Force transmission between thoracic and cervical segments of the spine during prone-lying high-velocity low-amplitude spinal manipulation: A proof of principle for the concept of regional interdependence.

BACKGROUND: Regional interdependence is conceptually based on observations that applying manual therapy to a remote anatomical region has an effect in the area of the patient's primary complaint. The current model for regional interdependence depends on force transmissibility within the body. This investigation sought to determine transmissibility between forces applied to the thoracic spine during prone-lying high-velocity low-amplitude spinal manipulative therapy and the cervical spine. METHODS: A chiropractic treatment table was modified to allow (or disallow) translation of the headrest in the caudal-cephalad direction when unlocked (or locked). Prone-lying high-velocity low-amplitude spinal manipulative therapy was applied to the thoracic region of 9 healthy participants with the headrest in both configurations. Head and thorax kinematics and kinetics were measured at interfaces between participant and the external environment, which included the clinician's hands. Compressive forces at the cervicothoracic junction and angular kinematics of the cervical spine were derived. Ratios between the clinician-applied forces (input) and the cervical compressive force (output) were also determined. FINDINGS: The cervical spine extended during all high-velocity low-amplitude spinal manipulative therapy trials. Force input-to-output ratios exceeded 1 for high-velocity low-amplitude spinal manipulative therapy trials performed with the headrest in the locked configuration, which was greater than ratios for the unlocked configuration. INTERPRETATION: Forces imparted to thoracic spine during high-velocity low-amplitude spinal manipulative therapy were transmitted to the cervical spine, which provided a precursor for the regional interdependence model for manual therapy. Friction between the participant's face and the treatment table's head rest likely amplified cervical compressive forces.

Ultrasound Assessment of Abdominal Muscle Thickness in Women With and Without Low Back Pain During Pregnancy.

OBJECTIVE: The aim of this preliminary study was to determine the differences in abdominal musculature thickness, within 1 month of delivery, in women who experienced back pain during pregnancy compared with those who did not. METHODS: B-mode ultrasound imaging was used to measure abdominal muscle thickness on 76 postpartum participants who participated in a larger study; 47 women experienced back pain during pregnancy, and 29 did not. Participant data were stratified by group, and primary comparisons were based on these grouping across the abdominal muscles, including rectus abdominis (upper and lower fibers), external oblique, internal oblique, and transversus abdominis. Means and standard deviations were also used to set parameters for future studies. RESULTS: In the present study, there was no difference in any abdominal muscle thickness between groups. Women with low back pain were significantly shorter (165.19 ± 6.64 cm) than women who did not have from back pain during pregnancy (169.38 ± 7.58 cm). All other demographics, such as age, weight, and date tested postpartum, were not significantly different between groups. CONCLUSION: The results of this study showed no variation in abdominal muscle thickness in women who had back pain during pregnancy and those who did not.

Manipulation Peak Forces Across Spinal Regions for Children Using Mannequin Simulators.

OBJECTIVE: The purpose of this work was to create an exploratory database of manipulation treatment force variability as a function of the intent of an experienced clinician sub-specializing in the care of children to match treatment to childhood category. Data of this type are necessary for realistic planning of dose-response and safety studies on therapeutic benefit. METHODS: The project evaluated the transmitted peak forces of procedures applied to mannequins of different stature for younger and older children. Common procedures for the cervical, thoracic, and lumbar spine and sacroiliac joint were administered to estimate variability by a single experienced practitioner and educator in pediatric manipulation attempting to modulate for childhood category. Results described for peak components in the cardinal axes and for peak total forces were cataloged and compared with consensus estimates of force from the literature. RESULTS: Mean force values for both components and total force peaks monotonically increased with childhood category analogous to consensus expectations. However, a mismatch was observed between peak values measured and consensus predictions that ranged by a factor of 2 to 3.5, particularly in the upper categories. Quantitative data permit a first estimate of effect size for future clinical studies. CONCLUSIONS: The findings of this study indicate that recalibration of spinal manipulation performance of experienced clinicians toward arbitrary target values similar to consensus estimates is feasible. What is unclear from the literature or these results is the identity of legitimate target values that are both safe and clinically effective based on childhood categories in actual practice.

