Chiropractic Clinical Research: Progress and Recommendations

Comparative Effects of Mulligan's Mobilization, Spinal Manipulation, and Conventional Massage Therapy in Cervicogenic Headache-A Prospective, Randomized, Controlled Trial

Background: There is ample evidence supporting the use of manual therapy techniques for the treatment of cervicogenic headache (CGH). Objective: The objective of this study was to find and compare the effects of different manual therapy approaches to cervicogenic headache. Methods: A randomized, controlled study was conducted on 84 CGH participants at the university hospital. The participants were divided into a Mulligan mobilization therapy group (MMT; n = 28), a spinal manipulation therapy group (SMT; n = 28), and a control group (Control; n = 28); they received the respective treatments for four weeks. The primary outcome (CGH frequency) and secondary outcomes (CGH pain intensity, CGH disability, neck pain frequency, pain intensity, pain threshold, flexion rotation (right and left), neck disability index, and quality of life scores) were measured at baseline, after 4 weeks, after 8 weeks, and at a 6-month follow-up. The one-way ANOVA test and repeated measures analysis of variance (rANOVA) test were performed to find the difference between the inter- and intra-treatment group effects. Results: Four weeks following training, the MMT group showed a statistically significant difference in the primary (CGH frequency) and secondary (CGH pain intensity, CGH disability, neck pain frequency, neck pain intensity, flexion rotation test, neck disability index, and quality of life) scores than those of the SMT and control groups (p < 0.001). The same difference was seen in the above variables at 8 weeks and at the 6-month follow-up. At the same time, the neck pain threshold level did not show any difference at the 4-week and the 8-week follow-up (p ≥ 0.05) but showed statistical difference at the 6-month follow-up. Conclusion: The study concluded that Mulligan’s mobilization therapy provided better outcomes in cervicogenic headache than those of spinal manipulation therapy and conventional massage therapy.

Looking back at the lawsuit that transformed the chiropractic profession part 6: Preparing for the lawsuit

OBJECTIVE

This is the sixth article in a series that explores the historical events surrounding the Wilk v American Medical Association (AMA) lawsuit in which the plaintiffs argued that the AMA, the American Hospital Association, and other medical specialty societies violated antitrust law by restraining chiropractors' business practices. The purpose of this article is to provide a brief review of the plaintiffs, lead lawyer, and the events immediately before the lawsuit was filed.

METHODS

This historical research study used a phenomenological approach to qualitative inquiry into the conflict between regular medicine and chiropractic and the events before, during, and after a legal dispute at the time of modernization of the chiropractic profession. Our methods included obtaining primary and secondary data sources. The final narrative recount was developed into 8 articles following a successive timeline. This article, the sixth of the series, explores the plaintiffs' stories.

RESULTS

Because of the AMA's boycott on chiropractic, chiropractors were not able to collaborate with medical physicians or refer patients to medical facilities, which resulted in restricted trade and potential harm to patients' well-being. The plaintiffs, Patricia Arthur, James Bryden, Michael Pedigo, and Chester Wilk, came from different regions of the United States. Each had unique experiences and were compelled to seek justice. The lead lawyer, Mr George McAndrews, was the son of a chiropractor and had witnessed the effect that the AMA's attacks on chiropractic had on his father. It took several years to gather enough resources to file the suit, which was submitted in 1976.

CONCLUSION

The conflicts that the plaintiffs experienced stimulated them to pursue a lawsuit against the AMA and other organized political medicine groups.

Looking back at the lawsuit that transformed the chiropractic profession part 4: Committee on Quackery

OBJECTIVE

This is the fourth article in a series that explores the historical events surrounding the Wilk v American Medical Association (AMA) lawsuit, in which the plaintiffs argued that the AMA, the American Hospital Association, and other medical specialty societies violated antitrust law by restraining chiropractors' business practices. The purpose of this article is to provide a brief review of the history of the origins of AMA's increased efforts to contain and eliminate the chiropractic profession and the development of the Chiropractic Committee, which would later become the AMA Committee on Quackery.

METHODS

This historical research study used a phenomenological approach to qualitative inquiry into the conflict between regular medicine and chiropractic and the events before, during, and after a legal dispute at the time of modernization of the chiropractic profession. Our methods included obtaining primary and secondary data sources. The final narrative recount was developed into 8 articles following a successive timeline. This article is the fourth of the series that explores the origins of AMA's increased efforts to contain and eliminate the chiropractic profession.

