Extrapolating Beyond the Data in a Systematic Review of Spinal Manipulation for Nonmusculoskeletal Disorders: A Fall From the Summit.

OBJECTIVE: The purpose of this article is to discuss a literature review-a recent systematic review of nonmusculoskeletal disorders-that demonstrates the potential for faulty conclusions and misguided policy implications, and to offer an alternate interpretation of the data using present models and criteria. METHODS: We participated in a chiropractic meeting (Global Summit) that aimed to perform a systematic review of the literature on the efficacy and effectiveness of mobilization or spinal manipulative therapy (SMT) for the primary, secondary, and tertiary prevention and treatment of nonmusculoskeletal disorders. After considering an early draft of the resulting manuscript, we identified points of concern and therefore declined authorship. The present article was developed to describe those concerns about the review and its conclusions. RESULTS: Three main concerns were identified: the inherent limitations of a systematic review of 6 articles on the topic of SMT for nonmusculoskeletal disorders, the lack of biological plausibility of collapsing 5 different disorders into a single category, and considerations for best practices when using evidence in policy-making. We propose that the following conclusion is more consistent with a review of the 6 articles. The small cadre of high- or moderate-quality randomized controlled trials reviewed in this study found either no or equivocal effects from SMT as a stand-alone treatment for infantile colic, childhood asthma, hypertension, primary dysmenorrhea, or migraine, and found no or low-quality evidence available to support other nonmusculoskeletal conditions. Therefore, further research is needed to determine if SMT may have an effect in these and other nonmusculoskeletal conditions. Until the results of such research are available, the benefits of SMT for specific or general nonmusculoskeletal disorders should not be promoted as having strong supportive evidence. Further, a lack of evidence cannot be interpreted as counterevidence, nor used as evidence of falsification or verification. CONCLUSION: Based on the available evidence, some statements generated from the Summit were extrapolated beyond the data, have the potential to misrepresent the literature, and should be used with caution. Given that none of the trials included in the literature review were definitively negative, the current evidence suggests that more research on nonmusculoskeletal conditions is warranted before any definitive conclusions can be made. Governments, insurers, payers, regulators, educators, and clinicians should avoid using systematic reviews in decisions where the research is insufficient to determine the clinical appropriateness of specific care.

Assessing Adverse Events After Chiropractic Care at a Chiropractic Teaching Clinic: An Active-Surveillance Pilot Study.

OBJECTIVE: This study aimed to assess the feasibility of implementing an active-surveillance reporting system within a chiropractic teaching clinic and subsequently determining the frequency of adverse events (AEs) after treatment administered by chiropractic interns. METHODS: Interns were invited to collect data from patients using 3 questionnaires that recorded patient symptom change: 2 completed by the patient (before and 7 days after treatment) and 1 completed by the intern (immediately after treatment). Worsened and new symptoms were considered AEs. Qualitative interviews were conducted with clinicians and interns to assess the feasibility of implementing the reporting system, with resulting data categorized under 4 domains: acceptability, implementation, practicality, and integration. RESULTS: Of the 174 eligible interns, 80 (46.0%) collected data from 364 patient encounters, with 119 (32.7%) returning their posttreatment form. Of the 89 unique patients (mean age = 39.5 years; 58.4% female, 41.6% male), 40.1% presented with low back pain and 31.1% with neck pain. After treatment, 25 symptoms (8.9%) were identified as AEs, mostly reported by patients as worsening discomfort or pain. Data from qualitative interviews suggest that the AE reporting system was well accepted; however, proposed specific modifications include use of longitudinal electronic surveys. CONCLUSION: Our findings suggest that it is feasible to conduct an active-surveillance reporting system at a chiropractic teaching clinic. Important barriers and facilitators were identified and will be used to inform future work regarding patient safety education and research.

Chiropractors' Perspectives on the Meaning and Assessment of Quality of Life Within Their Practice in New Zealand: An Exploratory Qualitative Study.

