Development of a new examination for the Canadian Chiropractic Examining Board.

OBJECTIVE: Since 1963 the Canadian Chiropractic Examining Board has conducted competency examinations for individuals seeking licensure to practice chiropractic in Canada. To maintain currency with changes in practice, examination content and methodology have been regularly updated since that time. This paper describes the process used by the Canadian Chiropractic Examining Board to restructure the examination to ensure it was current and to align it with the 2018 Federation of Canadian Chiropractic's Canadian Chiropractic Entry-to-Practice Competency Profile. METHODS: A subject-matter-expert committee developed proposed candidate outcomes (indicators) for a new examination, derived from the competency profile. A national survey of practice was undertaken to determine the importance and frequency-of-use of the profile's enabling competencies. Survey results, together with other practice-based data and further subject-matter-expert input, were used to validate indicators and to create a new structure for the examination. RESULTS: The new examination is a combination of single-focus and case-based multiple-choice questions, and OSCE (objective, structured, clinical examination) methodology. Content mapping and item weighting were determined by a blueprinting committee and are provided. CONCLUSION: Administration of the new examination commenced in early 2024.

Investigating force-time characteristics of prone thoracic SMT and self-reported patient outcome measures: a feasibility study.

BACKGROUND: Spinal manipulative therapy (SMT) is commonly used to treat musculoskeletal conditions, including thoracic spine pain. Applying patient-specific force-time characteristics are believed to be important to improve SMT's effectiveness. Investigating SMT as part of a multimodal approach is fundamental to account for the complexity of chiropractic clinical practice. Therefore, pragmatic investigations balancing minimal disruptions to the clinical encounter at the same time as ensuring a robust data quality with rigorous protocols are needed. Consequently, preliminary studies are required to assess the study protocol, quality of data recorded and the sustainability of such investigation. Therefore, this study examined the feasibility of investigating SMT force-time characteristics and clinical outcome measures in a clinical setting. METHODS: In this mixed-methods study, providers recorded thoracic SMT force-time characteristics delivered to patients with thoracic spinal pain during regular clinical encounters. Self-reported clinical outcomes of pain, stiffness, comfort during the SMT (using an electronic visual analogue scale), and global rating of change scale were measured before and after each SMT application. Feasibility was quantitatively assessed for participant recruitment, data collection and data quality. Qualitative data assessed participants' perceptions on the impact of data collection on patient management and clinical flow. RESULTS: Twelve providers (58% female, 27.3 ± 5.0 years old) and twelve patients (58% female, 37.2 ± 14.0 years old) participated in the study. Enrolment rate was greater than 40%, data collection rate was 49% and erroneous data was less than 5%. Participant acceptance was good with both providers and patients reporting positive experience with the study. CONCLUSIONS: Recording SMT force-time characteristics and self-reported clinical outcome measures during a clinical encounter may be feasible with specific modification to the current protocol. The study protocol did not negatively impact patient management. Specific strategies to optimize the data collection protocol for the development of a large clinical database are being developed.

Promoting the use of a self-management strategy among novice chiropractors treating individuals with spine pain: A mixed methods pilot clustered-clinical trial.

