Social inequity in chiropractic utilisation - a cross-sectional study in Denmark, 2010 and 2017.

BACKGROUND: Inequity in healthcare utilisation refers to differences between groups that remain after adjustment for need for health care. To our knowledge, no previous studies have aimed to assess social inequity in chiropractic utilisation in a general population. Therefore, the objective of this study was to evaluate social inequity in chiropractic utilisation in the general Danish population adjusted for health status as a proxy of need for chiropractic care. METHODS: A population-based repeated cross-sectional study design was used based on the Danish National Health Survey in 2010 and 2017. Overall, we included 288,099 individuals aged 30 years or older in 2010 or 2017. For each individual, information on chiropractic utilisation, socioeconomic status, and health status as a proxy of need for chiropractic care was retrieved from nationwide registers using the unique personal identification number. Measures of health status included demographics, poor self-rated physical health, activity limitations, musculoskeletal pain, number of musculoskeletal conditions, and number of chronic diseases. We investigated social inequity in chiropractic utilisation (yes, no) using logistic regression adjusted for health status, stratified by sex and year. Three characteristics of socioeconomic status (educational level, employment status and income) were investigated. To further quantify the degree of social inequity in chiropractic utilisation, we estimated the concentration index of inequity for each of the three characteristics of socioeconomic status. RESULTS: We found significantly higher odds of chiropractic utilisation among individuals with short or medium/long education compared with individuals with elementary education, and among employed individuals compared with individuals who were unemployed, receiving disability pension or retired. Furthermore, the odds of chiropractic utilisation increased with higher income. The concentration index indicated social inequity in chiropractic utilisation in favour of individuals with higher socioeconomic status, with income and employment status contributing more to inequity than educational level. CONCLUSION: The study demonstrated social inequity in chiropractic utilisation in Denmark beyond differences in health status as a proxy of need for chiropractic care in the general population. The results suggest that new strategies are required if equal treatment for equal need is the goal.

Intra-observer reliability study of lumbar segmental measurements utilizing ultrasonography.

Background: Spinal Manipulative Therapy (SMT) benefits LBP patients, but its mechanism is not well documented. One hypothesis indicates that SMT restores interspinal movements. Ultrasound measurement (UM) of spinous process separation (SPS) assesses the intersegmental movements. Methods: We used the test-retest reliability of UM between the L3, L4, L5, and S1 spinous processes on fifteen asymptomatic volunteers while lying prone on a chiropractic table. The participants then walked around for over 5 minutes, and ultrasound images were reperformed prone. UM identified the tips of the spinous processes and distances between L3-L4, L4-L5, and L5-S1. Reliability was assessed using intra-class correlation coefficient (ICC). Results: ICC values of SPS measurements were 0.982 for L3-L4, 0.992 for L4-L5, and 0.997 for L5-S1. Rootmean square difference between the two measures were 0.35mm for L5-S1, 0.36mm for L4-L5, and 0.57mm for L3-L4. Conclusions: This study found UM to be reliable in measuring interspinous distance.

Étude de la fiabilité intra-observateur des mesures segmentaires lombaires par échographie. Contexte: La thérapie par manipulation vertébrale (TMV) est bénéfique pour les patients souffrant de lombalgie, mais son mécanisme n'est pas bien établi. L'une des hypothèses est que la TMV rétablit les mouvements intervertébraux. La mesure par échographie (UM) de la séparation de l'apophyse épineuse évalue les mouvements intersegmentaires. Méthodologie: Nous avons utilisé la fiabilité de testretest de l'UM entre les apophyses épineuses L3, L4, L5 et S1 sur quinze bénévoles asymptomatiques en position couchée sur une table de chiropratique. Les participants ont ensuite marché pendant plus de 5 minutes et les images échographiques ont été refaites en position couchée. L'UM a permis de repérer les extrémités des apophyses épineuses et de déterminer les distances entre L3-L4, L4-L5 et L5-S1. La fiabilité a été évaluée à l'aide du coefficient de corrélation intraclasse (CCI). Résultats: Les valeurs CCI des mesures de la séparation de l'apophyse épineuse étaient de 0,982 pour L3-L4, 0,992 pour L4-L5 et 0,997 pour L5-S1. La différence quadratique moyenne entre les deux mesures était de 0,35 mm pour L5-S1, 0,36 mm pour L4-L5 et 0,57 mm pour L3-L4. Conclusions: Cette étude a montré que l'UM était fiable pour mesurer la distance interépineuse.

