Qualitative Assessment CIH Institutions' Engagement With Underserved Communities to Enhance Healthcare Access and Utilization.

Background: In North America, there is a notable underutilization of complementary and integrative health approaches (CIH) among non-White and marginalized communities. Objectives: This study sought to understand how CIH educational instutitions are proactively working to redress this disparity in access and utilization among these communities. Methods: We conducted interviews with 26 key informants, including presidents, clinicians, and research deans across 13 CIH educational institutions across the US and Canada. Thematic analysis included deductive codes based on the interview guide during interview scripts review. Results: Six themes were identified: (1) CIH institutions often had a long and varied history of community engaged care through partnerships to increase access and utilization; (2) CIH institutions' long-standing community outreach had been intentionally designed; (3) CIH institutions provided an array of services to a wide range of demographics and communities; (4) addressing healthcare access and utilization through community partnerships had a strong positive impact; (5) funding, staffing and COVID-19 were significant challenges that impeded efforts to increase CIH access through community engaged work; (6) identified gaps in community partnerships and services to increase access and utilization were recognized. Conclusion: These findings underscore significant efforts made to enhance healthcare access and utilization among marginalized, underserved, and racial and ethnic communities. However, barriers such as funding constraints, resource allocation, and the need for proper measurement and accountability hinder proactive initiatives aimed at redressing disparities in CIH utilization within these communities.

Building Bridges Toward Common Goals - A Call for Greater Collaboration Between Public Health and Integrative, Complementary and Traditional Health Providers.

This commentary makes the case for greater collaboration between public health professionals and integrative, complementary and traditional health practitioners (ICTHP). Previous partnerships have been successful, and more such collaborative work is needed to help overcome division, enhance the health workforce, and move all involved toward shared goals. ICTHP providers may be uniquely able to work across ideological differences and engage individuals and communities who are less trusting of public health, including those who are vaccine hesitant. Diverse partnerships can be difficult to maintain, but the application of equitable processes may aid their success. In the face of highly complex public health challenges, partnerships with ICTHP are critical.

The John A. Sweaney Lecture: Virtual, September 2021, Given by Dr Michele Maiers. A Time to Lead: Reflections During a Pandemic.

The following is The John A. Sweaney Lecture delivered by Dr Michele Maiers at the biannual Congress of the World Federation of Chiropractic that was held virtually on September 25, 2021.

Multidisciplinary integrative care versus chiropractic care for low back pain: a randomized clinical trial.

BACKGROUND: Low back pain (LBP) is influenced by interrelated biological, psychological, and social factors, however current back pain management is largely dominated by one-size fits all unimodal treatments. Team based models with multiple provider types from complementary professional disciplines is one way of integrating therapies to address patients' needs more comprehensively. METHODS: This parallel group randomized clinical trial conducted from May 2007 to August 2010 aimed to evaluate the relative clinical effectiveness of 12 weeks of monodisciplinary chiropractic care (CC), versus multidisciplinary integrative care (IC), for adults with sub-acute and chronic LBP. The primary outcome was pain intensity and secondary outcomes were disability, improvement, medication use, quality of life, satisfaction, frequency of symptoms, missed work or reduced activities days, fear avoidance beliefs, self-efficacy, pain coping strategies and kinesiophobia measured at baseline and 4, 12, 26 and 52 weeks. Linear mixed models were used to analyze outcomes. RESULTS: 201 participants were enrolled. The largest reductions in pain intensity occurred at the end of treatment and were 43% for CC and 47% for IC. The primary analysis found IC to be significantly superior to CC over the 1-year period (P = 0.02). The long-term profile for pain intensity which included data from weeks 4 through 52, showed a significant advantage of 0.5 for IC over CC (95% CI 0.1 to 0.9; P = 0.02; 0 to 10 scale). The short-term profile (weeks 4 to 12) favored IC by 0.4, but was not statistically significant (95% CI - 0.02 to 0.9; P = 0.06). There was also a significant advantage over the long term for IC in some secondary measures (disability, improvement, satisfaction and low back symptom frequency), but not for others (medication use, quality of life, leg symptom frequency, fear avoidance beliefs, self-efficacy, active pain coping, and kinesiophobia). Importantly, no serious adverse events resulted from either of the interventions. CONCLUSIONS: Participants in the IC group tended to have better outcomes than the CC group, however the magnitude of the group differences was relatively small. Given the resources required to successfully implement multidisciplinary integrative care teams, they may not be worthwhile, compared to monodisciplinary approaches like chiropractic care, for treating LBP. Trial registration NCT00567333.

