An epidemiological examination of the subluxation construct using Hill's criteria of causation

Exploring the immediate and short-term effect of lumbar spinal manipulation on pressure pain threshold: a randomized controlled trial of healthy participants

BACKGROUND

Lumbar spinal manipulative therapy (SMT) is a common intervention used to treat low back pain (LBP); however, the exact neurophysiological mechanisms of SMT reducing pain measured through pain pressure threshold (PPT) have not been fully explored beyond an immediate timeframe (e.g., immediately or five-minutes following) referencing a control group. Therefore, the purpose of this study was to investigate the neurophysiological effects of lumbar SMT compared to deactivated ultrasound using PPT immediately following and 30-minutes following SMT.

METHODS

A longitudinal, randomized controlled trial design was conducted between September to October 2023. Fifty-five participants were randomized into a control group of deactivated ultrasound (n = 29) or treatment group of right sidelying lumbar SMT (n = 26). PPT, recorded at the right posterior superior iliac spine (PSIS), was documented for each participant in each group prior to intervention, immediately, and 30-minutes after. A repeated measures ANOVA, with a post-hoc Bonferroni adjustment, was used to assess within-group and between-group differences in PPT. The significance level was set at a < 0.05 a priori.

RESULTS

Statistically significant differences were found between the deactivated ultrasound and lumbar SMT groups immediately (p = .05) and 30-minutes (p = .02) following intervention. A significant difference in the lumbar SMT group was identified from baseline to immediately following (p < .001) and 30-minutes following (p < .001), but no differences between immediately following and 30-minutes following intervention (p = .10). The deactivated ultrasound group demonstrated a difference between baseline and immediately after intervention with a reduced PPT (p = .003), but no significant difference was found from baseline to 30-minutes (p = .11) or immediately after intervention to 30-minutes (p = 1.0).

CONCLUSION

A right sidelying lumbar manipulation increased PPT at the right PSIS immediately after that lasted to 30-minutes when compared to a deactivated ultrasound control group. Future studies should further explore beyond the immediate and short-term neurophysiological effects of lumbar SMT to validate these findings.

TRIAL REGISTRATION

This study was retrospectively registered on 4 December 2023 in ClinicalTrials (database registration number NCT06156605).

The Inclusion of Chiropractic Care in the Healthy China Initiative 2030

The Healthy China Initiative 2030 represents a major shift in China's healthcare policies for health promotion and disease prevention. Chiropractic care, with its focus on musculoskeletal health and nonpharmacological treatment, can contribute to the goals of this initiative. However, its potential contribution is hampered by the lack of official recognition and regulation in mainland China, which restricts its general awareness and integration into healthcare systems, and potentially leads to untreated musculoskeletal disorders. This research proposes the inclusion of chiropractic care in the Healthy China Initiative 2030 framework. It provides an overview of the goals of this initiative and the current state of chiropractic care in China. The alignment of chiropractic principles and practices with the aims of the Healthy China Initiative 2030 is also discussed. Policy recommendations for integrating chiropractic care into the healthcare system are proposed, which include the establishment of education standards, licensing protocols, and collaborative research initiatives. Potential challenges, including regulatory barriers, a lack of awareness, and research limitations are highlighted. We also present potential strategies to leverage opportunities for promoting chiropractic care, such as the rising demand for musculoskeletal care. This research provides the first focused discussion on the integration of chiropractic care into China's evolving preventive healthcare landscape under the Healthy China Initiative 2030.

Student attitudes toward the International Clinical and Professional Chiropractic Education Position Statement and Evidence-based practice: a survey of UQTR chiropractic students

OBJECTIVE

The aim of this study is to describe the attitude of Université du Québec à Trois-Rivières (UQTR) chiropractic students toward the International Clinical and Professional Chiropractic Education Position Statement and evidence-based practice (EBP) beliefs.

METHODS

A cross-sectional survey was administered to all the UQTR chiropractic students. Using a five-point Likert scale, students were asked to rate their level of agreement with the position statement (10 items), EBP (2 items), interprofessional collaboration (2 items) and vitalistic philosophy (2 items).

RESULTS

Survey response rate was 71%. Students most frequently reported strong agreement with the position statement, EBP and interprofessional collaboration. They also most frequently disagreed with vitalistic philosophy. The attitude toward the position statement was positively correlated with the year of study in the program (r=0.10, p=0.019), EBP (r=0.56, p<0.001) and interprofessional collaboration (r=0.45, p <0.001).

CONCLUSIONS

UQTR chiropractic students demonstrate high levels of agreement with EBP and the Education Position Statement.

Prevalence of Chiropractic-Specific Terminology on Chiropractors' Websites in the United Kingdom With Comparison to Australia: An Analysis of Samples

OBJECTIVE

The purpose of this study was to compare the prevalence of 5 chiropractic-specific terms on UK chiropractic websites to findings in a previous study in Australia and to provide an argument against the use of these terms.

METHODS

We searched websites belonging to chiropractors registered with the General Chiropractic Council for 5 terms: subluxation, vital(-ism/-istic), wellness, adjust(-ing/-ment), and Innate (Intelligence). Of 3239 websites, 326 were sampled. Each page was searched, and terms were counted only if used in a chiropractic-specific context. Term occurrence and frequency were recorded. The data were analyzed using a single-sample χ² goodness-of-fit test for unequal proportions. The results were compared to those of our prior Australian study, using the χ² test of homogeneity to determine the differences between samples.

