A new role for spinal manual therapy and for chiropractic? Part I: weaknesses and threats.

Spinal manual therapy is central to chiropractic history, clinical practice, and professional identity. That chiropractors have developed an expertise in this domain has provided some considerable advantages. However, we contend it is also at the crux of the ideological schism that fractures the chiropractic profession. In this article, which is the first in a series of two, we discuss chiropractors' understanding and use of spinal manual therapy and do so with particular emphasis on what we see as weaknesses it creates and threats it gives rise to. These are of particular importance, as we believe they have limited the chiropractic profession's development. As we shall argue, we believe that these threats have become existential in nature, and we are convinced that they call for a resolute and unified response by the profession. Subsequently, in part II, we discuss various strengths that the chiropractic profession possesses and the opportunities that await, provided that the profession is ready to rise to the challenge.

A new role for spinal manual therapy and for chiropractic? Part II: strengths and opportunities.

In a previous paper, we presented some important weaknesses of and threats to the chiropractic profession as we see them. We further argued that the chiropractic profession's relationship with its principal clinical tool (spinal manual therapy) is at the core of the ideological divide that fractures the profession and prevents professional development towards greater integration in the healthcare landscape. In this manuscript, we shall argue that the historical predilection for spinal manipulation also gifts the profession with some obvious strengths and opportunities, and that these are inextricably linked to the management of musculoskeletal disorders. The onus is now on the chiropractic profession itself to redefine its raison d'être in a way that plays to those strengths and delivers in terms of the needs of patients and the wider healthcare system/market. We suggest chiropractors embrace and cultivate a role as coordinators of long-term and broad-focused management of musculoskeletal disorders. We make specific recommendations about how the profession, from individual clinicians to political organizations, can promote such a development.

A guide to evaluating systematic reviews for the busy clinicians or reluctant readers.

Systematic reviews (SRs) provide a solution to handle information overload for busy clinicians by summarising and synthesizing studies on a specific issue. However, because SRs are complicated and often boring to read, the busy or reluctant reader may make do with the abstract. When, as it has been shown, many authors overstate efficacy or understate harm in their abstracts, not consulting the underlying article could be misleading. This means that the prudent reader must have the ability to identify the 'tender points' of SRs to avoid falling for 'spin'. To this end we briefly review the method of SRs and ways to relatively quickly determine trustworthiness.

Associations between cardiovascular disease risk factors and spinal pain may be moderated by sex and health-related physical activity (CHAMPS Study-DK).

BACKGROUND: Spinal pain has been previously linked with cardiovascular disease risk factors in children. This study investigated the prospective associations between cardiovascular disease risk factors and non-traumatic spinal pain occurrences in children, and examined the moderating role of sex and health-related physical activity in these relationships. METHODS: We used prospective data from the Childhood Health, Activity, and Motor Performance School Study Denmark (CHAMPS Study-DK). The exposure variables were a clustered cardiovascular risk score and homeostasis assessment model-estimated insulin resistance (HOMA-IR) score collected in 2008 and 2010. The spinal pain outcome comprised the number of weeks of non-traumatic spinal pain from 2008-2010 and 2010-2012. Potential confounders included age, sex, and time spent in moderate-to-vigorous intensity physical activity. We constructed age-adjusted mixed negative binominal regression models to investigate the prospective associations of cardiovascular disease risk factors and non-traumatic spinal pain, while considering the potential moderating roles of sex and physical activity in these relationships. RESULTS: Girls with low HOMA-IR scores and boys with low clustered cardiovascular disease risk scores, who engaged in higher levels of moderate-to-vigorous physical activity, reported more weeks of spinal pain, compared to girls with high HOMA-IR scores (p = 0.001) and boys with high clustered cardiovascular disease risk scores (p = 0.024). whereas boys with higher clustered cardiovascular disease risk who had less time in moderate-to-vigorous physical activity reported more weeks of spinal pain than boys with low clustered cardiovascular disease risk score (p = 0.024). CONCLUSION: Our results show that cardiovascular disease risk factors are related to future occurrences of non-traumatic spinal pain. However, these relationships appear complex and dependent on the nature of the interactions with sex and physical activity.

No associations between C-reactive protein and spinal pain trajectories in children and adolescents (CHAMPS study-DK).

