August 2007

Quality of life evaluation

by Robert H. Blanks, PhD, President, RCS

Part 1: The biological and psychological domains of health

Quality of life (QOL) is a complex and multidimensional concept that until recently has been difficult to define and measure. [1,2,3]

Fortunately, within the past 10‑15 years, various conceptual and operational definitions have emerged to where quality‑of‑life assessment is now almost routine in a number of clinical settings [4,5] including chiropractic. [6,7,8]

The key to better quality‑of‑life assessment has been a) a clear definition of health, b) a framework, as first proposed by Wilson and Cleary, [9] linking physical and emotional changes with the patients perception of their health, and c) development of validated instruments to assess patient beliefs, values and behaviors across the many health domains.

Self‑reported quality of life (SRQOL) is an important indicator of health because it is found to be an independent predictor of clinical outcome and morbidity. [10] Even when numerous health status indicators are available, poor SRQOL is independently associated with increased mortality in different socioeconomic and age groups, in men and women, over time and among persons with or without chronic illness. [13,14,15]

Low self‑reported ratings of health are strongly associated with low fitness and energy, daily discomforts, presence of pain, abnormal sleep patterns, decreases in motivation and appetite. [14,15]

Moreover, even when controlling for age, education, physical health, and medical diagnoses, SRQOL was found to be an independent and more robust predictor of cytokine levels than physician‑rated health. [16]

These exciting findings suggest that an individual's health perception may be coupled to circulating cytokines and, thus, the status of the body's immune system.

This is the first of three articles on the use of QOL instruments in chiropractic. Over the next three months, I'll review the domains of health and put these data in concrete terms to demonstrate the impact of chiropractic on changing quality of life for people under care.

This will also help lead to more robust ways of measuring health beyond pain and disability by incorporating the broad bio, psycho, social, and spiritual domains of health using QOL assessment.

This first article will focus on the biological and psychological aspects of health. Subsequent articles will continue with the life enjoyment, social domains, and, finally, environmental impact on health and quality of life will be examined.

What WHO says about health

Health is defined by the World Health Organization (WHO) as "a state of complete physical, mental and social well‑being..." As such, it transcends the absence of death, disease and disability, and incorporates the multiple dimensions of well‑being and quality of life.

Likewise, measures of health must also transcend mortality and morbidity. The WHO Quality of Life (WHOQOL) was developed in 1991 to assess individuals' perceptions in the context of their culture and value systems, and their personal goals, standards and concerns, and have been widely field‑tested. [17,18]

Dozens of other QOL instruments have emerged that fall into two categories: health‑related QOL scales targeting specific disease entities (e.g., arthritis, diabetes, etc.) and general scales such as the WHOLQOL, SF‑36; and one specific for chiropractic the Self‑Reported QOL (SRQOL). [6,7,8]

The Centers for Disease Control (CDC) has taken a somewhat narrow view of QOL, and developed a health‑related quality of life (HRQOL) questionnaire to assess a person or group's perceived physical and mental health over time. [19]

Although narrowly focused on physical and mental health and not the other domains, this instrument allows physicians and public health officials to measure the effects of chronic illness in patients, to better understand how an illness interferes with a person's day‑to‑day life, and to identify interventions to improve health.

Additionally, a working group of state coordinators and CDC staff designed a Behavioral Risk Factor Surveillance System (BRFSS) to monitor physical and emotional health. A large survey of Americans by the CDC conducted in 2000 found the following: [20]

***  Americans said they feel unhealthy (physically or mentally) about 6 days per month and "healthy and full of energy" only about 19 days per month.

***  Nearly one‑third of Americans say they suffer from some mental or emotional problem every month ‑‑ including 10% who said their mental health was not good for 14 or more days a month.

***  Younger American adults, aged 18‑24 years, suffered the most mental health distress.

***  Older adults suffered the most poor physical health and activity limitation.

***  Americans with chronic diseases or disabilities reported high levels of unhealthy days.

As grim as these statistics are about the current general health of Americans, the reliability and validity of the findings of the Behavioral Risk Factor Surveillance System (BRFSS) have been confirmed in nearly 20 separate studies. [21,22]

These findings about the physical and emotional health of Americans are important because, while the United States provides more health care services at higher costs per capita than any other country in the world, we rank below most of the wealthy nations and even some of the poorer nations in basic health statistics like infant mortality and life expectancy.

In addition, the benefits of health care are spread unevenly across the population in the United States with large disparities depending on race, income and education levels.

Physical and mental health surveillance in chiropractic

Chiropractic has been evaluated using a number of QOL instruments, but the most complete study to date was a study I and my colleagues conducted on 2,818 patients undergoing Network Spinal Analysis (NSA) in 160 offices throughout the United States, Canada, Puerto Rico, and Australia. [6,7,8]

Results indicated that patients reported significant, positive perceived change (p<0.000) in all four domains of health (physical state, mental/emotional state, life enjoyment and stress evaluation), as well as, overall quality of life. These benefits are evident from as early as one‑to‑three months under care, and appear to show continuing clinical improvements in the duration of care intervals studied, with no indication of a maximum clinical benefit.

These findings are somewhat limited because they apply only to NSA. Moreover, the research design was cross‑sectional, meaning that one can only conclude a statistical association between NSA and self‑reported changes in QOL and not a cause‑effect relationship.

