Are Councils on Chiropractic Education expectations of chiropractic graduates changing for the better: a comparison of similarities and differences of the graduate competencies of the Chiropractic Council on Education-Australasia from 2009 to 2017.

BACKGROUND: The Council on Chiropractic Education Australasia (CCE-A) is tasked with assessment and accreditation of chiropractic programs (CPs) in the Australasian community. To achieve this process the CCE-A has developed educational standards and graduate competencies which include minimum expectations of graduates prior to entry into the workforce. We sought to explore if these are changing overtime, and if so are these changes for the better. METHOD: The CCE-A 2009 and 2017 Competency Standards were located and downloaded. The competencies were placed into tables for a comparative analyses in a systematic manner to enable the identification of similarities and differences. In addition, word counts were conducted for the most commonly occurring words and this took place in December 2019. RESULTS: The 2017 competency standards were over three times smaller than the previous standards 2009 standards. More similarities than differences between the old and the new standards were found. There were 18 additions to the 2017 graduate competencies with many that were in unison with contemporary aspects of healthcare such as patient centred-care, respect for practitioner-patient boundaries and patient sexual orientation, transitioning patients to self-management, and consideration of improving lifestyle options. Some competencies were not bought forward to the new standards and included, among others, students being competent in screening for mental health conditions, an expectation to discuss cost of care, re-evaluating and monitoring patients at each visit, and knowing when to discharge patients. The competencies continued to be silent on known issues within the chiropractic profession of a lack of a definition for chiropractic that would inform scope of practice and the presence of vitalism within CPs. CONCLUSION: There have been positive changes which reflect contemporary mainstream health care standards between CCE-A graduate competency revisions. The absence of a clear definition of chiropractic and its attendant scope of practice as well as continued silence on vitalism reflect known issues within the chiropractic profession. Recommendations are made for future accreditation standards to inform the required competencies and aid the integration of chiropractic into the broader health care community.

Characteristics of chiropractors who manage people aged 65 and older: A nationally representative sample of 1903 chiropractors.

OBJECTIVE: To examine the prevalence and profile of chiropractors who frequently manage people aged 65 years and older. METHODS: A national cross-sectional survey collected practitioner characteristics, practice settings and clinical management characteristics. Multiple logistic regression was conducted on 1903 chiropractors to determine the factors associated with the frequent treatment of people 65 years and older. RESULTS: In total, 73.5% of participants report "often" treating those aged 65 years and older. These chiropractors were associated with treating degenerative spine conditions (OR [odds ratio] 2.25; 95% [confidence interval] CI 1.72-2.94), working in a non-urban area (OR 1.85; 95% CI 1.35-2.54), treating low back pain (referred/radicular) (OR 1.74; 95% CI 1.26-2.40) and lower limb musculoskeletal disorders (OR 1.50; 95% CI 1.15-1.96). CONCLUSIONS: The majority of chiropractors report often providing treatment to older people. Our findings call for more research to better understand older patient complaints that are common to chiropractic practice and the care provided by chiropractors for this patient group.

Imaging use for low back pain by Ontario primary care clinicians: protocol for a mixed methods study - the Back ON study.

BACKGROUND: At any one time, one in every five Canadians has low back pain (LBP), and LBP is one of the most common health problems in primary care. Guidelines recommend that imaging not be routinely performed in patients presenting with LBP without signs or symptoms indicating a potential pathological cause. Yet imaging rates remain high for many patients who present without such indications. Inappropriate imaging can lead to inappropriate treatments, results in worse health outcomes and causes harm from unnecessary radiation. There is a need to understand the extent of, and factors contributing to, inappropriate imaging for LBP, and to develop effective strategies that target modifiable barriers and facilitators. The primary study objectives are to determine: 1) The rate of, and factors associated with, inappropriate lumbar spine imaging (x-ray, CT scan and MRI) for people with non-specific LBP presenting to primary care clinicians in Ontario; 2) The barriers and facilitators to reduce inappropriate imaging for LBP in primary care settings. METHODS: The project will comprise an inception cohort study and a concurrent qualitative study. For the cohort study, we will recruit 175 primary care clinicians (50 each from physiotherapy and chiropractic; 75 from family medicine), and 3750 patients with a new episode of LBP who present to these clinicians. Clinicians will collect data in the clinic, and each participant will be tracked for 12 months using Ontario health administrative and self-reported data to measure diagnostic imaging use and other health outcomes. We will assess characteristics of the clinicians, patients and encounters to identify variables associated with inappropriate imaging. In the qualitative study we will conduct in-depth interviews with primary care clinicians and patients. DISCUSSION: This will be the first Canadian study to accurately document the extent of the overuse of imaging for LBP, and the first worldwide to include data from the main healthcare professions offering primary care for people with LBP. This study will provide robust information about rates of inappropriate imaging for LBP, along with factors associated with, and an understanding of, potential reasons for inappropriate imaging.

