MODULE 9: RESEARCH
1.1 INTRODUCTION
It has been claimed that ‘it is arguable that the chiropractic profession in Canada is the most inquired into profession of health care professionals in the world [1]. This statement was based upon the fact that over a period of less than 25 years there had been five Provincial Royal Commissions of Inquiry, three Provincial Commissions of Inquiry and a Provincial Council of Health Report (Ontario), all considering questions relating to Chiropractic [1].
It is quite understandable that Canada, as the first British Commonwealth country to both register chiropractors as primary contact health care providers and to establish a Chiropractic College, was the place where official inquiry into the profession through Royal Commissions and other governmental authority occurred. [1]
With the growth of the profession in the early years of the twentieth century even the Southern hemisphere and European countries were to see chiropractic emerge as a new science. In Australia, on the 20th September 1905, just two days after the tenth anniversary of the founding of chiropractic, Mrs. Barbara Brake wrote to Dr. B.J. Palmer from Melbourne reporting that she had provided beneficial care to a number of Victorians, but only ‘to relatives and friends’ [2].It was on November 22nd 1905 that the first known Newspaper advertisement referring to chiropractic appeared in The Argus, a well-respected Melbourne newspaper of the day, the advertisement which was within the Medical classification read [1]:
’Chiropractic neuropathy is anew method of curing disease without drugs. Take lift to ‘chiropractor’ 3rd floor temperance-bldgs, corner of, swanston and little collinssts [p. 70]’
So the profession became established on other continents and in different countries and while some early mention was made in some medical and political circles no real interest was shown in seriously investigating this ‘new method’.This was made evident through formal inquiry made, as recently as the 1970s, of Australia’s most prominent medical research body by a Chiropractor engaged in research for his professional Association in the State of Victoria, Australia.
1.2 EARLY INVESTIGATION: NO REASON FOR FURTHER INQUIRY
In 1972, an inquiry made by Dr Peter Rome to the National Health and Medical Research Council (NHMRC) in Australia brought the following response from the Secretary of that organisation.
“I refer to your recent letter seeking information on the recommendations of the National Health and Medical Research Council concerning chiropractic.
The Second Session of the Council, held in June 1937, adopted the following resolution:
“The Council has had before it
- evidence given before the Select Committee of the House of Lords;
- the Report of the Honourable Mr Justice Hodgins of OntarioCanada.
And in view of these reports and of the fact that the medical Acts of the several States do not recognize chiroprais, the Council does not consider that there is any reason for further inquiry into the value of the work of chiropractors”[3]
In Canada, as early as 1900, ’chiropractors began lobbying the government for legislative recognition and regulation [4]. The College of Physicians and Surgeons of Ontario (CPSO) endeavoured unsuccessfully to eliminate the chiropractic profession under the authority of the Medical Act. After some years of controversy over definitions of ‘practice of medicine’ in 1913, the Premier, Sir James Whitney, undertook ’to appoint a Royal Commission to consider the whole question of medical education [5].‘In 1915, the Honourable Frank E. Hodgins, a Justice of the Court of Appeal was appointed as a Commissioner to enquire into all phases of medical education and practice in Ontario. The Commissioner concluded his task and reported to the Legislative Assembly in 1917. As Sutherland has pointed out Mr. Justice Hodgins, in announcing his decision, stated that he could not accept [4]:
‘… a system which denies the need of diagnosis, refers 95 per cent of disease to one and the same cause, and turns its back upon all modern scientific methods as being founded on nothing and unworthy even to be discussed.’
In the light of this statement, one may consider that the response of the NHMRC was not surprising. The decision of the Council was however made some 19 to 20 years beyond the report of Mr Justice Hodgins in Canada and its’ decision at its’ twenty sixth session, in 1948, some 30 years beyond the printing of the report in Ontario. [4]
The HodginsCommision had reported in 1917 and then ‘published it’sReport of the Ontario Committee on Medical Education (OCMER) in 1918 [5].’ By 1937, at the time of the NHMRC Second Session, ‘The Drugless Practitioners Act’, under which chiropractors became registered, had been in existence in the Province of Ontario for over twelve years. In 1935 amendments to this Act allowed chiropractors to diagnose along with other practitioners such as the osteopaths. as major classifications responsible for diagnosis [4].’By 1937, ’new regulations were passed which ‘further emphasized the requirement ‘by diagnosis’ for chiropractors by inserting the words ‘(including all diagnostic methods)’.
