Evaluation of United States chiropractic professional subgroups: a survey of randomly sampled chiropractors.

BACKGROUND: Professional subgroups are common and may play a role in aiding professional maturity or impeding professional legitimization. The chiropractic profession in the United States has a long history of diverse intra-professional subgroups with varying ideologies and practice styles. To our knowledge, large-scale quantification of chiropractic professional subgroups in the United States has not been conducted. The purpose of this study was to quantify and describe the clinical practice beliefs and behaviors associated with United States chiropractic subgroups. METHODS: A 10% random sample of United States licensed chiropractors (n = 8975) was selected from all 50 state regulatory board lists and invited to participate in a survey. The survey consisted of a 7-item questionnaire; 6 items were associated with chiropractic ideological and practice characteristics and 1 item was related to the self-identified role of chiropractic in the healthcare system which was utilized as the dependent variable to identify chiropractic subgroups. Multinomial logistic regression with predictive margins was used to analyze which responses to the 6 ideology and practice characteristic items were predictive of chiropractic subgroups. RESULTS: A total of 3538 responses were collected (39.4% response rate). Respondents self-identified into three distinct subgroups based on the perceived role of the chiropractic profession in the greater healthcare system: 56.8% were spine/neuromusculoskeletal focused; 22.0% were primary care focused; and 21.2% were vertebral subluxation focused. Patterns of responses to the 6 ideologies and practice characteristic items were substantially different across the three professional subgroups. CONCLUSIONS: Respondents self-identified into one of three distinct intra-professional subgroups. These subgroups can be differentiated along themes related to clinical practice beliefs and behaviors.

Differentiating intraprofessional attitudes toward paradigms in health care delivery among chiropractic factions: results from a randomly sampled survey.

BACKGROUND: As health care has increased in complexity and health care teams have been offered as a solution, so too is there an increased need for stronger interprofessional collaboration. However the intraprofessional factions that exist within every profession challenge interprofessional communication through contrary paradigms. As a contender in the conservative spinal health care market, factions within chiropractic that result in unorthodox practice behaviours may compromise interprofessional relations and that profession's progress toward institutionalization. The purpose of this investigation was to quantify the professional stratification among Canadian chiropractic practitioners and evaluate the practice perceptions of those factions. METHODS: A stratified random sample of 740 Canadian chiropractors was surveyed to determine faction membership and how professional stratification could be related to views that could be considered unorthodox to current evidence-based care and guidelines. Stratification in practice behaviours is a stated concern of mainstream medicine when considering interprofessional referrals. RESULTS: Of 740 deliverable questionnaires, 503 were returned for a response rate of 68%. Less than 20% of chiropractors (18.8%) were aligned with a predefined unorthodox perspective of the conditions they treat. Prediction models suggest that unorthodox perceptions of health practice related to treatment choices, x-ray use and vaccinations were strongly associated with unorthodox group membership (X(2) =13.4, p = 0.0002). CONCLUSION: Chiropractors holding unorthodox views may be identified based on response to specific beliefs that appear to align with unorthodox health practices. Despite continued concerns by mainstream medicine, only a minority of the profession has retained a perspective in contrast to current scientific paradigms. Understanding the profession's factions is important to the anticipation of care delivery when considering interprofessional referral.

Relationship between chiropractic teaching institutions and practice characteristics among Canadian doctors of chiropractic: a random sample survey.