Leadership and capacity building in international chiropractic research: introducing the chiropractic academy for research leadership (CARL).

In an evidence-based health care environment, healthcare professions require a sustainable research culture to remain relevant. At present however, there is not a mature research culture across the chiropractic profession largely due to deficiencies in research capacity and leadership, which may be caused by a lack of chiropractic teaching programs in major universities. As a response to this challenge the Chiropractic Academy for Research Leadership, CARL, was created with the aim of develop a global network of successful early-career chiropractic researchers under the mentorship of three successful senior academics from Australia, Canada, and Denmark. The program centres upon an annual week-long program residential that rotates continental locations over the first three-year cycle and between residentials the CARL fellows work on self-initiated research and leadership initiatives. Through a competivite application process, the first cohort was selected and consists of 13 early career researchers from five professions in seven countries who represent diverse areas of interests of high relevance for chiropractic. The first residential was held in Odense, Denmark, with the second being planned in April 2018 in Edmonton, Canada, and the final residential to be held in Sydney, Australia in 2019.

The schism in chiropractic through the eyes of a 1st year chiropractic student.

Since its inception, the chiropractic profession has been divided along ideological fault lines. These divisions have led to a profession wide schism, which has limited mainstream acceptance, utilisation, social authority and integration. The authors explore the historical origins of this schism, taking time to consider historical context, religiosity, perpetuating factors, logical fallacies and siege mentality. Evidence is then provided for a way forward, based on the positioning of chiropractors as mainstream partners in health care.

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.

Patient characteristics in low back pain subgroups based on an existing classification system. A descriptive cohort study in chiropractic practice.

Sub-grouping of low back pain (LBP) is believed to improve prediction of prognosis and treatment effects. The objectives of this study were: (1) to examine whether chiropractic patients could be sub-grouped according to an existing pathoanatomically-based classification system, (2) to describe patient characteristics within each subgroup, and (3) to determine the proportion of patients in whom clinicians considered the classification to be unchanged after approximately 10 days. A cohort of 923 LBP patients was included during their first consultation. Patients completed an extensive questionnaire and were examined according to a standardised protocol. Based on the clinical examination, patients were classified into diagnostic subgroups. After approximately 10 days, chiropractors reported whether they considered the subgroup had changed. The most frequent subgroups were reducible and partly reducible disc syndromes followed by facet joint pain, dysfunction and sacroiliac (SI)-joint pain. Classification was inconclusive in 5% of the patients. Differences in pain, activity limitation, and psychological factors were small across subgroups. Within 10 days, 82% were reported to belong to the same subgroup as at the first visit. In conclusion, LBP patients could be classified according to a standardised protocol, and chiropractors considered most patient classifications to be unchanged within 10 days. Differences in patient characteristics between subgroups were very small, and the clinical relevance of the classification system should be investigated by testing its value as a prognostic factor or a treatment effect modifier. It is recommended that this classification system be combined with psychological and social factors if it is to be useful.

Advising people with back pain to take time off work: a survey examining the role of private musculoskeletal practitioners in the UK.

