Research at the Colleges and Universities, Part I
JACA asked research officiais at a representative number of the chiropractic schools around the country to give a rundown on what’s new, promising, and provocative.
Cleveland Chiropractic College, Kansas City, MO
Cleveland Chiropractic College in Kansas City researchers presented 6 studies at the March Association of Chiropractic Colleges-Research Agenda Conference (ACC-RAC) “Best Practices” meeting in Las Vegas.
One poster presentation, in collaboration with the University of Kansas’ Department of Engineering, examined the effects of lumbosacral loads in students who carry backpacks. Among some 1,000 students, researchers found that many backpacks added as much as 30% to total body weight. “That’s way over the loading limits for most young people, even of college age,” says director of research Mark Pfefer, RN, MS, DC. “Alterations in posture were found that might be associated with back problems provoked by excessive backpack weight. For example, students’ heads were pulling forward a lot, so although the primary load is on the lower back, these excessive weights might cause neck pain.”
Two other presentations, both case studies, considered the effectiveness of the Graston technique, the patented form of instrument-assisted, soft-tissue mobilization that uses specially designed stainless steel instruments to detect and treat areas of soft-tissue fibrosis or chronic inflammation. “One case study involved the successful treatment of a failed neck surgery patient, and the other involved the successful treatment of a patient with a grade one Achilles tendon tear,” says Dr. Pfefer. “We’d like to do some future research using Graston as an adjunct to chiropractic adjustments.”
Also presented at ACC-RAC was a reliability study on the Sphinx position technique for motion palpation. “It’s widely taught, but no one’s looked at reliability,” says Dr. Pfefer. “We had three observers looking at about 20 students, and we examined inter- and intra-rater reliability. We did find some moderate reliability with this technigue, and we hope to publish the results.”
In terms of ongoing research, the largest current project is funded by the National Institute for Chiropractic Research. It compares traditional side-posture adjustments with Activator instrument adjusting in both acute and subacute lowback pain patients. This small, randomized comparative trial will accrue between 40 and 50 subjects and will examine both pain outcomes and functional outcomes.
Logan College of Chiropractic, Chesterfield, MO
Logan College of Chiropractic is now collaborating with several local medical centers in the St. Louis metropolitan area on a major research effort involving back pain and pregnancy. The 2-part study, led by principal investigator Clayton Skaggs, DC, will enroll about 1,500 patients per year. It will screen for back problems, then assess therapy effects. The year-old project is currently confined to 2 clinical settings, both with the same demographics-approximately 70% African-American patients, mostly on Medicaid or uninsured. Director of research Doug Dean, DC, reports that Logan is seeking funding to expand the number of research sites and broaden the study’s demographic reach.
Dr. Dean says, “About 70% of the women we’ve screened complain of pain in the low back, mid-back, and pelvis, with the lower back as the primary pain site. When mid-back or pelvic pain is involved, it exacerbates the discomfort, but these pain areas are seldom seen in isolation. We find that phenomenon biomechanically interesting because we don’t really understand why it happens.”
Since the prevalence of back pain in pregnancy is so high, what happens to such patients when they receive standard obstetrical care? Often, the research indicates, not much. “Approximately 85% indicated that they’d received no pain treatment from standard obstetrical care. That really surprised us,” says Dr. Dean. “Of those who were offered treatment, only 1% of patients were satisfied with it.” Among the remedies offered by obstetricians were aspirin or ibuprofen, lying on a heating pad, and refraining from wearing highheeled shoes. “The majority were told, ‘Live with it. It’ll go away when you deliver.'”
The researchers also found that back pain in pregnancy has a substantially negative impact on quality of life. “Of women who complained of back pain, 85% were sleeping fewer than 4 hours a night. By comparison, only 5% of the women not complaining of back pain had these kinds of severe sleep problems, which seems to indicate that sleep disruption is highly correlated with pain,” Dr. Dean reports. “Furthermore, 80% of the women who reported pain were taking pain medication, while only 8% of those not reporting pain were on such medication.”
Contrary to expectation, the research also indicates that back pain associated with pregnancy doesn’t vanish in the delivery room. “For 30% of the women in our study, the pain became chronic after delivery. It’s not simply pregnancy-dependent for a substantial number of women,” says Dr. Dean.
The therapy side of the study is still in its early stages. “We’ve started the patients on musculoskeletal treatments that include manual therapy, exercise, and some education. The preliminary result is that after 2 treatments, about 50% of the women are satisfied with their care,” an increase of 49% over more standard approaches to back pain care during pregnancy.
