Initial Choice of Spinal Manipulation Reduces Escalation of Care for Chronic Low Back Pain Among Older Medicare Beneficiaries.

STUDY DESIGN: We combined elements of cohort and crossover-cohort design. OBJECTIVE: The objective of this study was to compare longterm outcomes for spinal manipulative therapy (SMT) and opioid analgesic therapy (OAT) regarding escalation of care for patients with chronic low back pain (cLBP). SUMMARY OF BACKGROUND DATA: Current evidence-based guidelines for clinical management of cLBP include both OAT and SMT. For long-term care of older adults, the efficiency and value of continuing either OAT or SMT are uncertain. METHODS: We examined Medicare claims data spanning a five-year period. We included older Medicare beneficiaries with an episode of cLBP beginning in 2013. All patients were continuously enrolled under Medicare Parts A, B, and D. We analyzed the cumulative frequency of encounters indicative of an escalation of care for cLBP, including hospitalizations, emergency department visits, advanced diagnostic imaging, specialist visits, lumbosacral surgery, interventional pain medicine techniques, and encounters for potential complications of cLBP. RESULTS: SMT was associated with lower rates of escalation of care as compared to OAT. The adjusted rate of escalated care encounters was approximately 2.5 times higher for initial choice of OAT vs. initial choice of SMT (with weighted propensity scoring: rate ratio 2.67, 95% confidence interval 2.64-2.69, P < .0001). CONCLUSION: Among older Medicare beneficiaries who initiated long-term care for cLBP with opioid analgesic therapy, the adjusted rate of escalated care encounters was significantly higher as compared to those who initiated care with spinal manipulative therapy.Level of Evidence: 3.

Long-Term Medicare Costs Associated With Opioid Analgesic Therapy vs Spinal Manipulative Therapy for Chronic Low Back Pain in a Cohort of Older Adults.

OBJECTIVES: The purpose of this study was to compare Medicare healthcare expenditures for patients who received long-term treatment of chronic low back pain (cLBP) with either opioid analgesic therapy (OAT) or spinal manipulative therapy (SMT). METHODS: We conducted a retrospective observational study using a cohort design for analysis of Medicare claims data. The study population included Medicare beneficiaries enrolled under Medicare Parts A, B, and D from 2012 through 2016. We assembled cohorts of patients who received long-term management of cLBP with OAT or SMT (such as delivered by chiropractic or osteopathic practitioners) and evaluated the comparative effect of OAT vs SMT upon expenditures, using multivariable regression to control for beneficiary characteristics and measures of health status, and propensity score weighting and binning to account for selection bias. RESULTS: The study sample totaled 28,160 participants, of whom 77% initiated long-term care of cLBP with OAT, and 23% initiated care with SMT. For care of low back pain specifically, average long-term costs for patients who initiated care with OAT were 58% lower than those who initiated care with SMT. However, overall long-term healthcare expenditures under Medicare were 1.87 times higher for patients who initiated care via OAT compared with those initiated care with SMT (95% CI 1.65-2.11; P < .0001). CONCLUSIONS: Adults aged 65 to 84 who initiated long-term treatment for cLBP via OAT incurred lower long-term costs for low back pain but higher long-term total healthcare costs under Medicare compared with patients who initiated long-term treatment with SMT.

Initial Choice of Spinal Manipulative Therapy for Treatment of Chronic Low Back Pain Leads to Reduced Long-term Risk of Adverse Drug Events Among Older Medicare Beneficiaries.