Preliminary evidence points to a link between C-reactive protein (CRP) and spinal pain in adults. However, there is a paucity of research in younger populations. Therefore, we aimed to determine associations between CRP and spinal pain in childhood and adolescence. We identified trajectories of spinal pain from childhood to adolescence and investigated the associations between CRP and trajectory subgroups. Six- to 11-year-old children from 13 primary schools, were followed from October 2008 and until 2014. High-sensitivity CRP collected at baseline (2008) was measured using serum samples. The outcome was the number of weeks with non-traumatic spinal pain between November 2008 and June 2014. We constructed a trajectory model to identify different spinal pain trajectory subgroups. The associations between CRP and spinal pain trajectory subgroups were modelled using mixed-effects multinominal logistic regression. Data from 1556 participants (52% female), with a mean age of 8.4 years at baseline, identified five spinal pain trajectory subgroups: "no pain" (55.3%), "rare" (23.7%), "rare, increasing" (13.6%), "moderate, increasing" (6.1%), and "early onset, decreasing" (1.3%). There were no differences in baseline high-sensitivity CRP levels between spinal pain trajectory subgroups. Thus, the heterogeneous courses of spinal pain experienced were not defined by differences in CRP at baseline.

Who are the chiropractic students favouring a limitless scope of practice? Exploring the relationship with personality, magical thinking, and academic achievement.

INTRODUCTION: Some chiropractors seem to have an inflated belief in the powers of spinal manipulation (SMT), for example aiming at preventing future spinal degeneration and health problems, activities that are without supporting evidence. Non-evidenced health beliefs have been shown to be associated with a tendency toward magical thinking. Holding such beliefs about SMT is associated with a limitless scope of practice (LLSoP). Recent studies have shown that "chiropractic conservatism" (ChiroCon) is also associated with such approaches. We wanted to understand ChiroCon and these attitudes toward SMT by exploring three different factors: intolerance to uncertainty, academic achievement, and tendency toward magical thinking and how they relate to ChiroCon and LLSoP. METHOD: A cross-sectional survey of 243 chiropractic students from an Australian chiropractic program was conducted in May 2020. Students answered a questionnaire involving a patient case-scenario for LLSoP, levels of ChiroCon, validated questionnaires on (i) Intolerance of uncertainty, (ii) Academic achievement, and (iii) Magical thinking. LLSoP was defined as wanting to treat with SMT a 5-year-old asymptomatic child for future (i) Musculoskeletal (MSK) problems and/or (ii) Non-musculoskeletal diseases. Logistic regression models were used to confirm if there was an association between ChiroCon and LLSoP and to explore associations between LLSoP and (i) Intolerance of uncertainty, (ii) Academic achievement, and (iii) Magical thinking. We repeated the same analyses using ChiroCon as the outcome variable. RESULTS: We confirmed that chiropractic students in the more extreme ChiroCon group were more likely to want to prevent future spinal disorders in an asymptomatic 5-year-old child as compared to those with lower levels (OR = 3.9, (95%CI 1.97-7.72). This was also the case for the prevention of future diseases in the same child (OR = 6.9, (95%CI 3.11-15.06). Of the three predictor variables, magical belief was positively associated with both ChiroCon and LLSoP. CONCLUSION: Not surprisingly, ChiroCon is closely related to LLSoP and both were linked to magical thinking. Therefore, the questionnaire 'Magical Health Beliefs' could be a useful instrument to screen future chiropractic students to prevent a mismatch between student and institution. Depending on the outlook of the school, some schools would welcome these students, whereas other institutions would want to avoid them in their education program.

Spinal pain in childhood: prevalence, trajectories, and diagnoses in children 6 to 17 years of age.

