HRQL- An Important Research Instrument

by Terry A. Rondberg, DC

Stethoscope and ClipboardPreviously, researchers determined a patient’s level of health by measuring vital signs, recording frequency of symptoms, examining X‑Rays, and observing character. Rarely did they ask the patient how he or she felt. They took pride in judging the patient’s quality of life based just on objective measurements.

Recently, a new instrument allows researchers a more accurate picture into the patient’s state of well-being ‑‑ the health related quality of life survey.

According to a paper published in the British Medical Journal (BMJ 1998;316:542‑545), “It is now widely acknowledged that the personal burden of illness cannot be described fully by measures of disease status such as size of infarction, tumor load, and forced expiratory volume. Psychosocial factors such as pain, apprehension, restricted mobility and other functional impairments, difficulty fulfilling personal and family responsibilities, financial burden, and diminished cognition must also be encompassed. The area of research that has resulted from this recognition is termed ‘health related quality of life’ [HRQL]. It moves beyond direct manifestations of illness to study the patient’s personal morbidity.  That is, the various effects that illnesses and treatments have on daily life and life satisfaction. Although quality of life assessment was almost unknown a few years ago, it has rapidly become an integral variable of outcome in clinical research.”

The Internet has made these surveys more prominent and meritorious for scientists. The surveys are also more convenient for the researcher and the patient. “Instruments administered via the Internet appear to be reliable, and to be answered similarly to the way they are answered when they are administered via traditional mailed paper questionnaires,” reported Stanford University researchers in the Journal of Medical Internet Research (J Med Internet Res 2004;6(3):e29).

Measuring the impact of health care on the patient’s well-being has become so crucial that many medical experts say research that disregards such an element, may not be worthwhile for practitioners.

One research paper, published by Canada ‘s Centre for Health Evidence, reports, “When the goal of treatment is to improve how people are feeling (rather than to prolong their lives) and physiological correlates of patients’ experience are lacking, HRQL measurement is imperative. For example, we would pay little attention to studies of antidepressants that failed to measure patients’ mood, or trials of anti‑migraine medication that failed to measure pain.” (“How to Use Articles about Health‑Related Quality of Life Measurements,” by Gordon H. Guyatt,, for the Evidence Based Medicine Working Group).

Chiropractic care is no different.

If research fails to measure how patients view their own health, the results will be inaccurate and will fail to establish the relationship between subluxation correction and quality of life. Objective tests may show some stress reduction on the nervous system, but we must step out-of-bounds to clarify the effect of that reduction on the way people behave and feel.

We should not rely solely on health questionnaires, but combine the results with standardized clinical exams and observations.  This will enable us to answer many questions about chiropractic.

Prior to the Self‑Reported Quality of Life (SRQL) study, no specific outcome measurement existed for chiropractic care and very few non‑chiropractic quality of life surveys directed to chiropractic existed. With more than 7,000 records regarding the development and testing of patient‑reported health instruments indexed by the National Centre for Health Outcomes Development in Britain, only 17 engaged chiropractic. Of those 17, nine were specifically focused on back and neck pain, two on the symptom duration of myofascial pain, one on migraines, and two on general pain. One record was published in a non‑scientific trade newspaper when it should have appeared in a medical journal with comments and reviews from team experts.

Only one case out of 7,000 contained a broader application of chiropractic to quality of life issues – “A retrospective assessment of chiropractic care using a survey of self‑rated health, wellness and quality of life,” by Robert Blanks PhD, and colleagues, published in the Journal of Subluxation Research (JSR1997, 1:15‑31).

The quality of life questionnaire was created to specifically assess wellness via the patient’s self‑rating of the following: physical state, mental/emotional state, stress evaluation, life enjoyment, and general quality of life at two intervals: before and after they began chiropractic care.

I won’t regurgitate the technicalities involving the creation of this survey instrument.  The study revealed that patients reported significant change in all areas, including quality of life. They felt better physically and emotionally, experienced less stress and enjoyed themselves more simply thanks to chiropractic.

According to the results, improvements took effect about one month after care began. As long as they continued chiropractic care, they continued to make progress.  If this study had generated the international attention it deserved, thousands of people would have become better educated on how chiropractic could improve their well-being.  News flashes would have lit up the television screen while major newspapers would have posted such revolutionary news on the front-page.  Patients would have begun undergoing weekly adjustments and put aside their daily dose of aspirin.

There several reasons this did not occur.  The most obvious involves the domination of the pharmaceutical industry that pays advertisers a tremendous amount of money.

One research study out of 7,000 will not persuade the research community, the media and the general population. Data is necessary from thousands of patients along with dozens of well-conducted research papers published in major medical journals.

For every human being, we have composed a study to assess chiropractic’s influence on quality of life.  Mainstream media and the general public will not ignore this kind of evidence. It can transform health care to a higher level.