CHAPTER IX

CHIROPRACTIC RESEARCH

 

Reed B. Phillips, DC, PhD; Alan H. Adams, DC; Ruth Sandefur, DC, PhD

 

 A. History and Development of Research

1. Early Investigations and Research

"Legitimate, sustained, scientific research in chiropractic is a rather recent phenomenon. However, throughout chiropractic's 100-year history, the terms 'research' and 'science' have been among the most popular in the literature of chiropractic and have often been used in ways that are unfamiliar to most scientists" (Keating, 1995). In those early years, the term "science" was found in numerous publications in the professions such as The Science of Chiropractic and The Philosophy, Science and Art of Chiropractic Nerve Tracing, two books written by B.J. Palmer, the son of D.D. Palmer, the founder of the chiropractic profession. "Research" was also popular as evidenced by Willard Carver's Chiropractic Research University in Washington, D.C., and Hugh B. Logan’s International Chiropractic Research Foundation established in 1934 (Keating, 1995).

During the first half of the 20th century, D.D. Palmer and B.J. Palmer were noted for their theoretical explanations of their therapeutic success. The B.J. Palmer Research Clinic, located at the Palmer School of Chiropractic, accepted difficult cases and sought diligently to document patient care and progress as a means of investigating chiropractic. Chiropractors were anxious to develop methods and means to document clinical findings and patient response to care. X-ray became a useful tool for chiropractors to visualize the spine and to document changes attributed to their adjustive procedures. Chiropractors were the early developers of weight-bearing x-rays and full spine x-rays as a means of visualizing the entire spine when subjected to the effects of gravity (Keating, 1992).

Technological wizardry expanded beyond x-ray. A variety of instruments designed to detect spinal subluxations (misalignments) and the resulting physiological manifestations of the associated neurological disturbance began to appear. The neurocalometer was the most recognized of these paraspinal, heat-sensing instruments. Consistent with general trends during the first 50 years of the 20th century, instrumentation of all types was designed to provide a more thorough diagnosis, and to improve body functions in the hope of instilling longevity by wiping out disease and dysfunction. Such instruments were widely used by many professions and were not limited to chiropractic (Keating, 1995).

More specific to chiropractic was the development of adjustive techniques. With over 300 named techniques, it seemed like every practitioner who turned to teaching introduced a new way to treat a patient. Many of these systems included their own distinctive approach to defining what was wrong with the patient so that the patient's condition would be consistent with the therapeutic procedure to be administered. Many of these early techniques have survived and are still practiced in the profession today (Haldeman, 1992).

2. Establishment of the Foundation for Chiropractic Education and Research (FCER)

The need for research, organized at a national level, was stressed by C.O. Watkins as early as 1938 and later (1943) by C.W. Weiant, who had obtained a doctorate in anthropology from Columbia University in addition to his DC degree (Schierholz, 1986). In 1944, the National Chiropractic Association (NCA) created the Chiropractic Research Foundation (CRF) with the objective of acquiring funding for and promoting the development of research for the chiropractic profession (Schierholz, 1986). While research was important to the profession, the CRF focused its efforts on consolidating many small for-profit educational institutions into larger nonprofit professionally-controlled colleges (Keating, 1993).

During the 1960s, chiropractic educators realized the importance of upgrading educational standards to achieve nationally recognized accreditation. The NCA became the American Chiropractic Association (ACA) and the CRF became the Foundation for Accredited Chiropractic Education. What was originally conceived as an organization to support research became an organization to support the efforts of educational institutions wishing to become accredited. This goal was accomplished in 1974 when the United States Department of Health Education and Welfare (DHEW) recognized the Council on Chiropractic Education (CCE). In 1967, the Foundation for Accredited Chiropractic Education was reorganized as the Foundation for Chiropractic Education and Research (FCER). However, the emphasis was to remain on education rather than research for several more years (Keating, 1992). In the early 1970s, the ACA pressured FCER to fund research training for selected doctors of chiropractic. This was the genesis of an emerging research infrastructure within the profession. The Foundation also released funds to support research outside the profession.

In 1975, the U.S. DHEW sponsored a research conference on spinal manipulation. This conference heightened awareness of the need for research on spinal manipulation, given the absence of meaningful data. The next year, the DHEW insisted that the CCE stress the importance of research as part of the accreditation process. Soon thereafter (1977), FCER organized the Chiropractic Research Council (CRC) in an effort to bring together the research directors of all the chiropractic colleges. Such a group continues to meet under the auspices of the Chiropractic Research Consortium (also known by the acronym CRC), which is a separate entity from FCER's Chiropractic Research Council.

