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Dynamic Chiropractic – July 15, 2009, Vol. 27, Issue 15

Translating Practice Into Research

The Research Agenda and Practice-Based Research Networks

By Reed Phillips, DC, PhD

Every March, the Association of Chiropractic Colleges (ACC) annual meeting and the Research Agenda Conference (RAC) take place concurrently. This is where the academic and research communities mix and mingle. Excellent keynote speakers, high-profile people such as the executive director of the National Center for Complementary and Alternative Medicine (currently Dr. Josephine Briggs), are on the program. There are numerous other presentations worthy of attention, including the individual research paper and poster sessions. With more than 400 in attendance, this program continues to maintain a high standard of quality from both the speakers and the presentations. At times over the history of the RAC, effort has indeed been exerted to establish a "research agenda" for the chiropractic profession. Valiant attempts are made to set a compass course for the future direction of research. These efforts are to be applauded and encouraged.

The Council on Clinical Guidelines and Practice Parameters (CCGPP) refers to setting the "clinical compass" in the fulfillment of its mission: "The CCGPP's mission is to provide consistent and widely adopted chiropractic practice information, to perpetually distribute and update this data, as is necessary, so that consumers and others have reliable information on which to base informed health care decisions." With current knowledge, the ability to apply valid information to clinical care is the direction provided by this clinical compass.

The CCGPP tells us what has been done and what is acceptable based on current research. The RAC conference and subsequent resulting publications tell us what is happening now, what is being studied and how it may impact us in the future. The work of the CCGPP and current research publications (not requiring a subscription) are accessible through the Foundation for Chiropractic Education and Research's (FCER) at no charge. They are organized into clinical conditions or can be searched via PubMed or Google Scholar.

The challenge before chiropractic is its future: what is to be researched, who will fund it and who will decide these matters. In one sense, this is an easy question to answer by the use of the modified Golden Rule: He who has the gold, rules. In other words, the research agenda is partially set by those who fund it.

Beyond that, setting the research agenda becomes more complex. The FCER is occasionally berated by well-meaning practitioners for not supporting research in a particular area or for supporting too much research in another area. Some complain that we have enough randomized clinical trials on the manipulation of low back pain and shouldn't fund any more. While there is some validity to this concern, we must also recognize that those who would attack and demean chiropractic continue to claim that spinal manipulative therapy (SMT) has not yet been proven to be the most efficacious method of managing low back pain. It seems the evidence is there, but some put a twist on it to confuse the public.

Some exhort the FCER to put more emphasis on the treatment of extremities with manipulative therapy. Some say we need more research on the value of nutrition in chiropractic practice. Others want more evidence to support the use of a certain type of technique, or the treatment of various nonmusculoskeletal conditions, or evidence to support pediatric treatment. These are all valid areas of study for the chiropractic research community.

There is another agenda-setting mechanism that needs consideration. When a research director at a chiropractic institution is credentialed in a specific area of study, such as biochemistry, it is very difficult to transition that person's expertise into a proposal to do research on the manipulation of the ankle joint. Expertise and experience dictates the area of interest and the research effort an individual puts forth, regardless of what the chiropractic profession needs. We cannot successfully pound round pegs into square holes.

The FCER has used the phrase "Translating Research Into Practice" for years and will continue its efforts to help the doctor in practice capture and utilize the most current and up-to-date information related to chiropractic. There is a new twist on this phrase, however: "Translating Practice Into Research." Now there is an agenda-setting statement.

I have often quoted a statement from the cartoon character Ziggy: "Research is finding out if we should've done what we already did!" There have been many surveys over the years about what goes on in a chiropractic office, but no single survey has wrapped its arms around the diversity that exists. It has been shown that most of what we treat is back-related, most of what we do is spinal manipulation/spinal adjustment, and most patients are very satisfied with the care received.

It is time to step to the next level: translating practice into research. What is the nature of the back pain being seen in a chiropractic office? What is the type and extent of the treatment rendered? When a patient says they are satisfied, what does that mean? What other supportive care is rendered, if any? Do we really do lifestyle counseling and wellness care? How many children do we see and for which conditions?

There is a trend in the area of clinical research called practice-based research networks (PBRN). This is nothing more than a conglomerate of practitioners who have agreed to work with a research team gathering data from their daily practice settings. From the research perspective, the goal is to obtain real-time relevant data on patient care in individual offices. From the clinician's perspective, the goal is to provide meaningful data on patient care with the least amount of disruption in the clinical setting. At times, compatibility between the two can be challenging.

Working in conjunction with a variety of researchers, associations and specialty groups, the FCER will be seeking participation from individual practitioners in a PBRN. There may be multiple networks set up around very specific research questions. There is the potential to set up a national network that could address more global questions. This work will need time to take root and grow, but it has the potential to become a very sturdy oak tree.

Where to start? We will start small, in the sense that the PBRN will consist of a manageable number of people who can be contacted on a frequent basis to answer problems and resolve obstacles. The research question will need to be focused and clear. Data collection must be straightforward and unobtrusive. Staff will need to be educated and encouraged. The data obtained should have relevance to the needs of the practitioner. Not the least of our collective needs will be financing the project. Grants, private contributions, state associations and vendor support; no funding rock should be left undisturbed.

Funding must be made available to establish what the practice of chiropractic is all about in the annals of scientific documentation. When asked to participate, please take the opportunity to become involved in chiropractic research. Translate your practice into research.

As of press time, Dr. Phillips has informed us that he is no longer with the FCER. Dr. Phillips will continue writing for DC as a regular columnist, as he has done for years, and the FCER Forum column will of course also continue, with a replacement author to be named by the foundation soon.

Click here for previous articles by Reed Phillips, DC, PhD.

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