Various models and decision-making aids exist for chiropractic clinical practice.
Results
“PICO-D Man” (Patient-Intervention-Comparator-Outcome-Duration Management) is a decision-aid developed in an educational setting which field practitioners may also find useful for applying defensible evidence-based practice. Clinical decision-making involves understanding and evaluating both the proposed clinicalintervention(s) and the relevant and available management options with respect to describing the patient and their problem, clinical and cost effectiveness, safety, feasibility and time-frame.
Conclusions
For people consulting chiropractors this decision-aid usually requires the practitioner to consider a comparison of usual chiropractic care, (clinical management including a combination of active care and passive manual interventions), to usual medical care usually including medications, or other allied healthmanagement options while being mindful of the natural history of the persons’ condition.
Most existing models of clinical decision-making involve making a diagnosis and satisfying oneself that the patient is in the ‘right place at the right time’ [1]. Patient management in the contemporary health care environment is expected to be ‘evidence-based’ and suggests that patient outcomes are enhanced when their management is guided by the best available evidence [2, 3]. Furthermore it appears that when patient care is evidence based there is the potential for cost savings [4–6].
Undergraduate students are being trained in EBP [7], however it has been documented that it can be difficult to establish EBP amongst various professions, including chiropractic [8]. A number of potential barriers to the adoption of EBP in clinical practice have been identified and include; time restrictions, limited access to research studies, poor confidence in skills to identify and critically appraise research, and inadequate support [9–12]. A recent scoping review of chiropractors noted EBP gaps in the areas of assessment of activity limitation, determination of psychosocial factors influencing pain, general health indicators, establishing a prognosis, and exercise prescription. Chiropractors generally believe EBP and research to be important however use of EBP and guideline adherence varies widely [13]. There remain significant paradigmatic and cultural barriers in chiropractic along with other CAM professions to EBP; obstacles beyond merely the practical or knowledge deficiencies [14].
This paper seeks to simplify the clinical application of EBP by providing a clinical decision-aid. We use the example of acute or subacute low back pain presentation, since by far, the majority of patients that present to any chiropractic practice do so with spinal pain; be it labelled acute, subacute, chronic, non-specific, biomechanical or non-malignant [15]. It is important chiropractors realise the importance of adherence to clinical practice guidelines since spinal disorders are consistently within the top ten of the most expensive health care presentations [16, 17], thus some health system administrators are beginning to actually require practitioners to practice within clinical frameworks regardless of their profession particularly when third party payers such as insurers are involved [18].
Here we set out to expand on previously published models for clinical decision-making [19–21]. We feel since the one we present has been useful in an educational context it may assist field practitioners as well.
Models using diagnosis based decision-making must be tempered by the recognition that even experienced clinicians may be unaware of the correctness of their diagnoses at the time they make them [22–24]. Hoffman et al [21] presented a framework involving an active discourse between practitioner and patient which follows; “What will happen if we wait and watch? What are the test or treatment options? What are the benefits and harms of these options? How do the benefits and harms weigh up for this patient? Do both patient and practitioner have enough information to make a choice” [21]? Clinical decision support aids including the one we present assume and ensure use of best available evidence and patient-specific information to enhance patient care. They may encompass computerised alerts and reminders; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support, and contextually relevant reference information [25].
Evidence based practice (EBP) aims to facilitate the practitioner’s clinical decision making process [26] and is based upon the premise that patient management should be guided by methodologically robust research findings [27–30]. The ‘three pillars’ or ‘three legged stool’ [28, 31] of evidence-based practice constitute the philosophical foundation of our model; effectively a ‘social constructivist’ or ‘participatory’ paradigm where clinical reality is ‘constructed’ by the participants; clinician and patient engaging throughout the course of clinical encounters and the care journey [32]. Clinicians should actually incorporate knowledge from 5 distinct areas into each management decision: empirical evidence, experiential evidence, physiologic principles, patient and professional values, and system features. The relative weight given to each of these areas is not predetermined, but varies from case to case [33]. It is important to remember everything ‘starts and ends’ with the patient. In our view this is a pragmatic, defendable stance reflective of sensible clinical practice recognising that the very application of EBP itself requires clinician expertise.
All clinicians must be mindful to practice ethically and competently within their own legally allowed scope of practice. For chiropractors this role is best described as primary contact rather than primary care [34, 35]. The clinicians’ own education, experience and specific expertise, including training at undergraduate and postgraduate level must underpin all clinical decision-making.
We suggest clinicians firstly to refer to evidence-based guidelines (EBGs) or consensus clinical practice guidelines (CPGs) relating as closely as possible to the problem of concern in their individual patient. ‘Best evidence’ is contained in a clinical guidelines, thus the clinician may be reasonably confident a robust process has been followed in assessing available evidence to achieve consensus by expert panels [36]. Clinical practice guidelines are a useful resource for clinicians as they preclude the clinician having to access all the literature, while protecting clinicians from ‘selective citation’. However, clinical context; does the evidence help one care for this patient, is then always a ‘value call’ for the clinician [37, 38].
The strength of a recommendation in a guideline reflects the extent of confidence that desirable effects of an intervention outweigh undesirable effects [39, 40], the strength of recommendations are determined by the balance between desirable and undesirable consequences of alternative management strategies, quality of evidence, variability in values and preferences, and cost [30, 39, 41].