Combining motor imagery practice with physical practice optimizes the improvement in peak force control during thoracic spinal manipulation.

Spinal manipulation learning requires intensive practice, which can cause injuries in students. Motor imagery (MI) paired with physical practice (PP) appears to be a suitable means to reduce the number of physical repetitions without decreasing skill outcomes. This study examines whether a session of MI paired with PP leads to a similar improvement in the ability to precisely produce peak forces during a thoracic manipulation as PP alone. Chiropractic students participated in a thoracic manipulation training program for five weeks. They were randomised in two groups: the MI+PP group performed sessions combining physical and mental repetitions with 1/3 fewer PP sessions, while the PP group performed only PP. Thoracic manipulation performance was assessed in pre and post-tests, consisting of thoracic manipulations at three different strength targets. Absolute error (AE), corresponding to the difference between the force required and the force applied by the student, was recorded for each trial. The main result revealed that AE was significantly lower in post-test than in pre-test for both groups. Despite fewer physical repetitions, the MI+PP participants showed as much improvement as the PP participants. This result supports the use of MI combined with PP to optimise the benefits of physical repetitions on thoracic manipulation learning.

La combinaison de la pratique de l'imagerie motrice avec la pratique physique optimise l'amélioration du contrôle de la force maximale pendant la manipulation vertébrale thoracique.L'apprentissage de la manipulation vertébrale nécessite une pratique intensive qui peut entraîner des blessures chez les étudiants. L'imagerie motrice (IM) associée à la pratique physique (PP) semble être un moyen approprié pour réduire le nombre de répétitions physiques sans diminuer les acquis de compétences. Cette étude examine de quelle manière une séance d'IM combinée à la pratique physique entraîne une amélioration similaire pour doser avec précision leur force lors d'une manipulation thoracique par rapport à la pratique physique seule. Des étudiants en chiropratique ont participé à un programme de formation à la manipulation thoracique pendant cinq semaines. Ils ont été répartis au hasard en deux groupes: le groupe IM + PP a effectué des séances combinant des répétitions physiques et mentales avec 1/3 de séances PP en moins, tandis que le groupe PP n'a effectué que des séances PP. Les résultats des manipulations thoraciques ont été évalués lors de prétests et de post-tests, consistant en des manipulations thoraciques à trois niveaux de force différents. L'erreur absolue (EA), correspondant à la différence entre la force requise et la force appliquée par l'étudiant, a été enregistrée pour chaque essai. Le résultat principal a révélé que l'EA était significativement plus faible dans le post-test que dans le pré-test pour les deux groupes. Malgré un nombre inférieur de répétitions physiques, les participants IM+PP ont montré autant d'amélioration que les participants PP. Ce résultat soutient l'utilisation de l'IM combinée à la PP pour optimiser les avantages des répétitions physiques sur l'apprentissage de la manipulation thoracique.

A commentary on the use of mixed methods in chiropractic research: Part 2: findings and recommendations for improving future chiropractic mixed methods studies.

In part 1 of this commentary, we presented an overview of mixed methods research and the rationales for using this methodology with examples from the chiropractic literature. We also introduced readers to the three core mixed methods study designs, as well as the advantages and challenges of employing a mixed methods approach. In part 2 of this series, we provide a summary of the primary and secondary findings from our doctoral work involving mixed methods research and make recommendations for improving the reporting and conduct of future chiropractic mixed methods studies.