RESULTS

At least 1 of the 5 chiropractic-specific terms was found on 245 (75%) of UK websites. Adjust(-ing/-ment) was found on 222 (68%) of UK websites compared to 283 (77%) in Australia; wellness on 67 (5%) of UK sites compared to 199 (33%) in Australia; vital(-ism/-istic) on 30 (9%) of UK sites compared to 71 (19%) in Australia; subluxation on 17 (5%) of UK sites compared to 104 (28%) in Australia; and Innate on 10 (3%) of UK sites compared to 39 (11%) in Australia. A χ² test found that the terms were not equally distributed in the two samples, χ 4 2  = 404.080, P < .001. In the discussion, we explain why we feel that chiropractic-specific terms should be abandoned and standard biomedical terms used.

CONCLUSION

In the sample of websites we evaluated in this study, the majority in the United Kingdom used the 5 chiropractic-specific terms that we searched for. The terms were used less frequently than on websites in Australia but were in a similar order of prevalence.

Chiropractic students' cognitive dissonance to statements about professional identity, role, setting and future: international perspectives from a secondary analysis of pooled data

BACKGROUND

Chiropractic students demonstrate philosophically opposing views about the chiropractic profession. The primary aim was to describe chiropractic students' responses to statements about chiropractic identity, role, setting, and future direction. A secondary aim was to describe the frequency of internally conflicting responses.

METHODS

Three datasets from Europe, North America, and Australia/New Zealand were pooled in a secondary data analysis. Chiropractic students from 25 chiropractic training institutions completed interrelating surveys (combined response rate 21.9%) between 2013 and 2018. The survey instrument investigated student viewpoints about chiropractic professional identity, role, practice setting and future direction of chiropractic practice. Student attitudes about chiropractic were described using weighted proportions to adjust for unequal population sampling across the three geographical regions. The frequency of concordant and discordant student responses was described by combining identity items with items that explored responses about practice role, setting and future direction. The relationship between student characteristics (age, sex, education, association membership and geographical region) and ideologically conflicting responses were assessed using the Chi-squared test and Cramér's V.

RESULTS

Data from 2396 student chiropractors (50.8% female; from Europe 36.2%, North America 49.6% and Australia/New Zealand 14.5%) were analysed. For identity, nearly half of the chiropractic students (weighted 45.1%) agreed that it is important for chiropractors to hold strongly to the traditional chiropractic theory that adjusting the spine corrects "dis-ease" and agreed (weighted 55.5%) that contemporary and evolving scientific evidence is more important than traditional chiropractic principles. The frequency of discordant (ideologically conflicting) student responses ranged from 32.5% for statements about identity versus role, to 51.4% for statements about identity versus future. There was no association between student age, sex and internally conflicting responses. Chiropractic students' professional association membership status, pre-chiropractic education and geographical region were associated with ideologically conflicting responses.

CONCLUSIONS

Chiropractic students in this analysis show traditional and progressive attitudes towards the chiropractic profession. Individual student responses frequently contradict in terms of professional ideology, but most (approximately half) students demonstrate concordant progressive and mainstream attitudes. Ideological conflict may raise concerns about some students' ability to learn and make clinical judgements, and potential for disharmony in the chiropractic fraternity.

Informed consent, duty of disclosure and chiropractic: where are we?

BACKGROUND

The COVID-19 pandemic has seen the emergence of unsubstantiated claims by vertebral subluxation-based chiropractors that spinal manipulative therapy has a role to play in prevention by enhancing the body's immune function. We contend that these claims are unprofessional and demonstrate a disturbing lack of insight into the doctrine of informed consent. As such it is timely to review how informed consent has evolved and continues to do so and also to discuss the attendant implications for contemporary health practitioner practice. We review the origins of informed consent and trace the duty of disclosure and materiality through landmark medical consent cases in four common law (case law) jurisdictions. The duty of disclosure has evolved from a patriarchal exercise to one in which patient autonomy in clinical decision making is paramount. Passing time has seen the duty of disclosure evolve to include non-medical aspects that may influence the delivery of care. We argue that a patient cannot provide valid informed consent for the removal of vertebral subluxation. Further, vertebral subluxation care cannot meet code of conduct standards because it lacks an evidence base and is practitioner-centered. The uptake of the expanded duty of disclosure has been slow and incomplete by practitioners and regulators. The expanded duty of disclosure has implications, both educative and punitive for regulators, chiropractic educators and professional associations. We discuss how practitioners and regulators can be informed by other sources such as consumer law. For regulators, reviewing and updating informed consent requirements is required. For practitioners it may necessitate disclosure of health status, conflict of interest when recommending "inhouse" products, recency of training after attending continuing professional development, practice patterns, personal interests and disciplinary findings.

CONCLUSION

Ultimately such matters are informed by the deliberations of the courts. It is our opinion that the duty of a mature profession to critically self-evaluate and respond in the best interests of the patient before these matters arrive in court.

The Manchurian candidate: chiropractors as propagators of neoliberalism in health care

The rise of neoliberalism has influenced the health care sector, including the chiropractic profession. The neoliberal infiltration of market justice behavior is in direct conflict with the fiduciary agreement to serve the public good before self-interests and has compromised the chiropractor, who now may act as an agent of neoliberalism in health care. The purpose of this paper is to present an overview of the impact of neoliberalism on the chiropractic profession and provide recommendations for a professional philosophical shift from a market justice model to a communal and social justice model.

