Improving adherence to acute low back pain guideline recommendations with chiropractors and physiotherapists: the ALIGN cluster randomised controlled trial.

BACKGROUND: Acute low back pain is a common condition, has high burden, and there are evidence-to-practice gaps in the chiropractic and physiotherapy setting for imaging and giving advice to stay active. The aim of this cluster randomised trial was to estimate the effects of a theory- and evidence-based implementation intervention to increase chiropractors' and physiotherapists' adherence to a guideline for acute low back pain compared with the comparator (passive dissemination of the guideline). In particular, the primary aim of the intervention was to reduce inappropriate imaging referral and improve patient low back pain outcomes, and to determine whether this intervention was cost-effective. METHODS: Physiotherapy and chiropractic practices in the state of Victoria, Australia, comprising at least one practising clinician who provided care to patients with acute low back pain, were invited to participate. Patients attending these practices were included if they had acute non-specific low back pain (duration less than 3 months), were 18 years of age or older, and were able to understand and read English. Practices were randomly assigned either to a tailored, multi-faceted intervention based on the guideline (interactive educational symposium plus academic detailing) or passive dissemination of the guideline (comparator). A statistician independent of the study team undertook stratified randomisation using computer-generated random numbers; four strata were defined by professional group and the rural or metropolitan location of the practice. Investigators not involved in intervention delivery were blinded to allocation. Primary outcomes were X-ray referral self-reported by clinicians using a checklist and patient low back pain-specific disability (at 3 months). RESULTS: A total of 104 practices (43 chiropractors, 85 physiotherapists; 755 patients) were assigned to the intervention and 106 practices (45 chiropractors, 97 physiotherapists; 603 patients) to the comparator; 449 patients were available for the patient-level primary outcome. There was no important difference in the odds of patients being referred for X-ray (adjusted (Adj) OR: 1.40; 95% CI 0.51, 3.87; Adj risk difference (RD): 0.01; 95% CI - 0.02, 0.04) or patient low back pain-specific disability (Adj mean difference: 0.37; 95% CI - 0.48, 1.21, scale 0-24). The intervention did lead to improvement for some key secondary outcomes, including giving advice to stay active (Adj OR: 1.96; 95% CI 1.20, 3.22; Adj RD: 0.10; 95% CI 0.01, 0.19) and intending to adhere to the guideline recommendations (e.g. intention to refer for X-ray: Adj OR: 0.27; 95% CI 0.17, 0.44; intention to give advice to stay active: Adj OR: 2.37; 95% CI 1.51, 3.74). CONCLUSIONS: Intervention group clinicians were more likely to give advice to stay active and to intend to adhere to the guideline recommendations about X-ray referral. The intervention did not change the primary study outcomes, with no important differences in X-ray referral and patient disability between groups, implying that hypothesised reductions in health service utilisation and/or productivity gains are unlikely to offset the direct costs of the intervention. We report these results with the caveat that we enrolled less patients into the trial than our determined sample size. We cannot recommend this intervention as a cost-effective use of resources. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12609001022257 . Retrospectively registered on 25 November 2009.

Australian chiropractic students' perceptions of education: validation of a questionnaire.

BACKGROUND: This study aimed to validate a questionnaire to address an absence of a measure to evaluate Australian chiropractic students' perceptions of the quality of chiropractic programs. METHOD: Potential relevant questionnaire items were selected from the Australian chiropractic accreditation standards. Chiropractic students rated these items for clarity and relevance, which resulted in a pilot questionnaire of 47 items. Principal components analysis was used to establish the structure of the scales. Finally, intra-class correlation coefficients were used to establish the scales' test-retest reliability. RESULTS: Thirty-four items were omitted resulting in the retention of 13 items that strongly loaded onto five factors. Internal consistency was adequate. The test-retest reliability ranged from adequate to good for four of the derived factors. The fifth was poor and omitted. CONCLUSION: A valid questionnaire for assessing Australian chiropractic programs has been developed comprising four scales that enquire about: 1) quality of the educational program; 2) provision of student support services; 3) enablement of independent learning; and 4) adequacy of teaching resources.

