Period of Professionalism***

• Prelude to the future−Chung Ha Suh, PhD.−NINDS.−US Office of Education

1970’s***• 1973: First US government funding of Chiropractic

research

• 1973: Chiropractic included in Medicare

• 1974: CCE recognized by USOE

• 1976: Wilk vs. AMA

• 1978: JMPT first published

• 1979: New Zealand Report

1980’s***

• 1982: JMPT indexed by Index Medicus (NLM)

• 1982: First RCT of chiropractic for any health problem

1990’s***

• 1991: First Rand Study published. Additional studies in 92, 94, 98

• 1994: “Federal Guidelines for Low Back Pain” published

• 1997: Consortium Center for Chiropractic Research Funded (2.7M)

• 1999: Inclusion of chiropractic care for all US military mandated

Periods of Chiropractic History

• Period of Early Growth, 1895-1925−82/28000/4000

• Period of Conflict, 1925-1940−40/15000/1400

• Period of Change, 1941-1970−11/15000/2500

• Period of Professionalism, 1971-present−23/55000/15000

George McAndrews***

• “If the profession continues to publish theory, in the absence of scientific support, and continues to waste its funds on outrageous advertising rather than investigate the truth of the theory…the last 20 years will have been wasted.”

Objectives• To become familiar with the current

research relating to chiropractic care

• To understand the scope of conditions treated by chiropractic

• To understand the savings associated with chiropractic care

• To understand utilization and satisfaction associated with chiropractic care

• “Only 15% of medical interventions are supported by solid medical evidence…partly because only 1% of the articles are scientifically sound and partly because many treatments have never been assessed at all” - David Eddy M.D., “British Medical Journal”, October 1991

Food for thought**

• An expert committee of the Institute of Health stated in 1992

“Only about 4% of all services have strong strength of evidence and more than half have very weak or no evidence”

Efficacy of epidural steroid injections• “Whether epidural steroids are effective

in common low back pain and sciatica cannot be determined based on our review” French Task Force of Randomized Trials: 1999

• “failed to demonstrate clinical efficacy” Journal of Bone and Joint Surgery: 1985

• “of little value in the treatment of patients with chronic low back pain” N. E. Journal of Medicine: 1991

Food for thought***• Pfizer, Inc has 12,000 full time

researchers, chiropractic has less than 100

• Last year the top 25 medical schools received over $6 billion in grants, chiropractic has received less than $10 million total.

• NIH just approved a $30 million grant for construction of a research chimpanzee retirement home

***• Less than 10% of D.C.’s subscribe to

a peer reviewed journal

• Recently Parker RI sent out 400 e-mails to Dallas D.C.’s requesting assistance in a research project. 6 responses, 2 offering help, 6 “please delete me from your mailing list” requests.

Ann Intern Med. 2002;136:216-227

Questions that any therapy must answer:***• What conditions can be treated?

• How effective is the treatment?

• Is it cost effective?

• Is the patient satisfied with the treatment?

International Studies

New Zealand Commission Report**

• 1979

• Concluded “Modern chiropractic is a soundly based and valuable branch of healthcare in a specialized area”

• The first government recognition of the effectiveness of chiropractic care

Canadian Study*• Kirkaldy-Willis, Cassidy

• 1985

• SMT helpful for patients with referred pain and nerve compression syndromes

• Clinically significant improvement for subjects originally classified as totally disabled

Polish Study*• Kinalski

• 1986

• SMT with PT and drugs showed more improvement than PT and drugs alone

• Improvement continued in the SMT group until day of discharge

British Study**• Meade

• 1995

• Compared chiropractic and hospital care for low back pain

• 29% greater improvement in patients treated with chiropractic

Netherlands Study**• 1997

• Evaluated RCT’s

• SMT is one of the most effective treatments for low back pain

Efficacy for low back pain

“Chiropractic Adjustments in the Treatment of Low Back Pain: Controlled Clinical Trial in Egypt”, Journal of the International Chiropractic Association, 1983*

• Pain relief from chiropractic compared to drugs and bed-rest. “Chiropractic superior”

• “Treatments given by chiropractors is novel in this area of research”