Clearly the decision of the Australian NHMRC both in 1937 and in 1948 was based upon dated material and subsequently opportunities for early research in Australia into the practice of chiropractic were lost.
1.3 PROFESSIONAL AND POLITICAL REALITIES
While the NHMRC brushed aside any thought of valid research into the Chiropractic profession in both the late 1930s and 1940s, the Chiropractic Health Society of South Australia, under the leadership of Mr Lance Milne, was prevailing upon the South Australian Government to recognize the legal rights of chiropractors in South Australia. As Dr Phillip Donato recalled in 1996, ‘the reward of the Society’s efforts came three years later with the passage of the Chiropractic Act 1949 which established the identity of chiropractic under law and the legal right for chiropractors to practice in South Australia [6].’
Ironically, some 29 years after the NHMRC decided that it did ’not consider that there is any reason for further inquiry into the value of the work of chiropractors‘, an Australian Government appointed Committee of Inquiry, made up of three learned professors and a senior member of the medical profession, namely Professor E.C. Webb, Vice-Chancellor of Macquarie University [Chairman], Professor M.J.Rand, Professor of Pharmacology, University of Melbourne, Professor R.H.Thorp, Chairman of the Council of Australian Consumers Association and Professor of Pharmacology, University of Sydney and Dr CJ Cummins, Former Director-General of Public Health of New South Wales, recommended that this same body, the NHMRC, become involved in research into factors relating to the practice of Chiropractic. [7]
In the 1970s, Australasia saw four important Government or Parliamentary appointed inquiries into the Chiropractic profession (in some cases the Inquiry extended to other healing professions) all of which brought forward conclusions that have advanced the chiropractic profession in that region.
The following Table presents a comparison of the workings and outcome of these formal inquiries [1].
Since its inception, the chiropractic profession has relied upon clinical research and to some extent experimentation. In the 21st Century, chiropractic research is expanding at an incredible pace right around the world. Chiropractic colleges are active in research as are several excellent research organizations, which adhere to strict scientific standards.
Hereunder is a partial listing of major scientific studies and research conducted through four decades, along with extracts from reports of Government or Parliamentary investigation into the practice of Chiropractic.
1.3.1 PARLIAMENTARY INQUIRY: STATE OF VICTORIA, AUSTRALIA
1975: State of Victoria, Australia. Joint Select Committee (Osteopathy, Chiropractic and Naturopathy)
The function of this All-party Committee of the Parliament of Victoria was to inquire into report and make such recommendations as it considers necessary concerning the practice of osteopathy, chiropractic and naturopathy in Victoria [8].
The Committee was appointed on 19th June, 1973 and reported on 27th November, 1975.
Major findings included:
- The law should be amended to require the registration of chiropractors.
- Chiropractors, Osteopaths, Naturopaths and Physiotherapists should do a common core of basic subjects for the first two years of their tertiary education and then study for their specialty.
A consultant to the Committee, Dr John MJ.Jens, Orthopaedic Surgeon, who visited both North America and Great Britain inspecting Chiropractic educational institutions reported ’it is remarkable that organized medicine and organized medical science have made little if any effort to explain the very obvious benefits of manipulative work on spinal conditions.’ [8]
1.3.2 AUSTRALIAN GOVERNMENT INQUIRY
1977: Australian Government Committee of Inquiry into Chiropractic, Osteopathy, Homoeopathy and Naturopathy.
The Committee of Inquiry was established in August 1974 and the first meeting of the Committee took place on the 16th October, 1974 [7].
The Terms of Reference for this Committee were to conduct a scientific evaluation of chiropractic, osteopathy and naturopathy by:
- Examining available evidence and
- Obtaining new evidence as necessary
The Report of the Committee of Inquiry was submitted on the 27thApril, 1977 [7].
The Summary of Principal Recommendations included the following:
- That Chiropractors and Osteopaths be registered in each State and in the CommonwealthTerritories.