This study aimed to investigate the trajectories of spinal pain frequency from 6 to 17 years of age and describe the prevalence and frequency of spinal pain and related diagnoses in children following different pain trajectories. First through fifth-grade students from 13 primary schools were followed for 5.5 years. Occurrences of spinal pain were reported weekly via text messages. Children reporting spinal pain were physically evaluated and classified using International Classification of Disease criteria. Trajectories of spinal pain frequency were modeled from age 6 to 17 years with latent class growth analysis. We included data from 1556 children (52.4% female, mean (SD) baseline age = 9.1 (1.9) years) and identified 10,554 weeks of spinal pain in 329,756 weeks of observation. Sixty-three percent of children reported one or more occurrences of spinal pain. We identified five trajectories of spinal pain frequency. Half the children (49.8%) were classified as members of a "no pain" trajectory. The remaining children followed "rare" (27.9%), "rare, increasing" (14.5%), "moderate, increasing" (6.5%), or "early-onset, decreasing" (1.3%) spinal pain trajectories. The most common diagnoses in all trajectory groups were non-specific (e.g., "back pain"). Tissue-specific diagnoses (e.g., muscle strain) were less common and pathologies (e.g., fracture) were rare.  Conclusion: From childhood through adolescence, spinal pain was common and followed heterogeneous courses comprising stable, increasing, and early-onset trajectories. These findings accord with recommendations from adult back pain guidelines that most children with spinal pain can be reassured that they do not have a serious disease and encouraged to stay active. What is Known: • Spinal pain imposes a large burden on individuals and society. • Although many people first experience the condition in childhood, little is known about the developmental trajectories of spinal pain from childhood to adolescence. What is New: • Data from 1556 children and 329,756 participant weeks showed five unique spinal pain trajectories from 6 to 17 years: most children rarely reported spinal pain, while one in five followed increasing or early-onset trajectories. • Most pain occurrences were non-specific; pathological diagnoses were rare.

The importance of selecting the correct site to apply spinal manipulation when treating spinal pain: Myth or reality? A systematic review.

The concept that spinal manipulation therapy (SMT) outcomes are optimized when the treatment is aimed at a clinically relevant joint is commonly assumed and central to teaching and clinical use (candidate sites). This systematic review investigated whether clinical effects are superior when this is the case compared to SMT applied elsewhere (non-candidate sites). Eligible study designs were randomized controlled trials that investigated the effect of spinal manipulation applied to candidate versus non-candidate sites for spinal pain. We obtained data from four different databases. Risk of bias was assessed using an adjusted Cochrane risk of bias tool, adding four items for study quality. We extracted between-group differences for any reported outcome or, when not reported, calculated effect sizes from the within-group changes. We compared outcomes for SMT applied at a 'relevant' site to SMT applied elsewhere. We prioritized methodologically robust studies when interpreting results. Ten studies, all of acceptable quality, were included that reported 33 between-group differences-five compared treatments within the same spinal region and five at different spinal regions. None of the nine studies with low or moderate risk of bias reported statistically significant between-group differences for any outcome. The tenth study reported a small effect on pain (1.2/10, 95%CI - 1.9 to - 0.5) but had a high risk of bias. None of the nine articles of low or moderate risk of bias and acceptable quality reported that "clinically-relevant" SMT has a superior outcome on any outcome compared to "not clinically-relevant" SMT. This finding contrasts with ideas held in educational programs and clinical practice that emphasize the importance of joint-specific application of SMT.

Shoulder pain prevalence by age and within occupational groups: a systematic review.

BACKGROUND: Shoulder pain was previously shown to diminish in older populations and it was suggested that this could be explained by reduced usage with age. Our objectives were to investigate if estimates of shoulder pain continue to increase after the age of 50 in working populations and to compare these estimates in physically demanding occupations with sedentary occupations. METHODS: A systematic review of retrospective, cross-sectional, prospective, or longitudinal. studies reporting prevalence or incidence of non-specific shoulder pain in occupational groups stratified by age. Searches were conducted in PubMed, Scopus, and CINAHL from inception until January 2020. Study characteristics and prevalence estimates stratified by age were extracted. Two reviewers independently performed a critical analysis of the included studies to determine their validity and risk of bias. RESULTS: Twenty studies with a total of 40,487 participants and one study of a clinical data base were included and assigned a direction of the estimates for shoulder pain as either 'increasing', 'remaining stable' or 'decreasing' past the age of 50. Shoulder pain generally increased past 50, with 16 of the 21 included studies reporting higher estimates/odds ratios in older participants. In the more physically active occupations over 50, the estimates increased in 14 of the 18 samples compared to only two of the four involving sedentary occupations. CONCLUSIONS: Shoulder pain prevalence remains common in workers beyond the age of 50. Prevalence continues to increase in physically demanding occupations. Clinicians should consider factors of occupation when managing shoulder pain. TRIAL REGISTRATION: PROSPERO (CRD42019137831).