STUDY DESIGN: Retrospective observational study. OBJECTIVE: Opioid Analgesic Therapy (OAT) and Spinal Manipulative Therapy (SMT) are evidence-based strategies for treatment of chronic low back pain (cLBP), but the long-term safety of these therapies is uncertain. The objective of this study was to compare OAT versus SMT with regard to risk of adverse drug events (ADEs) among older adults with cLBP. SUMMARY OF BACKGROUND DATA: We examined Medicare claims data spanning a 5-year period on fee-for-service beneficiaries aged 65 to 84 years, continuously enrolled under Medicare Parts A, B, and D for a 60-month study period, and with an episode of cLBP in 2013. We excluded patients with a diagnosis of cancer or use of hospice care. METHODS: All included patients received long-term management of cLBP with SMT or OAT. We assembled cohorts of patients who received SMT or OAT only, and cohorts of patients who crossed over from OAT to SMT or from SMT to OAT. We used Poisson regression to estimate the adjusted incidence rate ratio for outpatient ADE among patients who initially chose OAT as compared with SMT. RESULTS: With controlling for patient characteristics, health status, and propensity score, the adjusted rate of ADE was more than 42 times higher for initial choice of OAT versus initial choice of SMT (rate ratio 42.85, 95% CI 34.16-53.76, P < 0.0001). CONCLUSION: Among older Medicare beneficiaries who received long-term care for cLBP the adjusted rate of ADE for patients who initially chose OAT was substantially higher than those who initially chose SMT.Level of Evidence: 2.

Spinal Manipulation vs Prescription Drug Therapy for Chronic Low Back Pain: Beliefs, Satisfaction With Care, and Qualify of Life Among Older Medicare Beneficiaries.

OBJECTIVE: The objective of this study was to compare patients' perspectives on the use of spinal manipulative therapy (SMT) compared to prescription drug therapy (PDT) with regard to health-related quality of life (HRQoL), patient beliefs, and satisfaction with treatment. METHODS: Four cohorts of Medicare beneficiaries were assembled according to previous treatment received as evidenced in claims data: SMT, PDT, and 2 crossover cohorts (where participants experienced both types of treatments). A total of 195 Medicare beneficiaries responded to the survey. Outcome measures used were a 0-to-10 numeric rating scale to measure satisfaction, the Low Back Pain Treatment Beliefs Questionnaire to measure patient beliefs, and the 12-item Short Form Health Survey to measure HRQoL. RESULTS: Recipients of SMT were more likely to be very satisfied with their care (84%) than recipients of PDT (50%; P = .002). The SMT cohort self-reported significantly higher HRQoL compared to the PDT cohort; mean differences in physical and mental health scores on the 12-item Short Form Health Survey were 12.85 and 9.92, respectively. The SMT cohort had a lower degree of concern regarding chiropractic care for their back pain compared to the PDT cohort's reported concern about PDT (P = .03). CONCLUSION: Among older Medicare beneficiaries with chronic low back pain, long-term recipients of SMT had higher self-reported rates of HRQoL and greater satisfaction with their modality of care than long-term recipients of PDT. Participants who had longer-term management of care were more likely to have positive attitudes and beliefs toward the mode of care they received.

A survey of chiropractic students' perceived business preparedness at graduation.

OBJECTIVE: The objective of this study was to assess chiropractic college graduates' business experience, education, and need for further education at the time of graduation. METHODS: We conducted an anonymous survey of graduating chiropractic students in 2015 and 2016 regarding their prior business experience, business courses taken before and during chiropractic education, business abilities and needs, and practice plans. RESULTS: Eighty-one responded out of 114 surveyed (71% response rate). Less than half had taken college-level business courses or had business experience prior to entering chiropractic college. Almost 90% of respondents took 1 or more of 3 elective courses in business skills during their chiropractic education. Sixty-eight percent planned to work as an associate doctor and to be in private practice after 5 years. The respondents indicated that they were more prepared in the business abilities of ethics/risk management/jurisprudence, employee management, strategic planning, and marketing/advertising, and least prepared in business operations, accounting, and billing/reimbursement. In the areas of economics, finance, business taxes, and starting a practice, the respondents indicated a need for further education or experience. It was statistically significant (p < .001) that students who had prior business experience and/or college business education were more confident in operating a health care practice. CONCLUSION: Chiropractic business education provides students with some of the practice management skills essential for operating a health care practice. Students with prior business experience and/or education reported more confidence in their ability to run a chiropractic practice immediately after graduation.