Procedure Selection and Patient Positioning Influence Spine Kinematics During High-Velocity, Low-Amplitude Spinal Manipulation Applied to the Low Back.

OBJECTIVES: This investigation compared indirect 3-dimensional angular kinematics (position, velocity, and acceleration) of the lumbar spine for 2 different high-velocity, low-amplitude (HVLA) spinal manipulation procedures (lumbar spinous pull or push), and altered initial patient lower limb posture. METHODS: Twenty-four participants underwent 6 HVLA procedures directed toward the presumed L4 vertebra, reflecting each combination of 2 variants of a spinal manipulation application technique (spinous pull and push) and 3 initial hip flexion angles (0°, 45°, and 90°) applied using a right lateral recumbent patient position. All contact forces and moments between the patient and the external environment, as well as 3-dimensional kinematics of the patient's pelvis and thorax, were recorded. Lumbar spine angular positions, velocities, and accelerations were analyzed within the preload and impulse stages of each HVLA trial. RESULTS: Lumbar spine left axial rotation was greater for the pull HVLA. The pull HVLA also generated a greater maximum (leftward) and lower minimum (rightward) axial rotation velocity and deceleration and greater leftward and rightward lateral bend velocities, acceleration, and deceleration components. Not flexing the hip produced the greatest amount of extension, as well as the lowest axial rotation and maximum axial rotation acceleration during the impulse. CONCLUSIONS: This investigation provides basic kinematic information for clinicians to understand the similarities and differences between 2 HVLA side-lying manipulations in the lumbar spine. Use of these findings and novel technology can drive future research initiatives that can both affect clinical decision making and influence teaching environments surrounding spinal manipulative therapy skill acquisition.

Core and Complementary Chiropractic: Lowering Barriers to Patient Utilization of Services.

OBJECTIVE: The use of chiropractic services has stalled while interest in accessing manipulation services is rising. The purpose of this paper is to consider this dilemma in the context of the dynamics of professional socialization, surveys of public attitudes, and a potential strategic action. DISCUSSION: This is a reflection work grounded in the literature on professional socialization and the attitudes held regarding chiropractic in modern society, to include its members, and in original data on training programs. Data were interpreted on the background of the authors' cross-cultural experiences spanning patient care, research, education, and interprofessional collaboration. Recommendation on a strategic action to counter barriers in patient referrals was synthesized. Professional socialization is the process by which society enables professional privilege. Illustration of typical and divergent professional socialization models emerged that explain cognitive dissonance toward the profession. Questions of trust are commensurate with the experiences during patient encounters rather than with a common identity for the profession. Diversity among encounters perpetuates the uncertainty that affects referral sources. Commonality as an anchor for consistent professional identity and socialization through the content of core chiropractic, defined by training and practice, offers a means to offset uncertainty. Complementary chiropractic, analogous to complementary medicine, provides an outlet under professional socialization for the interests to explore additional methods of care. CONCLUSION: The practice workplace is an effective lever for altering barriers to the use of services. Clarifying rhetoric through conceptualization of core and complementary practices simplifies the socialization dynamic. Further, it takes advantage of accepted cultural semantics in meaningful analogy while continuing to empower practical diversity in care delivery in response to evolving scientific evidence.

Development of a Linked Segment Model to Derive Patient Low Back Reaction Forces and Moments During High-Velocity Low-Amplitude Spinal Manipulation.