CONTEXTE: Cette étude visait à valider un questionnaire destiné à combler le manque d'outils pour connaítre l'opinion d'étudiants australiens en chiropratique de la qualité des programmes d'études. MÉTHODOLOGIE: Des points, éventuellement pertinents, ont été choisis en fonction des normes australiennes d'agrément en chiropratique. Des étudiants ont évalué leur clarté et leur pertinence; un questionnaire pilote comprenant 47 questions a été établi. Les points principaux ont servi à établir la structure des échelles. Des coefficients de corrélation interclasses ont servi à établir la fiabilité du test-retest des échelles. RÉSULTATS: Trente-quatre points ont été rejetés; on en a conservé 13 portant surtout sur cinq facteurs. La cohérence interne était suffisante. La fiabilité du test retest allait d'adéquate à bonne pour quatre des facteurs dérivés. Le degré de fiabilité du cinquième était faible et celui-ci a été omis. CONCLUSION: On a élaboré un questionnaire utile servant à évaluer des programmes d'études en chiropratique offerts en Australie. Quatre échelles ont servi à sonder les étudiants sur 1) la qualité des programmes de formation; 2) les services d'aide aux étudiants; 3) l'enseignement individualisé; et 4) la suffisance des ressources pédagogiques offerte.

Limited effects of long-term daily cranberry consumption on the gut microbiome in a placebo-controlled study of women with recurrent urinary tract infections.

BACKGROUND: Urinary tract infections (UTIs) affect 15 million women each year in the United States, with > 20% experiencing frequent recurrent UTIs. A recent placebo-controlled clinical trial found a 39% reduction in UTI symptoms among recurrent UTI sufferers who consumed a daily cranberry beverage for 24 weeks. Using metagenomic sequencing of stool from a subset of these trial participants, we assessed the impact of cranberry consumption on the gut microbiota, a reservoir for UTI-causing pathogens such as Escherichia coli, which causes > 80% of UTIs. RESULTS: The overall taxonomic composition, community diversity, carriage of functional pathways and gene families, and relative abundances of the vast majority of observed bacterial taxa, including E. coli, were not changed significantly by cranberry consumption. However, one unnamed Flavonifractor species (OTU41), which represented ≤1% of the overall metagenome, was significantly less abundant in cranberry consumers compared to placebo at trial completion. Given Flavonifractor's association with negative human health effects, we sought to determine OTU41 characteristic genes that may explain its differential abundance and/or relationship to key host functions. Using comparative genomic and metagenomic techniques, we identified genes in OTU41 related to transport and metabolism of various compounds, including tryptophan and cobalamin, which have been shown to play roles in host-microbe interactions. CONCLUSION: While our results indicated that cranberry juice consumption had little impact on global measures of the microbiome, we found one unnamed Flavonifractor species differed significantly between study arms. This suggests further studies are needed to assess the role of cranberry consumption and Flavonifractor in health and wellbeing in the context of recurrent UTI. TRIAL REGISTRATION: Clinical trial registration number: ClinicalTrials.gov NCT01776021 .

Association Between Chiropractic Students' Hand-Eye Coordination or General Self-efficacy and Their Performance on a Spinal Manipulative Therapy Examination: A Cross-sectional Study.

Objective: The purpose of this study was to investigate the association between either hand-eye coordination (HEC) or general self-efficacy (GSE) and spinal-manipulative-therapy (SMT) exam scores. We also measured the interrater reliability of the SMT marking criteria used in our study. Methods: Third-year chiropractic students were recruited from the chiropractic spinal technique course at Murdoch University. They completed an alternate-hand wall-toss test to assess HEC and a questionnaire to evaluate GSE. Linear regression models were used to assess the relationships between HEC and GSE on manual-therapy exam scores. Two assessors scored the examination, allowing the investigation of interrater reliability for the SMT marking criteria. Results: A total of 33 male and 31 female students, aged 20 to 44 years, completed both the GSE questionnaire and the SMT examination, but only 28 women also completed the HEC test. Male participants had higher scores on both HEC (9.4 additional catches, P < 0.001) and SMT (6.7%, P = .01) compared to female participants. There was no statistically significant relationship between HEC and SMT (P = .932). However, there was a linear relationship between GSE and SMT when adjusted for sex (P = .032). Furthermore, the intraclass correlation coefficient for the marking criteria was moderate to good, at 0.77 (95% confidence interval, 0.63-0.86). Conclusion: These preliminary results suggest that when adjusted for sex, a student's GSE may be related to their SMT exam scores. The alternate-hand wall-toss test was not correlated with SMT scores, but other HEC metrics may have a relationship.

The accreditation role of Councils on Chiropractic Education as part of the profession's journey from craft to allied health profession: a commentary.

