DCs as Leaders in Health and Wellness: Part I: Utilizing the Practice-Based Research Network to Show Evidence of Chiropractic’s Efficacy

The Chiro.Org Blog


By Jay S. Greenstein, DC

Don’t just sit idly by and wait for your colleague down the street to sign up for ICON. We need him or her, but we need you too. Sign up today, and be part of the clinician-researcher army to show the world how important and special we are. It will help our profession, it will help your practice and most important it will help the millions of patients who don’t yet know how much we can help them.

As national health care reform takes hold, health care provider groups are staking claim to their slice of the health care pie. In fact, even in our own profession, there is an ongoing debate as to the role doctors of chiropractic will play. Should we be primary care physicians in the medical home (see www.foundation4cp.com/files/cp-medicalhome.Pdf) and/or accountable care organizations (ACO)? Should we alter our scope of practice to include prescription rights? Should we focus primarily on the spine?

While the debate rages on the aforementioned questions, I personally believe that the profession can rally around an even more important concept: Chiropractic must be the leading profession in health and wellness. We can be the cultural authority on this topic regardless of the answers to the questions above. In fact, most of us already perceive ourselves as health and wellness providers. But what does the evidence suggest? The evidence for Ds improving the overall health of our patients is paltry compared with the evidence supporting chiropractic for low-back pain. When was the last time you saw an article in a peer-reviewed journal that said, “Doctor of chiropractic services improve overall health metrics in patients compared to medical doctors”?

Anecdotally, we see this in our practices every day. Sharing stories with colleagues about how we helped our patients not only heal from their back pain but also become truly healthier is a daily occurrence. We must now turn those stories into evidence. Our profession needs evidence based on the rest of the world’s standards of what constitutes high quality research. That’s where the practice-based research network (PBRN) comes in.

Practice-Based Research Network

The PBRN, according to the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ), is “a group of ambulatory practices devoted principally to the primary care of patients, and affiliated in their mission to investigate questions related to community-based practice and to improve the quality of primary care.”

Fortunately, the chiropractic profession has Cheryl Hawk, DC, PhD, a highly- regarded researcher at Logan College of Chiropractic, who, along with researchers at Parker University and Texas Chiropractic College, has built a new PBRN for chiropractic. This PBRN is named ICON, the Integrated Chiropractic Outcomes Network. There is a great need for this initiative, as well as a great need for every DC in the country to participate in this practice-based research initiative. I recently had the opportunity to sit down with Dr. Hawk to ask her about ICON.

In its simplest form, what is a PBRN?

Dr. Hawk: A practice-based research network (PBRN) is a group of clinicians and practices working together in ambulatory care to answer community-based health care questions and translate research findings into practice. [1] PBRNs address research questions that require a real-world setting to be answered.

What is ICON, and what is its mission?

Dr. Hawk: ICON is an inter-institutional collaboration combining the expertise of experienced investigators who have conducted a number of practice-based research studies in other venues. ICON is intended to be an engine that can drive projects that require a real-world ambulatory care setting in order to answer a specific research question. ICON’s mission is to conduct collaborative research through a partnership between researchers and chiropractic practitioners, with the ultimate goal of enhancing the health of the public and contributing to the scientific evidence base related to health promotion and disease prevention.

Why is ICON important to the chiropractic profession?

Dr. Hawk: According to Lawrence Green, an expert in both PBRNs and health education, “If we want more evidence-based practice, we need more practice-based evidence.” [2] Chiropractic research has focused more on pain and symptom management than on prevention and health promotion, even though chiropractic has traditionally considered itself prevention-oriented. [3] However, in a time when lifestyle factors have become the leading actual causes of death, [4] research into the role of chiropractic in disease prevention and health promotion must become a priority.

At this time, such evidence is scarce. Some studies have shown that wellness care accounts for a significant proportion of chiropractic patient visits, [5-7] and others suggest that patients receiving chiropractic care appear to be healthier than patients who do not. [6, 8] However, a cause-and-effect relationship between wellness care and improved long-term health outcomes has yet to be clearly demonstrated. We have the opportunity to change that, but we must get significantly greater participation from the practicing doctors across the country.

How is research done by clinicians different from that done by institutions?

Dr. Hawk: Technically, practice-based research is not “done” by clinicians. Data are collected from their practices, and investigators at the institutions associated with the PBRN design the studies and analyze the results.

PBRN studies are usually observational rather than experimental studies, since they are done to investigate usual and customary practice. Thus, the investigators do not control what the practitioners do; they carefully observe (by collecting data from the practitioners and their patients) procedures, characteristics and outcomes.

How is this research applicable to the doctors’ everyday practices?

Dr. Hawk: Because practice-based research studies everyday practice, its results are likely to be highly relevant. Experimental studies, where the type of patients and procedures are carefully controlled, are less likely to be generalizable to usual and customary practice.