OBJECTIVE: The purpose of this study was to gain an understanding on what quality of life (QOL) and its assessment means to chiropractors in everyday practice. METHODS: This study captured chiropractors' perspectives on the QOL construct and its assessment using a qualitative descriptive methodology that comprised 2 focus groups, each with 4 participants using semi-structured, open-ended questioning. Participants from Aotearoa, New Zealand, were also asked to evaluate 4 QOL patient-reported outcome measurements from a clinical perspective. RESULTS: Two of the participants were faculty at the New Zealand College of Chiropractic, 5 were in full-time practice, and 1 was practicing part time. Using qualitative content analysis, 3 main themes were identified. These chiropractors perceived that patients have misconceptions about how chiropractic can affect QOL. They lacked clarity in communicating QOL and its related concepts to establish a clinically meaningful patient encounter. Finally, there is uncertainty in how and when to measure QOL, which appears to affect how they discuss and assess QOL in practice. CONCLUSION: There is a complex combination of factors that makes communication regarding QOL challenging. This exploratory qualitative study helps to understand the challenges faced in how and when to communicate and assess QOL more effectively in chiropractic practice.

Best-Practice Recommendations for Chiropractic Management of Patients With Neck Pain.

OBJECTIVE: The purpose of this study was to develop best-practice recommendations for chiropractic management of adults with neck pain. METHODS: A steering committee of experts in chiropractic practice, education, and research drafted a set of recommendations based on the most current relevant clinical practice guidelines. Additional supportive literature was identified through targeted searches conducted by a health sciences librarian. A national panel of chiropractors representing expertise in practice, research, and teaching rated the recommendations using a modified Delphi process. The consensus process was conducted from August to November 2018. Fifty-six panelists rated the 50 statements and concepts and reached consensus on all statements within 3 rounds. RESULTS: The statements and concepts covered aspects of the clinical encounter, ranging from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral for patients presenting with neck pain. CONCLUSIONS: These best-practice recommendations for chiropractic management of adults with neck pain are based on the best available scientific evidence. For uncomplicated neck pain, including neck pain with headache or radicular symptoms, chiropractic manipulation and multimodal care are recommended.

A Qualitative Study of Doctors of Chiropractic in a Nova Scotian Practice-based Research Network: Barriers and Facilitators to the Screening and Management of Psychosocial Factors for Patients With Low Back Pain.

OBJECTIVES: This study aimed to assess chiropractors' awareness of clinical practice guidelines for low back pain and to identify barriers and facilitators to the screening and management of psychosocial factors in patients with low back pain. METHODS: This qualitative study used semi-structured interviews informed by the Theoretical Domains Framework with 10 Nova Scotian chiropractors who were members of a practice-based research network. RESULTS: The participants correctly identified what the guidelines generally recommend and described the value of psychosocial factors; however, none of the participants could name specific clinical practice guidelines for low back pain. We identified 6 themes related to barriers and facilitators for chiropractors screening and managing psychosocial factors. The themes revolved around the participants' desire to fulfill patients' anatomy-focused treatment expectations and a perceived lack of training for managing psychosocial factors. Participants had concerns about going beyond the chiropractic scope of practice, and they perceived a lack of practical psychosocial screening and management resources. Social factors, such as the influence of other health care practitioners, were reported as both barriers and facilitators to screening and managing psychosocial factors. CONCLUSIONS: The participants in this study reported that they mostly treated with an anatomical and biomechanical focus and that they did not always address psychosocial factors identified in their patients with low back pain. Although these findings are limited to Nova Scotian chiropractors, the barriers identified appeared to be potentially modifiable and could be considered in other groups. Low-cost interventions, such as continuing education using evidence-informed behavior change techniques, could be considered to address these barriers.

Chiropractic Integrated Care Pathway for Low Back Pain in Veterans: Results of a Delphi Consensus Process.