BACKGROUND: The uptake of Self-Management Support (SMS) among clinicians is suboptimal. To date, few studies have tested knowledge translation (KT) interventions to increase the application of SMS in chiropractic teaching clinics. STUDY OBJECTIVE: Evaluate the feasibility of implementing a KT intervention to promote the use of a SMS strategy among chiropractic interns, their supervisors, and individuals with spine pain compared to controls. METHODS: Mixed methods pilot clustered-clinical trial. Clusters of 16 Patient Management Teams were allocated to a complex KT intervention (online and workshop training). Primary feasibility outcomes for clinicians, interns and patients were rates of recruitment, retention, and adherence to protocol. A nominal group technique and interviews were used to seek end-users' views on the implementation process, and generate possible solutions. RESULTS: In total, 16 (84%) clinicians, 65 (26%) interns and 42 patients agreed to participate. All clinicians in the intervention group completed all KT intervention components, 23 interns (85%) completed the online training and 14 interns (51.8%) attended the workshop training. All clinicians in the intervention and seven (78%) in the control group completed all outcome measures at baseline and 6-month follow-up, while 15 (55.6%) and 23 (60.5%) interns in the intervention and control groups completed the questionnaires at baseline and 6-month follow-up, respectively. Among patients, 10 (52.6%) and 12 (52.2%) in the intervention and control groups respectively completed the questionnaires at the end of the study. Based on interview findings, solutions to improve the feasibility of conducting a full trial include: making SMS a part of the internship, changing the time of introducing the study to the interns, and having more training on SMS. CONCLUSION: Recruitment and retention of chiropractic interns and patients for a larger implementation trial in a single outpatient teaching clinic may be challenging.

Intervention usage for the management of low back pain in a chiropractic teaching clinic.

BACKGROUND: Despite numerous low back pain (LBP) clinical practice guidelines, published studies suggest guideline nonconcordant care is still offered. However, there is limited literature evaluating the degree to which chiropractors, particularly students, follow clinical practice guidelines when managing LBP. The aim of this study was to evaluate the frequency of use of specific interventions for LBP by students at a chiropractic teaching clinic, mapping recommended, not recommend, and without recommendation interventions based on two clinical practice guidelines. METHODS: This was a retrospective chart review of patients presenting to the Canadian Memorial Chiropractic College teaching clinic with a new complaint of LBP from January to July 2019. Interventions provided under treatment plans for each patient were extracted. Interventions were classified as recommended, not recommended, or without recommendation according to two guidelines, the NICE and OPTIMa LBP guideline. RESULTS: 1000 patient files were identified with 377 files meeting the inclusion criteria. The most frequent interventions provided to patients were manipulation/mobilization (99%) and soft tissue therapy (91%). Exercise, localized percussion, and advice and/or education were included in just under half of the treatment plans. Patient files contained similar amounts of recommended (70%) and not recommended (80%) interventions according to the NICE guideline classification, with half the treatment plans including an intervention without recommendation. Under the OPTIMa acute guideline, patient files contained similar amounts of recommended and not recommended care, while more recommended care was provided than not recommended under the OPTIMa chronic guideline. CONCLUSIONS: Despite chiropractic interns providing guideline concordant care for the majority of LBP patients, interventions classified as not recommended and without recommendation are still frequently offered. This study provides a starting point to understand the treatment interventions provided by chiropractic interns. Further research should be conducted to improve our understanding of the use of LBP guideline recommended care in the chiropractic profession. TRIAL REGISTRATION: Open Science Framework # g74e8.

Inter-rater reliability of the Quebec Task Force classification system for recent-onset Whiplash Associated Disorders.

PURPOSE: The inter-rater reliability of the Quebec Task Force (QTF) classification system for Whiplash-Associated Disorders (WAD) remains unknown. Our objective was to determine the inter-rater reliability of the WAD classification between an experienced chiropractic clinician and two chiropractic residents. METHODS: We conducted an inter-rater reliability study using baseline clinical data from 80 participants assessed for inclusion in a randomized clinical trial of the conservative management of WAD grades I and II. We reported reliability using Cohen's kappa (k) and 95% confidence intervals (CI). RESULTS: The mean duration of WAD symptoms was 7.6 days (s.d.=5.2). In our study, the interrater reliability of the WAD grade classification varied from k=0.04 (95% CI -0.04 to 0.12) to k=0.80 (95% CI 0.67 to 0.94). CONCLUSION: Inter-rater reliability of the WAD classification varied greatly across raters and may be associated with the experience of the raters and with their understanding of the criteria. Our results suggest that clinicians may benefit from training to standardize how they classify WAD. Furthermore, our results need to be tested in a different sample of patients and with a range of clinicians from different clinical disciplines.