How long does each study take?

Dr. Hawk: This depends on the purpose of the study. When we want to describe the participating practices, a snapshot or cross-sectional study is best. This may involve a week or even a day of data collection. If we want to observe treatment outcomes, then data would need to be collected again after an appropriate interval.

How much time is required of the doctors and their staffs?

Dr. Hawk: We design our studies to be minimally intrusive into the practices, and to take as little of the doctors’ and staffs’ time as possible. For many studies, the doctor will not have to do anything after filling out the initial forms describing his or her practice—the data collection will be with patients only, which involves some staff time in making sure that the forms are given to patients and mailed back to the PBRN office.

(JG Note: My practice, which has seven clinics across the Washington, D.C., metro region, is a member of ICON, and it has been extremely easy to participate in, with minimal time and effort required by my staff.)

When do doctors see the results of the studies?

Dr. Hawk: After all the data is collected, it usually takes us one to three months to enter and analyze the data. We then give the doctors a summary of the results. It takes longer for the paper to be written, submitted and published—the article may not appear for as many as six to 12 months, depending on the journal.

Where will the work be published?

Dr. Hawk: This depends on the particular study. We submit smaller pilot/preliminary studies to lower impact journals, but larger studies will be submitted to higher impact journals. We will always publish the results in a peer-reviewed scientific journal, however.

Are the doctors listed as authors?

Dr. Hawk: By the accepted rules of authorship, doctors do not qualify as authors. An author must have substantive input into the design, conduct, analysis and/or writing of the paper. However, all participating doctors are acknowledged by name in the “Acknowledgments” section of the article, which is the accepted practice for practice-based research publications.

How can someone join?

Dr. Hawk: Contact ICON Program Coordinator Michelle Anderson (Logan College of Chiropractic) at (636) 230- 1946 or michelle.anderson@logan.edu


While the health debate about scope of practice and national health care reform goes on, a path that will greatly enhance our role in the U.S. health care system is one that allows us to demonstrate that we are, in fact, the lead providers of health and wellness to the patient population. It’s one thing to say we’re the leaders; it’s a whole different thing to prove it.

We have a tremendous opportunity across all facets of our profession to build the case for chiropractic being the only profession that demonstrates that our focus is not on disease but on health and wellness. That takes work, hard work. We now have the infrastructure and the leadership among our institutional researchers, who are making ground-breaking progress, to show our impact on the population we treat.

Don’t just sit idly by and wait for your colleague down the street to sign up for ICON. We need him or her, but we need you too. Sign up today, and be part of the clinician-researcher army to show the world how important and special we are. It will help our profession, it will help your practice and most important it will help the millions of patients who don’t yet know how much we can help them.

Dr. Greenstein is CEO of Sport and Spine Rehab/Sport and Spine Athletics (www.ssrehab.com). He is Graston Technique® certified and a Titleist Performance Institute certified golf fitness instructor.


  1. Agency for Healthcare Research and Quality.
    http://www.ahrq.gov/research/pbrn/ pbrnfact.htm
  2. Green LW.
    From Research to “Best Practices” in Other Settings and Populations
    Am J Health Behav. 2001 (May); 25 (3): 165-78
  3. Evans MW, Jr., Rupert R.
    The Council on Chiropractic Education’s New Wellness Standard: A Call to Action for the Chiropractic Profession
    Chiropr Osteopat. 2006 (Oct 12); 14: 23
  4. Mokdad AH, Marks JS, Stroup DF, Gerberding JL.
    Actual Causes of Death in the United States, 2000
    JAMA. 2004 (Mar 10); 291 (10): 1238-45
  5. Rupert R.
    A Survey of Practice Patterns and the Health Promotion and Prevention Attitudes of US Chiropractors Maintenance Care: Part I
    J Manipulative Physiol Ther 2000 (Jan); 23 (1): 1–9
  6. Rupert RL, Manello D, Sandefur R.
    Maintenance Care: Health Promotion Services Administered to US Chiropractic Patients Aged 65 and Older, Part II
    J Manipulative Physiol Ther 2000 (Jan); 23 (1): 10–19
  7. Hawk C, Long CR, Boulanger KT, Morschhauser E, Fuhr AW.
    Chiropractic Care For Patients Aged 55 Years and Older: Report From a Practice-based Research Program
    J Am Geriatr Soc. 2000 (May); 48 (5): 534-45
  8. Coulter ID, Hurwitz EL, Aronow HU, Cassata DM, Beck JC.
    Chiropractic Patients in a Comprehensive Home-Based Geriatric Assessment, Follow-up and Health Promotion Program
    Topics In Clinical Chiropractic 1996 (Jun): 3 (2): 46–55