An Exploratory Analysis of Gender as a Potential Modifier of Treatment Effect Among Patients in a Randomized Controlled Trial of Integrative Acupuncture and Spinal Manipulation for Low Back Pain.

OBJECTIVE: To identify the potential association of self-reported gender on pain and disability among patients in a randomized controlled trial of integrative acupuncture and spinal manipulation therapy (SMT) for low back pain (LBP). METHODS: In the original study, 100 participants with LBP were randomized to receive acupuncture, SMT, or both combined. Eighty completed treatment and were followed for 60 days. Primary outcome measures were the Roland-Morris Disability Questionnaire and numeric pain scales. This study was a secondary analysis and used regression models to estimate and test for gender-specific differences in outcomes from baseline through end of treatment. RESULTS: Women assigned to acupuncture averaged a 3.8-point reduction in highest LBP vs 2.0 points for SMT, whereas men assigned to SMT averaged a 3.5-point reduction vs 1.8 points for acupuncture (P for interaction = .04). There was a trend toward the same for disability (P for interaction = .12). For women, acupuncture alone led to better outcomes without SMT, and for men, SMT alone led to better outcomes without acupuncture. Women who received acupuncture were more likely to experience 50% or greater reductions in disability and pain, whereas men who received SMT were more likely to experience 50% or greater reductions in disability and pain. CONCLUSION: An association was found between self-reported gender and response to LBP treatment. Women demonstrated a greater reduction in pain and disability with acupuncture and men with SMT. Future clinical trials should consider sex as a potential determinant of treatment outcomes for LBP.

Yoga for Quality of Life in Individuals With Chronic Disease: A Systematic Review.

BACKGROUND: Chronic diseases, including heart disease, stroke, cancer, and chronic pulmonary disease are the leading causes of death and disability worldwide. Compounding symptoms and loss of function, people living with chronic disease often experience reduced quality of life (QoL). Various physical and mental practices have been shown to relieve stress and improve QoL. Yoga is a physical and mental practice that may be a viable approach for improving QoL in people with chronic disease. OBJECTIVE: The objective of this study was to examine and summarize the evidence for the effectiveness of yoga on QoL in patients with chronic disease. DESIGN: The study design was a a systematic review with qualitative synthesis. METHODS: We included randomized controlled trials that evaluated the effect of yoga on QoL or health-related QoL (HRQoL) for individuals with chronic disease. We included only studies that used at least 1 previously validated measure of QoL or HRQoL and specified a minimum duration of follow-up of at least 1 wk. INTERVENTIONS: We included both movement-based and breath-based yoga practices. Studies that included yoga as part of a larger intervention program (eg, mindfulness-based stress reduction training) or studies that did not provide findings specific to yoga were excluded. PRIMARY OUTCOME MEASURES: The primary outcome analyzed was improvement in QoL as measured by a validated QoL or HRQoL scale. RESULTS: Among the 1488 studies that were identified on initial search, 7 articles met all inclusion criteria. Five studies reported a statistically significant advantage over usual care alone for improvement of QoL in patients with chronic disease, but the clinical significance of the differences was clear in only 1 trial. We found considerable heterogeneity among the included studies and study quality was generally low. CONCLUSIONS: More high-quality research is needed to determine the value of yoga as an adjunctive approach to improving QoL in patients with chronic disease.

The association between students taking elective courses in chiropractic technique and their anticipated chiropractic technique choices in future practice.