- No persons shall use the title ‘chiropractor’ or ‘osteopath’ unless he is registered under the Registration Act.
- That there should be uniform legislation throughout the Commonwealth.
- That there should be agreement between the Registration Boards as to the minimum educational standard for registration.
- That the basic course of training be at the tertiary level meeting standards determined by the registration boards.
- The course to occupy at least four years full time study and contain a broad spectrum of biological and biomedical sciences equivalent to a Bachelor’s degree course, and a substantial clinical component.In addition to the principle recommendations listed above two most important recommendations, which to the knowledge of this writer have never been acted upon, related to research. Vis [7]:
(26) That the Australian Government make available an annual sum of $200,000 for the support of research projects related to the maintenance of health or treatment of disease by chiropractic manipulation or other therapeutic procedures offered by non-medical practitioners. (Page 207)
(27) That the National Health and Medical Research Council and other research-funding bodies be asked to give special attention to support of research projects in the field of low back pain and other musculoskeletal disorders (P. 207).
1.3.3 NEW ZEALAND GOVERNMENT INQUIRY
1979: Chiropractic in New Zealand: Report of the Commission of Inquiry
On the 24th of January 1978 the New Zealand government commissioned what turned out to be an extensive 20-month study on the chiropractic profession [9]. The Commission’s task was:
‘To inquire into and report upon the desirability of providing health benefits under the Social Security Act 1964 and medical and related benefits under the Accident Compensation Act 1972 in respect of the performance of chiropractic services and, if thought fit that such benefits should be provided , the extent thereof:
And in considering these matters you are hereby directed to have regard to and consider:
- The practice and philosophy of chiropractic, its scientific and educational basis, and whether it constitutes a separate and distinct healing art;
- The contribution chiropractic could make to the health servicers of New Zealand;
- Any other matters that may be thought by you to be relevant to the general objects of the inquiry.
After gaining extension of time for the inquiry on two occasions the Commission subsequently reported nearly two years later, that: ‘This has certainly been the most thorough inquiry into chiropractic ever held in this country. We know of no similar inquiry overseas in which the facts have been more thoroughly investigated and tested.’
The Commission considered it helpful to summarise its principle findings, but in so doing they also emphasized that the report ‘needs to be read as a whole. The Summary included the following:
- Modern chiropractic is far from being an unscientific cult.
- Chiropractic is a branch of the healing arts specializing in the correction by spinal manual therapy of what chiropractors identify as biomechanical disorders of the spinal column. They carry out spinal diagnosis and therapy at a sophisticated and refined level.
- Chiropractors are the only health practitioners who are necessarily equipped by their education and training to carry out spinal manual therapy.
- General medical practitioners and physiotherapists have no adequate training in spinal manual therapy, though a few have acquired skill in it subsequent to a graduation.
- Spinal manual therapy in the hands of a registered chiropractor is safe.
- The education and training of a registered chiropractor are sufficient to enable him to determine whether there are contra-indications to spinal manual therapy in a particular case, and whether the patient should have medical care instead of or as well chiropractic care.
- The Chiropractic Board, the Chiropractors’ Association, and the Medical Association should make every effort to ensure that all practicing chiropractors in New Zealand are kept informed of current relevant developments in medical science and research.
- A properly designed programme of chiropractic research should be instituted, supported by Government funds, and based in a New Zealand medical school.
This Royal Commission is often cited as the most objective, thorough and unbiased inquiry ever conducted into the practice of chiropractic.
In commenting upon ‘Chiropractic Safety‘ relevant to the research they conducted into the practice of chiropractic within New Zealand the Commission made some far reaching statements on their findings. Vis [9]:
“We are satisfied that chiropractic treatment in New Zealand is remarkably safe… Tens of thousands of patients have gone through chiropractors’ hands in this country. They have apparently suffered no ill effects… We have no doubt that the chiropractor’s training adequately equips him to carry out his techniques without harm to the patient.”(p.77, 78).
1.3.4 STATE OF FLORIDAUSA WORKERS COMPENSATION
1988: Florida Worker’s Compensation Report
The Florida Worker’s compensate on report documents the costs for at work injuries in Florida. The study identified that chiropractic cost about 50% of the cost of medical treatment. The report concludes that chiropractic is a ‘cost-effective for treatment of work related injuries’ [10].
