The study will compare chiropractic with physical therapy, chiropractic without physical therapy, medical care with physical therapy, and medical care without physical therapy. The results should prove interesting reading.
The research team includes Gerry Kominski, PhD (UCLA Department of Health Services), and Philip Harber, MD (UCLA School of Medicine), among others from UCLA, and Albert Barnett, MD, and Gloria Mayer, RN, EdD, from Friendly Hills HealthCare Network (the site of the project).
The first proposal was submitted and considered by AHCPR in 1992. The project was finally accepted after three revisions, the last amended by consultant Alan Adams, DC, MSEd, DACBN, of the Los Angeles College of Chiropractic (LACC), and included the significant financial commitment from LACC.
This study is different from other recent randomized studies of low-back pain (e.g., Meade et al., Koes et al., in particular) in four very important ways:
l) The study will be conducted in a population that receives its health care, including hospitalization, from one source.
2) The study investigates the effectiveness of chiropractic care and medical care with and without physical therapy.
3) Patients with acute or chronic low-back pain with and without leg pain will be included.
4) The study will not only collect comprehensive data on pain, functional status, and patient satisfaction, but also information on psychosocial and occupational factors. Self-care will also be taken into account, which may influence low-back pain prognosis and the effects of treatment.
Project coordinator Eric Hurwitz, DC, MS, is a doctoral candidate at UCLA. He will effectively be a full investigator for the study, but because of his student status, he's not called a co-investigator on the grant. Dr. Hurwitz explained the genesis of the study:
"The idea for the study originated with my master's project, which was about the impact of chiropractic and medical management of low-back pain in multispecialty group practice. It was carried out in 1990 and was published last year in JMPT1. The findings were interesting, but because of limited resources of time (less than a year) and money ($2,500), the design and execution of the study were relatively weak. My (doctoral) advisor, Hal Morgenstern, PhD, was intrigued with designing a study that would deal with many of the problems inherent in my master's project, especially the lack of comparability between treatment groups, which could have accounted for the observed differences in outcomes.
In an exclusive interview, principal investigator Hal Morgenstern, PhD, described the study:
"It's a five year project, and the major purposes of the proposal were to compare the effectiveness and efficiency of chiropractic care versus medical care for the treatment of low back pain, as well as to evaluate the use of physical therapy for both chiropractic and medical care.
"The design of our study is a randomized, factorial design. All of the patients, there will be 1,000 of them with low back pain, will present to a single facility called Friendly Hills Health Care Network, which is a large managed care facility, an HMO that is on the Orange County/Los Angeles border in La Habra. Each of those 1,000 patients will be randomized to one of four routes: medical care vs. chiropractic care, with or without physical therapy.
"The major purposes of the study are to compare medical with chiropractic, and to evaluate the addition of physical therapy. We'll be considering a variety of health, biological clinical measures of outcome, including pain improvement and the like, but we'll also be considering the cost effectiveness of the different approaches as well as the different strategies. I have several collaborators on the study, including a chiropractor, a biologist, a physician who specializes in occupational problems like low back pain, and a health economist. The purpose of this study is not to assess the specific efficacies of individual therapies, but to compare the general patient management strategy.
"All 1,000 patients will have low back pain, but it's not limited to acute low back pain. There will be chronic low back pain as well, but we have little idea at this point what proportion of the patients will be chronic. The reason I say that is because most previous research and even ongoing research deals almost exclusively with effects of treatment among persons with acute low back pain.
"I think it is exciting. I'm looking forward to doing this project. I think it will provide what I think could be a lot of information that is particularly relevant to health care and the current trends and changes in the health care system. I think it'll further what we know about chiropractic and a very difficult to treat condition. There are even additional elements to the study that go beyond the randomization: we're very interested in the self-care that people give themselves for low back pain and how that might contribute to their outcome, as well as occupational factors."
Dr. Hurwitz added these comments:
"I think the funding of this project is especially exciting for aspiring chiropractic health services researchers. I'm hoping that this project will generate interest from chiropractic students (and others) who may not have thought previously about research as a viable career alternative. The chiropractic community desperately needs more people trained in research methods to design and carry out the studies necessary to properly evaluate the procedures we use in practice.
"The UCLA School of Public Health has been very supportive of my efforts, and I would encourage anyone with an interest in acquiring research skills to investigate the program there. In fact, since a top-notch curriculum is already in place at UCLA, there are preliminary discussions underway to look into the feasibility of beginning a training program aimed specifically for chiropractors and others who are interested in researching conditions seen and methods used by chiropractors and other alternative practitioners.
"The chiropractic community needs many more well-designed proposals in the funding pipeline to have a greater impact on health care and health policy. As illustrated by our project, the time line from research idea to successful proposal is a lengthy one. With a larger cadre of well-trained researchers who want to focus on spinal manipulation and other modalities used by chiropractors, we should see a significant increase in the number of funded proposals. I think the factors limiting our research output are primarily lack of interest and training, not lack of funding. If we can generate the interest and teach the skills of study design and proposal writing, the funding will follow.
1. Hurwitz EL. Relative impact of chiropractic vs. medical management of low back pain on health status in a multi-specialty group practice JMPT 1994;17(2):74-82.