OBJECTIVE: The purpose of this study was to develop an integrated care pathway for doctors of chiropractic, primary care providers, and mental health professionals who manage veterans with low back pain, with or without mental health comorbidity, within Department of Veterans Affairs health care facilities. METHODS: The research method used was a consensus process. A multidisciplinary investigative team reviewed clinical guidelines and Veterans Affairs pain and mental health initiatives to develop seed statements and care algorithms to guide chiropractic management and collaborative care of veterans with low back pain. A 5-member advisory committee approved initial recommendations. Veterans Affairs-based panelists (n = 58) evaluated the pathway via e-mail using a modified RAND/UCLA methodology. Consensus was defined as agreement by 80% of panelists. RESULTS: The modified Delphi process was conducted in July to December 2016. Most (93%) seed statements achieved consensus during the first round, with all statements reaching consensus after 2 rounds. The final care pathway addressed the topics of informed consent, clinical evaluation including history and examination, screening for red flags, documentation, diagnostic imaging, patient-reported outcomes, adverse event reporting, chiropractic treatment frequency and duration standards, tailored approaches to chiropractic care in veteran populations, and clinical presentation of common mental health conditions. Care algorithms outlined chiropractic case management and interprofessional collaboration and referrals between doctors of chiropractic and primary care and mental health providers. CONCLUSION: This study offers an integrative care pathway that includes chiropractic care for veterans with low back pain.

Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain: A Guideline From the Canadian Chiropractic Guideline Initiative.

OBJECTIVE: The objective of this study was to develop a clinical practice guideline on the management of acute and chronic low back pain (LBP) in adults. The aim was to develop a guideline to provide best practice recommendations on the initial assessment and monitoring of people with low back pain and address the use of spinal manipulation therapy (SMT) compared with other commonly used conservative treatments. METHODS: The topic areas were chosen based on an Agency for Healthcare Research and Quality comparative effectiveness review, specific to spinal manipulation as a nonpharmacological intervention. The panel updated the search strategies in Medline. We assessed admissible systematic reviews and randomized controlled trials for each question using A Measurement Tool to Assess Systematic Reviews and Cochrane Back Review Group criteria. Evidence profiles were used to summarize judgments of the evidence quality and link recommendations to the supporting evidence. Using the Evidence to Decision Framework, the guideline panel determined the certainty of evidence and strength of the recommendations. Consensus was achieved using a modified Delphi technique. The guideline was peer reviewed by an 8-member multidisciplinary external committee. RESULTS: For patients with acute (0-3 months) back pain, we suggest offering advice (posture, staying active), reassurance, education and self-management strategies in addition to SMT, usual medical care when deemed beneficial, or a combination of SMT and usual medical care to improve pain and disability. For patients with chronic (>3 months) back pain, we suggest offering advice and education, SMT or SMT as part of a multimodal therapy (exercise, myofascial therapy or usual medical care when deemed beneficial). For patients with chronic back-related leg pain, we suggest offering advice and education along with SMT and home exercise (positioning and stabilization exercises). CONCLUSIONS: A multimodal approach including SMT, other commonly used active interventions, self-management advice, and exercise is an effective treatment strategy for acute and chronic back pain, with or without leg pain.

Researching the Appropriateness of Care in the Complementary and Integrative Health Professions: Part I.

OBJECTIVES: The purpose of this article is to report on the Center of Excellence for Research on Complementary and Alternative Medicine at RAND Corporation. The overall project examined the appropriateness of chiropractic spinal manipulation and mobilization for chronic low back pain and chronic cervical pain using the RAND and University of California Los Angeles Appropriateness Method, including patient preferences and costs, to acknowledge the importance of patient-centered care in clinical decision-making. METHODS: This article is a narrative summary of the overall project and its inter-related components (ie, 4 Research Project Grants and 2 centers), including the Data Collection Core, whose activities and learning will be the subject of a following series of methods articles. RESULTS: The project team faced many challenges in accomplishing data collection goals. The processes we developed to overcome barriers may be of use to other researchers and for practitioners who may want to participate in such studies in complementary and integrative health, which previously was known as complementary and alternative medicine. CONCLUSION: For this large, complex, successful project, we gathered online survey data, collected charts, and abstracted chart data from thousands of chiropractic patients. The present article delineates the challenges and lessons that were learned during this project so that others may gain from the authors' experience. This information may be of use to future research that collects data from independent practitioners and their patients because it provides what is needed to be successful in such studies and may encourage participation.

Criteria to Screen for Traumatic Cervical Spine Instability: A Consensus of Chiropractic Radiologists.