Details of the study reveal that 10,652 patients with back injuries from work were included. Results reported that chiropractic patients had an approximately 50 percent shorter temporary total disability duration and almost 60percent lower cost for treatment. More that 50 percent of patient since the medical treatment group were hospitalised versus only 20 percent in the chiropractic group. [11]
Chiropractic patients also had return to work rates that were twice as fast as medical care in studies from Oregon and California.
1.3.5 BRITISH CHIROPRACTORS ASSOCIATION AND THE BRITISH MEDICAL RESEARCH COUNCIL
1990: British Medical Research Council
T.W. Meade, et al conducted this 3 year study, funded by the British Medical Research Council, the National Back Pain Association, the European Chiropractors Union, and the King Edward’s Hospital Fund for London [12].
There is little doubt that this study represents important original research, which scientifically demonstrated the effectiveness of chiropractic care in this focused and extended low back pain project. Its published findings revealed that chiropractic care was more effectivethan hospital outpatient treatment for long-term relief from low back pain. The total 741 patients, both male and female aged from 18 to 64 years with low back pain but without any contraindication to manipulation, attended Chiropractic clinics and Hospital outpatient departments in 11 different locations, but within reasonable travelling distance of each other. There was randomized allocation of the patients to the various clinics [13].
As reported by Professor Meade, ‘according to total Oswestry scores improvement in all patients at three years was about 29% more in those treated by chiropractors than in those treated by the hospitals. The beneficial effect of chiropractic on pain was particularly clear. Those treated by chiropractors had further treatments for back pain after the completion of trial treatment. Among both those initially referred from chiropractors and from hospitals more rated chiropractic helpful at three years than hospital management. [12]’
Professor Meade, along with his fellow researchers, Sandra Dyer, a statistician, Wendy Browne, a research nurseandA O Frank a consultant in rheumatology and rehabilitation, concluded, ’at three years the results confirm the findingsof an earlier report that when chiropractic or hospital therapiststreat patients with low back pain as they would in day to daypractice those treated by chiropractic derive more benefit andlong term satisfaction than those treated by hospitals [13]‘.
1.3.6 THE RAND CORPORATION AND FORD FOUNDATION USA
1991: The RAND Study
The Rand Corporation has been in existence since 1946. As shown on its’ Website, the name originated as a contraction of Research and Development. In 1948, with Ford Foundation support, RAND became an independent, non-profit research institution committed to exploring the most complex and consequential problems facing society. [14].
In 1991, neurologists, medical orthopaedists and chiropractors conducted an exhaustive study of chiropractic on behalf of the Corporation. The study determined not only that spinal manipulation is an effective and appropriate treatment for low back disorders, but that patients also recovered faster compared to other treatments. [15].
Further to the RAND ‘groundbreaking analysis’ on spinal manipulation, completed and reported upon in 1992, Coulter ID, Hurwitz EL, Adams AH, Meeker W, Hansen DT, Mootz R, Aker P, et al, conducted another significant study under the banner of RAND on ’The Appropriateness of Manipulation and Mobilization of the Cervical Spine [16].’
Their report presents results from a comprehensive study on the appropriateness of spinal manipulation and mobilization of the cervical spine.
’The study was designed to ascertain the clinical criteria for the appropriate use of cervical manipulation and mobilization to treat conditions such as neck pain and headache and to document treatment complications’.
A panel was convened of back-pain experts from the disciplines of orthopaedics, chiropractic, family medicine, and neurology to rate for appropriateness the indications for spinal manipulation and mobilization. The panellists rated the set of indications individually and then were convened as a group to rate the same indications following reporting and discussion of the individual ratings [16].
This report has proven of interest to clinicians who perform manipulation of the cervical spine, who work with patients with cervical problems, to health researchers and others concerned with appropriate indications for performing manipulation and mobilization.
1.3.7 THE OAKLANDUNIVERSITY STUDY USA
1993: The Oakland University Study [often referred to as the Stano Study]
MironStano, Ph.D. has been involved in a number of studies relating to the cost-effectiveness of chiropractic care and various forms of medical health care. This Oakland University Study reported in the June 1993 Journal of Manipulative and Physiological Therapeutics involved 395,641 patients with neuromusculoskeletal conditions [17].