RESULTS

In the 1950s, the number of chiropractors grew in Iowa, and chiropractors were seeking equity with other health professions through legislation. In response, the Iowa State Medical Society created a Chiropractic Committee to contain chiropractic and prompted the creation of the "Iowa Plan" to contain and eliminate the chiropractic profession. The AMA leadership was enticed by the plan and hired the Iowa State Medical Society's legislative counsel, who structured the operation. The AMA adopted the Iowa Plan for nationwide implementation to eradicate chiropractic. The formation of the AMA's Committee on Chiropractic, which was later renamed the Committee on Quackery (CoQ), led overt and covert campaigns against chiropractic. Both national chiropractic associations were fully aware of many, but not all, of organized medicine's plans to restrain chiropractic.

CONCLUSION

By the 1960s, organized medicine heightened its efforts to contain and eliminate the chiropractic profession. The intensified campaign began in Iowa and was adopted by the AMA as a national campaign. Although the meetings of the AMA committees were not public, the war against chiropractic was distributed widely in lay publications, medical sources, and even chiropractic journals. Details about events would eventually be more fully revealed during the Wilk v AMA trials.

Looking back at the lawsuit that transformed the chiropractic profession part 2: Rise of the American Medical Association

OBJECTIVE

This paper is the second in a series that explores the historical events surrounding the Wilk v American Medical Association (AMA) lawsuit in which the plaintiffs argued that the AMA, the American Hospital Association, and other medical specialty societies violated anti-trust law by restraining chiropractors' business practices. The purpose of this paper is to provide a brief review of the history of how the AMA rose to dominate health care in the United States, and within this social context, how the chiropractic profession fought to survive in the first half of the 20th century.

METHODS

This historical research study used a phenomenological approach to qualitative inquiry into the conflict between regular medicine and chiropractic and the events before, during, and after a legal dispute at the time of modernization of the chiropractic profession. Our methods included obtaining primary and secondary data sources. The final narrative recount was developed into 8 papers following a successive timeline. This paper is the second of the series that explores the growth of medicine and the chiropractic profession.

RESULTS

The AMA's code of ethics established in 1847 continued to direct organized medicine's actions to exclude other health professions. During the early 1900s, the AMA established itself as "regular medicine." They labeled other types of medicine and health care professions, such as chiropractic, as "irregulars" claiming that they were cultists and quacks. In addition to the rise in power of the AMA, a report written by Abraham Flexner helped to solidify the AMA's control over health care. Chiropractic as a profession was emerging and developing in practice, education, and science. The few resources available to chiropractors were used to defend their profession against attacks from organized medicine and to secure legislation to legalize the practice of chiropractic. After years of struggle, the last state in the US legalized chiropractic 79 years after the birth of the profession.

CONCLUSION

In the first part of the 20th century, the AMA was amassing power as chiropractic was just emerging as a profession. Events such as publication of Flexner's report and development of the medical basic science laws helped to entrench the AMA's monopoly on health care. The health care environment shaped how chiropractic grew as a profession. Chiropractic practice, education, and science were challenged by trying to develop outside of the medical establishment. These events added to the tensions between the professions that ultimately resulted in the Wilk v AMA lawsuit.

Looking back at the lawsuit that transformed the chiropractic profession part 1: Origins of the conflict

OBJECTIVE

This paper is the first in a series that explores the historical events surrounding the Wilk v American Medical Association (AMA) lawsuit in which the plaintiffs argued that the AMA, the American Hospital Association, and other medical specialty societies violated antitrust law by restraining chiropractors' business practices. The purpose of this paper is to provide a brief review of the history of the AMA and the origins of chiropractic and to explore how the AMA began its monopoly of health care in the United States, possible reasons that organized medicine acted against chiropractic, and how these events influenced the chiropractic profession.

METHODS

This historical research study used a phenomenological approach to qualitative inquiry into the conflict between regular medicine and chiropractic and the events before, during, and after a legal dispute at the time of modernization of the chiropractic profession. We used primary and secondary data sources. The final narrative recount was developed into 8 papers that follow a successive time line. This paper is the first of the series and explores the origins of the aversion of organized American medicine to other health professions and the origins of the chiropractic profession.

RESULTS

The AMA began in the mid-1800s to unify like-minded "regular" medical physicians who developed a code of ethics and promoted higher educational standards. Their efforts to unify had excluded other types of health care providers, which they called "irregular" practitioners. However, Americans were seeking more natural alternatives to the harsh methods that regular medical physicians offered at that time. Nearly 50 years after the AMA began, the chiropractic profession attempted to emerge during a time when many patients valued vitalism and their freedom to choose what health care provider they would access.

CONCLUSION

During the years that chiropractic developed as a healing profession, organized medicine was already well established and developing a monopoly in American health care. These events created the foundation on which the tensions between these professions were built and ultimately resulted in the Wilk v AMA lawsuit.