OBJECTIVE: The purpose of this study was to establish consensus on a radiographic definition for cervical instability for routine use in chiropractic patients who sustain trauma to the cervical spine. METHOD: We conducted a modified Delphi study with a panel of chiropractic radiologists. Panelists were asked to rate potential screening criteria for traumatic cervical spine instability when assessing cervical spine radiographs. Items rated as important for inclusion by at least 60% of participants in round 1 were submitted for a second round of voting in round 2. Items rated for inclusion by at least 75% of the participants in round 2 were used to create the consensus-based list of screening criteria. Participants were asked to vote and reach agreement on the final screening criteria list in round 3. RESULTS: Twenty-nine chiropractic radiologists participated in round 1. After 3 rounds of survey, 85% of participants approved the final consensus-based list of criteria for traumatic cervical spine instability screening, including 6 clinical signs and symptoms and 5 radiographic criteria. Participants agreed that the presence of 1 or more of these clinical signs and symptoms and/or 1 or more of the 5 radiographic criteria on routine static radiographic studies suggests cervical instability. CONCLUSION: The consensus-based radiographic definition of traumatic cervical spine instability includes 6 clinical signs and symptoms and 5 radiographic criteria that doctors of chiropractic should apply to their patients who sustain trauma to the cervical spine.

Pediatric Chiropractic Care: The Subluxation Question And Referral Risk.

Chiropractors commonly treat children for a variety of ailments by manipulating the spine to correct a 'vertebral subluxation' or a 'vertebral subluxation complex' alleged to be a cause of disease. Such treatment might begin soon after a child is born. Both major American chiropractic associations - the International Chiropractic Association and the American Chiropractic Association - support chiropractic care for children, which includes subluxation correction as a treatment or preventive measure. I do not know of any credible evidence to support chiropractic subluxation theory. Any attempt to manipulate the immature, cartilaginous spine of a neonate or a small child to correct a putative chiropractic subluxation should be regarded as dangerous and unnecessary. Referral of a child to a chiropractor for such treatment should not be considered lest a bad outcome harms the child or leads to a charge of negligence or malpractice.

Changes in Manipulative Peak Force Modulation and Time to Peak Thrust among First-Year Chiropractic Students Following a 12-Week Detraining Period.

OBJECTIVE: The purpose of this study was to analyze differences in peak force modulation and time-to-peak thrust in posterior-to-anterior (PA) high-velocity-low-amplitude (HVLA) manipulations in first-year chiropractic students prior to and following a 12-week detraining period. METHODS: Chiropractic students (n=125) performed 2 thrusts prior to and following a 12-week detraining period: total peak force targets were 400 and 600 N, on a force-sensing table using a PA hand contact of the participant's choice (bilateral hypothenar, bilateral thenar, or cross bilateral). Force modulation was compared to defined target total peak force values of 600 and 400 N, and time-to-peak thrust was compared between data sets using 2-tailed paired t-tests. RESULTS: Total peak force for the 600 N intensity varied by 124.11 + 65.77 N during the pre-test and 123.29 + 61.43 N during the post-test compared to the defined target of 600 N (P = .90); total peak force for the 400 N intensity varied by 44.91 + 34.67 N during the pre-test and 44.60 + 32.63 N during the post-test compared to the defined target of 400 N (P = .57). Time-to-peak thrust for the 400 N total peak force was 137.094 + 42.47 milliseconds during the pre-test and 125.385 + 37.46 milliseconds during the post-test (P = .0004); time-to-peak thrust for the 600 N total peak force was 136.835 + 40.48 milliseconds during the pre-test and 125.385 + 33.78 milliseconds during the post-test (P = .03). CONCLUSIONS: The results indicate no drop-off in the ability to modulate force for either thrust intensity, but did indicate a statistically significant change in time-to-peak thrust for the 400 N total peak force thrust intensity in first-year chiropractic students following a 12-week detraining period.

Best Practices for Chiropractic Care of Children: A Consensus Update.