OBJECTIVE: The objectives of this study were to determine if faction membership among Canadian doctors of chiropractic (DCs) is associated with differences in educational program characteristics among English-speaking Canadian and United States chiropractic colleges and to determine if those differences are expressed in terms of surveyed attitudes and behaviors regarding treatment efficacy, radiographic imaging, vaccinations, and interprofessional referrals. This study also aims to identify if educational programs may be a potential source of multiple professional identities. METHODS: A randomly selected sample of Canadian DCs, stratified across the English-speaking provinces, was surveyed by mail. Survey items included school of graduation, self-categorization by chiropractic subgroup, perceptions of condition-specific treatment efficacy, use of plain film radiographic imaging, vaccination attitudes/behaviors, and patient referral patterns. Self-categorization by chiropractic subgroup included: the unorthodox faction (associates the chiropractic subluxation as an encumbrance to the expression of health) and the orthodox perspective (associates with musculoskeletal joint dysfunction, public health, and lifestyle concerns). For data analysis, chiropractic schools were divided into 2 groups according to location: English-speaking Canada and the US. The US was further clustered into liberal ("interested in mixing elements of modern and alternative therapies into the practice of chiropractic") and conservative categories ("chiropractors who believe in continuing the traditions of chiropractic"). RESULTS: Of 740 deliverable questionnaires, 503 were returned for a response rate of 68%. χ(2) Testing revealed significant differences in self-categorized faction membership associated with the clustering of colleges based on ideological viewpoints (χ(2) = 27.06; P = .000). Descriptive results revealed a relationship between school of origin and perceived treatment efficacy, use of radiographic imaging, and vaccination attitudes. No significant differences were found relative to interprofessional referral patterns. CONCLUSION: Chiropractic program attended is a significant predictor of orthodox vs unorthodox faction membership and professional practice characteristics for Canadian DCs. This suggests that the current chiropractic education system may contribute to multiple professional identities.

Associations between demographics and clinical ideology, beliefs, and practice patterns: a secondary analysis of a survey of randomly sampled United States chiropractors.

BACKGROUND: The chiropractic profession in the United States (US) has a long history of intra-professional discourse surrounding ideology and beliefs. Large-scale efforts have evaluated 3 distinctive subgroups of US chiropractors focused on these areas of practice: spine/neuromusculoskeletal, primary care, and vertebral subluxation. To our knowledge, there have not been any prior studies exploring the factors associated with these ideology and belief characteristics of these subgroups. The purpose of this study was to explore, describe, and characterize the association of US chiropractors' ideology, beliefs, and practice patterns with: 1) chiropractic degree program of graduation, 2) years since completion of chiropractic degree, and 3) US geographic region of primary practice. METHODS: This was a secondary analysis of a cross-sectional survey of a random sample of US licensed chiropractors (n = 8975). A 10% random sample was extracted from each of the 50 states and District of Columbia chiropractic regulatory board lists. The survey was conducted between March 2018-January 2020. The survey instrument consisted of 7 items that were developed to elicit these differentiating ideologies, beliefs, and practice patterns: 1) clinical examination/assessment, 2) health conditions treated, 3) role of chiropractors in the healthcare system, 4) the impact of chiropractic adjustments [spinal manipulation] in treating patients with cancer, 5) vaccination attitudes, 6) detection of subluxation on x-ray, and 7) x-ray utilization rates. Multinomial regression was used to analyze associations between these 7 ideology and practice characteristic items from the survey (dependent variables) and the 3 demographic items listed above (independent variables). RESULTS: Data from 3538 respondents (74.6% male) were collected with an overall response rate of 39.4%. Patterns of responses to the 7 survey items for ideologies, beliefs, and practice characteristics were significantly different based on chiropractic degree program of graduation, years since completion of chiropractic degree, and geographic region of primary practice. CONCLUSIONS: Among US chiropractors, chiropractic program of graduation, years since completion of chiropractic degree, and geographic region of primary practice are associated with variations in clinical ideology, beliefs, and practice patterns. The wide variation and inconsistent beliefs of US chiropractors could result in public confusion and impede interprofessional integration.

Short-term effects of manipulation to the upper thoracic spine of asymptomatic subjects on plasma concentrations of epinephrine and norepinephrine-a randomized and controlled observational study.

