Since being named in 1998 to head the Consortial Center for Chiropractic Research (CCCR), Bill Meeker has been at the center of a burgeoning chiropractic research effort. Supported by the National Institutes of Healths National Center for Complementary and Alternative Medicine (NCCAM), CCCR is a joint endeavor that currently includes six chiropractic colleges and three state-supported universities. Its essential mission is twofold: to support high quality research projects and to create a sustainable chiropractic research infrastructure.
Meeker, who holds a chiropractic degree as well as a Masters in Public Health, has served since 1995 as director of the Palmer Center for Chiropractic Research, based at Palmer College of Chiropractic in Davenport, Iowa. Prior to that, he was Dean of Research at Palmer College of Chiropractic-West in San Jose, California. The author or co-author of numerous articles published in peer-reviewed, scientific journals including Spine, and Journal of Manipulative and Physiological Therapeutics, Dr. Meeker is one of two chiropractors currently serving on the advisory board of the National Center for Complementary and Alternative Medicine.
In this interview with Dr. Daniel Redwood, Dr. Meeker discusses recent developments at NIH related to chiropractic and other complementary and alternative medicine (CAM) methods and explains why CAM approaches are sometimes held to higher standards than conventional medicine. He also describes an evolving chiropractic culture, in which research is beginning to move beyond its historic focus on proving chiropractics validity toward a future where its primary goal is the improvement of chiropractic practice.
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DANIEL REDWOOD: In 1975, the National Institutes of Health sponsored a conference to evaluate the status of research on spinal manipulation. At that time, it was concluded that there was essentially no chiropractic research in the mainstream scientific literature. Since then, that situation has changed substantially for the better. What brought about the change?
BILL MEEKER: There has been a fair amount of clinical and basic science research published since 1975 thats related to spinal manipulation. Some of that research has been done by chiropractors and some by non-chiropractors. That conference in 1975 legitimized manipulation as a credible research topic, even though it hadnt been decided at the time whether it was good, bad, or indifferent. It basically said to the rest of the world, "Here is a topic that needs to be investigated scientifically." That really was the genesis of the modern era of chiropractic research.
Within a decade after that, by 1985, the profession had started to put together the rudiments of a research infrastructure, started peer reviewed journals, started to run annual research conferences, and started to charge the colleges with the responsibility of conducting research. There were the beginnings of a cadre of people with the proper training, attempting to do both clinical and basic science research. Chiropractic colleges began putting together laboratories for research. That effort has grown in fits and starts over the years, until finally in 1994 there was enough clinical trial research to allow a government-sponsored consensus panelfrom the Agency for Health Care Policy and Research [now the Agency for Healthcare Research and Quality]to basically endorse spinal manipulation as a safe and effective treatment for low back pain.
Then, in 1997, we had the advent of the Consortial Center for Chiropractic Research, funded by the National Institutes of Health. That was a historic milestone.
REDWOOD: Up to that time, had it been challenging for the chiropractic profession to move forward without the kind of federal financial help that was available to the medical profession?
MEEKER: Absolutely challenging, for a variety of reasons. There were a number of barriers to doing any kind of science in a profession and in institutions that were (and mostly still are) free-standing, tuition-dependent, private institutions with no history or track record dealing with federal funding mechanisms. There also was very little of the kind of scientific tradition that exists in other health professions, in terms of mentors, graduate students, and the whole scientific apprenticeship model. We had very few people with the proper training. There was little or no collaboration with any established scientific centers or institutions of higher learning. There were also some anti-scientific attitudes out there in the profession. And, there was simply a lack of money, too, a lack of financial resources to spend on these things. So it was a challenge, and still is.
REDWOOD: Why is research important, from the perspective of doctors, patients, and policy makers? Why should a profession like chiropractic (or acupuncture, massage, or medicine, for that matter) put resources into research?
MEEKER: I think the basic answer is cultural, that true professions control their own knowledge. They control the means by which they develop their own data base, the process by which they evolve and improve their methods. To the extent that chiropractic can control its knowledge base and discipline and its own special methods of investigation, and to the extent that it can develop its own scientifically valid knowledge that improves human health, then it is a credible, evolving profession. To the extent that it cant do that, then its something less. So its professional control of our own destiny that is the issue.