“Meta-analysis of Clinical Trials of Spinal manipulation”. JMPT, Mar 92*

• 38 of 44 studies SMT was better than comparison group

• Most studies compared to other effective comparison treatments

• SMT consistently effective

“Spinal Manipulation for Low Back Pain”. Annals of Internal Medicine, Oct 92**

• SMT for LBP at 3 weeks favors SMT

• SMT is of benefit in some patients with uncomplicated LBP

“Low Back Pain Of Mechanical Origin: Randomized Comparison of Chiropractic and Hospital Outpatient Treatment”. Medicine and Science in Sports and Exercise, Jun 1990**

• 741 Patients

• SMT more effective

• Benefit of treatment more apparent through follow-up period

“A RCT of Manual Therapy and Physiotherapy for Persistent Back and Neck Complaints: Subgroup Analysis Between Outcome Measures”. JMPT, May 1990**

• 256 patients with six weeks of LBP

• Improvement larger in patients with chronic conditions

• Improvements larger in patients younger than 40 years

• Differences in other groups less clear

“Conservative Treatment of Acute and Chronic Low Back Pain. A systematic Review of RCT’s of the Most Common Interventions”. Spine 1997*

• “Strong evidence also found for the effectiveness of spinal manipulation”

Annals of internal Medicine 10/2007***• Diagnosis and Treatment of Low Back Pain: A Joint

Clinical Practice Guideline from the American College of Physicians and the American Pain Society

• Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).

Neck Pain

“Manipulation and Mobilization of the Cervical Spine: A Systematic Review of the Literature”. Spine, 1996**

• Meta-analysis

• Improvement with SMT compared to muscle relaxants and usual medical care

“Manipulation of the Cervical Spine: A Pilot Study”. Journal of the Royal College Of General Practitioners,

1983*

• Neck pain and shoulder pain all improved after manipulation

“A Blinded RCT of Manual Therapy and Physiotherapy for Chronic Back and Neck Complaints”. JMPT, 1993*

• Results measured at 3, 6 and 12 weeks

• Improvement for manual therapy group was larger than for the other groups at all follow-up measurements

Headache

“Spinal Manipulation vs. Amitriptlyline for the Treatment of Chronic Tension-type Headache: A RCT”. JMPT, 1995**

• 150 subjects

• Outcome measures− Daily HA intensity− Weekly headache frequency− OTC medication usage− SF-36

• Both groups improved at similar rate

• At 4 weeks SMT showed 32%decrease in intensity, 42% decrease in frequency and 16% improvement in health status. Amitriptlyine returned to base line

“Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache”, Duke University Report, 2001**

• Studied behavioral interventions, acupuncture, spinal manipulation and physiotherapy for tx of cervicogenic and tension type headache.

• “Manipulation is effective in patients with cervicogenic headache, but its efficacy in patients with tension-type headache is unproven”

“The Effect of Spinal Manipulation in the Treatment of Cervicogenic Headache”. JMPT, 1997*

• As opposed to soft tissue therapy “spinal manipulation seems to have a positive effect”

Carpal Tunnel Syndrome*• “Comparative Efficacy of

Conservative Medical and Chiropractic Treatments: A RCT”. JMPT, 1998−“Both treatments effective, chiropractic

with less side effects”

Fibromyalgia*• “The Effectiveness of Chiropractic

Management of Fibromyalgia: A Pilot Study”. JMPT, 1997−21 patients, 18-70 years old−Significant improvement in flexibility

and reduction of pain levels

“Infantile Colic Treated by Chiropractors, A Prospective Study of 316 Cases”. JMPT 1989*

• Reduction in daily length of colic periods and a reduction in the number of colic periods per day

• Improvement could not be attributed to natural cessation of colic symptoms

“Short Term Effect of Spinal Manipulation in the Treatment of Infantile Colic: A RCT with a Blinded Observer”. JMPT, 1999*

• Chiropractic group had a 67% reduction of daily colic hours by day 12

• Dimethicone group had 38% reduction by day 12

Other Conditions** • Asthma

• Premenstrual syndrome

• Otitis media

• Sinusitis

• Migraine

Utilization*• New England Journal Medicine of Medicine-1993

− Visits in 1990 to alternative medicine providers exceeded visits to primary care medical doctors

− Follow-up survey in 1997 showed 25%increase

• Rand study: D.C’s deliver 40% of primary care to LBP patients, retain 92% of patients, perform 90% of SMT

Patient Satisfaction**• Harris and Associates patients satisfaction for low

pack pain− 63% D.C− 56% P.T− 52% M.D.− 50% D.O.

