Despite existing clinical practice guidelines for optimal management of axial spine pain,[1,2,3,4] the degree of adherence across different health care disciplines varies widely.[2,5,6,7] Known gaps between guidelines and routine health care practice reflect a universal need for more effective knowledge translation.[8,9] Particularly in primary care, effective knowledge translation strategies must consider the constraints faced by busy practitioners, including personal and organizational barriers to change. Targeted clinicians must also be convinced that study patients, from whom the data originate, are sufficiently representative of patients in their real-world practices.

Since knowledge translation often requires changes in clinicians’ beliefs and behavior, strategies should be based on explanatory frameworks explicitly recognizing the psychological determinants of behavior change.[10] With this in mind, chiropractic researchers have used the Theoretical Domains Framework (TDF) to inform the design of interventions aimed specifically at changing practice behavior,[11,12] and encouraging better adherence to neck pain clinical practice guidelines.[13] In keeping with the TDF approach, chiropractors’ beliefs about managing nonspecific neck pain were evaluated and their facilitators and barriers to implementing guidelines in routine practice were identified. These determinants of behavior change were then mapped to key theoretical domains of behavior change. Subsequently, relevant domain-specific behavior change techniques (from the literature) were selected to incorporate into a comprehensive knowledge translation package.[13] The proposed intervention includes (but is not limited to) problem-based webinars to promote active learning and enhance knowledge and skills, educational videos by respected opinion leaders to leverage social influence and promote modeling of expert behavior, and evidence summaries and practice tool kits to enhance the environmental context and available resources within private offices. Soon researchers will undertake a carefully designed cluster randomized trial to evaluate the effectiveness of their intervention package.[14]

Knowledge translation is a priority of chiropractic policymakers and is supported by every chiropractic regulatory and professional membership organization in Canada. More than a decade ago the Clinical Practice Guidelines Initiative was launched by both the Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards.[15] Its ongoing mission is to improve chiropractic care delivery in Canada through the development, dissemination, and effective implementation of clinical practice guidelines. The initiative recognizes busy clinicians often find it challenging to access the latest scientific evidence, let alone digest and implement it during routine practice. Therefore, through a dedicated website, clinicians are now provided with easy access to information promoting adherence to evidenced-informed practice, and contact information for 22 national chiropractic opinion leaders and more than 100 best-practices collaborators who are available to meet with private practitioners on demand.[16]

An extension of the initiative is the Canadian Chiropractic Practice-Based Research Network, involving partnerships between academic institutions, researchers, and community-based practitioners. In BC, chiropractors participate in systematic data collection while providing evidence-based education, exercises, and manual therapy to patients referred by a medical spine physician or surgeon. This participatory research setting allows investigators to formulate study hypotheses directly informed by experiences of grassroots clinicians while simultaneously engaging and educating clinicians in hypothesis-testing, and knowledge creation and implementation activities.

By definition practice guidelines and research networks aim to define credible benchmarks for care based on the best available scientific evidence, broad consensus among stakeholders, and efficient use of health care resources. In chiropractic, universal support of these initiatives is a significant achievement and testament to the profession’s commitment to the principles and objectives of evidence-informed health care.
—Jeffrey A. Quon, DC, MHSc, PhD, FCCSC
WorkSafeBC Chiropractic Consultant

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This article is the opinion of WorkSafeBC and has not been peer reviewed by the BCMJ Editorial Board.

References

1.    Koes BW, van Tulder M, Lin CW, et al. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010;19:2075-2094.

2.    Hurwitz EL, Carragee EJ, van der Velde G, et al. Treatment of neck pain: Noninvasive interventions: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008;33(suppl 4):S123-152.

3.    Nordin M, Carragee EJ, Hogg-Johnson S, et al. Assessment of neck pain and its associated disorders: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008;33(suppl 4):S101-122.

4.    Dagenais S, Tricco AC, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J 2010;10:514-529.

5.    Haldeman S, Dagenais S. A supermarket approach to the evidence-informed management of chronic low back pain. Spine J 2008;8:1-7.

6.    Hurwitz EL, Chiang LM. A comparative analysis of chiropractic and general practitioner patients in North America: Findings from the joint Canada/United States Survey of Health, 2002-03. BMC Health Serv Res 2006;6:49.

7.    Bussières AE, Sales AE, Ramsay T, et al. Practice patterns in spine radiograph utilization among doctors of chiropractic enrolled in a provider network offering complementary care in the United States. J Manipulative Physiol Ther 2013;36:127-142.

8.    Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care 2001;39(8 suppl 2):1146-1154.

9.    Schuster MA, McGlynn EA, Brook RH. How good is the quality of health care in the United States? Milbank Q 2005;83:843-895.

10.    Grol RP, Bosch MC, Hulscher ME, et al. Planning and studying improvement in patient care: The use of theoretical perspectives. Milbank Q 2007;85:93-138.

11.    Michie S, Johnston M, Abraham C, et al. Making psychological theory useful for implementing evidence based practice: A consensus approach. Qual Saf Health Care 2005;14:26-33.

12.    Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci 2012;7:37.

13.    Bussières AE, Al Zoubi F, Quon JA, et al. Fast tracking the design of theory-based KT interventions through a consensus process. Implement Sci 2015;10:18.

14.    Dhopte P, Ahmed S, Mayo N, et al. Testing the feasibility of a knowledge translation intervention designed to improve chiropractic care for adults with neck pain disorders: Study protocol for a pilot cluster-randomized controlled trial. Pilot and Feasibility Stud 2016;2:33.

15.    Bussières A. The Canadian Chiropractic Guideline Initiative: Progress to date. J Can Chiropr Assoc 2014;58:215-9.

16.    Canadian Chiropractic Association. Guidelines and best practice. Accessed 26 July 2016. www.chiropractic.ca/guidelines-best-practice/ [10].