OBJECTIVE: The purpose of this paper is to present the experimental setup, the development, and implementation of a new scalable model capable of efficiently handling data required to determine low back kinetics during high-velocity low-amplitude spinal manipulation (HVLA-SM). METHODS: The model was implemented in Visual3D software. All contact forces and moments between the patient and the external environment (2 clinician hand contact forces, 1 contact force between the patient and the treatment table), the patient upper body kinematics, and inertial properties were used as input. Spine kinetics and kinematics were determined from a single HVLA-SM applied to one healthy participant in a right side-lying posture to demonstrate the model's utility. The net applied force was used to separate the spine kinetic and kinematic time-series data from the HVLA-SM into preload as well as early and late impulse phases. RESULTS: Time-series data obtained from the HVLA-SM procedure showed that the participant's spine underwent left axial rotation, combined with extension, and a reduction in left lateral bending during the procedure. All components of the reaction force, as well as the axial twist and flexion/extension reaction moments demonstrated a sinusoidal pattern during the early and late impulse phases. During the early impulse phase, the participant's spine experienced a leftward axial twisting moment of 37.0 Nm followed by a rightward moment of -45.8 Nm. The lateral bend reaction moment exhibited a bimodal pattern during the early and late impulse phases. CONCLUSION: This model was the first attempt to directly measure all contact forces acting on the participant/patient's upper body, and integrate them with spine kinematic data to determine patient low back reaction forces and moments during HVLA-SM in a side-lying posture. Advantages of this model include the brevity of data collection (<1 hour), and adaptability for different patient anthropometries and clinician-patient contacts.

Effects of Axial Torsion on Disc Height Distribution: An In Vivo Study.

OBJECTIVES: Axial rotation of the torso is commonly used during manipulation treatment of low back pain. Little is known about the effect of these positions on disc morphology. Rotation is a three-dimensional event that is inadequately represented with planar images in the clinic. True quantification of the intervertebral gap can be achieved with a disc height distribution. The objective of this study was to analyze disc height distribution patterns during torsion relevant to manipulation in vivo. METHODS: Eighty-one volunteers were computed tomography-scanned both in supine and in right 50° rotation positions. Virtual models of each intervertebral gap representing the disc were created with the inferior endplate of each "disc" set as the reference surface and separated into 5 anatomical zones: 4 peripheral and 1 central, corresponding to the footprint of the annulus fibrosus and nucleus pulposus, respectively. Whole-disc and individual anatomical zone disc height distributions were calculated in both positions and were compared against each other with analysis of variance, with significance set at P < .05. RESULTS: Mean neutral disc height was 7.32 mm (1.59 mm). With 50° rotation, a small but significant increase to 7.44 mm (1.52 mm) (P < .0002) was observed. The right side showed larger separation in most levels, except at L5/S1. The posterior and right zones increased in height upon axial rotation of the spine (P < .0001), whereas the left, anterior, and central decreased. CONCLUSIONS: This study quantified important tensile/compressive changes disc height during torsion. The implications of these mutually opposing changes on spinal manipulation are still unknown.

Effect of Interactive Neurostimulation Therapy on Inflammatory Response in Patients With Chronic and Recurrent Mechanical Neck Pain.

OBJECTIVE: The purpose of this study is to evaluate the effect of treatment with a novel noninvasive interactive neurostimulation device (InterX5000) on the production of inflammatory biomarkers in chronic and recurrent mechanical neck pain (NP) syndrome. METHODS: This study represents pilot biological data from a randomized controlled clinical trial. Twenty-five NP patients and 14 asymptomatic subjects included for baseline comparison only completed the study. The patients received 6 InterX5000 or placebo treatments within 2 weeks, and pretreatment and post-treatment blood samples were collected for in vitro determination of biomarker production. Whole blood cell cultures were activated by lipopolysaccharide or by the combination of lipopolysaccharide and phytohemagglutinin for 24 to 48 hours. The levels of tumor necrosis factor α (TNFα) and its soluble type II receptor (sTNFR II), interleukin (IL) 1, IL-1 receptor antagonist (IL-1RA), IL-6, IL-10, and monocyte chemotactic protein (CCL2/MCP-1) were determined by specific immunoassays. RESULTS: Compared with asymptomatic subjects, baseline production levels of all proinflammatory mediators (TNFα, IL-1ß, IL-6, and CCL2/MCP-1) were significantly augmented or trended higher (P = .000-.008) in patients with NP. Of the anti-inflammatory markers, only IL-1RA was significantly elevated (P = .004). The increase in IL-10 and tumor necrosis factor receptor II levels did not reach statistical significance. Neither InterX5000 nor placebo therapy had any significant effect on the production of the inflammatory mediators over the study period. CONCLUSION: This investigation determined that inflammatory cytokine pathways are activated in NP patients but found no evidence that a short course of InterX5000 treatment normalized the production of inflammatory biomarkers.