"Like Peanut Butter and Jelly": A Qualitative Study of Chiropractic Care and Home Exercise Among Older Adults With Spinal Disability.

OBJECTIVE: A mixed-methods, randomized controlled trial comparing short- and long-term chiropractic care and exercise therapy for spinal disability in older adults found no between-group differences in the primary outcome. However, those who received long-term management reported greater improvement in neck pain, self-efficacy, function, and balance. This nested qualitative study explored participants' perceptions of the benefits and drawbacks of chiropractic care and exercise for spine-related outcomes, with an emphasis on understanding what makes treatment for spine-related problems worthwhile. METHODS: Of 171 individual interviews conducted after completing study treatment, 50 participants (25 per treatment group) were randomly selected for this analysis. Qualitative descriptive analysis included dual coding of verbatim transcripts by 2 investigators (MM and SAS), which was further distilled into a consensus-derived codebook of themes and organized using NVIVO software. RESULTS: Participants described trial interventions as complementary to one another for spine-related disability. Chiropractic care was viewed as improving spinal pain and controlling symptoms, while exercise therapy was noted for its long-term impact on self-efficacy and self-management. These older adults considered changes in pain, global sense of improvement, and improved biomechanical function as making treatment worthwhile. CONCLUSION: Older adults valued nonpharmacologic treatment options that aided them in controlling spine-related symptoms, while empowering them to maintain clinical benefit gained after a course of chiropractic spinal manipulation and exercise. The complementary nature of provider-delivered and active care modalities may be an important consideration when developing care plans. This study underscores the importance of understanding participants' values and experiences when interpreting study results and applying them to practice.

Discrepant Perceptions of Biopsychosocial and Active Care Recommendations Between Doctors of Chiropractic and Midlife and Older Adult Patients: A Descriptive Survey.

OBJECTIVE: The purpose of this study was to assess perceptions about the inclusion of biopsychosocial and active care recommendations during chiropractic clinical encounters between doctors of chiropractic (DCs) and their midlife and older adult patients and to identify whether there were any discrepancies between their recollections. METHODS: This descriptive cross-sectional survey was part of a mixed-methods research project designed to gather information about the role of electronic health interventions for midlife and older adults who use chiropractic care. For this study, a convenience sample of 29 DCs and 48 chiropractic patients aged 50 years and older from 2 metropolitan areas in the United States completed online surveys between December 2020 and May 2021. The survey matched questions about components of chiropractic care discussed by patients and providers over 12 months. We used descriptive statistics to explore congruence in perceptions between groups and qualitative content analysis to describe DC perceptions of working with this population. RESULTS: Doctors of chiropractic and patients agreed (>90%) that pain management was the top reason midlife and older adults seek chiropractic care, yet differed in their prioritization of maintenance/wellness care, physical function/rehabilitation, and injury treatment as care drivers. While DCs reported frequent discussions about psychosocial recommendations, fewer patients reported talking about treatment goals (51%), self-care (43%), stress reduction (33%), or the impact of psychosocial factors (23%) and beliefs/attitudes (33%) on spinal health. Patients reported varied recollections about discussing activity limitations (2%) and exercise promotion (68%), being taught exercises (48%), or reassessing exercise progress (29%), which differed from higher levels reported by DCs. Qualitative themes from DCs included psychosocial considerations in patient education, importance of exercise/movement, role of chiropractic in lifestyle changes, and reimbursement limitations for older patients. CONCLUSION: Doctors of chiropractic and their patients reported discrepant perceptions about biopsychosocial and active care recommendations during clinical encounters. Patients reported modest emphasis on exercise promotion and limited discussion on self-care, stress reduction, and psychosocial factors related to spine health compared to the recollections of DCs who reported frequent discussions of these topics.