Modifying this guideline ranking format to be relevant to patient choices could also be useful when providing a patient with their treatment/management options; “Will it help?” 1) Probably: thus most people in the same situation would choose the recommended course of action and only a small proportion would not, 2) Possibly: most people in the same situation would want the recommended course of action, but many would not, 3) Maybe: some people would choose the option but many would not, 4) Unlikely: some people may choose the option but most would not. Thus patient consent can be obtained in the context of probability, predictability and reliability of an outcome.
When there is inconclusive non-favourable evidence patients should be advised that this treatment is likely not to be effective and more effective treatments should be recommended where available. Where findings are reported as high and moderate quality negative evidence, patients should be actively advised against the use of this treatment and a more effective alternative should be recommended where available.
Patients’ expectations, goals, values and choices as components of EBP are important drivers of health care systems and technology developments [42, 43]. It remains critical that the priority of the patient’s right and ability to choose health care that suits their world view and personal preference is not compromised, so long as these choices are informed and reasonable and are not made as a result of coercion, deception or indefensible claims [44, 45]. Patients have questions; “What is wrong with me?” “Can you help?” “Is what you do safe?” “What are my options?” “What will happen if I do nothing?” “How much will it cost?” “How long will it take?” [46]. There are several additional questions the clinician should also ask themselves on behalf of the patient; “What else could it be?” “Is there anything that doesn’t fit?” and “Is it possible there is more than one problem?” The patient may well in the chiropractors’ opinion, have biomechanical or functional [47] spinal ‘lesions’, but what else might they have [48, 49]? Clearly, with aging populations, a significant proportion of people will have multiple health issues which will require management decisions including co-management.
Information for patients
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.
Methods
The decision-aid
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].
Fig. 1
The ‘PICO-D Man’ schematic clinical and educational chiropractic decision-aid for field practitioners and students
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.
Fig. 2
A table for applying the PICO-D Man decision-aid in clinical practice
We will now review the application of the ‘PICO-D Man’ decision-aid to a hypothetical example of acute and subacute low back pain.
Clinical scenario; A 28 year old male Caucasian carpenter presents with severe low back pain located over the right side of his low back region (he points to the right SI-J). It has been ten days since he reached under a bench for a jig-saw and felt a sharp pain which he now rates as a 7/10 on a numerical rating scale. It is not getting better, in fact if anything it is getting worse. He denies any radiations or pain on coughing or exertion, but it ‘grabs’ him when he twists to the right or looks upwards. He has had a couple of previous episodes about two years ago when he saw another chiropractor for a few weeks and has had no trouble since, however this time the pain also seems to travel up along his spine to the base of his neck. He has not seen anyone else about this pain and is not taking any medications except over the counter pills. He has never had any surgeries or hospitalisations and to his knowledge no family history of serious illnesses or back pain. He is an otherwise healthy male individual who is in obvious distress due to the pain. On examination; vital signs/reflexes/myotomes/dermatomes are all within normal limits. He has a low right iliac crest and left shoulder, muscle guarding over right Quadratus Lumborum, -ve Straight Leg Raise/Bilateral Leg Raise/Slump Test, -ve Valsalva, -ve Fabere-Patrick/Fig. 4, +ve R SI Thrust, Gaenslens, SI compression and distraction tests. Static and motion palpation of the spine and pelvis reveal significant findings in right SI-J. In addition, there are signs of spinal dysfunction affecting the upper thoracic and lower cervical spinal regions.
Diagnosis; acute, moderate, right sacro-iliac biomechanical dysfunction (acute low back pain) with associated cervico-thoracic spinal dysfunction (Primary dx: ICD code: M54.5).
Problem: acute and subacute low back (spinal) pain
“What is wrong with me, can you get rid of this pain?”; the patient description; diagnosis, desires, ideas, concerns and expectations.
Referring to contemporary guidelines for acute and subacute low back pain yields the following ‘generic’ recommendations;
Education: Provide advice and information addressing unhelpful beliefs, fear avoidance and to promote self-management.
Physical activity: advise patients with acute and subacute low back pain to stay active and continue activities of daily living within the limits permitted by their symptoms. Discourage prolonged bed rest.
Exercise: should be recommended to reduce the recurrence of low back pain.
Heat may be used for pain relief.
Intervention: usual chiropractic care (UCC)
“Can you help?”
Consider offering a course of manual care, including spinal manipulation over a period of up to 12 weeks in addition to the generic management already outlined [58, 64].
Comparator: usual medical care (UMC)
“What are my options?”
Simple analgesia (e.g. acetaminophen/paracetamol): is routinely recommended in guidelines for acute and subacute low back pain [65]. Recent evidence has however raised serious questions concerning effectiveness [66] and safety [67]). NSAIDs: may also be used for short-term pain relief. Opioids: cautious and responsible use of opioids may be considered for those carefully selected patients with severe acute pain not controlled with acetaminophen and NSAIDs at a minimum effective dose for a limited period of time, usually less than one to two weeks [68].
Other interventions
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].
Other factors considered within guidelines*
(*We have extracted relevant specific citations from clinical practice guidelines for risk, cost, feasibility, measures and duration).
Comparator: natural history
“What if I do nothing?”
