March 2006

HRQL an important research instrument

by Dr. David A. Jackson

In days past, researchers determined subjects' level of health. They measured vital signs, recorded frequency of symptoms, examined X‑rays and diagnostic imagery, and observed behavior. Seldom did they simply ask the person how he or she felt! In a more mechanistic age, researchers were confident in their ability to make judgments about the subjects' quality of life based solely on objective measurements.

But in recent years, a new instrument has been developed that permits researchers a far more accurate and in‑depth insight into the subject's true state of well-being ‑‑ the health‑related quality of life survey.

According to an paper published in the British Medical Journal (BMJ 1998;316:542‑545), "It is now widely acknowledged that the personal burden of illness cannot be described fully by measures of disease status such as size of infarction, tumor load, and forced expiratory volume. Psychosocial factors such as pain, apprehension, restricted mobility and other functional impairments, difficulty fulfilling personal and family responsibilities, financial burden, and diminished cognition must also be encompassed. The area of research that has resulted from this recognition is termed 'health related quality of life [HRQL]. It moves beyond direct manifestations of illness to study the patient's personal morbidity ‑‑ that is, the various effects that illnesses and treatments have on daily life and life satisfaction. Although quality of life assessment was almost unknown 15 years ago, it has rapidly become an integral variable of outcome in clinical research.'

The introduction of the Internet has made these surveys even more popular and valuable to scientists. In addition to being more convenient for both the researcher and the research subject, "instruments administered via the Internet appear to be reliable, and to be answered similarly to the way they are answered when they are administered via traditional mailed paper questionnaires," reported Sanford University researchers in the Journal of Medical Internet Research (J Med Internet Res 2004;6(3):e29).

Determining the impact of health care on the patient's quality of life has become so vital today that many medical experts say research conducted without considering that element may have little or no value to practitioners. One research paper, published by Canada's Centre for Health Evidence, noted that "When the goal of treatment is to improve how people are feeling (rather than to prolong their lives) and physiological correlates of patients' experience are lacking, HRQL measurement is imperative. For example, we would pay little attention to studies of antidepressants that failed to measure patients' mood, or trials of anti‑migraine medication that failed to measure pain." ("How to Use Articles About Health‑Related Quality of Life Measurements," by Gordon H. Guyatt, et.al, for the Evidence Based Medicine Working Group).

The same applies to chiropractic. Research that fails to measure patients' subjective perspective of their own health and well-being will not be enough to establish the relationship between subluxation correction and quality of life. We may find, through objective tests, that we have reduced the frequency or severity of subluxations, but we must go further to determine the effect of that reduction on the way people feel, act and live their lives.

Of course, no one is saying we can rely solely on quality of life questionnaires, but in combination with standardized clinical examinations and observations, we can answer many of the fundamental questions about chiropractic.

Until RCS (Research & Clinical Science) developed its Self‑Reported Quality of Life (SRQL) study, no such chiropractic‑specific research instrument existed and non‑chiropractic quality of life surveys applied to chiropractic were of extremely limited scope. In fact, a search of the more than 7,000 records relating to the development and testing of patient‑reported health instruments indexed by the National Centre for Health Outcomes Development in Britain resulted in only 17 involving chiropractic. Of those 17, nine were specifically focused on back and neck pain, two on the symptom duration of myofascial pain, one on migraines, and two on general pain. One appeared in a non‑scientific trade newspaper rather than a peer‑reviewed journal.

Only one involved a broader application of chiropractic to quality of life issues. One out of 7,000 reports! That single report was "A retrospective assessment of Network Care using a survey of self‑rated health, wellness and quality of life," by Robert Blanks PhD, and colleagues, published in the Journal of Vertebral Subluxation Research (JVSR1997, 1:15‑31).

The quality of life questionnaire was specially designed to assess wellness through the patients' self‑rating of four distinct health domains (physical state, mental/emotional state, stress evaluation, life enjoyment) and overall quality of life at two time‑points: before and after they started chiropractic care.

I won't go into all the technical jargon concerning the formulation of this research instrument (which involves such arcane elements as Cronbach's alpha, and theta coefficients derived from principal components factor analyses).

But the bottom line is the research showed that patients reported significant, positively perceived change in all four domains of health, as well as overall quality of life. That is, they felt better physically, mentally and emotionally, experienced less stress and enjoyed life more ‑‑ all because of chiropractic (specifically, in this study, Network chiropractic).

Furthermore, the study showed that the improvements began to manifest within as little as one month after care began, with no indication of a "maximum benefit." In other words, there appeared to be no limit to how much improvement they could enjoy if the chiropractic care continued.

Can you imagine if this study had generated the worldwide headlines it deserved? Millions of people would have read how chiropractic could enhance virtually every aspect of their well-being? There should have been front page stories on every magazine proclaiming: "Feel better in just one month ... with no end in sight!" People might have stopped taking their daily dose of aspirin and started getting an adjustment a week instead. They would have become as familiar with the word "subluxation" as they are with cholesterol or hypertension.

Why didn't that happen?

There are a lot of reasons, the most obvious being the long‑standing domination of the media by a pharmaceutical industry that pumps billions of dollars into print and broadcast advertisements. But even that hasn't stopped a few pro‑chiropractic stories ‑‑ like Madeline Behrendt's research on chiropractic and infertility ‑‑ from getting widespread coverage.

It doesn't help, too, that our own profession refuses to join together to promote and publicize research conducted by "the other side." Those organizations and leaders who envision chiropractic as a low‑back pain therapy will not rally around research that shows chiropractic's potential goes far beyond that limited scope. Professional and personal jealousy and politics have spurred some to criticize any research publication or effort that doesn't come from the "right" people.

But, frankly, the key reason is the figure I mentioned above. One research study out of 7,000. A study limited to 2,818 Network chiropractic patients.

That's not enough to convince the research community, the press, or the public. We need data from hundreds of thousands of patients from around the world. We need 30, 40, 50 or more research papers written by world‑class scientists published in every major journal.

That's the vision of RCS. No, not the vision. That's the plan, and we're already implementing it. Dr. Blanks has honed his quality of life study specifically for RCS. It has been designed to evaluate chiropractic's impact on the major aspects of quality of life for the widest possible spectrum of the population ‑‑ men, women and children; young, old and in between; symptom ridden and symptom free.

By combining the results of the RCS SRQL study with the standardized objective findings of thousands of doctors of chiropractic around the world, we'll compile the raw data needed by the RCS International Scientific Advisory Panel. That interdisciplinary panel, made up of PhDs, MDs, DCs and other health care experts and researchers, will be able to correlate the data to find out specifically how chiropractic care impacts the various elements of a person's quality of life. The results of their work will be submitted to peer‑reviewed journals (their work has already been published in the Journal of the American Medical Association, Journal of Neurobiology, Archives of Internal Medicine, Journal of Orthopedic and Sports Physical Therapy, Journal of Applied Physiology and many others).

No member of the press will be able to ignore that kind of evidence. Neither will the public. It's going to revolutionize health care. Think what it'll do for your practice!

(Dr. David A. Jackson is chief executive officer of Research and Clinical Science ‑‑ RCS ‑‑ a private sector research program exploring issues of subluxation correction and chiropractic care as they relate to health and wellness. Previously, he served as president of the Chiropractic Leadership Alliance and Creating Wellness Alliance and was owner/operator of several private practice offices in California and Idaho that specialized in high‑volume, family wellness‑based care. For more information on RCS, call 800‑909‑1354 or 480‑303‑1694, or visit the RCS website at www.rcsprogram.com. Doctors of chiropractic may log on to a special limited‑access area of the site by using the username DC1 and password RESEARCH.)