Gender diversity in chiropractic leadership: a cross-sectional study.

BACKGROUND: The purpose of this cross-sectional study was to compare the number of males and females in leadership positions, and whether there is a relationship between gender and degrees held in those positions, within chiropractic academic institutions, national regulatory bodies and the most widely representative national professional associations in the United States and Canada. METHODS: Publicly accessible websites from chiropractic institutions and organizations were used to collect data. Pearson χ2 tests of independence were conducted to determine the relationship between gender (male vs. female) and other variables, including position (principal vs secondary), and chiropractic and other advanced professional degrees. RESULTS: A total of 107 leaders were identified across institutions and organizations. Under one-third of leaders (30.8%) were identified as female. Males were more likely to be in principal leadership roles (86.2%) and more likely to be in a secondary leadership position (62.8%). CONCLUSION: Male leaders significantly outnumber female leaders in both principal and secondary leadership positions within American and Canadian chiropractic institutions. Strategies should be developed to include gender diversity within all chiropractic organizations.

CONTEXTE: Cette étude transversale visait à comparer le nombre d'hommes à celui de femmes occupant des postes de direction, et à savoir s'il existe un lien entre le sexe et les diplômes détenus par les titulaires de postes dans les établissements d'enseignement de la chiropratique, les organismes nationaux de réglementation et les associations professionnelles nationales les plus reconnues aux États-Unis et au Canada. MÉTHODOLOGIE: Des données ont été recueillies dans les sites Web accessibles au public des établissements chiropratiques. Des tests d'indépendance du shi-carré (χ2) ont été effectués pour établir le rapport hommesfemmes et le lien avec d'autres variables, notamment le rapport entre les postes de directeur principal et les postes de directeur adjoint, les diplômes en chiropratique et des diplômes d'études avancées. RÉSULTATS: On a recensé au total 107 directeurs de cliniques et d'organismes. Moins d'un tiers des titulaires de ces postes de direction (30,8 %) étaient des femmes. Les hommes étaient plus susceptibles d'occuper des postes de directeur principal (86,2 %) et des postes de directeur adjoint (62,8 %). CONCLUSION: Les hommes sont nettement plus nombreux que les femmes à occuper des postes de directeur principal ou de directeur adjoint dans les cliniques chiropratiques américaines et canadiennes. On devrait élaborer des stratégies visant à assurer la diversité des sexes dans toutes les cliniques chiropratiques.

Association Between Psychosocial Parameters and Response to Chiropractic Care Among Older Adults With Chronic Low Back Pain: Secondary Analysis of a Randomized Clinical Trial.

OBJECTIVES: The purpose of this study was to determine whether baseline self-efficacy, fear of pain with movement (kinesiophobia), or change in either were associated with clinically important improvement in disability among older adults with chronic low back pain after 12 weeks of chiropractic spinal manipulation (CSM) and exercise. METHODS: This secondary analysis used randomized trial data from community-dwelling adults aged 65 years or older with chronic spinal disability who received non-pharmacological treatment of CSM and exercise. Those with ≥30% reduction in the Oswestry Disability Index (ODI) after 12 weeks of treatment were considered responders to care. Psychosocial measures included the Pain Self-Efficacy Questionnaire (PSEQ) and the Tampa Scale of Kinesiophobia (TSK). Logistic regression-assessed associations were between psychosocial, demographic, and low back predictors and 30% ODI improvement. RESULTS: There were 176 community-dwelling older adults included in this analysis. Mean age was 71 years, 59.7% were women; 176 (96.7%) had complete data. Baseline disability (ODI = 26.1 ± 9.3) and back pain (5.0 ± 1.9, 0-10 scale) were moderate. Baseline PSEQ reflected higher self-efficacy (47.7 ± 7.8, 0-60 scale) with minimal kinesiophobia (TSK 34.3 ± 5.2, 17-68 scale). Seventy-two (40.9%) achieved 30% reduction in ODI (mean -5.4 ± 7.9) after 12 weeks of treatment. Mean self-efficacy improvement was clinically important (2.5 ± 6.5 points); kinesiophobia (-2.7 ± 4.4 points) and LBP (-1.6 points) also improved. Baseline PSEQ and percent improvement in PSEQ and TSK were associated with response to treatment in univariate regression analyses but not in multiple regression models that included low back predictors. LBP duration >4 years negatively impacted recovery. CONCLUSIONS: Among this sample of older adults who received chiropractic manipulation and exercise, baseline self-efficacy and improvements in self-efficacy and kinesiophobia were individually associated with clinically important reductions in disability post-intervention, although not in adjusted models when LBP duration was included.