OBJECTIF: La fiabilité inter-utilisateur du système de classification des troubles associés au coup de fouet cervical (TACF) établi par le Groupe de travail du Québec (GTQ) demeure inconnue. Notre étude visait à établir la fiabilité inter-évaluateur du système de classification des troubles associés au TACF utilisé par un chiropraticien clinicien d'expérience et deux résidents en chiropratique. MÉTHODOLOGIE: On a effectué notre étude à l'aide de données cliniques de départ sur 80 participants à un essai clinique, à répartition aléatoire, sur le traitement conservateur du TACF de stades I et II. On a utilisé le coefficient kappa (k) de Cohen et des intervalles de confiance (IC) à 95 % pour évaluer la fiabilité. RÉSULTATS: La durée moyenne des symptômes du TACF était de 7,6 jours (écart-type :5,2). La fiabilité inter-utilisateur de la classification des TACF a varié de k = 0,04 (IC à 95 % ­ de 0,04 à 0,12) à k = 0,80 (IC à 95 % de 0,67 à 0,94). CONCLUSION: La fiabilité inter-utilisateur de la classification des TACF a beaucoup varié d'un évaluateur à l'autre; l'écart pourrait être lié à l'expérience de l'évaluateur et à sa compréhension des critères de classification. Selon les résultats de notre étude, les cliniciens pourraient bénéficier d'une formation servant à normaliser leur méthode de classification des TACF. Nos résultats devraient être confirmés par une autre étude utilisant un autre échantillon de patients et un éventail de cliniciens appartenant à diverses disciplines.

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

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

Lessons learned from cases of rib fractures after manual therapy: a case series to increase patient safety.

OBJECTIVE: To identify commonalities among cases of rib fractures after spinal manipulative therapy (SMT); discuss chiropractors' case management perspectives; and propose strategies for prevention and/or management of future cases. METHODS: Semi-structured interviews were conducted with chiropractors who identified cases of rib fractures after SMT at a chiropractic institution's teaching clinics. Patient characteristics, incident characteristics, and chiropractors' perspectives were collected and analysed. RESULTS: Three chiropractors were interviewed, each identifying one case. Patient ages ranged from 57-77; two were female; two had osteopenia; two cases involved thoracic SMT; and one involved lumbar SMT. Chiropractors agreed that verifying and updating potential contributing factors for rib fractures, transparent communication prior to SMT and/or after the adverse event (AE) occurrence, and enhancing student education on AE management were important. CONCLUSION: Important lessons can be learned from AEs, despite their infrequent occurrences. A more open and constructive patient safety environment is needed within the chiropractic profession.

OBJECTIF: Établir les points communs entre des cas de fractures des côtes après des manipulations vertébrales (MV); examiner des points de vue de chiropraticiens sur la prise en charge de cas; proposer des stratégies de prévention et/ou de prise en charge des cas à venir. MÉTHODOLOGIE: On a fait des entrevues semi-structurées avec des chiropraticiens travaillant à la clinique d'un établissement d'enseignement de la chiropratique et ayant identifié des cas de fractures de côtes après des MV. Les caractéristiques des patients, les caractéristiques des incidents et les points de vue des chiropraticiens ont été recueillis et analysés. RÉSULTATS: Trois chiropraticiens ont été interrogés, chacun ayant identifié un cas. Les patients étaient âgés de 57 à 77 ans; deux étaient de sexe féminin; deux souffraient d'ostéopénie; deux cas avaient été traités par manipulations thoraciques et un cas par manipulations lombaires. Les chiropraticiens ont convenu qu'il était important de vérifier et de mettre à jour les facteurs contributoires potentiels de fractures des côtes, d'informer le patient, en toute transparence, avant d'effectuer des MV et après la survenue d'un événement (ÉI) et d'améliorer la formation des étudiants sur la prise en charge des ÉI. CONCLUSION: Les ÉI, bien qu'ils soient rares, peuvent nous permettent de tirer d'importantes leçons. Une attitude plus ouverte et plus constructive envers la sécurité du patient s'impose chez les chiropraticiens.