Commentaire sur l'utilisation de méthodes mixtes dans la recherche en chiropratique. Partie 2: résultats et recommandations pour améliorer les futures études sur les méthodes mixtes en chiropratique.Dans la première partie de cette étude, nous avons présenté un aperçu de la recherche par méthodes mixtes et les raisons d'utiliser cette méthodologie à l'aide d'exemples provenant des ouvrages sur la chiropratique. Nous avons également présenté aux lecteurs les trois principaux modèles d'étude des méthodes mixtes, ainsi que les avantages et les difficultés liés à l'utilisation de ces méthodes. Dans la deuxième partie de cette série, nous présentons un résumé des résultats primaires et secondaires de notre travail de doctorat concernant les méthodes mixtes de recherche et nous formulons des recommandations pour améliorer les rapports et la conduite des futures études sur les méthodes mixtes en chiropratique.

Axillary-Subclavian Venous Thrombosis following a weightlifting injury in an elderly patient: a case report.

Background: Axillary-subclavian venous thrombosis (ASVT) is a type of upper extremity deep vein thrombosis (UEDVT). UEDVTs are classified as either primary or secondary depending on their etiology. Although uncommon, clinicians should be aware of the clinical presentation of UEDVT as timely diagnosis and early treatment is critical in preventing possible post-thrombotic complications. Case presentation: We report a rare case of axillary-subclavian and internal jugular vein thrombosis in the absence of clear risk factors in a 78-year-old male weightlifter who presented to the office with two-week duration of left upper extremity pain and swelling following strenuous exercise at the gym. Summary: The combination of unusual thrombi location, in addition to the unusual absence of existing thoracic-outlet compression or indwelling medical hardware, makes our case of UEDVT especially uncommon. Clinicians should be aware of this rare disease due to the debilitating effects both in the short and long term.

Spinal ependymoma presenting as subtle neurological findings in a VA chiropractic clinic: a case report in differential diagnosis and appropriate use of diagnostic imaging.

Background: Lhermitte's sign is a nonspecific historical and exam finding that carries with it a differential diagnosis of cervical myelopathy, multiple sclerosis, intradural tumors, or other central nervous system pathology. Regardless of the suspected diagnosis, further diagnostic investigation is indicated to determine etiology of symptoms. Case presentation: In this case, a 67-year-old male Veteran presents to a Veterans Affairs (VA) outpatient chiropractic clinic with an insidious 6-month onset of neck pain with historical description of a positive Lhermitte's sign, a single episode of bladder incontinence, and mild changes in upper extremity manual dexterity. These subtle historical findings prompted referral for a brain and cervical spine MRI, revealing an ependymoma in the cervical spine. Urgent neurosurgical referral was made, and the patient underwent C3-C7 laminectomy, C3-T2 fusion, and tumor resection. Summary: This case represents an example of clinical reasoning in a VA chiropractic clinic when presented with subtle neurologic findings, and discusses the differential diagnoses and decision-making process to pursue imaging that resulted in appropriate neurosurgical management.

Chiropractic management of lumbar spinal epidural lipomatosis in a U.S. Veterans Affairs clinic: a report of two cases.

Background: Spinal epidural lipomatosis (SEL) is a rare contributor of low back pain (LBP) that can present with or without radicular symptoms. Case Presentation: A 51-year-old and 65-year-old male presented with chronic LBP to the Veterans Affairs chiropractic clinic for a trial of care. One had a moderate degree of lumbar spinal stenosis with known SEL and the other had severe. The patient with moderate grade stenosis responded favorably with weeks of transient benefit after visits and the patient with severe grade did not find benefit with care. Summary: SEL is a condition that conservative care providers should be aware of as a potential cause of central canal stenosis or neuroforaminal narrowing. Chiropractic management of SEL has been scarcely reflected in the published literature, but may be a viable option for transient symptom management.

Fluoroquinolone-induced Achilles tendinitis: a case report.

Although most cases of Achilles tendinitis are caused by some form of biomechanical stress, other factors may play a role in its etiology. Fluoroquinolone use is a well-known contributing factor to Achilles tendon pathology. This report describes a case of fluoroquinolone-induced Achilles tendinitis in a 77-year-old woman. Eight weeks after she presented to our office, the patient reported significant improvements after a course of care that included low level laser therapy (LLLT), activity modification and graduated exercises. Management can include many of the treatment tools used for biomechanically induced tendinopathy, with particular consideration given to delaying more advanced weight-bearing rehabilitative exercise due to the increased risk of rupture.