In 1979, FCER hired a director of research who expanded the research fellowship program and established a competitive scientific review process for submitted proposals. The Foundation also implemented an annual research conference for paper presentations, research training, and interprofessional dialogue. This meeting has grown to become the International Conference on Spinal Manipulation (ICSM), which attracts researchers from multiple disciplines from around the world.

While the bulk of the financial support for the FCER has come from the ACA (approximately $350,000 per year) (Keating, 1992), corporate vendors and FCER's own informational center have also enhanced FCER’s financial base. An individual chiropractor, Dr. William Harris, and the National Chiropractic Mutual Insurance Company have also provided substantial support. Federal research dollars have not passed through FCER. The Foundation continues to serve the profession through its support for the research fellowship programs, international conferences, and individual research projects within and outside the profession.

B. The Infrastructure and Research Capacity of the Chiropractic Profession

Other organizations have also contributed to the growth of a chiropractic research infrastructure. The National Institute for Chiropractic Research has supported research on chiropractic history and on specialized techniques. In 1986-87, the California Chiropractic Association (CCA) supported the development of the Pacific Consortium for Chiropractic Research (PCCR). The research directors from the chiropractic colleges in California and Oregon and the CCA joined as charter members. As membership expanded beyond the West Coast, the Pacific portion of the name was dropped so that the organization became known as the Consortium for Chiropractic Research (CCR). Research directors from all but one chiropractic college have maintained membership in this organization. The CCR has sponsored the annual Conference on Research and Education (CORE) held in conjunction with the annual meeting of the California Chiropractic Association. In 1996, the CCR altered their organizational structure to become more focused on fund raising to support research and is now called the American Spinal Research Foundation (ASRF).

In addition to benefiting from FCER or CCR funding, many of the individual chiropractic colleges have made their own commitments to research. A recent survey of the 17 colleges in North America (16 in the United States and 1 in Canada) found that the number of full-time faculty in each college assigned to research as their principal appointment ranged from 0-14 (median = 3). Internal research budgets for the 1994-95 fiscal year totaled $4.8 million and ranged from $8,000 to $861,000 (median = $205,000) at the 17 colleges. This represented between 0.6% and 4.1% of their total institutional expenses. In the 1994-95 fiscal year chiropractic faculty published 210 papers and submitted a total of 114 grant proposals to external funding agencies. Twenty-three (20%) of these proposals were funded. A total of $4.5 million was awarded with grants ranging from $20,000 to $1 million (mean = $194,130) (Meeker, 1996).

C. Sources of Funding

1. Chiropractic-Related Funding Sources

Research in chiropractic has been funded largely from within the profession, a significant portion coming from chiropractic college tuition dollars. National professional organizations (the American Chiropractic Association and the International Chiropractic Association) and State chiropractic associations have also given financial support to chiropractic research. For example, the California Chiropractic Foundation (CCF), the educational body of the California Chiropractic Association, has donated 6.5% of its annual budget to the Consortium for Chiropractic Research (CCR) since the 1980s (CCR, 1995), and the Florida Chiropractic Association is currently supporting activities of the Consortium. Other funding has come from philanthropic chiropractic practitioners, the National Chiropractic Mutual Insurance Company (NCMIC), and Foot Levelers, Inc., an orthotics supplier.

Until recently, Federal funding has been almost nonexistent. In 1991, a federally-commissioned study conducted by the Corporate Health Policy Group reported that there was an "inherent bias" in favor of medical researchers when competing with chiropractors for Federal grants because of the superior research track record of medical researchers (Keating, 1992). Nonetheless, a small number of Federal grants recently have been awarded to projects involving chiropractic.

In 1994-95, half of all grant funding to chiropractic researchers was from the U.S. Health Resources and Services Administration (7 grants totaling $2.3 million) and most of the remainder was from the FCER (11 grants totaling $881,000) and the CCR (4 grants totaling $519,000). The following paragraphs describe the major chiropractic sources of funds for chiropractic research since 1990 and the types of studies that have been funded.

