Published by Australian Spinal Research Foundation at August 4, 2017
Thanks to advancements in many health-related fields, we are staying alive longer. But as life expectancies in developed countries reach new heights, an increasing number of people are asking important questions with regard to maintaining health and quality of life as they age. Indicative of this trend is the growing amount of money the Baby Boomer generation is spending on health. It seems we are increasingly concerned with quality of life, not just living longer.
The term ‘quality of life’ refers to a person’s ability to stay independent, and perform activities involved in daily living and participation in life. It doesn’t take much imagination to see how pain or restricted movement could impact on social, emotional and other areas of life. The term itself has been around since the days of Aristotle, but as much as it has become an important term in healthcare, it has also remained somewhat non-specific. How do we measure it, for example, and how do we collect reliable data to compare against the term?
QOL in through the Chiropractic lens
Quality of life (QoL) question is commonly measured by academics against eight criteria. Among them are physical health, leisure and social interactions, and overall experience of life [2]. Among chiropractic research circles, we are seeing a steady increase in case reports, case series and even a small handful of randomized control trials on the topic of chiropractic care and quality of life. There is, in fact, some evidence that chiropractic care can result in improved quality of life in patients.
Patient centred outcome measures (or PROMs) are common tools in the measurement of quality of life and, in chiropractic research, we are seeing an increasing in the use of PROMs to evaluate the impact of chiropractic care on QoL in people experiencing both musculoskeletal and non-musculoskeletal conditions.
Among these are generic measures, like the SF-36 tool, more condition specific questionnaires and pain scale measures. “The focus is often on the illness end of the health continuum as the tools are used to assess functional disability rather than QoL, “says Dr Tanja Glucina, author of a recent study examining chiropractors perspectives on QoL and its measurement in practice [3]. “Many chiropractors consider the disease model of care to be limiting and instead prefer a model of care that focuses on an individual’s global health, wellness and QoL. Feedback from PROMs facilitates a patient-centered practice; it allows the practitioner to monitor and provide information on patient progress, whilst also assisting patients to reflect and appraise themselves.”
Glucina’s study, which looked specifically at New Zealand chiropractors, provided some fascinating insight, as it is the first piece of research relating to practicing chiropractors perspectives on this important issue. It found that: “the idea of QoL is relevant to the chiropractic profession. However, coupled with a perceived unclear public identity and the predominance of the bio-medical model of health, the chiropractors in the focus groups found the communication of the concept of QoL a challenge. Many of the participants shared that they chose not to specifically discuss the concept overtly in practice, and only some formally assessed QoL through PROMs. Additionally, the study found that chiropractors were unclear as to how and when to best measure QoL in clinical practice. Focus group participants reported that the burden of time for patients to complete and practitioners to interpret the PROM were considered most significant in the lack of use in clinical practice.
Research oriented towards QoL communication and evaluation may contribute to enhancing the chiropractor’s ability to confidently articulate and assess QoL in practice. This can enable better patient care and quality of care which ultimately supports chiropractors to assist patients in achieving better health.”
The findings seem to indicate that we have an opportunity to better harness QoL as a means of enhancing communication and quality of care, but that at this point in time, it is somewhat poorly understood. Still, the evidence is there, although certainly there is always room for more. Study types range from randomized control trials, to case series/reports or pilot studies.
The Current State of Evidence
Though time would not permit a summary of every chiropractic QoL-related piece of published evidence, there have been a number of recent and/or poignant studies that are worth noting. In 2016, chiropractic researcher Dr. Kelly Holt (and team) published a randomised control trial looking at falls prevention in older adults. Among the study’s revelations was the discovery that: “the chiropractic group… displayed small, statistically significant improvements in quality of life related to physical health when compared with a ‘usual care’ control. These results support previous research that suggests that chiropractic care may alter somatosensory processing, and sensorimotor integration and improve the physical component of quality of life [1].” (Read more on that study here)
Dr Holt’s study measured QoL using the New Zealand version of the SD-36 version 2.0 short-form health survey. Being that the length of the study only spanned twelve weeks, and the sample size was under one-hundred, some caution is advised while interpreting the results of the survey. Still it provides us with some evidence that chiropractic care can impact health related QoL, and Holt noted that “a small number of controlled trials have reported similar findings to those reported here in different study populations [1].”
