Goal setting in people with low back pain attending an education and exercise program (GLA:D Back) and the impact of demographic factors.

BACKGROUND: Individual goal setting is a fundamental element in self-management supportive interventions, serving to guide actions and enhance motivation for engagement. Despite this, little is known about the goals people with back pain have and to what extent these differ across genders, age groups and geographical location. This study aimed to elucidate this by first describing individual goals set by Danish and Canadian participants in a self-management intervention for people with back pain using the ICF framework; then, determining what proportion of these goals met criteria for being specific, measurable, acceptable, and time bound, and finally, by investigating differences between countries, sexes, and age groups. METHODS: In a cross-sectional study conducted August 2018 to June 2020, 394 Danish and 133 Canadian (Alberta Province) participants defined their individual goals of participating in a self-management programme involving patient education and supervised exercises. The goals were linked to the ICF framework. Distribution of goals was compared between countries, sexes, and age groups. RESULTS: Goals most often related to the ICF component of 'Activity and Participation'. The most prevalent goals were "Walking" (DK: 20%; CA: 15%) and "Maintaining a body position" (DK: 17%; CA: 22%). Only few goals differed between populations, age and sex. All elements of SMART goal setting were recorded for 88% of Danish and 94% of Alberta participants. CONCLUSIONS: People with low back pain attending a self-management programme established goals according to the SMART criteria and focused primarily on activity. Goals were similar across countries and showed few differences across sex and age groups. The high number of different goals points to the need for individualised person-centred care.

Presenters at chiropractic research conferences 2010-2019: is there a gender equity problem?

BACKGROUND: Presenting at professional and scientific conferences can be an important part of an individual's career advancement, especially for researchers communicating scientific findings, and can signal expertise and leadership. Generally, women presenting at conferences are underrepresented in various science disciplines. We aimed to evaluate the gender of presenters at research-oriented chiropractic conferences from 2010 to 2019. METHODS: We investigated the gender of presenters at conferences hosted by chiropractic organisations from 2010 to 2019 that utilised an abstract submission process. Gender classification was performed by two independent reviewers. The gender distribution of presenters over the ten-year period was analysed with linear regression. The association of conference factors with the gender distribution of presenters was also assessed with linear regression, including the gender of organising committees and abstract peer reviewers, and the geographic region where the conference was hosted. RESULTS: From 39 conferences, we identified 4,340 unique presentations. Women gave 1,528 (35%) of the presentations. No presenters were classified as gender diverse. Overall, the proportion of women presenters was 30% in 2010 and 42% in 2019, with linear regression demonstrating a 1% increase in women presenting per year (95% CI = 0.4-1.6%). Invited/keynote speakers had the lowest proportion of women (21%) and the most stagnant trajectory over time. The gender of conference organisers and abstract peer reviewers were not significantly associated with the gender of presenters. Oceanic conferences had a lower proportion of women presenting compared to North America (27% vs. 36%). CONCLUSIONS: Overall, women gave approximately one-third of presentations at the included conferences, which gradually increased from 2010 to 2019. However, the disparity widens for the most prestigious class of keynote/invited presenters. We make several recommendations to support the goal of gender equity, including monitoring and reporting on gender diversity at future conferences.

Why do patients with low back pain seek care at emergency department? A cross-sectional study.

BACKGROUND: It is unclear why patients with low back pain seek care in emergency departments. OBJECTIVES: We aim to describe the demographic, physical, and psychological characteristics, and reasons for seeking care at emergency departments due to an episode of low back pain. METHODS: This is a cross-sectional study conducted in an emergency department of a public hospital in São Paulo, Brazil, from September 2018 to May 2019. All patients who presented with a new episode of low back pain as the main complaint for seeking care at the emergency department on regular weekdays were invited to participate. We collected data on sociodemographic characteristics, general health characteristics, psychosocial risk factors, and reasons for visiting the emergency department. RESULTS: A total of 200 patients participated. We observed that most patients (68%) were women, with a mean age of 55 years, and who had previous episodes of low back pain (86%). Most patients went to the emergency department because they were worried about their pain (78%) and because they could not control their pain (73%). Patients also choose the emergency department because it is always available, it is free, and provided them good care. CONCLUSIONS: Most patients with low back pain seek care at emergency departments because they were worried about their pain and because the department is always open and does not require appointment. Understanding these reasons is an important step for the implementation of future public policies to make health care more efficient, to reduce unnecessary expenses and to avoid low-value care.