Looking back at the lawsuit that transformed the chiropractic profession part 7: Lawsuit and decisions

OBJECTIVE

This is the seventh paper in a series that explores the historical events surrounding the Wilk v American Medical Association (AMA) lawsuit in which the plaintiffs argued that the AMA, the American Hospital Association, and other medical specialty societies violated antitrust law by restraining chiropractors' business practices. The purpose of this paper is to provide a summary of the lawsuit that was first filed in 1976 and concluded with the final denial of appeal in 1990.

METHODS

This historical research study used a phenomenological approach to qualitative inquiry into the conflict between regular medicine and chiropractic and the events before, during, and after a legal dispute at the time of modernization of the chiropractic profession. Our methods included obtaining primary and secondary data sources. The final narrative recount was developed into 8 papers following a successive time line. This paper, the seventh of the series, considers the information of the 2 trials and the judge's decision.

RESULTS

By the time the first trial began in 1980, the AMA had already changed its anti-chiropractic stance to allow medical doctors to associate with chiropractors if they wished. In the first trial, the chiropractors were not able to overcome the very stigma that organized medicine worked so hard to create over many decades, which resulted in the jury voting in favor of the AMA and other defendants. The plaintiffs, Drs Patricia Arthur, James Bryden, Michael Pedigo, and Chester Wilk, continued with their pursuit of justice. Their lawyer, Mr George McAndrews, fought for an appeal and was allowed a second trial. The second trial was a bench trial in which Judge Susan Getzendanner declared her final judgment that "the American Medical Association (AMA) and its members participated in a conspiracy against chiropractors in violation of the nation's antitrust laws." After the AMA's appeal was denied by the Court of Appeals for the Seventh Circuit in 1990, the decision was declared permanent. The injunction that was ordered by the judge was published in the January 1, 1988, issue of the Journal of the American Medical Association.

CONCLUSION

The efforts by Mr McAndrews and his legal team and the persistence of the plaintiffs and countless others in the chiropractic profession concluded in Judge Getzendanner's decision, which prevented the AMA from rebuilding barriers or developing another boycott. The chiropractic profession was ready to move into its next century.

Looking back at the lawsuit that transformed the chiropractic profession part 3: Chiropractic growth

OBJECTIVE

This is the third paper in a series that explores the historical events surrounding the Wilk v American Medical Association (AMA) lawsuit in which the plaintiffs argued that the AMA, the American Hospital Association, and other medical specialty societies violated antitrust law by restraining chiropractors' business practices. The purpose of this paper is to provide a brief review of the history of the growth of chiropractic, its public relations campaigns, and infighting that contributed to the events surrounding the Wilk v AMA lawsuit.

METHODS

This historical research study used a phenomenological approach to qualitative inquiry into the conflict between regular medicine and chiropractic and the events before, during, and after a legal dispute at the time of modernization of the chiropractic profession. Our methods included obtaining primary and secondary data sources. The final narrative recount was developed into 8 papers following a successive timeline. This paper is the third of the series that explores the growth the chiropractic profession.

RESULTS

By the 1930s, the AMA was already under investigation for violation of antitrust laws and the National Chiropractic Association was suggesting that the AMA was establishing a health care monopoly. Chiropractic schools grew and the number of graduates rose quickly. Public relations campaigns and publications in the popular press attempted to educate the public about chiropractic. Factions within the profession polarized around differing views of how they thought that chiropractic should be practiced and portrayed to the public. The AMA leaders noted the infighting and used it to their advantage to subvert chiropractic.

CONCLUSION

Chiropractic grew rapidly and established its presence with the American public through public relations campaigns and popular press. However, infighting would give the AMA material to further its efforts to contain and eliminate the chiropractic profession.

Looking back at the lawsuit that transformed the chiropractic profession part 8: Judgment impact

OBJECTIVE

This paper is the eighth in a series that explores the historical events surrounding the Wilk v American Medical Association (AMA) lawsuit in which the plaintiffs argued that the AMA, the American Hospital Association, and other medical specialty societies violated antitrust law by restraining chiropractors' business practices. The purpose of this paper is to discuss the possible impact that the final decision in favor of the plaintiffs may have had on the chiropractic profession.

METHODS

This historical research study used a phenomenological approach to qualitative inquiry into the conflict between regular medicine and chiropractic and the events before, during, and after a legal dispute at the time of modernization of the chiropractic profession. Our methods included obtaining primary and secondary data sources. The final narrative recount was developed into 8 papers following a successive timeline. This paper is the eighth of the series that discusses how the trial decision may have influenced the chiropractic that we know today in the United States.

RESULTS

Chiropractic practice, education, and research have changed since before the lawsuit was filed. There are several areas in which we propose that the trial decision may have had an impact on the chiropractic profession.