What were some of those findings? Generally, the SF-36 physical component summary scores increased, with a significantly greater improvement noted at the 12-week mark as compared with the baseline, control group and 4-week mark. Whilst the primary purpose of that study was to investigate whether chiropractic care could contribute to a reduction in falls risk for older adults, it did prompt Dr Holt to comment on the study’s relevance to chiropractors and the issue of quality of life.“In general, older people are underrepresented in many chiropractic practices. That’s a real shame and it may come down to a belief that they’re beyond help and just have to accept the inevitable decline in their health and function that comes with ageing. This study should give chiropractors confidence that they can help improve function in their older patients and that may have an impact on their overall health and quality of life. We should encourage older adults to get checked! [1]”
Holt’s work followed on the heels of a 2014 study looking at the role of the chiropractor in community-based falls prevention [5]. The study, entitled “Community-based falls prevention: lessons from an interprofessional mobility clinic,” concluded that chiropractors “can reduce falls risk through active screening,” and that “screening for falls should be done yearly for all patients 65 years and older or in those with a pre-disposing medical condition [5].”
Another study published in the Journal Manipulative and Physiological Therapeutics surveyed 1,057 (American) Medicare beneficiaries over the age of 70 in order to compare the effectiveness of treatment for uncomplicated back conditions. The study, which took place over two years, examined two treatment categories – chiropractic care and medical care. The authors found [6]:
•“Chiropractic visits were greater in number and longer in duration than those of medical providers.
•Chiropractic care was protective against declines in self-rated health
•Chiropractic care was protective against declines in Lower Body Functioning“
The study provided clear evidence that, “chiropractic care is beneficial for older adults in the important areas of self-rated health and daily living function [3]” although further work defining key therapeutic levels would indeed aid understanding.
Adding weight to the case for chiropractic care in enhancing QoL are a number of case studies and case series’ looking at the physical aspects of QoL. Whilst we can’t give case series’ the same weight as randomized control trials or systemic reviews, it pays to note the peer-reviewed case series that do exist. Some of them include:
•Russell et al [7] put together a case series following 7 older adult patients, all of whom were receiving care using Activator Methods Chiropractic Technique. The sample included 4 females and 3 males aged from 69 – 80 years. Primary presentations included a variety of musculoskeletal conditions and the course of care ranged from 5 weeks to 15 months with an initial frequency of 1-3 visits weekly for 4-8 weeks of care. The activator methods chiropractic technique was used, as it “may be well suited for the aging spine [7].” Interestingly, “Each of the patients selected for this case series demonstrated clinically important improvements in SF-36 scores and subjectively reported improvements in symptoms, health and/or QoL, both musculoskeletal and non-musculoskeletal.” Individual, self-reported improvements included “improvements in breathing, state of mind, energy levels, sleep, strength, stamina, well-being, fuzzy head and alertness levels,” along with reductions in low back pain, leg pain, hypertension, inflammation and improvements in general wellness. Although chiropractic care does not claim to cure or treat conditions, this case series and those that follow provide an insightful look at the variety of improvements that may occur when the body is able to self-heal and self-regulate, even in older adulthood.
•McMaster and Wild [8] produced an intriguing case study covering a 74-year-old male receiving chiropractic care. The patient was described as asymptomatic, having presented as part of a chiropractic research trial. The patient was adjusted using a Torque Release Technique, twice a week for eight weeks, and then once a week until the end of the three month trial. The researchers claimed that, “Over the course of the three months of care the patient showed significant improvement in joint position sense, postural stability, and reaction time [5].” He was unable to keep his balance with his eyes closed when initially assessed for balance. After the 12 weeks, he could keep his balance, with eyes closed, while standing on a perturbing foam cushion. He also saw an improvement of 15% in choice stepping reaction time, and a 30% improvement in joint position sense. These improvements occurred in an asymptomatic patient, giving rise to a suggestion that chiropractors may have a role in caring for older patients regardless of their state of illness or wellness.