When considering the natural history of spinal pain it must be noted that there is wide variation in the literature, with up to 80% chance of recurrence and up to a 30% chance of non-resolution inside a year [69]. For patients with multiple regions of pain, the prognosis is even more bleak [70]. Thus, acute back pain can be considered neither as automatically self-limiting nor insignificant. Natural history may possibly be described as “the future will likely reflect the past. If you have had episodes of pain in the past, recurrence is common”.
Risk: “Is it safe?”
Serious direct adverse events following generic active lifestyle and behaviour modification and self-care recommendations are predictably rare since they essentially relate to natural history [71–73] and the main risk associated with natural history is progression to chronicity [74, 75]. Chiropractic spinal manipulation for acute and subacute low back pain is also rarely associated with serious adverse outcomes, we could locate no documented cases of mortality from low back spinal manipulation and even mild adverse events have not been shown to be more common than placebo [76, 77]. Pharmaceutical management however, is however associated with significantly greater risk even for simple analgesia, especially in children and vulnerable populations [78, 79]. Persons with one or more GI risk factor (longer duration of use, higher dose, age 60 years or older, history of peptic ulcer disease, alcohol use, concomitant use of corticosteroids or anticoagulants, or general frailty) should either lower their NSAID dose, take the drugs intermittently - or not to take them at all [80–82]. NSAID use is associated with an increased risk of death or myocardial infarction by up to 5 times that of non-users [83]. Acetaminophen (paracetamol) even taken in low doses by pregnant women is associated with side-effects including higher incidence of ADHD and is the cause of poisoning in 8000 Australians per year [84–86]. Opioid drugs and benzodiazepines are associated with significant risks and complications related to tolerance (and escalating doses), addiction, misuse, abuse and death, particularly with chronic or recurrent spinal pain syndromes. Notwithstanding, some clinical guidelines recommend the judicious use of strong analgesics and benzodiazepines, such as tramadol, oxycodone and diazepam, in acute cases of back pain of less than 4 weeks duration, even though the supporting research evidence is weak [87].
Cost and feasibility: “How much does it cost?”
Feasibility and practicality; “is the proposed plan of management available and within the means of the patient?” Practitioners must bear in mind that they are acting in effect as the patients’ ‘agent’. There is usually a direct financial benefit that accrues to the practitioner following recommendations, thus there is the issue of the ‘agent moral hazard’ of which to be mindful [88]. Regulations govern the appropriate scheduling and degree of servicing in plans of management [50]. Current data support the management of spinal pain with an approach that includes spinal manipulation and chiropractic compares favourably in cost effectiveness studies [89–91].
Outcome measures: “How will we measure improvement?”
All plans of management should include outcomes, milestones or goals. Goals that are focused on function set a more meaningful and holistic target to work towards than those focused on impairments. Management is clinically justified when it promotes independence, improves function and participation, or demonstrably prevents the person from significantly deteriorating from their current level of function [18, 69, 92]. Goals and outcomes should ideally be framed in a SMART format. This acronym is commonly used in many contexts including healthcare. Specific; names the particular variable of interest, e.g. the distance the patient is able to walk, or hours at work, Measurable; there is a measurement unit (e.g. metres, hours, 0-10 scale), Achievable; the goal is likely to be achieved given the diagnosis and prognosis and any environmental constraints, Relevant; the goal is important to the person and other stakeholders and there is a Time-frame; within which the goal is expected to be achieved. These “outcome measures” thus are framed in terms of the subjective, objective and patient specific (activities of daily living) measures. There are reliable, validated (questionnaire) outcome measures freely available that may be used such as; Revised Oswestry Back Pain Disability Questionnaire and the Quebec Back Pain Disability Scale [93, 94].
Duration/timing
Current guidelines recommend plans of management for acute and subacute low back pain be framed with a duration no longer than 12 weeks with appropriate milestones [64].
Summary
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].
Results and Discussion
The application of EBP may seem an insurmountable and complex challenge to the field practitioner due to many factors. Among other well described barriers is the sheer volume of published material against a backdrop of the human propensity to ‘cherry pick’ the evidence to find that which supports one’s preferred methods which leads to a situation in virtually all professions where proponents despair about the low adoption of, and field resistance to EBP [12, 96]. When ‘PICO-D Man’ is applied in a pragmatic and feasible way, we feel these ‘barriers’ may become ‘enablers’ for the chiropractic profession as clinicians and patients are both empowered by evaluation and application of evidence. Reasoned debate around the issue of adoption of evidence in clinical practice (EBP) must include the evaluation of the options available to consumers (comparator). At best, it is incomplete to consider only the proposed intervention side of the equation. In the chiropractic context, evaluation of effectiveness of usual chiropractic care intervention is almost meaningless if not accompanied with both that of usual medical and other care options including the natural history for the condition. When neither intervention is shown to be clinically superior, patient preference becomes the salient variable. Preference-sensitive treatment decisions involve making value trade-offs between benefits and harms that should depend on informed patient choice. There is strong evidence that patient decision-aids not only improve decision quality but also prevent the overuse of options that informed patients do not value [97].
Implementation
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.
Strengths and limitations
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’.