Words matter: the prevalence of chiropractic-specific terminology on Australian chiropractors' websites

BACKGROUND

Chiropractors use words and phrases in unique ways to express traditional, chiropractic-specific theories. This lexicon represents concepts that reinforce the separation of chiropractic from other health care professions. It may impact referrals both to and from chiropractors, lead to public confusion about health care issues, and reduce cross-disciplinary research. Therefore, it is important to understand how prevalent chiropractic-specific terms are in publicly available media.

METHODS

Five chiropractic terms were selected: subluxation, adjustment, vital (-ism/-istic), wellness, and Innate (Intelligence). States and territories in Australia were proportionately sampled according to population of chiropractors using a Google search for chiropractors' private practice websites. The top results were recorded. Websites were word-searched on every publicly available page for the five terms. Context was checked to count only terms that were used to support a chiropractic-specific concepts. The number of occurrences of each term was recorded, tallied nationally and by state/territory. Descriptive statistics were applied to determine prevalence.

RESULTS

Three hundred sixty-nine websites were sampled, based on an estimate of 5500 chiropractors practising in Australia. Nationally, 85% of chiropractors used one or more terms. The term adjust (-ing/-ment) occurred most frequently, being found on 283 websites (77%) with a total of 2249 occurrences. Wellness was found on 199 websites (54%) with 872 occurrences; subluxation was found on 104 websites (28%), 489 occurrences; vital (-ism/-istic) on 71 websites (19%) with 158 occurrences; and Innate was least used, being found on 39 websites (11%) with 137 occurrences.

CONCLUSION

A majority of the Australian chiropractors sampled used one or more chiropractic-specific terms on their websites. Future research should explore the effects of chiropractic language on the public, policy-makers, and other health care professionals.

The "subluxation" issue: an analysis of chiropractic clinic websites

Background

Vertebral subluxation theories are controversial in chiropractic. Divisions are evident in the chiropractic community among those who align their practices to subluxation theories and those who do not. This study investigated how many clinics offering chiropractic in the Canadian province of Alberta promote a theory of subluxation, which health ailments or improvements were linked to subluxation, and whether the subluxation discourse was used to promote chiropractic for particular demographics.

Methods

Using the search engine on the Canadian Chiropractic Associations’ website, we made a list of all clinics in Alberta. We then used Google searches to obtain a URL for each clinic with a website, totalling 324 URLs for 369 clinics. We then searched on each website for “subluxation” and performed content analysis on the related content.

Results

One hundred twenty-one clinics’ websites (33%) presented a theory of vertebral subluxation. The health ailments and improvements discussed in relation to subluxation were wide-ranging. An observed trend was the marketing of chiropractic for children, which was observed on 29 clinic websites (8%).

Conclusions

Based on the controversy surrounding vertebral subluxation, the substantial number of clinic websites aligning their practice with vertebral subluxation should cause concern for regulatory bodies.

Medicine is Patriarchal, But Alternative Medicine is Not the Answer

Women are over-represented within alternative medicine, both as consumers and as service providers. In this paper, I show that the appeal of alternative medicine to women relates to the neglect of women's health needs within scientific medicine. This is concerning because alternative medicine is severely limited in its therapeutic effects; therefore, those who choose alternative therapies are liable to experience inadequate healthcare. I argue that while many patients seek greater autonomy in alternative medicine, the absence of an evidence base and plausible mechanisms of action leaves patients unable to realize meaningful autonomy. This seems morally troubling, especially given that the neglect of women's needs within scientific medicine seems to contribute to preferences for alternative medicine. I conclude that the liberatory credentials of alternative medicine should be questioned and make recommendations to render scientific medicine better able to meet the needs of typical alternative medicine consumers.

The Chiropractic Vertebral Subluxation Part 5: The First Research Era From 1928 to 1949

OBJECTIVE

The purpose of this paper is to review and discuss the history of chiropractic vertebral subluxation theories between 1928 and 1949.

DISCUSSION

Theories during this period grew in complexity and developed in 4 primary ways: upper cervical models, reflex models, global models, and models based on the work of Speransky. Authors, theorists, and technique developers during this time included B. J. Palmer, R. J. Watkins, Galen Price, John Hurley, Hugh Logan, Major Bertrand DeJarnette, Richard Van Rumpt, Roy Ashton, Joseph Janse, Henri Gillet, James Firth, and J. R. Verner. At least 8 perspectives on chiropractic vertebral subluxation were advanced through research, modeling, and applied clinical methods. By understanding the complexity of this period and analyzing the research, the modern practitioner will be able to appreciate this era. The foundations of modern clinical practice and theoretical applications have roots in this period.

CONCLUSION

Theories during this period developed in levels of complexity, expanding existing models and clinical practice methods. The theories and research from this period had an effect on the chiropractic profession for the subsequent decades.

The Chiropractic Vertebral Subluxation Part 10: Integrative and Critical Literature From 1996 and 1997

OBJECTIVE

The purpose of this paper is to review and discuss the history of chiropractic vertebral subluxation (CVS) during 1996 and 1997. The literature during this period offered critical and integrative models emphasized by a need for research into operational and functional definitions.