Health-related quality of life and balance confidence among participants in a senior community-based exercise (SWIFT) program compared to age matched controls: a cross-sectional study.

BACKGROUND: Staying Well, Independent and Fit Together (SWIFT), a seniors' exercise program, aims to promote health, strength, mobility and community engagement. We compared quality of life and balance confidence in SWIFT participants and non-participants, aged 60 years and older. METHODS: Cross-sectional study comparing participants and non-participants in SWIFT program using Older People's Quality of Life Questionnaire (OPQOL) and Activities-specific Balance Confidence Scale (ABCS). RESULTS: Seventy participants completed surveys, 41 in experimental and 29 in control group. We found a statistically significant between group difference favoring the control group in overall OPQOL score but not in OPQOL subscale nor overall ABCS scores. Participants in both groups participating in weekly exercises had non-significantly higher quality of life subscale scores. CONCLUSION: Results suggest seniors in both study groups who participate in exercise have non-significantly higher quality of life scores compared to those who do not participate in exercise. Participation in the SWIFT exercise program or activity in general, contributes to quality of life in seniors.

CONTEXTE: Staying Well, Independent and Fit Together (SWIFT) est un programme d'exercice physique pour personnes âgées visant à promouvoir la santé, la force, la mobilité et la participation aux activités de la collectivité. Nous avons comparé la qualité de vie et le degré de confiance de la personne dans son équilibre entre des sujets participant au programme SWIFT et des sujets n'y participant pas, tous ayant 60 ans et plus. MÉTHODOLOGIE: Étude transversale visant à comparer l'état de participants au programme SWIFT à celui de non-participants à l'aide de l'Older People's Quality of Life Questionnaire (OPQOL) et de l'échelle de mesure du degré de confiance de la personne dans son équilibre associé aux gestes de la vie quotidienne (échelle ABC-S). RÉSULTATS: Soixante-dix participants ont rempli les questionnaires, 41 dans le groupe expérimental et 29 dans le groupe témoin. On a observé une différence importante sur le plan statistique entre les groupes en faveur du groupe de contrôle pour ce qui est du score global au OPQOL, mais non pour le score de la souséchelle du OPQOL ni pour le score global de l'échelle ABC-S. Chez les sujets des deux groupes faisant les exercices hebdomadaires, on n'a pas observé de scores supérieurs significatifs de la sous-échelle de la qualité de vie. CONCLUSION: Les résultats semblent montrer que chez les sujets âgés des deux groupes suivant le programme d'exercices, les scores de qualité de vie ne sont pas plus élevés, d'une manière significative, que ceux des sujets ne suivant pas le programme. Le programme SWIFT, et de façon générale l'activité physique, contribue à la qualité de vie des personnes âgées.

Promoting the use of self-management in patients with spine pain managed by chiropractors and chiropractic interns: barriers and design of a theory-based knowledge translation intervention.

