putting a face to a name so please say hello if we are ever at an event together, or if you are visiting Toronto!

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