DISCUSSION

Several integrative approaches emerged, from Rome's 296 synonyms to Bergman's Pain/Tenderness, Asymmetry/Alignment, Range of Motion Abnormality, Tissue Tone, Texture, Temperature Abnormality, and Special Tests (PARTS) analysis adopted by the profession in the United States. Other noteworthy contributions included Ruch's Atlas of Common Subluxations, Epstein's introduction of network spinal analysis, and Kent's review of CVS models. Boone's introduction of the Journal of Vertebral Subluxation Research was accompanied by his 3-part model with Dobson. These years also included the paradigm statement of the Association of Chiropractic Colleges, which was adopted by the American Chiropractic Association, International Chiropractors Association, and World Federation of Chiropractic. Two other papers included Nelson's critique of the CVS paradigm and Keating's 1996 "Hunt for the Subluxation."

CONCLUSION

The CVS reached a new stage of complexity and critique and offered new directions for research, integration, and development.

The Chiropractic Vertebral Subluxation Part 1: Introduction

OBJECTIVE

The objective of this article is to present a rationale for the need of a history of chiropractic vertebral subluxation (CVS) theory based on primary sources.

DISCUSSION

There is a dichotomy in the chiropractic profession around subluxation terminology, which has many facets. The literature around this topic spans social, economic, cultural, and scientific questions. By developing a rationale for a historical perspective of CVS theory, including the tracking of the historical development of ideas throughout the profession, a foundation for future discourse may emerge.

CONCLUSIONS

By using primary sources, ideas in chiropractic on the development of CVS theory are proposed. This introduction presents a basis for the need of a history of CVS theory and suggests how this work may be used to further philosophical dialogs in chiropractic.

The prevalence of the term subluxation in chiropractic degree program curricula throughout the world

Background

The subluxation construct generates debate within and outside the profession. The International Chiropractic Education Collaboration, comprised of 10 chiropractic programs outside of North America, stated they will only teach subluxation in a historical context. This research sought to determine how many chiropractic institutions worldwide still use the term in their curricula and to expand upon the previous work of Mirtz & and Perle.

Methods

Forty-six chiropractic programs, 18 United States (US) and 28 non-US, were identified from the World Federation of Chiropractic Educational Institutions list. Websites were searched by multiple researchers for curricular information September 2016–September 2017. Some data were not available on line, so email requests were made for additional information. Two institutions provided additional information. The total number of mentions of subluxation in course titles, technique course (Tech) descriptions, principles and practice (PP) descriptions, and other course descriptions were reported separately for US and non-US institutions. Means for each category were calculated. The number of course titles and descriptions using subluxation was divided by the total number of courses for each institution and reported as percentages.

Results

Means for use of subluxation by US institutions were: Total course titles = .44; Tech = 3.83; PP = 1.50; other = 1.16. For non-US institutions, means were: Total course titles = .07; Tech = .27; PP = .44; other = 0. The mean total number of mentions was 6.94 in US vs. 0.83 in non-US institutions. Similarly, the mean course descriptions was 6.50 in US vs. 0.72 in non-US institutions.

Conclusions

The term subluxation was found in all but two US course catalogues. The use of subluxation in US courses rose from a mean of 5.53 in 2011 to 6.50 in 2017. US institutions use the term significantly more frequently than non-US. Possible reasons for this were discussed. Unscientific terms and concepts should have no place in modern education, except perhaps in historical context. Unless these outdated concepts are rejected, the chiropractic profession and individual chiropractors will likely continue to face difficulties integrating with established health care systems and attaining cultural authority as experts in conservative neuro-musculoskeletal health care.

Effect of chiropractic treatment on primary or early secondary prevention: a systematic review with a pedagogic approach

Introduction

The chiropractic vitalistic approach to the concept of 'subluxation' as a cause of disease lacks both biological plausibility and possibly proof of validity. Nonetheless, some chiropractors purport to prevent disease in general through the use of chiropractic care. Evidence of its effect is needed to be allowed to continue this practice. The objective of this systematic review was therefore to investigate if there is any evidence that spinal manipulations/chiropractic care can be used in primary prevention (PP) and/or early secondary prevention in diseases other than musculoskeletal conditions.

Method

We searched PubMed, Embase, Index to Chiropractic Literature, and some specialized chiropractic journals, from inception to October 2017, using terms including: "chiropractic", "subluxation", "wellness", "prevention", "spinal manipulation", "mortality". Included were English language articles that indicated that they studied the clinical preventive effect of or benefit from manipulative therapy/chiropractic treatment in relation to PP and/or early treatment of physical diseases/morbidity in general, other than musculoskeletal disorders. Also, population studies were eligible. Checklists were designed in relation to the description of the reviewed articles and some basic quality criteria. Outcomes of studies were related to their methodological quality, disregarding results from those unable to answer the research questions on effect of treatment.

Results

Of the 13.099 titles scrutinized, 13 articles were included (eight clinical studies and five population studies). These studies dealt with various disorders of public health importance such as diastolic blood pressure, blood test immunological markers, and mortality. Only two clinical studies could be used for data synthesis. None showed any effect of spinal manipulation/chiropractic treatment.

Conclusion

We found no evidence in the literature of an effect of chiropractic treatment in the scope of PP or early secondary prevention for disease in general. Chiropractors have to assume their role as evidence-based clinicians and the leaders of the profession must accept that it is harmful to the profession to imply a public health importance in relation to the prevention of such diseases through manipulative therapy/chiropractic treatment.