Secondly, if research is simply looked at as a way to obtain the best possible information on how to make decisions, then research is a way to improve chiropractic practice. So thats good for individual chiropractors and, obviously, for patients. For the profession as a whole, if we control our information, that gives us credibility and legitimacy in the eyes of policy makers, third party payers, and the whole health care delivery system. So they work hand in hand.
REDWOOD: How would you summarize the current state of clinical research on chiropractic?
MEEKER: At this point there are about 50 randomized controlled trials on spinal manipulation for head, neck, and back pain. Then theres something like a dozen for all other conditions.
REDWOOD: Overall, what have those studies shown?
MEEKER: About two-thirds of those trials have demonstrated that manipulation was better than whatever it was compared with. There has not been a single trial that showed that manipulation was poorer than what it was compared with, although there have been some that showed it to be the same. When we look at the various meta-analyses, reviews, and consensus processes that have evaluated this body of research, we can say it is highly likely that manipulation is effective for patients with acute and chronic low back pain, as long as were talking about short-term outcomes. By short-term, I mean three weeks or a month.
REDWOOD: Does this mean that it isnt effective over the long term, or that there havent been enough studies to determine this? I know that the study by the orthopedic surgeon Thomas Meade, published in British Medical Journal, showed excellent long term outcomes for chiropractic care of low back pain.
MEEKER: Based on studies that have been done so far, we dont really know for certain about long-term outcomes. For example, measuring outcomes a year outso many things happen to a patient in a year. Frankly, we dont ask that question about aspirin.
REDWOOD: Is that true?
MEEKER: Its a real bias, I think. No one ever looks at the effect of a course of aspirin a year later. So why are we worried about the long-term effect of manipulation?
REDWOOD: This raises an important question. Do you feel that chiropractic and other complementary and alternative methods are sometimes held to a higher standard than conventional methods?
MEEKER: Yes, absolutely.
MEEKER: There are two reasons, though it varies a bit from procedure to procedure. All of CAM has its problems, but it varies within CAM. First of all, for many CAM methods including manipulation, the mechanism by which it has its effect is not well understood. So without a logical, physiological mechanism with which to explain the results, its harder to believe the results. Its just harder psychologically, for some reason. So I think we do need to put some effort into explaining why manipulation works, not just that it does. Thats a challenge; its hard to do.
Second, because there is a cultural dominance to so-called "conventional" methods, when youre number two, youve simply got to try harder. The burden of proof is on the new, untried, untested, innovative strangers who have to come in and prove themselves. The burden of proof for something new is different than the burden of proof for something that has become a habit. So the playing field is not exactly level. You put those two reasons together, and youve got a higher bar. Its just a fact of life. Wayne Jonas [Wayne Jonas, M.D., the former director of the NIH Office of Alternative Medicine] has pointed this out.
REDWOOD: Ive seen him talk about homeopathy in this regard. The Journal of Alternative and Complementary Medicine just published a commentary by Dr. Jonas on this topic.
MEEKER: Homeopathy has the same problem.
REDWOOD: Probably worse, because its theoretical mechanism is much tougher for people to conceive of than spinal manipulations mechanism.
MEEKER: Ive got a problem with it. Yet I know that there are plenty of randomized trials where homeopathic remedies are more effective than a placebo. Yet I still say to myself, "I dont know if I really believe this." So its the same thing. Were all guilty of this to one extent or another.
REDWOOD: What are some models youve seen of chiropractic integrating with conventional medicine, either in practice, research, or education? What are some of the trends here?
MEEKER: In terms of practice, I think theres a grassroots integration going on that health services researchers and policy makers have totally missed. Its going on right under our very eyes. If we did a survey of the profession, and asked how many of you are in practice with some other kind of providerwhether its a medical doctor, physical therapist, or whateverI think wed be amazed at the number of practices out there involving business relationships with combined providers, interdisciplinary or multidisciplinary. It may be sharing office space or actually working together on patients. There are all these different models that exist. I think wed be astounded at the amount thats going on at the grassroots level. No ones done that survey yet. It would be a very illuminating project.
Second, whether we like it or not, managed care has forced a level of integration into some health care delivery systems that wouldnt have done it otherwise. Theyve done it because theyve got patient demand, theyve got market forces, and also in some cases because they think its the right thing to do.