CONCLUSION

The lawsuit removed the barriers that were implemented by organized medicine against the chiropractic profession. The quality of chiropractic practice, education, and research continues to improve and the profession continues to meet its most fundamental mission: to improve the lives of patients. Chiropractors practicing in the United States today are allowed to collaborate freely with other health professionals. Today, patients have the option to access chiropractic care because of the dedicated efforts of many people to reduce the previous barriers. It is up to the present-day members of the medical and chiropractic professions to look back and to remember what happened. By recalling the events surrounding the lawsuit, we may have a better understanding about our professions today. This information may help to facilitate interactions between medicine and chiropractic and to develop more respectful partnerships focused on creating a better future for the health of the public. The future of the chiropractic profession rests in the heads, hearts, and hands of its current members to do what is right.

Looking back at the lawsuit that transformed the chiropractic profession part 5: Evidence exposed

OBJECTIVE

This is the fifth article in a series that explores the historical events surrounding the Wilk v American Medical Association (AMA) lawsuit in which the plaintiffs argued that the AMA, the American Hospital Association, and other medical specialty societies violated antitrust law by restraining chiropractors' business practices. The purpose of this article is to provide a brief review of events surrounding the eventual end of the AMA's Committee on Quackery and the exposure of evidence of the AMA's efforts to boycott the chiropractic profession.

METHODS

This historical research study used a phenomenological approach to qualitative inquiry into the conflict between regular medicine and chiropractic and the events before, during, and after a legal dispute at the time of modernization of the chiropractic profession. Our methods included obtaining primary and secondary data sources. The final narrative recount was developed into 8 articles following a successive timeline. This article, the fifth of the series, explores the exposure of what the AMA had been doing, which provided evidence that was eventually used in the Wilk v AMA antitrust lawsuit.

RESULTS

The prime mission of the AMA's Committee on Quackery was "first, the containment of chiropractic and, ultimately, the elimination of chiropractic." However, the committee did not complete its mission and quietly disbanded in 1974. This was the same year that the chiropractic profession finally gained licensure in all 50 of the United States; received recognition from the US Commissioner of Education, Department of Health, Education and Welfare; and was successfully included in Medicare. In 1975, documents reportedly obtained by the Church of Scientology covert operatives under Operation AMA Doom revealed the extent to which the AMA and its Committee on Quackery had been working to contain and eliminate the chiropractic profession. The AMA actions included influencing mainstream media, decisions made by the Joint Commission on Accreditation of Hospitals, and the Department of Health, Education, and Welfare. Other actions included publishing propaganda against chiropractic and implementing an anti-chiropractic program aimed at medical students, medical societies, and the American public.

CONCLUSION

After more than a decade of overt and covert actions, the AMA chose to end its Committee on Quackery. The following year, documents exposed the extent of AMA's efforts to enact its boycott of chiropractic.

Chiropractic case reports: a review and bibliometric analysis

Objective

To determine publication trends, gaps, and predictors of citation of chiropractic case reports (CRs).

Methods

A bibliometric review was conducted by searching PubMed, Index to Chiropractic Literature (ICL), and Google Scholar to identify PubMed-indexed CRs, which were screened according to selection criteria. Case reports were categorized by International Classification of Disease (ICD-10) code, patient age, topic describing case management or adverse effects of care, focus being spinal or non-spinal, journal type, integrative authorship, title metrics, and citation metrics. Binary logistic regression was used to identify independent predictors of citations per year and total citations greater than the median values.

Results

The search identified 1176 chiropractic CRs meeting selection criteria. There was an increasing trend of CRs having a case management topic, non-spinal focus, non-chiropractic journal, neuromusculoskeletal-focus, diagnosis of vascular pathology, and a decreasing trend of adverse effect vascular pathology CRs. Independent predictors of greater total citations (or citation rate) included ICD-10 categories of perinatal conditions, infections, “case” in title, case management topic, and physical therapy, integrative, and dental journal type. Predictors of fewer citations included diseases of the blood, neoplasms, other findings not elsewhere classified, a title > 11 words, and multidisciplinary authorship. ICD-10 categories describing non-musculoskeletal diseases and special populations such as pediatrics, pregnancy, and perinatal conditions had few CRs.

Conclusion

Chiropractic CRs are diversifying from spine-related topics. Chiropractors are encouraged to publish objective, structured CRs within defined research gaps. Published CRs can inform the design of future research studies with a higher level of clinical relevance and evidence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-021-00374-5.

Doing the Same Thing and Expecting a Different Outcome: It Is Time for a Questioning Philosophy and Theory-Driven Chiropractic Research

OBJECTIVE

The purpose of this commentary is to discuss the philosophical and hypothetical underpinnings of chiropractic and consider whether there is a need for chiropractic to have a questioning philosophy and theory-driven process to guide future scientific endeavors in the profession.