Ultrasound Assessment of Abdominal Muscle Thickness in Postpartum vs Nulliparous Women.

OBJECTIVE: The purpose of this study was to determine the effect size in measurable change of abdominal musculature morphology using ultrasonography in postpartum women within 1 month of a healthy, vaginal delivery. METHODS: One hundred fifty-six participants were recruited for this study. B-mode ultrasound imaging was used to measure abdominal muscle thickness on 80 nulliparous women and 76 mothers who had delivered within the past 4 weeks. Measures were taken for the upper and lower rectus abdominus, external and internal obliques, and transversus abdominus at rest. RESULTS: Statistically significant differences were found in the thickness of the rectus abdominus muscle at both sites; upper (P < .0001) and lower (P < .0001) as well as the internal oblique (P < .0001). All 3 muscles were thinner in postpartum participants (8.29 ± 1.83 mm, 8.89 ± 2.29 mm, and 7.06 ± 1.82 mm, respectively) within the first month of delivery than in controls (10.82 ± 1.93 mm, 11.13 ± 2.38 mm, and 8.36 ± 1.87 mm, respectively). Large effect sizes were found for the influence of pregnancy on the rectus muscle segments (1.35 for the upper rectus abdominus and 1.00 for the lower rectus abdominus) and a medium effect size for the internal oblique (0.71). No significant differences were observed in the remaining 2 muscles. CONCLUSION: This study showed that there are differences in morphology of the abdominal muscles in pregnant women vs nonpregnant controls. The large effect sizes reported may provide the basis for future studies examining relationships between morphology, functional change, and back pain during pregnancy.

Consistency and malleability of manipulation performance in experienced clinicians: a pre-post experimental design.

OBJECTIVE: The purpose of this study was to sample the stability of spinal manipulation performance in peak impulse force development over time and the ability of clinicians to adapt to arbitrary target levels with short-duration training. METHODS: A pre-post experimental design was used. Human analog mannequins provided standardized simulation for performance measures. A convenience sample was recruited consisting of 41 local doctors of chiropractic with 5 years of active clinical practice experience. Thoracic impulse force was measured among clinicians at baseline, after 4 months at pretraining, and again posttraining. Intraclass correlation coefficient values and within-subject variability defined consistency. Malleability was measured by reduction of error (paired t tests) in achieving arbitrary targeted levels of force development normalized to the individual's typical performance. RESULTS: No difference was observed in subgroup vs baseline group characteristics. Good consistency was observed in force-time profiles (0.55 ≤ intraclass correlation coefficient ≤ 0.75) for force parameters over the 4-month interval. With short intervals of focused training, error rates in force delivery were reduced by 23% to 45%, depending on target. Within-subject variability was 1/3 to 1/2 that of between-subject variability. Load increases were directly related to rate of loading. CONCLUSION: The findings of this study show that recalibration of spinal manipulation performance of experienced clinicians toward arbitrary target values in the thoracic spine is feasible. This study found that experienced clinicians are internally consistent in performance of procedures under standardized conditions and that focused training may help clinicians learn to modulate procedure characteristics.

Staging the use of teaching aids in the development of manipulation skill.

Skill development in manual therapies is influenced by a number of factors. The effects of the training program organization, mentor coaching, feedback in various forms, and electromechanical training aids are factors that have been studied. A significant gap exists in understanding when teaching aids might be most effective within a defined curriculum structure. This project used the ratio of instructional theory and laboratory practice to define the learning context. An electromechanical training aid (Dynadjust™) was introduced at different stages (year 2 and year 4) of training for high-velocity, low-amplitude (HVLA) manipulation. Learners were assigned to either the Aid group or the NoAid group. Independent assessment of skill was evaluated before and after 6 weeks by means of recording force-time profiles of HVLA performance. Repeated measures analysis of variance (ANOVA) evaluated change scores in the force amplitude and rate of rise in force. Program features were dominated by a low ratio of laboratory practice to didactic foundational education components. Use of the aid was not associated with any measurable gains for participants when used in year 2. Later participation in year 4 suggested enhanced development in rate of rise for force (p < 0.0597) and for peak force (p < 0.0303). Careful attention should be given to the sequencing of content and laboratory work in designing curricula for training programs. For programs using lower ratios of laboratory contact hours, teaching aids to augment practice may result in better performance gains when introduced later than if added early in the curriculum.

