In this Health Insights Today interview, Dr. Hawk discusses Cleveland Chiropractic College’s decision to focus on two key research areas: geriatrics and prevention. Realizing that the growth and development of chiropractic research depends on each college choosing different areas in which to specialize, Dr. Hawk and the Cleveland administrative team have targeted these topics for two reasons: (1) they are broadly recognized as areas of increasing importance to society; and (2) they are areas where other chiropractic college research departments have not specialized.

Why is research important to the chiropractic profession?

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 (or for your patients to get paid) by third party payers. That’s really the bottom line, and why everyone is realizing that research is important. But we haven’t taken the next step, which is to say that if the evidence is this important, then the evidence base is everyone’s job.

When you say that it’s everyone’s job, I think that most people can see how it’s the research department’s job, I think they can see how it’s the faculty’s job to at least convey the information developed by researchers to students and practitioners …

That should be one part of it.

… but how can the field practitioner, the practicing chiropractor in private practice, help to create and utilize research?

There are two ways. I’m on the executive committee of CCGPP [Council on Chiropractic Guidelines and Practice Parameters], since I’m the chair of the scientific commission. A key part of their role is disseminating information. Field doctors need to know how to use the information with their patients to provide optimal patient care, but they also need to know how to use it with payers if a claim is being disputed. We have people every single day coming to us saying, “I’m in New Jersey (or South Dakota or Ohio) and we’re having problems getting paid. Can you help us? Tell us how to use the evidence.”

How do you respond?

CCGPP has a rapid response team. For instance, United Health Care was refusing to cover chiropractic for children. They were basing it on some findings in certain research studies, and what we (the members of the executive committee) did was to write a letter making an argument for why it was appropriate, even though the evidence is limited. It made a real difference. It was important to make the case that chiropractic helps musculoskeletal problems in adults, that children also have musculoskeletal problems, and that there’s plenty of evidence that chiropractic is safe. So even if there is not much of an evidence base at this time on chiropractic applied to children, one can make a plausible argument that it is appropriate. There haven’t been many medical studies on children either, because there are restrictions on using children as research subjects.

The Foundation for Chiropractic Education and Research is now funding a study that involves a consensus process on chiropractic care for children. Cleveland Chiropractic College has the grant and I am the principal investigator. The idea is that there is not a lot of evidence, and in the absence of higher levels of evidence, a formal consensus process of experts is useful. We will use the evidence that does exist and work to come up with a statement on best practices for chiropractic and children.

What do practicing chiropractors need to know about research?

You have to understand the different levels of evidence. When practitioners don’t know that, they are much more likely to be talked into anything by anybody. Sometimes chiropractors can make claims that make the profession look ridiculous, all because they don’t understand how to read the scientific evidence. They don’t have to be scientists, but they do have to have critical thinking skills so that they can avoid making ridiculous claims.

Once you’ve developed the evidence and you’ve packaged it, what is the final step of effectively disseminating that chiropractic research evidence to the field practitioners? How is that being done?

That’s what we’re talking about doing with CCGPP. I’ve given postgraduate seminars on evidence-based practice at five chiropractic colleges, one of them being Cleveland before I worked here. I gave one just last week at Logan.

To me, the most important first step is that you need to have all the faculty on board at all the chiropractic colleges. They have to understand how important research is for the practitioners and that they therefore have to teach it well to the students. Then the students will go out into practice well informed from day one. The second thing is that we need to provide postgraduate education for practitioners who are already out there, to help them understand the evidence. They need talking points, a series of sheets that say, “Here’s what you need to know about this topic.”

Is there a chiropractic research website that you would recommend to practitioners?

DC Consult is very helpful. That’s been a really good way to introduce students to the evidence. Dr. Ron Rupert at Parker has done a really good job, working with FCER, to make this available free of charge. We don’t want it to just sit there in the library or as an unused link on the computer. We need to connect the dots.

What are some of the recent and current research projects being pursued by Cleveland Chiropractic College? What are you most enthusiastic about?

When I came here, we decided that we can’t do everything. We’ve got reasonable funding and we need to apply it through a research agenda that has an overarching focus. Our focus is health promotion and improvement in quality of life, especially through improving patients’ ability to be active. This is reflected by our KC campus’s balance studies with older adults and our LA campus’s studies on functional improvement of hip and knee conditions. At our LA campus, Dr. Jim Brantingham is using the Berg balance scale to evaluate hip osteoarthritis, which contributes to poor functioning in older adults, which in turn leads to falls. Expanding our knowledge about fall prevention, particularly for older adults, is among the most important things we can do. The population is aging; there’s funding for fall prevention. They estimate that it will cost $12 billion a year by 2020.

Once you fall, in many cases you don’t get up again. For many people, falls cause fractures, which result in disability that can lead to a nursing home. There are real quality of life issues. So we have decided to focus on geriatrics, with a special focus on fall prevention. I believe that this will be a major area in which Cleveland Chiropractic College can contribute to the advancement of the chiropractic profession and, most importantly, to older chiropractic patients everywhere.

What research are we doing now about fall prevention?

We started with some small studies, for which we received FCER funding, and which we are still doing. These involve looking at balance in older adults, because poor balance is definitely a risk factor for falls. We want to see if chiropractic manipulation has an effect on balance. We’ve finished one small feasibility study and we’re doing an FCER-funded study, which also has an aspect of maintenance care. Dr. Mark Pfefer, our Director of Research, and I feel that maintenance care may keep especially older adults functioning better.