Research has demonstrated that health care practitioners' adherence to guidelines for managing low back pain (LBP) remain suboptimal in recommending work absence, but specific beliefs about their role in maintaining patients at work have not been adequately researched. We examined private musculoskeletal practitioners' (chiropractors, osteopaths, and physiotherapists) beliefs and reported clinical behaviours in reference to patients' work. A cross-sectional postal questionnaire of 900 musculoskeletal practitioners included the Attitudes to Back pain in musculoskeletal practitioners questionnaires, reported frequency of four work-related behaviours, and a new measure of practitioners' work-related beliefs. Data from 337 respondents (37%) were analysed. Eighty percent of respondents reported recommending work absence to patients with LBP sometimes, and 14% recommended a work absence often or always. Seventy percent of practitioners never visit the patient's workplace. Most practitioners report that they prescribe exercises that can be carried out at work. Physiotherapists visited the workplace more frequently and gave less sick leave certification than either of the other groups. They also regarded work as more beneficial and less of a threat to exacerbate patients' LBP. There were small but significant correlations between work-related beliefs and reported behaviours. Our study confirms that, in contrast to current guidelines, many practitioners believe that LBP necessitates work absence. Overall, practitioners perceived their role in returning patients to work as limited, and believed that direct contact with employers was beyond their remit. In the UK, physiotherapists appear to be better placed to liaise with work in terms of both their beliefs and activities.

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.

An independent review of NCCAM-funded studies of chiropractic.

To promote an independent and critical evaluation of 11 randomised clinical trials (RCTs) of chiropractic funded by the National Centre for Complementary and Alternative Medicine (NCCAM). Electronic searches were conducted to identify all relevant RCTs. Key data were extracted and the risk of bias of each study was determined. Ten RCTs were included, mostly related to chiropractic spinal manipulation for musculoskeletal problems. Their quality was frequently questionable. Several RCTs failed to report adverse effects and the majority was not described in sufficient detail to allow replication. The criticism repeatedly aimed at NCCAM seems justified, as far as their RCTs of chiropractic is concerned. It seems questionable whether such research is worthwhile.

Trends and predictors of publicly subsidized chiropractic service use among adults age 50+.

OBJECTIVES: This article examines trends in and predictors of publicly subsidized chiropractic use from 1991 to 2000, a decade characterized by health care system reforms throughout North America. SAMPLE: The sample included adults age 50+ who visited a publicly subsidized chiropractor in the Canadian province of British Columbia during the study period. DESIGN: Administrative claims data for chiropractic service use were drawn from the Medical Services Plan (MSP) Master file in the British Columbia Linked Health Data resource. The MSP Master file contains claims reported for every provincially insured medical service and supplementary health benefit including chiropractic visits. RESULTS: Joinpoint regression analyses demonstrate that while annual rates of chiropractic users did not change over the decade, visit rates decreased during this period. Predictors of a greater number of chiropractic visits include increasing age, female gender, urban residence, low to moderate income, and use of chiropractic services earlier in the decade. CONCLUSIONS: The trend toward decreasing visit rates over the 1990s both conflicts with and is consistent with findings from other North American chiropractic studies using similar time periods. Results indicating that low and moderate income and advancing age predict more frequent chiropractic service are novel. However, given that lower income and older individuals were exempted from chiropractic service limits during this period, these results suggest support for the responsive nature of chiropractic use to financial barriers.

The effectiveness of a posted information package on the beliefs and behavior of musculoskeletal practitioners: the UK Chiropractors, Osteopaths, and Musculoskeletal Physiotherapists Low Back Pain ManagemENT (COMPLeMENT) randomized trial.

STUDY DESIGN: Randomized controlled trial. OBJECTIVE: To investigate the effect of a printed information package on the low back pain (LBP)-related beliefs and reported behavior of musculoskeletal practitioners (chiropractors, osteopaths, and musculoskeletal physiotherapists) across the United Kingdom. SUMMARY OF BACKGROUND DATA: A substantial proportion of musculoskeletal practitioners in United Kingdom does not follow current LBP guideline recommendations. METHODS: In total, 1758 practitioners were randomly allocated to either of the 2 study arms. One arm was posted a printed information package containing guideline recommendations for the management of LBP (n = 876) and the other received no intervention (n = 882). The primary outcome measure consisted of 3 "quality indicators" (activity, work, and bed-rest) relating to a vignette of a patient with LBP, in which responses were dichotomized into either "guideline-inconsistent" or "guideline-consistent." The secondary outcome was the practitioners' LBP-related beliefs, measured using the Health Care Providers Pain and Impairment Relationship Scale. Outcomes were measured at baseline and at 6 months. RESULTS: Follow-up at 6 months was 89%. The changes in reported behavior on the quality indicators were as follows: activity, odds ratio (OR) 1.29 (95% confidence interval, 1.03-1.61) and number needed to be treated (NNT), 19 (15-28); work, OR 1.35 (1.07-1.70) and NNT 19 (14-29); and bed-rest, OR 1.31 (0.97-1.76) and NNT 47 (33-103). The composite NNT for a change from guideline-inconsistent to guideline-consistent behavior on at least 1 of the 3 quality indicators was 10 (9-14). LBP-related beliefs were significantly improved in those who were sent the information package (P = 0.002), but only to a small degree (mean difference, 0.884 scale points; 95% confidence interval, 0.319-1.448). CONCLUSION: Printed educational material can shift LBP-related beliefs and reported behaviors of musculoskeletal practitioners, toward practice that is more in line with guideline recommendations.