Conclusion
The decision-aid is offered here in the hope it may prove useful to educators and field clinicians alike in applying evidence-informed practice within the chiropractic profession. Academics, clinicians, researchers, students and patients often view the health-care world and the place of chiropractic in it in drastically different ways. Thus, this paper is partly aspirational and is presented principally to assist chiropractic students, educators and field practitioners in ethical and defensive, contextual clinical decision-making. Students often appear unable to integrate the principles of EBP they have learned in the academic curriculum in a practical clinical setting, and field practitioners frequently express an overt disinterest or outright antithesis toward EBP, a phenomenon by no means confined to the chiropractic profession. For students, one collateral effect of engaging in a formal ‘application’ process is often enhanced confidence in clinical management-plan construction, and for field practitioners, (for example) justification for payment. With integration into informed consent, patient feedback and possibly simulated learning and ongoing learning (CPD) scenarios; the decision-aid could conceivably inform research and further facilitate evidence-informed clinical practice. The decision-aid may also help clinicians provide healthcare consumers with patient-centred care.
Abbreviations
ADHD:
Attention deficit hyperactivity disorder
CPD:
Continuing professional development
CPG:
Clinical practice guideline
EBCP:
Evidence-based chiropractic practice
EBG:
Evidence-based guideline
EBP:
Evidence-based practice
GI:
Gastro-intestinal
LBP:
Low back pain
NH:
Natural history
NSAIDs:
Non-steroidal anti-inflammatory drugs
SMART:
Specific measurable achievable relevant timed (Goals)
UCC:
Usual chiropractic care
UMC:
Usual medical care.
Declarations
Acknowledgement
The authors acknowledge Dr Craig Moore for review of the final manuscript.
Funding
Not applicable. The authors declare no conflict of interest.
Availability of data and materials
Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
Authors’ contributions
LAW conceived and developed the decision-aid including the table and the figure and drafted the original manuscript, BEL contributed to editing and redrafting the final manuscript. Both authors read and approved the final manuscript.
Competing interests
Not applicable.
Consent for publication
Not applicable.
Ethics approval and consent to participate
Not applicable.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Authors’ Affiliations
(1)
School of Health Professions
References
Nowak NA, Rimmasch H, Kirby A, Kellogg C. Right care, right time, right place, every time. Healthc Financ Manage. 2012;66(4):82–8.PubMedGoogle Scholar
Swan BA, Boruch RF. Quality of evidence: usefulness in measuring the quality of health care. Med Care. 2004;42(2 Suppl):Ii12–20.PubMedGoogle Scholar
Leach MJ. Evidence-based practice: a framework for clinical practice and research design. Int J Nurs Pract. 2006;12(5):248–51.PubMedView ArticleGoogle Scholar
Lubarsky DA, Glass PS, Ginsberg B, Dear GL, Dentz ME, Gan TJ, Sanderson IC, Mythen MG, Dufore S, Pressley CC, et al. The successful implementation of pharmaceutical practice guidelines. Analysis of associated outcomes and cost savings. SWiPE Group. Systematic Withdrawal of Perioperative Expenses. Anesthesiology. 1997;86(5):1145–60.PubMedView ArticleGoogle Scholar
Fritz JM, Cleland JA, Brennan GP. Does adherence to the guideline recommendation for active treatments improve the quality of care for patients with acute low back pain delivered by physical therapists? Med Care. 2007;45(10):973–80.PubMedView ArticleGoogle Scholar
Rutten GM, Degen S, Hendriks EJ, Braspenning JC, Harting J, Oostendorp RA. Adherence to clinical practice guidelines for low back pain in physical therapy: do patients benefit? Phys Ther. 2010;90(8):1111–22.PubMedView ArticleGoogle Scholar
Hall G. Attitudes of chiropractors to evidence-based practice and how this compares to other healthcare professionals: a qualitative study. Clin Chiropr. 2011;14(3):106–11.View ArticleGoogle Scholar
Newell D, Cunliffe C. Attitudes toward research in undergraduate chiropractic students. Clin Chirop. 2003;6(3):109–19.View ArticleGoogle Scholar
Cote AM, Durand MJ, Tousignant M, Poitras S. Physiotherapists and use of low back pain guidelines: a qualitative study of the barriers and facilitators. J Occup Rehabil. 2009;19(1):94–105.PubMedView ArticleGoogle Scholar
Lugtenberg M, Burgers JS, Besters CF, Han D, Westert GP. Perceived barriers to guideline adherence: a survey among general practitioners. BMC Fam Pract. 2011;12(1):1–9.View ArticleGoogle Scholar
