INTRODUCTION

As the chiropractic profession grows and evolves, there remain barriers to evidence-based practice (EBP), research uptake (RU), and knowledge translation (KT) among chiropractors and chiropractic students.1 Chiropractic school administrators and faculty have focused on implementing a culture of research through various mechanisms at an institutional level.2 However, a series of surveys of chiropractors suggest there remains a gap in the uptake and use of clinical research in daily practice, citing “lack of time” and “lack of clinical evidence” as potential barriers.3–6 Many chiropractors reported little to no education or training in conducting clinical research or systematic reviews and applying research evidence to clinical practice, but they did report some form of training in EBP.4 More opportunities for faculty and students to participate in research activities are needed.

Some chiropractic institutions have taken steps toward enhancing their research culture through federally funded grant mechanisms. The federal government provided grants to four chiropractic institutions in 2005 through the NIH R25 initiative to strengthen research and EBP curriculum.7 Since then, the Council on Chiropractic Education (CCE) has moved to strengthen the curriculum at chiropractic colleges through meta-competencies, intended to ensure students reach a doctorate level of didactic and clinical education that demonstrates their proficiency to locate, critically appraise, and use relevant scientific literature.8 The 2025 CCE accreditation standards also include a section that requires institutions to demonstrate support for research and scholarly activity from faculty, staff, and, when appropriate, students. Yet, there remain key barriers to faculty scholarship, including excessive teaching loads, lack of research as a primary role, and lack of incentives or mentorship for aspiring researchers.2 Barriers to faculty scholarship subsequently limit opportunities for student research involvement.

Chiropractic students tend to embrace EBP but also report a lack of skills in conducting and appraising research. A study of 303 chiropractic students found that 99% of the students thought that chiropractic research was necessary for growth in the profession but lacked confidence in conducting their own research.9 While education on research methods improves student knowledge, it may require clinical application and faculty involvement to improve chiropractic student behavior and attitudes toward research.10

The NIH generated the R15 mechanism to provide federal funding to smaller institutions which have not been historically competitive for other NIH funding mechanisms. According to the NIH, the goals of the grant are to support meritorious research, strengthen the environment of the institution, expose graduate students to biomedical research, and generate interest in a career as a clinical-researcher. Southern California University of Health Sciences (SCU) was awarded R15 grants in 2018 and again in 2022. Only one other chiropractic school, Palmer College of Chiropractic (PCC), has also received R15 funding.

DISCUSSION

Chiropractic Student Involvement in NIH-Funded Research

Research Project Objectives

The R15 funded research at SCU employed observational designs to evaluate the quality and value of spine care for Medicare beneficiaries. The first aim of the initial R15 project was to compare spinal manipulative services (SMS) and prescription drug therapy (PDT) treatment for chronic low back pain (LBP) for their association with objective healthcare outcomes. The second aim was to compare SMS with PDT treatment for chronic LBP for their association with self-reported quality of life and satisfaction with care. The second R15 project focused on evaluating healthcare outcomes for beneficiaries with neck pain. The specific aims were to compare the safety of SMT vs PDT as measured by the likelihood of adverse outcomes, to compare the efficiency of SMT vs PDT as measured by rates of escalation of care, and to compare the costs of SMT vs PDT as measured by payer expenditures and patient cost sharing.

Student Recruitment and Research Training

For both projects at SCU, a campus-wide email was sent out to Doctor of Chiropractic Students for a chance to participate in a research selective course to identify interest and prepare students for the R15 grant activities. Students were eligible to enroll if they were full-time students who completed their first academic year in good standing and had a cumulative grade point average of 3.0 or above. Students who signed up for the selective were required to complete a 30-hour course, which involved 2 hours of lecture per week for a single trimester and exposure to an extensive selection of research literature. The lectures were led by research experts in spine pain and chiropractic care. The content was intended to introduce various topics of spine care research with a focus on application of concepts, diverse research methods, and biostatistics. Each lecture featured didactic instruction and facilitated discussion on various topics with the intent to deepen student’s understanding and practical skills in healthcare research methods along with reading and appraisal of published health science literature. Students received 2 credits toward their total required hours for graduation.

