Swiss chiropractic cohort (Swiss ChiCo) pilot study: feasibility for a musculoskeletal cohort study conducted within a nationwide practice-based research network.

PURPOSE: Practice-based research networks are collaborations between clinicians and researchers to advance primary care research. This study aims to assess the feasibility for longitudinal data collection within a newly established chiropractic PBRN in Switzerland. METHODS: A prospective observational cohort feasibility study was performed. PBRN participating chiropractors were asked to recruit patients seeking new conservative health care for musculoskeletal pain from March 28, 2022, to September 28, 2022. Participants completed clinically oriented survey questions and patient-reported outcome measures before the initial chiropractic assessment as well as 1 h, 2 weeks, 6 weeks, and 12 weeks thereafter. Feasibility was assessed through a variety of process, resource, and management metrics. Patient clinical outcomes were also assessed. RESULTS: A total of 76 clinicians from 35 unique primary care chiropractic clinics across Switzerland participated. A total of 1431 patients were invited to participate, of which 573 (mean age 47 years, 51% female) were enrolled. Patient survey response proportions were 76%, 64%, 61%, and 56%, at the 1-h, 2-, 6-, and 12-week survey follow-ups, respectively. Evidence of an association was found between increased patient age (OR = 1.03, 95%CI 1.01-1.04), patient from a German-speaking region (OR = 1.81, 95%CI 1.17-2.86), non-smokers (OR = 1.89, 95%CI 1.13-3.17), and increased pain impact score at baseline (OR = 1.18, 95%CI 1.01-1.38) and response to all surveys. CONCLUSION: The Swiss ChiCo pilot study exceeded its prespecified feasibility objectives. Nationwide longitudinal data capture was highly feasible. Similar to other practice-based cohorts, participant retention remains a challenge. Trial registration Swiss chiropractic cohort (Swiss ChiCo) pilot study (ClinicalTrials.gov identifier: NCT05116020).

The Effects of Chiropractic Spinal Adjustment on EEG in Adults with Alzheimer's and Parkinson's Disease: A Pilot Randomised Cross-over Trial.

OBJECTIVES: In this study, we explored the effects of chiropractic spinal adjustments on resting-state electroencephalography (EEG) recordings and early somatosensory evoked potentials (SEPs) in Alzheimer's and Parkinson's disease. METHODS: In this randomized cross-over study, 14 adults with Alzheimer's disease (average age 67 ± 6 years, 2 females:12 males) and 14 adults with Parkinson's disease (average age 62 ± 11 years, 1 female:13 males) participated. The participants underwent chiropractic spinal adjustments and a control (sham) intervention in a randomized order, with a minimum of one week between each intervention. EEG was recorded before and after each intervention, both during rest and stimulation of the right median nerve. The power-spectra was calculated for resting-state EEG, and the amplitude of the N30 peak was assessed for the SEPs. The source localization was performed on the power-spectra of resting-state EEG and the N30 SEP peak. RESULTS: Chiropractic spinal adjustment significantly reduced the N30 peak in individuals with Alzheimer's by 15% (p = 0.027). While other outcomes did not reach significance, resting-state EEG showed an increase in absolute power in all frequency bands after chiropractic spinal adjustments in individuals with Alzheimer's and Parkinson's disease. The findings revealed a notable enhancement in connectivity within the Default Mode Network (DMN) at the alpha, beta, and theta frequency bands among individuals undergoing chiropractic adjustments. CONCLUSIONS: We found that it is feasible to record EEG/SEP in individuals with Alzheimer's and Parkinson's disease. Additionally, a single session of chiropractic spinal adjustment reduced the somatosensory evoked N30 potential and enhancement in connectivity within the DMN at the alpha, beta, and theta frequency bands in individuals with Alzheimer's disease. Future studies may require a larger sample size to estimate the effects of chiropractic spinal adjustment on brain activity. Given the preliminary nature of our findings, caution is warranted when considering the clinical implications. CLINICAL TRIAL REGISTRATION: The study was registered by the Australian New Zealand Clinical Trials Registry (registration number ACTRN12618001217291 and 12618001218280).

A Systems Approach for Assessing Low Back Pain Care Quality in Veterans Health Administration Chiropractic Visits: A Cross-Sectional Analysis.