Dr. Dean hopes that this study-for which he expects to have final data within 2 years-will provide solid evidence to use in influencing medical centers to add musculoskeletal care to their obstetrical services. Early signs are promising. “This approach, of course, means working side by side with allopathic and osteopathic physicians. There was some skepticism at first in the medical centers, but once they saw the numbers and realized it’s a chronic condition-and that we can do something about it-many have been won over.” Working with 2 medical centers, the Logan researchers have submitted 2 joint grant proposals to the NIH, one to the National Center for Complementary and Alternative Medicine, and the other to the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
Several ongoing studies led by John Zhang, DC, examine heart rate variability before and after chiropractic care. “Resting heart rates in athletes can be as low as 30 beats per minute, and athletes’ ability to raise their heart rates is elevated, as high as 200 BPM,” Dr. Dean says. “The ability of the body to regulate its heart rate is now recognized as a measure of fitness, but also as a measure of disease. If you’re in pain, your resting heart rate will go up, and you can’t vary it like you normally would.”
Study participants are asked to rate their levels of pain before and after chiropractic treatment, using a standard visual pain scale. Researchers also take measures of their varying heart rates, and reassess their pain in the context of heart rate variability. To date, investigators have examined more than 5,000 patients, in collaboration with other chiropractic colleges across the country. all sites are using a heart rate variability monitor made by Biocom, which funds the project.
“Although our findings remain preliminary, they’re very promising, and track with our expectation, which is that decreasing a patient’s pain levels leads to an increased ability to vary the heart rate,” Dr. Dean says. “We’re a small part of a larger study in medical centers across the country that’s looking at heart rate variability in normal control patients and in people with diabetes and heart disease. Our study is one of the few with a therapeutic component.”
He expects that the study and its results will be published in about a year. “After that, we might want to continue the research and isolate it further-to include manipulation, exercise prescription, or stretching, and how each affects the patient’s ability to vary the heart rate.”
Dr. Norman Kettner, chairman of the radiology department at Logan, formed a partnership with Massachusetts General Hospital in 2001 to do acupuncture pain research. The study is evaluating the effects of acupuncture on neural networks that are involved with pain processing located in the cortex and sub-cortex of the brain, using an advanced MRI technology known as “functional MRI,” or fMRI. While MRI provides high-resolution anatomical images of soft tissues in the body, fMRI measures blood flow to specific areas of the brain and then provides a visual scan of images that show changes in brain activity based on that flow when specific areas of the brain are stimulated, as with acupuncture. The fMRI scan can then be superimposed on an anatomical MRI image, allowing scientists to observe brain activity in specific areas of the brain and “map” various regions by function-such as thought, motor control, and pain processing. In time, says Dr. Kettner, the brain maps being developed with fMRI technology should be able to measure effects of other forms of stimulation to treat pain, such as spinal manipulation, massage, and exercise. Neurolmage Journal is reviewing the preliminary findings for publication later this year.
National University of Health Sciences, Lombard, IL
Magnetic Resonance Imaging (MRI) is a major component of current chiropractic research at National University of Health Sciences (NUHS).
In 3 recent studies, NUHS researchers used MRI to display the existence of anatomical, structures and events not previously shown. “Our research demonstrated several subtle, but important, structures-and other studies showed that chiropractic adjustments affect the tissues of the spine,” says the dean of research, Greg Cramer, DC, PhD.
In one study conducted in collaboration with Canadian Memorial Chiropractic College’s Kirn Humphreys, DC, PhD, MRI-based research not only confirmed the existence of connective tissue extending inward from the ligamentum nuchae and rectus capitis posterior minor muscle of the cervical region, but also demonstrated that the connective tissue attachments continued to the spinal dura mater. These anatomical structures had never been sufficiently documented on MRI before. NUHS confirmed the connection by studying 30 cadavers and taking MRI scans of 4 of them before and after dissection. The findings of this study could lead to new insights into certain injuries, such as whiplash.
In a second series of studies, NUHS researchers took measurements from images of the zygapophyseal joints (Z joints) before and after chiropractic adjustments. They compared the measurements to those taken from control subjects. The results showed that chiropractic adjustment of the lumbar spine does create increased gapping of the Z joints. This beneficial expansion of the area within and between the joints is believed to break up adhesions due to hypomobility, and also possibly stimulate mechanoreceptors in the Z-joint capsule and transversospinalis muscles, thus affecting spinal and neurological health. Previous research claimed that no gapping occurred in the lumbar spines of healthy individuals.