The details of this study are described in The Cost-Effectiveness of Chiropractic compiled by Frank M. Painter, D.C. on the website of The Chiropractic Resource Organisation [18]. [Extracts adapted and included hereunder]
The objective of the study was to compare costs of patients undertaking chiropractic treatment against those treated medical doctors and osteopaths. The study was a retrospective statistical analysis of a large national database (395,641) of claims information. Two years of claims data was studied from ambulatory and inpatient figures. To be included the data needed at least one of the ICD-9 codes for neuromusculoskeletal disorders. Data was analysed based on hospital admission rates and different insurance payment categories.
The results showed that almost 25% of the patients had chiropractic treatment. Chiropractic treatment costs were lower by up to $1000 across the whole sample and also for specific conditions. [19]
Note: Further studies in this area of interest by MironStano include:-
a) Stano M., Smith M. Chiropractic and medical costs of low back care medical care. March 1996;34(3):191-204,
b) Stano, M, et al. MEDSTAT Database Review. The Journal of American Health Policy; 1992;2(6).
c)Smith M, Stano M. Costs and recurrences of chiropractic and medical episodes of low-back care. J Manipulative PhysiolTher 1997 Jan;20(1):5-12.
1.3.8 GOVERNMENT OF ONTARIO, CANADA
1993: The Manga Report: A Study to Examine the Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain
This most significant study, funded by the Ontario Ministry of Health in Canada, examined in detail the incidence and cost of Low Back Pain, not only in the Province of Ontario, but for the whole of Canada.
The Ontario Government’s Medical Health Care Program commissioned this Chiropractic study, headed byPran Manga, Ph.D. a Professor and Director of the Masters in Health Administration Program at the University of Ottawa; and President of Pran Manga and Associates Inc., Ottawa. He was ably assisted in his task by Douglas Angus, Adjunct Professor at the University of Ottawa and Project Director of ‘The Cost-Effectiveness of the Canadian Health Care System’, at Queen’s – University of Ottawa Economic Projects, Costa Papadopoulos, MHA, Health Care Consultant and Associate of Pran Manga and Associates, Inc and William Swan, B.Comm a Consultant in Health Care Economics.
After an in-depth analysis of the incidence, prevalence and economic costs of Low-Back Pain, not just in the province of Ontario but indeed throughout the whole of Canada and even beyond, these ‘Manga Report’ investigators concluded, ’it is the massive economic significance of low-back pain that has made it the focus of our review and we have been surprised at the depth of the evidence to support the proposition that chiropractic management of low back pain is well proven to be successful in terms of effectiveness, cost-effectiveness and patient satisfaction [20].’
The ‘Executive Summary’ lists 9 major ‘Findings’ and 10 ‘Recommendations’;
The first of the major Findings outlines that [20]:
‘On the evidence, particularly the most valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for low back-pain (LBP). Many medical therapies are of questionable validity or are clearly inadequate [p.11].’
The Eighth (8th) Recommendation reads as follows [20]:
’The government should make the requisite research funds and resources available for further clinical evaluation of chiropractic management of LBP, and for further socio-economic and policy research concerning the management of LBP generally. Such research should include surveys to obtain a better understanding of patients’ choices, attitudes and knowledge of treatments with respect to LBP. The object of these surveys should be better information for health policy, programme planning and consumer education purposes [p. 13].’
1.3.9 GOVERNMENT OF THE UNITED STATES OF AMERICA
1.3.9.1 1994: U.S. Government’s ‘Agency for Health Care Policy and Research’ (AHCPR)
Formed in 1989, the Agency for Health Care Policy and Research (AHCPR) focus is on health care services and ensuring quality and access to these services [21].
Not all persons involved with the treatment of patients afflicted with low-back pain were happy with the conclusions reached by the research team and with subsequent guidelines. As a direct result of the conclusions reached and guidelines promulgated the AHCPR was confronted by a group of disgruntled surgeons that disagreed with AHCPR findings on low back pain [23].