BACKGROUND: Chiropractors see themselves as well positioned to provide safe, effective and economical care for the on-going financial burden that spinal pain imposes. However, in many places of the world, the chiropractic profession continues to find itself struggling to gain acceptance as a mainstream allied health care provider. There is evidence of the existence of undesirable chiropractic practice patterns and it is in part due to some of the world's accredited chiropractic programs. This indicated a need for scrutiny of international chiropractic educational accreditation standards, which are the responsibility of Councils on Chiropractic Education (CCEs). To this end we reviewed an emerging body of evidence about the chiropractic educational system in order to identify issues and make recommendations that may enhance professional acceptance through improved graduate outcomes and hopefully the quality of patient care. This commentary summarises the findings of that research. MAIN TEXT: We reviewed recent relevant studies, including our own, into the role and function of CCEs and found that there is sufficient evidence to identify areas of concern that could be addressed, at least in part, by improvements to CCEs' educational standards and processes. Areas included a lack of definitions for key terms such as, 'chiropractic', 'diagnosis', and 'competency', without which there can be no common understanding at a detailed level to inform graduate competencies and standards for a matching scope of practice. Further, there is some evidence to suggest that in some cases this level of detail is avoided in order to enable a "big tent" approach that allows for a diversity of approaches to clinical care to co-exist. This combined with the held view that chiropractic is "unique", highly valued, and best understood by other chiropractors, explains how students and practitioners can cling to 'traditional' thinking. This has implications for public safety and patient quality of care. CONCLUSION: If chiropractic care is to gain mainstream acceptance worldwide then it needs to adopt, through revitalised CCE accreditation standards and processes, those of other allied healthcare professions and wholeheartedly embrace science, evidence-based practice and patient centred care.

Knowledge, beliefs, and influences associated with complementary and alternative medicine among physiotherapy and counselling students.

OBJECTIVE: The objective of this study is to determine whether physiotherapy and counselling students, who represent a future generation of two health professions, have differing views about complementary and alternative medicine (CAM). METHODS: In order to determine physiotherapy and counselling students' self-rated knowledge and beliefs about CAM and the factors which influence that understanding, a modified 10-item CAM Health Belief Questionnaire was administered across all year groups to physiotherapy students and counselling students at two universities in Perth, Western Australia. The self-rated paper-based survey measured knowledge of CAM among physiotherapy and counselling students, evaluation of their beliefs regarding the use of CAM, factors that influence their knowledge and beliefs, and their likelihood of recommending CAM to future patients. RESULTS: A response rate of 96.8% was achieved, with 387 physiotherapy students and 88 counselling students. Moderately positive beliefs about CAM were confirmed in both groups, with mean scores of 42.8/70 for physiotherapy students and 43.3/70 for counselling students. There were no significant differences between the student groups in overall self-rated knowledge of CAM. The main factors that influenced the students' responses were personal experience for counselling students and scientific evidence for physiotherapy students. Other factors included university training, attitudes of lecturers, tutors and fellow students, cultural background, and opinions of external practitioners. Counselling students were more likely than physiotherapy students to recommend CAM therapies to their future patients. CONCLUSION: The results from this study demonstrate minimal self-rated knowledge but moderately positive attitudes towards CAM by both physiotherapy and counselling students.

A failed review of CCE site inspection standards and processes.

Background: Accreditation of educational programs involves an independent agency assessing quality against a set of defined standards. Site inspection teams are appointed by an accrediting agency and compile a report with the intention of identifying deficiencies and making recommendations for their rectification and continued improvement. For chiropractic programs accreditation is carried out by Councils on Chiropractic Education (CCEs). However, the reliability of their site inspection teams remains unknown. Recent research has suggested that variability in chiropractic practice may be partially traced back to the education provider. This raises the possibility of deficient accreditation procedures that may include unsatisfactory site inspection standards or processes or the accreditation standards by which they work to.We sought to compare the various CCEs documented standards and processes for site inspection teams for similarities and differences with the intent of making recommendations to create uniform and high quality standards. Further, we sought to compare a sample of CCEs site inspection team surveys / reports for commonly identified recommendations and quality improvements and determine if they are adequately described in their accreditation standards. Method: In December of 2018 invitation emails were sent to 4 CCEs through their website portals outlining a proposed study investigating site inspection teams' standards and processes. Access was requested to all appropriately redacted documentation relating to site inspection teams and their chiropractic program reports. Follow up emails were sent several weeks later. Results: Only one of four of the CCEs responded by providing the requested information. Conclusion and recommendations: Three CCEs did not cooperate with this educational research. The possible reasons for the non-engagement is discussed.