The supply and demand of chiropractors in the United States from 1996 to 2005.

CONTEXT: The chiropractic profession is the largest, most established complementary and alternative medical (CAM) profession in the United States. The use of unconventional healthcare in the United States has increased in recent years, yet little is known about the market for specific CAM professions such as chiropractic. OBJECTIVE: To evaluate the market for US chiropractors between 1996 and 2005. DESIGN, SETTING, AND PARTICIPANTS: We conducted a descriptive study of the chiropractic profession from 1996 to 2005 using data from the Medical Expenditure Survey, the National Center for Education Statistics, and the US Bureau of Labor Statistics. MAIN OUTCOME MEASURES: The amount and proportion of outpatient healthcare expenditures on chiropractic care in the United States, total chiropractors, number of chiropractors per adult population (>18 years), graduates from chiropractic schools, and professional income of chiropractors. RESULTS: From 1996 to 2005 the proportion of outpatient US healthcare expenditures spent on chiropractic care increased from 2.15% to 3.26%. The total number of US chiropractors increased from 43 663 to 52 687 in 2004, but growth slowed between 2002 and 2004, resulting in a decrease in the number of chiropractors per 10000 US adults. Between academic years 1996 and 2001, chiropractic schools graduated about 3700 students each year; however, between 2001 and 2003, the annual number of chiropractic graduates decreased by 28%. Between 1998 and 2005, the inflation-adjusted median self-reported annual income of employed chiropractors fell from $76598 to $67200. CONCLUSION: From 1996 to 2005, relative expenditures on chiropractic care increased; however, the number of chiropractic graduates, the rate of growth of chiropractors, and the incomes of chiropractors have declined. Future research is needed to investigate why national expenditures on chiropractic care have increased despite an apparent decrease in the supply of US chiropractors.

Chiropractic and public health: current state and future vision.

This article provides an overview of primary chiropractic issues as they relate to public health. This collaborative summary documents the chiropractic profession's current involvement in public health, reflects on past barriers that may have prevented full participation within the public health movement, and summarizes the relationship of current chiropractic and public health topics. Topics discussed include how the chiropractic profession participates in preventive health services, health promotion, immunization, geriatrics, health care in a military environment, and interdisciplinary care.

Developmental issues in chiropractic: a South African practitioner and patient perspective.

OBJECTIVE: This study explores pertinent aspects of chiropractic practice in contemporary South Africa in terms of the domains of beliefs, philosophy, professional matters, and education. METHODS: Ten practitioners were purposively sampled. From these, 3 were used as gatekeepers to access 6 patients. Semistructured interviews were conducted with the 16 respondents, and computer-assisted thematic analysis was used to interpret data. RESULTS: The practitioners in this study distinguish between 2 main views of the chiropractic identity--the "technician" and "physician." The patients interviewed responded that the strengths of the chiropractic profession lie in its social desirability and its health care utility. Two factors seem important in endorsing chiropractic, namely, on the grounds of patient beliefs and philosophical views with respect to health care and the model of practice encountered in the chiropractor's office. However, some patients seem confused by the lack of health care system integration and consequently display uncertainty of the status the chiropractor can claim professionally and educationally. Practitioners portrayed a view, indicating that chiropractic cannot claim coherence in any of the 3 domains investigated. Issues such as the apparent lack of conceptual identity of chiropractic; the absence of a coherent, marketable model of chiropractic practice; and poor interprofessional relationships with mainstream health care stakeholders were observed. The issue of integrated public health care practices as part of the education process and the concomitant perceived lack of exposure especially to black South Africans emerged as interesting and pertinent developmental themes in the local context. CONCLUSIONS: The international discourse related to issues in the domains of philosophy, professionalism, and education and their effect on the practice of chiropractic seem reflected locally. The notion that an increased presence in the public sector might simultaneously increase social awareness and facilitate health care system integration requires further investigation.

