Professions have altruism as one of their core values. Altruism is the act of putting others before oneself. This is congruent with the nature of charities, too; they provide people with an outlet for their altruism.
The Duty to Conduct Research
Our profession needs more full-time researchers to help expand the evidence base for the diagnostic tests and therapeutic interventions we use or maybe should use in clinical practice. But even though there is a need for more researchers, money is still a limiting factor; there just isn't enough money to support quality research.
When I speak to doctors in seminars and my students at the University of Bridgeport College of Chiropractic, they often express amazement at the slow pace of research. It just seems to people not involved in research that it should be easy enough to get the studies done. I'd like to point out a paper by Cambron, et al.,1 which I believe illustrates the fallacy of this belief.
This study involved an extensive advertising campaign in the Chicago area, with an estimated 798,000 people as potential eligible research subjects. The campaign resulted in 1,211 people calling for more information about being research subjects. That seems like a good pool of research subjects. However, of the 1,211, only 60 were ultimately able to become subjects in four different experimental groups; thus only 15 subjects per group. The cost per subject just for recruiting was very high, hence the need for more money.
Even for the established and well-funded researcher, much of their time can be spent in pursuit of money for the next project, rather than conducting research, data analysis and publishing the results of that research.
As I wrote about earlier this year, "As a profession, we have the duty to conduct the research that tests the many hypotheses we have developed over more than a century of our existence."2 Our profession has developed some funding mechanisms internally. The defunct Foundation for Chiropractic Education and Research provided more than $11 million in funding for graduate education and research over its 60-year history. In fact, I was a co-investigator on a study funded by FCER.
The end of FCER left a vacuum that the NCMIC Foundation is filling. While NCMIC has donated millions of dollars for research training and research, now through the NCMIC Foundation it is growing a reserve while funding projects that should produce positive outcomes for our profession for years to come.
The Canadian Chiropractic Research Foundation (CCRF) has an impressive record of funding research chairs and professorships at major universities in many of the Canadian provinces. The European Chiropractors' Union (ECU) Research Fund is also working on funding research and training, and many member countries in Europe have their own research funding organizations.
Research Funding (and Non-Funding)
In Australia, there are two organizations funding chiropractic research; one is the Chiropractic and Osteopathic College of Australasia (COCA), which is the original sponsor for the journal Chiropractic & Osteopathy (now called Chiropractic & Manual Therapies – C&MT). In the interest of full disclosure I'm honored to serve as an associate editor of C&MT.
COCA funded the journal as a way to disseminate research for the benefit of the profession and the public without any gain for the organization. The journal is free for all online. Obviously this was done with altruistic intent. Likewise, the European Academy of Chiropractic (part of the ECU) and the Royal College of Chiropractors (who also fund research and training) have put their money where it is needed and also are funding C&MT.
Not content to only provide a vehicle for dissemination of research, COCA Research Limited, as with these other organizations, has been funding research and scholarships for research training.
Unfortunately, not all the groups that one would assume have altruistic intent when it comes to chiropractic research appear to function that way. Recently, there was an exposé in a blog from "The Rogue Chiropractor" regarding the other Australian organization purportedly funding chiropractic research, the Australian Spinal Research Foundation.3 The Australian media has picked up this story, too.4 It seems that ASRF has donated 6.88 percent of its funds for research over the past 13 years. On the other hand, COCA Research Limited has disbursed 87 percent of its funds for research or education.
In 2012 alone, ASRF had more than $600,000 in employee benefits and expenses, but only granted $52,000 for research! This is astonishing given the year's income of $1.6 million. COCA Research has disbursed 87 percent of the $200,000 it has raised since 2010 for research, with only $25,000 in expenses.8 Where's the research funding?
There are calls for the Australian regulators of charities to investigate ASRF. In the United States, the Charity Navigator suggests a charity should disburse at least two-thirds of its money for programs and services.5 While COCA Research does better than that with 87 percent for research or scholarships, ASRF's 6.88 percent is abysmal.
Part of the problem may be ASRF's very restrictive idea of what appropriate chiropractic research is and even how it fulfills its mission. Nevertheless, the organization should be funding more research – or at least its employee benefits and expenses shouldn't be more than 10 times the amount of money used for research.
ASRF recently held a conference called "Dynamic Growth Congress" (its only other event is called "The 6 Pillars of an Epic Paediatric Practice"). However, no researchers were speakers at either event. The only presentations that appeared to have anything to do with research were titled "The Intersection Between Research and Philosophy" by Martin Harvey and "Not Blinding Them With Science – How to Easily Explain Chiropractic Research," also by Martin Harvey. Based on his bio on the ASRF website and his practice site, it appears that he isn't a researcher ... but he is the president of ASRF.