Tendinite du tendon d'Achille induite par les fluoroquinolones: un rapport de casBien que la plupart des cas de tendinite d'Achille soient causés par une forme quelconque de stress biomécanique, d'autres facteurs peuvent jouer un rôle dans son étiologie. L'utilisation de fluoroquinolones est un facteur bien connu qui contribue à la pathologie du tendon d'Achille. Ce rapport décrit un cas de tendinite d'Achille induite par les fluoroquinolones chez une femme de 77 ans. Huit semaines après s'être présentée à notre clinique, la patiente a fait état d'améliorations notables après un traitement comprenant un traitement au laser de faible puissance, une modification de l'activité et des exercices progressifs. La prise en charge peut inclure de nombreux outils de traitement utilisés pour les tendinopathies d'origine biomécanique, avec une attention particulière pour retarder les exercices de réadaptation avec mise en charge plus avancés en raison du risque accru de rupture.

Chiropractors' perceptions on the use of spinal radiographs in clinical practice: a qualitative study.

BACKGROUND: Radiography is commonly used in the assessment of spinal disorders, despite a lack of high-quality evidence demonstrating improved clinical outcomes or additional benefit to the patient. There is disagreement amongst chiropractors regarding the appropriate use of radiography for clinical management. This study aims to qualitatively explore chiropractors' perceptions on the use of spinal radiographs in clinical practice with respect to how they determine when to order radiographs; and how they use radiographs to inform clinical management. METHODS: Online qualitative semi-structured interviews were conducted with 17 Australian chiropractors who currently manage patients with spinal disorders. Convienence, snowball, and purposive sampling strategies were used to ensure an appropriate breadth and depth of participant characterisitcs and beliefs. Interview data were recorded, transcribed and analysed using framework analysis. RESULTS: Three themes were developed to describe how chiropractors determined when to order radiographs. These themes included specific findings from the clinical encounter that may inform clinical management, their perceptions of radiation risk, and the influence of clinical experience/intuition. Three themes and four subthemes were developed for how chiropractors use radiographs to inform their management. These themes explored the use of radiography for the application of chiropractic technique, as well as the role of radiographs in predicting patient prognosis, and as an educational tool to provide reassurance. CONCLUSION: Australian chiropractors' decision-making around spinal radiography is diverse and can be influenced by a number of clinical and external factors. Previously unexplored uses of spinal radiography in clinical practice were highlighted. Some chiropractors reported potential benefits of radiography that are currently not supported by research evidence. Future research should address how radiographic findings are reported to patients with spinal disorders and how this could be optimised to improve patient outcomes.

Association of Opioid Use Disorder Diagnosis with Management of Acute Low Back Pain: A Medicare Retrospective Cohort Analysis.

BACKGROUND: Practice guidelines recommend nonpharmacologic and nonopioid therapies as first-line pain treatment for acute pain. However, little is known about their utilization generally and among individuals with opioid use disorder (OUD) for whom opioid and other pharmacologic therapies carry greater risk of harm. OBJECTIVE: To determine the association between a pre-existing OUD diagnosis and treatment of acute low back pain (aLBP). DESIGN: Retrospective cohort study using 2016-2019 Medicare data. PARTICIPANTS: Fee-for-service Medicare beneficiaries with a new episode of aLBP. MAIN MEASURES: The main independent variable was OUD diagnosis measured prior to the first LBP claim (i.e., index date). Using multivariable logistic regressions, we assessed the following outcomes measured within 30 days of the index date: (1) nonpharmacologic therapies (physical therapy and/or chiropractic care), and (2) prescription opioids. Among opioid recipients, we further assessed opioid dose and co-prescription of gabapentin. Analyses were conducted overall and stratified by receipt of physical therapy, chiropractic care, opioid fills, or gabapentin fills during the 6 months before the index date. KEY RESULTS: We identified 1,263,188 beneficiaries with aLBP, of whom 3.0% had OUD. Two-thirds (65.8%) did not receive pain treatments of interest at baseline. Overall, nonpharmacologic therapy receipt was less prevalent and opioid and nonopioid pharmacologic therapies were more common among beneficiaries with OUD than those without OUD. Beneficiaries with OUD had lower odds of receiving nonpharmacologic therapies (aOR = 0.62, 99%CI = 0.58-0.65) and higher odds of prescription opioid receipt (aOR = 2.24, 99%CI = 2.17-2.32). OUD also was significantly associated with increased odds of opioid doses ≥ 90 morphine milligram equivalents/day (aOR = 2.43, 99%CI = 2.30-2.56) and co-prescription of gabapentin (aOR = 1.15, 99%CI = 1.09-1.22). Similar associations were observed in stratified groups though magnitudes differed. CONCLUSIONS: Medicare beneficiaries with aLBP and OUD underutilized nonpharmacologic pain therapies and commonly received opioids at high doses and with gabapentin. Complementing the promulgation of practice guidelines with implementation science could improve the uptake of evidence-based nonpharmacologic therapies for aLBP.