The treatment of migraine patients within chiropractic: analysis of a nationally representative survey of 1869 chiropractors

BACKGROUND

While the clinical role of manual therapies in migraine management is unclear, the use of chiropractors for this condition is considerable. The aim of this study is to evaluate the prevalence and characteristics of chiropractors who frequently manage patients with migraine.

METHODS

A national cross-sectional survey of chiropractors collected information on practitioner characteristics, clinical management characteristics and practice settings. A secondary analysis was conducted on 1869 respondents who reported on their migraine caseload to determine the predictors associated with the frequent management of patients with migraine.

RESULTS

A large proportion of chiropractors report having a high migraine caseload (HMC) (n = 990; 53.0%). The strongest factors predicting a chiropractor having a HMC include the frequent treatment of patients with axial neck pain (OR = 2.89; 95%CI: 1.18, 7.07), thoracic pain (referred/radicular) (OR = 2.52; 95%CI: 1.58, 3.21) and non-musculoskeletal disorders (OR = 3.06; 95%CI: 2.13, 4.39).

CONCLUSIONS

Several practice-setting and clinical management characteristics are associated with chiropractors managing a HMC. These findings raise key questions about the therapeutic approach to chiropractic migraine management that deserves further examination. There is a need for more primary research to assess the approach to headache and migraine management provided by chiropractors and to understand the prevalence, burden and comorbidities associated with migraine found within chiropractic patient populations. This information is vital in helping to inform safe, effective and coordinated care for migraine sufferers within the wider health system.

Appeal to fear in health care: appropriate or inappropriate?

AIM

This paper examines appeal to fear in general: its perceived positive aspects, its negative characteristics, its appropriate as well as its fallacious use.

BACKGROUND

Appeal to fear is a commonly used marketing method that attempts to change behaviour by creating anxiety in those receiving a fearful message. It is regularly used in public health initiatives such as anti-smoking, anti-drunk driving campaigns as well as in hypertension awareness campaigns. Some chiropractors appear to use appeal to fear to promote subluxation awareness and thereby encourage the use of chiropractic treatment. Research supporting its use is equivocal; nevertheless, when used judiciously, appeal to fear probably has sufficient strengths to warrant its continued conditional use. When used to promote care for which there is no supporting evidence, its use is fallacious.

DISCUSSION

Appeal to fear has been used in health promotion campaigns for sixty years or more with the intent of modifying behaviours. While there is evidence to suggest that appeal to fear may motivate some individuals to modify offending behaviour or adopt recommended behaviour there is growing resistance to the use of appeal to fear on ethical and psychological grounds. Using appeal to fear as a tool of persuasion can be valid or fallacious depending on the truth of the premises within the argument. When used to raise awareness about genuine health concerns such as smoking, drunk driving and hypertension appeal to fear is considered to be a valid approach with certain caveats. However, when appeal to fear, not based on evidence or reason, is used as motivator to get others to accept unnecessary interventions for unproven disorders, the use of appeal to fear is fallacious.

CONCLUSION

In spite of the evidence against its use, it seems likely that appeal to fear will continue to be used in conjunction with other public awareness initiatives to modify recognized detrimental behaviours such as smoking and drunk driving as well as silent killers such as hypertension. However, when used to promote a treatment that has no evidentiary basis such as subluxation based practice in chiropractic the appeal to fear is a fallacy and must be stopped.

Use of Integrative Medicine in the United States Military Health System

Integrative medicine (IM) is a model of care which uses both conventional and nonconventional therapies in a "whole person" approach to achieve optimum mental, physical, emotional, spiritual, and environmental health, and is increasingly popular among patients and providers seeking to relieve chronic or multifactorial conditions. The US Department of Defense (DoD) shows particular interest in and usage of IM for managing chronic conditions including the signature "polytrauma triad" of chronic pain, traumatic brain injury (TBI), and posttraumatic stress disorder (PTSD) among its beneficiaries in the Military Health System (MHS). These modalities range from conventional nondrug, nonsurgical options such as cognitive-behavioral therapy to nonconventional options such as acupuncture, chiropractic, and mind-body techniques. These are of particular interest for their potential to relieve symptoms without relying on opiates, which impair performance and show high potential for abuse while often failing to provide full relief. This review describes the use of IM in the MHS, including definitions of the model, common therapies and potential for use, and controversy surrounding the practice. More research is needed to build a comprehensive usage analysis, which in turn will inform sound clinical and financial practice for the MHS and its beneficiaries.

Historical influence on the practice of chiropractic radiology: Part I - a survey of Diplomates of the American Chiropractic College of Radiology

BACKGROUND

It is known that not all chiropractors follow mainstream guidelines on the use of diagnostic ionising radiation. Various reasons have been discussed in the literature, including using radiography to screen for congenital anomalies, to perform postural analysis, to search for contraindications to spinal manipulation, and to document chiropractic subluxations, i.e., tiny anatomical displacements of vertebrae thought to affect nerves and health. The visualisation of subluxations was the reason chiropractic first adopted the x-ray in 1910. There has never been a study of the influence of this historical paradigm of radiography on the practices of chiropractic radiologists (DACBRs or Diplomates of the American Chiropractic College of Radiology).

METHODS

A survey was administered with a modified Dillman method using SurveyMonkey and supplemented by hard copies distributed at a professional conference. The target population was all active DACBRs. There were 34 items, which consisted of multiple choice and open-ended interrogatives on all three areas in which chiropractic radiologists work: education, clinical practice, and radiology practice.