The impact and public health response of chiropractors to the COVID-19 pandemic: a survey across four continents.

BACKGROUND: The unprecedented impact of COVID-19 on healthcare professionals has implications for healthcare delivery, including the public health guidance provided to patients. This study aims to assess the response and impact of COVID-19 on chiropractors internationally, and examines the public health response of chiropractors to the COVID-19 pandemic practising under a musculoskeletal spine-care versus subluxation-based care paradigm. METHODS: A survey was distributed to chiropractors in Australia, Canada, Denmark, Hong Kong, United Kingdom and United States (Oct. 2nd-Dec. 22nd, 2020) via professional bodies/publications, and social media. Questions were categorised into three domains: socio-demographic, public health response and business/financial impact. Multivariable logistic regression explored survey items associated with chiropractors practising under different self-reported paradigms. RESULTS: A total of 2061 chiropractors representing four global regions completed the survey. Our recruitment method did not allow the calculation of an accurate response rate. The vast majority initiated COVID-19 infection control changes within their practice setting, including increased disinfecting of treatment equipment (95%), frequent contact areas (94%) and increased hand hygiene (94%). While findings varied by region, most chiropractors (85%) indicated that they had implemented regulator advice on the use of personal protective equipment (PPE). Suspension of face-to-face patient care during the peak of the pandemic was reported by 49% of the participants with 26% implementing telehealth since the pandemic began. Chiropractors practising under a musculoskeletal spine-care paradigm were more likely to implement some/all regulator advice on patient PPE use (odds ratio [OR] = 3.25; 95% confidence interval [CI]: 1.57, 6.74) and practitioner PPE use (OR = 2.59; 95% CI 1.32, 5.08); trust COVID-19 public health information provided by government/World Health Organisation/chiropractic bodies (OR = 2.47; 95% CI 1.49, 4.10), and initiate patient telehealth in response to COVID-19 (OR = 1.46; 95% CI 1.02, 2.08) compared to those practising under a subluxation-based paradigm. CONCLUSIONS: Chiropractors who responded to our survey made substantial infectious control changes in response to COVID-19. However, there was regional variation in the implementation of the advised practitioner and patient use of PPE and limited overall use of telehealth consultations by chiropractors during COVID-19. Musculoskeletal spine-care chiropractors were more adaptive to certain COVID-19 public health changes within their practice setting than subluxation-based chiropractors.

GLA:D® Back Australia: a mixed methods feasibility study for implementation.

BACKGROUND: Practice-based guidelines recommend patient education and exercise as first-line care for low back pain (LBP); however, these recommendations are not routinely delivered in practice. GLA:D® Back, developed in Denmark to assist clinicians to implement guideline recommendations, offers a structured education and supervised exercise program for people with LBP in addition to a clinical registry to evaluate patient outcomes. In this study we evaluated the feasibility of implementing the GLA:D® Back program in Australia. We considered clinician and patient recruitment and retention, program fidelity, exploring clinicians' and patients' experiences with the program, and participant outcome data collection. METHODS: Clinicians (chiropractors and physiotherapists) were recruited and participated in a 2-day GLA:D® Back training course. Patients were eligible to participate if they had persistent or recurrent LBP. Feasibility domains included the ability to: (1) recruit clinicians to undergo training; (2) recruit and retain patients in the program; (3) observe program fidelity; and (4) perceive barriers and facilitators for GLA:D® Back implementation. We also collected data related to: (5) clinician confidence, attitudes, and behaviour; and (6) patient self-reported outcomes related to pain, disability, and performance tests. RESULTS: Twenty clinicians (8 chiropractors, 12 physiotherapists) participated in the training, with 55% (11/20) offering GLA:D® Back to their patients. Fifty-seven patients were enrolled in the program, with 67% (38/57) attending the final follow-up assessment. Loss to follow up was mainly due to the effects of the COVID-19 pandemic. We observed program fidelity, with clinicians generally delivering the program as intended. Interviews revealed two clinician themes related to: (i) intervention acceptability; and (ii) barriers and facilitators to implementation. Patient interviews revealed themes related to: (i) intervention acceptability; and (ii) program efficacy. At 3 months follow-up, clinicians demonstrated high treatment confidence and biomedical orientation. Patient outcomes trended towards improvement. CONCLUSION: GLA:D® Back implementation in Australia appears feasible based on clinician recruitment, program acceptability and potential benefits for patient outcomes from the small sample of participating clinicians and patients. However, COVID-19 impacted patient recruitment, retention, and data collection. To scale-up GLA:D® Back in private and public settings, further work is warranted to address associated barriers, and to leverage facilitators.