DISCUSSION

The earliest beliefs of the chiropractic founders centered on chiropractic vertebral subluxation but differed on whether this was a static, bone-out-of-place misalignment or a lesion whereby joints had lost their normal direction or range of motion. More recently, new hypotheses such as dyskinesia, inflammation, and neuroplasticity attempt to explain the purported clinical effects of chiropractic. Yet practitioners and students advocate for both traditional viewpoints that typically tout misalignment and embrace a science of chiropractic. I propose that chiropractors should not have to choose between philosophy and science. Instead, they should advocate for adoption of a modern questioning philosophy that not only informs their clinical questions and drives their theories, but also that is in turn influenced by outcomes from their research. Such a questioning philosophy is in stark contrast with the dogma that some have mislabeled as "philosophy" in the profession. I recommend that a review of chiropractic hypotheses and a theory-driven research process is needed to help guide the profession's research agenda given its wide range of clinical activities and limited resources. As the chiropractic profession increasingly embraces evidence-informed practice, enhanced integration within the wider health care community may then result in further gains in utilization.

CONCLUSION

Theory-driven research that results from and subsequently informs a questioning philosophy may expose truths related to practice behaviors, activities, and outcomes, and spur more complete integration of chiropractic within the wider health care community.

Scoping review of priority setting of research topics for musculoskeletal conditions

OBJECTIVE

Describe research methods used in priority-setting exercises for musculoskeletal conditions and synthesise the priorities identified.

DESIGN

Scoping review.

SETTING AND POPULATION

Studies that elicited the research priorities of patients/consumers, clinicians, researchers, policy-makers and/or funders for any musculoskeletal condition were included.

METHODS AND ANALYSIS

We searched MEDLINE and EMBASE from inception to November 2017 and the James Lind Alliance top 10 priorities, Cochrane Priority Setting Methods Group, and Cochrane Musculoskeletal and Back Groups review priority lists. The reported methods and research topics/questions identified were extracted, and a descriptive synthesis conducted.

RESULTS

Forty-nine articles fulfilled our inclusion criteria. Methodologies and stakeholders varied widely (26 included a mix of clinicians, consumers and others, 16 included only clinicians, 6 included only consumers or patients and in 1 participants were unclear). Only two (4%) reported any explicit inclusion criteria for priorities. We identified 294 broad research priorities from 37 articles and 246 specific research questions from 17 articles, although only four (24%) of the latter listed questions in an actionable format. Research priorities for osteoarthritis were identified most often (n=7), followed by rheumatoid arthritis (n=4), osteoporosis (n=4) and back pain (n=4). Nearly half of both broad and specific research priorities were focused on treatment interventions (n=116 and 111, respectively), while few were economic (n=8, 2.7% broad and n=1, 0.4% specific), implementation (n=6, 2% broad and n=4, 1.6% specific) or health services and systems research (n=15, 5.1% broad and n=9, 3.7% specific) priorities.

CONCLUSIONS

While many research priority-setting studies in the musculoskeletal field have been performed, methodological limitations and lack of actionable research questions limit their usefulness. Future studies should ensure they conform to good priority-setting practice to ensure that the generated priorities are of maximum value.

PROSPERO REGISTRATION NUMBER

CRD42017059250.

Dose-response of spinal manipulation for cervicogenic headache: study protocol for a randomized controlled trial

BACKGROUND

Cervicogenic headache is a prevalent and costly pain condition commonly treated by chiropractors. There is evidence to support the effectiveness for spinal manipulation, but the dose of treatment required to achieve maximal relief remains unknown. The purpose of this paper is to describe the methodology for a randomized controlled trial evaluating the dose-response of spinal manipulation for chronic cervicogenic headache in an adult population.

METHODS/DESIGN

This is a mixed-methods, two-site, prospective, parallel groups, observer-blind, randomized controlled trial conducted at university-affiliated research clinics in the Portland, OR and Minneapolis, MN areas. The primary outcome is patient reported headache frequency. Other outcomes include self-reported headache intensity, disability, quality of life, improvement, neck pain intensity and frequency, satisfaction, medication use, outside care, cervical motion, pain pressure thresholds, health care utilization, health care costs, and lost productivity. Qualitative interviews are also conducted to evaluate patients' expectations of treatment.

DISCUSSION

With growing concerns regarding the costs and side effects of commonly used conventional treatments, greater numbers of headache sufferers are seeking other approaches to care. This is the first full-scale randomized controlled trial assessing the dose-response of spinal manipulation therapy on outcomes for cervicogenic headache. The results of this study will provide important evidence for the management of cervicogenic headache in adults.

TRIAL REGISTRATION

ClinicalTrials.gov (Identifier: NCT01530321).

