This is one of the largest studies to examine chiropractors’ perspectives relative to EBP, and to our knowledge, the first national survey to be conducted in the United States. One other EBP study was performed in the US, however the sample was limited to mid-western chiropractors with advanced training in orthopedics [22]. Despite the large absolute sample size of our survey (n = 1,314), it represents only a small relative cross-sectional sample of the American chiropractic profession (n = 60,000) [27-29]. However, the demographic characteristics of our sample (Table 1) are strikingly similar to those reported by three National Board of Chiropractic Examiners’ Job Analysis Reports [27-29]. This provides support for the generalizability of our survey results and makes us more confident that we have obtained a representative sample of US chiropractors.

The results suggest that our respondents generally have positive attitudes about evidence-based practice and a high level of self-reported skills in EBP, but only a modest level of EBP uptake in their clinical practices. These results are relatively similar to those reported from a recent EBP survey of Australian chiropractors [19] and are consistent with the observation that passive diffusion of knowledge does not automatically translate into clinical implementation [6]. Further, it emphasizes the need for high quality EBP continuing education programs to meet the needs of the chiropractic profession.

Our participants reported generally positive attitudes toward EBP, with most agreeing that EBP is important for improving practice, patient care, and advancing the profession. Noteworthy was that nearly a third strongly agreed that there is a ‘lack of evidence from clinical trials to support most of the treatments I use in my practice’. Similarly, only 42% agreed or strongly agreed that ‘EBP takes into account a patient’s preference for treatment’. These findings suggest that the basic principles of EBP may be misunderstood by DCs given the original definition of EBP clearly states that clinical expertise, patient values and best available research evidence are all integral components of evidence-based practice [1]. However, these opinions might also reflect what has become a growing recognition across healthcare fields; that clinical research needs to become more patient-oriented, pragmatic and generalizable to “real life” clinical practice [30].

Our sample of DCs reported that their poorest EBP skills were in conducting clinical research and/or systematic reviews; given that this survey was of practicing DCs without academic or research affiliation, this is not surprising. Distinctions have been drawn between the expectation for practitioners to be ‘consumers’ who ‘use’ research rather than ‘manufacturers’ who ‘produce’ research [31]; future studies should take this into consideration by ensuring that data collection instruments reflect this thinking.

Most of our sample reported above average skills in EBP, particularly in relation to identifying answerable clinical questions, identifying knowledge gaps in practice, locating professional literature and online database searching. However, nearly a third of respondents rated themselves only in the mid-range on nearly all of the EBP skill items. Some of these skills included the ability to synthesize research evidence, sharing evidence with colleagues, and using the findings from systematic reviews. Interestingly, while almost two-thirds reported above-average to advanced skills in using findings from clinical research, less than half reported the same level of skill in using findings from systematic reviews. This suggests that DCs have a limited understanding of the value and availability of systematic reviews, which is problem shared by many health professionals [32].

The introduction of EBP into the curricula of US chiropractic colleges is a relatively new phenomenon that has largely occurred over the past decade. The National Center for Complementary and Integrative Health (formerly NCCAM) has provided funding through its R25 mechanism to nine CAM colleges - four of them with chiropractic education programs - to develop institutional programs focused on teaching EBP. An overarching goal of these R25 research education grants was to provide CAM faculty and students with the skills they need to apply a rigorous evidence-based perspective to their training and practice. Adding research literacy and EBP competencies to the curricula at these CAM colleges has led to changes in their institutional cultures, such as increased faculty use of EBP case studies in the classroom and student-led research/journal clubs [33-35]. However, with approximately two thirds of our sample receiving their chiropractic training 11 to 30 years ago, it is likely that many of our participants never received what would now be considered foundational training in EBP.

Additionally, our results suggest that educational emphasis should be focused on improving the skills of appraising and applying research evidence in clinical practice. This needs to be done in a way that provides clinicians with ‘real life’ clinical examples, in order to overcome the barriers of lack of interest or clinical relevance to chiropractic practice. This issue was addressed in the second phase of our project, which explores the effectiveness of online EBP educational modules and “booster exercises” that incorporate clinical examples relevant to chiropractors. Results of the second phase of this project will be reported in a future publication.

The results of this survey also indicate that there are serious gaps in the uptake of research evidence into chiropractic practice, with nearly half reporting only a very small proportion of what they do in their clinical practice is based on research evidence. DCs appear to have challenges with performing online searches of the literature and interpreting the results of systematic reviews. Although most DCs in our sample reported they had above average skills in locating literature online, they also indicated that they did not engage in the uptake of EBP on a frequent basis (> six times a month). This apparent contradiction may be associated with the issues of time and lack of evidence, as discussed in the next paragraph. However, almost 90% of our sample indicated that they were interested in learning or improving the skills necessary to incorporate EBP into their practices (Table 3). Educational interventions and strategies are more likely to be successful if they are informed by known barriers and facilitators [36-39].

On the whole, most DCs indicated there were few barriers to their uptake of EBP, which is consistent with their generally positive attitudes toward EBP. It is worth noting however, that almost half of DCs indicated that the two biggest barriers to EBP uptake were ‘lack of time’ and ‘lack of clinical evidence in CAM’. A sizeable proportion (a quarter to one third) also cited: ‘lack of industry support’; ‘lack of incentive’; ‘insufficient skills for interpreting research’; ‘locating and critically appraising research’; ‘lack of colleague support for EBP’; and ‘lack of relevance to chiropractic practice’. Many of the barriers identified in this study are similar to those found for chiropractors in Australia [19], Canada [20] and Great Britain [21] as well as a sub-specialty of chiropractic orthopedists in the US [22]. Interestingly, many of the same barriers are encountered in the medical and nursing professions [5,6], leading us to conclude that the challenges facing the chiropractic profession in implementing EBP are not unique.

Interestingly, very few DCs indicated that computer, internet, or database access were barriers to their uptake of EBP. Coupled with our sample’s perceived usefulness of all of the listed facilitator items, these findings underscore the importance of providing clinicians with training in EBP skills, particularly through online resources. Our findings also suggest a need for greater support from professional organizations to facilitate collegial support of EBP, as well as better collaboration between scientists and practitioners in the design of clinically applicable research. Indeed, while educational strategies are an important part of narrowing the gap between science and practice for chiropractic and other health disciplines, they will likely be insufficient on their own to accomplish true change. Comprehensive and multi-faceted approaches that take into account all the relevant levels affecting EBP, including professional, managerial, organizational and health systems, will likely be needed to integrate research into practice [41].

There were several limitations to this study. The first is inherent to any type of survey design, which is reliance on self-reporting. For example, the ‘skills’ sub-score was based upon the participants’ self-perceived level of skill; we did not directly test a participant’s knowledge or skills in EBP. It would be useful in future studies to correlate an actual “grade” from tests or quizzes of EBP knowledge with the self-reported survey data. Another inherent limitation is selection bias; it is possible that the ‘attitudes’ sub-scores were skewed toward higher values because participants were already in favor of an evidence-based practice paradigm prior to commencing the survey.

Although we had a relatively large number of survey responders (n = 1,314), this number represents only a small proportion of the approximately 60,000 licensed chiropractors in the US. We made some minor modifications in the original EBASE questionnaire, chiefly to use the word “chiropractic” in certain questions. We do not believe these minor changes altered the intrinsic properties of the EBASE, however we did not formally conduct a psychometric evaluation of this modified version.