•Patel and Russell [9] followed the care of an 82-year old female under chiropractic care, who presented with bilateral osteoarthritis of the knees. She also suffered from degenerative disc disease and postural alterations through the lumbar spine and experienced emotional stress associated with her conditions. These impacted her quality of life, and had been a factor for five years during which she suffered pain with fluctuating severity. She had decreased range of motion, bilateral foot flare and waddling gait, along with a restricted range of motion of the cervical spine (at 65 degrees). She was assessed using a RAND36 and PHQ-4 questionnaire, along with radiographic imaging that revealed a plethora of problems.
The patient’s outcomes over 5 and a half months were quite notable. She subjectively noted “improvements in mobility with increased willingness to exercise in the form of walking. Other areas of her health including digestion, sleep, wellbeing, eating habits, toilet habits and stamina, we also reported to have improved at progress visits. Initial complaints of knee pain were not completely resolved, however, improvements to pain levels with reduction to 5/10 at worst (previously 8/10), and increased mobility were reported [6].” Her RAND36 and PHQ-4 scores, range of motion and spinal subluxation findings also improved significantly over time. Once again, the case revealed improvements outside of the original complaint.
The evidence is surely showing us something here – the evidence for the impact of chiropractic care on QoL is present and growing, and offering us an opportunity to enhance patient care through communicating QoL-related outcome measures. The methods by which we, as chiropractors, achieve this may yet remain a growth area in terms of data. But what an opportunity it is!
References
[1] Staff Writer, (2016), “Chiropractic care and falls prevention in older people,” Australian Spinal Research Foundation, https://spinalresearch.com.au/chiropractic-care-falls-prevention-older-people/
[2] Staff Writer, (2015), “Quality of life indicators,” Eurostat, http://ec.europa.eu/eurostat/statistics-explained/index.php/Quality_of_life_indicators_-_measuring_quality_of_life
[3] Glucina, T.T., Farvid, P., Krageloh, C (2017) New Zealand Chiropractors’ Perspectives on the Meaning and Assessment of “Quality of Life” in Relation to Chiropractic Practice. Scholarly Commons; Auckland University of Technology, Auckland
[4] Holt, Kelly R et al, “Effectiveness of Chiropractic Care to Improve Sensorimotor Function Associated With Falls Risk in Older People: A Randomized Controlled Trial,” Journal of Manipulative and Physiological Therapeutics.
[5] Bauman C, Milligan J, Patel T, Pritchard S, Labreche T, Dillon-Martin S, Ilich A, Riva J (2014), “Community-based falls prevention: lessons from an Interprofessional Mobility Clinic,” Journal Canadian Chiropractic Association, 2014; 58(3), pp 300 – 312
[6] Staff Writer, (2014), “Comparing the Effects of Chiropractic and Medical Treatment for Older Adults,” Palmer Center for Chiropractic Research: Research Summary Series,
http://www.palmer.edu/uploadedFiles/Pages/Research/Press_Room/Research_Factsheets/Weigel-DC-Factsheet-Final-RV.pdf from Weigel PA, Hockenberry J, Bentler SE, Wilinsky FD. The comparative effect of episodes of chiropractic and medical treatment on the health of older adults. J Manipulative Physiol Ther 2014;37(3):143-54.
[7] Russell D, Kimura M, Cowie B, de Groot C, McMinn E, Sherson M, (2014), “Changes in Quality of Life in 7 Older Adult Patients Receiving Activator Methods Chiropractic Technique,” Journal Chiropractic Medicine, (2016) 15, 59-66 http://dx.doi.org/10.1016/j.jcm.2016.02.008
[8] Wild M and McMaster P (2017), “Improvement in Sensorimotor Function, Postural Stability, Joint Position Sense and Reaction Time in an Asymptomatic 74-year-old Male Receiving Chiropractic Care,” Annals of Vertebral Subluxation Research, April 10, 2017, pp 61-63
[9] Patel D and Russell D (2015), “Improvement in Mobility, Emotional Wellbeing and Quality of Life in an Older Adult Following Subluxation Based Chiropractic Care: A Case Report,” Annals of Vertebral Subluxation Research, September 17, 2015, pp 157-162