Cross-Sectional Survey of Opinions, Professional Changes, and Personal Hardships of COVID-19 on Chiropractors in the United States.

OBJECTIVE: The purpose of this study was to assess self-reported data from a sample of U.S. doctors of chiropractic during the COVID-19 pandemic about levels of psychological stress and beliefs of the association between chiropractic spinal manipulation and the immune system. METHODS: Chiropractors in the United States were invited via social media and e-mail to complete a survey about chiropractic and COVID-19. The survey collected demographic information, office protocols, changes made during the COVID-19 pandemic, chiropractic profession opinions, information related to stress, and personal beliefs from April 19 to May 3 of 2020. Data were analyzed using descriptive statistics. RESULTS: Of approximately 77000 U.S.-licensed chiropractors,750 responded. Of this sample, 51.2% reported moderate and 30.4% reported severe levels of psychological stress. The primary stressors were financial and business concerns. There was a mixed response regarding beliefs if there was evidence to support a connection between spinal manipulation and the immune system. A majority (76.1%) responded that there should be no advertising for immune-boosting effects of spinal manipulation during the pandemic. A minority (18.3%) reported adding use of telehealth to deliver their services. CONCLUSION: A majority of chiropractors included in this survey reported that the COVID-19 pandemic caused them psychological stress. More than half of the respondents reported moderate stress, with the second highest number of respondents reporting severe stress. Subgroup differences were noted in stress levels and causes, as well as pandemic-related practice changes. A dichotomy was noted between beliefs and recommended actions about effects on the immune system, which may represent that providers are aware of current evidence and considering association recommendations.

Aromatherapy for test anxiety in chiropractic students.

OBJECTIVE: Up to 85% of college students experience test anxiety, which may contribute to decreased academic performance. The purpose of this study was to assess the feasibility of recruiting chiropractic students for a randomized trial involving aromatherapy for anxiety reduction. METHODS: This study enrolled chiropractic students who were randomly assigned to separate rooms during a biochemistry test. Waterless diffusers dispersed a lemon and rosemary blend of essential oils in the experimental room and water in the control room. Students completed pretest surveys rating current and general anxiety. Posttest surveys included rating current anxiety. Analysis of covariance (ANCOVA) was preformed to determine within- and between-group differences for current anxiety. Feasibility was the primary aim, and the statistical significance of anxiety test scores between rooms was the secondary aim. RESULTS: Sixty-four students were included in the study. The feasibility of research methods was noted for adherence to the study protocol (informed consent, randomization, and survey distribution and completion) and resource allocation. Design improvements are required in recruitment methods, follow-up surveys, and intervention blinding. ANCOVA for between-group comparisons showed no statistically significant difference between groups' pre- and posttest anxiety scores (p = .22). Two reported side effects, eye and sinus irritation, could not be attributed to treatment group. Most students were willing to use aromatherapy for test anxiety in the future. CONCLUSION: We demonstrated feasibility in conducting a randomized study to measure the influence of aromatherapy on test anxiety in chiropractic students. A powered, randomized study is needed to determine if aromatherapy may be effective in reducing test anxiety.

Improper Communication Makes for Squat: A Qualitative Study of the Health-Care Processes Experienced By Older Adults in a Clinical Trial for Back Pain.

BACKGROUND: The study focused on perceptions of older adults toward the healthcare processes they experienced during a clinical trial for back pain that involved family medicine residents and licensed chiropractors. METHODS: Individual semi-structured interviews were conducted with 115 older adults after a 12-week, 3-arm, randomized controlled trial. Two researchers conducted thematic analysis with inductive coding using qualitative software to identify participants' salient experiences of the doctor-patient relationship, healthcare process, and collaboration between study providers. Investigators categorized thematic codes within an existing framework of clinical excellence in primary care. RESULTS: Participants emphasized provider communication and interpersonal relationships, professionalism and passion for patient care, clinical and diagnostic acumen, and skillful negotiation of the health-care system. Older adults also described the importance of interdisciplinary collaboration and their preferences for receiving hands-on treatments for musculoskeletal conditions. CONCLUSION: These older adults valued doctors who communicated clearly and spent time listening to their concerns. Many participants appreciated clinicians who supported an active role for patients in their health-care and who provided touch-based care for musculoskeletal conditions.