Changes in vertebral artery blood flow following various head positions and cervical spine manipulation.

OBJECTIVE: The objective of the study was to investigate the cerebrovascular hemodynamic response of cervical spine positions including rotation and cervical spine manipulation in vivo using magnetic resonance imaging technology on the vertebral artery (VA). METHODS: This pilot study was conducted as a blinded examiner cohort with 4 randomized clinical tasks. Ten healthy male participants aged 24 to 30 years (mean, 26.8 years) volunteered to participate in the study. None of the participants had a history of disabling neck, arm, or headache pain within the last 6 months. They did not have any current or history of neurologic symptoms. In a neutral head position, physiologic measures of VA blood flow and velocity at the C1-2 spinal level were obtained using phase-contrast magnetic resonance imaging after 3 different head positions and a chiropractic upper cervical spinal manipulation. A total of 30 flow-encoded phase-contrast images were collected over the cardiac cycle, in each of the 4 conditions, and were used to provide a blood flow profile for one complete cardiac cycle. Differences between flow (in milliliters per second) and velocity (in centimeters per second) variables were evaluated using repeated-measures analysis of variance. RESULTS: The side-to-side difference between ipsilateral and contralateral VA velocities was not significant for either velocities (P = .14) or flows (P = .19) throughout the conditions. There were no other interactions or trends toward a difference for any of the other blood flow or velocity variables. CONCLUSIONS: There were no significant changes in blood flow or velocity in the vertebral arteries of healthy young male adults after various head positions and cervical spine manipulations.

Retention of blinding at follow-up in a randomized clinical study using a sham-control cervical manipulation procedure for neck pain: secondary analyses from a randomized clinical study.

OBJECTIVE: Participants in clinical trials of spinal manipulation have not been rigorously blinded to group assignment. This study reports on secondary analyses of the retention of participant blinding beyond the immediate posttreatment time frame following a single-session, randomized clinical study. A novel control cervical manipulation procedure that has previously been shown to be therapeutically inert was contrasted with a typical manipulation procedure. METHODS: A randomized clinical study of a single session of typical vs sham-control manipulation in patients with chronic neck pain was conducted. Findings of self-reported group registration at 24 to 48 hours posttreatment were computed. The Blinding Index (BI) of Bang et al was then applied to both the immediate and post-24- to 48-hour results. RESULTS: Twenty-four to 48 hours after treatment, 94% and 22% of participants in the typical and control groups, respectively, correctly identified their group assignment. When analyzed with the BI of Bang et al, the immediate posttreatment BI for the group receiving a typical manipulation was 0.22 (95% confidence interval [CI], -0.03 to 0.47); for the group receiving a control manipulation, it was 0.19 (95% CI, -0.06 to 0.43). The BI at post-24 hours was as follows: typical = 0.75 (95% CI, 0.59-0.91) and control = -0.34 (95% CI, -0.58 to -0.11). CONCLUSIONS: This study found that the novel sham-control cervical manipulation procedure may be effective in blinding sham group allocation up to 48 hours posttreatment. It appears that, at 48 hours posttreatment, the modified form of the typical cervical manipulation was not. The sham-control procedure appears to be a promising procedure for future clinical trials.

Review of methods used by chiropractors to determine the site for applying manipulation.