NUHS also engages in studies that explore better ways to use MRI to observe unique structures of the spine, including one that determined the best way MRI can be used to observe fine ligaments known as transforaminaL ligaments that traverse the intervertebral foramina. By comparing participating radiologists’ results, they determined optimal techniques for capturing accurate images of these structures and the reliability of MRI in demonstrating them.
1. Cramer G, Skogsbergh D, Bakkum B, Winterstein J, Yu SW, Tuck NR. Evaluation of transforaminal ligaments by magnetic resonance imaging. J Manip Physiol Ther 2002;25:199-208.
2. Cramer GD, Gregerson DM, Knudsen JT, Hubbard BB, Ustas LM, Cantu JA. The effects of side posture positioning and spinal adjusting on the lumbar z-joints: a randomized controlled trial of 64 subjects. Spine 2002;27:2459-2466.
3. Humphreys BK, Kem’n S, Hubbard B, Cramer GD. Investigation of connective tissue attachments to the cervical spinal dura mater. Clin Anatomy 2003;16:152-159.
4. Cramer, GD, Wolcott CC, Cantu JA, Fergus MP, Cambron JA, Gregerson DM, Knudsen, JT. The effects of side posture adjusting on the lumbar zygapophyseal joints of low-back pain patients as evaluated by magnetic resonance imaging: a preliminary study. 2004. Association of Chiropractic Colleges/9th Research Agenda Conference, Las Vegas, NV.
Palmer College of Chiropractic, Davenport, IA
“We’re fortunate to have a very active group of faculty members involved in research, in both clinical and basic sciences. We think both forms of research are important to the overall effort,” says Bill Meeker, DC, Palmer’s vice president for research. “We have 9 full-time faculty members and 19 staff members who devote 90% of their time to research. At any given time, we have 2530 projects going on simultaneously in various phases of planning or completion, which includes our California and Florida campuses.”
Palmer’s research portfolio comprises basic biomechanics and neuroscience, clinical trials evaluating chiropractic care for patient conditions, chiropractic technique and technology assessment, and health services. Palmer also received a multi-year contract from the U.S. Health Resources and Services Administration (HRSA) to produce the annual Research Agenda Conference (RAC), held in collaboration with the annual conference of the Association of Chiropractic Colleges every March.
The most significant recent development is the NIH award establishing the “Center for the Study of Mechanisms and Effects of Chiropractic Manipulation.” This 3-year effort is a collaboration involving investigators at the Palmer Center for Chiropractic Research (PCCR) and the University of Iowa (UI), National University of Health Sciences (NUHS), Kansas State University (KSU), and State University of New York at Stony Brook (SUNY). The center encompasses 3 basic science projects and one clinical study. All relate to both experimental model building and to understanding the physiological mechanisms of subluxation and spinal adjustments.
Project #1 is led by Joel Pickar, DC, PhD (PCCR), and Partap Khalsa, DC, PhD (SUNY). It focuses on changes in neural discharge from paraspinal receptors in the facet joint capsule. Altered sensory input from this articular structure during vertebral dysrelationships has long been considered an important contributor to conditions for which patients seek chiropractic. To date, nothing is known about the response characteristics of these neurons to physiological motions and manipulative loads. Project #1 uses state-of-the-art tech7nology to determine how facet joint afferents respond to mechanical loading in the spine and specifically to a high-velocity, low-amplitude thrust in an animal model. Drs. Pickar and Khalsa have both previously received NIH funding for studies that led up to this one.
Project #2 is led by Charles Henderson, DC, PhD (PCCR), and Tae-Hong Lim, PhD (UI). It focuses on vertebral dysrelationships and mechanical loads. Dr. Henderson previously established a spinal fixation model showing increased spine stiffness and degenerative spine changes in the rat. The investigators are extending the use of this model in 2 ways. First, they will evaluate behavioral changes that might occur with spine fixation. This would provide the first animal model to investigate the relationship between the integrity of the vertebral column and a general state of wellness. Second, they will determine the effects of several types of spinal manipulation on fixation-induced stiffness and degenerative changes within the spine itself.
Project #3 is a clinical study led by William Meeker, DC, MPH (PCCR), and David Wilder, PhD (UI). They are studying 250 patients with subacute and chronic back pain to explore which clinical parameters, biomechanical parameters, and neuromuscular parameters might have predictive value for determining which patients will benefit from chiropractic techniques. The character of those parameters would point to scientific directions that can be explored more mechanistically. Being able to know what kinds of patients will respond best to which techniques will be extremely helpful in clinical practice.