A perspective on Councils on Chiropractic Education accreditation standards and processes from the inside: a narrative description of expert opinion: Part 2: Analyses of particular responses to research findings.

Background: This is the second article reporting on a study that sought the views of people with extensive experience in Councils on Chiropractic Education (CCEs) on research that has raised concerns about variability in accreditation standards and processes for chiropractic programs (CPs) and chiropractic practice in general. Methods: This qualitative study employed in-depth semi-structured interviews that consisted of open-ended questions asking experts about their thoughts and views on a range of issues surrounding accreditation, graduate competency standards and processes. The interviews were audio-recorded, and transcribed verbatim in June and July of 2018. The transcripts were reviewed to develop codes and themes. The study followed the COREQ guidelines for qualitative studies. Results: The interviews revealed that these CCE experts were able to discern positive and negative elements of the accreditation standards and processes. They were, in general, satisfied with CCEs accreditation standards, graduating competencies, and site inspection processes. Most respondents believed that it was not possible to implement an identical set of international accreditation standards because of cultural and jurisdictional differences. This was thought more likely to be achieved if based on the notion of equivalence. Also, they expressed positive views toward an evidence-based CP curriculum and an outcomes-based assessment of student learning. However, they expressed concerns that an evidence-based approach may result in the overlooking of the clinician's experience. Diverse views were found on the presence of vitalism in CPs. These ranged from thinking vitalism should only be taught in an historical context, it was only a minority who held this view and therefore an insignificant issue. Finally, that CCEs should not regulate these personal beliefs, as this was potentially censorship. The notable absence was that the participants omitted any mention of the implications for patient safety, values and outcomes. Conclusions: Expert opinions lead us to conclude that CCEs should embrace and pursue the widely accepted mainstream healthcare standards of an evidence-based approach and place the interests of the patient above that of the profession. Recommendations are made to this end with the intent of improving CCE standards and processes of accreditation.

A perspective on Chiropractic Councils on Education accreditation standards and processes from the inside: a narrative description of expert opinion: Part 1: Themes.

Background: The aim of this study was to report on key informant opinions of Councils on Chiropractic Education (CCE) regarding recent research findings reporting on improving accreditation standards and processes for chiropractic programs (CPs). Methods: This qualitative study employed in-depth semi-structured interviews with key experienced personnel from the five CCEs in June and July of 2018. The interviews consisted of open-ended questions on a range of issues surrounding accreditation, graduate competency standards and processes. All interviews were audio-recorded, and transcribed verbatim. The transcripts were analysed to develop codes and themes using thematic analysis techniques assisted by NVivo coding software. The study followed the COREQ guidelines for qualitative studies. Results: Six themes were isolated from the interview transcripts; they were: professional differences; keep it in the family; to focus on outcomes or be prescriptive?; more resources please; inter-profession integration; and CPs making ends meet. Most respondents saw a need for CCEs standards and processes to improve interdisciplinarity while at the same time preserving the 'uniqueness' of chiropractic. Additionally, informants viewed CCEs as carrying out their functions with limited resources while simultaneously dealing with vocal disparate interest groups. Diverse views were observed on how CCEs should go about their business of assessing chiropractic programs for accreditation and re-accreditation. Conclusions: An overarching confounder for positive changes in CCE accreditation standards and processes is the inability to clearly define basic and fundamental terms such as 'chiropractic' and its resultant scope of practice. This is said to be because of vocal, diverse and disparate interest groups within the chiropractic profession. Silence or nebulous definitions negotiated in order to allow a diversity of chiropractic practice to co-exist, appears to have complicated and hindered the activities of CCEs. Recommendations are made including an adoption of an evidence-based approach to accreditation standards and processes and the use of expertise from other health professions. Further, the focus of attention should be moved away from professional interests and toward that of protection of the public and the patient.

Attempting to explore chiropractors and their clinical choices: an examination of a failed study.