Qualitative Analysis of Illness Representations and Coping Perceptions Among Older Adults With Chronic Spinal Disability: "A Thought in the Back of My Mind".

OBJECTIVE: The purpose of this study was to explore older adults' illness representations, their beliefs about health, and their coping perceptions of chronic spinal disability. METHODS: This qualitative descriptive study used structured interviews that were completed during a randomized trial of non-pharmacological management of spine-related disability with chiropractic spinal manipulative therapy and exercise. Dual coders conducted a descriptive thematic analysis of 50 randomly selected transcripts supported by qualitative data management software. The Common-Sense Model provided an organizing framework for coding and interpretation. RESULTS: Fifty participants (34 women, median age: 68 years) described 4 illness representations, 4 coping styles, and 6 coping strategies for their management of spinal disability. Illness representations formed a continuum of little-to-no health impact to bothersome symptoms to heightened symptom intensity to unmanaged pain and/or disability. Most participants adopted either self-care or self-management coping styles, but some used healthcare-seeking or fear avoidance with worsening symptoms or interference with employment or preferred activities. Participants mentioned 6 coping strategies for spinal disability. Distraction included position changes, hobbies, and supportive relationships. Limitation focused on rest and/or relaxation, restricted movements, and activity modifications. Prevention enhanced self-care knowledge, posture and/or ergonomics, nutrition, and stress management. Movement emphasized stretching, home exercise and/or walking, and exercise therapy. Palliation augmented patient comfort through the use of heat and/or ice, over-the-counter medicine, and spinal manipulation. Avoidance strategies included missing employment, stopping house and/or yard work, and prescription medication. CONCLUSION: The community-dwelling older adults in this study offered varied illness representations of their chronic spinal disability. Most participants combined and personalized coping strategies to minimize pain and symptom impact; thus, representations may influence the coping styles adopted by older persons to manage their spinal conditions. A quote from a participant that pain was "a thought in the back of my mind" suggests the presence of cognitive and emotional processes that may influence individual perceptions and feelings about their spinal symptoms or conditions. These findings suggest that there may be a broader role for spine care clinicians to include teaching older people about self-management strategies to better cope with spinal disabilities.

Comparing Two Moderate-to-Vigorous Physical Activity Accelerometer Cut Points in Older Adults With Neck and Back Disabilities Undergoing Exercise and Spinal Manipulation Interventions.

Different techniques used to analyze and reduce accelerometer data may impact its interpretation. To determine which variables were impacted by changing analysis parameters, the authors performed a secondary analysis of data gained from a clinical trial conducted on older adults (aged ≥65 years; M = 71.1 and SD = 5.3; n = 100) with neck and back disabilities and compared the effects of two different cut- point sets (Matthews and Freedson sets) commonly used to analyze older adult accelerometry data. The Matthews set was found to assign significantly greater moderate-to-vigorous physical activity per day than the Freedson set in all comparisons. This suggests that, if moderate-to-vigorous physical activity per unit time is a primary outcome measure, the choice of which analysis method is used should be carefully considered. Further results from analyses of dependent variables, time in moderate-to-vigorous physical activity bouts of >10 min/day, mean bout length, and number of bouts per day are discussed.

Assessing attitudes of patient-centred care among students in international chiropractic educational programs: a cross-sectional survey.