OBJECTIVE: The purpose of this study was to investigate the short-term effects of spinal manipulation applied to a hypomobile segment of the upper thoracic spine (T1-T6), on plasma concentrations of norepinephrine (NE) and epinephrine (E) in asymptomatic subjects, under strictly controlled conditions. METHODS: Fifty-six asymptomatic subjects were randomly assigned to receive either a chiropractic manipulative intervention or a sham intervention in the upper thoracic spine. A 20-gauge catheter fitted with a saline lock was used to sample blood before, immediately after, and 15 minutes after intervention. Plasma NE and E concentrations were determined using an enzyme-linked immunosorbent assay. Changes in plasma catecholamine concentrations were analyzed within and between groups using 1- and 2-sample t tests, respectively. RESULTS: The plasma samples of 36 subjects (18 treatment, 18 control) were used in the analysis. Mean plasma concentrations of NE and E did not significantly differ between the 2 groups at any time point and did not change significantly after either the manipulative or sham intervention. CONCLUSIONS: The results of this study indicate that a manipulative thrust directed to a hypomobile segment in the upper thoracic spine of asymptomatic subjects does not have a measurable effect on the plasma concentrations of NE or E. These results provide a baseline measure of the sympathetic response to spinal manipulation.

Chiropractic care and public health: answering difficult questions about safety, care through the lifespan, and community action.

The purpose of this collaborative summary is to document current chiropractic involvement in the public health movement, reflect on social ecological levels of influence as a profession, and summarize the relationship of chiropractic to the current public health topics of: safety, health issues through the lifespan, and effective participation in community health issues. The questions that are addressed include: Is spinal manipulative therapy for neck and low-back pain a public health problem? What is the role of chiropractic care in prevention or reduction of musculoskeletal injuries in children? What ways can doctors of chiropractic stay updated on evidence-based information about vaccines and immunization throughout the lifespan? Can smoking cessation be a prevention strategy for back pain? Does chiropractic have relevance within the VA Health Care System for chronic pain and comorbid disorders? How can chiropractic use cognitive behavioral therapy to address chronic low back pain as a public health problem? What opportunities exist for doctors of chiropractic to more effectively serve the aging population? What is the role of ethics and the contribution of the chiropractic profession to public health? What public health roles can chiropractic interns perform for underserved communities in a collaborative environment? Can the chiropractic profession contribute to community health? What opportunities do doctors of chiropractic have to be involved in health care reform in the areas of prevention and public health? What role do citizen-doctors of chiropractic have in organizing community action on health-related matters? How can our future chiropractic graduates become socially responsible agents of change?

An examination of the observed placebo effect associated with the treatment of low back pain - a systematic review.

OBJECTIVE: To determine whether the nonspecific effects that occur following the use of sham interventions to treat nonspecific low back pain (LBP) are large enough to be considered clinically meaningful. DESIGN: Electronic databases were searched systematically for randomized placebo-controlled trials of interventions for LBP that used sham ultrasound, sham laser or sham drug therapy as the placebo control. Study selection was accomplished via independent evaluation of scientific admissibility by three reviewers and final decisions of inclusion were based on consensus. RESULTS: None of the studies using sham ultrasound as the placebo control in the treatment of LBP were acceptable for inclusion. Twelve studies were included in the present evaluation of the placebo effect - eight trials that met the strict inclusion criteria for best evidence (three using sham laser placebo and five using sham medication placebo) and four sham medication studies that 'just missed' the inclusion criteria for best evidence. Although the evidence from studies using sham laser was inconclusive, the present review did find a clinically meaningful change in LBP scores following the use of sham oral medications. CONCLUSIONS: The present best-evidence review found a clinically meaningful change in pain scores following the use of sham oral medications for the treatment of nonspecific LBP. This finding suggests that further clinical research is warranted to identify which patient subgroups could benefit most from such treatment and to distinguish the true contribution of the placebo effect from other nonspecific effects.

The relationship between self-rated disability, fear-avoidance beliefs, and nonorganic signs in patients with chronic whiplash-associated disorder.

