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 s 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:

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 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 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 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, 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, 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