research methods objectives to become familiar with the current research relating to chiropractic...
TRANSCRIPT
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