A commentary on the use of mixed methods in chiropractic research: Part 3: integration of qualitative research with randomized controlled trials.

This is the third of three papers in our series of articles on the use of mixed methods in chiropractic research. In this commentary, we discuss the mixed methods experimental (or intervention) design. This design is a complex mixed methods research design in which qualitative research is integrated with randomized controlled trials. We provide a brief overview of this study design as well as a case example from the literature to illustrate how this approach can be applied to research within the chiropractic profession.

Étude sur l'utilisation de méthodes mixtes dans la recherche en chiropratique. Partie 3: intégration de la recherche qualitative aux essais cliniques randomisés.Cet article est le troisième d'une série de trois articles sur l'utilisation de méthodes mixtes dans la recherche en chiropratique. Dans cet article, nous abordons le modèle expérimental (ou d'intervention) des méthodes mixtes. Il s'agit d'un modèle complexe de recherche par méthodes mixte dans lequel la recherche qualitative est intégrée à des essais cliniques randomisés. Nous présentons un aperçu de ce modèle d'étude ainsi qu'un exemple issu des ouvrages spécialisés afin d'illustrer la manière dont cette approche peut être appliquée à la recherche dans le domaine de la chiropratique.

A commentary on the use of mixed methods in chiropractic research: Part 1: overview of mixed methods research.

We recently each completed doctoral programs where the major focus of our work was in mixed methods research. In the first part of this three-part commentary, we present an overview of mixed methods research. In the second part, we present a summary of our primary and secondary research findings from our doctoral work involving mixed methods. In a third paper, we will discuss integrating qualitative research with randomized controlled trials and how this mixed methods study design can be applied to research within the chiropractic profession. Our aim with these papers is to increase awareness amongst the chiropractic community of the value (and challenges) of using this unique methodology. We also make recommendations for improving the quality of reporting and conduct of future chiropractic mixed methods studies. Further dissemination of this work will occur through online webinars and conference presentations.

Étude sur l'utilisation de méthodes mixtes dans la recherche en chiropratique. Partie 1: aperçu des méthodes mixtes de rechercheNous avons récemment terminé chacun un programme de doctorat dont l'objectif principal était les méthodes mixtes de recherche. Dans la première partie de cette étude en trois parties, nous présentons un aperçu sur les méthodes mixtes de recherche. Dans la deuxième partie, nous présentons un résumé des résultats de nos recherches primaires et secondaires dans le cadre de nos travaux de doctorat impliquant des méthodes mixtes. Dans un troisième article, nous discuterons de l'intégration de la recherche qualitative aux essais cliniques randomisés et de la manière dont ce modèle d'étude mixte peut être appliqué à la recherche au sein de la profession chiropratique.L'objectif de ces articles est de sensibiliser la communauté chiropratique à la valeur (et aux difficultés) de l'utilisation de cette méthodologie unique. Nous formulons également des recommandations pour améliorer la qualité des rapports et la conduite des futures études sur les méthodes mixtes en chiropratique. La diffusion de ce travail se fera par des webinaires en ligne et des présentations lors de conférences.

