Toward an evidence-based model for chiropractic education and practice

Self-reported attitudes, skills and use of evidence-based practice among Swiss chiropractors: a national survey

STUDY OBJECTIVES

The high burden of disease associated with musculoskeletal disorders severely impacts patients' well-being. As primary care providers, Swiss chiropractors ought to contribute towards identifying and using effective treatment strategies. An established approach is the full integration of evidence-based practice (EBP). This study aimed to investigate the attitudes, skills and use of EBP among Swiss chiropractors, as well as investigating potential facilitators and barriers for its adoption.

METHODS AND MATERIAL

All 329 members of the Swiss Association of Chiropractic (ChiroSuisse) were invited in March 2021 to participate in this cross-sectional survey. Data were acquired anonymously online, using the Evidence-Based practice Attitude and utilization SurvEy (EBASE). The survey encompassed 55 questions measuring attitudes (n = 8, response range 1-5; total score range of 8-40), skills (n = 13, response range 1-5; total score range of range of 13-65) and use of EBP (n = 6, response range 0-4; total score range of 0-24).

RESULTS

228 (69.3%) chiropractors returned complete EBASE questionnaires. This sample was representative of all ChiroSuisse members with respect to gender, age groups and proportion of chiropractic residents. Respondents generally held positive attitudes towards EBP, as indicated by the high mean (31.2) and median (31) attitude sub-score (range 11-40). Self-reported skills had a mean sub-score of 40.2 and median of 40 (range 13-65). Knowledge about EBP-based clinical practice had been primarily obtained in chiropractic under- or postgraduate education (33.8% and 26.3%, respectively). Use of EBP achieved a lower sub-score, with mean and median values of 7.4 and 6, respectively (range 0-24). The most commonly identified barriers preventing EBP uptake were lack of time (67.9%) and lack of clinical evidence in chiropractic/manual therapy-related health fields (45.1%).

CONCLUSION

Swiss chiropractors held favourable attitudes and reported moderate to moderate-high skill levels in EBP. Nevertheless, similar to chiropractors in other countries, the self-reported use of EBP was relatively low, with lack of time and lack of clinical evidence being the most named barriers.

Restructuring of an evidence-based practice curriculum and assessment with structural mapping by course outcome verb

OBJECTIVE

An evidence-based clinical practice (EBCP) subcurriculum within a chiropractic curriculum was restructured to distribute EBCP topics to courses throughout the curriculum. We posited that this would enhance student learning through early exposure, repetition, and the use of progressively more difficult levels of learning. In this paper we describe how we determined if Bloom's verb level trended upward from the beginning of the curriculum to the end and if there were any gaps in presentation of topics periodically in the curriculum. We describe how we determined if the restructured subcurriculum provided adequate integration of topics.

METHODS

EBCP committee chairs created templates of the new structure, solicited feedback from the faculty, and faculty members volunteered to assimilate topics into courses. Support for the faculty included comprehensive PowerPoint production and in-service training. Assessment for trends and gaps was performed of the resultant learning outcomes by mapping 13 quarters against 6 Bloom's verb levels for 19 topics.

RESULTS

Fourteen of the topics had increasing linear model trends indicating verb progression. Decreased attention to EBCP topics was identified in some quarters.

CONCLUSION

The graphical mapping process seemed useful to find EBCP topics that did not show progression of Bloom's verb difficulty and gaps in topics in the restructured subcurriculum.

Anatomical Sciences in Chiropractic Education: A Survey of Chiropractic Programs in Australia

Human anatomy knowledge is a core requirement for all health care clinicians. There is a paucity of information relating to anatomy content and delivery in Australian chiropractic programs. The aim of this study was to describe anatomy teaching in Australian chiropractic programs, utilizing a survey which was distributed to all four programs, requesting information on: anatomy program structure, delivery methods, assessment, teaching resources, and academic staff profile at their institution. The survey was undertaken in 2016 and documented practices in that academic year. All four institutions responded. There was a reported difference in the teaching hours, content, delivery and assessment of anatomy utilized in Australian chiropractic programs. Anatomy was compulsory at all four institutions with the mean total of 214 (SD ± 100.2) teaching hours. Teaching was undertaken by permanent ongoing (30%) and sessional academic staff, and student to teacher ratio varied from 15:1 to 12:1. A variety of teaching resources were utilized, including human tissue access, either as prosected cadavers or plastinated body parts. The results of this survey confirm that anatomy has an established place in chiropractic education programs in Australia and while curricular variations exist, all programs had similar course design, delivery, and assessment methods. This study confirmed the provision of a strong foundation in topographical anatomy and neuroanatomy, while other anatomical sciences, such as histology and embryology were not consistently delivered. Formalization of a core anatomy curriculum together with competency standards is needed to assist program evaluation and development, and for accreditation purposes.

Development and psychometric evaluation of an information literacy self-efficacy survey and an information literacy knowledge test

OBJECTIVE

To develop and psychometrically evaluate an information literacy (IL) self-efficacy survey and an IL knowledge test.