The Consortium for Chiropractic Research

The Consortium for Chiropractic Research (CCR), established in 1989, is an organization composed of the 16 U.S. chiropractic colleges accredited by the Council on Chiropractic Education (CCE), and associate members who conduct or fund research. It is the largest single organized body of institutions dedicated to chiropractic research (CCR, 1995). Since 1990, CCR has awarded more than $660,000 to support four projects: the appropriateness of spinal manipulation of the cervical spine, the role of chiropractic in meeting rural health care needs, and randomized trials of the effect of chiropractic on chronic neck pain and childhood asthma.

The Foundation for the Advancement of Chiropractic Education

In 1981, Dr. William Harris, a chiropractor in private practice, established the Foundation for the Advancement of Chiropractic Education (FACE), a not-for-profit organization that has contributed more than $3 million to chiropractic research. In addition to funding research projects, FACE has provided funds to build research infrastructure at several chiropractic colleges and has contributed large sums to support research through the Foundation for Chiropractic Education and Research and the National Institute of Chiropractic Research.

Foundation for Chiropractic Education and Research

The Foundation for Chiropractic Education and Research (FCER), established in 1967, had become the largest organization funding chiropractic research by 1992 (Keating, 1992). In 1990 the annual budget of FCER was about $2 million (Keating, 1990). Between 1990 and 1995, FCER has independently or jointly awarded approximately $3.7 million to more than 25 projects. During this time period, FCER has also awarded educational grants totaling $277,000 to 34 individuals, fulfilling one part of its mission (Peterson, 1995). The projects funded by FCER include a national study of the use of chiropractic services and evaluations of the effect of chiropractic care on back and neck problems, headaches, idiopathic scoliosis, asthma, dysmenorrhea, hypertension, and colic.

National Chiropractic Mutual Insurance Company

The National Chiropractic Mutual Insurance Company (NCMIC) and FCER have co-funded more than 14 studies of the effect of chiropractic care on clinical problems such as dysmenorrhea, carpal tunnel syndrome, hypertension, and otitis media. Other jointly funded projects include studies of the role of chiropractors as primary care gatekeepers and analysis of referral patterns. They have also funded an effort to develop plans for an infrastructure to support a multidisciplinary practice-based research network. In total, FCER and NCMIC have jointly awarded almost $2 million in grants. On its own, NCMIC has awarded a grant to study the complications of chiropractic care.

Lincoln College Education and Research Fund, Inc.

A non-profit corporation dedicated to the advancement of chiropractic science, the Lincoln College Education and Research Fund, Inc. (LCERF), was established in 1979. Funding research and educational pursuits, it has donated more than $250,000 toward establishing an eminent scholar chair at Florida State University in the College of Human Sciences. The LCERF has also funded various scholarships.

National Institute of Chiropractic Research

The National Institute of Chiropractic Research (NICR) was established in 1987 as a non-profit corporation that conducts and supports chiropractic research (CCR, 1995). Founded by Dr. Arlan Fuhr, a chiropractor in private practice, the NICR is the only organization with an ongoing grant mechanism to fund chiropractic historical research. The NICR has awarded more than $325,000 to projects studying kinematic assessments of vertebral subluxation adjustments and leg length inequalities, cervical function measures, and others. The NICR has also supported research education and has jointly funded three studies with the FACE. Totaling almost $400,000, these studies have addressed kinematic methods to assess neck injury, biomechanics of the human spine, and outcome measures for cervical spine patients.

2. Federal Agencies

The Agency for Health Care Policy and Research

In 1993, the Federal Agency for Health Care Policy and Research (AHCPR) awarded $980,000 to Group Health Cooperative of Puget Sound for a randomized trial comparing chiropractic, McKenzie physical therapy, and an educational booklet for low back problems. More recently, the AHCPR awarded UCLA $1.8 million to compare chiropractic, physical therapy, and usual medical care for low back pain. This project has involved collaboration with the Los Angeles College of Chiropractic. AHCPR also awarded a grant to the University of North Carolina to compare the costs and outcomes of the care for low back pain provided by primary care physicians, orthopedic surgeons, and chiropractors (Carey, 1995).

Other Federal Agencies

The Health Resource and Services Agency (HRSA) funded three projects studying biomechanics of flexion-distraction therapy, manual therapy in the management of low back pain syndromes with myofascial and articular dysfunction, and low back pain practice activities and patient outcomes. These projects totaled more than $2 million. The Veterans Administration (VA) awarded a contract for the study of the biomechanics of cervical diagnostic maneuvers.