OBJECTIVE: The purpose of this study was to explore a systemwide process for assessing components of low back pain (LBP) care quality in Veterans Health Administration (VHA) chiropractic visits using electronic health record (EHR) data. METHODS: We performed a cross-sectional quality improvement project. We randomly sampled 1000 on-station VHA chiropractic initial visits occurring from October 1, 2017, to September 30, 2018, for patients with no such visits within the prior 12 months. Characteristics of LBP visits were extracted from VHA national EHR data via structured data queries and manual chart review. We developed quality indicators for history and/or examination and treatment procedures using previously published literature and calculated frequencies of visits meeting these indicators. Visits meeting our history and/or examination and treatment indicators were classified as "high-quality" visits. We performed a regression analysis to assess associations between demographic/clinical characteristics and visits meeting our quality criteria. RESULTS: There were 592 LBP visits identified. Medical history, physical examination, and neurologic examination were documented in 76%, 77%, and 63% of all LBP visits, respectively. Recommended treatments, such as any manipulation, disease-specific education/advice, and therapeutic exercise, occurred in 75%, 69%, and 40% of chronic visits (n = 383), respectively. In acute/subacute visits (n = 37), any manipulation (92%), manual soft tissue therapy (57%), and disease-specific advice/education (54%) occurred most frequently. Female patients and those with a neck pain comorbid diagnosis were significantly less likely to have a "high-quality" visit, while other regression associations were non-significant. CONCLUSION: This study explored a systemwide process for assessing components of care quality in VHA chiropractic visits for LBP. These results produced a potential framework for uniform assessment of care quality in VHA chiropractic visits for LBP and highlight potential areas for improvements in LBP care quality assessments.

Guideline-concordant utilization of magnetic resonance imaging in adults receiving chiropractic manipulative therapy vs other care for radicular low back pain: a retrospective cohort study.

BACKGROUND: Lumbar magnetic resonance imaging (LMRI) is often performed early in the course of care, which can be discordant with guidelines for non-serious low back pain. Our primary hypothesis was that adults receiving chiropractic spinal manipulative therapy (CSMT) for incident radicular low back pain (rLBP) would have reduced odds of early LMRI over 6-weeks' follow-up compared to those receiving other care (a range of medical care, excluding CSMT). As a secondary hypothesis, CSMT recipients were also expected to have reduced odds of LMRI over 6-months' and 1-years' follow-up. METHODS: A national 84-million-patient health records database including large academic healthcare organizations (TriNetX) was queried for adults age 20-70 with rLBP newly-diagnosed between January 31, 2012 and January 31, 2022. Receipt or non-receipt of CSMT determined cohort allocation. Patients with prior lumbar imaging and serious pathology within 90 days of diagnosis were excluded. Propensity score matching controlled for variables associated with LMRI utilization (e.g., demographics). Odds ratios (ORs) of LMRI over 6-weeks', 6-months', and 1-years' follow-up after rLBP diagnosis were calculated. RESULTS: After matching, there were 12,353 patients per cohort (mean age 50 years, 56% female), with a small but statistically significant reduction in odds of early LMRI in the CSMT compared to other care cohort over 6-weeks' follow-up (9%, 10%, OR [95% CI] 0.88 [0.81-0.96] P = 0.0046). There was a small but statistically significant increase in odds of LMRI among patients in the CSMT relative to the other care cohort over 6-months' (12%, 11%, OR [95% CI] 1.10 [1.02-1.19], P < 0.0174) and 1-years' follow-up (14%, 12%, OR [95% CI] 1.21 [1.13-1.31], P < 0.0001). CONCLUSIONS: These results suggest that patients receiving CSMT for newly-diagnosed rLBP are less likely to receive early LMRI than patients receiving other care. However, CSMT recipients have a small increase in odds of LMRI over the long-term. Both cohorts in this study had a relatively low rate of early LMRI, possibly because the data were derived from academic healthcare organizations. The relationship of these findings to other patient care outcomes and cost should be explored in a future randomized controlled trial. REGISTRATION: Open Science Framework ( https://osf.io/t9myp ).

Assessing the Significance of Individual Change in 2 Samples of Patients in Treatment for Low Back Pain Using 5 Different Statistical Indicators.