Background: Recent studies have shown that psychological factors, attitudes and beliefs impact on the quality of chiropractic student clinical decisions. This association has not been studied among qualified chiropractors. Our objective was to investigate if personality, psychological factors and/or unorthodox beliefs among chiropractors are related to choices of management in specific clinical scenarios. Method: In February 2018, a subsample of chiropractors (N = 700) from a practitioner-based research network in Australia known as ACORN (N = 1680), were invited to respond to an on-line anonymous questionnaire. Questions included items relating to management of specific clinical scenarios, intolerance of uncertainty (IU) and the 'Big-5' personality score, adoption of a prescriptive technique system, self-rating of chiropractic abilities, and the level of importance of subluxation and chiropractic philosophy in the delivery of care. Descriptive analysis was to be reported and associations examined between i) personality and psychology factors, unorthodox beliefs and ii) scores obtained for management of specific clinical scenarios, numbers of interdisciplinary referrals, and guideline-based X-ray use. Results: The number of respondents was 141 (20%) and 33 of their responses were largely incomplete resulting in a final response rate of 108 (15.4%). In addition, some questions were left unanswered. These related mainly to IU and Big-5 personality measurements. Some sample characteristics (age, number of patients per week, hours worked per week) were similar to the larger ACORN project sample. However, the low response rate indicated that the final study sample was unlikely to be truly representative of the study population and the low number of participants made association testing unsuitable. Conclusion and recommendations: The low response rate and small study sample in this study made any substantive analysis inappropriate. For these reasons, the study was not concluded. However, the potential reasons for the low response from this large database of volunteer research participants are of interest and need to be investigated. Clearly, it is necessary to engage this population better to explore sensitive issues such as personality inventories and different practice profiles in the interest of effective health care delivery and patient safety.

Manipulation-induced hypoalgesia in musculoskeletal pain populations: a systematic critical review and meta-analysis.

Background: Manipulation-induced hypoalgesia (MIH) represents reduced pain sensitivity following joint manipulation, and has been documented in various populations. It is unknown, however, whether MIH following high-velocity low-amplitude spinal manipulative therapy is a specific and clinically relevant treatment effect. Methods: This systematic critical review with meta-analysis investigated changes in quantitative sensory testing measures following high-velocity low-amplitude spinal manipulative therapy in musculoskeletal pain populations, in randomised controlled trials. Our objectives were to compare changes in quantitative sensory testing outcomes after spinal manipulative therapy vs. sham, control and active interventions, to estimate the magnitude of change over time, and to determine whether changes are systemic or not. Results: Fifteen studies were included. Thirteen measured pressure pain threshold, and four of these were sham-controlled. Change in pressure pain threshold after spinal manipulative therapy compared to sham revealed no significant difference. Pressure pain threshold increased significantly over time after spinal manipulative therapy (0.32 kg/cm2, CI 0.22-0.42), which occurred systemically. There were too few studies comparing to other interventions or for other types of quantitative sensory testing to make robust conclusions about these. Conclusions: We found that systemic MIH (for pressure pain threshold) does occur in musculoskeletal pain populations, though there was low quality evidence of no significant difference compared to sham manipulation. Future research should focus on the clinical relevance of MIH, and different types of quantitative sensory tests. Trial registration: Prospectively registered with PROSPERO (registration CRD42016041963).

The interrater reliability of static palpation of the thoracic spine for eliciting tenderness and stiffness to test for a manipulable lesion.

Background: Despite widespread use by manual therapists, there is little evidence regarding the reliability of thoracic spine static palpation to test for a manipulable lesion using stiffness or tenderness as diagnostic markers. We aimed to determine the interrater agreement of thoracic spine static palpation for segmental tenderness and stiffness and determine the effect of standardised training for examiners. The secondary aim was to explore expert consensus on the level of segmental tenderness required to locate a "manipulable lesion". Methods: Two experienced chiropractors used static palpation of thoracic vertebrae on two occasions (pragmatic and standardised approaches). Participants rated tenderness on an 11-point numerical pain rating scale (NPRS) and raters judged segmental stiffness based on their experience and perception of normal mobility with the requested outcomes of hypomobile or normal mobility. We calculated interrater agreement using percent agreement, Cohen's Kappa coefficients ( κ ) and prevalence-adjusted bias-adjusted Kappa coefficients (PABAK). In a preliminary study, an expert panel of 10 chiropractors took part in a Delphi process to identify the level of meaningful segmental tenderness required to locate a "manipulable lesion". Results: Thirty-six participants (20 female) were enrolled for the reliability study on the 13th March 2017. Mean (SD) age was 22.4 (3.4) years with an equal distribution of asymptomatic (n = 17) and symptomatic (n = 17) participants. Overall, the interrater agreement for spinal segmental stiffness had Kappa values indicating less than chance agreement [ κ range - 0.11, 0.53]. When adjusted for prevalence and bias, the PABAK ranged from slight to substantial agreement [0.12-0.76] with moderate or substantial agreement demonstrated at the majority of spinal levels (T1, T2 and T6 to T12). Generally, there was fair to substantial agreement for segmental tenderness [Kappa range 0.22-0.77]. Training did not significantly improve interrater agreement for stiffness or tenderness. The Delphi process indicated that an NPRS score of 2 out of 10 identified a potential "manipulable lesion". Conclusion: Static palpation was overall moderately reliable for the identification of segmental thoracic spine stiffness and tenderness, with tenderness demonstrating a higher reliability. Also, an increased agreement was found within the mid-thoracic spine. A brief training intervention failed to improve reliability.

