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Newsletter of the European Chiropractors’ Union
Feature
Knowledge translation in chiropractic:
Is research supporting practice?
From time to time we offer a guest spot for chiropractors to discuss relevant
topics. This is a guest perspective by Daniel Moore, Chiropractic Course
Leader, Teesside University
REMEMBER SEEING the sign: ‘Please don’t walk on the
I grass!’ It was 2004, and I was embarking upon my first degree
when I experienced a first spark of interest in knowledge transfer.
Do people walk on the grass? Now, 16 years later with a very wellestablished
interest in knowledge, its dissemination and how we
monitor that, I find myself pondering the same kind of questions.
With regard the chiropractic profession, is research impactful? Do
guidelines have high levels of adherence?
The very recent update to the 2018 Lancet series on lower back
pain highlights, in part, the lack of guidance adherence, leading to
low-value care still being all too common in the management of lower
back pain. So, are we looking in the right places for the answers?
In this article, I hope to address what knowledge translation
is within chiropractic, what human traits affect it, and the
importance of monitoring it. My aim is to spark your interest, so
we all can endeavour to think more around this important topic.
Transfer and translation
I believe this is a necessary distinction to make. To transfer
something is to take it and disseminate it to another group.
Translation is to take something, repackage it to be understandable
or usable to a certain group or a given context.
Transfer, in making people aware that research exists, does happen
in health care and certainly within chiropractic. For example, in the
UK, via the Royal College of Chiropractors (RCC), I received seven
‘New Research Article’ emails containing up-to-date research links in
July 2020. In my view, this is a good example of an effective transfer
of knowledge. However, are these emails read and understood and
do they have an effect on the people who read them?
This is where the concept of translation starts to become
important. In health care we also have clinical practice guidelines.
For example, in the UK the National Institute of Clinical
Excellence guidelines NG59 & CG177 are both very relevant to
chiropractors. The RCC over recent years has also produced eight
quality standards, the most recent of which addresses headaches,
and outlines in a concise and understandable document what a
care pathway for this presenting complaint may look like. This, in
my view, is a good start to knowledge translation.
Who reads these important guidelines?
I am confident that many conscientious chiropractors do read
these quality standards and guidelines. However, we don’t really
know how many! They are surely introduced at an undergraduate
level and, as I am developing the chiropractic course at Teesside, I
will undoubtedly embed these useful tools within the course. This
will likely have a positive impact but is not sufficient in itself.
In 2004 John Gabbay and Andreé le May coined the term
mindlines, as opposed to guidelines. They identified that in general
medical practice, people didn’t read guidelines. Clinicians valued two
things; what they had been taught (existing knowledge), and what
their peers knew. So, coffee room chat was often the way in which
problems were solved, or queries were answered, rather than clinicians
referring to the most recent edition of the British Medical Journal or
similar publication. Peer knowledge often beats research evidence.
In addition, psychology comes into play. Nobel Prize winner
Daniel Kahneman articulates very well in his book Thinking, Fast
and Slow just how much we resort to cognitive ease over cognitive
strain as a natural reaction to inquisition. Read this short puzzle
Kahneman created and listen to your intuition:
A bat and ball costs £1.10p
The bat costs £1 more than the ball.
How much does the ball cost?
Your intuition likely says ten pence? But you feel uneasy about
that answer. You now can’t work it out because one part of your
brain won’t let the ten pence answer go. The ball costs 5p, the bat
£1.05p (one pound more). This demonstrates our mind’s desire
to be a little lazy, and if something in context makes sense, we’ll
probably accept it.
We also naturally sell ourselves the value of our decision over an
alternative option requiring more cognitive effort. In The Chimp
Paradox by Steve Peters, it is shown that the chimp often wins,
and we use intuition and emotion to make decisions instead of
rational thinking. We must understand the impact psychology has
in research translation, and not be naive to human behaviour.
Where do we look next?
I believe the general consensus would be that research supports
many aspects of practice, and that the value of informed
chiropractors, with a current, up-to-date knowledge base, is an
accepted standard. Guidelines provide a great tool to translate
often long and complex research articles into usable information
for chiropractors. However, often by their nature they struggle
to account for clinical context, varied contextual factors and
individual circumstances. So, investigation to understand these
varied knowledge sources in more depth, within a particular
context, while taking account of the psychology of decisionmaking
could be extremely valuable to our profession.
This discussion, as well as how we demonstrate our translational
competence over time as we move further away from our
undergraduate education, and how our psychology and social
environment impact our decisions in practice, could be the
necessary focus of our future investigations.
It is likely that people don’t walk on the grass… but it’s not
because of the sign.
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