OBJECTIVES: The purpose of this study was to determine the role of standard and novel (cervical) nonorganic signs in patients with chronic whiplash-associated disorder (WAD). METHODS: Chronic WAD I to III patients (>3 months) were recruited from private chiropractic practice in Canada. Subjects completed a Neck Disability Index (NDI), Tampa Scale for Kinesiophobia (TSK), pain visual analog scale, and pain diagram. Clinical and demographic data were also obtained. Nine standard nonorganic pain behavior tests and 4 novel cervical nonorganic simulation signs (C-NOSS) tests were applied. Bivariate correlations were obtained with the Pearson correlation coefficient. Items achieving statistical significance on univariate analysis were loaded in a sequential linear regression analysis. Post hoc analyses were conducted with analysis of variance tests of NDI and TSK scores. RESULTS: Ninety-one subjects were investigated (49 males and 42 females), with a mean age of 41.7 (SD, 14.7) years and a mean duration of 9.4 (SD, 11.2) months. Because mean NDI scores were 57.5 (SD, 17.8) and mean pain scores were 68.3 (SD, 21.0), this sample represents moderate-to-severe WAD. Fair to moderately strong correlations were obtained between the NDI and the TSK, pain visual analog scale and nonorganic symptoms and signs (NOS-9) and C-NOSS scores, but not with "age," "sex," or "duration." The NOS-9 and C-NOSS scores correlated most strongly at 0.70. A multivariate model accounting for 53% of the variance of the NDI scores (P < .001) was obtained with the TSK, pain severity, and NOS-9 scores. There was no significant correlation between C-NOSS and TSK scores. At least 25% of subjects scored either 5 of 9 or 2 of 4 on the NOS-9 and C-NOSS tests, respectively. CONCLUSIONS: Based on the findings of this study, nonorganic signs should be considered in the interpretation of self-rated disability in patients with moderate-to-severe chronic WAD.

Stereospecificity of myo-inositol hexakisphosphate hydrolysis by a protein tyrosine phosphatase-like inositol polyphosphatase from Megasphaera elsdenii.

Inositol polyphosphatases (IPPases), particularly those that can hydrolyze myo-inositol hexakisphosphate (Ins P(6)), are of biotechnological interest for their ability to reduce the metabolically unavailable organic phosphate content of feedstuffs and to produce lower inositol polyphosphates (IPPs) for research and pharmaceutical applications. Here, the gene coding for a new protein tyrosine phosphatase (PTP)-like IPPase was cloned from Megasphaera elsdenii (phyAme), and the biochemical properties of the recombinant protein were determined. The deduced amino acid sequence of PhyAme is similar to known PTP-like IPPases (29-44% identity), and the recombinant enzyme displayed strict specificity for IPP substrates. Optimal IPPase activity was displayed at an ionic strength of 250 mM, a pH of 5.0, and a temperature of 60 degrees C. In order to elucidate its stereospecificity of Ins P(6) dephosphorylation, a combination of high-performance ion-pair chromatography and kinetic studies was conducted. PhyAme displayed a stereospecificity that is unique among enzymes belonging to this class in that it preferentially cleaved Ins P(6) at one of two phosphate positions, 1D-3 or 1D-4. PhyAme followed two distinct and specific routes of hydrolysis, predominantly degrading Ins P(6) to Ins(2)P via: (a) 1D-Ins(1,2,4,5,6)P(5), 1D-Ins(1,2,5,6)P(4), 1D-Ins(1,2,6)P(3), and 1D-Ins(1,2)P(2) (60%) and (b) 1D-Ins(1,2,3,5,6)P(5), 1D-Ins(1,2,3,6)P(4), Ins(1,2,3)P(3), and D/L-Ins(1,2)P(2)(35%).

A protein tyrosine phosphatase-like inositol polyphosphatase from Selenomonas ruminantium subsp. lactilytica has specificity for the 5-phosphate of myo-inositol hexakisphosphate.