OBJECTIVE:: To assess students' opinions of the potential influence of taking elective courses in chiropractic techniques and their future practice preferences. METHODS:: An anonymous, voluntary survey was conducted among graduating students from a doctor of chiropractic program. The survey included questions regarding the chiropractic technique elective courses they had completed and the potential influence of these courses on their chiropractic technique choices in future practice. Surveys were pretested for face validity, and data were analyzed using descriptive and inferential statistics. RESULTS:: Of the 56 surveys distributed, 46 were completed, for a response rate of 82%. More than half of the students reported having taken at least 1 elective course in diversified technique (80%), Cox technique (76%), Activator Methods (70%), or sacro-occipital technique (63%). Less than half of the respondents reported taking technique elective courses in Gonstead or Thompson techniques. More than half of the students stated they were more likely to use Activator (72%), Thompson (68%), diversified (57%), or Cox (54%) techniques in their future practice after taking an elective course in that technique. Females stated that they were more likely to use Activator Methods ( p = .006) in future practice. CONCLUSION:: Chiropractic technique elective courses in the doctor of chiropractic curriculum may influence students' choices of future practice chiropractic technique.

Insurance Reimbursement for Complementary Healthcare Services.

INTRODUCTION: Insurance reimbursement for clinical services provided by complementary healthcare professionals in the United States likely differs by provider specialty. It is hypothesized that a lower likelihood of insurance reimbursement demonstrates that complementary healthcare services are not utilized to an optimal level and are not financially accessible to all who may need or want these services. The purpose of this project was to evaluate the likelihood of insurance reimbursement for complementary healthcare services compared with other complementary services and with conventional primary care medical services in New Hampshire. METHODS: The authors studied health claims for services provided in a nonemergent outpatient setting in New Hampshire in 2014. The study population consisted of New Hampshire residents aged 18-99 years with claims for selected clinical services commonly provided by complementary healthcare providers. The authors modeled the proportion of reimbursed claims by specialty of complementary healthcare service provider, compared with the reimbursement rate for primary care physicians' claims. The authors modeled first for the proportion of reimbursement for any selected clinical service, next for any evaluation and management (E&M) service, and finally for the most commonly used E&M procedure code, current procedural terminology (CPT) 99213 (reevaluation of established patient). RESULTS: Compared with primary care physicians, the likelihood of reimbursement for any service was 69% lower for acupuncturists, 71% lower for doctors of chiropractic medicine, and 62% lower for doctors of naturopathic medicine. For any E&M service, likelihood of reimbursement was 69% lower for acupuncturists, 78% lower for doctors of chiropractic medicine, and 60% lower for doctors of naturopathic medicine. With further restriction to CPT 99213 only, likelihood of reimbursement was 34% lower for acupuncturists, 77% lower for doctors of chiropractic medicine, and 60% lower for doctors of naturopathic medicine. CONCLUSIONS: In New Hampshire, the likelihood of health insurance reimbursement for certain clinical services differs significantly by provider specialty. More research is needed to evaluate the extent and cause of such differences and the effect of such differences on the utilization of complementary healthcare services in the United States.

Integrative Acupuncture and Spinal Manipulative Therapy Versus Either Alone for Low Back Pain: A Randomized Controlled Trial Feasibility Study.

OBJECTIVES: The objective of this study was to assess the feasibility of conducting a large-scale randomized controlled trial (RCT) examining whether an integrative care model combining spinal manipulative therapy (SMT) and acupuncture can lead to better outcomes for low back pain (LBP) than either therapy alone. METHODS: This study was conducted at a complementary and alternative medicine university health center. Participants with acute or chronic LBP were randomized to (1) acupuncture, (2) SMT, or (3) integrative acupuncture and SMT groups. Treatments were provided over 60 days by licensed doctors of chiropractic and acupuncturists. Acupuncture treatments consisted of needling of acupoints combined with electrotherapy, moxibustion, cupping, and Tui Na. SMT used specific contact points on vertebral processes, along with soft tissue therapy and physiotherapy. Primary outcome measures were the Roland-Morris LBP Disability Questionnaire and 0 to 10 Numeric Rating Scale for LBP. RESULTS: Participants in all 3 groups experienced clinically meaningful improvements in the primary outcome measures; however, no between-group differences in outcomes were apparent. CONCLUSIONS: This study indicated that it is feasible to conduct an RCT to compare the effectiveness of integrative acupuncture and SMT for LBP to either therapy alone. Future studies should include a larger sample to increase the power for detecting clinically meaningful differences between groups.