A Reference Database of Standardised Continuous Lumbar Intervertebral Motion Analysis for Conducting Patient-Specific Comparisons.

Lumbar instability has long been thought of as the failure of lumbar vertebrae to maintain their normal patterns of displacement. However, it is unknown what these patterns consist of. Research using quantitative fluoroscopy (QF) has shown that continuous lumbar intervertebral patterns of rotational displacement can be reliably measured during standing flexion and return motion using standardised protocols and can be used to assess patients with suspected lumbar spine motion disorders. However, normative values are needed to make individualised comparisons. One hundred and thirty-one healthy asymptomatic participants were recruited and performed guided flexion and return motion by following the rotating arm of an upright motion frame. Fluoroscopic image acquisition at 15fps was performed and individual intervertebral levels from L2-3 to L5-S1 were tracked and analysed during separate outward flexion and return phases. Results were presented as proportional intervertebral motion representing these phases using continuous means and 95%CIs, followed by verification of the differences between levels using Statistical Parametric Mapping (SPM). A secondary analysis of 8 control participants matched to 8 patients with chronic, non-specific low back pain (CNSLBP) was performed for comparison. One hundred and twenty-seven asymptomatic participants' data were analysed. Their ages ranged from 18 to 70 years (mean 38.6) with mean body mass index 23.8 kg/m2 48.8% were female. Both the flexion and return phases for each level evidenced continuous change in mean proportional motion share, with narrow confidence intervals, highly significant differences and discrete motion paths between levels as confirmed by SPM. Patients in the secondary analysis evidenced significantly less L5-S1 motion than controls (p < 0.05). A reference database of spinal displacement patterns during lumbar (L2-S1) intersegmental flexion and return motion using a standardised motion protocol using fluoroscopy is presented. Spinal displacement patterns in asymptomatic individuals were found to be distinctive and consistent for each intervertebral level, and to continuously change during bending and return. This database may be used to allow continuous intervertebral kinematics to drive dynamic models of joint and muscular forces as well as reference values against which to make patient-specific comparisons in suspected cases of lumbar spine motion disorders.

A consensus approach toward the standardization of spinal stiffness measurement using a loaded rolling wheel device: results of a Delphi study.