REDWOOD: Do you mean that when patients ask their primary care physician (PCP) for a referral to a chiropractor, in a situation where that referral is required in order for the patient to be reimbursed by insurance, that the PCP is more likely say yes than would otherwise be the case?
MEEKER: Yes. Kaiser in California finally said yes to including chiropractors. The integration at the delivery system level is starting to happen. That process has not been very comfortable, but its definitely happening.
REDWOOD: When it comes to integration in research, you have some non-chiropractic institutions in the CCCR.
MEEKER: We do. We have a number of departments at the University of Iowa, the School of Veterinary Medicine at Kansas State University, and the Bioengineering Department at the State University of New York at Stony Brook. There are also six chiropractic colleges involvedPalmer, National, Western States, Northwestern, Los Angeles, and Canadian Memorial.
REDWOOD: So integration is beginning to happen not only at the doctor-to-doctor level in practice, but also in research. And there is now, for the first time, a chiropractor, Christine Goertz, who is employed full-time at NIH at the National Center for Complementary and Alternative Medicine.
MEEKER: Yes, and Dr. Lisa Killinger, who is on our faculty here at Palmer, is a consultant to the Health Resources & Services Administration (HRSA). So yes, we now have at least 2 chiropractors working in official positions in the government.
REDWOOD: You serve on the advisory board of the National Center for Complementary and Alternative Medicine, as does another chiropractor, Dana Lawrence. What have you found most encouraging there? And what, if anything, has been discouraging or challenging?
MEEKER: Its been quite a learning experience for me just to figure out how the machinery of NIH works. The policies, the procedures, the politics, the whole nine yards. NIH has a very distinct culture. I think, encouragingly, that theres a real commitment at NIH to pursue CAM research, and its very clear that chiropractic is in that picture. Ive been made to feel very welcome in that regard. Steven Strauss, the director of NCCAM, deserves some real credit. I liked Wayne Jonas, and Im sorry he had to leave. But Steve Strauss has more clout within NIH. Hes fair, hes competent, and hes a highly respected scientist, who seems to be very energetic and very dedicated to NCCAM. I think he does listen to the council, which is a bit of a strange animal as NIH councils go, because Congress mandated that it include such a large proportion of non-MD practitioners. They dont normally legislate that to the degree they did in this case. It caused some concern at NIH, but its worked out pretty well. Were still evolving as a council; we still have some things to learn.
I am very encouraged by the fact that the money is coming in, the fact that theyve hired Christine Goertz, and the fact that next year theyre likely to get even more money than the current annual budget of $70 million. Also, the fact that theyve designed funding mechanisms that we can take advantage of, training-wise and project-wise.
REDWOOD: Youre describing some extremely positive and unprecedented developments here.
MEEKER: Sources of money are not our problem any more. Our chiropractic research problem is writing high-quality proposals to get the money and then doing the research in a high-quality way and getting it published. NCCAM says, "Heres the money, folks. Here are the rules you have to follow to get it. If you follow the rules, you can get it." Weve got to find the people who know how to follow the rules. Thats a major change from 4 or 5 years ago. Totally different.
REDWOOD: Having been in chiropractic academia for a couple of decades, would you say that the anti-scientific attitude that you mentioned earlier has diminished substantially?
MEEKER: I think so, but I have to sometimes remind myself to take the long view here. I think we need to do a much better job of teaching chiropractors how to critically evaluate scientific literature, and more importantly, how to apply it in their own practices. Research is still seen by many chiropractors as a way of validating the profession, of proving it rather than improving it. Thats an attitude and behavior change that were still in the midst of. But on the other hand, I have to say that the leadership of the chiropractic profession has begun to understand that science is not just public relations. Its a process that we have to engage in. Engaging in the process properly is as important as the outcomes themselves.
REDWOOD: How is the Consortial Center for Chiropractic Research, aside from its financial support for particular studies, trying to change chiropractics internal culture?
MEEKER: The CCCR has 12 specific aims and only a few of them are actually related to specific research projects. The rest all have to do with developing the infrastructure to be able to do those things. This includes training programs, skills development, assisting investigators to develop higher quality projects, linking practitioners to scientists so they can collaborate, and developing biostatistical and data management capabilities within institutions. Basically, all the things that have to be done to put the machinery together to do research.
