To the EditorI read with appreciation the perspectives included in the article by Goertz et al.1

Goertz CM, Hurwitz E, Murphy B, Coulter I. Extrapolating beyond the data in a systematic review of spinal manipulation for nonmusculoskeletal disorders: a fall from the summit [e-pub ahead of print]. J Manipulative Physiol Ther. 2021 Apr 17.https://doi.org/10.1016/j.jmpt.2021.02.003. Accessed April 20, 2021.

that provided an alternate analysis of the Global Summit, which conducted a systematic review of the literature about spinal manipulative therapy (SMT) for the management of nonmusculoskeletal disorders.

I would like to offer from my personal experience additional concerns about taking giant leaps by using weak scientific evidence to make policy recommendations. Over the past 25 years, I have been involved in the development of Ontario Ministry of Health and Long Term Care health policies and standards as a chiropractic expert. By being involved in this work, I have learned about the complex and lengthy processes that are involved when converting evidence into health policy. Although health policy can be developed on the basis of evidence and through expert opinion, it is imperative that this process has its foundation in quality research and its relevance to population health.

Currently, there is not enough research of sufficient strength about SMT for the management of nonmusculoskeletal disorders to transition these findings to policy. To rely on expert opinion significantly increases the influence of bias both in choice of methodology and in drawing conclusions. As Gilbert and Taylor report, the most critical part of clinical policy development or evaluation “is the quality of the evidence supporting it and the rigor of the developers’ review of that evidence.”2How to evaluate and implement clinical policies. And, they note that most clinical policies are not based on evidence but rather on the opinions of groups of experts, that expert opinion is subject to many types of biases, and that “clinical policies based on anything less than a good review of existing evidence should be approached with considerable caution.”2How to evaluate and implement clinical policies.In my opinion, there is considerable risk in extrapolating equivocal scientific findings to health policy. Health policies take years to develop and even longer to reverse. For example, consider if in 1991 health policy in Ontario had been based on the paucity of science around the efficacy of SMT for neck or back pain at that time, which would have resulted in the exclusion of SMT for treatment of these conditions when the Regulated Health Professions Act was finalized? Notably, over 30 years, there have been no changes in this policy to expand the scope of chiropractors’ practice despite provision of sound evidence, such as that chiropractors are trained and competent to order advanced imaging studies. This is an example of how health policies are almost impossible to reverse or change once put forward. Therefore, policies need to be made with robust evidence and a clear understanding of health needs and priorities.Health policy recommendations are complex and should not be made simply on the basis of lack of research in any one area. Population health, safety, costs, risk, community needs, and patients’ preferences should be considered when making policy recommendations.2How to evaluate and implement clinical policies. Policy conclusions that go beyond the reach of the evidence potentially pose a risk to the future of chiropractic practice.References

Goertz CM, Hurwitz E, Murphy B, Coulter I. Extrapolating beyond the data in a systematic review of spinal manipulation for nonmusculoskeletal disorders: a fall from the summit [e-pub ahead of print]. J Manipulative Physiol Ther. 2021 Apr 17.https://doi.org/10.1016/j.jmpt.2021.02.003. Accessed April 20, 2021.

How to evaluate and implement clinical policies.

Fam Pract Manag. 6: 28-33

Chiropractic Act, 1991. Government of Ontario. Available at: www.Ontario.ca/laws/statute/91c21. Accessed March 2, 2021.

Article InfoPublication History

Published online: June 20, 2021

Accepted: April 19, 2021

Received: April 19, 2021

Publication stageIn Press Corrected ProofIdentification

DOI: https://doi.org/10.1016/j.jmpt.2021.04.007

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© 2021 by National University of Health Sciences.

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