Background: Patient-centred care is internationally recognized as a foundation of quality patient care. Attitudes of students towards patient-centred care have been assessed in various health professions. However, little is known how chiropractic students' attitudes towards patient-centred care compare to those of other health professions or whether they vary internationally, and between academic programs. Objective: To assess the association of select variables on student attitude towards patient-centred care among select chiropractic programs worldwide. Methods: We conducted a cross-sectional study using the Patient-Practitioner Orientation Scale (PPOS) to assess students' patient-centred attitudes towards the doctor-patient relationship. Eighteen items were scored on a 1 to 6 Likert scale; higher scores indicating more patient-centredness. All students from seven chiropractic educational programs worldwide were invited to complete an online survey. Results were analyzed descriptively and inferentially for overall, sharing and caring subscales. General linear regression models were used to assess the association of various factors with PPOS scores. Results: There were 1858 respondents (48.9% response rate). Student average age was 24.7 (range = 17-58) years and 56.2% were female. The average overall PPOS score was 4.18 (SD = 0.48) and average sharing and caring subscale scores were 3.89 (SD = 0.64) and 4.48 (SD = 0.52), respectively. There were small but significant differences in all PPOS scores by gender, age, and program. Year/semester of study within a program typically was not associated with scores, neither was history of previous chiropractic care nor having family members who are health professionals. Conclusion: This is the first international study assessing students' attitudes of patient-centred care in chiropractic educational programs. We found small but significantly different PPOS scores between chiropractic programs worldwide that did not change across year/semester of study. Scores tended to be lower than those reported among medical students. Observed differences may be related to curricular content, extent of patient exposure and/or regional cultural realities.

Differences in Function and Comorbidities Between Older Adult Users and Nonusers of Chiropractic and Osteopathic Manipulation: A Cross-sectional Analysis of the 2012 National Health Interview Survey.

OBJECTIVE: The purpose of this cross-sectional study was to compare functional limitations and comorbidity prevalence between older adult users and nonusers of chiropractic and osteopathic (DC/DO) manipulation to inform provider training. METHODS: We conducted a secondary analysis of the 2012 National Health Interview Survey data. Adults age 65 or older who responded to the survey were included. Descriptive statistics are reported for adults who used DC/DO manipulation (vs nonusers) regarding function, comorbidities, musculoskeletal complaints, and medical services. Weighted percentages were derived using SAS and compared with χ2 tests. RESULTS: The DC/DO users were more often female, overweight or obese, and of white race than nonusers. More DC/DO users reported arthritis (55.3% vs 47.0%, <0.01) or asthma (15.0% vs 10.0%, P < .01) than nonusers; hypertension (61.9% vs 55.5%, P = .02) and diabetes (20.3% vs 15.7%, P = .02) were more prevalent in nonusers; and other comorbidities were comparable. The DC/DO users reported more joint pain/stiffness (55.7% vs 44.8%), chronic pain (19.8% vs 14.2%), low back pain (27.8% vs 18.4%), low back with leg pain (18.8% vs 10.6%), and neck pain (24.2% vs 13.1%) than nonusers (all P < .01). Functional limitations affected two-thirds overall, but DC/DO users reported more difficulties stooping and bending; other limitations were comparable. One in 9 reported activities of daily living or instrumental activities of daily living limitations; nonusers were more affected. Surgery was more common among DC/DO users (26.1% vs 19.3%, <0.01); emergency room visits were comparable. CONCLUSION: Differences existed between older adult manipulation users and nonusers, especially surgical utilization, musculoskeletal complaints, and comorbidities; functional differences were modest. Our findings highlight areas for provider training and awareness regarding comorbidity burden and management needs in older patients who may simultaneously use manipulation and medical care for musculoskeletal complaints.

Spinal manipulative therapy and exercise for older adults with chronic low back pain: a randomized clinical trial.