Goderis G, Borgermans L, Mathieu C, Van Den Broeke C, Hannes K, Heyrman J, Grol R. Barriers and facilitators to evidence based care of type 2 diabetes patients: experiences of general practitioners participating to a quality improvement program. Implement Sci. 2009;4:41.PubMedPubMed CentralView ArticleGoogle Scholar
McDonnell Norms Group. Enhancing the use of clinical guidelines: a social norms perspective. J Am Coll Surg. 2006;202(5):826–36.View ArticleGoogle Scholar
Bussières AE, Al Zoubi F, Stuber K, French SD, Boruff J, Corrigan J, Thomas A. Evidence-based practice, research utilization, and knowledge translation in chiropractic: a scoping review. BMC Complement Altern Med. 2016;16:216.PubMedPubMed CentralView ArticleGoogle Scholar
Hufford DJ, Sprengel M, Ives JA, Jonas W. Barriers to the entry of biofield healing into “Mainstream” healthcare. Global Adv Health Med. 2015;4(suppl):79–88.View ArticleGoogle Scholar
French S, Charity M, Forsdike K, Gunn J, Polus B, Walker B, Chondros P, Britt H. Chiropractic Observation and Analysis STudy (COAST): providing an understanding of current chiropractic practice. Med J Aust. 2013;199(10):687–91.PubMedGoogle Scholar
Amorin-Woods L, Parkin-Smith G. Clinical decision-making to facilitate appropriate patient management in chiropractic practice: ‘the 3-questions model’. Chiropr Man Therap. 2012;20(1):6.PubMedPubMed CentralView ArticleGoogle Scholar
Murphy D, Hurwitz E. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. BMC Musculoskel Dis. 2007;8(1):75.View ArticleGoogle Scholar
Hoffmann TC, Légaré F, Simmons MB, McNamara K, McCaffery K, Trevena LJ, Hudson B, Glasziou PP, Del Mar CB. Shared decision making: what do clinicians need to know and why should they bother? Med J Aust. 2014;201(1):35–9.PubMedView ArticleGoogle Scholar
Hoffman P. The paramorphic representation of clinical judgment. Psychol Bull. 1960;57(2):116–31.PubMedView ArticleGoogle Scholar
Donelson R. Evidence-based low back pain classification. Improving care at its foundation. Eura Medicophys. 2004;40(1):37–44.PubMedGoogle Scholar
Friedman CP, Gatti GG, Franz TM, Murphy GC, Wolf FM, Heckerling PS, Fine PL, Miller TM, Elstein AS. Do physicians know when their diagnoses are correct? J Gen Intern Med. 2005;20(4):334–9.PubMedPubMed CentralView ArticleGoogle Scholar
Banzai R, Derby DC, Long CR, Hondras MA. International web survey of chiropractic students about evidence-based practice: a pilot study. Chiropr Man Therap. 2011;19(1):6.PubMedPubMed CentralView ArticleGoogle Scholar
Budovec JJ, Kahn Jr CE. Evidence-based radiology: a primer in reading scientific articles. AJR Am J Roentgenol. 2010;195(1):W1–4.PubMedView ArticleGoogle Scholar
Sackett DL, Rosenberg WMC, Muir Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ (Clin Res Ed). 1996;312(7023):71–2.View ArticleGoogle Scholar
Straus S, Richardson WS, Glasziou P, Haynes RB. Evidence-based medicine: How to practice and teach EBM, 3rd ed [4th Ed.: 2011] edn. Edinburgh: Churchill Livingstone; 2005.Google Scholar
Eddy DM. Evidence-based medicine: a unified approach. Health Aff. 2005;24(1):9–17.View ArticleGoogle Scholar
Kaplan BJ, Giesbrecht G, Shannon S, McLeod K. Evaluating treatments in health care: the instability of a one-legged stool. BMC Med Res Methodol. 2011;11:65.PubMedPubMed CentralView ArticleGoogle Scholar
Heron J, Reason P. A participatory inquiry paradigm. Qual Inq. 1997;3(3):274–94.View ArticleGoogle Scholar
Tonelli MR. The limits of evidence-based medicine. Respir Care. 2001;46(12):1435–40. discussion 1440-1431.PubMedGoogle Scholar
Nelson C, Lawrence D, Triano J, Bronfort G, Perle S, Metz RD, Hegetschweiler K, LaBrot T. Chiropractic as spine care: a model for the profession. Chiropr Osteopat. 2005;13(1):9.PubMedPubMed CentralView ArticleGoogle Scholar
Murphy D, Justice B, Paskowski I, Perle S, Schneider M. The establishment of a primary spine care practitioner and its benefits to health care reform in the United States. Chiropr Man Therap. 2011;19(1):17.PubMedPubMed CentralView ArticleGoogle Scholar
Lewis S, Warlow C. How to spot bias and other potential problems in randomised controlled trials. J Neurol Neurosur Ps. 2004;75(2):181–7.View ArticleGoogle Scholar
Enkin M, Jadad A. Using anecdotal information in evidence-based health care: Heresy or necessity? Ann Oncol. 1998;9(9):963–6.PubMedView ArticleGoogle Scholar
Guyatt G, Oxman A, Kunz R, Falck-Ytter Y, Vist G, Liberati A, Schünemann H, GRADE Working Group. Rating quality of evidence and strength of recommendations: Going from evidence to recommendations. BMJ. 2008;336(7652):1049–51.PubMedPubMed CentralView ArticleGoogle Scholar
Schunemann H, Best D, Vist G, Oxman A. Letters, numbers, symbols and words: how to communicate grades of evidence and recommendations. CMAJ. 2003;169:677–80.PubMedPubMed CentralGoogle Scholar
Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, Vist GE, Falck-Ytter Y, Meerpohl J, Norris S, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401–6.PubMedView ArticleGoogle Scholar
