By Mark Crawford
CHIROPRACTIC PHYSICIANS, CHIROPRACTIC TEACHING INSTITUTIONS AND ASSOCIATIONS need to work together to step up their research efforts. The stakes are high.
Top-level research supports and expands the credibility of the chiropractic profession. Research discoveries lead to new clinical applications, cross-disciplinary work and collaboration with other medical professionals and institutions. Successful research can also energize a DC’s approach to practice and improve patient outcomes. Countries like Denmark, Canada, Switzerland and Australia are conducting impressive clinical research studies that are filling gaps in our knowledge base and validating how we treat patients. Chiropractic was founded in the United States in 1895 — and so research here should lead the way.
Some chiropractic colleges have research departments; others leave it up to individual faculty members to pursue research projects. Regardless of the approach, what can be accomplished seems to be directly related to funding. As financial sources dwindle, competition for existing funds becomes fiercely competitive. Projects that win out typically comply with accepted research protocols and investigate topics that have widespread health impact. In order to compete, DCs must have well-defined research projects that conform to what the funding agencies are looking for and then be effective in selling them — a process that seems daunting and time-consuming to many DCs.
“Research universities and colleges are all driven, to some degree, by funding,” says David O’Bryon, executive director for the Association of Chiropractic Colleges in Bethesda, Md. “The federal government has cut back on funding, and chiropractic competes with everyone else for the reduced dollars. National Institutes of Health (NIH) funding is more limited now and the Health Resources and Services Administration (HRSA) has also fallen off as a resource.”
As a result, “federal funding for chiropractic research is increasingly competitive, at a time of overall decreasing available funds,” adds Mitch Haas, DC, MA, and associate vice president of research at the University of Western States in Portland, Ore. “I know of one major chiropractic research center that is essentially closing down due to costs of the research effort.”
Another way to create funding is to pursue research projects that will generate revenue that can be reinvested in future research. To make ends meet, Dr. Haas notes, some senior research administrators at other institutions are restructuring their programs to require that any future research projects will be structured to be net income generators for their colleges.
Combining Research and Education
A significant trend is the increase in highquality research coming out of Denmark, Canada, Switzerland and Australia. Chiropractic is completely integrated into these state university systems and collaborates with other disciplines. “Not only do these studies improve our cultural authority, the fact that these DCs are doing good science, surrounded by people who at one time thought of us as magicians, also changes our cultural authority across the larger scientific community,” says Stephen M. Perle, DC, MS, and professor of clinical sciences at the University of Bridgeport in Bridgeport, Conn.
These advancements are possible because the national chiropractic associations and/or federal governments are making serious efforts to support chiropractic research, including significant government funding. In fact, the Danish government supports chiropractic research by paying for the education of DCs who want to earn PhDs — even providing them with a living-wage stipend during their education.
In Canada, the Canadian Chiropractic Association has been successful in helping DCs get PhD positions at major provincial universities. “These positions then transition into tenure-track positions,” says Dr. Perle. “As faculty members, they have been quite successful in getting Canadian Foundation for Healthcare Improvement money and sometimes even NIH funding. Australian DCs receive financial support from the Chiropractic and Osteopathic College of Australasia. There are many DCs in Australia who have received their PhDs with this assistance, which is an effective way to stimulate research.”
Becoming More Relevant
More chiropractic research is emphasizing clinical outcomes. “It’s not enough to demonstrate to third-party payers that you have a reasonable biological mechanism for your care — they want to see evidence that it actually works in the real world with real patients,” says William J. Lauretti, DC, and associate professor of chiropractic clinical sciences at New York Chiropractic College in Seneca Falls, N.Y. “However, with all the variables seen among patients and among doctors who claim to practice the same techniques, this type of research is very challenging to perform.”