1.3.9.2 1998: U.S. Government’s ‘Agency for Health Care Policy and Research’ (AHCPR)
In 1998, a second breakthrough study funded by the U.S. government’s Agency for Health Care Policy and Research (AHCPR), supported by grant number HS07915, was released. This collaboration among scholars, researchers, medical doctors and chiropractors resulted in a 100-page report entitled Chiropractic in the United States: Training, Practice, and Research. [AHCPR Publication No.98-N002 December 1997]. It highlighted the valuable role of chiropractic care within the health care community. [24].’
Explanatory Note:
Agency for Healthcare Research and Quality – AHRQ Organization URL(s):
[email protected]
www.ahrq.gov
The Agency for Healthcare Research and Quality’s (AHRQ) is an American organisation with the aim to improve all matters related to health care, such as safety and effectiveness. AHRQ is the body formerly known as the Agency for Health Care Policy and Research [25].
1.3.10 PARLIAMENT OF THE UNITED KINGDOM
It was through the House of Lords that in 1935 a Report, that had some bearing upon the Chiropractic profession, were generated. Some evidence from that report was examined by the Australian National Health and Medical Research Council at the Second Session of the Council, held in June 1937. [See 1.2 Early Investigation: No Reason for Further Inquiry, above] The NHMRC had before it ’evidence given before the Select Committee of the House of Lords’. [3], [4]
Students first travelled from England to the USA to study chiropractic in the early 1900s. Small numbers were able to go due to the cost of such an education. By 1920, there were only six chiropractors in England. [26].Clearly, with such small numbers, the chiropractic profession was not in a good position to mount a campaign to gain legislative recognition. It took some decades before such recognition eventuated.
‘Since 1965, when Anglo-European College of Chiropractic was founded, the number of chiropractors in England has increased significantly. The General Chiropractic Council had 2300 registered chiropractors as members in 2006.[26]
1.3.10.2 2000: House of Lords Select Committee on Science and Technology – Sixth Report Comment
A Select Committee of the House of Lords made and published its first recorded Report on Osteopathy in 1935. Within that report there may have been some reference made to the Chiropractic Profession. That report is certainly known to be have been negative with regard to the hopes and aspirations of the Osteopathic profession.
Some 65 years later the House of Lords Select Committee on Science and Technology, ‘Sixth Report’ in 2000 [27] shows evidence of a comprehensive inquiry into ‘Complementary and Alternative Medicine’ and points the way to meaningful research which can only benefit the professions involved and those members of the public who seek the services of such health care professionals.
The select committee recommendations apply to chiropractic and other CAM disciplines. Chiropractic is grouped with osteopathy, acupuncture, herbal medicine and homeopathy as the principal CAM disciplines. [27]
The report outlines the research questions that CAM disciplines should focus on and why. The three research issues are:
1. Study the CAM treatment for possible areas of improvement and to assess its’ effectiveness compared to placebo and whether it offers any extra knowledge to add to conventional medical treatment.
2. Is the treatment considered sage, are there hazards for patients
3. Compare the effectiveness and cost effectiveness of the treatments so as to allow for better selection by patents and health personnel.
The report suggests a need for a large research effort to be put into CAM to the level of that demanded by conventional medicine and including studies such as RCTs.
The report also comments on the need for research funding agencies to build a database of those CAM practitioners that have research skills. Additionally funding needs to be made available for CAM practitioners to undertake further study and academic posts need to be established at universities.The committee also reminds CAM registration bodies to ensure their members only make claims that are supported by strong evidence. [27]
REFERENCES
- Hunt RG. Factors which influenced the implementation of legislative recognition of chiropractic in the State of Victoria. MC Sc Thesis. Melbourne RMIT University. 2000 p.39, 61, 70.
- Peters RE, Chance MA. Chiropractic in Australia: first contact. Chiropr J Aust 1995; 25(1): 2-5.
- Greville HW. Letter to Dr P.L. Rome: archives. Chiropractors’ Association of Australia (Victorian Branch) 1972 Feb 8.
- SutherlandDC. Chiropractic: from rejection to acceptance 1900-1980. J Can ChiroprAssoc 1998; 42(3):164,165.
- Brown DM. CMCC’s persistent pursuit of university affiliation: part 1. J Can ChiroprAssoc 1992 Mar;36(1).