Swan M. Emerging patient-driven health care models: an examination of health social networks, consumer personalized medicine and quantified self-tracking. Int J Environ Res Public Health. 2009;6(2):492–525.PubMedPubMed CentralView ArticleGoogle Scholar
Bronfort G, Haas M, Evans R, Leiniger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. 2010;18:3.PubMedPubMed CentralView ArticleGoogle Scholar
Matthys J, Elwyn G, Van Nuland M, Van Maele G, De Sutter A, De Meyere M, Deveugele M. Patients’ ideas, concerns, and expectations (ICE) in general practice: impact on prescribing. Br J Gen Pract. 2008;59(558):29–36.PubMed CentralView ArticleGoogle Scholar
Verbeek J, Sengers M-J, Riemens L, Haafkens J. Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies. Spine. 2004;29(20):2309–18.PubMedView ArticleGoogle Scholar
Rome P. Usage of chiropractic terminology in the literature: 296 ways to say “subluxation”: complex issues of the vertebral subluxation. Chiro Tech. 1996;8(2):49–60.Google Scholar
Groopman J. How Doctors Think. New York: Houghton Mifflin; 2007.Google Scholar
Crawford C. Guest editorial: semantics, pedantics and the chiropractic lesion; the great subluxation Debate. COMSIG Rev. 1994;3(3):70–2.PubMed CentralGoogle Scholar
Weir M. Obligation to advise of options for treatment - medical doctors and complementary and alternative medicine practitioners. J Law Med. 2003;10:296.PubMedGoogle Scholar
Leask J, Wiley K, Tjokrowidjaja A. SEIB Colloquium, School of Public Health, National Centre for Immunisation Research & Surveillance, University of Sydney. 2012.Google Scholar
Amorin-Woods LG. Sophisticated research design in chiropractic and manipulative therapy; “what you learn depends on how you ask”. Part A. Quantitative research: size does matter. Chir J Aust. 2016;44(2):85–105.Google Scholar
Amorin-Woods LG. Sophisticated research design in chiropractic and manipulative therapy; “what you learn depends on how you ask”. Part B: Qualitative research; quality vs. quantity. Chir J Aust. 2016;44(2):106–20.Google Scholar
Amorin-Woods LG. Sophisticated research design in chiropractic and manipulative therapy; what you learn depends on how you ask. Part C: Mixed Methods: “why can’t science and chiropractic just be friends?”. Chir J Aust. 2016;44(2):121–41.Google Scholar
Goertz M, Thorson D, Bonsell J, Bonte B, Campbell R, Haake B, Johnson K, Kramer C, Mueller B, Peterson S, Setterlund L, Timming R. Institute for Clinical Systems Improvement. Adult Acute and Subacute Low Back Pain. Updated November 2012. https://www.icsi.org/_asset/bjvqrj/LBP.pdf. Accessed 15 Nov 2016.
Livingston C, King V, Little A, Pettinari C, Thielke A, Gordon C. State of Oregon Evidence-based Clinical Guidelines Project. Evaluation and management of low back pain: A clinical practice guideline based on the joint practice guideline of the American College of Physicians and the American Pain Society (Diagnosis and treatment of low back pain). Salem, OREGON: Office for Oregon Health Policy and Research; 2011.Google Scholar
Savigny P, Kuntze S, Watson P, Underwood M, Ritchie G, Cotterell M, Hill D, Browne N, Buchanan E, Coffey P, Dixon P, Drummond C, Flanagan M, Greenough C, Griffiths M, Halliday-Bell J, Hettinga D, Vogel S, Walsh D. Low Back Pain: early management of persistent non-specific low back pain. London: National Collaborating Centre for Primary Care and Royal College of General Practitioners. https://www.nice.org.uk/guidance/cg88/evidence/full-guideline-243685549. Accessed 15 Nov 2016.
Williams CM, Maher CG, Latimer J, McLachlan AJ, Hancock MJ, Day RO, Lin C-WC. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet 2014.Google Scholar
Machado GC, Maher CG, Ferreira PH, Pinheiro MB, Lin C-WC, Day RO, McLachlan AJ, Ferreira ML. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ (Clin Res Ed). 2015;350:h1225.Google Scholar
Parkin-Smith G, Amorin-Woods L, Davies S, Losco B, Adams J. Spinal pain: current understanding, trends, and the future of care. J Pain Res. 2015;8:741–52.PubMedPubMed CentralView ArticleGoogle Scholar
Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, York J, Das A, McAuley JH. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ. 2008;337:a171.Google Scholar
Vasseljen O, Woodhouse A, Bjørngaard J, Leivseth L. Natural course of acute neck and low back pain in the general population: the HUNT study. Pain. 2013;154(8):1237–44.PubMedView ArticleGoogle Scholar
Dahm K, Brurberg K, Jamtvedt G, Hagen K. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010, 6(CD007612).Google Scholar
Henschke N, Ostelo RWJG, van Tulder MW, Vlaeyen JWS, Morley S, Assendelft WJJ, CJ. M: Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev. 2010, 7(Art. No.: CD002014).Google Scholar