Commentary: the National Workshop to Develop the Chiropractic Research Agenda: 10 years on, a new set of white papers.

This commentary reports on the advances that have occurred over the 10-year period since the first National Workshop to Develop the Chiropractic Research Agenda was held and introduces the second set of white papers that were produced as a result of the 10th annual Research Agenda Conference. Four working groups were convened to update the original 5 white papers that represented the most significant results from the first workshop in 1996. Each group was to review the first report, examine the action steps and recommendations that were published in each report to see how much had been completed in the past decade, and develop new action steps and recommendations for the future. Four new articles were developed, each updating and adding significant amounts of new research to the original versions. New action steps and recommendations will help move the profession forward into the future. Chiropractic scientists have worked diligently over the past decade to address the recommendations noted in the first set of white papers. Despite significant advances in knowledge and scientific capacity, the chiropractic profession is still confronted with a large number of research challenges.

Chiropractic clinical research: progress and recommendations.

OBJECTIVE: The purpose of this white paper is to help inform the chiropractic clinical research agenda with a focus on the United States. METHODS AND DISCUSSION: The recommendations and action items from 2 previous articles published in 1997 are discussed within the context of 3 broad topics: research culture, research infrastructure, and clinical research studies. Progress made toward the action items in these areas is summarized. A summary of findings is presented of the most influential clinical research studies during the past decade performed by or with major contributions by chiropractic investigators. In light of the current evidence and previous recommendations, new clinical research recommendations are proposed. CONCLUSIONS: Based on the assessment of the scientific literature and research currently underway, it is evident that members of the chiropractic research community have made important progress in becoming active players in the clinical research arena. During the past decade, the work of chiropractic researchers has contributed substantially to the amount and quality of the evidence for or against spinal manipulation in the management of low back pain, neck pain, headache, and other conditions.

History and overview of theories and methods of chiropractic: a counterpoint.

Spinal manipulation has been used for its therapeutic effects for at least 2500 years. Chiropractic as we know it today began a century ago in a simplistic manner but has developed into to a well-established profession with 33 colleges throughout the world. During the initial, bumpy years, many people thought it had little more value than a placebo. Nevertheless, there have always been satisfied recipients of chiropractic care during the years, and the profession slowly gained prominence--mostly by word of mouth. More recently, personal opinions based on isolated incidents have given way to the results of numerous clinical and basic science studies, primarily regarding low back pain. As of 2002, 43 randomized trials of spinal manipulation for low back pain had been published with 30 showing more improvement than with the comparison treatment, and none showing it to be less effective. Other studies have shown that chiropractic care compared with medical care is safer, costs no more and often costs much less, and has consistently greater patient satisfaction for treatment of similar conditions. Consequently, there is now better public and professional opinion of chiropractic with coverage by insurance companies and government agencies. That trend is likely to continue.

Chiropractic: history and overview of theories and methods.

Chiropractic is one of the most controversial and poorly defined healthcare professions with recognition and licensure in the United States. Chiropractic was started by D. D. Palmer, a magnetic healer who formulated the vertebral subluxation theory. The profession was developed by his son, B. J. Palmer. Although the definition of chiropractic as a method of correcting vertebral subluxations to restore and maintain health is questionable, spinal manipulation is of value in the treatment of some types of back pain. The chiropractic profession is still based on the vertebral subluxation theory, and has the confusing image of a back specialty capable of treating a broad scope of health problems. Despite opposition to use of spinal manipulation as a method of treating a broad scope of health problems (as opposed to the generally accepted use of manipulation in the treatment of back pain), chiropractors seek support as primary care providers in alternative medicine. It is essential to understand the theories, philosophies, and methods of chiropractic for an objective evaluation.