In practice, DCs are seeing an increasing number of treatments being ruled as experimental (and therefore not reimbursable) by third-party payers. These include foot orthotics, electrical muscle stimulation and treatments for certain populations, such as pediatrics or cervical-spine conditions. These are all areas that would benefit from research studies that would prove they are not experimental treatments (see sidebar, Chiropractic Research in the United States).
Palmer College of Chiropractic pursues research that is directly relevant to patient care. This is part of the mission of the five-year strategic plan for the Palmer Center for Chiropractic Research (PCCR).
“Our primary goals are to develop our basic, clinical and translational research abilities across all campuses, translate research findings into both clinical and public health practices and be acknowledged by scientific and health care peers as the leading center for chiropractic research,” says Christine Goertz, DC, PhD, and vice chancellor for research and health policy for Palmer College of Chiropractic.
About six years ago, PCCR received $2.75 million from the National Center for Complementary and Alternative Medicine (NCCAM) at NIH to establish a developmental center for clinical and translational research in chiropractic. Goals include developing advanced clinical and translational research abilities, strengthening scientific expertise and research infrastructure (especially for clinical research) and continuing its partnership- building with major universities. [Editor’s Note: On Dec. 17, 2014, NCCAM received a new, congressionally mandated name — the National Center for Complementary and Integrative Health, or NCCIH.]
“Our goal is always to collaborate on research and funding with research-intensive universities that may have more resources than we do,” says Dr. Goertz. “This emphasis on collaboration has been one of the key reasons why the PCCR has been so successful in building our program and obtaining grant funding.” Current translational research projects include a $7 million, Department of Defense-funded collaboration with RAND and the Samueli Institute to conduct the largest study of chiropractic to date (currently ongoing at three military sites) and a $700,000 NIH planning grant that includes collaboration with the University of Iowa and the Veterans Health Administration.
Wanted: More Resources
The single greatest obstacle for chiropractic research is the lack of resources. “If it takes a village to raise a child, it takes a small city to run a randomized clinical trial,” says Dr. Goertz. “Palmer has 30 people working full time on our research efforts. The college spends approximately seven percent of our annual budget [roughly $5 million] on research.” About half of that money comes directly from Palmer, with most of the rest coming from federal grants.
A common problem for many colleges is the lack of a campus-wide research culture. Chiropractic colleges tend to be modeled more after liberal arts colleges, with a focus on teaching and community service, rather than major research universities, where faculty are considered researchers first and teachers second. “Therefore it is more difficult for chiropractic colleges to develop a ‘critical mass’ of accomplished researchers who can mentor the next generation and build on each other,” indicates Dr. Lauretti.
Even though the colleges may have opportunities for clinical research through their outpatient clinics, they typically don’t have the expertise for designing and running a quality clinical research study.
“Teaching/clinic loads are too heavy and research training and experience are too limited,” says Dr. Haas. “Most faculty members are hired without the expectation of doing research, and changing career paths is far from easy. The expertise in research methodology and statistical analysis, research facilities, as well as grant writing, oversight, management and institutional support, requires a large investment of time and money to be adequate to the task.”
For schools that are determined to expand their research capabilities, the first step is providing the necessary guidance and training regarding study design, statistical measures, etc. “It would be very beneficial for these schools to provide advisors in research methods, human protection and other key categories, as well as other necessary resources, so high-quality studies can be conducted,” says Mabel Chang, DC, MPH, and adjunct professor at D’Youville College in Buffalo, N.Y. “This would greatly improve the chiropractic research capacity.”
Another way to gain this knowledge is by utilizing the expertise and resources of other research institutions through partnerships that share research goals. “Palmer has been very fortunate in working with established scientists at researchintensive universities who are interested in collaborating with chiropractic scientists to answer questions that are directly relevant to the delivery of chiropractic care,” says Dr. Goertz.