Investigating the effects of chiropractic care on resting-state EEG of MCI patients.

Introduction: Mild cognitive impairment (MCI) is a stage between health and dementia, with various symptoms including memory, language, and visuospatial impairment. Chiropractic, a manual therapy that seeks to improve the function of the body and spine, has been shown to affect sensorimotor processing, multimodal sensory processing, and mental processing tasks. Methods: In this paper, the effect of chiropractic intervention on Electroencephalogram (EEG) signals in patients with mild cognitive impairment was investigated. EEG signals from two groups of patients with mild cognitive impairment (n = 13 people in each group) were recorded pre- and post-control and chiropractic intervention. A comparison of relative power was done with the support vector machine (SVM) method and non-parametric cluster-based permutation test showing the two groups could be separately identified with high accuracy. Results: The highest accuracy was obtained in beta2 (25-35 Hz) and theta (4-8 Hz) bands. A comparison of different brain areas with the SVM method showed that the intervention had a greater effect on frontal areas. Also, interhemispheric coherence in all regions increased significantly after the intervention. The results of the Wilcoxon test showed that intrahemispheric coherence changes in frontal-occipital, frontal-temporal and right temporal-occipital regions were significantly different in two groups. Discussion: Comparison of the results obtained from chiropractic intervention and previous studies shows that chiropractic intervention can have a positive effect on MCI disease and using this method may slow down the progression of mild cognitive impairment to Alzheimer's disease.

A descriptive evaluation of a job analysis survey in the chiropractic profession in Switzerland - an update after more than 10 years.

OBJECTIVES: The aim of this cross-sectional study was to update the results of the first Swiss Job Analysis Survey in 2009 with regard to the demographics of the chiropractors and their patients, practice characteristics, interprofessional collaboration, the importance of imaging, and job satisfaction. METHODS: In April 2020, the adapted 2009 questionnaire was electronically sent to all members of the Swiss Chiropractic Association ChiroSuisse (N = 316). Only complete questionnaires were included in the descriptive analysis. Demographic data were compared to all ChiroSuisse members. RESULTS: The response rate was 76.3%. The mean age of the participants was 49.9 ± 12.3 years and 62.2% were male. Among the younger chiropractors (≤ 15 years of professional experience), 51.6% were male. Almost half of the participants worked in a joint office and one in five worked in a multidisciplinary setting. The typical chiropractic patient was middle-aged, female and suffered most frequently from acute lower back/pelvis pain and second most frequently from neck pain. Diversified osseous adjustment was the most commonly used technique, followed by advice on activities of daily living and trigger point therapy. Images (X-ray, CT, MRI) were ordered in less than 20% of the patients. 95% of the chiropractors were satisfied with their career choice. CONCLUSIONS: No changes to 2009 were observed in terms of the typical patient or the applied techniques. However, the Swiss chiropractors were more experienced, to a larger proportion female, more often worked in multidisciplinary settings, and ordered fewer images. Job satisfaction among Swiss chiropractors was high.

Insights into physical activity promotion among Australian chiropractors: a cross-sectional survey.