Although it is becoming well known that myo-inositol polyphosphates and the enzymes involved in their metabolism play a critical role in eukaryotic systems, little is understood of their significance in prokaryotic systems. A novel protein tyrosine phosphatase (PTP)-like inositol polyphosphatase (IPPase) gene has been cloned from Selenomonas ruminantium subsp. lactilytica (phyAsrl). The deduced amino acid sequence of PhyAsrl is most similar to a PTP-like IPPase from the anaerobic bacterium S. ruminantium (35% identity), but also shows similarity (19-30% identity) to various other putative prokaryotic PTPs. Recombinant PhyAsrl could dephosphorylate myo-inositol hexakisphosphate (Ins P(6)) in vitro, and maximal activity was displayed at an ionic strength of 200 mM, a pH of 4.5, and a temperature of 55 degrees C. In order to elucidate its substrate specificity and pathway of Ins P(6) dephosphorylation, a combination of kinetic and high-performance ion-pair chromatography studies were conducted. The data indicated that PhyAsrl has a general specificity for polyphosphorylated myo-inositol substrates, but can also dephosphorylate molecules containing high energy pyrophosphate bonds in vitro. PhyAsrl is unique from other microbial IPPases in that it preferentially cleaves the 5-phosphate position of Ins P(6). Furthermore, it can produce Ins(2)P via a highly unique and ordered pathway of sequential dephosphorylation: Ins P(6), Ins(1,2,3,4,6)P(5), D-Ins(1,2,3,6)P(4), Ins(1,2,3)P(3), and D/L-Ins(1,2)P(2). Finally, reverse transcription PCR was used to determine that phyAsrl is constitutively expressed, and together with bioinformatic analysis, was used to gain an understanding of its physiological significance.

Kinetic and structural analysis of a bacterial protein tyrosine phosphatase-like myo-inositol polyphosphatase.

PhyA from Selenomonas ruminantium (PhyAsr), is a bacterial protein tyrosine phosphatase (PTP)-like inositol polyphosphate phosphatase (IPPase) that is distantly related to known PTPs. PhyAsr has a second substrate binding site referred to as a standby site and the P-loop (HCX5R) has been observed in both open (inactive) and closed (active) conformations. Site-directed mutagenesis and kinetic and structural studies indicate PhyAsr follows a classical PTP mechanism of hydrolysis and has a broad specificity toward polyphosphorylated myo-inositol substrates, including phosphoinositides. Kinetic and molecular docking experiments demonstrate PhyAsr preferentially cleaves the 3-phosphate position of Ins P6 and will produce Ins(2)P via a highly ordered series of sequential dephosphorylations: D-Ins(1,2,4,5,6)P5, Ins(2,4,5,6)P4, D-Ins(2,4,5)P3, and D-Ins(2,4)P2. The data support a distributive enzyme mechanism and suggest the PhyAsr standby site is involved in the recruitment of substrate. Structural studies at physiological pH and high salt concentrations demonstrate the "closed" or active P-loop conformation can be induced in the absence of substrate. These results suggest PhyAsr should be reclassified as a D-3 myo-inositol hexakisphosphate phosphohydrolase and suggest the PhyAsr reaction mechanism is more similar to that of PTPs than previously suspected.

Description of the case mix experienced by chiropractic students during a clinical internship.

OBJECTIVE: The primary objective of this study was to describe the case mix experienced by chiropractic students during their clinical internship at the Canadian Memorial Chiropractic College. Secondary objectives were to characterize teaching clinic patient populations, assess the similarity to previously published data for practicing chiropractors, and describe the treatment plans being recommended by interns. METHODS: A prospective, observational study was conducted using a convenience sample of 24 chiropractic interns. Data were collected by interns using a standardized form that was completed for each new patient and each new complaint examined during the 1-year internship. Standardized forms included data regarding patient demographics, complaint characteristics, and treatment recommendations. RESULTS: Data were included for 23 of 24 participating interns, who described 828 patients and a total of 948 unique complaint presentations. Overall, 60% of patients were female, 86% were 18 to 64 years old, and 23% were naive to chiropractic care. Of all presenting complaints, 93% were pain-based, 67% were chronic, 65% included spinal complaints, and 7% presented with red flags; individual interns' experiences were variable and are described. On average, treatment recommendations called for 9.4 visits and often included multimodal treatment approaches, most commonly soft-tissue therapies (91%), home-based active care (84%), and spine manipulation (70%). CONCLUSIONS: The findings of this study suggest that patients presenting to CMCC teaching clinics are similar to those reported previously to attend private chiropractic clinics. While all participating interns encountered multiple complex clinical cases, very few had experience with pediatric populations. This study adds to the few that detail the characteristics of patients attending chiropractic teaching clinics; to our knowledge it is the first to describe average case loads of chiropractic interns.