Perhaps the greatest research weakness the chiropractic profession has is a lack of appreciation for just how important clinically-based, patient-oriented outcomes research will be in the near future as the U.S. health care system continues to evolve. “We have a real need to develop evidence-based best practices — not just to improve patient results but also to validate chiropractic for the benefit of payers and health policy makers,” says Dr. Lauretti. “Further real-world research is needed to demonstrate our worth.”
The Canadian Approach
IN 1995, THE CANADIAN CHIROPRACTIC ASSOCIATION (CCA) launched a task force to support the development of a true research culture and dramatically expand the profession’s research capacity. Today, Canada has world-class chiropractic researchers at top universities who have established the profession’s credibility in neurophysiology, epidemiology, biomechanics and cellular/molecular biology. Three strategies were critical to this success:
• The CCA helped chiropractors pursue full-time careers in research and obtain their PhDs in the process (today, 30 DC PhDs pursue full-time research in Canada).
• A “research consortium” of chiropractic researchers at 25 different universities holds a symposium every two years to focus on innovative research, cross-disciplinary relationships and new perspectives on improving the health of Canadians.
• The Canadian Chiropractic Research Foundation provides research funds for relevant clinical, biomedical, health services and population health research projects that have immediate, practical value for improving health.
Chiropractic Research in the United States
THERE IS MUCH CHIROPRACTIC RESEARCH UNDERWAY IN THE UNITED STATES especially since 1994 when the University of Western States or UWS (then Western States Chiropractic College) became the first chiropractic college ever awarded a federal grant for research. The nearly million dollar grant from the Department of Health and Human Services (HRSA) funded a collaborative study with Oregon Health Science University’s Department of Family Medicine. Since then, the UWS Center for Outcome Studies has received additional grants from HRSA, which supported a series of studies regarding low back pain. There are now six chiropractic colleges that have received federal research funding. [UWS, Palmer College of Chiropractic, National University of Health Sciences, Northwestern Health Sciences University, Logan University and New York Chiropractic College.]
Private funding is important too. NCMIC Group, Inc. President Louis Sportelli, DC, wrote in an article on The Critical Importance of Best Practices Documents in Sept. 2014 ACA News on Page 18 :
"A few years ago, the chiropractic profession was confronted by various payer groups regarding the “appropriateness” of care in the areas of pediatrics, geriatrics and wellness. Challenging the appropriateness of care was then extended to challenging the appropriateness of reimbursement for such services. In light of insufficient research specifically supporting such chiropractic care, which ironically had been delivered to infants and seniors and incorporated in wellness concepts for more than a century, NCMIC Foundation funded several consensus processes (e.g., wellness, geriatrics, pediatrics) to provide an initial basis for determining appropriateness and ultimately to stimulate further research projects in these areas."
The stage was set for the NCMIC-funded projects by the chapters from the Council for Chiropractic Guidelines and Practice Parameters (CCGPP) on wellness, non-musculoskeletal and special populations (e.g., geriatrics, pediatrics and pregnant women). This project was headed by Cheryl Hawk, DC, PhD, associate vice president of Research and Health Policy at Logan University. (For more on CCGPP, see May 2014 ACA News , Page 10.)
The chapter on low-back pain (LBP) guidelines was part of the same CCGPP process and was based on a literature synthesis study headed by Dana Lawrence, DC, MMedEd senior director, Center for Teaching and Learning, Palmer College of Chiropractic.
Dr. Sportelli gives accolades to the individual DCs whose names appear on the published best-practice documents in the Journal of Manipulative and Physiological Therapeutics and worked diligently on these consensus documents without compensation. The list of dedicated researchers is too numerous to mention here. Go to http://mydigimag.rrd.com/publication/?i=221336 .
Many DCs have received grants to further chiropractic research. For example, it was big news in 2013 when the Patient-Centered Outcomes Research Institute (PCORI) approved funding for a research project lead by Michael J. Schneider, DC, PhD, with the University of Pittsburgh, which studies non-surgical treatment methods for patients with lumbar spinal stenosis. — Lori A. Burkhart