Comparing the old to the new: A comparison of similarities and differences of the accreditation standards of the chiropractic council on education-international from 2010 to 2016.

Background: Chiropractic programs are accredited and monitored by regional Councils on Chiropractic Education (CCE). The CCE-International has historically been a federation of regional CCEs charged with harmonising world standards to produce quality chiropractic educational programs. The standards for accreditation periodically undergo revision. We conducted a comparison of the CCE-International 2016 Accreditation Standards with the previous version, looking for similarities and differences, expecting to see some improvements. Method: The CCE-International current (2016) and previous versions (2010) were located and downloaded. Word counts were conducted for words thought to reflect content and differences between standards. These were tabulated to identify similarities and differences. Interpretation was made independently followed by discussion between two researchers. Results: The 2016 standards were nearly 3 times larger than the previous standards. The 2016 standards were created by mapping and selection of common themes from member CCEs' accreditation standards and not through an evidence-based approach to the development and trialling of accreditation standards before implementation. In 2010 chiropractors were expected to provide attention to the relationship between the structural and neurological aspects of the body in health and disease. In 2016 they should manage mechanical disorders of the musculoskeletal system. Many similarities between the old and the new standards were found. Additions in 2016 included a hybrid model of accreditation founded on outcomes-based assessment of education and quality improvement. Both include comprehensive competencies for a broader role in public health. Omissions included minimal faculty qualifications and the requirement that students should be able to critically appraise scientific and clinical knowledge. Another omission was the requirement for chiropractic programs to be part of a not-for-profit educational entity. There was no mention of evidence-based practice in either standards but the word 'evidence-informed' appeared once in the 2016 standards. Conclusions: Some positive changes have taken place, such as having bravely moved towards the musculoskeletal model, but on the negative side, the requirement to produce graduates skilled at dealing with scientific texts has been removed. A more robust development approach including better transparency is needed before implementation of CCE standards and evidence-based concepts should be integrated in the programs. The CCE-International should consider the creation of a recognition of excellence in educational programs and not merely propose minimal standards.

Testing a strength and conditioning program to prevent common manipulative technique training injuries in chiropractic students: a study protocol for a randomised controlled trial.

Background: Spinal manipulation is the primary therapy utilised by chiropractors in the management of their patients. The skills required may feel foreign to chiropractic students as they need strength and endurance in movement patterns they may not have otherwise been exposed to. This may lead to injury while learning manipulative techniques. It is plausible to suggest that the implementation of a strength and conditioning program early in a practitioner's career could reduce the incidence and progression of injuries. The study aims to test the effectiveness of a strength and conditioning program in reducing the risk of chiropractic students' acquiring injuries while learning the skill of spinal manipulation. Methods: This study will involve a prospective cohort of chiropractic students who are currently learning manual therapy at an undergraduate level. Participants will be eligible for inclusion if they are enrolled in 3rd or 4th-year chiropractic manual therapy units at Murdoch University chiropractic course. The intervention group will follow a 12-week strength and conditioning program comprised of preventative exercises that address each body region previously identified as being prone to injury. The control group will complete a 12-week walking program. The primary outcome is injury rate, measured via a short questionnaire. The secondary outcome will be strength, measured via submaximal strength tests. Discussion: The prescribed exercises are aimed at improving the strength and endurance of those muscle groups involved in commonly taught manual therapy tasks. The resistance bands have been chosen as they are inexpensive, simple to implement for the purposes of the study, and acceptably safe. A video format was selected to allow ease of access for participants, provide a detailed description and a visual representation of the exercises to be performed. A questionnaire was designed as a means to assess the influence of the strength and conditioning program on injury rate and the impact this may have on the students' ability to continue practicing. The International Physical Activity Questionnaire has been chosen to measure the participants level of activity before beginning the exercise program. Conclusion: This research protocol will be the first large-scale study to investigate the effectiveness of a strength and conditioning program to reduce injuries within chiropractic students learning manual therapy. Trial registration: Australia New Zealand Clinical Trials Registry (ACTRN12617001638325p).