RESULTS

The response rate was 38% (73 of 190 DACBRs). Respondents reported that the historical paradigm of radiography was found in all areas of practice, but not as a major aspect. The majority of respondents did not condone that historical paradigm, but many tolerated it, particularly from referring chiropractors. Radiographic subluxation analysis was reportedly perpetuated by private clinical practitioners as well as technique instructors and supervising clinicians in the teaching institutions.

CONCLUSIONS

Within the chiropractic profession, there is a continuing belief in radiographically visible subluxations as a cause of suboptimal health. This situation is sustained in part due to the reticence of other chiropractors to report these practices to licensing and registration boards. Investigation into other structures supporting a vitalistic belief system over science in chiropractic is recommended. In addition, it may be useful to explore remunerative systems that move beyond the inherently conflicted fee-for-service model.

Analysis and Adjustment of Vertebral Subluxation as a Separate and Distinct Identity for the Chiropractic Profession: A Commentary

OBJECTIVE

The purpose of this paper is to discuss various statements related to chiropractic identity from¹ D. D. Palmer²; selected chiropractic organizations, associations, and colleges; and³ attitudes and perceptions of chiropractic from chiropractic students, practitioners, and patients.

DISCUSSION

For comparison purposes, identity statements and perceptions from the various chiropractic associations and colleges, as well as from students and patients, were explored. Identity statements for chiropractic were searched in various sources such as Palmer's 1910 textbook, recent literature on viewpoints from chiropractic students and practitioners, and websites for chiropractic colleges and organizations. Palmer taught that the chiropractor's focus was on vertebral subluxation. Today, a number of chiropractic colleges and organizations continue to include the vertebral subluxation model in their instruction, with a majority of students and practitioners subscribing to the model. Conversely, a number of other colleges and organizations portray chiropractic as being essentially about the treatment of back and neck pain, which is what patients associate with chiropractic. However, settling on any particular identity for the chiropractic profession will likely be met with resistance by some, given the plethora of opinions among chiropractic professionals as to what the identity of the chiropractic profession should be. Common ground between the different factions within the chiropractic profession might be found in a unifying expression such as "functional neurology."

CONCLUSION

When a profession's identity is not clear with respect to its area of interest and mission, then the public may be less inclined to seek its services. Identifying the chiropractic profession with a focus on vertebral subluxation would give the profession uniqueness not duplicated by other health care professions and, therefore, might legitimatize the existence of chiropractic as a health care profession. An identity having a focus on vertebral subluxation would also be consistent with the original intent of the founding of the chiropractic profession.

A plausible causal link between antiretroviral therapy and increased blood pressure in a sub-Saharan African setting: A propensity score-matched analysis

BACKGROUND

The transition from association to causation could represent a fundamental step for taking preventive action against hypertension and its complications, especially among HIV-infected persons on antiretroviral therapy in sub-Saharan African countries.

METHODS

406 consecutive HIV-infected adults attending a tertiary HIV clinic in semi-urban Nigeria were prospectively recruited between August and November 2014. These participants were stratified by antiretroviral treatment status. A propensity score matching model was fitted to examine the causal average treatment effects on the treated (ATT) of antiretroviral therapy on blood pressure. Propensity score matching entailed using nearest neighbour matching with a calliper width of 0.2 to achieve similarity in the baseline characteristics between participants naïve and exposed to antiretroviral therapy.

RESULTS

Matching HIV-infected patients naïve and exposed to antiretroviral therapy on the propensity score yielded a total of 303 participants - 229 antiretroviral-exposed and 74 antiretroviral-naïve - matched without any residual differences in the baseline characteristics between both groups of patients. In this propensity score-matched sample, the estimated ATT for the effects of antiretroviral therapy on systolic (7.85mmHg, 95% CI 3.72 to 15.68) and diastolic blood pressure (7.45mmHg, 95% CI 4.99 to 13.61) were statistically significant (P<0.001 for each).

CONCLUSIONS

There is a high probability that the epidemiological association between antiretroviral therapy and increased blood pressure be causal in nature among people living with HIV in sub-Saharan African settings. HIV-infected patients commencing antiretroviral treatment in these settings may require regular hypertension screening and other cardiovascular risk assessments.

A supervised adverse drug reaction signalling framework imitating Bradford Hill's causality considerations

Big longitudinal observational medical data potentially hold a wealth of information and have been recognised as potential sources for gaining new drug safety knowledge. Unfortunately there are many complexities and underlying issues when analysing longitudinal observational data. Due to these complexities, existing methods for large-scale detection of negative side effects using observational data all tend to have issues distinguishing between association and causality. New methods that can better discriminate causal and non-causal relationships need to be developed to fully utilise the data. In this paper we propose using a set of causality considerations developed by the epidemiologist Bradford Hill as a basis for engineering features that enable the application of supervised learning for the problem of detecting negative side effects. The Bradford Hill considerations look at various perspectives of a drug and outcome relationship to determine whether it shows causal traits. We taught a classifier to find patterns within these perspectives and it learned to discriminate between association and causality. The novelty of this research is the combination of supervised learning and Bradford Hill's causality considerations to automate the Bradford Hill's causality assessment. We evaluated the framework on a drug safety gold standard known as the observational medical outcomes partnership's non-specified association reference set. The methodology obtained excellent discrimination ability with area under the curves ranging between 0.792 and 0.940 (existing method optimal: 0.73) and a mean average precision of 0.640 (existing method optimal: 0.141). The proposed features can be calculated efficiently and be readily updated, making the framework suitable for big observational data.