Potential publication bias in chiropractic and spinal manipulation research listed on clinicaltrials.gov.

INTRODUCTION: Clinical trial registries are used to help improve transparency in trial reporting. Our study aimed to identify potential publication bias in chiropractic and spinal manipulation research by assessing data drawn from published studies listed in clinincaltrials.gov. METHODS: We searched the clinicaltrials.gov registry database for completed trials tagged with the key indexing terms chiropractic or spinal manipulation. We assessed if the trial registry had been updated with data, then searched for publications corresponding to the registered trials. Finally, the frequency of positive or negative results was determined from published studies. RESULTS: For the term 'chiropractic', 63% of studies supported the intervention and 52% supported the intervention for the term 'spinal manipulation'. DISCUSSION: Publication bias in chiropractic and spinal manipulation research listed in clinicaltrials.gov appears to occur. Further work may help understand why this happens and what may be done to mitigate this moving forward.

INTRODUCTION: Les registres des essais cliniques servent à accroître la transparence des rapports sur les essais. Notre étude visait à trouver les éventuels partis pris de publication dans les travaux de recherche sur la chiropratique et les manipulations vertébrales à l'aide de données tirées d'études publiées et répertoriées dans clinincaltrials.gov. MÉTHODOLOGIE: Dans la base de données du registre clinicaltrials.gov, nous avons cherché des essais terminés marqués par les termes d'indexation « chiropratique ¼ et « manipulation vertébrale ¼. Nous avons cherché à savoir si le registre des essais avait été mis à jour par l'ajout de données, puis nous avons recherché les publications correspondant aux essais répertoriés. Enfin, nous avons établi la fréquence des résultats positifs et négatifs à l'aide des études publiées. RÉSULTATS: Avec le terme « chiropratique ¼, 63 % des études étaient en faveur des interventions; avec l'expression « manipulation vertébrale ¼,52 % des études étaient en faveur des interventions. DISCUSSION: Il semble y avoir un parti pris de publication dans les travaux de recherche sur la chiropratique et les manipulations vertébrales répertoriés dans clinicaltrials.gov. D'autres travaux pourraient aider à comprendre la cause de ce phénomène et à trouver des moyens de le réduire dans l'avenir.

Measuring biopsychosocial risk for back pain disability in chiropractic patients using the STarT back screening tool: a cross-sectional survey.

Background: The Keele STarT Back Screening Tool (SBT), a 9-item questionnaire, screens for pain, physical functioning, fear-avoidance beliefs, catastrophizing, anxious thoughts, low mood, and bothersomeness in persons with back pain. SBT scores designate low, medium, or high risk for developing persistent disabling back pain. The primary study aim was to report the prevalence of SBT-calculated risk for back pain disability in US patients seeking chiropractic care. Methods: The SBT questionnaire was administered to patients ≥18 years in 3 Chiropractic College outpatient teaching clinics in Iowa and Illinois (May 2017). Descriptive statistics were used to analyze respondent characteristics and prevalence of SBT-calculated risk subgroups. Binary logistic regression analysis was used to examine the relationship between respondent characteristics and SBT scores (including psychological subscores). Results: Of 550 respondents, 496 completed the SBT; 392 (79%) scored low-risk, 81 (16%) medium-risk, and 23 (5%) high-risk. Mean (SD) age was 44.8 (15.9), 56.9% were female, 88.2% white, 62.6% employed, mean current pain was 2.9 (2.1) out of 10, and 62% reported symptom duration > 3 months. Eighteen percent of respondents reported anxious thoughts, 32% low mood, 41% ≥ 1 and 21% ≥ 3 SBT psychological risk factors. Respondents reporting higher average pain (OR = 1.8 [1.4, 2.3]) and pain severity (OR = 1.3 [1.0 to 1.6]) were more likely to score with medium or high risk. Respondents reporting mid back versus low back pain (OR = 0.2 [0.1, 0.7]), and those employed less than full-time versus full-time (0.2 [01, 0.5]) were less likely to score with medium or high risk. Respondents reporting higher average pain were more likely to report ≥1 psychological factor (OR = 1.8 [1.5, 2.0]). Respondents employed part-time were less likely to report ≥1 psychological factor than those employed full-time (OR = 0.4 [0.2, 0.7]). Conclusion: The sample surveyed was less likely to score with medium or high risk for back pain disability than previous samples studied, perhaps due to differences in study design and sample characteristics. Rates of low mood and anxious thoughts indicate a need for future research to explore psychological factors among persons seeking chiropractic care.