Background: The literature supports the effectiveness of self-management support (SMS) to improve health outcomes of patients with chronic spine pain. However, patient engagement in SMS programs is suboptimal. The objectives of this study were to: 1) assess participation in self-care (i.e. activation) among patients with spine pain, 2) identify patients' barriers and enablers to using SMS, and 3) map behaviour change techniques (BCTs) to key barriers to inform the design of a knowledge translation (KT) intervention aimed to increase the use of SMS. Methods: In summer 2016, we invited 250 patients with spine pain seeking care at the Canadian Memorial Chiropractic College in Ontario, Canada to complete the Patient Activation Measure (PAM) survey to assess the level of participation in self-care. We subsequently conducted individual interviews, in summer 2017, based on the Theoretical Domains Framework (TDF) in a subset of patients to identify potential challenges to using SMS. The interview guide included 20 open-ended questions and accompanying probes. Findings were deductively analysed guided by the TDF. A panel of 7 experts mapped key barriers to BCTs, designed a KT intervention, and selected the modes of delivery. Results: Two hundred and twenty-three patients completed the PAM. Approximately 24% of respondents were not actively involved in their care. Interview findings from 13 spine pain patients suggested that the potential barriers to using SMS corresponded to four TDF domains: Environmental Context and Resources; Emotion; Memory, Attention & Decision-Making; and Behavioural Regulation. The proposed theory-based KT intervention includes paper-based educational materials, webinars and videos, summarising and demonstrating the therapeutic recommendations including exercises and other lifestyle changes. In addition, the KT intervention includes Brief Action Planning, a SMS strategy based on motivational interviewing, along with a SMART plan and reminders. Conclusions: Almost one quarter of study participants were not actively engaged in their spine care. Key barriers likely to influence uptake of SMS among patients were identified and used to inform the design of a theory-based KT intervention to increase their participation level. The proposed multi-component KT intervention may be an effective strategy to optimize the quality of spine pain care and improve patients' health-outcomes.

Promoting the use of self-management in novice chiropractors treating individuals with spine pain: the design of a theory-based knowledge translation intervention.

BACKGROUND: Clinical practice guidelines generally recommend clinicians use self-management support (SMS) when managing patients with spine pain. However, even within the educational setting, the implementation of SMS remains suboptimal. The objectives of this study were to 1) estimate the organizational readiness for change toward using SMS at the Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario from the perspective of directors and deans, 2) estimate the attitudes and self-reported behaviours towards using evidence-based practice (EBP), and beliefs about pain management among supervisory clinicians and chiropractic interns, 3) identify potential barriers and enablers to using SMS, and 4) design a theory-based tailored Knowledge Translation (KT) intervention to increase the use of SMS. METHODS: Mixed method design. We administered three self-administered questionnaires to assess clinicians' and interns' attitudes and behaviours toward EBP, beliefs about pain management, and practice style. In addition, we conducted 3 focus groups with clinicians and interns based on the Theoretical Domain Framework (TDF) to explore their beliefs about using SMS for patients with spine pain. Data were analysed using deductive thematic analysis by 2 independent assessors. A panel of 7 experts mapped behaviour change techniques to key barriers identified informing the design of a KT intervention. RESULTS: Participants showed high level of EBP knowledge, positive attitude of EBP, and moderate frequency of EBP use. A number of barrier factors were identified from clinicians (N = 6) and interns (N = 16) corresponding to 7 TDF domains: Knowledge; Skills; Environmental context and resources; Emotion; Beliefs about Capabilities; Memory, attention & decision making; and Social Influence. To address these barriers, the expert panel proposed a multifaceted KT intervention composed of a webinar and online educational module on a SMS guided by the Brief Action Planning, clinical vignettes, training workshop, and opinion leader support. CONCLUSION: SMS strategies can help maximizing the health care services for patients with spine pain. This may in turn optimize patients' health. The proposed theory-based KT intervention may facilitate the implementation of SMS among clinicians and interns.

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.

Observed improvements in an intern's ability to initiate critical emergency skills in different cardiac arrest scenarios using high-fidelity simulation.

Objective : The objective of this study was to report observed changes in an intern's ability to initiate critical emergency skills in different cardiac arrest scenarios with high-fidelity simulation over a 10-month period. Methods : One intern's performance was retrospectively analyzed using video recordings of 4 simulations at different stages in the training program. The key outcome was the duration of time expired for 4 critical skills, including activating the emergency response system, initiating cardiopulmonary resuscitation (CPR), using an automated external defibrillator (AED), and passively administrating oxygen. Results : The intern became more efficient in each subsequent simulation for activating the emergency response system and initiating CPR. The time to use the AED stayed relatively constant. The administration of oxygen was inconsistent. Conclusion : An improvement in the speed of applying emergency critical skills was observed with this intern. These improvements in skill may improve patient outcomes and survival rates. We propose further educational research with high-fidelity simulation in the area of assessing emergency skills.