OBJECTIVE: The purpose of this study was to estimate the significance of individual change using 5 statistical indicators in 2 samples of patients treated for low back pain. METHODS: This secondary analysis used observational and clinical trial data from 2 samples of patients with low back pain to compare 5 ways of estimating significant individual change on the Impact Stratification Score (ISS) administered at the following 2 time points: 3 months apart in an observational study of 1680 patients undergoing chiropractic care, and 6 weeks apart in a randomized trial of 750 active-duty military personnel with low back pain. The following 5 methods were compared: (1) standard deviation index; (2) standard error of measurement (SEM); (3) standard error of estimate (SEE); (4) standard error of prediction (SEP); and (5) the reliable change index (RCI). The ISS is the sum of the Patient-Reported Outcomes Measurement Information System (PROMIS)-29 v2.1 physical function, pain interference, and pain intensity scores and is scored to have a possible range of 8 (least impact) to 50 (greatest impact). RESULTS: The amount of change on the ISS needed for significant individual change in both samples was 5 for the SEM and for the SEE and 7 for the SEP and RCI. CONCLUSIONS: The results of the current study provide some preliminary support for use of the SEP or the RCI to identify significant individual change and provide estimated thresholds of individual change that can be used for the ISS. The SEP and RCI estimates of significant change were consistent with retrospective ratings of change of at least moderately better in prior research. These 2 were less likely than other methods to classify people with low back pain as responders who have not actually gotten better (false positive). In contrast, the SEM and SEE were less likely to miss real change (false negative).

Perceptions of Chiropractic Care Among Women With Migraine: A Qualitative Substudy Using a Grounded-Theory Framework.

OBJECTIVE: The purpose of this study was to characterize expectations, attitudes, and experiences of individuals with migraine who were randomly assigned to receive chiropractic care delivered within a randomized controlled trial in a hospital-based integrative care center. METHODS: This qualitative substudy was conducted as a part of a 2-arm pilot pragmatic randomized controlled trial investigating a multimodal model of chiropractic care for women with episodic migraine (4-13 migraines per month). Women were randomly assigned to chiropractic care (10 sessions over 14 weeks) plus enhanced usual care vs enhanced usual care alone. Semistructured interviews were conducted at baseline and 14-week follow-up with 15 randomly selected participants from the 29 participants randomized to the chiropractic group. Qualitative analysis was performed by 2 independent reviewers using a constant comparative method of analysis for generating grounded theory. RESULTS: Integrating baseline and follow-up interviews, 3 themes emerged: over the course of treatment with chiropractic care, participants became more aware of the role of musculoskeletal tension, pain, and posture in triggering migraine; participants revised their prior conceptions of chiropractic care beyond spinal manipulation; and participants viewed the chiropractor-patient relationship as an essential and valuable component to effectively managing their migraines. CONCLUSION: In this qualitative study, women with episodic migraine after receiving comprehensive chiropractic care described chiropractic as a multimodal intervention where they learned about musculoskeletal contributions to migraine, discovered new ways to affect their symptoms, and developed a collaborative patient-practitioner relationship. The results of this study provide insights into perceptions of chiropractic care among women with migraine and suggestions for future trials.

Predictors of visit frequency for patients using ongoing chiropractic care for chronic low back and chronic neck pain; analysis of observational data.

BACKGROUND: Chronic spinal pain is prevalent, expensive and long-lasting. Several provider-based nonpharmacologic therapies have now been recommended for chronic low-back pain (CLBP) and chronic neck pain (CNP). However, healthcare and coverage policies provide little guidance or evidence regarding the long-term use of this care. To provide one glimpse into the long-term use of nonpharmacologic provider-based care, this study examines the predictors of visit frequency in a large sample of patients with CLBP and CNP using ongoing chiropractic care. METHODS: Observational data were collected from a large national sample of chiropractic patients in the US with non-specific CLBP and CNP. Visit frequency was defined as average number of chiropractic visits per month over the 3-month study period. Potential baseline predictor variables were entered into two sets of multi-level models according to a defined causal theory-in this case, Anderson's Behavioral Model of Health Services Use. RESULTS: Our sample included 852 patients with CLBP and 705 with CNP. Visit frequency varied significantly by chiropractor/clinic, so our models controlled for this clustering. Patients with either condition used an average of 2.3 visits per month. In the final models visit frequency increased (0.44 visits per month, p = .008) for those with CLBP and some coverage for chiropractic, but coverage had little effect on visits for patients with CNP. Patients with worse function or just starting care also had more visits and those near to ending care had fewer visits. However, visit frequency was also determined by the chiropractor/clinic where treatment was received. Chiropractors who reported seeing more patients per day also had patients with higher visit frequency, and the patients of chiropractors with 20 to 30 years of experience had fewer visits per month. In addition, after controlling for both patient and chiropractor characteristics, the state in which care was received made a difference, likely through state-level policies and regulations. CONCLUSIONS: Chiropractic patients with CLBP and CNP use a range of visit frequencies for their ongoing care. The predictors of these frequencies could be useful for understanding and developing policies for ongoing provider-based care.