Impacting public health by affecting individual health: A focus group study with chiropractic students after an international clinical experience.

PURPOSE: To describe chiropractic students' perceptions of their future role in public health following an international service-learning experience. METHODS: Four, 60-minute focus groups were held with 17 upper-level students from 1 U.S. chiropractic college after a mentored clinical experience in 4 international settings. Two investigators analyzed the transcribed focus group interviews. RESULTS: We identified 3 themes where chiropractic students emphasized the public health contributions of chiropractors, usually through one-on-one interactions with patients. The primary theme was the prevention and treatment of spine and musculoskeletal conditions through chiropractic care. Next, chiropractors might improve patients' access to health services through screenings, referrals, and monitoring acute and chronic conditions. Lastly, patient education could help patients manage spinal health and make lifestyle modifications. CONCLUSION: Incorporating service learning strategies within chiropractic curriculum may increase student awareness and participation in public health activities.

OBJECTIF: Décrire la façon dont les étudiants en chiropratique perçoivent leur futur rôle dans la santé publique suite à une expérience d'apprentissage par le service menée à l'échelle internationale. MÉTHODOLOGIE: À la suite d'une expérience clinique encadrée dans 4 établissements reconnus à l'échelle internationale, on a tenu quatre séances de discussion de 60 minutes avec 17 étudiants inscrits au programme d'études supérieures d'un collège de chiropratique des É-U. Deux investigateurs ont examiné les transcriptions des entrevues avec les groupes de discussion. RÉSULTATS: Voici les trois points sur lesquels les étudiants en chiropratique ont insisté en parlant de l'apport des chiropraticiens à la santé publique, habituellement au moyen de rencontres personnalisées avec les patients. Premier point : les soins chiropratiques contribuent à la prévention et le traitement des troubles de la colonne vertébrale et des affections musculosquelettiques. Deuxième point : les chiropraticiens facilitent l'accès aux services de santé en faisant des dépistages, en dirigeant des patients vers des ressources appropriées et en surveillant les troubles aigus et chroniques. Enfin, le troisième point : l'information au patient peut l'aider à prendre en charge sa santé vertébrale et à modifier son mode de vie. CONCLUSION: L'intégration de stratégies d'apprentissage par le service au programme d'études en chiropratique peut permettre de mieux sensibiliser l'étudiant et d'accroître sa participation à des activités de santé publique.

A focus group study of chiropractic students following international service learning experiences.

OBJECTIVE: One objective of chiropractic education is to cultivate clinical confidence in novice practitioners. The purpose of this qualitative study was to describe how participation in a short-term international service learning experience changed perceptions of clinical confidence in senior chiropractic students. METHODS: Seventeen senior chiropractic students participated in 4 moderated focus group sessions within 4 months after a clinical educational opportunity held in international settings. Participants answered standard questions on how this educational experience may have changed their clinical confidence. Two investigators performed qualitative thematic analysis of the verbatim transcripts to identify core concepts and supporting themes. RESULTS: The core concept was transformation from an unsure student to a confident doctor. The service learning experience allowed students to deliver chiropractic treatment to patients in a real-world setting, engage in frequent repetitions of technical skills, perform clinical decision-making and care coordination, and communicate with patients and other health professionals. Students described increased clinical confidence in 9 competency areas organized within 3 domains: (1) chiropractic competencies including observation, palpation, and manipulation; (2) clinical competencies including problem solving, clinic flow, and decision-making; and (3) communication competencies, including patient communication, interprofessional communication, and doctor-patient relationship. Students recommended that future service learning programs include debriefing sessions similar to the experience offered by these focus groups to enhance student learning. CONCLUSION: Senior chiropractic students who participated in an international service learning program gained confidence and valuable practical experience in integrating their chiropractic, clinical, and communication skills for their future practices.

Do informed consent documents for chiropractic clinical research studies meet readability level recommendations and contain required elements: a descriptive study.