METHODS

In this test-retest reliability study, a 25-item IL self-efficacy survey and a 50-item IL knowledge test were developed and administered to a convenience sample of 53 chiropractic students. Item analyses were performed on all questions.

RESULTS

The IL self-efficacy survey demonstrated good reliability (test-retest correlation = 0.81) and good/very good internal consistency (mean κ = .56 and Cronbach's α = .92). A total of 25 questions with the best item analysis characteristics were chosen from the 50-item IL knowledge test, resulting in a 25-item IL knowledge test that demonstrated good reliability (test-retest correlation = 0.87), very good internal consistency (mean κ = .69, KR20 = 0.85), and good item discrimination (mean point-biserial = 0.48).

CONCLUSIONS

This study resulted in the development of three instruments: a 25-item IL self-efficacy survey, a 50-item IL knowledge test, and a 25-item IL knowledge test. The information literacy self-efficacy survey and the 25-item version of the information literacy knowledge test have shown preliminary evidence of adequate reliability and validity to justify continuing study with these instruments.

Using PubMed search strings for efficient retrieval of manual therapy research literature

OBJECTIVE

The aim of this study was to construct PubMed search strings that could efficiently retrieve studies on manual therapy (MT), especially for time-constrained clinicians.

METHODS

Our experts chose 11 Medical Subject Heading terms describing MT along with 84 additional potential terms. For each term that was able to retrieve more than 100 abstracts, we systematically extracted a sample of abstracts from which we estimated the proportion of studies potentially relevant to MT. We then constructed 2 search strings: 1 narrow (threshold of pertinent articles ≥40%) and 1 expanded (including all terms for which a proportion had been calculated). We tested these search strings against articles on 2 conditions relevant to MT (thoracic and temporomandibular pain). We calculated the number of abstracts needed to read (NNR) to identify 1 potentially pertinent article in the context of these conditions. Finally, we evaluated the efficiency of the proposed PubMed search strings to identify relevant articles included in a systematic review on spinal manipulative therapy for chronic low back pain.

RESULTS

Fifty-five search terms were able to extract more than 100 citations. The NNR to find 1 potentially pertinent article using the narrow string was 1.2 for thoracic pain and 1.3 for temporomandibular pain, and the NNR for the expanded string was 1.9 and 1.6, respectively. The narrow search strategy retrieved all the randomized controlled trials included in the systematic review selected for comparison.

CONCLUSION

The proposed PubMed search strings may help health care professionals locate potentially pertinent articles and review a large number of MT studies efficiently to better implement evidence-based practice.

Attitudes toward evidence-based clinical practice among doctors of chiropractic with diplomate-level training in orthopedics

Background

Evidence-based clinical practice (EBCP) is a practice model gaining prominence within healthcare, including the chiropractic profession. The status of EBCP has been evaluated in a variety of healthcare disciplines, but little is known regarding the attitudes doctors of chiropractic (DCs) hold toward this model of healthcare. This project examines the attitudes toward EBCP within a specialty discipline of DCs.

Methods

We identified a survey questionnaire previously used to evaluate EBCP among non-chiropractic complementary and alternative practitioners. We adapted this questionnaire for use among DCs and pretested it in 5 chiropractic college faculty. The final version was administered to DCs with diplomate-level training in orthopedics. The survey was emailed to 299 potential participants; descriptive results were calculated.

Results

144 surveys were returned, resulting in a 48% response rate. The majority of respondents perceived EBCP as an important aspect of chiropractic practice. Respondents also believed themselves to have an above average skill level in EBCP, reported that training originated from their diplomate education, and based the majority of their practice on clinical research.

Conclusion

Doctors of chiropractic with an orthopedic diplomate appear to have favorable attitudes toward EBCP. Further study will help understand EBCP perceptions among general field DCs. A logical next step includes validation of this questionnaire.

Evaluation of the effects of an evidence-based practice curriculum on knowledge, attitudes, and self-assessed skills and behaviors in chiropractic students

OBJECTIVE

The purpose of this study was to evaluate the effects of an evidence-based practice (EBP) curriculum incorporated throughout a chiropractic doctoral program on EBP knowledge, attitudes, and self-assessed skills and behaviors in chiropractic students.

METHODS

In a prospective cohort design, students from the last entering class under an old curriculum were compared with students in the first 2 entering classes under a new EBP curriculum during the 9th and 11th quarters of the 12-quarter doctoral program at the University of Western States in Portland, OR (n = 370 students at matriculation). Analysis of variance (ANOVA) was performed using a 3-cohort × 2-quarter repeated cross-sectional factorial design to assess the effect of successive entering classes and stage of the students' education.

RESULTS

For the knowledge exam (primary outcome), there was a statistically significant cohort effect with each succeeding cohort showing better performance (P < .001); students also performed slightly better in the 11th quarter than in the 9th quarter (P < .05). A similar pattern in cohort and quarter effects was found with behavior self-appraisal for greater time accessing databases such as PubMed. Student self-appraisal of their skills was higher in the 11th than the 9th quarter. All cohorts rejected a set of sentinel misconceptions about application of scientific literature (practice attitudes).