Research mentoring: Suggestions and encouragement from a reflection exercise

Supervisors direct people, but mentors are valued and trusted advisors. Recently, the author took a course in supervising postgraduate research, which included surveying the literature as well as discussions with colleagues who have various levels of experience in research supervision. Through this exercise, some basic ideas for best practices in research mentoring became clear, particularly for those in professions without a strong history of research and therefore lacking in trained research supervisors. The concept of mentoring, rather than just supervision, gained focus. Three main categories can be identified within the realm of research mentorship: choose your candidate wisely, be diligent, and be nurturing. The purpose of this commentary is to identify methods of supervision of graduate research degree (masters/doctorate level) candidates that may enhance the process, as well as improve the chances of completion, and to encourage academics to learn the techniques of high-quality supervision with a goal of becoming mentors. Additionally, it is hoped that this commentary may encourage students and colleagues without advanced degrees to consider pursuing them; this, in turn would likely lead to more opportunities for supervision, as well as help to create links with other academic and clinical institutions.

Nonmedical methods to relieve low back pain caused by lumbar disc herniation: a descriptive study in northeastern Turkey

Low back pain due to the effects of lumbar disc herniation is a common complaint of patients who often subsequently seek help from medical professionals. It is also a significant health problem which is quite difficult to treat. This descriptive study was conducted to determine nonmedical methods used by patients with lumbar disc herniation to relieve low back pain; the patients' intensity of low back pain when they were admitted to the hospital was also explored. Ninety-two patients with lumbar disc herniation participated in this study, which was carried out at a university hospital in northeastern Turkey. Data were collected using a patient information form and the visual analog scale (VAS). When the patients were admitted to hospital, their mean VAS score was 6.56 ± 2.45. The study results showed that as a first choice nearly all of the patients (94.6%) with lumbar disc herniation preferred consulting with their physicians before to obtain relief for low back pain. However, in addition to seeing their physician, more than one-half of these patients (57.6%) also used nonmedical methods. The primary nonmedical methods were hot/cold compresses, wrapping various substances on the back, and herbal preparations. An increase in pain was noted by 17.0% of patients after using nonmedical methods. Findings indicated that more than two-thirds of patients experienced either no change or an increase in pain after using nonmedical methods to find relief.

The first research agenda for the chiropractic profession in Europe

Background

Research involving chiropractors is evolving and expanding in Europe while resources are limited. Therefore, we considered it timely to initiate a research agenda for the chiropractic profession in Europe. The aim was to identify and suggest priorities for future research in order to best channel the available resources and facilitate advancement of the profession.

Methods

In total, 60 academics and clinicians working in a chiropractic setting, and who had attended any of the annual European Chiropractors’ Union/European Academy of Chiropractic (ECU/EAC) Researchers’ Day meetings since their inception in 2008, were invited to participate. Data collection consisted of the following phases: phase 1 identification of themes; phase 2 consensus, which employed a Delphi process and allowed us to distill the list of research priorities; and phase 3 presentation of the results during both the Researchers’ Day and a plenary session of the annual ECU Convention in May 2013. In addition, results were distributed to all ECU member countries.

Results

The response rate was 42% from phase 1 and 68% from phase 2. In general, participants were middle-aged, male and had been awarded a Doctor of Philosophy (PhD) as well as chiropractic degree. Approximately equal numbers of participants had obtained their chiropractic degree from the UK/Europe and North America. The majority of participants worked primarily in an academic/research environment and approximately half worked in an independent institution. In total, 58% of the participants were from the UK and Denmark, collectively representing 44% of the chiropractors working in Europe. In total, 70 research priorities were identified, of which 19 reached consensus as priorities for future research. The following three items were thought to be most important: 1) cost-effectiveness/economic evaluations, 2) identification of subgroups likely to respond to treatment, and 3) initiation and promotion of collaborative research activities.

Conclusions

This is the first formal and systematic attempt to develop a research agenda for the chiropractic profession in Europe. Future discussion and study is necessary to determine whether the themes identified in this survey should be broadly implemented.

Essential literature for the chiropractic profession: a survey of chiropractic research leaders

Background

Evidence-based clinical practice (EBCP) is an accepted practice for informed clinical decision making in mainstream health care professions. EBCP augments clinical experience and can have far reaching effects in education, policy, reimbursement and clinical management. The proliferation of published research can be overwhelming—finding a mechanism to identify literature that is essential for practitioners and students is desirable. The purpose of this study was to survey leaders in the chiropractic profession on their opinions of essential literature for doctors of chiropractic, faculty, and students to read or reference.

Methods

Deployment of an IRB exempted survey occurred with 68 academic and research leaders using SurveyMonkey®. Individuals were solicited via e-mail in August of 2011; the study closed in October of 2011.