The most visible thing weve done, aside from sponsor specific research projects, is to sponsor annual Research Agenda Conferences (weve now had five), which have really gone a long way toward developing a sense of community among the relatively small number of chiropractors who want to do research. Its developed their skills, their confidence levels, and given them a shot in the arm. These conferences are supported financially by two federal agencies, the Health Resource and Services Administration (HRSA) and the NCCAM.
REDWOOD: What are some of the studies going on right now at the Palmer Center for Chiropractic Research?
MEEKER: The Palmer Center has about 50 projects going on, both basic science and clinical science. In basic science, we have a biomechanics emphasis and a neuroscience emphasis. Joel Pickar and Chuck Henderson are both neuroscientists, each with his own set of projects looking at basic physiologic mechanisms and the nervous system. Chuck Henderson is focusing on an animal model of a spinal subluxation, where hes fixating spinal segments in laboratory animals and assessing the effects. Joel Pickar is using basic neuroscience methods to figure out what happens when we exert a manipulative load on spinal tissues. How does the nervous system react to that? What are the pathways? What actually happens?
In biomechanics, Ram Gudavalli is working on projects to describe, explain, and model biomechanical and manipulative forces, to basically figure out how manipulation works from an engineering point of view. Hes working on developing a better explanatory model for what goes wrong with the spine, and also to develop better training methods for teaching chiropractic students how to adjust the spine.
REDWOOD: So this research is attempting to provide a scientific explanation for why chiropractic works, which you said earlier is essential for chiropractic and other CAM approaches to clear the hurdles they face. Aside from these basic science studies, what other research are you doing?
MEEKER: Weve got both clinical trial and outcome studies.
REDWOOD: For the non-scientists reading this, could you please explain the difference between the two?
MEEKER: Sure. Basically, outcome studies are experimentally less controlled, observational studies of cohorts [groups] of patients going through some [health] care process, where were not trying to figure out cause and effect relationships between any component of the care package and the particular outcome that they have. What were looking for ishow did patients health status change as a result of going through the care process?
REDWOOD: More of a "real life care in the office" model.
MEEKER: Yes. Its a very generalizable kind of thing. In that regard, Cheryl Hawk is the director of the Palmer practice-based research program. This is a network of about 200 practicing chiropractors in the United States, Canada, and Mexico, who agree to follow standardized protocols in assessing their patients, filling out certain forms that we collect in a central location. Our office of data management then runs the stats and manages the data. We can do some fairly interesting outcome studies and descriptive studies about what goes on in chiropractic practices. For example, Cheryl recently had a paper published in the Journal of the American Geriatric Society, looking at patients in chiropractic practices who are over age 55. This had not been done before, believe it or not.
REDWOOD: What did the study find?
MEEKER: That at least half of those patients choose the chiropractor as their primary contact or primary care practitioner for those conditions. Most of those patients have multiple pain complaints; not just back or neck or head pain, for example, but back and neck and head complaints. They run the gamut from mild to severe. They only get moderately better in the first four weeks, which is all that we measured in this study, but they are highly satisfied with their care. They also get a substantial amount of recommendations on exercise, nutrition, and other health promotion approaches.
We have also looked at non-musculoskeletal complaints in chiropractic practices. We recruited doctors who said they had a high proportion of non-musculoskeletal complaints. But interestingly, even in the group that said they had a high proportion of non-musculoskeletal cases, the average was 15 percent. For the profession overall, its about 5 percent.
REDWOOD: I know you were in practice for a few years in the 1980s. Having made the choice to put your primary energy into research and research administration, do you miss being in practice?
MEEKER: Not any more. I did miss it sometimes, years ago. But I made a choice at the time it was either going to be practice or academia. I dont like being bored, and I am just way more drawn to the scientific challenges. I like working in an institution. I like the group-thinking, the structure, the resources that are available, and the ability to move groups of people. Of course, I never really intended to have a career like this [no such career track existed in chiropractic until the 1990s], but there was such a vacuum. I found myself doing things that no one else was doing, and people appreciated it. I saw a real need, things that needed to be done. So I set about doing it. At this point in life, Ive accepted that this is what I was destined to do.
©2000 by Daniel Redwood
Dr. Daniel Redwood
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