BACKGROUND: Despite the well-known benefits of physical activity, physical inactivity is presently a global health pandemic. Allied healthcare providers, such as chiropractors, knowingly recognise the importance of physical activity and are prepared to routinely discuss and/or counsel patients on this topic; however, little is known about Australian chiropractors in the physical activity setting. Our aim was to explore and identify factors associated with physical activity promotion among Australian chiropractors, including their knowledge of the physical activity and sedentary behaviour guidelines and their own levels of physical activity. METHODS: From February to May 2021, a convenience sample of Australian chiropractors completed an online survey. Items assessed by Likert scale included: physical activity promotion frequency, with the type, quantity, barriers, perceptions, and feasibility. We asked questions about their familiarity with, and knowledge of, Australian Physical Activity and Sedentary Behaviour Guidelines, chiropractors' own physical activity, and whether the chiropractors met activity guidelines. Survey responses were descriptively reported. Univariable logistic regression models explored factors explaining frequent physical activity promotion. RESULTS: Of 217 respondents, 64% reported that they frequently (≥ 70%) recommended a more physically active lifestyle. Only 15% often performed pre-exercise screening, 73% frequently prescribed resistance exercise, 19% reported time as the most frequent barrier, while 37% reported being not at all familiar with the guidelines. Univariable logistic regression models found male chiropractors were more likely to promote physical activity, [odds ratio (OR) = 2.33; 95% confidence interval (CI): 1.32-4.12)], while chiropractors who frequently treat children 0-3 years (OR = 0.5; 95% CI: 0.28-0.87), children 4-18 years (OR = 0.42; 95% CI: 0.21-0.86), and pregnant women (OR = 0.5; 95% CI: 0.26-0.94) were less likely. Chiropractors were more likely to promote physical activity if they were familiar with the activity guidelines (OR = 2.9; 95% CI: 1.32-6.41), were confident promoting (OR = 11.6; 95% CI: 1.37-98.71) and prescribing physical activity programs (OR = 4.5; 95% CI: 2.03-9.99). CONCLUSION: Most chiropractors confidently and regularly integrate physical activity into practice. Yet, despite acknowledging its importance, one third of chiropractors reported poor knowledge of the Physical Activity and Sedentary Behaviour Guidelines. Identifying barriers to the awareness, and implementation of physical activity guidelines should be further explored within chiropractic clinical settings.

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.

An investigation into the chiropractic practice and communication of routine repetitive radiographic imaging for the location of postural misalignments.

Many clinicians use radiological imaging in efforts to locate and diagnose the cause of their patient's pain, relying on X-rays as a leading tool in clinical evaluation. This is fundamentally flawed because an X-ray represents a "snapshot" of the structural appearance of the spine and gives no indication of the current function of the spine. The health and well-being of any system, including the spinal motion segments, depend on the inter-relationship between structure and function. Pain, tissue damage, and injury are not always directly correlated. Due to such a high incidence of abnormalities found in asymptomatic patients, the diagnostic validity of X-rays can be questioned, especially when used in isolation of history and/or proper clinical assessment. The utility of routine X-rays is, therefore, questionable. One may posit that their application promotes overdiagnosis, and unvalidated treatment of X-ray findings (such as changes in postural curvature), which may mislead patients into believing these changes are directly responsible for their pain. A substantial amount of research has shown that there is no association between pain and reversed cervical curves. Accuracy can also be questioned, as X-ray measurements can vary based on the patient's standing position, which research shows is influenced by an overwhelming number of factors, such as patient positioning, patient physical and morphological changes over time, doctor interreliability, stress, pain, the patient's previous night's sleep or physical activity, hydration, and/or emotional state. Furthermore, research has concluded that strong evidence links various potential harms with routine, repeated X-rays, such as altered treatment procedures, overdiagnosis, radiation exposure, and unnecessary costs. Over the past two decades, medical boards and health associations worldwide have made a substantial effort to communicate better "when" imaging is required, with most education around reducing radiographic imaging. In this review, we describe concerns relating to the high-frequency, routine use of spinal X-rays in the primary care setting for spine-related pain in the absence of red-flag clinical signs.

Towards the diagnosis of osteoporosis - contributions from coincidental diagnostic imaging findings in chiropractors' practice.