BACKGROUND: Informed consent documents (ICD) in research are designed to educate research participants about the nature of the research project in which he or she may participate. United States (US) law requires the documents to contain specific elements present and be written in a way that is understandable to research participants. The purpose of this research is to determine if ICDs from randomized controlled trials conducted at chiropractic colleges meet recommended readability standards and contain the 13 content items required by US law. METHODS: This study was approved by Palmer College of Chiropractic's IRB #2012-12-3-T and was conducted between December 3, 2012 and February 14, 2013. We contacted the research directors of five chiropractic colleges that have received federal funding supporting their clinical research. A total of 13 informed consent documents from four chiropractic colleges were analyzed using the Flesch-Kincaid measurement. We assigned a grade-level readability score to the document based on the average of three separate grade level scores conducted on the three largest uninterrupted blocks of text. Content of the 13 ICDs was assessed using a 13-element checklist. A point was given for every element present in the document, giving a score range of "0, no elements are present", to "13, all elements are present." RESULTS: The mean Flesch-Kincaid grade level readability was 10.8 (range 7.2 -14.0). Our sample had a mean readability score 2.8 grade levels above the generally-accepted US average reading level. Content varied among the 13 informed consent forms, ranging from only nine elements present in one document to all 13 required in five documents. Additionally, we collated the risks presented in each document. CONCLUSION: These results strongly suggest that chiropractic clinical researchers are not developing ICDs at a readability level congruent with the national average acceptable level. The low number of elements in some of the informed consent documents raises concern that not all research participants were fully informed when given the informed consent, and it may suggest that some documents may not be in compliance with federal requirements. Risk varies among institutions and even within institutions for the same intervention.

Bladder and bowel symptoms among adults presenting with low back pain to an academic chiropractic clinic: results of a preliminary study.

OBJECTIVE: The purposes of this study were to estimate the 1-month point prevalence of bowel and bladder symptoms (BBS) among adult chiropractic patients and to evaluate associations between these symptoms and low back pain (LBP). METHODS: Patients 18 years or older presenting to a chiropractic college academic health clinic between March 25 and April 25, 2013, were asked to complete a symptom screening questionnaire. Descriptive statistics, binary logistic regression, Fisher exact test, and P values were calculated from the sample. RESULTS: The sample included 140 of 1300 patients who visited the clinic during the survey period (11%). Mean age was 47.5 (range 18-79) years. LBP was the primary chief complaint in 42%. The 1-month point prevalence of any bladder symptoms was 75%, while the rate for bowel symptoms was 62%; 55% reported both BBS. Binary logistic regression analyses showed no statistically significant association between a chief complaint of LBP and combined BBS (OR = 1.67, P = .164). CONCLUSION: The prevalence of bowel and bladder symptoms in chiropractic patients was high. There was no statistically significant association between these symptoms and LBP in this group of patients seeking care for LBP.

Financial attitudes, knowledge, and habits of chiropractic students: A descriptive survey.

OBJECTIVE: Our purpose was to describe the financial knowledge, habits and attitudes of chiropractic students. METHODS: We designed a cross-sectional survey to measure basic financial knowledge, current financial habits, risk tolerance, and beliefs about future income among 250 students enrolled in business courses at one US chiropractic college. Descriptive statistical analyses were performed. RESULTS: We received 57 questionnaires (23% response rate). Most respondents would accumulate over $125,000 in student loan debt by graduation. Financial knowledge was low (mean 77%). Most respondents (72%) scored as average financial risk takers. Chiropractic students reported recommended short-term habits such as having checking accounts (90%) and health insurance (63%) or paying monthly bills (88%) and credit cards (60%). Few saved money for unplanned expenses (39%) or long-term goals (26%), kept written budgets (32%), or had retirement accounts (19%). CONCLUSION: These chiropractic students demonstrated inadequate financial literacy and did not engage in many recommended financial habits.

