When Evidence Based Practice is Required, but Little Evidence is Available
Written by Editor   
Sunday, October 04, 2015 08:56 PM

All clinicians of today know that scientific evidence is the base on which clinical practice should rest. However, this is not always easy, in particular in those disciplines, where the evidence is scarce. Although the last decades have brought an impressive production of research that is of interest to chiropractors, there are still many areas such as diagnosis, prognosis, choice of treatment, and management that have not been subjected to extensive scrutiny.

This paper presents a simple system consisting of three questions will help clinicians deal with some of the complexities of clinical practice, in particular what to do when clear clinical evidence is lacking. Question 1 asks: are there objectively tested facts to support the concept? Question 2: are the concepts that form the basis for this clinical act or decision based on scientifically acceptable concepts? And question three; is the concept based on long-term and widely accepted experience? This method that we call the "Traffic Light System" can be applied to most clinical processes.

For health care practitioners, the first clinical encounter has several important goals, two of these are:

1) to get an idea of what is wrong with the patient and

2) to detect any cases that should be directed elsewhere.

Chiropractors, and other professionals who often provide manual therapies, will also work out a “technical” diagnosis in relation to where and what to treat. Thereafter follows the treatment itself, any follow-up procedure, and the long-term strategy. 

Although the last decades have brought an impressive production of research, there are still many areas such as diagnosis, prognosis, choice of treatment, and management that have not been subjected to extensive scrutiny. Therefore, some aspects of health care are accepted on their logic and face value and through their repeated and successful use over time.

If the underlying rationale is plausible, in addition to the procedure or concept being accepted by many clinicians, then it is likely that it will be considered relatively “acceptable”. However, the level of acceptance is lower for only logic and experience than it is for scientific evidence. However, if the concept, act or procedure is not biologically plausible, as judged by the scientific community in general, then experience is not enough to justify its use. 

Obviously, there are many aspects in clinical practice that lurk in the areas of no specific evidence yet considered to be perfectly acceptable because they are based on sound and generally accepted biological/ physiological/ anatomical/ pathological concepts combined with longstanding and widespread experience.  For example within spinal care it would be considered acceptable to advise a patient with a very painful and antalgic lumbar spine against digging up his garden whilst in such a state. This advice has never been tested in a randomized controlled clinical trial; instead it is based on our present understanding of the pathology of the disc and backed up by our experience of outcome in relation to whether this type of patients avoid aggravating activities or not.

It can be challenging and confusing to make clinical decisions in situations where clear evidence is lacking. Many people find it uncomfortable and difficult to deal with uncertainty and feel safer if they can follow an algorithm of thought, some sort of recipe on how to proceed.

In this paper we argue that a simple system consisting of three questions will help clinicians deal with some of the complexities of clinical practice, in particular what to do when clear clinical evidence is lacking. This method, the “Traffic Light System”, can be applied to most clinical processes. We shall explain how the Traffic Light System can be used as a framework to help chiropractors make clinical decisions in a simple and lucid manner. We do this by explaining the roles of biological plausibility and clinical experience and how they should be weighted in relation to scientific evidence in the clinical decision making process.

According to the Traffic Light System, decision making is based on some simple concepts. First, scientific evidence carries more weight than biological plausibility and experience and, in particular, when there is lack of biological plausibility, there is a much stronger need for evidence. On the other hand, if there is biological plausibility, strong evidence may not always be needed, provided that the concept is also backed up by considerable clinical experience. 

The Traffic Light System is a method of approach that can be used to deal with the triad of: evidence, plausibility and clinical experience. We suggest that three questions be asked, whenever facing a clinical task, and that the continued activities should be based on a set method to interpret the answers to these questions. In order to provide a simple and easy-to-remember algorithm, we have incorporated the three traffic light colors into the system, green (go), yellow (go with care), and red (stop). The three questions are presented below together with their traffic light interpretations in three steps:

Step 1:   Are there objectively tested facts to support the concept?

In other words, is there sufficient sound research (evidence) supporting this?
If the answer is “yes”, the light is green, and you can go on with your procedure or decision.
If the answer is “no”, go to the second question.

 

Step 2:   Are the concepts that form the basis for this clinical act or decision based on scientifically acceptable concepts?

In other words, is it logical and lucid, biologically plausible?
If the answer is “yes”, go to question three.
If the answer is “no”, the light is red and you should stop here.

 

Step 3:   Is the concept based on long-term and widely accepted experience?

In other words, is ‘everybody’ doing it?
If also this answer is “yes”, the light is yellow and you can proceed with care.
If the answer is “no”, then stop for the red light.

 

With these explanations we hope to have shown how the Traffic Light System can be used to guide chiropractors through a simple thought process, in which they should habitually consider the three questions. 

 

IMAGE:  http://www.chiro.org/LINKS/ABSTRACTS/How_to_Proceed_When_Evidence-based_Figure_1.jpg


Source:  http://www.chiro.org/LINKS/ABSTRACTS/How_to_Proceed_When_Evidence-based.shtml