The quality of placebos used in randomized, controlled trials of lumbar and pelvic joint thrust manipulation-a systematic review.

BACKGROUND CONTEXT: Spinal manipulative therapy (SMT) has been attributed with substantial non-specific effects. Accurate assessment of the non-specific effects of SMT relies on high-quality studies with low risk of bias that compare with appropriate placebos. PURPOSE: This review aims to characterize the types and qualities of placebo control procedures used in controlled trials of manually applied, lumbar and pelvic (LP)-SMT, and to evaluate the assessment of subject blinding and expectations. STUDY DESIGN: This is a systematic review of randomized, placebo-controlled trials. METHODS: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Index to Chiropractic Literature, and relevant bibliographies. We included randomized, placebo or sham-controlled trials where the index treatment was manually applied LP-SMT. There were no restrictions on the type of condition being investigated. Two independent reviewers selected the studies, assessed study quality, and extracted the data. Relevant data were the type and quality of placebo control(s) used, the assessment of blinding and expectations, and the results of those assessments. RESULTS: Twenty-five randomized, placebo-controlled trials were included in this review. There were 18 trials that used a sham manual SMT procedure for their placebo control intervention; the most common approach was with an SMT setup but without the application of any thrust. One small pilot study used an unequivocally indistinguishable placebo, two trials used placebos that had been validated as inert a priori, and eight trials reported on the success of subject blinding. Risk of bias was high or unclear, for all included studies. CONCLUSIONS: Imperfect placebos are ubiquitous in clinical trials of LP-SMT, and few trials have assessed for successful subject blinding or balanced expectations of treatment success between active and control group subjects. There is thus a strong potential for unmasking of control subjects, unequal non-specific effects between active and control groups, and non-inert placebos in existing trials. Future trials should consider assessing the success of subject blinding and ensuring inertness of their placebo a priori, as a minimum standard for quality.

Is "fear of passive movement" a distinctive component of the Fear-Avoidance Model in whiplash?

OBJECTIVES: Modify the Tampa Scale for Kinesiophobia (TSK) for 'fear of passive motion' beliefs. METHODS: With permission, a 14-item modification, the TSK-PM (passive movement), was created. Test-retest reliability was tested first. Construct validity was tested in chronic whiplash patients by comparing the TSK-PM with the TSK, the Neck Disability Index (NDI) and cervical ranges of motion. RESULTS: The TSK-PM showed high test-retest reliability (r = 0.83) and high correlation with the original TSK (r = 0.84). Low, non-significant correlations were found with other variables. NDI scores were strongly correlated with ranges of motion. CONCLUSIONS: While having high test-retest reliability and a single factor structure, the TSK-PM failed to demonstrate distinctive construct validity vs the original TSK. The original TSK is likely to be sufficient to assess fear of being moved in neck pain patients in a clinical setting. Modifications to the current version of the TSK-PM might improve its construct validity in future studies.

OBJECTIFS: Modifier l'échelle de Tampa (TSK) pour l'évaluation de l'indice de kinésiophobie pour définir la « crainte du mouvement passif ¼. MÉTHODOLOGIE: Un questionnaire TSK-MP (mouvements passifs) a été créé en modifiant 14 points de la TSK avec permission. Tout d'abord, on a évalué la fiabilité de test-retest. La validité conceptuelle a été testée chez des patients souffrant d'entorse cervicale chronique en comparant le TSK-MP avec la TSK, l'indice d'incapacité cervicale (NDI) et les amplitudes de mouvement cervical. RÉSULTATS: Le TSK-MP a montré une grande fiabilité test-retest (r = 0,83) et une forte corrélation avec la TSK originale (r = 0,84). On a observé de faibles corrélations non significatives avec d'autres variables. Les résultats de l'indice d'incapacité cervicale étaient fortement corrélés avec les amplitudes de mouvement. CONCLUSIONS: Tout en ayant une haute fiabilité test-retest et une structure à un seul facteur, le TSK-MP n'a pas démontré une validité conceptuelle distincte par rapport à la TSK originale. La TSK originale est probablement suffisante pour évaluer la crainte d'être déplacé chez les patients atteints de douleurs cervicales dans un cadre clinique. Les modifications apportées à la version actuelle du TSK-MP pourraient améliorer sa validité conceptuelle dans des études futures.