Engers A, Jellema P, Wensing M, van der Windt D, Grol R, van Tulder M. Individual patient education for low back pain. Cochrane Database Syst Rev. 2008, Issue 1(Art. No.: CD004057).Google Scholar
Voscopoulos C, Lema M. When does acute pain become chronic? Brit J Anaesth. 2010;105 suppl 1:i69–85.PubMedView ArticleGoogle Scholar
Grotle M, Foster NE, Dunn KM, Croft P. Are prognostic indicators for poor outcome different for acute and chronic low back pain consulters in primary care? Pain. 2010;151(3):790–7.PubMedPubMed CentralView ArticleGoogle Scholar
Assendelft WJ, Bouter LM, Knipschild PG. Complications of spinal manipulation: a comprehensive review of the literature. J Fam Pract. 1996;42:475–80.PubMedGoogle Scholar
Walker BF, Hebert JJ, Stomski NJ, Clarke BR, Bowden RS, Losco B, French SD. Outcomes of usual chiropractic. The OUCH randomized controlled trial of adverse events. Spine (Phila Pa 1976). 2013;38(20):1723–9.View ArticleGoogle Scholar
Rajanayagam J, Bishop JR, Lewindon PJ, Evans HM. Paracetamol-associated acute liver failure in Australian and New Zealand children: high rate of medication errors. Arch Dis Child. 2014.Google Scholar
Pratt N, Roughead EE, Ryan P, Gilbert AL. Differential impact of NSAIDs on rate of adverse events that require hospitalization in high-risk and general veteran populations. Drugs Aging. 2010;27(1):63–71.PubMedView ArticleGoogle Scholar
Meara AS, Simon LS. Advice from professional societies: appropriate use of NSAIDs. Pain Med. 2013;14:S3–S10.PubMedView ArticleGoogle Scholar
Wilcox C, Cryer B, Triadafilopoulos G. Patterns of use and public perception of over-the-counter pain relievers: focus on nonsteroidal antiinflammatory drugs. J Rheumatol. 2005;32:2218–24.PubMedGoogle Scholar
Wong A, Graudins A, Kerr F, Greene S. Paracetamol toxicity: what would be the implications of a change in Australian treatment guidelines? Emerg Med Australas. 2014;26(2):183–7.PubMedView ArticleGoogle Scholar
Lieu Z, Ritz B, Rebordosa C, Lee P-C, Olsen J. Acetaminophen use during pregnancy, behavioral problems, and hyperkinetic disorders. JAMA Pediatr. 2014;168(4):313–20.View ArticleGoogle Scholar
Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-Based Management of Acute Musculoskeletal Pain. 2003.Google Scholar
Mooney G, Ryan M. Agency in health care: Getting beyond first principles. J Health Econ. 1993;12(2):125–35.PubMedView ArticleGoogle Scholar
Lin C, Haas M, Maher C, Machado L, van Tulder M. Cost-effectiveness of guidelines-endorsed treatments for low back pain: a systematic review. Eur Spine J. 2011;20(7):1024–38.PubMedPubMed CentralView ArticleGoogle Scholar
Michaleff Z, Lin C, Maher C, van Tulder M. Spinal manipulation epidemiology: systematic review of cost effectiveness studies. J Electromyogr Kinesiool. 2012;22(5):655–62.View ArticleGoogle Scholar
Sarnat RL, Winterstein J, Cambron JA. Clinical utilization and cost outcomes from an integrative medicine independent physician association: an additional 3-year update. J Manip Physiol Ther. 2007;30(4):263–9.View ArticleGoogle Scholar
Australasian Faculty of Occupational and Environmental Medicine, Position Statement: Realising the Health Benefits of Work. Sydney: Australasian Faculty of Occupational & Environmental Medicine; 2011:p22.Google Scholar
Deyo R, Battie M, Beurskens A, et al. Outcome measures for low back pain research: a proposal for standardized use. Spine. 1998;23:2003–13.PubMedView ArticleGoogle Scholar
Kopec J, Esdaile J, Abrahamowicz M, et al. The Quebec Back Pain Disability Scale: conceptualization and development. J Clin Epidemiol. 1996;49:151–61.PubMedView ArticleGoogle Scholar
Amorin-Woods LG, Parkin-Smith GF, Saboe V, Rosner AL. Recommendations to the Musculoskeletal Health Network, Health Department of Western Australia related to the spinal pain model of care made on behalf of the chiropractors association of Australia (Western Australian Branch). Top Integr Health Care. 2014, 5(2):ID: 5.2002.Google Scholar
Green LW. Making research relevant: if it is an evidence-based practice, where’s the practice-based evidence? Fam Pract. 2008;25(suppl_1):i20–24.PubMedView ArticleGoogle Scholar
O’Connor AM, Wennberg JE, Legare F, Llewellyn-Thomas HA, Moulton BW, Sepucha KR, Sodano AG, King JS. Toward the ‘Tipping Point’: decision aids and informed patient choice. Health Aff. 2007;26(3):716–25.View ArticleGoogle Scholar
Fritsche L, Greenhalgh T, Falck-Ytter Y, Neumayer HH, Kunz R. Do short courses in evidence based medicine improve knowledge and skills? Validation of Berlin questionnaire and before and after study of courses in evidence based medicine. BMJ (Clin Res Ed). 2002;325(7376):1338–41.View ArticleGoogle Scholar
Shaneyfelt T, Baum KD, Bell D, et al. Instruments for evaluating education in evidence-based practice: a systematic review. JAMA. 2006;296(9):1116–27.PubMedView ArticleGoogle Scholar