BACKGROUND: Spinal stiffness assessment has the potential to become an important clinical measure. Various spinal stiffness-testing devices are available to help researchers objectively evaluate the spine and patient complaints. One of these is VerteTrack, a device capable of measuring posteroanterior displacement values over an entire spinal region. This study aimed to develop a best-practice protocol for evaluating spinal stiffness in human participants using VerteTrack. METHODS: Twenty-five individuals with research experience in measuring spinal stiffness, or who were trained in spinal stiffness measurement using the VerteTrack device, were invited to participate in this 3-Round Delphi study. Answers to open-ended questions in Round 1 were thematically analyzed and translated into statements about VerteTrack operation for spinal stiffness measurements. Participants then rated their level of agreement with these statements using a 5-point Likert scale in Rounds 2 and 3. A descriptive statistical analysis was performed. Consensus was achieved when at least 70% of the participants either strongly agreed, agreed, (or strongly disagreed, disagreed) to include a statement in the final protocol. RESULTS: Twenty participants completed Round 1 (80%). All these participants completed Rounds 2 and 3. In total, the pre-defined consensus threshold was reached for 67.2% (123/183) of statements after three rounds of surveys. From this, a best-practice protocol was created. CONCLUSIONS: Using a Delphi approach, a consensus-based protocol for measuring spinal stiffness using the VerteTrack was developed. This standard protocol will help to improve the accuracy, efficiency, and safety of spinal stiffness measurements, facilitate the training of new operators, increase consistency of these measurements in multicenter studies, and provide the synergy and potential for data comparison between spine studies internationally. Although specific to VerteTrack, the resulting standard protocol could be modified for use with other devices designed to collect spinal stiffness measures.

Leadership and capacity building in chiropractic research: report from the first CARL cohort.

The Chiropractic Academy for Research Leadership (CARL) was formed in 2016 in response to a need for a global network of early career researchers and leaders in the chiropractic profession. Thirteen fellows were accepted competitively and have since worked together at residentials and virtually on many research and leadership projects. In 2020, the CARL program ended for this first cohort, and it is now timely to take stock and reflect on the achievements and benefits of the program. In this paper we present the structure of CARL, the scientific and leadership outputs as well as the personal value of CARL for the participating fellows. As a result of the success of the first CARL cohort, organizations from Europe, North America, and Australia have supported a second cohort of 14 CARL fellows, who were competitively accepted into the program in early 2020.

Texture analysis in the classification of T2 -weighted magnetic resonance images in persons with and without low back pain.

Magnetic resonance imaging findings often do not distinguish between people with and without low back pain (LBP). However, there are still a large number of people who undergo magnetic resonance imaging to help determine the etiology of their back pain. Texture analysis shows promise for the classification of tissues that look similar, and machine learning can minimize the number of comparisons. This study aimed to determine if texture features from lumbar spine magnetic resonance imaging differ between people with and without LBP. In total, 14 participants with chronic LBP were matched for age, weight, and gender with 14 healthy volunteers. A custom texture analysis software was used to construct a gray-level co-occurrence matrix with one to four pixels offset in 0° direction for the disc and superior and inferior endplate regions. The Random Forests Algorithm was used to select the most promising classifiers. The linear mixed-effect model analysis was used to compare groups (pain vs. pain-free) at each level controlling for age. The Random Forest Algorithm recommended focusing on intervertebral discs and endplate zones at L4-5 and L5-S1. Differences were observed between groups for L5-S1 superior endplate contrast, homogeneity, and energy (p = .02). Differences were observed for L5-S1 disc contrast and homogeneity (p < .01), as well as for the inferior endplates contrast, homogeneity, and energy (p < .03). Magnetic resonance imaging textural features may have potential in identifying structures that may be the target of further investigations about the reasons for LBP.

Effects of muscle activity on lumbar spinal stiffness in asymptomatic adults: An investigation using a novel rolling device.

BACKGROUND: Device-based measurement of lumbar spinal stiffness has the potential to identify patients with low back pain who are more likely to improve with spinal manipulative therapy. This study evaluates how voluntary contraction of spine muscles may impact stiffness measures. OBJECTIVE: To determine how the contraction of different spinal muscles may influence spinal stiffness at all lumbar levels. DESIGN: Experimental study. METHOD: A mechanical device was used to measure spinal stiffness (N/mm) from L1 to L5 in 12 asymptomatic participants, while muscle activity from four pairs of thoracolumbar muscles was recorded. A baseline measurement was collected with the participants holding their breath at normal exhalation. Participants stiffness was then measured while performing (1) an isometric hip extension, (2) an isometric shoulder flexion, and (3) a deep held inhalation. Mixed-model ANOVAs were used to evaluate the effects of the perturbations on spinal stiffness at each lumbar level. Friedman's test was then computed to evaluate the differences in muscle activity between the perturbations. RESULTS: Globally, the designed perturbations generated activity in different muscles with different magnitudes (P-values≤0.05). Increased spinal stiffness was observed at each spinal level during the hip extension, and at L5 during the held inhalation (P-values<0.05). A differential effect of the spinal levels on the spinal stiffness was observed during the hip extension and held inhalation (P-values<0.05). CONCLUSION: This study provides evidence that the magnitude of muscle activity influences spinal stiffness, but not equally between lumbar levels.