Tooth erosion and eating disorders: a systematic review and meta-analysis

Background

Eating disorders are associated with the highest rates of morbidity and mortality of any mental disorders among adolescents. The failure to recognize their early signs can compromise a patient's recovery and long-term prognosis. Tooth erosion has been reported as an oral manifestation that might help in the early detection of eating disorders.

Objectives

The aim of this systematic review and meta-analysis was to search for scientific evidence regarding the following clinical question: Do eating disorders increase the risk of tooth erosion?

Methods

An electronic search addressing eating disorders and tooth erosion was conducted in eight databases. Two independent reviewers selected studies, abstracted information and assessed its quality. Data were abstracted for meta-analysis comparing tooth erosion in control patients (without eating disorders) vs. patients with eating disorders; and patients with eating disorder risk behavior vs. patients without such risk behavior. Combined odds ratios (ORs) and a 95% confidence interval (CI) were obtained.

Results

Twenty-three papers were included in the qualitative synthesis and assessed by a modified version of the Newcastle-Ottawa Scale. Fourteen papers were included in the meta-analysis. Patients with eating disorders had more risk of tooth erosion (OR = 12.4, 95%CI = 4.1–37.5). Patients with eating disorders who self-induced vomiting had more risk of tooth erosion than those patients who did not self-induce vomiting (OR = 19.6, 95%CI = 5.6–68.8). Patients with risk behavior of eating disorder had more risk of tooth erosion than patients without such risk behavior (Summary OR = 11.6, 95%CI = 3.2–41.7).

Conclusion

The scientific evidence suggests a causal relationship between tooth erosion and eating disorders and purging practices. Nevertheless, there is a lack of scientific evidence to fulfill the basic criteria of causation between the risk behavior for eating disorders and tooth erosion.

Beyond spinal manipulation: should Medicare expand coverage for chiropractic services? A review and commentary on the challenges for policy makers

OBJECTIVES

Private insurance plans typically reimburse doctors of chiropractic for a range of clinical services, but Medicare reimbursements are restricted to spinal manipulation procedures. Medicare pays for evaluations performed by medical and osteopathic physicians, nurse practitioners, physician assistants, podiatrists, physical therapists, and occupational therapists; however, it does not reimburse the same services provided by chiropractic physicians. Advocates for expanded coverage of chiropractic services under Medicare cite clinical effectiveness and patient satisfaction, whereas critics point to unnecessary services, inadequate clinical documentation, and projected cost increases. To further inform this debate, the purpose of this commentary is to address the following questions: (1) What are the barriers to expand coverage for chiropractic services? (2) What could potentially be done to address these issues? (3) Is there a rationale for Centers for Medicare and Medicaid Services to expand coverage for chiropractic services?

METHODS

A literature search was conducted of Google and PubMed for peer-reviewed articles and US government reports relevant to the provision of chiropractic care under Medicare. We reviewed relevant articles and reports to identify key issues concerning the expansion of coverage for chiropractic under Medicare, including identification of barriers and rationale for expanded coverage.

RESULTS

The literature search yielded 29 peer-reviewed articles and 7 federal government reports. Our review of these documents revealed 3 key barriers to full coverage of chiropractic services under Medicare: inadequate documentation of chiropractic claims, possible provision of unnecessary preventive care services, and the uncertain costs of expanded coverage. Our recommendations to address these barriers include the following: individual chiropractic physicians, as well as state and national chiropractic organizations, should continue to strengthen efforts to improve claims and documentation practices; and additional rigorous efficacy/effectiveness research and clinical studies for chiropractic services need to be performed. Research of chiropractic services should target the triple aim of high-quality care, affordability, and improved health.

CONCLUSIONS

The barriers that were identified in this study can be addressed. To overcome these barriers, the chiropractic profession and individual physicians must assume responsibility for correcting deficiencies in compliance and documentation; further research needs to be done to evaluate chiropractic services; and effectiveness of extended episodes of preventive chiropractic care should be rigorously evaluated. Centers for Medicare and Medicaid Services policies related to chiropractic reimbursement should be reexamined using the same standards applicable to other health care providers. The integration of chiropractic physicians as fully engaged Medicare providers has the potential to enhance the capacity of the Medicare workforce to care for the growing population. We recommend that Medicare policy makers consider limited expansion of Medicare coverage to include, at a minimum, reimbursement for evaluation and management services by chiropractic physicians.

The immediate effects of modified Yoga positions on musculoskeletal pain relief

Many musculoskeletal pains are related to poor posture. Thus, the aim of the present study was to assess the efficiency of a single session of two modified Yoga positions with 110 subjects and their 147 pain-related complaints. The participants were divided into two groups: The Yoga Group, which received treatment of two 20-min postures and the Control Group, which received a placebo treatment of 15 min with a turned off ultrasound. All volunteers experienced some pain before treatment and were assessed before and after treatment using the analog pain scale. A score of 0 indicated no pain whereas 10 was the maximum degree of pain on the scale. The difference before and after treatment was compared between the groups with a p-value of 0.0001, as measured by the Student's t-test. It is possible to conclude that one therapy session is effective in the treatment of various musculoskeletal problems.