CONCLUSIONS

The implementation of the EBP curriculum at this institution resulted in acquisition of knowledge necessary to access and interpret scientific literature, the retention and improvement of skills over time, and the enhancement of self-reported behaviors favoring use of quality online resources.

Development and psychometric evaluation of an evidence-based practice questionnaire for a chiropractic curriculum

OBJECTIVE

The purposes of this study were to describe the questionnaire development process for evaluating elements of an evidence-based practice (EBP) curriculum in a chiropractic program and to report on initial reliability and validity testing for the EBP knowledge examination component of the questionnaire.

METHODS

The EBP knowledge test was evaluated with students enrolled in a doctor of chiropractic program in the University of Western States. The initial version was tested with a sample of 374 and a revised version with a sample of 196 students. Item performance and reliability were assessed using item difficulty, item discrimination, and internal consistency. An expert panel assessed face and content validity.

RESULTS

The first version of the knowledge examination demonstrated a low internal consistency (Kuder-Richardson 20 = 0.55), and a few items had poor item difficulty and discrimination. This resulted in an expansion in the number of items from 20 to 40, as well as a revision of the poorly performing items from the initial version. The Kuder-Richardson 20 of the second version was 0.68; 32 items had item difficulties of between 0.20 and 0.80, and 26 items had item discrimination values of 0.20 or greater.

CONCLUSIONS

A questionnaire for evaluating a revised EBP-integrated curriculum was developed and evaluated. Psychometric testing of the EBP knowledge component provided some initial evidence for acceptable reliability and validity.

Evidence-Based Practice and Chiropractic Care

Evidence-based practice has had a growing impact on chiropractic education and the delivery of chiropractic care. For evidence-based practice to penetrate and transform a profession, the penetration must occur at 2 levels. One level is the degree to which individual practitioners possess the willingness and basic skills to search and assess the literature. Chiropractic education received a significant boost in this realm in 2005 when the National Center for Complementary and Alternative Medicine awarded 4 chiropractic institutions R25 education grants to strengthen their research/evidence-based practice curricula. The second level relates to whether the therapeutic interventions commonly employed by a particular health care discipline are supported by clinical research. A growing body of randomized controlled trials provides evidence of the effectiveness and safety of manual therapies.

Effectiveness of an evidence-based chiropractic continuing education workshop on participant knowledge of evidence-based health care

BACKGROUND

Chiropractors must continue to learn, develop themselves professionally throughout their careers, and become self-directed and lifelong learners. Using an evidence-based approach increases the probability of optimal patient outcomes. But most chiropractors lack knowledge and interest in evidence-based approaches. The purpose of this study was to develop and measure the effectiveness of evidence-based training for chiropractic practitioners in a continuing education setting.

METHODS

We developed and evaluated a continuing education workshop on evidence-based principles and methods for chiropractic practitioners. Forty-seven chiropractors participated in the training and testing. The course consisted of 12.5 hours of training in which practitioners learned to develop focused questions, search electronic data bases, critically review articles and apply information from the literature to specific clinical questions. Following the workshop, we assessed the program performance through the use of knowledge testing and anonymous presentation quality surveys.

RESULTS

Eighty-five percent of the participants completed all of the test, survey and data collection items. Pretest knowledge scores (15-item test) were low (47%). Post intervention scores (15-item test) improved with an effect size of 2.0. A 59-item knowledge posttest yielded very good results (mean score 88%). The quality of presentation was rated very good, and most participants (90%) would "definitely recommend" or "recommend" the workshop to a colleague.

CONCLUSION

The results of the study suggest that the continuing education course was effective in enhancing knowledge in the evidence-based approach and that the presentation was well accepted.

Applying evidence-based health care to musculoskeletal patients as an educational strategy for chiropractic interns (a one-group pretest-posttest study)

OBJECTIVE

To describe and measure the effectiveness of a problem-based educational strategy for teaching evidence-based health care (EBHC) to chiropractic interns, which focused on the development and appraisal of answerable clinical questions using actual musculoskeletal patients.

METHODS

A 1-group pretest-posttest design (simple panel design) with investigator-blinded survey administration was used to measure effectiveness of educational activities using adult learning theory with a study population of interns (n=31) at a chiropractic college (Los Angeles College of Chiropractic, Southern California University of Health Sciences [LACC/SCUHS]) teaching clinic. Activities included 2 workshops on constructing clinical questions and critical appraisal of published research and independent patient-based EBHC assignments. A qualitative self-assessment survey was administered before and after a 6-week period of EBHC activities to measure their effectiveness. Sign tests and paired t tests were utilized to determine P values for significant difference of score results.

RESULTS

Eighty-one percent of subjects completed the pretest-posttest surveys. All survey item responses showed an average increase in subjects' self-rating of skills and attitudes from pretest to posttest. There were statistically significant differences in interns' self-assessed ability to construct an answerable clinical question and appraise research articles and apply them to patient management, as well as their rating of importance of EBHC in patient decision making.

CONCLUSIONS

The results of this study suggest that having chiropractic interns apply EBHC to actual musculoskeletal patients along with attending EBHC workshops had a positive impact on interns' perceived ability to practice EBHC.