OBJECTIVE: Chiropractic care is the most common complementary and integrative medicine practice used by children in the United States, and it is used frequently by children internationally as well. The purpose of this project was to update the 2009 recommendations on best practices for chiropractic care of children. METHODS: A formal consensus process was completed based on the existing recommendations and informed by the results of a systematic review of relevant literature from January 2009 through March 2015. The primary search question for the systematic review was, "What is the effectiveness of chiropractic care, including spinal manipulation, for conditions experienced by children (<18 years of age)?" A secondary search question was, "What are the adverse events associated with chiropractic care including spinal manipulation among children (<18 years of age)?" The consensus process was conducted electronically, by e-mail, using a multidisciplinary Delphi panel of 29 experts from 5 countries and using the RAND Corporation/University of California, Los Angeles, consensus methodology. RESULTS: Only 2 statements from the previous set of recommendations did not reach 80% consensus on the first round, and revised versions of both were agreed upon in a second round. CONCLUSIONS: All of the seed statements in this best practices document achieved a high level of consensus and thus represent a general framework for what constitutes an evidence-based and reasonable approach to the chiropractic management of infants, children, and adolescents.

Characteristics of US Adults Who Have Positive and Negative Perceptions of Doctors of Chiropractic and Chiropractic Care.

OBJECTIVE: The purpose of this study was to compare characteristics, likelihood to use, and actual use of chiropractic care for US survey respondents with positive and negative perceptions of doctors of chiropractic (DCs) and chiropractic care. METHODS: From a 2015 nationally representative survey of 5422 adults (response rate, 29%), we used respondents' answers to identify those with positive and negative perceptions of DCs or chiropractic care. We used the χ(2) test to compare other survey responses for these groups. RESULTS: Positive perceptions of DCs were more common than those for chiropractic care, whereas negative perceptions of chiropractic care were more common than those for DCs. Respondents with negative perceptions of DCs or chiropractic care were less likely to know whether chiropractic care was covered by their insurance, more likely to want to see a medical doctor first if they were experiencing neck or back pain, less likely to indicate that they would see a DC for neck or back pain, and less likely to have ever seen a DC as a patient, particularly in the recent past. Positive perceptions of chiropractic care and negative perceptions of DCs appear to have greater influence on DC utilization rates than their converses. CONCLUSION: We found that US adults generally perceive DCs in a positive manner but that a relatively high proportion has negative perceptions of chiropractic care, particularly the costs and number of visits required by such care. Characteristics of respondents with positive and negative perceptions were similar, but those with positive perceptions were more likely to plan to use-and to have already received-chiropractic care.

OVERCOMING BARRIERS To DIVERSITY IN CHIROPRACTIC PATIENT AND PRACTITIONER POPULATIONS: A COMMENTARY.

Increasing the diversity of practitioner and patient populations has been identified as a worthy goal in the chiropractic profession, which has predominantly white male practitioners and white female patients in the USA. Toward that end, 'diversity' has been the topic of several papers and was the theme of a 2012 conference of chiropractic educators. However, generally just the microcosm of the interactions of practitioners with patients or teachers with students has been discussed. The macrocosm of larger societal issues and government policies has not been broached. Examples of issues and policies that affect diversity within a profession include portrayals of, and value judgements on diversity by the media and politicians, as well as public funding for healthcare and education. Diversity was defined in this paper to mean differences in race, sex, sexual orientation, economic status, ethnicity, religion and other life circumstances in a population. The purpose of this paper is to raise awareness of evidence that social issues and government policy affect the diversity of practitioners and patients, and to suggest that the barriers to diversity present in these realms be addressed with a cogent, profession-wide effort in order to help increase the diversity of people involved with chiropractic.

Consensus process to develop a best-practice document on the role of chiropractic care in health promotion, disease prevention, and wellness.

OBJECTIVE: The purposes of this project were to develop consensus definitions for a set of best practices that doctors of chiropractic may use for promoting health and wellness and preventing disease and to describe the appropriate components and procedures for these practices. METHODS: A multidisciplinary steering committee of 10 health care professionals developed seed statements based on their clinical experience and relevant literature. A Delphi consensus process was conducted from January to July 2011, following the RAND methodology. Consensus was reached when at least 80% of the panelists were in agreement. There were 44 Delphi panelists (36 doctors of chiropractic, 6 doctors of philosophy, 1 doctor of naturopathy, 1 registered nurse). RESULTS: The statements developed defined the terms and practices for chiropractic care to promote health and wellness and prevent disease. CONCLUSION: This document describes the procedures and features of wellness care that represent a reasonable approach to wellness care and disease prevention in chiropractic clinical practice. This living document provides a general framework for an evidence-based approach to chiropractic wellness care.