BACKGROUND: With the development of increasing evidence for the use of manipulation in the management of musculoskeletal conditions, there is growing interest in identifying the appropriate indications for care. Recently, attempts have been made to develop clinical prediction rules, however the validity of these clinical prediction rules remains unclear and their impact on care delivery has yet to be established. The current study was designed to evaluate the literature on the validity and reliability of the more common methods used by doctors of chiropractic to inform the choice of the site at which to apply spinal manipulation. METHODS: Structured searches were conducted in Medline, PubMed, CINAHL and ICL, supported by hand searches of archives, to identify studies of the diagnostic reliability and validity of common methods used to identify the site of treatment application. To be included, studies were to present original data from studies of human subjects and be designed to address the region or location of care delivery. Only English language manuscripts from peer-reviewed journals were included. The quality of evidence was ranked using QUADAS for validity and QAREL for reliability, as appropriate. Data were extracted and synthesized, and were evaluated in terms of strength of evidence and the degree to which the evidence was favourable for clinical use of the method under investigation. RESULTS: A total of 2594 titles were screened from which 201 articles met all inclusion criteria. The spectrum of manuscript quality was quite broad, as was the degree to which the evidence favoured clinical application of the diagnostic methods reviewed. The most convincing favourable evidence was for methods which confirmed or provoked pain at a specific spinal segmental level or region. There was also high quality evidence supporting the use, with limitations, of static and motion palpation, and measures of leg length inequality. Evidence of mixed quality supported the use, with limitations, of postural evaluation. The evidence was unclear on the applicability of measures of stiffness and the use of spinal x-rays. The evidence was of mixed quality, but unfavourable for the use of manual muscle testing, skin conductance, surface electromyography and skin temperature measurement. CONCLUSIONS: A considerable range of methods is in use for determining where in the spine to administer spinal manipulation. The currently published evidence falls across a spectrum ranging from strongly favourable to strongly unfavourable in regard to using these methods. In general, the stronger and more favourable evidence is for those procedures which take a direct measure of the presumptive site of care- methods involving pain provocation upon palpation or localized tissue examination. Procedures which involve some indirect assessment for identifying the manipulable lesion of the spine-such as skin conductance or thermography-tend not to be supported by the available evidence.

Elevated production of inflammatory mediators including nociceptive chemokines in patients with neck pain: a cross-sectional evaluation.

OBJECTIVE: This study investigated whether the production of inflammatory mediators and chemotactic cytokines (chemokines) is altered in patients with chronic and recurrent neck pain (NP). METHODS: Cross-sectional data evaluating blood and serum samples were obtained from 27 NP patients and 13 asymptomatic (control) subjects recruited from a chiropractic outpatient clinic. Cell cultures were activated by lipopolysaccharide (LPS) and phytoheamagglutinin for 24 to 48 hours. The levels of tumor necrosis factor α (TNF-α), monocyte chemotactic protein 1, also known as CCL2 (CCL2/MCP-1), and macrophage inflammatory protein 1α or CCL3 (CCL3/MIP-1α) were determined by specific immunoassays. Serum levels of nitric oxide metabolites were evaluated simultaneously, in vanadium III-reduced samples, by Griess reaction. RESULTS: Low levels of constitutive (spontaneous) TNF-α production were present in 7 of the 27 cultures from patients with NP. Both LPS-induced TNF-α production and inducer (LPS/phytoheamagglutin)-stimulated production of CCL2 were significantly elevated (P = .00) in patients compared with controls. In patients, the constitutive synthesis of CCL3 occurred significantly more frequently (P = .00) and ranged from 30 to more than 2000 pg/mL. Finally, serum levels of nitric oxide were significantly elevated (P = .00) in NP patients. CONCLUSIONS: Production of inflammatory mediators was consistently elevated in NP patients in this study, both in vitro and in vivo, and activation of inflammatory pathways was accompanied by up-regulation of CC chemokine synthesis. This suggests that, in NP patients, CC chemokines may be involved in regulation of local inflammatory response through recruitment of immune cells to the inflamed tissue and exert pronociceptive effects.

Maturation in rate of high-velocity, low-amplitude force development.

