The clinical encounter has many aspects – evidence-based practice expected
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. This is a relatively complex process, as many different pieces of information must be considered, brought into a coherent picture and acted upon. In addition, clinicians are expected to keep updated on that part of dynamic knowledge – research – that concerns their area of practice and to apply this knowledge on each patient.
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. There is also the issue of the definition of “evidence”. Textbooks have been devoted to this. Throughout this text we shall assume that “evidence” equals the “best evidence” available at the time, when evaluating the value of a clinical procedure.
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. Therefore, some aspects of health care are accepted on their logic and face value and through their repeated and successful use over time.
If no evidence: plausibility and experience
This lack of specific evidence, however, is not always worrying, as it is considered acceptable to extrapolate from generally acknowledged scientific concepts, and it follows that procedures and concepts will, generally, not be questioned when this happens.
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. This means that decisions and actions based solely on logic and experience usually cannot stand on their own. An example is that the plausible and frequently used test for an acutely injured lumbar disc, antalgia on flexion of the lumbar spine, can be used to help diagnose this disc problem [1], but that other corroborating information is needed before the diagnosis is accepted.
Lack of generally acceptable logical concept
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. This is not surprising, because if a procedure or decision is based on a biologically implausible rationale, it is unlikely that it will be clinically valid.
An example of a non-acceptable procedure is the use of a pendulum in order to define the gender of the unborn baby. This method lacks an acceptable contemporary scientific rationale, so even if some people think that this method is useful, it cannot be introduced in an obstetrics department, unless several well carried out studies have shown, unequivocally, that the vast majority of unborn babies can be correctly classified by gender using a pendulum. Thus a very heavy onus of proof would rest upon any person who would claim that this method can be used for this purpose.
On the other hand, if, against all odds, a test or treatment that lacks (contemporary) plausibility is shown to be clinically valid in several well designed and appropriately performed studies, then it will be considered “acceptable”. The reason for this is, that the contemporary knowledge may not be sufficient to explain why this is so. An historical example of how, sadly, “the evidence” won over common sense and repeated observations is how dirty hands were dismissed as a cause of puerperal fever in childbirth, because its pathogens had not been discovered [2].
Sometimes the question on whether a concept is logical or not will be answered differently by different groups of practitioners. It is, however, outside the scope of this article to define further “logical” and “biologically plausible” in relation to various chiropractic concepts; this discussion belongs elsewhere. However, the plausibility here refers to that which would be acknowledged as such by the contemporary general scientific community.
Easy clinical decisions vs. difficult decisions
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. The rationale for this advice is that such activity would be likely to aggravate the affected spinal structures. 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.
However, there are other times when clinicians may become confused. For example, when the above patient asks how many treatments he will need and how frequently these should be administered, the rationale for this is not so clear. Should there be frequent treatments over a short period of time (rationale: the more the better) or does it suffice with few treatments (rationale: a few treatments will help the process on its way and healing takes the time it takes)? Further, the experiences of various clinicians may be difficult to evaluate, as each of them probably predominantly acknowledges their own specific rationale and therefore has limited experiences to draw on. Each is likely to assume that their specific approach and experiences represents the gold standard. We contend that the same uncertainty will arise over and over, as other unstudied cases present themselves in the practice.
What to do in these cases?
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. This probably explains the plethora of more or less complicated experience-based recipe-type techniques that are available in the chiropractic profession.
On the other hand, attempts have been made since the early 1990s to assist chiropractors to perform in an evidence-based and streamlined manner. Most manual and/or observational tests in many health care fields would probably be classified under this category. Examples are visual inspections of radiographs, orthopedic and neurological tests, and auscultation of the abdomen and heart. Other examples would be those chiropractic tests that have been poorly studied or studied with conflicting results yet based on a seemingly logical patho-anatomical concept.
Over the past 25 years, particular since the Mercy Guidelines [3] substantial efforts have resulted in several clinical algorithms pertinent to chiropractic practice in specific domains [4–7], but we have been unable to find a simplistic, general algorithm, applicable to chiropractic practice in general.
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. This concept is illustrated in Figure 1.
We shall present two clinical situations in which the Traffic Light approach can be used: 1) when examining a patient, and 2) when choosing an appropriate method of treatment. However, we propose that the same approach can be used throughout the entire clinical decision-making process.