Practice analysis of chiropractic radiology: identifying items for part I of the clinical competency examination.

OBJECTIVE: The purpose of this study was to describe the current scope of practice of chiropractic radiologists by identifying frequent tasks conducted as well as those conditions most often seen and those that present the greatest risk of harm to patients. METHODS: A mixed-methods approach was used. An online survey was conducted with 91 diplomates listed with the American Chiropractic Board of Radiology. Participants rated the frequency of tasks they perform and conditions they see on a 5-point scale from "never" to "daily." They also rated the level of risk each condition presents to patients on a 5-point scale from "no risk" to "severe risk." Frequency and risk ratings were then presented in rank order to 22 subject matter experts at 3 focus groups. RESULTS: The most frequent task reported was writing radiology reports (mean [SD], 4.29 [1.58]). Ratings of the frequency of conditions seen in practice and the risk they present to patients were ranked from the highest to lowest for frequency and risk separately. The most frequent conditions seen were reportedly those with structural or joint derangement; the highest risk conditions seen are those that are systemic. Focus group members recommended that some conditions receive higher rankings and that certain conditions be recategorized for future practice analyses. CONCLUSIONS: This study helps to define the current scope of practice of chiropractic radiologists and identify frequent tasks and conditions. These results inform the development of a new test outline for Part I of the chiropractic radiology certification examination to ensure that examinees are tested on the most important conditions chiropractic radiologists see in practice.

A survey of wellness management strategies used by Canadian doctors of chiropractic.

OBJECTIVE: The purpose of this study was to investigate if Canadian doctors of chiropractic consider using wellness strategies after functional recovery in acute and chronic conditions. This study also attempted to determine if there is a difference in the use of wellness management strategies between broad and narrow scope practitioners. METHODS: Forty-one practicing, licensed chiropractors were recruited to complete an interview survey regarding 2 mock clinical case presentations. Interviews were recorded, and influential words or word pairings were identified. Investigators formulated criteria to divide practitioners into broad scope (mixers) and narrow scope (straights). Data were analyzed using Crawdad Analysis Software (version 1.2). RESULTS: All subjects indicated that they would provide information regarding public health and wellness strategies to a patient after functional resolution of the presenting chronic or acute complaints. The responses of broad scope (mixer) chiropractors appeared to be focused on the patient specifically, whereas narrow scope (straight) responses appeared to be more varied when analyzed for noun and noun-pair influence. CONCLUSION: This study of practicing, licensed Canadian chiropractors suggests that wellness strategies may be commonly considered in practice. All subjects in this study reported a number of strategies to educate patients regarding wellness after functional recovery of a complaint.

Chiropractic in North America: toward a strategic plan for professional renewal--outcomes from the 2006 Chiropractic Strategic Planning Conference.

OBJECTIVE: This report describes the process, participation, and recommendations of a set of consensus conferences on strategy for professional growth that emphasized elements of public trust and alignment between the chiropractic profession and its stakeholders. METHODS: In February and August 2006, an invitational group of leaders in the chiropractic profession convened an ad hoc Chiropractic Strategic Planning Conference. Public notice was given and support solicited through the Foundation of Chiropractic Education and Research. A series of international and interdisciplinary speakers gave presentations on the shifting of external social dynamics and medical culture, illuminating opportunities for the profession to extend its privilege and service. A systematic round-robin discussion was followed by group breakout sessions to develop recommendations on priorities for the profession to respond to challenges and opportunities. Recommendations were reviewed by the group as a whole and voted to consensus requiring more than 70% agreement. RESULTS: Participants determined a series of recommendations within 5 key domains for improving health professions practice: education, research, regulation, workplace, and leadership. CONCLUSION: The action steps proposed by the Strategic Planning Committee are first steps to provide better service to the public while making use of the inherent strengths of the profession.