A MINI-REVIEW OF CHIROPRACTCIC PBR

Healthcare research is beginning to trend towards a model that takes into account the entire patient encounter. While Randomized Controlled Clinical Trials (RCTs) remain the gold standard to assess clinical outcomes, there are many critics that feel this research does not evaluate the true clinical effects. The sterile environment may taint and narrow the clinical encounter that, in a holistic practice environment, has historically led to positive patient outcomes. Practice-based research (PBR) allows for the generation of healthcare data on a large-scale collaborative basis while maintaining the integrity of a traditional clinical environment.

Chiropractors see amazing results in their patients on a daily basis; however, if time and care are not taken to track the information in a valid format; present the information to peers; and publish the information for the general public, then the global impact of these stories remains limited. Planned research and implementation of research tools provides the potential fuel for Chiropractic to become a global leader in the healthcare system. While some PBR does exist in the chiropractic field, there has yet to be an adaptable instrument with a strong committed group of doctors implemented that consistently supplies data that answers relevant research questions key to the advancement of the profession and care of the patient.

There have already been a number of attempts by researchers in the chiropractic field to employ practice-based research networks to answer many of these questions. Some of the earliest work was done by Cheryl Hawk while at Palmer College. She used the SF-36 to look at patient characteristics in a number of practices and published those findings in a variety of places.[1-3] Hoiriis and Owens did very similar work at Life University in the early 1990s, focusing on Upper Cervical practitioners. Several articles were published in the Chiropractic Research Journal (CRJ) that showed significant increases in health scores on the SF-36 survey, changes in x-ray listings and improvements in general health impression.[4-6] They also showed how challenging it is to follow groups of patients over a whole course of care. Their follow-up rate was only about 50%. Some prominent researchers from the RAND Corporation also followed this model of practice-based research, looking at the characteristics of chiropractic patients across a wide range of practices.[7]

Rupert used PBR methods to explore questions about the use of maintenance care in Chiropractic, [8-10] and Alcantara has done several studies looking at chiropractic care for children.[11-12] Nyeindo and Haas probably did the best practice-based study of low back pain, comparing chiropractic care to medical care. They managed to incorporate a four year follow-up.[13-16]

The studies above were all carried out using surveys that patients and doctors filled out on paper or electronically. More recently, governments, insurance companies and HMOs have been looking at their claims data to evaluate the cost-effectiveness of chiropractic care compared to other types of care.[17-19] They have also realized that access to patient data in their databases could open the doors to studying a wider range of questions besides the financial one.

Life University seeks to develop a dynamic, progressive practice based research network (PBRN) that will advance the mission and core proficiencies of the University through LIFE-focused research questions and engaging the chiropractic and human performance community in the research process. This project will include the development of a platform and protocols for the collection of valid and reliable information, recruitment and training of chiropractors in the field, as well as development and implementation of studies designed to answer high-level specific research questions relevant to the current needs of the profession, including cost-effectiveness.

References (these should all be linked to DOI, or PubMed abstracts, if available. We can offer CRJ articles as full text. Palmer research articles, perhaps as well, with permission.)
1. Hawk C, Morter MT. The use of general health status in chiropractic patients: a pilot study. Palmer J Research 1995; 2(2): 39-45.
http://www.chiroindex.org/?search_page=articles&action=&articleId=20853

2. Hawk C. Practice-based research. Palmer J Research 1995; 2(3): 72-73.
http://www.chiroindex.org/?search_page=articles&action=&articleId=20873

3. Hawk C, Rupert RL, Colonvega M, Boyd J, Hall S. Comparison of bioenergetic synchronization technique and customary chiropractic care for older adults with chronic musculoskeletal pain. J Manipulative Physiol Ther. 2006 Sep;29(7):540-9.
http://www.sciencedirect.com/science/article/pii/S0161475406001710

4. Hoiriis KT, Owens EF, Pfleger B. Changes in general health status during upper cervical chiropractic care: A practice based research project. Chirop Res J 4(1):18-26, 1997.