The same QOL instruments have been applied recently by RCS (Research & Clinical Science) in a major clinical trial to evaluate a large group of patients undergoing subluxation‑centered chiropractic against a control group of individuals who have never had chiropractic care.

The first snapshot of these data is ready for publication. Results were compiled by 76 participating offices on a total of 2,156 subjects (1,363 patients; 793 controls).

Results are very encouraging and demonstrate that patients under care experience an improvement of 16% in physical health, 16% in mental/emotional health, 29% in stress and 7% in life enjoyment.

Overall, patients under care experienced a 17% improvement in SRQOL compared to comparable age‑ and sex‑matched subjects who never received care. These results, to be published shortly, suggest a major impact of subluxation‑centered chiropractic care on the physical and emotional domains of health and even greater effects alleviating stress and improving overall QOL.

Moreover, because this study employs a prospective design and use of a control group, the evidence for causality is even stronger between care and the noted improvement in quality of life.

References

1. Bergner M. "Quality of life, health status, and clinical research." Med Care 1989;27:S148‑S156.

2. Cella DF. "Quality of life: Concepts and definition." J Pain Symptom Manage 1994;9:186‑192.

3. Mast ME. "Definition and measurement of quality of life in oncology nursing research: Review and theoretical implications." Oncol Nurs Forum 1995;22:957‑964.

4. Gill TM, Feinstein AR. "A critical appraisal of the quality of quality of life measurements." JAMA 1994;272:619‑626.

5. Jones PW. "Measurement of quality of life in chronic obstructive lung disease." Eur Respir Rev 1991;1:445‑453.

6. Blanks, RHI, Schuster, TL, Dobson, M. "A retrospective assessment of network care using a survey of self‑rated health, wellness and quality of life." J. Vertebral Subluxation Res. 1:15‑31, 1997.

7. Schuster, TL, Dobson, M, Jaregui, M, Blanks, RHI. "Wellness lifestyles II: Modeling Relationships Between Wellness, Health Lifestyle Practices, and Network Spinal Analysis." J. Alternative and Complementary Med. 10(2):357‑368, 2004.

8. Schuster, TL, Dobson M, Jaregui, M. Blanks, RHI. "Wellness Lifestyles 1: A Theoretical Framework Linking Wellness, Health Lifestyles, and Complementary and Alternative Medicine." J. Alternative and Complementary Med. 10(2):349‑356, 2004.

9. Wilson IB, Cleary PD. "Linking clinical variables with health‑related quality of life." JAMA 1995;273(1):59‑65.

10. Fayers PM, Sprangers MA. "Understanding self‑rated health." Lancet 2002; 359:187‑8.

11. Idler EL, Benyamini Y. "Self‑rated health and mortality: a review of twenty‑seven community studies." J Health Soc Behav 1997;38:21‑37.

12. Burstrom B, Frelund P. "Self‑rated health: Is it as good a predictor of subsequent mortality among adults in lower as well as in higher social classes?" J Epidemiol Community Health 2001;55:836‑40.

13. Shadbolt B, Barresi J, Craft P. "Self‑rated health as a predictor of survival among patients with advanced cancer." J Clin Oncol 2002; 20:2514‑9.

14. Undon AL, Elofsson S: "Self‑rated health in a European Perspective, Swedish council for planning and coordination of research," 2000;41‑54.

15. Dantzer R. "Cytokine‑induced sickness behavior: where do we stand?" Brain Behav Immun 2001;15:7‑24.

16. Lekander M, Elofsson S, Neve IM, Hansson LO, Unden AL. "Self‑rated health is related to levels of circulating cytokines." Psychosomatic Medicine 66:559‑563

17. World Health Organization (1993). WHOQOL Study Protocol. WHO (MNH7PSF/93.9).

18. Murphy B, Herrman H, Hawthorne G, Pinzone T, Evert H (2000). Australian WHOQOL instruments: User's manual and interpretation guide. Australian WHOQOL Field Study Centre, Melbourne, Australia.

19. http://www.cdc.gov/hrqol/

20. http://www.cdc.gov/hrqol/findings.htm

21. Nelson DE, Holtzman D, Bolen J, Stanwyck CA, Mack KA. "Reliability and validity of measures from the Behavioral Risk Factor Surveillance System (BRFSS)." Social and Preventive Medicine, 2001;46 Suppl 1:S03‑S42

22. Nelson DE, Powell‑Griner E, Town M, Kovar MG. "A comparison of national estimates from the National Health Interview Survey and the Behavioral Risk Factor Surveillance System." American Journal of Public Health, 2003; 93:1335‑‑1341

(RCS co‑founder and President Dr. Robert Blanks is Professor in the Department of Biomedical Sciences at Florida Atlantic University and a past Professor of Anatomy and Neurobiology at the University of California, Irvine. Prior to this he spent two years at the Max Planck Institute for Brain Research in Frankfurt, Germany and two years in the Department of Anatomy at Harvard Medical School. Dr. Blanks is on the Advisory Board of the International Spinal Health Institute, is a Board Member of the Council on Chiropractic Practice and is actively involved in chiropractic research. To learn more about health outcomes research and RCS, call 800‑909‑1354 or 480‑303‑1694.)