The Utilization of Joint Mobilization As Part of a Comprehensive Program to Manage Carpal Tunnel Syndrome: A Systematic Review.

OBJECTIVE: The purpose of this review is to identify the role of joint mobilization for individuals with Carpal tunnel syndrome (CTS). METHODS: A systematic search of 5 electronic databases (PubMed, CINAHL, Scopus, Cochrane Central Register of Controlled Trials, and SPORTDiscus) was performed to identify eligible full-text randomized clinical trials related to the clinical question. Joint mobilization had to be included in one arm of the randomized clinical trials to be included. Two reviewers independently participated in each step of the screening process. A blinded third reviewer assisted in cases of discrepancy. The PEDro scale was used to assess quality. RESULTS: Ten articles were included after screening 2068 titles. In each article where joint mobilization was used, positive effects in pain, function, or additional outcomes were noted. In most cases, the intervention group integrating joint mobilization performed better than the comparison group not receiving joint techniques. CONCLUSION: In the articles reviewed, joint mobilization was associated with positive clinical effects for persons with CTS. No studies used joint mobilization in isolation; therefore, results must be interpreted cautiously. This review indicates that joint mobilization might be a useful adjunctive intervention in the management of CTS.

Measurement and Analysis of Biomechanical Outcomes of Chiropractic Adjustment Performance in Chiropractic Education and Practice.

OBJECTIVE: The purpose of this study was to compare biomechanical measures of chiropractic adjustment performance of the McTimoney toggle-torque-recoil (MTTR) technique among students and chiropractors. METHODS: Fifty-three participants (15 year-3 [Y3] and 16 year-5 chiropractic students and 22 McTimoney chiropractors [DCs]) participated in this study. Each applied 10 MTTR thrusts to a dynamic load cell, 5 each with their left and right hands. Biomechanical variables including preload force, peak force, time to peak force, thrust duration, and total thrust time were computed from each of the force-time histories and compared within groups using a series of 2-way analysis of variance to evaluate the effects of sex and handedness, and between groups to determine the effect of experience using a series of 3-way analysis of variance. The Games-Howell post hoc test was used to further assess pairwise comparisons. RESULTS: Mean time to peak force was more than 3 × shorter for DCs (69.96 ms) compared with Y3 students (230.36 ms) (P = .030). Likewise, mean thrust duration was also found to be nearly 2.5-fold significantly shorter for DCs (117.77 ms) compared with Y3 students (283.84 ms) (P = .030). The DCs took significantly less total thrust time (mean = 1.27 seconds) in administering MTTR thrusts than Y3 students (1.89 seconds) (P = .006). No significant differences were found among any of the 3 clinician groups for peak force or in time to peak force or thrust duration for comparisons of all 10 MTTR thrusts among year-5 students and DCs. Higher peak forces were observed for thrusts delivered with clinicians' dominant hands (P = .001), and the fastest thrusts were found for the dominant hands of DCs (P = .001). Sex had no significant effect on biomechanical variables. The Y3 students had significant greater variability in thrust times for each hand and for analyses of both hands combined (P = .001). CONCLUSION: Training and experience were found to result in shorter MTTR thrust times and other biomechanical variables that have been identified as important factors in the mechanisms of chiropractic adjustments. Identification of such biomechanical markers as performance outcomes may be of assistance in providing feedback for training in chiropractic education and technique application.

GLA:D® Back: implementation of group-based patient education integrated with exercises to support self-management of back pain - protocol for a hybrid effectiveness-implementation study.

BACKGROUND: Reassuring patient education and exercise therapy are widely recommended interventions for back pain in clinical guidelines. However, many patients are offered non-guideline endorsed options, and strategies for effective implementation of guideline-based care have not yet been developed. This protocol outlines the evaluation of a strategy for nationwide implementation of standardised patient education and exercise therapy for people with persistent or recurrent back pain in a hybrid implementation-effectiveness design. The strategy and the evaluation were planned using the framework of the Behaviour Change Wheel. METHODS: The main activity of the implementation strategy is a two-days course for physiotherapists and chiropractors in delivering patient education and exercise therapy that is aimed at supporting patient self-management. This comes with ready-to-use patient education materials and exercise programs. The clinical intervention is a group-based program consisting of two sessions of patient education and 8 weeks of supervised exercises. The program uses a cognitive-behavioural approach and the aim of the exercise component is to restore the patient's ability and confidence to move freely. The implementation process is evaluated in a dynamic process monitoring the penetration, adoption and fidelity of the clinical intervention. The clinical intervention and potential effect mechanisms will be evaluated at the patient-level using measures of knowledge, skills, beliefs, performance, self-efficacy and success in self-management. The education of clinicians will be evaluated via clinician-level outcomes, including the Pain Attitudes and Beliefs Scale, the Practitioner Confidence Scale, and the Determinants of Implementation Behaviour Questionnaire. Effects at a national level will be investigated via data from national registries of health care utilisation and sick-leave. DISCUSSION: This implementation-effectiveness study is designed to evaluate the process of implementing an evidence-based intervention for back pain. It will inform the development of strategies for implementing evidence-based care for musculoskeletal pain conditions, it will enhance the understanding of mechanisms for developing patient self-management skills, and it will demonstrate the outcomes that are achievable in everyday clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT03570463 . Registered 27 June 2018.