5. Owens EF, Hoiriis KT, Burd D. Changes in general health status during upper cervical chiropractic care: PBR progress report. Chirop Res J 5(1):9-16, 1998.
http://www.sherman.edu/research/archives/more/pbr99.html

6. Hoiriis KT, Burd D, Owens EF. Changes in general health status during upper cervical chiropractic care: A practice-based research project update. Chiropr Res J 1999; 6(2):65-70.

7. Coulter ID, Hurwitz EL, Adams AH, Genovese BJ, Hays R, Shekelle PG. Patients using chiropractors in North America: who are they, and why are they in chiropractic care? Spine (Phila Pa 1976). 2002 Feb 1;27(3):291-6.
http://www.ncbi.nlm.nih.gov/pubmed/11805694

8. Rupert RL. A survey of practice patterns and the health promotion and prevention attitudes of US chiropractors. Maintenance care: part I. J Manipulative Physiol Ther. 2000 Jan;23(1):1-9.
http://www.sciencedirect.com/science/article/pii/S0161475400901076

9. Rupert RL, Manello D, Sandefur R. Maintenance care: health promotion services administered to US chiropractic patients aged 65 and older, part II. J Manipulative Physiol Ther. 2000 Jan;23(1):10-9.
http://link.springer.com/article/10.1186%2F2045-709X-20-21

10. Daniel DM, Ndetan H, Rupert RL, Martinez D. Self-reported recognition of undiagnosed life threatening conditions in chiropractic practice: a random survey. Chiropr Man Therap. 2012 Jul 5;20:21.
http://www.sciencedirect.com/science/article/pii/S1479235409000078

11. Alcantara J. The presenting complaints of pediatric patients for chiropractic care: Results from a practice-based research network. Clinical Chiropr 2008 11:193-198.
http://www.sciencedirect.com/science/article/pii/S1550830709002079

12. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY). 2009 Sep-Oct;5(5):290-5.
http://www.sciencedirect.com/science/article/pii/S016147540106239X

13. Nyiendo J, Lloyd C, Haas M. Practice-based research: the Oregon experience. J Manipulative Physiol Ther. 2001 Jan;24(1):25-34.
http://www.sciencedirect.com/science/article/pii/S016147540141428X

14. Nyiendo J, Haas M, Goldberg B, Sexton G. Patient characteristics and physicians’ practice activities for patients with chronic low back pain: a practice-based study of primary care and chiropractic physicians. J Manipulative Physiol Ther. 2001 Feb;24(2):92-100.
http://www.sciencedirect.com/science/article/pii/S016147540141428X

15. Nyiendo J, Attwood M, Lloyd C, Ganger B, Haas M. Data management in practice-based research. J Manipulative Physiol Ther. 2002 Jan;25(1):49-57.
http://www.sciencedirect.com/science/article/pii/S0161475402736737

16. Haas M, Goldberg B, Aickin M, Ganger B, Attwood M. A practice-based study of patients with acute and chronic low back pain attending primary care and chiropractic physicians: two-week to 48-month follow-up. J Manipulative Physiol Ther. 2004 Mar-Apr;27(3):160-9.
http://www.sciencedirect.com/science/article/pii/S0161475403002422

17. Manga P. Economic case for the integration of chiropractic services into the health care system. J Manipulative Physiol Ther. 2000 Feb;23(2):118-22. Review.
http://www.sciencedirect.com/science/article/pii/S0161475400900800

18. Grieves B, Menke JM, Pursel KJ. Cost minimization analysis of low back pain claims data for chiropractic vs medicine in a managed care organization. J Manipulative Physiol Ther. 2009 Nov-Dec;32(9):734-9.
http://www.sciencedirect.com/science/article/pii/S0161475409002656

19. Whedon JM, Song Y, Davis MA, Lurie JD. Use of chiropractic spinal manipulation in older adults is strongly correlated with supply. Spine (Phila Pa 1976). 2012 Sep 15;37(20):1771-7.
http://europepmc.org/articles/PMC3414681/reload=0;jsessionid=yHGO9Znh2hvjxwmG9bvG.56