Collected data were checked for citation accuracy and compiled to determine multiple responses. A secondary analysis assessed the scholarly impact and Internet accessibility of the recommended literature.

Results

Forty-three (43) individuals consented to participate; seventeen (17) contributed at least one article of importance. A total of 41 unique articles were reported. Of the six articles contributed more than once, one article was reported 6 times, and 5 were reported twice.

Conclusions

A manageable list of relevant literature was created. Shortcomings of methods were identified, and improvements for continued implementation are suggested. A wide variety of articles were reported as “essential” knowledge; annual or bi-annual surveys would be helpful for the profession.

Increasing research capacity in the chiropractic profession: A case study and evaluation of an innovative research program in Norway

OBJECTIVE

The subject of research methods is not commonly covered in continuing professional development (CPD) courses in spite of its emphasis in undergraduate education. This initiative aimed to develop postgraduate research competency and recruit chiropractors to musculoskeletal research.

METHODS

The program was delivered as a university-based program with 20 credits over seven contact weekends covering topics of evidence-based practice, research methods, statistics, ethics, resources, and funding. Students were assessed through assignments showing competency in critical literature review, case report writing, and production of a research protocol as the final assessment. Non-student participation for CPD points was possible. A student evaluation survey was completed after the end of the academic year.

RESULTS

There were 26 participants: 16 as students handing in assignments, 10 as non-student participants for up to 94 CPD points. Three submitted a final protocol and two registered at a university PhD program. A network of research clinics was established for data collection for future multicenter studies.

CONCLUSIONS

The program was well received by the participants and gave them the tools and resources to perform research. The two-level attendance system afforded a basis for setting up a network of research clinics with a fundamental understanding of optimal data collection. This initiative has shown that research skills can be revisited through CPD programs as part of evidence-based lifelong learning.

Evaluating the relationship among cavitation, zygapophyseal joint gapping, and spinal manipulation: an exploratory case series

OBJECTIVE

This project determined the feasibility of conducting larger studies assessing the relationship between cavitation and zygapophyseal (Z) joint gapping following spinal manipulative therapy (SMT).

METHODS

Five healthy volunteers (average age, 25.4 years) were screened and examined against inclusion and exclusion criteria. High-signal magnetic resonance imaging (MRI) markers were fixed to T12, L3, and S1 spinous processes. Scout images were taken to verify the location of the markers. Axial images of the L4/L5 and L5/S1 levels were obtained in the neutral supine position. Following the first MRI, accelerometers were placed over the same spinous processes; and recordings were made from them during side-posture positioning and SMT. The accelerometers were removed, and each subject was scanned in side-posture. The greatest central anterior to posterior Z joint spaces (gap) were measured from the first and second MRI scans. Values obtained from the first scan were subtracted from those of the second, with a positive result indicating an increase in gapping following SMT (positive gapping difference). Gapping difference was compared between the up-side (SMT) joints vs the down-side (non-SMT) joints and between up-side cavitation vs up-side noncavitation joints.

RESULTS

Greater gapping was found in Z joints that received SMT (0.5 ± 0.6 mm) vs non-SMT joints (-0.2 ± 0.6 mm), and vertebral segments that cavitated gapped more than those that did not cavitate (0.8 ± 0.7 vs 0.4 ± 0.5 mm).

CONCLUSIONS

A future clinical study is quite feasible. Forty subjects (30 in an SMT group and 10 in a control group) would be needed for appropriate power (0.90).

The association of chiropractic colleges educational conference and research agenda conference: 17 years of scholarship and collaboration

This editorial presents a brief description of the Association of Chiropractic Colleges Educational Conference and Research Agenda Conference, the components of the conference, and long range goals of the peer-review committee.

Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research

OBJECTIVES

(1) To evaluate the evidence on the effect of chiropractic care, rather than spinal manipulation only, on patients with nonmusculoskeletal conditions; and (2) to identify shortcomings in the evidence base on this topic, from a Whole Systems Research perspective.

DESIGN

Systematic review.

METHODS

Databases included were PubMed, Ovid, Mantis, Index to Chiropractic Literature, and CINAHL. Search restrictions were human subjects, peer-reviewed journal, English language, and publication before May 2005. All randomized controlled trials (RCTs) were evaluated using the Scottish Intercollegiate Guidelines Network (SIGN) and Jadad checklists; a checklist developed from the CONSORT (Consolidated Standards of Reporting Trials) guidelines; and one developed by the authors to evaluate studies in terms of Whole Systems Research (WSR) considerations.

RESULTS

The search yielded 179 papers addressing 50 different nonmusculoskeletal conditions. There were 122 case reports or case series, 47 experimental designs, including 14 RCTs, 9 systematic reviews, and 1 a large cohort study. The 14 RCTs addressed 10 conditions. Six RCTs were rated "high" on the 3 conventional checklists; one of these 6 was rated "high" in terms of WSR considerations.