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.

The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders: a systematic review of the literature.

BACKGROUND: A small proportion of chiropractors, osteopaths, and other manual medicine providers use spinal manipulative therapy (SMT) to manage non-musculoskeletal disorders. However, the efficacy and effectiveness of these interventions to prevent or treat non-musculoskeletal disorders remain controversial. OBJECTIVES: We convened a Global Summit of international scientists to conduct a systematic review of the literature to determine the efficacy and effectiveness of SMT for the primary, secondary and tertiary prevention of non-musculoskeletal disorders. GLOBAL SUMMIT: The Global Summit took place on September 14-15, 2019 in Toronto, Canada. It was attended by 50 researchers from 8 countries and 28 observers from 18 chiropractic organizations. At the summit, participants critically appraised the literature and synthesized the evidence. SYSTEMATIC REVIEW OF THE LITERATURE: We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health, and the Index to Chiropractic Literature from inception to May 15, 2019 using subject headings specific to each database and free text words relevant to manipulation/manual therapy, effectiveness, prevention, treatment, and non-musculoskeletal disorders. Eligible for review were randomized controlled trials published in English. The methodological quality of eligible studies was assessed independently by reviewers using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for randomized controlled trials. We synthesized the evidence from articles with high or acceptable methodological quality according to the Synthesis without Meta-Analysis (SWiM) Guideline. The final risk of bias and evidence tables were reviewed by researchers who attended the Global Summit and 75% (38/50) had to approve the content to reach consensus. RESULTS: We retrieved 4997 citations, removed 1123 duplicates and screened 3874 citations. Of those, the eligibility of 32 articles was evaluated at the Global Summit and 16 articles were included in our systematic review. Our synthesis included six randomized controlled trials with acceptable or high methodological quality (reported in seven articles). These trials investigated the efficacy or effectiveness of SMT for the management of infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. None of the trials evaluated the effectiveness of SMT in preventing the occurrence of non-musculoskeletal disorders. Consensus was reached on the content of all risk of bias and evidence tables. All randomized controlled trials with high or acceptable quality found that SMT was not superior to sham interventions for the treatment of these non-musculoskeletal disorders. Six of 50 participants (12%) in the Global Summit did not approve the final report. CONCLUSION: Our systematic review included six randomized clinical trials (534 participants) of acceptable or high quality investigating the efficacy or effectiveness of SMT for the treatment of non-musculoskeletal disorders. We found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function. Governments, payers, regulators, educators, and clinicians should consider this evidence when developing policies about the use and reimbursement of SMT for non-musculoskeletal disorders.

Early life chronic inflammatory conditions predict low back pain in adolescence and young adulthood.

BACKGROUND: Associations between inflammatory conditions and low back pain (LBP) have been found frequently in older populations. However, the nature of these relationships in younger populations is unknown. This study aimed to investigate the associations between early life chronic or recurrent inflammatory conditions and impactful LBP in adolescence and young adulthood. METHODS: In this longitudinal study, we used data from the Raine Study Gen2 participants at the 1, 2, 3, 5, 8, 10, 14, 17, 20 and 22-year follow-ups (N = 2,868). Data were collected on inflammatory conditions from 1 to 22 years of age and occurrences of impactful LBP from 14 to 22 years of age. Longitudinal and cross-sectional associations between inflammatory conditions and impactful LBP occurrence were examined. Potential dose-response relationships between the number of inflammatory conditions and impactful LBP were also assessed. Logistic regression models were used in the analysis. RESULTS: Participants with respiratory or atopic conditions during childhood had increased odds of future impactful LBP in adolescence and young adulthood (odds ratio (OR) [95% confidence interval (CI)] = 1.29 [1.07, 1.54] and 1.23 [1.02, 1.49], respectively). There were cross-sectional associations between inflammatory conditions including respiratory, skin, musculoskeletal, autoimmune and atopic conditions, with impactful LBP. Participants with two illnesses and three or more illnesses had an increased odds (OR [95% CI] =1.68 [1.30, 2.18] and OR [95% CI] =2.12 [1.54, 2.89], respectively) of reporting impactful LBP. CONCLUSIONS: Overall, longitudinal and cross-sectional associations of respiratory and atopic conditions with impactful LBP in adolescence and young adulthood were identified. More evidence is needed to determine whether there is a causal relationship between chronic inflammatory conditions and impactful LBP. SIGNIFICANCE: Low back pain (LBP) is a prominent and significant health problem and associations between inflammatory conditions and LBP have been found frequently in older populations. We found that children with respiratory or atopic conditions and those with several chronic inflammatory conditions are at increased odds of impactful LBP in adolescence and young adulthood. In clinical practice and future research, there is a need to consider comorbidities also in younger populations.