Project #4 is being conducted by Joel Pickar, DC, PhD (PCCR), and Michael Kinney, PhD (KSU). It addresses whether vertebral dysrelationships have somatovisceral consequences by measuring sympathetic nerve discharge to 4 different organ beds in a rat model. In addition, the possibility that vertebral dysrelationships affect the state of the central nervous system will be investigated by looking at the effects of high-velocity adjustments in both the presence and absence of an imposed mechanical load on a single vertebra.
If Project #2 finds that spine fixation produces behavioral change, and Projects #1 and #4 find that mechanical loading of the spine substantially alters facet joint input and sympathetic nerve discharge, this would provide exciting preliminary data for future investigation of the causal relation between altered sensory input from paraspinal tissues and changes in physiological function. The theoretical framework for understanding manipulation will be clearer, providing more precise avenues for productive research, and the quality of clinical procedures could be significantly improved.
Another large randomized clinical trial funded by HRSA is being undertaken. “Palmer is working with the University of Iowa to compare 2 chiropractic case management styles-flexion-distraction adjustment and side posture high-velocity adjustment-with medical care for chronic back pain in the elderly. This has not been done before,” Dr. Meeker says. “We are just beginning to enroll 200 patients to undergo 6 weeks of care and extensive pre- and post-treatment biomechanical testing.”
Last year, Palmer also launched an NIH-funded clinical research training program aimed at nurturing chiropractic clinical scientists, and established a program that will confer a master of science degree in clinical research. The program began in fall 2003, and now has 3 full-time fellows; Dr. Meeker reports that they hope to have 4 to 6 new full-time fellows in fall 2004.
“The clinical research training program is an onsite, in-residence program that immerses fellows in our clinical research activities while they also take classes,” says Dr. Meeker. “It’s organized in collaboration with the University of Iowa. We’re particularly proud of it because we think it’s one of the first NIH-funded training programs led by a chiropractic institution. We hope that our fellows will eventually carry on the profession’s clinical research at an increasingly sophisticated level.”
Palmer College of Chiropractic- West, San Jose, CA
Dr. Michael T. Haneline recently joined PCCW as a full-time researcher. His credentials include working with Dr. C.H. Suh in computer-aided design of mechanisms, and extensive involvement with the Spine Research Institute of San Diego.
Dr. Robert Cooperstein recently participated in a 2-day strategic planning retreat at the PaLmer Center for Chiropractic Research. The planning session formulated short-, mid-, and long-term plans for the center’s existing and proposed programs/disciplines.
Research projects underway or in the planning stages include:
* The validity of manual palpation for assessing vertebral rotational subluxation
* Patient blocking preferences, as related to pelvic torsion and sagittal plane postures
* Chiropractic care of acute cervical pain: a practice-based study
* Chiropractic college student palpatory skill development
* Inventory of chiropractic college protocols for thrusting procedures in laboratory environments
* In vivo measurement of intradiscal pressure during spinal manipulation
Parker College of Chiropractic, Dallas, TX
The Research Institute has been involved in several important collaborative projects. This includes a joint publication this year with Yale University Medical School and current work with the University of Chicago, the University of Texas Medical Center at Houston, Jiangsu Province Institute of Anesthesiology, the World Federation of Chiropractic, the Public Health Department of the City of Irving, Texas, and other research studies with chiropractic individuals or organizations in the United States, Canada, and Australia.
A major area of research focus is wellness and public health, reports the director of research Ron Rupert, MS, DC. “We currently have 3 studies ongoing in that category. One is a pilot study on smoking cessation and co-management with counseling and chiropractic care. It involves 25 patients and is led by Dr. Cheryl Hawk,” Dr. Rupert says. The internally funded study intends to assess whether chiropractic care, including spinal adjustment, other manual therapies, counseling, self-help material, and doctor-patient interaction, increases the effectiveness of the current standard smoking cessation programs. It has been historically believed that chiropractic care is helpful in stress management, and perhaps it can help smokers manage the stressful situations that they often cite as particularly difficult to manage without a cigarette. Patients will receive adjustments no less than weekly during the 60-day active period of the study. Another pilot study is being conducted in collaboration with the World Federation of Chiropractic’s “Chiropractors Against Tobacco” campaign in conjunction with the World Health Organization (WHO).