- Donato PR. In memoriam: the honourable Kenneth Lance Milne 1915-1995. Chiropr J Aust 1996; 26(2):69.
- Report of the committee of inquiry into chiropractic, osteopathy, homoeopathy and naturopathy. Canberra: Australian Government Publishing Service (ACT); 1977 Apr.
- Report from the osteopathy, chiropractic and naturopathy committee together with appendices by Authority Rixon CH. Melbourne: Government Printer; 1975 Nov.p.77-78.
- Chiropractic in New Zealand report. New Zealand: Government Printer Wellington; 1979.p.206-207, 77-78.
- 1988: Florida workers’ compensation report; Available from URL: http://www.drrami.com/chiropracticproven.html
- The Floridia study- shorter disability/ lower costs/ lower hospitalisation rates: Available from URL: http://www.foster4health.com/index.php?p=21008
- Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomized comparison of chiropractic and hospital outpatient treatment. BMJ 1990;300:1431-1437.
- Meade TW, Dyer S, Browne W, Frank AO. Randomized comparison of chiropractic and hospital out patient management for low back pain: results from extended follow up. BMJ 1995 Aug 5;311:349-351.
- Rand Corporation [Online]. 1994-2010 [cited 2010 Mar]; Available from: URL:http://www.rand.org/about/faq.html
- Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Park RE, Phillips RB, et al. The appropriateness of spinal manipulation for low-back pain: indications and ratings by a multidisciplinary expert panel RAND Corporation. Santa Monica, California; 1991.
- Coulter ID, Hurwitz EL, Adams AH, Meeker W, Hansen DT, Mootz R, et al. The appropriateness of manipulation and mobilization of the cervical spine MR-781-CCR.1996. Available from: http://192.5.14.43/content/dam/rand/pubs/monograph_reports/2007/MR781.pdf
- Stano M. Stano/Medstat Research. Available from: URL http://www.draukerman.com/Research.htm
- Painter FM. The cost-effectiveness of chiropractic [Online]. 2003-2010 [cited 2010 Mar]; Available from: URL http://www.chiro.org/LINKS/Cost_Effectiveness.shtml
- Stano M. A comparison of health care costs for chiropractic and medical patients. J Manipulative PhysiolTher 1993:16(5):291-299.Available from URL: http://www.ncbi.nlm.nih.gov/pubmed/8345311
- Manga P. Angus D. Papadopoulos C. Swan W. The effectiveness and cost- effectiveness of chiropractic management of low-back pain. Richmond Hill, Ontario: Kenilworth Publishing, 1993.p.79, 11, 13.
- National Library of Medicine. 14: Acute low back problems in adults clinical practice guideline: AHCPR Publication No. 95-0642 [Online]. 1994 Dec [cited 2010 Mar]; Available from:URL:http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hsarchive&part=A25870#top
- US Department of Health and Human Services. New federal study recommends spinal manipulation for back pain relief, Dallas: PR Newswire [Online]. 1994 Dec 8 [cited 2010 Mar]; Available from: URL:http://www.silcom.com/~dwsmith/qcover.html
- Gray B, Gusmano M, Collins S. AHCPR and the changing politics of health services research [Online]. 2003 Jun 25 [cited 2010 Mar]; Available from: URL:http://content.healthaffairs.org/cgi/content/full/hlthaff.w3.283v1/DC1
- Cherkin D, Mootz R.Chiropractic in the United States: training, practice, and research [AHCPR Publication No. 98-N002-December 1997] [Online]. 1998 May 4 [cited 2010 Mar]; Available from: URL:http://www.chiroweb.com/archives/ahcpr/uschiros.PDF
- U.S. Department of Health & Human Services. Agency for healthcare research and quality (AHRQ) [Online]. 2007 Aug [cited 2010 Mar]; Available from: URL:http://www.healthfinder.gov/orgs/hr0021.htm
- Chiropractic in England. History of chiropractic [Online]. 2010 [cited 2010 Mar]; Available from: URL:http://www.integrativechiropractic.com.sg/chiropractic.php
- House of Lords, Select Committee on Science and Technology Sixth Report 2000; Available from URL: http://www.publications.parliament.uk/pa/ld199900/ldselect/ldsctech/123/12322.htm