Comparing the effectiveness of group-based exercise to other non-pharmacological interventions for chronic low back pain: A systematic review.

BACKGROUND: Low back pain (LBP) is the leading cause of disability worldwide with a substantial financial burden on individuals and health care systems. To address this, clinical practice guidelines often recommend non-pharmacological, non-invasive management approaches. One management approach that has been recommended and widely implemented for chronic LBP is group-based exercise programs, however, their clinical value compared with other non-pharmacological interventions has not been investigated systematically. OBJECTIVE: To compare the effectiveness of group-based exercise with other non-pharmacological interventions in people with chronic LBP. METHODS: Four electronic databases were searched by two independent reviewers. Only randomized controlled trials that compared group-based exercise with other non-pharmacological interventions for chronic LBP were eligible. Study quality was assessed using the Cochrane Handbook for systematic reviews of Interventions by two independent reviewers. RESULTS: Eleven studies were eligible. We identified strong evidence of no difference between group exercise and other non-pharmacologic interventions for disability level and pain scores 3-month post-intervention in people with chronic LBP. We could not find any strong or moderate evidence for or against the use of group-based exercise in the rehabilitation of people with chronic LBP for other time-points and health measurement outcomes. We found no statistically significant differences in disability and quality of life and pain between the group and individual non-pharmacological interventions that included exercise. CONCLUSION: With this equivocal finding, group-based exercise may be a preferred choice given potential advantages in other domains not reviewed here such as motivation and cost. Further research in this area is needed to evaluate this possibility.

Beliefs, perceptions and practices of chiropractors and patients about mitigation strategies for benign adverse events after spinal manipulation therapy.

BACKGROUND: Approximately 50% of patients who receive spinal manipulative therapy (SMT) experience some kind of adverse event (AE), typically benign and transient in nature. Regardless of their severity, mitigating benign AEs is important to improve patient experience and quality of care. The aim of this study was to identify beliefs, perceptions and practices of chiropractors and patients regarding benign AEs post-SMT and potential strategies to mitigate them. METHODS: Clinicians and patients from two chiropractic teaching clinics were invited to respond to an 11-question survey exploring their beliefs, perceptions and practices regarding benign AEs post-SMT and strategies to mitigate them. Responses were analyzed using descriptive statistics. RESULTS: A total of 39 clinicians (67% response rate) and 203 patients (82.9% response rate) completed the survey. Most clinicians (97%) believed benign AEs occur, and 82% reported their own patients have experienced one. For patients, 55% reported experiencing benign AEs post-SMT, with the most common symptoms being pain/soreness, headache and stiffness. While most clinicians (61.5%) reported trying a mitigation strategy with their patients, only 21.2% of patients perceived their clinicians had tried any mitigation strategy. Clinicians perceived that patient education is most likely to mitigate benign AEs, followed by soft tissue therapy and/or icing after SMT. Patients perceived stretching was most likely to mitigate benign AEs, followed by education and/or massage. CONCLUSIONS: This is the first study comparing beliefs, perceptions and practices from clinicians and patients regarding benign AEs post-SMT and strategies to mitigate them. This study provides an important step towards identifying the best strategies to improve patient safety and improve quality of care.

Vaccination discourses among chiropractors, naturopaths and homeopaths: A qualitative content analysis of academic literature and Canadian organizational webpages.