Background: Low back pain (LBP) is a common disabling condition in older adults which often limits physical function and diminishes quality of life. Two clinical trials in older adults have shown spinal manipulative therapy (SMT) results in similar or small improvements relative to medical care; however, the effectiveness of adding SMT or rehabilitative exercise to home exercise is unclear. Methods: We conducted a randomized clinical trial assessing the comparative effectiveness of adding SMT or supervised rehabilitative exercise to home exercise in adults 65 or older with sub-acute or chronic LBP. Treatments were provided over 12-weeks and self-report outcomes were collected at 4, 12, 26, and 52 weeks. The primary outcome was pain severity. Secondary outcomes included back disability, health status, medication use, satisfaction with care, and global improvement. Linear mixed models were used to analyze outcomes. The primary analysis included longitudinal outcomes in the short (week 4-12) and long-term (week 4-52). An omnibus test assessing differences across all groups over the year was used to control for multiplicity. Secondary analyses included outcomes at each time point and responder analyses. This study was funded by the US Department of Health and Human Services, Health Resources and Services Administration. Results: 241 participants were randomized and 230 (95%) provided complete primary outcome data. The primary analysis showed group differences in pain over the one-year were small and not statistically significant. Pain severity was reduced by 30 to 40% after treatment in all 3 groups with the largest difference (eight percentage points) favoring SMT and home exercise over home exercise alone. Group differences at other time points ranged from 0 to 6 percentage points with no consistent pattern favoring one treatment. One-year post-treatment pain reductions diminished in all three groups. Secondary self-report outcomes followed a similar pattern with no important group differences, except satisfaction with care, where the two combination groups were consistently superior to home exercise alone. Conclusions: Adding spinal manipulation or supervised rehabilitative exercise to home exercise alone does not appear to improve pain or disability in the short- or long-term for older adults with chronic low back pain, but did enhance satisfaction with care. Trial registration: NCT00269321.

Short- or Long-Term Treatment of Spinal Disability in Older Adults With Manipulation and Exercise.

OBJECTIVE: Back and neck pain are associated with disability and loss of independence in older adults. Whether long-term management using commonly recommended treatments is superior to shorter-term treatment is unknown. This randomized clinical trial compared short-term treatment (12 weeks) versus long-term management (36 weeks) of back- and neck-related disability in older adults using spinal manipulative therapy (SMT) combined with supervised rehabilitative exercises (SRE). METHODS: Eligible participants were ages ≥65 years with back and neck disability for ≥12 weeks. Coprimary outcomes were changes in Oswestry Disability Index (ODI) and Neck Disability Index (NDI) scores after 36 weeks. An intent-to-treat approach used linear mixed-model analysis to detect between-group differences. Secondary analyses included other self-reported outcomes, adverse events, and objective functional measures. RESULTS: A total of 182 participants were randomized. The short-term and long-term groups demonstrated significant improvements in back disability (ODI score -3.9 [95% confidence interval (95% CI) -5.8, -2.0] versus ODI score -6.3 [95% CI -8.2, -4.4]) and neck disability (NDI score -7.3 [95% CI -9.1, -5.5] versus NDI score -9.0 [95% CI -10.8, -7.2]) after 36 weeks, with no difference between groups (back ODI score 2.4 [95% CI -0.3, 5.1]; neck NDI score 1.7 [95% CI 0.8, 4.2]). The long-term management group experienced greater improvement in neck pain at week 36, in self-efficacy at weeks 36 and 52, and in functional ability, and balance. CONCLUSION: For older adults with chronic back and neck disability, extending management with SMT and SRE from 12 to 36 weeks did not result in any additional important reduction in disability.

Chiropractic in Global Health and wellbeing: a white paper describing the public health agenda of the World Federation of Chiropractic.

The World Federation of Chiropractic supports the involvement of chiropractors in public health initiatives, particularly as it relates to musculoskeletal health. Three topics within public health have been identified that call for a renewed professional focus. These include healthy ageing; opioid misuse; and women's, children's, and adolescents' health. The World Federation of Chiropractic aims to enable chiropractors to proactively participate in health promotion and prevention activities in these areas, through information dissemination and coordinated partnerships. Importantly, this work will align the chiropractic profession with the priorities of the World Health Organization. Successful engagement will support the role of chiropractors as valued partners within the broader healthcare system and contribute to the health and wellbeing of the communities they serve.

Functional Limitations in Adults Who Utilize Chiropractic or Osteopathic Manipulation in the United States: Analysis of the 2012 National Health Interview Survey.