We also forged an alliance with Fit for Life, in Raytown, Missouri, which is a fitness center for seniors. It’s great. The CEO’s corporation owns the fitness center and also an independent living and skilled nursing facility right in that same area. He’s very dedicated to improving function in older people. So we’re looking to do more than just improve balance. Our new study, that we’re just starting, is about “better performance.” If you can walk around and get around better, that improves your quality of life and prevents falls. I ran into some research by people at the National Institute on Aging, that we’re all very excited about. Most of the measures we’re using, like the Berg Balance Scale, are used for hospitalized patients or other people who are very low functioning. This means that most of these function tests have a ceiling effect, in that if you’re already doing pretty well to start with, it’s very hard to show any measurable improvement at the top.

It certainly seems that helping someone who is doing moderately well to do significantly better is a very worthwhile goal, even if it hasn’t been the subject of much study yet.

We’re finding that with many of our Fit for Life patients, even though we didn’t expect them to be doing that well, were actually trucking right along, doing reasonably well despite their problems. Since they were doing really well on the balance test, if that was what we were using as a measure of improvement, they had nowhere to go. So I was thinking that we really needed a way to measure improvement in the people who were already doing pretty well.

What have you found?

Fortunately, it turns out that there are some really good tests that are already validated by experts in the field. Basically these involve walking around and different kinds of movements. We’re setting up in our research room so that we can do a whole battery of tests. We’re recruiting patients. You have to be 65 years or older. An example of these tests I’m talking about is the “timed up and go.” This is a simple test where you stand up and walk three meters and back. If it takes you more than 14 seconds, you’re at risk for falls. That’s been shown previously by other researchers. So this is an easy test, one that’s validated, and we’re using it.

So are the people who are slower at the timed up and go test at greater risk for falls because the slowness means that they move in a more halting manner, which leads to falls?

That would certainly be at least part of the explanation. And if you’re someone who can do it in less than 14 seconds, in the past we wouldn’t have had a way to measure you, because we didn’t have outcomes. But I’ve found a whole new bunch of them, where the patients then go on to more difficult tasks. There’s a narrow walk, a 400-meter long distance corridor walk. You’re timed during that. We’ll compare our patients’ results to what’s been done at other places. The next step, which hasn’t been done before, is that we’ll observe them to see if chiropractic care results in improvements, not only for people who are at risk for falls, but also for people who are not in that risk category but have room for improvement. Older people who are already okay, but where we’re looking to slow the progression of aging. We want to keep them functioning well.

For so many years, thoughtful chiropractors and other practitioners interested in prevention, have focused on sick people, who are in really bad shape, to see how we can help them improve.

Which is great.

And here you’re also talking about taking someone who is in reasonably good shape and making them even better.

With an older person, if you can move around, that’s an extremely important part of your quality of life. The longer you can stay independent, the better. When we were talking to the medical people at Truman Medical Center (where Cleveland Chiropractic College has a clinic), we were talking about driving. If patients can’t turns their necks very much, it really decreases their driving ability and their safety on the road. Right now, we’re just looking at ambulation. If people can get around and not be at risk for falls, this is a huge benefit.

Our hypothesis is that chiropractic makes you less stiff and less in pain. So instead of just looking at pain measures, which we still look at, all it takes is to adjust your thinking. If you’re thinking of removing pain, why don’t you also think about restoring function. Pain, then, becomes a secondary outcome measure. Restoring function, even if some pain remains, has become the primary focus of musculoskeletal disorders treatment, across all the professions that deal with these problems. Because I can tell you, these older patients are all in pain, but they say, “I don’t let it stop me.” They score really well on the pain disability index even though they have a lot of chronic pain. So while they do have pain, they don’t have as much disability as you might expect, because they “just do it.”

So what you’re describing here is a research project and a research niche in the making, one that is focused on prevention and health promotion and is among the first emerging bodies of research by a chiropractic institution that is truly and specifically focused on prevention.

No one has been looking at improving function and removing risk factors for falls. It needs to be done and we’ve set out to do it

What other projects are Cleveland researchers pursuing?

At our Los Angeles campus, Dr. James Brantingham is also filling a very important niche with his focus on extremity research, which is also in very short supply in the profession. He’s done several studies on knee problems and is currently working on a grant-funded project on hip osteoarthritis. Since hip and knee problems are among the most important causes of limited mobility in the elderly, these studies not only meet an important gap in chiropractic research, but are also in keeping with our focus on increasing older adults’ ability to remain independent.

In Kansas City, we’re going to be very busy with the various aspects of this falls and balance project. They loved us so much at the fitness center that now we’re going to go to an independent living center and do the balance study there. Hopefully we’ll also send them over here to the college to take part in the function assessment. We’ve hired Dr. Katherine Smith, an additional person, to treat the patients.

Also, we have Practice-based Research, which we’ve folded into this project. We’re asking all of the participating field doctors to do a timed up and go with all patients 65 and above who come into their offices. Just to do whatever they normally do, but add the timed up and go. The patient will sign an informed consent and it’s all ready to go. Then, whenever the participating field doctor would normally reassess that patient (at six weeks or eight weeks), they’ll just do the timed up and go again. So these doctors can be part of our project. It’s a wonderful way to involve alumni and other interested chiropractors.

Daniel Redwood, DC, the interviewer, is Editor-in-Chief of Health Insights Today.