1. Anatomy of a Research Article Human Subject Protection
Research Methods
Anatomy of a Research Article
Human Subject Protection

2. Anatomy of a Research Paper
Dissecting the Basis Product of Research the Published Research Article

3. 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)

4. 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

5. Elements of a Research Article (IMRaD format)
Abstract
Introduction
Methods
Results
Discussion
Conclusions
References

6. Abstract Summary of article (Usually 250 words or less) Design
Objectives
Background
Methods
Results
Conclusions

7. Abstract
Dangerous to read only abstract due to limited information and possible author bias
If the abstract is not structured, be very cautious
If abstract does not address randomization, beware
If results only expressed as “p” value, caution advised

8. Introduction Discusses the importance and purpose of the research
Reviews previous related research
States hypothesis being tested

9. Methods Most important portion of an article Includes: Design
Subject or population used
Subject selection
Procedures
Variables measured
Statistical analysis (Descriptive and analytic)

10. Research Variables How measured
Quality of measures (reliability, accuracy, validity)
Incomplete information makes measuring the adequacy of the research difficult

11. Results Summarizes all pertinent data Tables and graphs
Results of statistical analysis
Reports all research outcomes related to the stated hypothesis

12. Discussion
Interprets data and discusses the importance of the research
Identifies weakness
Outlines need for future research

13. Cautions Especially subject to author bias
Look for exaggerations or inappropriate conclusions
Look for errors in statistics

14. 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?

15. Acknowledgements Usually in bottom left hand corner
Describes funding and assistance
Author contact and information about reprints

16. Abstract and Conclusion
“doubtful or invalid statements were found in 76% of the conclusions or abstracts”
Controlled Clinical Trials, 1989, 10:31-56

17. 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

18. References- Adequate, timely, quality

19. Research Methods

20. 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

21. Food for thought
“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

22. 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

23. 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

24. 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.

25. Ann Intern Med. 2002;136:

26. 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?

27. International Studies
New Zealand Commission Report
Canadian Study
Polish Study
British Study
Netherlands Study

28. 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

29. 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

30. 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

31. British Study
Meade
1995
Compared chiropractic and hospital care for low back pain
29% greater improvement in patients treated with chiropractic

32. Netherlands Study 1997 Evaluated RCT’s
SMT is one of the most effective treatments for low back pain

33. Efficacy for low back pain

34. “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”

35. “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

36. “Spinal Manipulation for Low Back Pain”
“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

37. Benefit of treatment more apparent through follow-up period
“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

38. 256 patients with six weeks of LBP
“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

39. “Conservative Treatment of Acute and Chronic Low Back Pain
“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”

40. Neck Pain

41. “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

42. Neck pain and shoulder pain all improved after manipulation
“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

43. Results measured at 3, 6 and 12 weeks
“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

44. Headache

45. “Spinal Manipulation vs
“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

46. “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”

47. “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”

48. Carpal Tunnel Syndrome
“Comparative Efficacy of Conservative Medical and Chiropractic Treatments: A RCT”. JMPT, 1998
“Both treatments effective, chiropractic with less side effects”

49. 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

50. Infantile Colic

51. “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

52. “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

53. Other Conditions Asthma Premenstrual syndrome Otitis media Sinusitis
Migraine

54. 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

55. 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.”

56. 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: days.

57. Chiropractic Health Care Demonstration Project

58. How satisfied were you with improvement in your condition
Chiropractic: 81.5% excellent
13.8% somewhat
4.6% poor
Medical: % excellent
22.9% somewhat
21.5 poor

59. I feel better now Chiropractic: 78.5% Strongly agree
14.6% Somewhat agree
3.3% Strongly disagree
Medical: % Strongly agree
22.0% Somewhat agree
28.8% Strongly disagree

60. What best describes you today?
Chiropractic: % Not restricted
44.1% Somewhat restricted
7.4% Very restricted
Medical: % Not restricted
50.0% Somewhat restricted
17.9% Very restricted

61. Days on restricted duty
Chiropractic: % 0 days
4.2% 1-4 days
24.3% 5+ days
Medical: % 0 days
8.2% 1-4 days
40.7% 5+ days

62. 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”

63. Conclusions
“The incorporation of chiropractic care within the DoD is not advisable