Clinical Outcomes in Neurogenic Claudication Using a Multimodal Program for Lumbar Spinal Stenosis: A Study of 49 Patients With Prospective Long-term Follow-up.

OBJECTIVE: The purpose of this study was to assess long-term outcomes of a 6-week multimodal program (manual therapy, exercises, and self-management strategies) in patients with neurogenic claudication due to degenerative lumbar spinal stenosis. METHODS: This study evaluated 49 patients with neurogenic claudication who completed a 6-week multimodal program between 2010 and 2013. Outcomes included Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ), and Numeric Rating Scale. Mean differences, paired t tests, and the Wilcoxon rank-sum test were used to compare outcomes at baseline, 6 weeks, and long-term follow-up. RESULTS: Twenty-three patients completed the follow-up questionnaire (47% response rate). Median follow-up was 3.6 years (interquartile range: 3.3-4.6). The mean age was 73.5 years (standard deviation: 8.5). Between baseline and long-term follow-up, there were statistically significant and clinically important improvements in disability (ODI: -23.7 [95% confidence interval (CI): -15.7 to -31.6]; ODI walking item: -1.96 [95% CI: -1.34 to -2.57]; ZCQ function scale: -0.42 [95% CI: -0.10 to -0.70]) and pain (leg pain: -3.53 [95% CI: -1.80 to -5.20]; ZCQ symptom scale: -0.71 [95% CI: -0.30 to -1.10]), but not low back pain (Numeric Rating Scale: -1.03 [95% CI: -1.00 to 3.10]). There was no statistically significant change in any outcomes between 6 weeks and long-term follow-up. CONCLUSION: In a sample of patients with neurogenic claudication participating in a 6-week multimodal program, clinically important improvements in leg pain and disability, but not low back pain while walking, were maintained in the long term (median duration of 3.6 years) when compared to baseline.

Prospective Cohort Study of Patients With Neck Pain in a Manual Therapy Setting: Design and Baseline Measures.

OBJECTIVES: The purpose of this study was to describe the design and baseline measurements of a prospective multicenter cohort study in patients with neck pain treated by Dutch manual therapists. Objectives of the study were to determine which patients seek help from a manual therapist, to describe usual care manual therapy in patients with neck pain, to examine the occurrence of nonserious adverse events after treatment, to describe predictors of adverse events, and to determine whether the occurrence of nonserious adverse events affect outcome after manual therapy care. METHODS: During a 3-month inclusion period, consecutive patients aged between 18 and 80 years presenting with neck pain in manual therapy practices in The Netherlands were included in the study. Baseline questionnaires included the Numeric Rating Scale, Neck Disability Index (NDI), Neck Bournemouth Questionnaire, Fear Avoidance Beliefs Questionnaire (FABQ), and Patient Expectancy List. Within the treatment episode, manual therapist clinical reasoning and applied interventions were registered and patients reported on adverse events. At the end of the treatment episode and at 12-month follow-up, pain intensity (Numeric Rating Scale), functional outcomes (NDI, Neck Bournemouth Questionnaire), personal factors (FABQ), and global perceived effect were measured. RESULTS: During the 3-month inclusion period, 263 participating manual therapists collected data on 1193 patients with neck pain. Most patients (69.4%) were female. The mean age was 44.7 (±13.7) years. The NDI showed overall mild disability (mean score 26%). Mean scores in pain intensity were moderate (4.8), and there was low risk of prolonged disability owing to personal factors (FABQ). CONCLUSION: This study provides information on baseline characteristics of patients visiting manual therapists for neck pain. In The Netherlands, patients seeking care of manual therapists are comparable to patients in other countries regarding demographics and neck pain characteristics.

Comparative Effectiveness of Usual Care With or Without Chiropractic Care in Patients with Recurrent Musculoskeletal Back and Neck Pain.