Chiropractic conservatism among chiropractic students in Denmark: prevalence and consequences.

BACKGROUND: The chiropractic profession is split between those practicing evidence-based and those whose practice is honed by vitalism. The latter has been coined 'chiropractic conservatism'. In Denmark, the chiropractic education program is university-based in close collaboration with a medical faculty. We wanted to investigate if such conservative attitudes were present in this environment. Our objectives were to i) determine the level of chiropractic conservatism, ii) investigate if this was linked to academic year of study, iii) determine the level of clinical appropriateness, and iv) to investigate if this was affected by the level of conservatism among students in a chiropractic program, where the students are taught alongside medical students at the University of Southern Denmark (SDU). METHODS: A cross-sectional survey of 146 (response-rate 76%) 3rd to 5th year pre-graduate students and 1st year postgraduate clinical interns from the chiropractic degree course at the University of Southern Denmark was conducted during autumn of 2019. The students' levels of conservatism were dichotomized into appropriate/inappropriate, summed up, and used in a linear regression model to determine the association with academic year of study. Thereafter, the conservatism score was categorized into four groups (from low -1- to high -4-). Conservatism groups were cross-tabulated with the ability to answer appropriately on nine cases concerning i) contra-indications, ii) non-indications, and iii) indications for spinal manipulation and analyzed using logistic regression. RESULTS: Generally, the Danish chiropractic students had low conservatism scores, decreasing with increasing academic year of study. Seventy percent of the students were placed in the two lowest conservative groups. The level of conservatism (categories 1-3) was moderately (but not statistically significantly) associated with an inability to recognize non-indications to treatment. Three outliers (category 4), however, revealed a highly inappropriate handling of the clinical cases. CONCLUSIONS: Chiropractic students enrolled at a university-based course closely integrated with a medical teaching environment are not immune to chiropractic conservatism. However, the course appears to attenuate it and limit its effect on clinical decision-making compared to other educational institutions.

Misinformation, chiropractic, and the COVID-19 pandemic.

BACKGROUND: In March 2020, the World Health Organization elevated the coronavirus disease (COVID-19) epidemic to a pandemic and called for urgent and aggressive action worldwide. Public health experts have communicated clear and emphatic strategies to prevent the spread of COVID-19. Hygiene rules and social distancing practices have been implemented by entire populations, including 'stay-at-home' orders in many countries. The long-term health and economic consequences of the COVID-19 pandemic are not yet known. MAIN TEXT: During this time of crisis, some chiropractors made claims on social media that chiropractic treatment can prevent or impact COVID-19. The rationale for these claims is that spinal manipulation can impact the nervous system and thus improve immunity. These beliefs often stem from nineteenth-century chiropractic concepts. We are aware of no clinically relevant scientific evidence to support such statements. We explored the internet and social media to collect examples of misinformation from Europe, North America, Australia and New Zealand regarding the impact of chiropractic treatment on immune function. We discuss the potential harm resulting from these claims and explore the role of chiropractors, teaching institutions, accrediting agencies, and legislative bodies. CONCLUSIONS: Members of the chiropractic profession share a collective responsibility to act in the best interests of patients and public health. We hope that all chiropractic stakeholders will view the COVID-19 pandemic as a call to action to eliminate the unethical and potentially dangerous claims made by chiropractors who practise outside the boundaries of scientific evidence.

Correction to: Feasibility study: one year fortnightly follow-up of the evolution of supra-spinatus degeneration via text-messages.

An amendment to this paper has been published and can be accessed via the original article.