Research Methods

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

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

• Last month Parker sent out 400 e-mails to Dallas D.C.’s requesting assistance. 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

• Canadian Study

• Polish Study

• British Study

• Netherlands Study

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”

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

“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.

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