• University of Washington School of Medicine “rated the care they received much more highly than persons who sought care from primary physicians.”

Cost Effectiveness**• Florida W.C. (1988)

−D.C treated patient less likely to become disabled and if disabled it is for a shorted period of time

• Australia WC (1992): Decreased costs and fewer compensation days when treated by D.C. rather than M.D.

• Journal of Family Practice, 1992−Disability for D.C treated patient: 10.8 days−Disability for M.D. treated patient: 37.8

days.

Cost Effectiveness**• Archives of Internal Medicine, Oct 2004

• Compared two health plans over 4 years (700,000/1,000,000) for back care cost

• Chiropractic health plan:− 41% reduction in hospitalizations− 37% reduction in MRI/CT− 32% reduction in back surgeries− 23% reduction in x-rays− Overall cost per episode of back pain was

reduced 28%

Chiropractic Health Care Demonstration Project**

How satisfied were you with improvement in your condition

• Chiropractic: 81.5% excellent

• 13.8% somewhat

• 4.6% poor

• Medical: 55.6% excellent

• 22.9% somewhat

• 21.5 poor

I feel better now

• Chiropractic: 78.5% Strongly agree

• 14.6% Somewhat agree

• 3.3% Strongly disagree

• Medical: 49.2% Strongly agree

• 22.0% Somewhat agree

• 28.8% Strongly disagree

What best describes you today?• Chiropractic: 48.5% Not restricted

• 44.1% Somewhat restricted

• 7.4% Very restricted

• Medical: 32.1% Not restricted

• 50.0% Somewhat restricted

• 17.9% Very restricted

Days on restricted duty• Chiropractic: 71.5% 0 days

• 4.2% 1-4 days

• 24.3% 5+ days

• Medical: 51.1% 0 days

• 8.2% 1-4 days

• 40.7% 5+ days

Comments***• “Patients more likely to give their

provider excellent marks if they were seen by a chiropractor”

• “Patients of doctors of chiropractic were significantly more likely to show self-reported improvement….than patients who saw traditional providers”

Conclusions***• “The incorporation of chiropractic

care within the DoD is not advisable

Research MethodsAnatomy of a Research Article

Anatomy of a Research Paper• Dissecting the Basis Product of

Research the Published Research Article

Research Journals**• Editorials, commentaries, letters to the

editor…..(points of view or opinion)

• Literature reviews…..(summarizes other work)

• Descriptive studies…..(observe/record and explain findings)

• Experiments…..(researcher actively designs and places controls on the study)

Critical Reading• Knowing the elements of a article

and what each element is supposed to accomplish gives us the knowledge upon which to evaluate the quality of research

Elements of a Research Article (IMRaD format)**• Abstract

• Introduction

• Methods

• Results

• Discussion

• Conclusions

• References

Methods***

• Most important portion of an article

• Includes:−Design−Subject or population used−Subject selection−Procedures−Variables measured−Statistical analysis (Descriptive and

analytic)

Research Variables**• How measured

• Quality of measures (reliability, accuracy, validity)

• Incomplete information makes measuring the adequacy of the research difficult

Results**• Summarizes all pertinent data

• Tables and graphs

• Results of statistical analysis

• Reports all research outcomes related to the stated hypothesis

Discussion**• Interprets data and discusses the

importance of the research

• Identifies weakness

• Outlines need for future research

Cautions**• Especially subject to author bias

• Look for exaggerations or inappropriate conclusions

• Look for errors in statistics

References*• Author consideration of other work

• Quality of other work (JMPT, Gray’s Anatomy, National Inquirer, etc.)

• How recent the references?

• Other important research omitted?

• Do most supporting references come from the author?

Acknowledgements*• Usually in bottom left hand corner

• Describes funding and assistance

• Author contact and information about reprints

Abstract and Conclusion**• “doubtful or invalid statements were

found in 76% of the conclusions or abstracts”

• Controlled Clinical Trials, 1989, 10:31-56

Summary• Abstract- Summary of the research

• Introduction- Importance, literature review, hypothesis

• Methods- Design, sample selection, data collection

• Results- Data summarized, analysis of data, tables and charts

• Discussion- Conclusions supported, no exaggerations, weakness stated

• References- Adequate, timely, quality