D. Chiropractic Journals

There are currently 14 peer-reviewed chiropractic journals in English (Table 28). All are indexed in the Index to Chiropractic Literature (ICL). Only the Journal of Manipulative and Physiological Therapeutics is indexed in Index Medicus. The Chiropractic Journal of Australia is indexed in the Australian version of Index Medicus. Several chiropractic journals including Topics in Clinical Chiropractic and the Journal of Chiropractic Humanities are indexed in the Cumulative Index to Nursing and Allied Health Literature (CINAHL). There are also a number of chiropractic publications that are not peer-reviewed. These include State and national association journals and various magazines, which emphasize the economic and political aspects of the chiropractic profession.

In addition to publishing in chiropractic journals, chiropractic scholars have published in journals such as the Annals of Internal Medicine, Pain, The American Journal of Public Health, Spine, Clinical Biomechanics and Health Services Research. However, chiropractic researchers recognize that relatively little of their work is published in journals read by scientists outside the profession and have identified steps that can be taken to reduce their scientific isolation (Brennan, 1997).

Table 28. Peer-Reviewed Chiropractic Journals Published in English

Journal Name

Annual Cost*

Editor and Editorial Address

Publisher and Subscription Address

The Journal of Chiropractic Research and Clinical
Investigation
$80 Paul Jascoviak, DC
300 East Irving Blvd.
Irving, TX 75060
Busch Publishing Company
5005 Riviera Court
Fort Wayne, IN 46825
Chiropractic History $50‡
($20)
Russell W. Gibbons
207 Grand View Dr. So.
Pittsburgh, PA 15215
Association for the History of Chiropractic
1000 Brady St.
Davenport, IA 52803
Journal of Sports Chiropractic and Rehabilitation $71
($46)
Dana Lawrence, DC
444 Montrose
Elmhurst, IL 60126
Williams and Wilkins, Inc.
351 W. Camden St.
Baltimore, MD 21201-2436
Chiropractic Technique $69
($49)
Dana Lawrence, DC
200 E. Roosevelt Rd.
Lombard, IL 60148
Williams and Wilkins, Inc.
351 W. Camden St.
Baltimore, MD 21201-2436
European Journal of Chiropractic 35.00 Simon M. Leyson, DC
16 Uplande Crescent
Swansea SA1 0PB
United Kingdom
Blackwell Scientific Publication Ltd.
Oxford at Osney Mead
Oxford OX2 OEL
United Kingdom
Journal of Chiropractic Education $28 Grace E. Jacobs, D.A.
(see Publisher Address)
All Correspondence to the Editor
2045 Christensen Ave. #144
West St. Paul, MN 55118
Chiropractic Journal of Australia US $63 Mary Ann Chance, DC
Rolf Peters, DC
PO Box 748
Wagga Wagga 2650 NSW
Australian Chiropractor’s Assoc.
Subscriptions to Editor’s Address
Journal of the Canadian Chiropractic Association $57† Alan Gotlib, DC
(see Publisher Address)
Canadian Chiropractic Association
1396 Eglinton Ave. West
Toronto, Ontario M6C 2E4
Journal of Manipulative and Physiological Therapeutics $92
($52)
Dana Lawrence, DC
200 E. Roosevelt Rd.
Lombard, IL 60148
Williams and Wilkins, Inc.
351 W. Camden St.
Baltimore, MD 21201-2436
Journal of the Neuromusculoskeletal
System
$58
($35)
Rand S. Swensen, DC Data Trace Chiropractic Publishers
PO Box 1239
Baltimore, MD 21022
Topics in Clinical Chiropractic $69.75
($39.75)
Robert D. Mootz, DC
Department of Labor and Industry
PO Box 44321
Olympia, WA 98504
Aspen Publishers, Inc.
7201 McKinney Circle
PO Box 990
Frederick, MD 21701
Chiropractic Research Journal $40 Ed Owens, DC Chiropractic Research Journal
1269 Barclay Circle,
Marietta, GA 30060
Journal of Chiropractic Humanities Free Dana Lawrence, DC
200 E. Roosevelt Rd.
Lombard, IL 60148
Send to Editor’s Address
Topics in Diagnostic Radiology and Advanced Imaging $75 John Stites, DC ACA Council on Diagnostic Imaging
PO Box 25
Palatine, IL 60078

*1995-96 costs; numbers in parentheses indicate student rates; †in Canadian dollars; ‡subscription included in annual member dues.

