The Future Adjustment Podcast Episode 9: Palmer Military Research Grant

Daniel: Welcome to The Future Adjustment: Chiropractic Economics podcast series on what’s new and notable in the world of chiropractic. I’m Daniel Sosnoski, the editor in chief of Chiropractic Economics, and our guest today is Dr. Christine Goertz. She received her Doctor of Chiropractic degree from North Western Health Sciences University and her Ph.D. in Health Services Research, Policy and Administration from the University of Minnesota. She has extensive experience as a program official at The National Center for Complementary and Integrative Health, part of The National Institutes of Health. She’s here today to talk to us about some of the research efforts she’s been conducting on behalf of Palmer College of Chiropractic as well as her work with Spine IQ.

Dr. Goertz, back in September 2014 we interviewed you about a collaboration you were undertaking at Palmer with the Rand Corporation and the Samueli Institute. This study regarding the effectiveness of chiropractic care for active duty military personnel is supported by the largest grant ever awarded for chiropractic research, and you’ve been working on this project for nearly three years. I understand you’re close to publishing your findings.

Dr. Goertz: Hello, Daniel. First of all, I wanna say what a pleasure it is to be able to speak with you today. So, thank you for your time. Well, Daniel, actually it has been about seven years since we submitted the application for our Department of Defense grant. It’s amazing how fast the time flies and it’s also amazing how long it takes to conduct a clinical trial of this level of complexity. It’s actually three clinical trials. We did a main study on 3 sites that includes 750 people who were randomized to either receive usual medical care alone or usual medical care plus chiropractic. And in addition, we also conducted a study to look at the impact of chiropractic in reaction times in our Special Operations Forces, and are currently in the middle of data collection for our third study which is looking at the impact of chiropractic on strengths at balance and whether or not people have increased or decreased episodes of chronic low back pain following chiropractic care.

Daniel: Right, I understand that military personnel on the field, they have to wear backpacks that can weigh up to a 100 pounds and they’re jogging over uneven terrain, and the effects on the spinal column must be incredibly severe.

Dr. Goertz: They are. And also, driving a tank or riding in a tank is difficult on your back as is…pilots also have trouble with back pain. So, there are a lot of reasons why people in the Department of Defense might be even a little bit more impacted by low back pain than civilian population. We’ve finished data collection on the first two studies that I mentioned and are just getting ready to publish those results. I’m really excited to say that the… We’ve called these studies acts, act one, act two and act three for assessment of chiropractic treatment. And act one is the largest study that I spoke about first then at the… We’re excited to say that at the World Federation’s 14th Biennial Congress, which was held as part of the DC 2017 meeting in Washington DC in March of this year, our paper presented there, received the Scott Haldeman Award for outstanding research for a research paper.

Daniel: Yes. Heard about that.

Dr. Goertz: We’re now, as I said before, we’re getting ready to publish the results so stay tuned for what will be seen there. I can tell you that since we did present those results in a meeting, I can tell you that our research shows that those who received chiropractic care did have decreases in both pain and physical functioning. In addition, those who received chiropractic care were more likely to be satisfied and to perceive that they had gotten considerably better at the end of treatment.

Daniel: That’s really good news to hear and I hope that that will help address some of the concerns that we have with veterans who are having problems with excessive pharmacological treatment. Well, we’re gonna look for the act one results and we’ll be very happy to report on them in the magazine. I understand that there’s actually a new grant that Palmer is being awarded as part of a…I believe the military has allocated a total of $81 million across a number of healthcare fields, and Palmer’s online to get another $7 million funding for additional research.

Dr. Goertz: That is correct. Actually, this is hot off the press literally [SP]. NIH just released the press release yesterday on this award, and it is a joint collaboration between The National Institute of Health just spearheaded by The National Center for Complementary and Integrative Health as well as The Department Of Defense and the DA. And as you said, they’re committing $81 million in total to fund 11 projects in addition to a Coordinating Center. So, it’s an opportunity to bring a lot of investigators together with really similar research interests and to provide some synergy and coordination in a way that we really haven’t seen before at this level for complementary and integrative health in the DOD and the DA.

Daniel: And I know that the NCCIH is going to be exploring some different areas including meditation, structured exercise, Tai-Chi and, of course, manual therapy including spinal manipulation, massage and acupuncture.

Dr. Goertz: Right, so with our study we’re gonna be looking at this whole issue of dosing. As I’m sure you’re already aware and certainly our audience is aware, there’s a lot of controversy about how many times does a person need to go to a doctor of chiropractic in order to have the best benefit but not experience excessive care. And we really don’t know nearly as much about that as we should. In addition, as I’m sure you’re aware, right now Medicare considers what we call maintenance care to be not medically necessary, even though that’s not an evidence-based payment decision. So, with this study, we hope to tackle both of those issues. And so, it’s gonna be in veterans and we’re going to be for veterans. It’s a veterans population that we’ll be studying and we will be randomizing people to either receive about 5 visits, 5 or 6 visits, or about 10 to 12 visits within a 10-week period of time for chronic low back pain. And then, after that first initial active treatment period ends, we’ll be re-randomizing people to receive either one maintenance care visit or not.

Daniel: Very good.

Dr. Goertz: And we’ll be following them for about a year.