OBJECTIVES: The purpose of this study was to examine the maturation of force development during a thoracic high-velocity, low-amplitude displacement procedure at stages throughout chiropractic education. The hypothesis posed a natural development in rate of force directly related to the duration of experience. The analysis sought to define interrelationships between key characteristics within the procedure. METHODS: Fifty volunteers (17 women and 33 men) from a Canadian chiropractic college participated in this study. Participants were block randomized into 5 cohorts of 10 subjects, representing years 1 to 4 and graduates with more than 5 years of practice experience. Participants performed a hypothenar transverse push procedure on the upper thoracic spine, with the subjects lying on a force-sensing table. The average of 3 force-time profiles of the procedures was compared across cohorts using analysis of variance for differences between groups, and pairwise comparisons by Scheffé test, using Holms method for P value adjustment. RESULTS: Peak force, force rate, and rise time revealed strong differences based on cohort (P < .001). A natural maturation in high-velocity, low-amplitude force development occurs during training. Little change in peak force occurs in the first 2 years. The majority of development occurs in year 3, with tapering through year 4. A reciprocal coupling exists between peak force and force rate. CONCLUSIONS: Group means revealed statistically significant and monotonic increase in force rate, a decreased rise time, and decreased peak force during delivery of the therapeutic peak force. These differences paralleled growth in experience but with an asymptotic leveling of change between the fourth year of training and 5 years of clinical practice experience. This study showed a systematic maturation in performance associated with educational experience. The reciprocal coupling between rate of force development and peak force created a relatively stable impulse.

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.

What constitutes evidence for best practice?

The guiding principles, methods, and common factors that serve as the foundation for the Commission of the Council on Chiropractic Guidelines and Practice Parameters best practices initiative are discussed in the context of the chiropractic practice environment.

Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis.

OBJECTIVES: The purpose of this project was to review the literature for the use of spinal manipulation for low back pain (LBP). METHODS: A search strategy modified from the Cochrane Collaboration review for LBP was conducted through the following databases: PubMed, Mantis, and the Cochrane Database. Invitations to submit relevant articles were extended to the profession via widely distributed professional news and association media. The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. RESULTS: A total of 887 source documents were obtained. Search results were sorted into related topic groups as follows: randomized controlled trials (RCTs) of LBP and manipulation; randomized trials of other interventions for LBP; guidelines; systematic reviews and meta-analyses; basic science; diagnostic-related articles, methodology; cognitive therapy and psychosocial issues; cohort and outcome studies; and others. Each group was subdivided by topic so that team members received approximately equal numbers of articles from each group, chosen randomly for distribution. The team elected to limit consideration in this first iteration to guidelines, systematic reviews, meta-analyses, RCTs, and coh ort studies. This yielded a total of 12 guidelines, 64 RCTs, 13 systematic reviews/meta-analyses, and 11 cohort studies. CONCLUSIONS: As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence. There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.

Literature syntheses for the Council on Chiropractic Guidelines and Practice Parameters: methodology.

OBJECTIVE: The purpose of this project was to initiate an iterative process for systematic review of the literature involving a broad spectrum of individuals with experience across multiple domains (clinicians, educators, clinical scientists, and politically active) within the chiropractic profession. METHODS: The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence-based values for chiropractic care. Content and process-experienced team leaders were selected to manage 8 domains based on regional disorders: low back and related lower extremity conditions; neck pain, headache, and related upper extremity conditions; costovertebral and thoracic conditions; upper extremity disorders; lower extremity disorders; nonmusculoskeletal disorders; and subluxation. Team efforts in review, rating, and reporting of literature synthesis were guided, as best possible, by the widely accepted Appraisal of Guidelines for Research and Evaluation process. The main features included (1) review by a panel of experts; (2) detailed topic selection based on literature of most common conditions and procedures; (3) structured instruments for rating the quality of and results from the literature; (4) formal consensus process to adjudicate differences in professional opinion; and (5) wide stakeholder review by patients, professionals, policymakers, and third-party payers. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-2008) to allow for an open process and the broadest possible mechanism for stakeholder input. RESULTS: Reports on findings from this process are being published. The reports from each domain summarize methodological challenges and their unique content. CONCLUSIONS: Although all literature in health care is challenged by complex methodological issues that limit how the information may be generalized, the preponderance of evidence in any of the domains can be informative to the clinician as well as give guidance to new scientific efforts to improve the quality of care.