The Five Eras of Chiropractic & the future of chiropractic as seen through the eyes of a participant observer

Chiropractic has endured a turbulent history, marked by tremendous advances in areas such as education and licensing while marred by interprofessional conflict and a poor public image. The prolonged interprofessional conflict was instrumental in shaping the culture of chiropractic. These obstacles have long-since been removed although there are lingering effects from them.This article examines the chiropractic profession's history by dividing it into five Eras and suggests that there are three options available for the future of the profession. One: maintaining the status quo. Two: uniting under an evidence based scientific approach as partners in the health care delivery system that has buried the "one-cause, one-cure" sacred cow. The steps required to achieve this outcome are outlined. Three: openly dividing the profession into evidence based practitioners and subluxation based practitioners. Adopting this option would allow each branch of the profession to move forward in the health care delivery system unhindered by the other.It is unclear which option the profession will choose and whether the profession is mature enough to follow option two remains to be seen. What is evident is that the time to act is now.

Chiropractic at the crossroads or are we just going around in circles?

Background

Chiropractic in Australia has seen many changes over the past 30 years. Some of these changes have advanced the professional status of chiropractic, improved undergraduate training and paved the way for a research culture. Unfortunately, other changes or lack of changes, have hindered the growth, public utilisation and professional standing of chiropractic in Australia. This article explores what influences have impacted on the credibility, advancement and public utilisation of chiropractic in Australia.

Discussion

The 1970's and 1980's saw a dramatic change within the chiropractic profession in Australia. With the advent of government regulation, came government funded teaching institutions, quality research and increased public acceptance and utilisation of chiropractic services. However, since that time the profession appears to have taken a backward step, which in the author's opinion, is directly linked to a shift by sections of the profession to the fundamentalist approach to chiropractic and the vertebral subluxation complex. The abandonment, by some groups, of a scientific and evidenced based approach to practice for one founded on ideological dogma is beginning to take its toll.

Summary

The future of chiropractic in Australia is at a crossroads. For the profession to move forward it must base its future on science and not ideological dogma. The push by some for it to become a unique and all encompassing alternative system of healthcare is both misguided and irrational.

Spinal manipulations for the treatment of migraine: A systematic review of randomized clinical trials

Aims: The objective of this systematic review was to assess the effectiveness of spinal manipulations as a treatment for migraine headaches.

Method: Seven databases were searched from inception to November 2010. All randomized clinical trials (RCTs) investigating spinal manipulations performed by any type of healthcare professional for treating migraine headaches in human subjects were considered. The selection of studies, data extraction and validation were performed independently by two reviewers.

Results: Three RCTs met the inclusion criteria. Their methodological quality was mostly poor and ranged between 1 and 3 on the Jadad scale. Two RCTs suggested no effect of spinal manipulations in terms of Headache Index or migraine duration and disability compared with drug therapy, spinal manipulation plus drug therapy, or mobilization. One RCT showed significant improvements in migraine frequency, intensity, duration and disability associated with migraine compared with detuned interferential therapy. The most rigorous RCT demonstrated no effect of chiropractic spinal manipulation compared with mobilization or spinal manipulation by medical practitioner or physiotherapist on migraine duration or disability.

Conclusions: Current evidence does not support the use of spinal manipulations for the treatment for migraine headaches.

Chiropractic treatment for gastrointestinal problems: a systematic review of clinical trials

Many chiropractors believe that chiropractic treatments are effective for gastrointestinal disorders. The aim of the present systematic review was to critically evaluate the evidence from controlled clinical trials supporting or not supporting this notion. Six electronic databases were searched for relevant studies. No limits were applied to language or publication date. Prospective, controlled, clinical trials of any type of chiropractic treatment for any type of gastrointestinal problem, except infant colic, were included. Only two trials were found--one was a pilot study, and the other had reached a positive conclusion; however, both had serious methodological flaws. There is no supportive evidence that chiropractic is an effective treatment for gastrointestinal disorders.

An independent review of NCCAM-funded studies of chiropractic

To promote an independent and critical evaluation of 11 randomised clinical trials (RCTs) of chiropractic funded by the National Centre for Complementary and Alternative Medicine (NCCAM). Electronic searches were conducted to identify all relevant RCTs. Key data were extracted and the risk of bias of each study was determined. Ten RCTs were included, mostly related to chiropractic spinal manipulation for musculoskeletal problems. Their quality was frequently questionable. Several RCTs failed to report adverse effects and the majority was not described in sufficient detail to allow replication. The criticism repeatedly aimed at NCCAM seems justified, as far as their RCTs of chiropractic is concerned. It seems questionable whether such research is worthwhile.

The great subluxation debate: a centrist's perspective

OBJECTIVE

This commentary describes the debate and some of the associated issues involving the subluxation construct.

DISCUSSION

The long-standing debate regarding the chiropractic subluxation has created substantial controversy within the profession. Currently, this phenomenon can be compared with a country with a 2-party system that has a large silent majority sitting between the 2 factions. It is argued that the position held by those in the middle (the centrists) may be the most rational view when considering all of the available evidence. It is also suggested that the subluxation construct is similar to the Santa Claus construct in that both have a factual basis as well as social utility. Ultimately, the centrists must become proactive if they want to protect the profession and further advance the evidence in regard to the subluxation. They must not only engage in the debate, but fund the research that will investigate various aspects of the subluxation and then help disseminate this evidence to fellow doctors of chiropractic, other practitioners, health care policy makers, and society at large.

CONCLUSION

The role of subluxation in chiropractic practice, the progression of this debate, and the future of the profession will be directly determined by the role that centrists choose to play.