OBJECTIVES: The goals of this study were to identify self-reported differences in function, comorbidities, and medical service utilization among adults who reported using chiropractic and/or osteopathic manipulation in the 2012 National Health Interview Survey, and to compare these between older and younger adults. METHODS: We conducted a descriptive study of adults aged 18 or older who were included in the 2012 National Health Interview Survey and the Alternative Medicine Questionnaire. We included those who reported using chiropractic and/or osteopathic manipulation in the past 12 months. Responses were analyzed using SAS software. Weighted estimates were reported as percentages of chiropractic/osteopathic users overall and by age group (<65 years vs ≥65 years). RESULTS: Among the 8.5% of US adults who reported receiving manipulation, 97.6% saw chiropractors. Most adults were under age 65 (83.7%), female (56.6%), and white (85.1%). Except for sitting tolerance, functional limitations were significantly higher among older manipulation users compared with younger manipulation users (all P < .001). Older (vs younger) chiropractic/osteopathic users more often reported functional limitations (65.7% vs 37.2%), had difficulty walking without equipment (14.7% vs 2.8%), found it very difficult or were unable to walk one-quarter mile (15.7% vs 3.8%) or climb 10 steps (11.4% vs 2.5%), and needed help with instrumental activities of daily living (6.9% vs 2.0%). Comorbidities differed by age: cardiovascular events/conditions, cancer, diabetes, and arthritis were more common among older adults, and headaches, neck pain, and depression were more frequent in younger adults. Similar proportions of older and younger adults had emergency room visits (23.0% vs 21.7%); older adults reported more surgeries (26.1% vs 15.4%). CONCLUSIONS: Notable differences exist in functional limitations and comorbidities between older and younger chiropractic and osteopathic manipulation users. This information could inform clinical practice, education, and policy.

Selecting and training opinion leaders and best practice collaborators: experience from the Canadian Chiropractic Guideline Initiative.

OBJECTIVES: To describe the process for selecting and training chiropractic opinion leaders (OLs) and best practice collaborators (BPCs) to increase the uptake of best practice. METHODS: In Phase 1, OLs were identified using a cross-sectional survey among Canadian chiropractic stakeholders. A 10-member committee ranked nominees. Top-ranked nominees were invited to a training workshop. In Phase 2, a national e-survey was administered to 7200 Canadian chiropractors to identify additional OLs and BPCs. Recommended names were screened by OLs and final selection made by consensus. Webinars were utilized to train BPCs to engage peers in best practices, and facilitate guideline dissemination. RESULTS: In Phase 1, 21 OLs were selected from 80 nominees. Sixteen attended a training workshop. In Phase 2, 486 chiropractors recommended 1126 potential BPCs, of which 133 were invited to participate and 112 accepted. CONCLUSIONS: OLs and BPCs were identified across Canada to enhance the uptake of research among chiropractors.

OBJECTIFS: Décrire le processus permettant de choisir et former les leaders d'opinion (LO) et collaborateurs des pratiques d'exemplaire (CPE) en chiropratique dans le but de favoriser l'adoption des pratiques d'excellence. MÉTHODOLOGIE: Lors de la première phase, on a désigné les LO au moyen d'une enquête transversale parmi les intervenants canadiens de la chiropratique. Un comité composé de dix membres a classé les candidats. Les candidats les mieux classés ont été invités à un atelier de formation. Lors de la deuxième phase, 7 200 chiropraticiens canadiens se sont soumis à une enquête nationale en ligne visant à désigner d'autres LO et CPE. Les noms recommandés ont été présélectionnés par les LO et le choix final s'est fait d'un commun accord. On s'est servi de webinaires pour former les LO à encourager leurs pairs à adopter des pratiques d'excellence et faciliter la diffusion des lignes directrices. RÉSULTATS: Lors de la première phase, on a choisi 21 LO parmi 80 candidats. Seize d'entre eux ont assisté à un atelier de formation. Lors de la deuxième phase, 486 chiropraticiens ont recommandé 1 126 LO potentiels, parmi lesquels 133 ont été invités à participer et 112 ont accepté. CONCLUSIONS: On a désigné des LO et CPE à l'échelle du pays pour favoriser l'adoption de la recherche parmi les chiropraticiens.