Parker is also involved in a weight-loss study in partnership with the city of Irving, Texas, and its department of public health. It involves more than 500 subjects who are participating in the “Ultimate Weight-loss Challenge” on the Dr. Phil Show. “It doesn’t involve chiropractic care directly, but is a collaborative study in keeping with our emphasis on wellness and global health issues,” says Dr. Rupert. “We collected baseline data related to weight, BMI, and blood pressure, as well as psychological measures and general health status. We are monitoring patient progress and providing analysis of the results.”
Parker researchers are also pursuing basic science studies using the rat model. Xuejun Song MD, PhD, has recently published several papers related to chronic pain that involves the rat model he has developed. “We know a lot about acute pain, but much less about chronic pain,” he says. His studies provide solid neurophysiological evidence underlying the neural mechanisms of chronic pain after nerve injury,” Dr. Rupert states. “One of Dr. Song’s studies deals particularly with understanding how B vitamins may affect chronic pain. We know they support the nervous system, but how do they affect pain?” Dr. Rupert asks. One of these studies, released in early 2003, received a lot of press attention-including coverage on NBC and CBS and in lay periodicals like Psychoiogy Today and Shape. It found that B vitamins such as Bl, B6, and B12 and their combinations are showing significant results in reducing pain in laboratory rats. “As much as we know about the B vitamins, there’s much more we don’t know,” says Dr. Rupert.
Dr. Song is also using rats to study the model of chiropractic subluxation. “One of the models he’s used deals with inflammation around a nerve root,” Dr. Rupert says. Researchers use different forms of chiropractic adjustments on the rats with inflammation to identify any changes in the pain pattern. “One of his recent studies shows a statistically significant decrease in lumbar nerve root inflammation, which is common in humans, within 3 days of adjustments. These findings dovetail well with the rat subluxation research that’s going on at other colleges.”
Also on the rat-model research agenda at Parker are head-to-head studies of various soft-tissue techniques used in chiropractic practice to see which, if any, are superior to the others. “There have never been head-to-head comparison studies of these techniques,” Dr. Rupert says. “We’re looking at cross-frictional massage, Nimmo, and a longitudinal axis soft-tissue technique in treatment of tendonitis. Those are the 3 primary techniques getting the most press in resolving this condition.”
The rats are injected with collagenase to induce a condition like an Achilles tendon sprain. “They’ll walk gingerly for a couple of days,” Dr. Rupert explains. “We then sedate the rats and massage the tendons. We’ve already seen some significant changes with the techniques, and all 3 seem to deliver some effective relief over the control group, to various degrees. Once we’ve nailed down the best technique and best dose response in rats, we want to move on to human studies.” Parker researchers are also involved in several epidemiological studies. One recently completed project examined 700 middle-school, children and their patterns of pain associated with backpack use. “We know that neck and shoulder pain accompany overweighted backpacks, but foot pain often gets neglected,” says Dr. Rupert. “About 30% of the children in our study had foot pain, which was much higher than I expected. We’re now trying to define if there’s a relationship between the pattern of pain, the backpack’s weight, how the backpack is carried, and/or the type of shoe the child wears.”
Chiropractic practice itself also is of interest to Parker researchers. One study they recently presented at ACC-RAC examined work-related injuries to chiropractors. “We as a profession talk about proper lifting, proper biomechanics, and proper ergonomics-but do we practice that, and are there serious injuries when we don’t?” asks Dr. Rupert.
Using a national survey of a statistically representative group of 1,500 randomly selected practicing doctors of chiropractic, the epidemiological study found an unusually high injury rate. “While at least 50% had low-back injury to some extent, by far the greatest area of complaint was the wrist,” Dr. Rupert says. “That’s not surprising when you consider the multiple adjustments given over the course of a chiropractic career. Now that we understand more about this, we can do more to warn people about occupational injuries in chiropractic.”
Parker researchers are also collecting data from doctors on what elements of practice have helped to make them successful. This self-selected sample of 1,200 doctors was asked to list personal characteristics that had contributed to the success of their practices-they cited “communications skills” as by far the most important. When asked to identify their biggest mistake in practice from a list of more than 60 possibilities, the doctors identified borrowing too much money in college as no.l, followed closely by not adequately training staff. “This research is our way of returning something very pragmatic to the practitioners,” says Dr. Rupert.
Next month: New York College of Chiropractic, Northwestern Health Sciences University, Southern California University of Health Sciences, Texas Chiropractic College, Western States College of Chiropractic, and the University of Bridgeport’s College of Chiropractic.
Copyright American Chiropractic Association Jul 2004
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