Hands-on Student Involvement

Upon completion of the research specialty course, 4 students were selected to participate in each of the R15 projects, based on class performance and grade point average. These students were required to complete training in the protection of human subjects as required for NIH funded research. Each project spanned 2 years and involved a total of 360 hours (60 hours/4unit equivalent per trimester) per student for an average of 4 hours per week. Students met weekly with research faculty to plan, design, and draft manuscripts related to the project. Along with these regular weekly check-ins, students met monthly to continue learning from lead investigators in spine care research. Topics included screening tools, inferential methods, statistics, and post-graduate opportunities for research training. After completion of the human protections training, students were able to participate in data analysis meetings biweekly as the project investigators reviewed, interpreted, and discussed data collection, analysis and reporting. The student researchers were supported by grants to attend and present their findings at research conferences.

Combined, these R15 projects produced 10 peer-reviewed papers comparing chiropractic vs. medical care regarding safety, efficiency, cost, and patient satisfaction for older Medicare beneficiaries with spinal pain. Students were given the opportunity to co-author selected papers and to spearhead development of manuscripts related to their own research activities.

Between both R15 projects at SCU, the student researchers participated in the development and conduct of a national survey of Medicare beneficiaries and presented the findings through platform and poster presentations at four conferences. One of the student presentations was selected to receive the National Board of Chiropractic Examiner’s (NBCE) award at the Association of Chiropractic Colleges Research Agenda Conference. The first project produced 4 peer-reviewed papers, 3 of which were co-authored by student researchers. The second R15 project produced 4 peer-reviewed papers with opportunities for co-authorship by students. In addition, student researchers developed and submitted for publication a case report and this perspective paper, attended and presented at 3 conferences, and presented project research findings at SCU’s weekly Integrative Clinical Rounds. Students also received travel grants from organizations supporting student chiropractic researchers.

Structural Facilitators and Barriers

As mentioned previously, the second R15 project was intended to be a joint effort between SCU and PCC, which offered benefits and challenges. Having faculty and students from both colleges created an innovative opportunity for student researchers to share differing experiences at the 2 institutions. The partnership between SCU and PCC contributed to the success of the project and established a collaborative effort between both institutions. The faculty members who mentored the students are distinguished scholars with the knowledge and capability to produce successful grant writing. The accomplishments and success of the project is largely due to the experience and mentorship from these faculty members. Prior to the initiation of the project, teleconferencing software infrastructure improved due in part to the Covid-19 pandemic, assisting in the collaboration across institutions. However, the differences in academic calendars, scheduling of classes, and the time zone difference led to scheduling conflicts. Since SCU and PCC campuses span 3 US time zones, teleconferencing software enabled conference calls to be recorded for later viewing by those that missed the meetings. Nonetheless, the differences in academic progress and requirements between students at SCU and PCC created conflicting time constraints. For example, students at PCC who were involved in their capstone projects were unable to continue participating in the development of the perspective paper manuscript. Time constraints, varying degrees of commitment, and different levels of capacity also led to some students taking on increasingly more workload.

Student Insights

The extra-curricular workload on top of the already accelerated learning pathway of a graduate program placed increased stress on the chiropractic student researchers. Two major motivating factors for the students were the opportunity to gain hands-on experience in research and the financial incentives via a stipend. The students reported no prior experience writing or preparing a manuscript in their undergraduate programs. Students identified the time commitment as the most significant barrier, often resulting in fatigue and challenges in maintaining a healthy work-life balance. Students noted important takeaways, including the opportunity to network with lead investigators in the chiropractic field and insights on how much effort, time, and financial/institutional support it takes to generate federally funded research. Some of the students reported an interest in continuing to pursue post-doctoral graduate opportunities that may guide them to careers as clinical researchers. The students stated the R15 grant was instrumental in enabling them to deliver platform presentations at various conferences, publish peer-reviewed articles, and obtain clinical opportunities including internships through network opportunities achieved by attending conferences. Students also noted their confidence in reading and appraising relevant research which they believe will inform their work as future clinicians and lead to better outcomes for their patients.

CONCLUSION

This approach to student participation in research created a positive experience that enhanced EBP skills, enriched the student experience, and generated interest in careers as clinician researchers. Expanding opportunities for more chiropractic students to participate in hands-on research via R15 funding may increase EBP and research skills and foster the next generation of leaders in the chiropractic profession. Because R15 grants target institutions with limited NIH funding, they offer an ideal entry point for chiropractic schools seeking federal support. Barriers should be addressed when attempting another R15 project to ensure the capacity and commitment of the students is sufficient for the duration of the project.