Combining Spinal Manipulation With Standard Counseling for Tobacco Cessation: Results of a Feasibility Randomized Clinical Trial.

OBJECTIVE: The purpose of this study was to test the feasibility of a randomized clinical trial on the effectiveness of combining spinal manipulation (SM) with standard tobacco cessation counseling. METHODS: A randomized clinical trial was conducted. Participants in the intervention group received 2 months of counseling plus SM delivered by doctors of chiropractic, whereas control group participants received counseling alone. Primary outcome measures were smoking decreases and 7-day smoking abstinence as measured by a tobacco diary and urinary cotinine. Descriptive statistics were calculated. RESULTS: Recruitment proved to be difficult because of reluctance of participants to commit to a 2-month course of care. Ten participants completed this pilot study. Counseling plus SM group participants had greater improvement in the number of cigarettes smoked and urinary cotinine. Three participants achieved at least 7 days of tobacco abstinence, all in the counseling plus SM group. CONCLUSIONS: In this feasibility study, doctors of chiropractic appeared to be capable of conducting effective smoking cessation counseling. The preliminary information indicated that there may be some benefit for including chiropractic care in addition to counseling. Researchers conducting future studies that are adequately powered should consider using multiple locations and incentives adequate to recruit participants.

Perceived stress and fatigue among students in a doctor of chiropractic training program.

OBJECTIVE: High levels of stress and fatigue are associated with decreased academic success, well-being, and quality of life. The objective of this research was to quantify levels of perceived stress and fatigue among chiropractic students to identify sources of and student coping mechanisms for perceived stress and fatigue and to identify the relationship between students' perceived stress and fatigue. METHODS: A survey comprised of the Perceived Stress Scale, the Undergraduate Sources of Stress Survey, and the Piper Fatigue Scale was administered to chiropractic students in their 2nd, 5th, and 8th trimesters of doctoral study. Data were analyzed by descriptive statistics, 1-way analysis of variance, and linear correlation tests. RESULTS: Students reported having moderate to high levels of stress and fatigue, with higher levels of stress and fatigue seen in women than in men. A nonsignificant difference among stress scores and a significant difference among fatigue scores were observed based on program term. Levels of stress predicted levels of fatigue, and stress was strongly correlated with psychological health, relationships with family members, mood, and need for learning accommodations. Fatigue was strongly correlated with psychological health, academic demands, and conflicts between studies and other activities. CONCLUSION: There are differences in the reporting of perceived stress and fatigue levels in this chiropractic student population based on gender. The correlation between fatigue and stress also suggests that measures that may alleviate one may likely affect the other.

Bioidentical Estrogen for Menopausal Depressive Symptoms: A Systematic Review and Meta-Analysis.

BACKGROUND: Proponents of bioidentical estrogens claim that they are superior for treating menopausal symptoms, including depressive symptoms. Small trials examining the effects of bioidentical estrogens on depressive symptoms show conflicting results. We conducted a systematic review to assess the effectiveness and safety of bioidentical estrogens for treatment of depressive symptoms in peri- and postmenopausal women. METHODS: We searched the scientific literature for randomized controlled trials of at least 4 weeks duration, comparing bioidentical estrogen with placebo for depressive symptoms in menopausal women. The main outcome measure was improvement in depressive symptoms on a validated scale. RESULTS: We found 12 clinical trials that met inclusion criteria, two of which contained insufficient data for quantitative analysis. In the 10 studies (inclusive of 1208 subjects) for which complete data were available for inclusion in the meta-analysis, bioidentical estrogen had no clinically significant effect on depressive symptoms (standardized mean difference [SMD] -0.02; confidence interval [95% CI] -0.41 to +0.38). Pooled studies were highly heterogeneous, and numerous approaches to reducing heterogeneity were unsuccessful. Subgroup analyses showed no significant difference in effect for women treated with adjunctive progestogen, women treated with unopposed estrogen, perimenopausal, or postmenopausal and mixed populations. A possible benefit in perimenopausal women treated with unopposed estradiol may have been diluted by studies including older postmenopausal women whose depressive symptoms were unrelated to menopause. CONCLUSIONS: In this first systematic review of bioidentical hormone replacement therapy, we found that bioidentical estrogen has no clear benefit in treating depressive symptoms in menopausal women, but heterogeneity of available studies limits the potential for definitive conclusions. Future research should compare bioidentical estrogen with nonbioidentical estrogen for treatment of depressive symptoms in perimenopausal women.