I have no problem with seminars that teach life skills or practice management. I know that being a better person and learning to improve the efficiency of one's business are valuable to how we relate to our patients and how our business functions. The problem is, where's the research from a charity that says: "Our focus is chiropractic research?"
I was a speaker at one of the last programs FCER put on, in Tacoma Wash., in 2007. The title of the program was,"Translating Evidence Into Practice." All of the presentations were about research, the current best evidence, how to find the evidence or how to appraise the evidence.
I do not know what regulators in Australia will do about a research charity that barely funds research and barely disseminates research knowledge. However, it does seem to me that the profession in Australia needs to refocus its efforts on its moral duty to the public to fund, conduct, disseminate and make clinical use of research.
Where Private Practice and Research Collide
I know that to many in private practice, research seems to be something whose impact is only on those in academia; or is the tool insurance companies use to cut claims or deny coverage. And if that were true, then it really doesn't matter what happens to that money in Australia, or whether or not chiropractors get funded for research, or get positions at universities in Canada or elsewhere in the world.
When I talked earlier about research as a moral issue, it was in the abstract sense, without current examples. But there have been concrete examples of research impacting our patients and us. Early research suggested cervical manipulation caused strokes6-7 and we responded by changing what we informed patients. But the best evidence today doesn't support a causal link, and that changes what our informed consent includes.8 Likewise, early research suggested there were common transient, minor side effects from manipulation,9-11 but that may not be the case anymore.12
Recently, I was informed that our systematic review of manipulation for lower extremity conditions13 was cited by a large managed care organization in its policy on those conditions, opening up payment for conditions that previously weren't covered. Keep in mind that this systematic review was authored by chiropractors from around the U.S., as well as from Australia and South Africa.
Chiropractic research isn't a local affair and its effects on the profession will not be local. As such, we should all be concerned about the funding and dissemination of research in the profession worldwide. Each of us needs to ensure that our local chiropractic research organizations are living up to their altruistic duty. What's more, we need to do our duty to help fund those chiropractic research organizations, volunteer to participate in research when asked, and perhaps even take the big step and obtain research training and become a part- or full-time researcher.
References
- Cambron JA, Dexheimer JM, Chang M, Cramer GD. Recruitment methods and costs for a randomized, placebo-controlled trial of chiropractic care for lumbar spinal stenosis: a single-site pilot study. J Manipulative Physiol Ther, 2010 Jan;33(1):56-61.
- Perle SM. "Chiropractic Research: A Moral Issue." Dynamic Chiropractic, June 1, 2013.
- "Australian Spinal Research Foundation: It's Time to Drop the Pretense." The Rogue Chiropractor (blog), posted Oct. 9, 2013.
- Bramwell N. "Chiropractic Charity Spending Questioned." Medical Observer, Nov. 5, 2013.
- Charity Navigator - Financial Ratings Tables. www.charitynavigator.org
- Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case-control study. Stroke, 2001;32(5):1054-60.
- Smith WS, Johnston SC, Skalabrin EJ, Weaver M, Azari P, Albers GW, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology, 2003 May 13;60(9):1424-8.
- Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine, 2008 Feb 15;33(4 Suppl):S176-83.
- Senstad O, Leboeuf-Yde C, Borchgrevink C. Frequency and characteristics of side effects of spinal manipulative therapy. Spine, 1997;22(4):435-40; discussion 440-1.
- Hurwitz EL, Morgenstern H, Vassilaki M, Chiang L-M. Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study. Spine, 2005 Jul 1;30(13):1477-84.
- Eriksen K, Rochester RP, Hurwitz EL. Symptomatic reactions, clinical outcomes and patient satisfaction associated with upper cervical chiropractic care: a prospective, multicenter, cohort study. BMC Musculoskelet Disord, 2011;12:219.
- Walker BF, Hebert JJ, Stomski NJ, Clarke BR, Bowden RS, Losco B, et al. Outcomes of usual chiropractic. The OUCH Randomized Controlled Trial of Adverse Events. Spine, 2013 Sep 15;38(20):1723-9.
- Brantingham JW, Bonnefin D, Perle SM, Cassa TK, Globe G, Pribicevic M, et al. Manipulative therapy for lower extremity conditions: update of a literature review. J Manipulative Physiol Ther, 2012 Feb;35(2):127-66.
Click here for previous articles by Stephen M. Perle, DC, MS.