CONCLUSIONS

(1) Adverse effects should be routinely reported. For the few studies that did report, adverse effects of spinal manipulation for all ages and conditions were rare, transient, and not severe. (2) Evidence from controlled studies and usual practice supports chiropractic care (the entire clinical encounter) as providing benefit to patients with asthma, cervicogenic vertigo, and infantile colic. Evidence was promising for potential benefit of manual procedures for children with otitis media and elderly patients with pneumonia. (3) The RCT design is not necessarily incompatible with WSR. RCTs could improve generalizability by basing protocols on usual practice. (4) Case reports could contribute more to WSR by increasing their emphasis on patient characteristics and patient-based outcomes. (5) Chiropractic investigators, practitioners, and funding agencies should increase their attention to observational designs.

Financial Support for Research Training and Career Development in Complementary and Alternative Medicine from the National Institutes of Health

Research careers are a relatively new reality for complementary and alternative medicine (CAM) practitioners (eg, chiropractors, naturopaths, doctors of oriental medicine, etc). Before the establishment in 1998 of the National Center for Complementary and Alternative Medicine (NCCAM) as part of the National Institutes of Health (NIH), there were few funding resources available for those interested in a CAM research career and fewer still feasible paths. Now, however, NCCAM provides a broad array of research training and career development awards for those seeking a long-term career in CAM research. These awards include predoctoral and postdoctoral fellowships, individual career development awards, and institutional training awards. The goal of this article is to provide information about current research training funding opportunities from NCCAM and NIH as a whole that are available to CAM practitioners in the context of the historical challenges of transitioning from a clinical career in CAM practice to a CAM research career.

Disentangling manual muscle testing and Applied Kinesiology: critique and reinterpretation of a literature review

Cuthbert and Goodheart recently published a narrative review on the reliability and validity of manual muscle testing (MMT) in the Journal. The authors should be recognized for their effort to synthesize this vast body of literature. However, the review contains critical errors in the search methods, inclusion criteria, quality assessment, validity definitions, study interpretation, literature synthesis, generalizability of study findings, and conclusion formulation that merit a reconsideration of the authors' findings. Most importantly, a misunderstanding of the review could easily arise because the authors did not distinguish the general use of muscle strength testing from the specific applications that distinguish the Applied Kinesiology (AK) chiropractic technique. The article makes the fundamental error of implying that the reliability and validity of manual muscle testing lends some degree of credibility to the unique diagnostic procedures of AK. The purpose of this commentary is to provide a critical appraisal of the review, suggest conclusions consistent with the literature both reviewed and omitted, and extricate conclusions that can be made about AK in particular from those that can be made about MMT. When AK is disentangled from standard orthopedic muscle testing, the few studies evaluating unique AK procedures either refute or cannot support the validity of AK procedures as diagnostic tests. The evidence to date does not support the use of MMT for the diagnosis of organic disease or pre/subclinical conditions.

On the reliability and validity of manual muscle testing: a literature review

INTRODUCTION

A body of basic science and clinical research has been generated on the manual muscle test (MMT) since its first peer-reviewed publication in 1915. The aim of this report is to provide an historical overview, literature review, description, synthesis and critique of the reliability and validity of MMT in the evaluation of the musculoskeletal and nervous systems.

METHODS

Online resources were searched including Pubmed and CINAHL (each from inception to June 2006). The search terms manual muscle testing or manual muscle test were used. Relevant peer-reviewed studies, commentaries, and reviews were selected. The two reviewers assessed data quality independently, with selection standards based on predefined methodologic criteria. Studies of MMT were categorized by research content type: inter- and intraexaminer reliability studies, and construct, content, concurrent and predictive validity studies. Each study was reviewed in terms of its quality and contribution to knowledge regarding MMT, and its findings presented.

RESULTS

More than 100 studies related to MMT and the applied kinesiology chiropractic technique (AK) that employs MMT in its methodology were reviewed, including studies on the clinical efficacy of MMT in the diagnosis of patients with symptomatology. With regard to analysis there is evidence for good reliability and validity in the use of MMT for patients with neuromusculoskeletal dysfunction. The observational cohort studies demonstrated good external and internal validity, and the 12 randomized controlled trials (RCTs) that were reviewed show that MMT findings were not dependent upon examiner bias.

CONCLUSION

The MMT employed by chiropractors, physical therapists, and neurologists was shown to be a clinically useful tool, but its ultimate scientific validation and application requires testing that employs sophisticated research models in the areas of neurophysiology, biomechanics, RCTs, and statistical analysis.