BACKGROUND: Osteoporosis is significantly associated with fractures and burdens the health of especially older people. Osteoporotic fractures cause pain, disability, and increased mortality. Early diagnosis of osteoporosis allows earlier initiation of treatment, thereby reducing the risk of osteoporotic fractures. Chiropractors encounter potential osteoporotic patients daily, and perform radiological evaluation of these and other patients, including evaluation of X-rays done for other purposes than osteoporosis. Therefore, chiropractors may identify vertebral fractures, vertebral deformity or osteopenia not otherwise suspected or recorded. METHODS: This study examines procedures available to the chiropractor to describe conventional X-rays with the focus of osteoporosis related findings. We review the indications for radiological examination in chiropractic practice, and in the realm of osteoporosis we describe radiological methods available for examination of conventional radiographs, and the necessity of inter-disciplinary communication. RESULTS: National guidelines are available regarding referral for X-rays in chiropractic practice. Standardized protocols ensure image acquisition of the highest quality in the chiropractors' radiological department. Conventional X-ray examination is not indicated on clinical suspicion of osteoporosis alone, as bone mineral density testing is the diagnostic test. Radiological assessment of all available X-rays of patients above the age of 50 years should include evaluation of the bone quality, and hip and vertebral fracture assessment. The Singh index, Genant Semi-Quantitative tool (GSQ), and Algorithm-Based Qualitative method (ABQ) should be used consistently during interpretation. Referral for additional imaging and evaluation should be prompt and systematic when needed. CONCLUSIONS: This article presents an overview of evidence-based radiological procedures for the purpose of promoting early diagnosis of osteoporosis. We present recommendations to the clinicians where we propose an opportunistic evaluation of X-rays, done for any reason, which include systematic evaluation of bone quality, presence of hip and vertebral fractures, and vertebral deformation of all patients above the age of 50 years. Detailed referral to healthcare professionals for further diagnostic evaluation is performed when needed. Consistent, high-quality radiological procedures in chiropractic practices could feasibly contribute to the timely diagnosis of osteoporosis, ultimately minimizing the impact of osteoporosis-related complications on patients' health.

Pain trajectories over 12 months following conservative care consultation in patients with lumbar spinal stenosis.

OBJECTIVE: To investigate symptom trajectories in chiropractic patients with lumbar spinal stenosis (LSS). METHODS: Patients diagnosed with LSS were recruited from chiropractic clinics and self-reported questionnaires were collected at baseline and 1-year follow-up. Patients received weekly text messages about low back pain (LBP) and leg symptoms for 1 year. Group-based trajectory modelling was performed to identify symptom trajectory groups. The groups were compared based on patient characteristics, LBP and leg pain intensity, Oswestry Disability Index (ODI) and Zurich Claudication Questionnaire (ZCQ). RESULTS: A total of 90 patients were included in the analysis. A three-group trajectory model was chosen: 'improving' (16%), 'fluctuating/improving' (30%), and 'persistent' (54%). The 'persistent' group had a higher proportion of women [71% (95% CI 57-82%)] than the 'improving' group 29% (95% CI 11-56%), and a higher ODI score at both baseline [34.2 (95% CI 29.7-38.8) vs. 22.8 (16.4-29.1)] and 1-year follow-up [28.1 (95% CI 23.2-33.0) vs. 4.8 (0.1-9.4)]. Similar differences were observed for ZCQ symptom and function scores. CONCLUSIONS: Pain symptoms in people with LSS followed distinctly different trajectories. Half of the sample had a pattern of consistently severe symptoms over a year, while the other half either improved rapidly or experienced fluctuating symptoms with some improvement.

Cervical Spine Manipulation and Causation of Cervical Artery Dissection: A Review of 10 Case Reports.

Recent media coverage of high-profile cases of cervical artery dissection (CAD) has ignited the discussion about the role of cervical spine manipulation (CSM) in causing cervical artery dissection. However, research does not support a causal association between cervical spine manipulation and cervical artery dissection in a healthy cervical spine. The objective of this study was to review the 10 most recent case reports of cervical spine manipulation and cervical artery dissection for convincing evidence of the causation of cervical artery dissection by cervical spine manipulation. Nine of 10 case reports showed no convincing evidence of a causal relationship between cervical spine manipulation and cervical artery dissection. The 10th case report was exceptional as the CSM was contraindicated by pre-existing cervical spine pathology. We conclude that these 10 case reports provide no convincing evidence of the causation of cervical artery dissection by cervical spine manipulation in a healthy cervical spine. One case report demonstrated that cervical spine manipulation can cause cervical artery dissection when performed in the presence of pre-existing cervical spine pathology. Therefore, we conclude that practitioners should exclude cervical spine pathology before performing cervical spine manipulation.