Vaccine hesitancy-the reluctance to receive recommended vaccination because of concerns and doubts about vaccines-is recognized as a significant threat to the success of vaccination programs and has been associated with recent major outbreaks of vaccine-preventable diseases. Moreover, the association between complementary and alternative medicine (CAM) use and vaccine hesitancy and/or refusal has been frequently reported in the literature. To date, significant gaps persist in our understanding of contemporary Canadian CAM providers' beliefs regarding vaccination and how socio-professional influences may shape their vaccine-related attitudes and behaviours. To address the latter gap, the current study aims to explore the content of professional guidelines, recommendations and other discourses among CAM providers as they concern vaccination by analyzing both academic, peer-reviewed literature and Canadian organizational webpages prepared by and/or for practicing chiropractors, naturopaths and homeopaths. In the academic literature, we identified a number of complex and diverging views on vaccination that spanned topics of effectiveness; safety; theoretical, empirical, and ethical soundness; political justifiability; and compatibility with CAM philosophy and professional boundaries. However, in its current state the CAM literature cannot be described in broad strokes as being either pro- or anti-vaccination without considering finer areas of disagreement. Compared to the academic literature, which focuses more on the conceptual and evidentiary basis of vaccination, a greater proportion of vaccine-related content on Canadian CAM organizations' webpages seems to be dedicated to offering specific directives and prescriptions to providers. Guidelines and standards of practice address a number of issues, including vaccine administration, counsel, education and marketing. As CAM organizations further evolve in Canada and elsewhere as part of a broader "professionalization" initiative, greater attention will need to be directed at their role in shaping providers' beliefs and practices that both support and undermine vaccine promotion efforts.

Misinformation about spinal manipulation and boosting immunity: an analysis of Twitter activity during the COVID-19 crisis.

BACKGROUND: Social media has become an increasingly important tool in monitoring the onset and spread of infectious diseases globally as well monitoring the spread of information about those diseases. This includes the spread of misinformation, which has been documented within the context of the emerging COVID-19 crisis. Understanding the creation, spread and uptake of social media misinformation is of critical importance to public safety. In this descriptive study, we detail Twitter activity regarding spinal manipulative therapy (SMT) and claims it increases, or "boosts", immunity. Spinal manipulation is a common intervention used by many health professions, most commonly by chiropractors. There is no clinical evidence that SMT improves human immunity. METHODS: Social media searching software (Talkwalker Quick Search) was used to describe Twitter activity regarding SMT and improving or boosting immunity. Searches were performed for the 3 months and 12 months before March 31, 2020 using terms related to 1) SMT, 2) the professions that most often provide SMT and 3) immunity. From these searches, we determined the magnitude and time course of Twitter activity then coded this activity into content that promoted or refuted a SMT/immunity link. Content themes, high-influence users and user demographics were then stratified as either promoting or refuting this linkage. RESULTS: Twitter misinformation regarding a SMT/immunity link increased dramatically during the onset of the COVID crisis. Activity levels (number of tweets) and engagement scores (likes + retweets) were roughly equal between content promoting or refuting a SMT/immunity link, however, the potential reach (audience) of tweets refuting a SMT/immunity link was 3 times higher than those promoting a link. Users with the greatest influence on Twitter, as either promoters or refuters, were individuals, not institutions or organizations. The majority of tweets promoting a SMT/immunity link were generated in the USA while the majority of refuting tweets originated from Canada. CONCLUSION: Twitter activity about SMT and immunity increased during the COVID-19 crisis. Results from this work have the potential to help policy makers and others understand the impact of SMT misinformation and devise strategies to mitigate its impact.

A united statement of the global chiropractic research community against the pseudoscientific claim that chiropractic care boosts immunity.

BACKGROUND: In the midst of the coronavirus pandemic, the International Chiropractors Association (ICA) posted reports claiming that chiropractic care can impact the immune system. These claims clash with recommendations from the World Health Organization and World Federation of Chiropractic. We discuss the scientific validity of the claims made in these ICA reports. MAIN BODY: We reviewed the two reports posted by the ICA on their website on March 20 and March 28, 2020. We explored the method used to develop the claim that chiropractic adjustments impact the immune system and discuss the scientific merit of that claim. We provide a response to the ICA reports and explain why this claim lacks scientific credibility and is dangerous to the public. More than 150 researchers from 11 countries reviewed and endorsed our response. CONCLUSION: In their reports, the ICA provided no valid clinical scientific evidence that chiropractic care can impact the immune system. We call on regulatory authorities and professional leaders to take robust political and regulatory action against those claiming that chiropractic adjustments have a clinical impact on the immune system.