Straus SE, Green ML, Bell DS, Badgett R, Davis D, Gerrity M, Ortiz E, Shaneyfelt TM, Whelan C, Mangrulkar R. Evaluating the teaching of evidence based medicine: conceptual framework. BMJ (Clin Res Ed). 2004;329(7473):1029–32.View ArticleGoogle Scholar
Cohen AM, Stavri PZ, Hersh WR. A categorization and analysis of the criticisms of Evidence-Based Medicine. Int J Med Inform. 2004;73(1):35–43.PubMedView ArticleGoogle Scholar
Haynes RB. What kind of evidence is it that Evidence-Based Medicine advocates want health care providers and consumers to pay attention to? BMC Health Serv Res. 2002;2(1):3.PubMedPubMed CentralView ArticleGoogle Scholar
Goldgar C, Keahey D. Evidence for Evidence-Based Medicine. J Physician Assist Educ. 2007;18(4):52–6.View ArticleGoogle Scholar
Lewis S, Orland B. The importance and impact of Evidence Based Medicine. J Manag Care Pharm. 2004;10(5 Supp A):S3–5.PubMedGoogle Scholar
Gupta M. Improved health or improved decision making? The ethical goals of EBM. J Eval Clin Pract. 2011;17(5):957–63.PubMedView ArticleGoogle Scholar
Hjørland B. Evidence-based practice: an analysis based on the philosophy of science. J Am Soc Inf Sci Technol. 2011;62(7):1301–10.View ArticleGoogle Scholar
Scuffham P, Nikles J, Mitchell G, Yelland M, Vine N, Poulos C, Pillans P, Bashford G, del Mar C, Schluter P, et al. Using N-of-1 trials to improve patient management and save costs. J Gen Intern Med. 2010;8:906–13.View ArticleGoogle Scholar
Tonelli M. Integrating evidence into clinical practice: an alternative to evidence-based approaches. J Eval Clin Pract. 2006;12:248–56.PubMedView ArticleGoogle Scholar
Evidence Based Manual Medicine: A problem based approach. Philadelphia: Saunders Elsievier; 2007.Google Scholar
Riva JJ, Malik KMP, Burnie SJ, Endicott AR, Busse JW. What is your research question? An introduction to the PICOT format for clinicians. J Can Chiropr Assoc. 2012;56(3):167–71.PubMedPubMed CentralGoogle Scholar
Rome P. Neurovertebral influence upon the autonomic nervous system: some of the somato-autonomic evidence to date. Chir J Aust. 2009;39(1):2–17.Google Scholar
Amorin-Woods LG, Beck RW, Parkin-Smith GF, Lougheed J, Bremner AP. Adherence to clinical practice guidelines among three primary contact professions: a best evidence synthesis of the literature for the management of acute and subacute low back pain. J Can Chiropr Assoc. 2014;58(3):220–37.PubMedPubMed CentralGoogle Scholar
Kongsted A, Vach W, Axo M, Bech RN, Hestbaek L. Expectation of recovery from low back pain: a longitudinal cohort study investigating patient characteristics related to expectations and the association between expectations and 3-month outcome. Spine. 2014;39(1):81–90.PubMedView ArticleGoogle Scholar
Malkin I, Williams FMK, LaChance G, Spector T, MacGregor AJ, Livshits G. Low back and common widespread pain share common genetic determinants. Ann Hum Genet. 2014;78(5):357–66.PubMedView ArticleGoogle Scholar
Triano J. What constitutes evidence for best practice? J Manip Physiol Ther. 2008;31(9):637–43.View ArticleGoogle Scholar
Sox H. Screening mammography in women younger than 50 years of age. Ann Intern Med. 1995;122:550–2.PubMedView ArticleGoogle Scholar
Leboeuf-Yde C, Lanlo O, Walker B. How to proceed when evidence-based practice is required but very little evidence available? Chiropr Man Therap. 2013;21(1):24.PubMedPubMed CentralView ArticleGoogle Scholar
Emanuel E, Wendler D, Killen J, Grady C. What makes clinical research in developing countries ethical? The benchmarks of ethical research. J Infect Dis. 2004;189(5):930–7.PubMedView ArticleGoogle Scholar
Benatar S. Avoiding exploitation in clinical research. Camb Q Health Ethics. 2000;9(4):562–5.View ArticleGoogle Scholar
Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655.PubMedPubMed CentralView ArticleGoogle Scholar
Kessler R, Glasgow RE. A proposal to speed translation of healthcare research into practice: dramatic change is needed. Am J Prev Med. 2011;40(6):637–44.PubMedView ArticleGoogle Scholar
Jackson R, Ameratunga S, Broad J, Connor J, Lethaby A, Robb G, Wells S, Glasziou P, Heneghan C. The GATE frame: critical appraisal with pictures. Evid Based Med. 2006;11(2):35–8.PubMedView ArticleGoogle Scholar
O'Connor AM, Rostom A, Fiset V, Tetroe J, Entwistle V, Llewellyn-Thomas H, Holmes-Rovner M, Barry M, Jones J. Decision aids for patients facing health treatment or screening decisions: systematic review. BMJ (Clin Res Ed). 1999;319(7212):731–4.View ArticleGoogle Scholar
Kassirer J. Incorporating patients’ preferences into medical decisions. N Engl J Med. 1994;330:1895–6.PubMedView ArticleGoogle Scholar
Adams J, Steel A, Chang S, Sibbritt D. Helping address the national research and research capacity needs of Australian chiropractic: introducing the Australian Chiropractic Research Network (ACORN) project. Chiropr Man Therap. 2015, 23(12).Google Scholar
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