Diagnostic and treatment methods used by chiropractors: A random sample survey of Canada's English-speaking provinces.

OBJECTIVE: It is important to understand how chiropractors practice beyond their formal education. The objective of this analysis was to assess the diagnostic and treatment methods used by chiropractors in English-speaking Canadian provinces. METHODS: A questionnaire was created that examined practice patterns amongst chiropractors. This was sent by mail to 749 chiropractors, randomly selected and stratified proportionally across the nine English-speaking Canadian provinces. Participation was voluntary and anonymous. Data were entered into an Excel spreadsheet, and descriptive statistics were calculated. RESULTS: The response rate was 68.0%. Almost all (95.1%) of respondents reported performing differential diagnosis procedures with their new patients; most commonly orthopaedic testing, palpation, history taking, range of motion testing and neurological examination. Palpation and painful joint findings were the most commonly used methods to determine the appropriate joint to apply manipulation. The most common treatment methods were manual joint manipulation/mobilization, stretching and exercise, posture/ergonomic advice and soft-tissue therapies. CONCLUSIONS: Differential diagnosis is a standard part of the assessment of new chiropractic patients in English-speaking Canadian provinces and the most common methods used to determine the site to apply manipulation are consistent with current scientific literature. Patients are treated with a combination of manual and/or manipulative interventions directed towards the joints and/or soft-tissues, as well as exercise instruction and postural/ergonomic advice.

OBJECTIF: Il est important de comprendre la pratique des chiropraticiens qui dépasse le cadre de leur éducation formelle. L'objectif de cette analyse était d'évaluer les méthodes de diagnostic et de traitement utilisées par les chiropraticiens dans les provinces canadiennes anglophones. MÉTHODOLOGIE: Un questionnaire a été créé pour examiner les habitudes de pratique des chiropraticiens et a été envoyé par la poste à 749 d'entre eux, choisis au hasard et stratifiés proportionnellement entre les neuf provinces anglophones. La participation était volontaire et anonyme. Les données ont été saisies dans un tableur Excel, et les statistiques descriptives ont été calculées. RÉSULTATS: Le taux de participation a été de 68,0 %. Presque tous (95,1 %) les répondants ont déclaré effectuer des diagnostics différentiels de leurs nouveaux patients; plus couramment des tests orthopédiques, la palpation, l'anamnèse, des tests d'amplitude de mouvement et l'examen neurologique. La palpation et la détection d'articulations douloureuses étaient les méthodes les plus couramment utilisées pour déterminer l'articulation appropriée à manipuler. Les méthodes de traitement les plus fréquentes étaient la manipulation ou la mobilisation manuelle des articulations, les étirements et les exercices, les conseils posturaux ou ergonomiques et la thérapie des tissus mous. CONCLUSIONS: Le diagnostic différentiel fait partie de la norme d'évaluation de nouveaux patients chiropratiques dans les provinces anglophones canadiennes, et les méthodes les plus couramment utilisées pour déterminer les points à manipuler concordent avec les publications scientifiques actuelles. Les patients sont traités par une combinaison d'interventions manuelles ou de manipulation axées sur les articulations ou tissus mous, ainsi que par des instructions d'exercice et des conseils posturaux et ergonomiques.

Self-rated disability, fear-avoidance beliefs, nonorganic pain behaviors are important mediators of ranges of active motion in chronic whiplash patients.