Our future in the hands of Millennials.

The future of any profession is in the hands of its students and early career practitioners. The Millennial generation of chiropractors embody attributes that are uniquely suited to the evolving landscape of 21st century healthcare. Globalization and rapid advancements in technology demand different styles of communication, attitudes toward diversity, styles of professional engagement, and perhaps most importantly, idealism about the future. Millennial chiropractors have a clear vision for this future of the profession, and are equipped to actualize that ideal.

L'avenir de toute profession est entre les mains des étudiants et des praticiens en début de carrière. Les chiropraticiens de la génération du millénaire possèdent des qualités particulièrement adaptées au secteur des soins de santé du 21e siècle, qui est en constante évolution. La mondialisation et les progrès rapides de la technologie rendent nécessaire l'adoption d'autres styles de communication, d'autres attitudes à l'égard de la diversité, d'un autre type d'engagement professionnel et peut-être ce qui importe le plus, d'autres idéaux pour l'avenir. Les chiropraticiens du millénaire ont une vision claire de l'avenir de cette profession et sont équipés pour matérialiser cet idéal.

Culturally Sensitive Chiropractic Care of the Transgender Community: A Narrative Review of the Literature.

OBJECTIVES: Transgender individuals commonly experience barriers to quality health care and may suffer from unique musculoskeletal complaints. Although these needs are often inadequately addressed within the health care system, they could be attended to by the chiropractic community. This narrative review describes best practices for delivering culturally sensitive care to transgender patients within the context of chiropractic offices. METHODS: A literature search generated peer-reviewed material on culturally competent care of the transgender community. Google Scholar and trans-health RSS feeds on social media were also searched to find relevant gray literature. Information pertinent to a chiropractic practice was identified and summarized. RESULTS: Contemporary definitions of transgender, gender identity, and sexual orientation provide a framework for culturally sensitive language and clinic culture. Small changes in record keeping and office procedures can contribute to a more inclusive environment for transgender patients and improve a chiropractor's ability to collect important health history information. Special considerations during a musculoskeletal examination may be necessary to properly account for medical and nonmedical practices transgender patients may use to express their gender. Chiropractors should be aware of health care and social and advocacy resources for transgender individuals and recommend them to patients who may need additional support. CONCLUSIONS: Small yet intentional modifications within the health care encounter can enable chiropractors to improve the health and well-being of transgender individuals and communities.

What do patients value about spinal manipulation and home exercise for back-related leg pain? A qualitative study within a controlled clinical trial.

BACKGROUND: Patient perceptions may influence the effectiveness and utilization of healthcare interventions, particularly for complex health conditions such as sciatica or back-related leg pain (BRLP). OBJECTIVES: To explore BRLP patients' perceptions of spinal manipulative therapy (SMT) and home exercise with advice (HEA). DESIGN: Qualitative study in a controlled clinical trial. METHOD: Semi-structured interviews conducted after 12 weeks of treatment asked participants about satisfaction with care and whether treatment was worthwhile. An interdisciplinary research team conducted content analysis using qualitative data analysis software to identify and summarize themes. RESULTS: Of 192 trial participants, 174 (91%) completed interviews (66% female, age 57.0 ± 11.5 years). Participants identified interactions with providers and staff, perceived treatment effects, and information as key contributors to both their satisfaction and the worthwhile nature of treatment. HEA was liked for its convenience and ability to foster an exercise habit. SMT was liked for specific aspects of the modality (e.g. manipulation, stretching) and provider competency. Most participants reported no dislikes for SMT or HEA, but some noted the dose/time commitment for SMT and discipline of HEA as least liked aspects of the interventions. CONCLUSIONS: The quality of patient-provider interactions, perceived treatment effects, and information sharing influenced BRLP patients' satisfaction with care. Qualitative research describing patients' preferences can facilitate translation of study findings into practice and allow clinicians to tailor treatments to facilitate compliance and satisfaction with care.