Trailblazer

Many practising health professionals become so wrapped up in day-to-day clinical practice that sometimes they forget to reflect on the time and effort invested into the research that most clinical protocols are based on.

Many practising health professionals become so wrapped up in day-to-day clinical practice that sometimes they forget to reflect on the time and effort invested into the research that most clinical protocols are based on. Research is the vehicle that has transported the profession through time and space – from David Palmer’s little office in Davenport, Iowa, in 1895 to the Oval Office and worldwide acceptance in 2013.

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Historically, practising chiropractors have relied on the outcome of research studies to develop procedures in clinical protocols, interdisciplinary acceptance and development of insurance company policies. In a recent interview, Dr. Cheryl Hawk, dean of research at Logan Chiropractic College, commented on the importance of research to practising chiropractors.

“With the emphasis on evidence-based practice and documenting outcomes, if you don’t have research, it’s going to be harder and harder to get paid by third-party payers,” Dr. Hawk says.

Reviewing the past
As researchers and as practising chiropractors, it is important to reflect on significant research from the past that have shaped the way insurance companies, patients and health professionals view the role of chiropractic care.

1. Low back pain of mechanical origin: Randomised comparison of chiropractic and hospital outpatient treatment, Meade et al., BMJ 1990; 300:1431.
For patients with low back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile, long-term benefit in comparison with hospital outpatient management. The benefit is seen mainly in those with chronic or severe pain. Introducing chiropractic into national health-care system practice should be considered.

What did this mean?
For the first time a well-known medical journal studied chiropractic care in a clinical setting and revealed the significant clinical and financial benefits associated with using chiropractors as allied health professionals. This study was monumental in the development of extended health-care plans that began to include chiropractic care as a regular benefit.

2. Magnetic resonance imaging of the lumbar spine in people without back pain, Jensen et al., N Engl J Med. 1994 Jul 14; 331(2):69-73.
On MRI examination of the lumbar spine, many people without back pain have disk bulges or protrusions but not extrusions. Given the high prevalence of these findings and of back pain, the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental.

What did this mean?
This study was the first of its kind in such a prominent medical journal to illustrate that many disc surgeries may be unnecessary and the use of other forms of conservative care should be given more of an opportunity in patients with low back pain.

3. The needle effect in the relief of myofascial pain, Karel Lewit, Pain. 1979 Feb; 6(1):83-90.
Dry needling is highly effective for the treatment of chronic myofascial pain. Researcher Karel Lewit referred to it as the “needle effect” in an article that demonstrated that needling painful regions provided immediate pain modulation.

What did this mean?
This was the first piece of work in western medicine that validated what traditional Chinese acupuncture had been saying for over 2,000 years. The needle itself played the largest role in analgesia – more than the actual local anesthetic or injectable anti-inflammatory. This study also set the framework for contemporary forms of medical acupuncture, which many chiropractors incorporate in their daily practice today.

Back to the future
I recently interviewed Dr. Steven Passmore, assistant professor and holder of a Canadian Chiropractic Research Foundation Professorship in Spine Biomechanics and Human Neurophysiology in the School of Medical Rehabilitation at the University of Manitoba. Dr. Passmore is one of the chiropractic profession’s most respected researchers today. He demonstrates how practising chiropractors and chiropractic students can learn to better appreciate, interpret and apply research concepts to enhance their body of clinical knowledge.

Following are some of the highlights of my conversation with Dr. Passmore (SP).

What is your educational background?
SP: I graduated with an honours degree in kinesiology from McMaster University and then I completed my master of science degree at University of Nevada in Las Vegas. Then it was off to New York Chiropractic College where I earned my doctorate Of chiropractic, and then I completed my PhD in kinesiology at McMaster University.

Why did you become interested in research?
SP: When I was an undergraduate student at McMaster, I would see posters advertising for research participants. After I volunteered for a study, I saw for the first time the process of collecting research data. I became fascinated and signed up for as many [studies] as I could – both to help contribute to the science, and to ask questions of the researchers about what they do and why.