PURPOSE: The influence of self-rated disability and fear-avoidance beliefs on whiplash sufferers in their performance of active ranges of motion has not been studied well. We undertook a cross-sectional study to determine this. METHODS: Chronic whiplash subjects completed a standard clinical examination. They completed the Neck Disability Index (NDI), the Tampa Scale for Kinesiophobia (TSK) and pain visual analog scale (VAS). Active ranges of motion (goniometer) and cervical nonorganic simulation signs (C-NOSS) were obtained by the examiner. Univariate and multivariable analyses were conducted on these scores. RESULTS: Sixty-four subjects (37 female) with a mean age of 41.4 (SD 16.1) years completed all scores. NDI, pain VAS and C-NOSS correlated significantly with ROM. In a multivariable model, only the NDI score contributed significantly to the variance of the ROM scores (14%). CONCLUSION: As chronic whiplash sufferers perform ROM in a clinical examination, these ranges are importantly influenced by their self-perceived disability. Cervical nonorganic simulation signs can be helpful in distinguishing high from very high levels of disability and motion restriction. The lack of correlation with the TSK may present a challenge to the Fear Avoidance Model in whiplash. Implications for Rehabilitation Self-ratings of disability in chronic whiplash sufferers are influenced by their fear-avoidance beliefs. While self-ratings of disability are known to predict chronicity of whiplash, there is less known about how these ratings affect impairment assessment during recovery. This study shows that self-ratings of disability influence the presentation of impairment by chronic whiplash sufferers with respect to their ranges of neck motion. Signs of nonorganic behavior also influence ranges of motion and self-ratings of disability. These findings should be incorporated into the interpretation of impairment findings in chronic whiplash sufferers in order to improve management.

Cross-frictional therapy and stretching for the treatment of palmar adhesions due to Dupuytren's contracture: a prospective case study.

OBJECTIVE: To examine the potential for treatment of palmar adhesions associated with Dupuytren's contracture using instrument-assisted cross-frictional massage (CFM) and stretching. METHODS: This was a prospective case study. The primary intervention consisted of a 2-min multi-planar CFM over the affected area of the palm, followed by a 2-min maximal finger-extension stretch. RESULTS: Following eight weeks of treatment there were increases in both passive and active extension range of motion of the digits, reduction in the visibility of palmar adhesions, and subjective improvements in hand function. CONCLUSIONS: This treatment protocol may offer a substitute for the current invasive surgical and injection procedures that are available.

Systematic review of clinical trials of cervical manipulation: control group procedures and pain outcomes.

OBJECTIVE: To characterize the types of control procedures used in controlled clinical trials of cervical spine manipulation and to evaluate the outcomes obtained by subjects in control groups so as to improve the quality of future clinical trials METHODS: A search of relevant clinical trials was performed in PubMed 1966-May 2010 with the following key words: "Chiropractic"[Mesh] OR "Manipulation, Spinal"[Mesh]) AND "Clinical Trial "[Publication Type]. Reference lists from these trials were searched for any additional trials. The reference lists of two prior studies, one review and one original study were also searched. Accepted reports were then rated for quality by 2 reviewers using the PEDro scale. Studies achieving a score of >50% were included for data extraction and analysis. Intra-group change scores on pain outcomes were obtained. For determining clinically important outcomes, a threshold of 20% improvement was used where continuous data were available; otherwise, an effect size of 0.30 was employed RESULTS: The PubMed search yielded 753 citations of which 13 were selected. Eight (8) other studies were identified by reviewing two systematic reviews and through reference searches. All studies scored >50% on the PEDro scale. There were 9 multi-session studies and 12 single-session studies. The most commonly used control procedure was "manual contact/no thrust". Four (4) studies used a placebo-control (patient blinded). For two of these studies with VAS data, the average change reported was 4.5 mm. For the other control procedures, variable results were obtained. No clinically important changes were reported in 57% of the paired comparisons, while, in 43% of these, changes which would be considered clinically important were obtained in the control groups. Only 15% of trials reported on post-intervention group registration. CONCLUSIONS: Most control procedures in cervical manipulation trials result in small clinical changes, although larger changes are observed in 47% of paired comparisons. The vast majority of studies do not result in subject blinding; the effect of unmasking of control subjects in these studies makes the interpretation of the existing clinical trials challenging. The greatest majority of trials do not report on post-intervention blinding. A small number of candidate procedures for effective control interventions exist. Much more research is required to improve this important aspect of clinical trial methodology in cervical manipulation studies.