Low back pain: a major global problem for which the chiropractic profession needs to take more care.

An important series of papers have been published in the Lancet. These papers provide a comprehensive update for the major global problem of low back pain, and the challenges that low back pain presents to healthcare practitioners and policy makers. Chiropractors are well placed to reduce the burden of low back pain, but not all that chiropractors do is supported by robust, contemporary evidence. This commentary summarises the Lancet articles. We also make suggestions for how the chiropractic profession should most effectively help people with low back pain by implementing practices supported by high quality evidence.

How frequent are non-evidence-based health care beliefs in chiropractic students and do they vary across the pre-professional educational years.

Background: Evidence suggests that a students' beliefs already prior to entering a program may be important as a determinant in sustaining unsuitable health care beliefs. Our objectives were to investigate the proportion of Australian chiropractic students who hold non-evidence-based beliefs in the first year of study and the extent to which they may be involved in non-musculoskeletal health conditions. Finally, to see if this proportion varies over the course of the chiropractic program. Method: In 2016, students from two Australian chiropractic programs answered a questionnaire on how often they would give advice on five common health conditions in their future practices as well as their opinion on whether chiropractic spinal adjustments could prevent or help seven health-related conditions. Results: From a possible 831 students, 444 responded (53%). Students were highly likely to offer advice (often/quite often) on a range of non-musculoskeletal conditions. The proportions were lowest in first year and highest the final year. Also, high numbers of students held non-evidence-based beliefs about 'chiropractic spinal adjustments' which tended to occur in gradually decreasing in numbers in sequential years, except for fifth year when a reversal of the pattern occurred. Conclusions: New strategies are required for chiropractic educators if they are to produce graduates who understand and deliver evidence-based health care and able to be part of the mainstream health care system.

Chiropractic student choices in relation to indications, non-indications and contra-indications of continued care.

Background: The quality of health care provider clinical decisions has long been recognized as variable. Research has focused on clinical decision making with the aim of improving patient outcomes. No studies have looked at chiropractic students´ abilities in this regard. Method: In 2016, advanced students from two Australian chiropractic programs (N = 444) answered a questionnaire on patient case scenarios for neck and low back pain (LBP). We selected 7 scenarios representing the three categories; continuing care, non-indicated care, and contraindicated care. This represented a total of 21 tested scores. Comparisons of correct answers were made a) for program years 3, 4 and 5, and b) between the three categories of care. Results: In almost 1/3 of scenarios, correct scores were 70% or greater. Best results were for two neck pain cases (simple and with spinal cord involvement). Continued care showed most improvements with study year. However, the scenarios that reflected non-indication for continued care had much worse results and did not improve in higher years. For the obvious contraindicated neck scenario, the results were good from the beginning and progressively improved and for a contraindicated LBP scenario the results started poorly in year 3 but improved over the program years. Conclusions: Although student responses were generally good, there is still room for improvement, especially for non-indicated care. The quality of students' clinical decisions can be measured and thus has the potential to be used by chiropractic educators and regulatory bodies to identify student's in need of assistance as well as to monitor chiropractic programs in relation to student competence. Trial registration: Not applicable.

Knowledge, attitude, influences and use of complementary and alternative medicine (CAM) among chiropractic and nursing students.