What would be the ideal relationship between research and clinical practice?
SP: It would be very close to what I have created with my team in my current laboratory setup in the School of Medical Rehabilitation at the University of Manitoba. I host weekly clinics in a treatment room in my laboratory, which is housed within a full-scale urban rehabilitation hospital. When patients are suitable as research participants, they are asked if they would like to participate. If they agree, they proceed to the informed consent process and merely step into the research laboratory with state-of-the-art equipment in the next room. It is a virtually seamless way to collect data from clinically symptomatic patients. It also does not require an additional visit to the laboratory for patients with mobility issues. It is a model that functions optimally when researchers are placed in an environment where a high volume of special clinical population is seen. The positions held by DC PhDs at major medical-doctoral research-intensive universities are the ideal settings for such work.   

How much of an impact does research have on the future of chiropractic?
SP: Research has a tremendous impact on the future of chiropractic. It is a process that helps to provide insight as to why clinicians do what they do, and potentially how to streamline or improve the efficiency and efficacy of care delivery. Research also allows for the identification of populations who may benefit from chiropractic care but are presently underserved by the existing health-care paradigm.

Published research findings provide something tangible that chiropractors can turn to when they discuss their role in health care with patients, clinicians from other disciplines and government stakeholders.

How can researchers and readers of research avoid research bias to obtain the true value of the research paper?
SP: The answer for the consumer of research is to read the method and results sections first. The method section should tell you in sufficient detail how the study data were collected and in what context. The results section will allow you to see the statistical measures applied and the strength of the measured effects and relationships among variables. The other sections in the article (introduction, discussion, and conclusion) are subject to interpretation. The sections other than the method and results are the attempt to put the research question tested into the context of the existing literature and it is where any bias of the author might be found. In the end, the true goal of any scientist should be to remain objective and not interpret their findings beyond the scope of their data.

In the research process, bias can be avoided by your experimental design. For example, you can attempt to “blind” patients as to the intervention they are receiving, or you can “blind” your research staff regarding whether a patient received an intervention or not. 

What would you tell someone who is thinking about entering chiropractic research?
SP: The future is bright, and the opportunities in the coming years have the potential to grow if they are properly developed, cultivated and supported by the chiropractic profession, universities and government health-care funding agencies. There has never been a better time for chiropractors to pursue graduate degrees within the Canadian university system. Thanks to the initiatives of the Canadian Chiropractic Research Foundation and other self-driven clinician-scientists, chiropractors with the interest, desire and aptitude can approach DC PhDs at research intensive universities across the country to supervise master degrees, or PhDs in the behavioral/neural sciences, epidemiology, or basic bench laboratory sciences. The research community is also one that has no borders. Research opportunities are growing both locally, and abroad for those ready for different cultural experiences around the globe. 

Next time you receive a referral from a medical doctor or a recommendation from a surgeon to try conservative chiropractic care on a patient, remember that somewhere along the way a researcher blazed a trail to create that working relationship. As clinicians, we should make it a habit to read and follow current research so we can become committed to clinical excellence.

Published work by Dr. Steven Passmore
Dr. Steven Passmore has authored and co-authored several peer reviewed articles in a number of professional journals. Below is a list of some of his research work.

• Performance based objective outcome measures and spinal manipulation
• Relationship between ambulatory performance and self-rated disability in patients with lumbar spinal stenosis
• Anatomically remote muscle contraction facilitates patellar tendon reflex reinforcement while mental activity does not: a within-participants experimental trial
• Head movement kinematics during rapid aiming task performance in healthy and neck-pain participants: the importance of optimal task difficulty
• Spinal manipulation impacts cervical spine movement and fitts’ task performance: a single-blind randomized before-after trial
• Chiropractors at McMaster University: The formation and direction of a university-based multidisciplinary chiropractic working group
• A cross-sectional analysis of clinical outcomes following chiropractic care in veterans with and without post-traumatic stress disorder
• Positive patient outcome after spinal manipulation in a case of cervical angina
• Consultation request patterns, patient characteristics, and utilization of services within a Veterans Affairs medical center chiropractic clinic
• Older adults demonstrate reduced performance in a Fitts’ task involving cervical spine movement
• Chiropractic evaluation and management of the pregnant patient: an update from recent literature
• Head-putter coordination patterns in expert and less skilled golfers
• Effects of focus of attention depend on golfers’ skill

* For a link to any of these titles, visit Passmore’s profile on LinkedIn.

Anthony Lombardi, DC, is a consultant to athletes in the NFL, CFL and NHL, and founder of the Hamilton Back Clinic, based in Hamilton, Ont. He also conducts practice-building workshops for health professionals. Visit www.exstore.ca for more information.