OBJECTIF: Notre but était de décrire les connaissances, les habitudes et les attitudes en matière de finances des étudiants en chiropratique. MÉTHODOLOGIE: Nous avons conçu une étude transversale pour mesurer les connaissances financières de base, les habitudes financières actuelles, la tolérance au risque, et les opinions sur les revenus futurs d'un groupe de 250 étudiants inscrits à des cours de commerce dans un collège de chiropratique aux États-Unis. Des analyses statistiques descriptives ont été effectuées. RÉSULTATS: Nous avons reçu 57 questionnaires (taux de réponse de 23 %). La plupart des répondants accumuleraient plus de 125 000 $ de dette en prêts aux étudiants avant d'obtenir leur diplôme. Le taux des connaissances financières est faible (moyenne de 77 %). La plupart des répondants (72 %) ont obtenu une note moyenne comme preneurs de risque financier. En ce qui concerne les habitudes recommandées à court terme, les étudiants en chiropratique ont signalé avoir des comptes chèques (90 %) et une assurance maladie (63 %), ou payer les factures (88 %) et les cartes de crédit (60 %) tous les mois. Peu disent économiser de l'argent pour des dépenses imprévues (39 %) ou pour des objectifs à long terme (26 %), maintenir des budgets écrits (32 %), ou avoir des comptes de retraite (19 %). CONCLUSION: Ces étudiants en chiropratique ont fait preuve de connaissances financières insuffisantes et d'un manque d'engagement dans de nombreuses habitudes financières recommandées.

Attitudes toward evidence-based clinical practice among doctors of chiropractic with diplomate-level training in orthopedics.

BACKGROUND: Evidence-based clinical practice (EBCP) is a practice model gaining prominence within healthcare, including the chiropractic profession. The status of EBCP has been evaluated in a variety of healthcare disciplines, but little is known regarding the attitudes doctors of chiropractic (DCs) hold toward this model of healthcare. This project examines the attitudes toward EBCP within a specialty discipline of DCs. METHODS: We identified a survey questionnaire previously used to evaluate EBCP among non-chiropractic complementary and alternative practitioners. We adapted this questionnaire for use among DCs and pretested it in 5 chiropractic college faculty. The final version was administered to DCs with diplomate-level training in orthopedics. The survey was emailed to 299 potential participants; descriptive results were calculated. RESULTS: 144 surveys were returned, resulting in a 48% response rate. The majority of respondents perceived EBCP as an important aspect of chiropractic practice. Respondents also believed themselves to have an above average skill level in EBCP, reported that training originated from their diplomate education, and based the majority of their practice on clinical research. CONCLUSION: Doctors of chiropractic with an orthopedic diplomate appear to have favorable attitudes toward EBCP. Further study will help understand EBCP perceptions among general field DCs. A logical next step includes validation of this questionnaire.

Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: results of a pragmatic randomized comparative effectiveness study.

STUDY DESIGN: Randomized controlled trial. OBJECTIVE: To assess changes in pain levels and physical functioning in response to standard medical care (SMC) versus SMC plus chiropractic manipulative therapy (CMT) for the treatment of low back pain (LBP) among 18 to 35-year-old active-duty military personnel. SUMMARY OF BACKGROUND DATA: LBP is common, costly, and a significant cause of long-term sick leave and work loss. Many different interventions are available, but there exists no consensus on the best approach. One intervention often used is manipulative therapy. Current evidence from randomized controlled trials demonstrates that manipulative therapy may be as effective as other conservative treatments of LBP, but its appropriate role in the healthcare delivery system has not been established. METHODS: Prospective, 2-arm randomized controlled trial pilot study comparing SMC plus CMT with only SMC. The primary outcome measures were changes in back-related pain on the numerical rating scale and physical functioning at 4 weeks on the Roland-Morris Disability Questionnaire and back pain functional scale (BPFS). RESULTS: Mean Roland-Morris Disability Questionnaire scores decreased in both groups during the course of the study, but adjusted mean scores were significantly better in the SMC plus CMT group than in the SMC group at both week 2 (P < 0.001) and week 4 (P = 0.004). Mean numerical rating scale pain scores were also significantly better in the group that received CMT. Adjusted mean back pain functional scale scores were significantly higher (improved) in the SMC plus CMT group than in the SMC group at both week 2 (P < 0.001) and week 4 (P = 0.004). CONCLUSION: The results of this trial suggest that CMT in conjunction with SMC offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care, for men and women between 18 and 35 years of age with acute LBP.

Radiographic analysis of the anterior to posterior open mouth (APOM) cervical spine view: frequency of atlas transverse process overlap of the inferior tip of the mastoid process.