BACKGROUND: Chiropractic care is a popular alternative for back and neck pain, with efficacy comparable to usual care in randomized trials. However, the effectiveness of chiropractic care as delivered through conventional care settings remains largely unexplored. OBJECTIVE: To evaluate the comparative effectiveness of usual care with or without chiropractic care for patients with chronic recurrent musculoskeletal back and neck pain. STUDY DESIGN: Prospective cohort study using propensity score-matched controls. PARTICIPANTS: Using retrospective electronic health record data, we developed a propensity score model predicting likelihood of chiropractic referral. Eligible patients with back or neck pain were then contacted upon referral for chiropractic care and enrolled in a prospective study. For each referred patient, two propensity score-matched non-referred patients were contacted and enrolled. We followed the participants prospectively for 6 months. MAIN MEASURES: Main outcomes included pain severity, interference, and symptom bothersomeness. Secondary outcomes included expenditures for pain-related health care. KEY RESULTS: Both groups' (N = 70 referred, 139 non-referred) pain scores improved significantly over the first 3 months, with less change between months 3 and 6. No significant between-group difference was observed. (severity - 0.10 (95% CI - 0.30, 0.10), interference - 0.07 (- 0.31, 0.16), bothersomeness - 0.1 (- 0.39, 0.19)). After controlling for variances in baseline costs, total costs during the 6-month post-enrollment follow-up were significantly higher on average in the non-referred versus referred group ($1996 [SD = 3874] vs $1086 [SD = 1212], p = .034). Adjusting for differences in age, gender, and Charlson comorbidity index attenuated this finding, which was no longer statistically significant (p = .072). CONCLUSIONS: We found no statistically significant difference between the two groups in either patient-reported or economic outcomes. As clinical outcomes were similar, and the provision of chiropractic care did not increase costs, making chiropractic services available provided an additional viable option for patients who prefer this type of care, at no additional expense.

Chiropractic spinal manipulative therapy for migraine: a three-armed, single-blinded, placebo, randomized controlled trial.

BACKGROUND AND PURPOSE: To investigate the efficacy of chiropractic spinal manipulative therapy (CSMT) for migraineurs. METHODS: This was a prospective three-armed, single-blinded, placebo, randomized controlled trial (RCT) of 17 months duration including 104 migraineurs with at least one migraine attack per month. The RCT was conducted at Akershus University Hospital, Oslo, Norway. Active treatment consisted of CSMT, whereas placebo was a sham push manoeuvre of the lateral edge of the scapula and/or the gluteal region. The control group continued their usual pharmacological management. The RCT consisted of a 1-month run-in, 3 months intervention and outcome measures at the end of the intervention and at 3, 6 and 12 months follow-up. The primary end-point was the number of migraine days per month, whereas secondary end-points were migraine duration, migraine intensity and headache index, and medicine consumption. RESULTS: Migraine days were significantly reduced within all three groups from baseline to post-treatment (P < 0.001). The effect continued in the CSMT and placebo group at all follow-up time points, whereas the control group returned to baseline. The reduction in migraine days was not significantly different between the groups (P > 0.025 for interaction). Migraine duration and headache index were reduced significantly more in the CSMT than the control group towards the end of follow-up (P = 0.02 and P = 0.04 for interaction, respectively). Adverse events were few, mild and transient. Blinding was strongly sustained throughout the RCT. CONCLUSIONS: It is possible to conduct a manual-therapy RCT with concealed placebo. The effect of CSMT observed in our study is probably due to a placebo response.

Chiropractic management of dominating one-sided pelvic girdle pain in pregnant women; a randomized controlled trial.

BACKGROUND: The aim of this study was to investigate the outcome of chiropractic management for a subgroup of pregnant women with dominating one-sided pelvic girdle pain (PGP). METHODS: The study population was recruited from a prospective longitudinal cohort study of pregnant women. Women reporting pelvic pain (PP), and who were diagnosed with dominating one-sided PGP after a clinical examination, were invited to participate in the intervention study. Recruitment took place either at 18 weeks, or after an SMS-tracking up to week 29. The women were randomized into a treatment group or a control group. The treatment group received chiropractic treatment individualized to each woman with regards to treatment modality and number of treatments. The control group was asked to return to conventional primary health care. The primary outcome measure was new occurrence of full time and/or graded sick leave due to PP and/or low back pain. Secondary outcome measures were self-reported PP, physical disability and general health status. Proportion of women reporting new occurrence of sick leave were compared using Chi squared tests. Differences in secondary outcome measures were estimated using linear regression analyses. RESULTS: Fifty-Six women were recruited, and 28 of them were randomized into the treatment group, and 28 into the control group. There was no statistically significant difference in sick leave, PP, disability or general health status between the two groups during pregnancy or after delivery. CONCLUSION: The study did not demonstrate superiority of chiropractic management over conventional care for dominating one-sided PGP during pregnancy. However, the analyses revealed wide confidence intervals containing both positive and negative clinically relevant effects. TRIAL REGISTRATION: The study was registered in ClinicalTrials.gov ( NCT01098136 ; 22/03/2010).

Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial.

OBJECTIVES: To investigate the efficacy of shoe orthotics with and without chiropractic treatment for chronic low back pain compared with no treatment. DESIGN: Randomized controlled trial. SETTING: Integrative medicine teaching clinic at a university. PARTICIPANTS: Adult subjects (N=225) with symptomatic low back pain of ≥3 months were recruited from a volunteer sample. INTERVENTIONS: Subjects were randomized into 1 of 3 treatment groups (shoe orthotic, plus, and waitlist groups). The shoe orthotic group received custom-made shoe orthotics. The plus group received custom-made orthotics plus chiropractic manipulation, hot or cold packs, and manual soft tissue massage. The waitlist group received no care. MAIN OUTCOME MEASURES: The primary outcome measures were change in perceived back pain (numerical pain rating scale) and functional health status (Oswestry Disability Index) after 6 weeks of study participation. Outcomes were also assessed after 12 weeks and then after an additional 3, 6, and 12 months. RESULTS: After 6 weeks, all 3 groups demonstrated significant within-group improvement in average back pain, but only the shoe orthotic and plus groups had significant within-group improvement in function. When compared with the waitlist group, the shoe orthotic group demonstrated significantly greater improvements in pain (P<.0001) and function (P=.0068). The addition of chiropractic to orthotics treatment demonstrated significantly greater improvements in function (P=.0278) when compared with orthotics alone, but no significant difference in pain (P=.3431). Group differences at 12 weeks and later were not significant. CONCLUSIONS: Six weeks of prescription shoe orthotics significantly improved back pain and dysfunction compared with no treatment. The addition of chiropractic care led to higher improvements in function.

Provider and patient perspectives on opioids and alternative treatments for managing chronic pain: a qualitative study.

BACKGROUND: Current literature describes the limits and pitfalls of using opioid pharmacotherapy for chronic pain and the importance of identifying alternatives. The objective of this study was to identify the practical issues patients and providers face when accessing alternatives to opioids, and how multiple parties view these issues. METHODS: Qualitative data were gathered to evaluate the outcomes of acupuncture and chiropractic (A/C) services for chronic musculoskeletal pain (CMP) using structured interview guides among patients with CMP (n = 90) and primary care providers (PCPs) (n = 25) purposively sampled from a managed care health care system as well as from contracted community A/C providers (n = 14). Focus groups and interviews were conducted patients with CMP with varying histories of A/C use. Plan PCPs and contracted A/C providers took part in individual interviews. All participants were asked about their experiences managing chronic pain and experience with and/or attitudes about A/C treatment. Audio recordings were transcribed and thematically coded. A summarized version of the focus group/interview guides is included in the Additional file 1. RESULTS: We identified four themes around opioid use: (1) attitudes toward use of opioids to manage chronic pain; (2) the limited alternative options for chronic pain management; (3) the potential of A/C care as a tool to help manage pain; and (4) the complex system around chronic pain management. Despite widespread dissatisfaction with opioid medications for pain management, many practical barriers challenged access to other options. Most of the participants' perceived A/C care as helpful for short term pain relief. We identified that problems with timing, expectations, and plan coverage limited A/C care potential for pain relief treatment. CONCLUSIONS: These results suggest that education about realistic expectations for chronic pain management and therapy options, as well as making A/C care more easily accessible, might lead to more satisfaction for patients and providers, and provide important input to policy makers. TRIAL REGISTRATION: ClinicalTrials.gov NCT01345409 , date of registration 28/4/2011.

Differences in Practice Characteristics Between Male and Female Chiropractors in Switzerland.