BACKGROUND: Complementary and alternative medicine (CAM) is becoming more widely used in the community however there are differences in knowledge and attitudes among and within the various health professions. Chiropractic and nursing students represent a future generation of two health profession groups who may have differing views on CAM. The objectives of this study were to investigate the knowledge, attitudes and beliefs of nursing and chiropractic students about CAM. To investigate the factors that influence their attitudes and beliefs and their likelihood of recommending CAM; and to compare the findings between nursing and chiropractic students to determine similarities and differences. METHODS: A modified and pre-tested survey including a previously validated 10-item CAM Health Belief Questionnaire (CHBQ) was administered to nursing and chiropractic students at Murdoch University. Student's demographics were collected as well as other information regarding knowledge, attitudes, influences and use of CAM. RESULTS: Three hundred twenty-one nursing and 227 chiropractic students responded with a 91% response rate. The CHBQ overall mean scores for nursing and chiropractic students were 47.6 and 47.4 out of possible 70 respectively, confirming positive attitudes toward CAM in both groups. Nursing and chiropractic students also demonstrated similar knowledge levels. Factors that were most influential in shaping both chiropractic and nursing students' attitudes and beliefs towards CAM were personal experience and the influence of external peers. Nursing students would not dissuade future patients from CAM, however chiropractic students were more likely to recommend CAM to their future patients. CONCLUSIONS: Nursing and chiropractic students demonstrate relatively positive attitudes and beliefs towards CAM despite, their limited knowledge concerning CAM modalities generally.

The relationship between intolerance of uncertainty in chiropractic students and their treatment intervention choices.

BACKGROUND: Psychological factors, such as intolerance of uncertainty (IU), have been shown to impact on the quality of medical care. However, this psychological measure has not been studied in the chiropractic profession. Our objective was to investigate if higher levels of IU in chiropractic students were related to poor choices of management in specific clinical scenarios. Also, we sought to investigate if levels of IU were related to students' intentions to adopt a prescriptive chiropractic technique system and evaluate their levels of self-belief. METHOD: Between October and November of 2016, students from two Australian chiropractic programs (N = 444) answered a questionnaire on measures of IU levels, patient case scenarios for neck and low back pain, and questions about self-ratings of their future chiropractic abilities and perceived need for the adoption of a chiropractic technique system. Associations were tested by the IU score and the therapeutic choices relating to a) a neck pain case scenario, b) a low back pain scenario, c) various technique systems, and d) the self-rated competence level treating the IU score both as a continuous and a categorical variable. RESULTS: There was an overall response rate of 53%. Those students who were high in levels of IU were significantly more likely to make incorrect clinical decisions than those with normal or low levels of IU for the neck pain case scenario. No differences were found on the low back pain scenario, on preferences to use a technique system in the future, or on predicted self-rating of competence after graduation. CONCLUSIONS: Psychological factors, such as IU, may have an impact on chiropractic students' clinical decisions. However, it does not impact on all aspects of practice. This finding has implications for chiropractic educators, especially when dealing with neck pain. However, it may be relevant to continue the search for specific personality profiles in relation to various favourable and unfavourable practice patterns, as it is unknown whether these dynamics are important for other aspects of chiropractic education.

Current and Prospective Use of Musculoskeletal Diagnostic Ultrasound Imaging at Chiropractic Teaching Institutions: A Worldwide Survey of Diagnostic Imaging Staff.

OBJECTIVE: The purpose of this study was to survey the use of musculoskeletal diagnostic ultrasound imaging (MSK-DUSI) at chiropractic educational programs worldwide and to elicit opinions of academic diagnostic imaging staff of its prospective use at their teaching institutions. METHODS: An electronic questionnaire was delivered in 2014 using SurveyMonkey and notifications were disseminated by e-mail to 127 diagnostic imaging staff at chiropractic programs worldwide. The questionnaire consisted of 27 items using multiple-choice, Likert-type, and open-ended questions. Descriptive statistics were used for basic demographic data and the results of the numerical scales used in each item. RESULTS: Fifty-nine respondents (46.5%) from 24 (24/41) chiropractic programs returned questionnaires. The reported use of MSK-DUSI at chiropractic programs is low (n = 5/24); however, respondents from 9 institutions stated that it is planned to be implemented. Few respondents stated they had formal MSK-DUSI qualifications (4/59); however, 7 respondents stated they were in the process of becoming certified. Most respondents expressed an interest in the prospect of incorporating MSK-DUSI at their chiropractic program. Sixty-five percent stated that chiropractic programs should provide MSK-DUSI training to chiropractic students, and 75% of respondents stated that chiropractic programs should be providing accredited postgraduate MSK-DUSI courses. CONCLUSIONS: The current use of MSK-DUSI among chiropractic programs that responded to this survey is low. The opinions of diagnostic imaging staff who responded suggest a positive attitude to its use and possible growth in its use if foundational work, including gaining funding, accreditation, and acceptance of within the scope of chiropractic practice, is undertaken.