OBJECTIVE: The purpose of this study was to measure the frequency with which the atlas transverse process is overlapped by the inferior tip of the mastoid process based upon radiographic analysis of the anterior to posterior open mouth (APOM) cervical spine view. METHODS: This is a retrospective study. Anterior to posterior open mouth radiographs (N = 120) were obtained from patient files at a chiropractic clinic. Dimensions were bilaterally measured: the vertical distance from the inferior mastoid to the superior margin of the C1 transverse process (C1TP) and the vertical distance from the inferior mastoid to the inferior margin of the C1TP. The percentage of the C1TP occluded by the mastoid process was calculated by determining the occlusal distance. These percentages were grouped into 4 categories: no occlusion, 1% to 50%, 50% to 99%, and 100%. RESULTS: The occlusal distance for the left and right ranged from -7.1 to 19.0 mm and -7.5 to 19.5 mm, respectively. The mean occlusal distance was identical on the left and right sides (4.6 [SD, 5.1 mm] and 4.7 mm [SD, 5.0 mm], respectively). The percentage of occlusion for the left and right transverse processes ranged from 0% to 80% and 0% to 100%, respectively. The mean percentage was 6.4% (SD, 16.4) on the left and 6.2% (SD, 16.3) on the right. CONCLUSION: This study shows that the occlusal distance for the left and right ranged from -7.1 to 19.0 mm and -7.5 to 19.5 mm, respectively. A total occlusion of the C1TP occurred in 1 side of 120 participants in this sample.

Human subject research: reporting ethics approval and informed consent in 3 chiropractic journals.

OBJECTIVE: To date, there have been no reports of ethics board approval or informed consent within the chiropractic literature or within chiropractic research. The purpose of this study was to assess the reporting of ethics approval and informed consent in articles published during the 2008 volume year of 3 chiropractic research journals included in PubMed. METHODS: A quantitative assessment of the articles published in each journal for the 2008 volume year was performed. Information collected included if the article involved human subject research, if it reported ethics board approval, and if informed consent was given to subjects. Data were collected as descriptive statistics (frequency counts and percentages). RESULTS: In aggregate, 50 articles of a total of 143 published involved human subject research (35%). 44 reported ethics board approval (88%), and 28 reported that informed consent had been obtained (56%). Forty-five percent of articles published in the Journal of Manipulative and Physiological Therapeutics involved human subject research (39/87), of which 95% reported ethics board approval (37/39) and 64% reported informed consent (25/39); 12.5% of articles from the Journal of the Canadian Chiropractic Association involved human subject research (5/40), of which 80% reported ethics board approval (4/5) and 40% reported informed consent (2/5); and 37.5% of articles published in Chiropractic and Osteopathy involved human subject research (6/16), of which 50% reported ethics board approval (3/6) and 17% reported informed consent (1/6). CONCLUSION: Overall, most articles reported ethics approval, and more than half reported consent. This was harmonious with research on this topic from other disciplines. This situation indicates a need for continued quality improvement and for better instruction and dissemination of information on these issues to researchers, to manuscript reviewers, to journal editors, and to the readers.

A descriptive analysis and checklist critique of the articles in the Journal of Clinical Chiropractic Pediatrics, 1996 to 2007.

OBJECTIVE: The purpose of this study was to conduct a bibliographic analysis and assessment of the literature published in the Journal of Clinical Chiropractic Pediatrics (JCCP). METHODS: The content of the 13 existing issues of the JCCP (1996-2007) were assessed. Articles were categorized by type, and information concerning author affiliation, academic/professional background and gender were tabulated. A second-level analysis applied specific criteria checklists to applicable articles to determine the quality rating of each paper. RESULTS: There were 72 articles included in the analysis, of which 46% were case reports, 17% editorials, 13% case series, 10% narrative literature reviews, 10% commentaries, 4% "other," and 1% cross-sectional studies. Seventy-five percent of the authors were "private practitioners." A certification in chiropractic pediatrics was held by 43% of the authors; 65% of the authors were females, and 83% of the articles had a single author. After applying the checklist to specific articles, 13 articles (18%) scored 40% or better (range of 40%-67%), whereas 59 articles (82%) scored less than 40%. CONCLUSIONS: The findings of this analysis suggest there is room for improvement in article type and publication quality of papers in the JCCP.