OBJECTIVES: A total of 75% of the chiropractic medicine students in the new program at the University of Zürich are women, which is in stark contrast to the traditional ratio of chiropractors in Switzerland, where 75% have been men. Therefore, the purpose of this study was to compare work behaviors between female and male chiropractors relating to workload, patient variety, and chiropractic treatment techniques. METHODS: This is a secondary analysis of data from the Swiss Job Analysis 2009 study. The design was an online survey to all practicing chiropractors in Switzerland that had a 70% response rate of 183 returned surveys. Differences between male and female chiropractors in the various categorical responses involving practice workload, characteristics and patient types were compared using the χ2 test. RESULTS: Male chiropractors had significantly more years in practice (P = .0001), worked more hours per week (P = .0001), and saw more patients (P = .0001) and more new patients (P = .004) per week compared with female chiropractors. Female chiropractors spent significantly more time with patients during follow-up visits (P = .017). There were no significant differences in treatment techniques used or the types of patients seen between the sexes. CONCLUSION: Because female chiropractors work fewer hours and see fewer patients per week, this may lead to a shortage of chiropractors in the future as the sex ratio within the profession slowly changes in Switzerland.

Effects of 12 Weeks of Chiropractic Care on Central Integration of Dual Somatosensory Input in Chronic Pain Patients: A Preliminary Study.

OBJECTIVE: The purpose of this preliminary study was to assess whether the dual somatosensory evoked potential (SEP) technique is sensitive enough to measure changes in cortical intrinsic inhibitory interactions in patients with chronic neck or upper extremity pain and, if so, whether changes are associated with changes in pain scores. METHODS: The dual peripheral nerve stimulation SEP ratio technique was used for 6 subjects with a history of chronic neck or upper limb pain. SEPs were recorded after left or right median and ulnar nerve stimulation at the wrist. SEP ratios were calculated for the N9, N13, P14-18, N20-P25, and P22-N30 peak complexes from SEP amplitudes obtained from simultaneous median and ulnar stimulation divided by the arithmetic sum of SEPs obtained from individual stimulation of the median and ulnar nerves. Outcome measures of SEP ratios and subjects' visual analog scale rating of pains were recorded at baseline, after a 2-week usual care control period, and after 12 weeks of multimodal chiropractic care (chiropractic spinal manipulation and 1 or more of the following: exercises, peripheral joint adjustments/manipulation, soft tissue therapy, and pain education). RESULTS: A significant decrease in the median and ulnar to median plus ulnar ratio and the median and ulnar amplitude for the cortical P22-N30 SEP component was observed after 12 weeks of chiropractic care, with no changes after the control period. There was a significant decrease in visual analog scale scores (both for current pain and for pain last week). CONCLUSION: The dual SEP ratio technique appears to be sensitive enough to measure changes in cortical intrinsic inhibitory interactions in patients with chronic neck pain. The observations in 6 subjects revealed that 12 weeks of chiropractic care improved suppression of SEPs evoked by dual upper limb nerve stimulation at the level of the motor cortex, premotor areas, and/or subcortical areas such as basal ganglia and/or thalamus. It is possible that these findings explain one of the mechanisms by which chiropractic care improves function and reduces pain for chronic pain patients.

Best Practices for Chiropractic Care for Older Adults: A Systematic Review and Consensus Update.

OBJECTIVE: The purpose of this study was to update evidence-based recommendations on the best practices for chiropractic care of older adults. METHODS: The project consisted of a systematic literature review and a consensus process. The following were searched from October 2009 through January 2016: MEDLINE, Index to Chiropractic Literature, CINAHL (Cumulative Index to Nursing and Allied Health Literature), AMED (Allied and Complementary Medicine Database), Alt HealthWatch, Cochrane Database of Systematic Reviews, and Cochrane Registry of Controlled Trials. Search terms were: (manipulation, spinal OR manipulation, chiropractic OR chiropract*) AND (geriatric OR "older adult*"). Two reviewers independently screened articles and abstracts using inclusion and exclusion criteria. The systematic review informed the project steering committee, which revised the previous recommendations. A multidisciplinary panel of experts representing expertise in practice, research, and teaching in a variety of health professions serving older adults rated the revised recommendations. The RAND Corporation/University of California, Los Angeles methodology for a modified Delphi consensus process was used. RESULTS: A total of 199 articles were found; after exclusion criteria were applied, 6 articles about effectiveness or efficacy and 6 on safety were added. The Delphi process was conducted from April to June 2016. Of the 37 Delphi panelists, 31 were DCs and 6 were other health care professionals. Three Delphi rounds were conducted to reach consensus on all 45 statements. As a result, statements regarding the safety of manipulation were strengthened and additional statements were added recommending that DCs advise patients on exercise and that manipulation and mobilization contribute to general positive outcomes beyond pain reduction only. CONCLUSIONS: This document provides a summary of evidence-informed best practices for doctors of chiropractic for the evaluation, management, and manual treatment of older adult patients.