The effect of obesity on treatment outcomes for low back pain.

BACKGROUND: The objective of this study was to estimate the effect of obesity, as measured by body mass index (BMI), on treatment outcomes for low back pain (LBP). METHODS: Data from the University of California, Los Angeles, and Friendly Hills Healthcare Network low back pain study (collected from 1995 to 2000) were used to perform a secondary data analysis of this randomized clinical trial on adults who sought care for LBP. BMI was the primary predictor variable. Binary logistic regression modeling was performed to estimate odds ratios adjusted for the effects of confounders. RESULTS: Using normal weight as the referent population, underweight and overweight populations did not display significant odds ratios for any of the outcome variables. The obese population demonstrated odds ratios of 0.615 (0.379, 0.998) for improvement of disability and 0.550 (0.341, 0.889) for improvement of most severe back pain. CONCLUSION: The results of this study support an association between obesity and less effective treatment outcomes whether measured by disability (Roland-Morris scale) or pain (most severe pain NRS). Overweight and underweight populations do not appear to have significantly different outcomes than normal weight populations. TRIAL REGISTRATION: This trial was designed and conducted prior to the advent of registries.

The influence of curricular and extracurricular learning activities on students' choice of chiropractic technique.

OBJECTIVE: Surveys for the National Board of Chiropractic Examiners indicate that diversified chiropractic technique is the most commonly used chiropractic manipulation method. The study objective was to investigate the influences of our diversified core technique curriculum, a technique survey course, and extracurricular technique activities on students' future practice technique preferences. METHODS: We conducted an anonymous, voluntary survey of 1st, 2nd, and 3rd year chiropractic students at our institution. Surveys were pretested for face validity, and data were analyzed using descriptive and inferential statistics. RESULTS: We had 164 students (78% response rate) participate in the survey. Diversified was the most preferred technique for future practice by students, and more than half who completed the chiropractic technique survey course reported changing their future practice technique choice as a result. The students surveyed agreed that the chiropractic technique curriculum and their experiences with chiropractic practitioners were the two greatest bases for their current practice technique preference, and that their participation in extracurricular technique clubs and seminars was less influential. CONCLUSIONS: Students appear to have the same practice technique preferences as practicing chiropractors. The chiropractic technique curriculum and the students' experience with chiropractic practitioners seem to have the greatest influence on their choice of chiropractic technique for future practice. Extracurricular activities, including technique clubs and seminars, although well attended, showed a lesser influence on students' practice technique preferences.

Chiropractic identity, role and future: a survey of North American chiropractic students.