E. Scope of Research and Efforts To Develop a Chiropractic Research Agenda

Although there are relatively few chiropractors actively engaged in research and their resources for conducting research have been very limited (Meeker, 1996), the scope of chiropractic research parallels that of medical research. Specifically, chiropractic researchers are actively involved in research in each of the following areas: basic science (Brennan, 1997), education (Adams, 1997), health services research (Mootz, 1997), outcomes research (Nyiendo, 1997), and clinical research (Sawyer, 1997). Chiropractic researchers with recognized expertise in each of these areas were recently invited to prepare annotated bibliographies and position papers on the current status and recommendations for future chiropractic research in their area. These papers were circulated to 35 key individuals invited to participate in the National Workshop to Develop the Chiropractic Research Agenda, held July 12-14, 1996, in Washington, D.C. (Mulrouney, 1996; Hawk, 1997). This conference, funded by the U.S. Health Resources and Services Administration's Bureau of Health Professions, had the goal of developing a research agenda for the chiropractic profession (Hawk, 1997). Although considerable progress was made and specific research topics were delineated in some areas (e.g., health services research), many of the recommendations emerging from the conference focused on issues of infrastructure development rather than prioritization of research questions. In order to facilitate the implementation of the recommendations, HRSA has sponsored a second workshop in 1997 to develop more specific research plans and to identify resources and personnel to pursue grant and project development.

References

Adams AH, Gatterman M. The state of the art of research on chiropractic education. J Manipulative Physiol Ther 1997;20(3):179-84.

Brennan PC, Cramer GD, Kirstukas SJ, Cullum ME. Basic science research in chiropractic: state-of-the-art and recommendations for a research agenda. J Manipulative Physiol Ther 1997;20(3):150-68.

Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker D. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. N Engl J Med 1995;333(14):913-7.

Consortium for Chiropractic Research. Fact Book. San Jose, CA: CCR, 1995.

Haldeman S (ed). Principles and Practice of Chiropractic, 2nd Ed. Norwalk, CT: Appleton Lange, 1992.

Hawk C, Meeker W, Hansen D. The national workshop to develop the chiropractic research agenda. J Manipulative Physiol Ther 1997;20(3):147-9.

Keating JC, Lawrence DJ, Leach RA, Bergmann TF, Shrader TL. Clinical scholarship in chiropractic: in search of a commitment. ACA Chiropr 1990;27(3):38,74-8.

Keating JC. Toward a Philosophy of the Science of Chiropractic: A Primer for Clinicians. Stockton, CA: Stockton Foundation for Chiropractic Research, 1992.

Keating JC, Dishman RW, Oliva M, Phillips RB. Roots of the LACC: the Southern California College of Chiropractic. J Chiropr Humanities 1993;3:21-41.

Keating JC, Green BN, Johnson CD. "Research" and "science" in the first half of the chiropractic century. J Manipulative Physiol Ther 1995;18(6):357-78.

Meeker W, Marchiori D, Hawk C, Jansen R, Osterbauer P. Chiropractic research capacity, and infrastructure in North America: results of four surveys. In Mulrouney S, et al. (eds.). Proceedings of the National Workshop to Develop the Chiropractic Research Agenda, July 12-14, 1996. Washington, DC: U.S.. Health Resources and Services Administration and Palmer Center for Chiropractic Research, 1996.

Mootz RD, Coulter ID, Hansen DT. Health services research related to chiropractic: review and recommendations for research prioritization by the chiropractic profession. J Manipulative Physiol Ther 1997;20(3):201-17.

Mulrouney S, Meeker W, Hawk C, et al. National Workshop to Develop the Chiropractic Research Agenda: Workshop Program, July 12-14, 1996. Alexandria, VA: US DHHS, Health Resources and Services Administration, Bureau of Health Professions (Contract #240-95-0036), 1996.

Nyiendo J, Haas M, Hondras MA. Outcomes research in chiropractic: the state of the art and recommendations for the chiropractic research agenda. J Manipulative Physiol Ther 1997;20(3):185-200.

Peterson D, Wiese G. Chiropractic: An Illustrated History. St. Louis, MO: Mosby Year Book, 1995.

Sawyer C, Haas M, Nelson C, Elkington W. Clinical research within the chiropractic profession: status, needs and recommendations. J Manipulative Physiol Ther 1997;20(3):169-78.

Schierholz AM. "The Foundation for Chiropractic Education & Research: A History." Arlington, VA: FCER, 1986 (Unpublished) (Referenced in Keating, et al., 1995).


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