Daniel: And my understanding is that the key issue for doctors of chiropractic is that after whatever set number of visits is approved, they’ll simply have to make a determination whether medical necessity can be established for additional treatments. Hopefully, your results will, you know, tease out some data that’ll help us zero in on how that can be done.

Dr. Goertz: And that’s certainly our goal.

Daniel: You know, also, I think back in 2014 you were commended by The Foundation for Chiropractic Progress about another grant that Palmer received for a three-year planning project for The Veterans Health Administration about the development of clinical practice guidelines for veterans with muscular, skeletal and mental health conditions. That was a different study?

Dr. Goertz: It was a different study but it actually provided some pilot information. Actually, both The Department of Defense study, the act one stage [SP] which was conducted in The Department of Defense and then this planning project that you just mentioned, we were able to use data that we collected from both of those efforts in order to support the submission of the application that resulted in the grant that we’re just getting now. So, what we’ve done is we’ve developed some clinical guidelines and we’re right now just starting the pilot project in which we will implement those guidelines in clinical practice and see how patients react and gather some information about the doctor’s experience in using those guidelines.

Daniel: And I understand that now doctors of chiropractic are being integrated into The Veterans Health Administration across the U.S. Do you have any kind of specific numbers on how many of the VA facilities or what percentage of them now have DCs on board?

Dr. Goertz: I don’t know what percentage but I believe there are more than a 100 DCs who are now working within The Veterans Health Administration.

Daniel: Well, I know that in every study I’ve looked at, veterans who get to work with DCs generally come away with extremely favorable experiences and they’re very satisfied with that treatment. Well, hey, moving on…

Dr. Goertz: And I would say, just really quickly, I would say that my understanding is that the DCs who work with veterans have that same experience and that they’re really gratified to be able to provide help to those who, you know, have sacrificed so much to serve our country.

Daniel: I know, I know. It’s really gratifying. Actually, let’s just jump ahead to 2016, that survey that you were part of at Palmer with the Gallup Polling Organization, that survey was really major. It was probably one of the most in-depth studies ever undertaken about the American public’s impressions of chiropractic and their experiences, and that gave the profession and its leadership some direction about public attitudes towards chiropractic. Is there anything you like to say about that?

Dr. Goertz: Well, don’t know if you saw but Gallup held an event on September 12, regarding our latest findings from the third year of this survey, which found that in this year Gallup found that 78% of people that responded would prefer to use non-drug therapies before they would want to turn to prescription medications. We had an opportunity to discuss those results. We had a fantastic keynote presentation by Dr. Erin Karol who is a pediatrician who wrote a blog post in The New York Times’ Upshot earlier in the summer in which he entitled it “It’s time to rethink bias against chiropractic”. But he was the keynote and talked in-depth about the opioid crisis and then we had a panel of speakers that included Dr. Carolyn Clancy [SP] from the VA, Dr. David Shurtleff from NCCIH and then Dr. Joe Selby from The Patient-Centered Outcomes Research Institute as well as myself to talk about various initiatives that are ongoing to either research or support the integration of non-drug therapies for people who are at risk of becoming addicted to opioids.

Daniel: That’s right. That study was gonna have or the Gallup poll was gonna follow up through a three-year period. We’re going to definitely take a look at that and see if we can get that data published in the “Chiropractic Economics.” Hey, will you just have enough time to just touch a little bit on your work with The Spine Institute for Quality, known as The Spine IQ? In May this year, you partnered with the ACA working to develop a clinical data registry to collect data on spine-related disorders and treatment, and this’ll help DCs who wanna report to CMS on quality measures. Can you tell us a little more about that?

Dr. Goertz: Yes, absolutely. We’re excited that our conservative spine care registry was approved as a QCDR, actually for the second year in a row, so that doctors of chiropractic will be able to use that to report for MIPS and MACRA and that whole alphabet soup of CMS that’s part of the CMS quality program. But, in addition, our chiropractors who may not be interested or are not MIPS eligible, who we believe would also be interested, for one thing, we’re gonna be developing a nationwide network of DCs who are participating in the registry as a demonstration of their commitment to quality of care and then those who are meeting at the benchmarks and who ask us to do so, we will be able to designate them as high performers. So, we’re really excited about that opportunity.

One of the questions I get asked most often these days is, in reference to chiropractic, is “How do I find a good one?” And we think that instead of having that be someone’s opinion that to be able to have that question and answer based on whether a DC is following best practices and whether or not they’re having good patient outcomes is really the best way to do that.

Daniel: I know there’s always been efforts in the medical community to establish what they call centers of excellence, and it looks that registry is gonna be a way for DCs to establish themselves in that capacity.

Dr. Goertz: That really is our plan. Those of us who’ve been in clinical practice and those of us who are conducting research have an opportunity to see the results of chiropractic patient care on a daily basis, but there are many others who wonder about the quality and consistency of chiropractic care. And this is a great way to help alleviate those concerns.

Daniel: All right. Well, hey, Dr. Goertz, you have always been at the forefront of evidence-based practice and research and helping us to collect the kind of data that can really move the profession forward and I wanna thank you sincerely for spending some time with us this morning. It’s been tremendously insightful and you’ve given us an evidence-based look at The Future Adjustment. I’m Dan Sosnoski and we’ll see you next time. Thank you, Dr. Goertz.