BACKGROUND: The literature pertaining to chiropractic students' opinions with respect to the desired future status of the chiropractic physician is limited and is an appropriate topic worthy of study. A previous pilot study was performed at a single chiropractic college. This current study is an expansion of this pilot project to collect data from chiropractic students enrolled in colleges throughout North America. OBJECTIVE: The purpose of this study is to investigate North American chiropractic students' opinions concerning professional identity, role and future. METHODS: A 23-item cross-sectional electronic questionnaire was developed. A total of 7,455 chiropractic students from 12 North American English-speaking chiropractic colleges were invited to complete the survey. Survey items encompassed demographics, evidence-based practice, chiropractic identity and setting, and scope of practice. Data were collected and descriptive statistical analysis was performed. RESULTS: A total of 1,247 (16.7% response rate) questionnaires were electronically submitted. Most respondents agreed (34.8%) or strongly agreed (52.2%) that it is important for chiropractors to be educated in evidence-based practice. A majority agreed (35.6%) or strongly agreed (25.8%) the emphasis of chiropractic intervention is to eliminate vertebral subluxations/vertebral subluxation complexes. A large number of respondents (55.2%) were not in favor of expanding the scope of the chiropractic profession to include prescribing medications with appropriate advanced training. Most respondents estimated that chiropractors should be considered mainstream health care practitioners (69.1%). Several respondents (46.8%) think that chiropractic research should focus on the physiological mechanisms of chiropractic adjustments. CONCLUSION: The chiropractic students in this study showed a preference for participating in mainstream health care, report an exposure to evidence-based practice, and desire to hold to traditional chiropractic theories and practices. The majority of students would like to see an emphasis on correction of vertebral subluxation, while a larger percent found it is important to learn about evidence-based practice. These two key points may seem contradictory, suggesting cognitive dissonance. Or perhaps some students want to hold on to traditional theory (e.g., subluxation-centered practice) while recognizing the need for further research to fully explore these theories. Further research on this topic is needed.

Prevalence of adverse effects among students taking technique classes: A retrospective study.

Objective : The main objective of this study was to determine characteristics of injuries experienced by students while learning chiropractic procedures in the classroom. Methods : Injury was defined as any physical adverse effect such as pain, stiffness, headache, and muscle spasm. Survey questions included age, sex, role, anatomical areas of injury, adjustive technique utilized, types of injury, treatment (if any), and recovery time. The survey was administered among the students in the 5th, 6th, and 8th trimesters of our doctor of chiropractic program. Only students who had completed one or more chiropractic procedures courses at the institution were asked to participate in the study. Results : Female recipients had a higher prevalence of adverse effects as the recipient of the adjustment than did male recipients. The most common site for injury overall was the lower back. The relationship between recipient role and sacroiliac joint injury and the relationship between adjustor role and wrist/hand injury were statistically significant. Students were more likely to be injured in the beginning of their technique education. Conclusion : This study suggests that students in technique courses learning adjustive procedures experience minor adverse physical effects related to the physical skills being learned. Strategies for prevention need to be considered.

Integrative therapies for low back pain that include complementary and alternative medicine care: a systematic review.

STUDY DESIGN: Systematic review of the literature. OBJECTIVE: To evaluate whether an integrated approach that includes different Complementary and Alternative Medicine (CAM) therapies combined or CAM therapies combined with conventional medical care is more effective for the management of low back pain (LBP) than single modalities alone. SUMMARY OF BACKGROUND DATA: LBP is one of the leading causes of disability worldwide, yet its optimal management is still unresolved. METHODS: The PRISMA Statement guidelines were followed. The Cochrane Back Review Group scale was used to rate the quality of the studies found. RESULTS: Twenty-one studies were found that met the inclusion criteria. The CAM modalities used in the studies included spinal manipulative therapy, acupuncture, exercise therapy, physiotherapy, massage therapy, and a topical ointment. Twenty studies included acupuncture and/or spinal manipulative therapy. Nine high quality studies showed that integrative care was clinically effective for the management of LBP. Spinal manipulative therapy combined with exercise therapy and acupuncture combined with conventional medical care or with exercise therapy appears to be promising approaches to the management of chronic cases of LBP. CONCLUSIONS: There is support in the literature for integrated CAM and conventional medical therapy for the management of chronic LBP. Further research into the integrated management of LBP is clearly needed to provide better guidance for patients and clinicians.

Multiple views to address diversity issues: an initial dialog to advance the chiropractic profession.

The purpose of this article is to provide expert viewpoints on the topic of diversity in the chiropractic profession, including cultural competency, diversity in the profession, educational and clinical practice strategies for addressing diversity, and workforce issues. Over the next decades, changing demographics in North America will alter how the chiropractic profession functions on many levels. As the population increases in diversity, we will need to prepare our workforce to meet the needs of future patients and society.