The use of internet analytics by a Canadian provincial chiropractic regulator to monitor, evaluate and remediate misleading claims regarding specific health conditions, pregnancy, and COVID-19.

BACKGROUND: Internet analytics are increasingly being integrated into public health regulation. One specific application is to monitor compliance of website and social media activity with respect to jurisdictional regulations. These data may then identify breaches of compliance and inform disciplinary actions. Our study aimed to evaluate the novel use of internet analytics by a Canadian chiropractic regulator to determine their registrants compliance with three regulations related to specific health conditions, pregnancy conditions and most recently, claims of improved immunity during the COVID-19 crisis. METHODS: A customized internet search tool (Market Review Tool, MRT) was used by the College of Chiropractors of British Columbia (CCBC), Canada to audit registrants websites and social media activity. The audits extracted words whose use within specific contexts is not permitted under CCBC guidelines. The MRT was first used in October of 2018 to identify words related to specific health conditions. The MRT was again used in December 2019 for words related to pregnancy and most recently in March 2020 for words related to COVID-19. In these three MRT applications, potential cases of word misuse were evaluated by the regulator who then notified the practitioner to comply with existing regulations by a specific date. The MRT was then used on that date to determine compliance. Those found to be non-compliant were referred to the regulator's inquiry committee. We mapped this process and reported the outcomes with permission of the regulator. RESULTS: In September 2018, 250 inappropriate mentions of specific health conditions were detected from approximately 1250 registrants with 2 failing to comply. The second scan for pregnancy related terms of approximately1350 practitioners revealed 83 inappropriate mentions. Following notification, all 83 cases were compliant within the specified timeframe. Regarding COVID-19 related words, 97 inappropriate mentions of the word "immune" were detected from 1350 registrants with 7 cases of non-compliance. CONCLUSION: Internet analytics are an effective way for regulators to monitor internet activity to protect the public from misleading statements. The processes described were effective at bringing about rapid practitioner compliance. Given the increasing volume of internet activity by healthcare professionals, internet analytics are an important addition for health care regulators to protect the public they serve.

Potential mechanisms for lumbar spinal stiffness change following spinal manipulative therapy: a scoping review.

INTRODUCTION: In individuals having low back pain, the application of spinal manipulative therapy (SMT) has been shown to reduce spinal stiffness in those who report improvements in post-SMT disability. The underlying mechanism for this rapid change in stiffness is not understood presently. As clinicians and patients may benefit from a better understanding of this mechanism in terms of optimizing care delivery, the objective of this scoping review of current literature was to identify if potential mechanisms that explain this clinical response have been previously described or could be elucidated from existing data. METHODS: Three literature databases were systematically searched (MEDLINE, CINAHL, and PubMed). Our search terms included subject headings and keywords relevant to SMT, spinal stiffness, lumbar spine, and mechanism. Inclusion criteria for candidate studies were publication in English, quantification of lumbar spinal stiffness before and after SMT, and publication between January 2000 and June 2019. RESULTS: The search identified 1931 articles. Of these studies, 10 were included following the application of the inclusion criteria. From these articles, 7 themes were identified with respect to potential mechanisms described or derived from data: 1) change in muscle activity; 2) increase in mobility; 3) decrease in pain; 4) increase in pressure pain threshold; 5) change in spinal tissue behavior; 6) change in the central nervous system or reflex pathways; and 7) correction of a vertebral dysfunction. CONCLUSIONS: This scoping review identified 7 themes put forward by authors to explain changes in spinal stiffness following SMT. Unfortunately, none of the studies provided data which would support the promotion of one theme over another. As a result, this review suggests a need to develop a theoretical framework to explain rapid biomechanical changes following SMT to guide and prioritize future investigations in this important clinical area.