Statin induced myopathy presenting as mechanical musculoskeletal pain observed in two chiropractic patients.

Lipid lowering drugs, such as statins, are commonly used to treat approximately 10 million Canadians affected by hypercholesterolemia. The most commonly experienced side-effect of statin medication is muscle pain. Statin induced myopathy consists of a spectrum of myopathic disorders ranging from mild myalgia to fatal rhabdomyolysis. The following is a presentation of 2 cases of statin induced myopathy in patients presenting in a chiropractic setting. In addition, discussion will surround the mechanism, predisposing risk factors and frequency of statin induced myopathy while highlighting the role that chiropractors and other manual therapists may play in its recognition and management.

Rhabdomyolysis: a case study exploring the possible side effect of lipid lowering medication by a HIV positive patient taking a protease inhibitor.

This case study explores the incidence of rhabdomyolysis in a HIV positive patient that was taking a lipid lowering drug and a protease inhibitor concurrently while under chiropractic treatment for generalized muscular soreness. Dyslipidemia is a very common problem both in the general and HIV population, with many patients being prescribed lipid lowering drugs. While extremely rare, adverse effects of lipid lowering drugs have been documented to include myopathy such as rhabdomyolysis. It is imperative that chiropractors are aware of the possible adverse side effect of lipid lowering drug therapy in their patients complaining of musculoskeletal pain. It is even more important that chiropractors treating the HIV population are aware of the potential interactions between these medications and protease inhibitors to cause myopathy.

Heel pain and HIV-associated lipodystrophy: a report of two cases.

Plantar fasciitis is diagnosed based on a pathognomonic clinical presentation and physical examination including plantar heel pain with the initial few steps after a period of inactivity. People living with HIV/AIDS, who are taking anti-retroviral medications, often have an associated redistribution of body fat (lipodystrophy). Lipoatrophy of the extremities may involve the heel fat-pad in this population and result in the signs and symptoms of plantar fasciitis. Two cases of plantar heel pain in HIV-associated lipodystrophy are presented to discuss the possible clinical association between the two conditions. Although conservative therapies have limited evidence, they are commonly used and have been seen, clinically, to result in a resolution of symptoms. In the presented cases, the individuals benefited from soft tissue therapy, modalities, activity modification and education on proper footwear. Clinicians should be aware that the association between these two conditions may be a significant cause of morbidity in a population of patients with HIV.

Collaborative community-based teaching clinics at the Canadian Memorial Chiropractic College: addressing the needs of local poor communities.

INTRODUCTION: Inequities in access to health services, resulting from cuts in public sector budgets and inflation, greatly affect Canada's poorest and most vulnerable people. The purpose of this article is to describe the experiences of the community-based teaching clinics of the Canadian Memorial Chiropractic College (CMCC), located in the poor, inner city region of Toronto, where access to chiropractic care for this population has been enabled. DISCUSSION: Three chiropractic teaching clinics have been established in host facilities in the inner city community of Toronto. For over a decade, CMCC has had collaborative chiropractic clinics in the Sherbourne Health Centre (a southeast Toronto primary care facility), and Anishnawbe Health Toronto (an aboriginal health facility addressing the needs of urban First Nations people). For 3 years, we have been providing chiropractic services in the Department of Family and Community Medicine at St Michael's Hospital. The priority for these programs was the minimization of economic barriers to accessing care for poor and marginalized people. Outcomes have demonstrated high use when there is no economic barrier, excellent clinical outcomes and patient satisfaction, and a high level of collaboration with other health practitioners. CONCLUSION: The CMCC's external clinics program has enabled access to chiropractic services to thousands of people living in the inner city and urban aboriginal communities of Toronto. This has resulted in the minimization of barriers to accessing care, the provision of appropriate and effective care, and collaboration. These clinics also greatly increase students' awareness of, sensitivity to, and commitment to being part of the solution to these problems.