BACKGROUND: In the United States (US) a shortage of primary care physicians has become evident. Other health care providers such as chiropractors might help address some of the nation's primary care needs simply by being located in areas of lesser primary care resources. Therefore, the purpose of this study was to examine the distribution of the chiropractic workforce across the country and compare it to that of primary care physicians.

METHODS: We used nationally representative data to estimate the per 100,000 capita supply of chiropractors and primary care physicians according to the 306 predefined Hospital Referral Regions. Multiple variable Poisson regression was used to examine the influence of population characteristics on the supply of both practitioner-types.

RESULTS: According to these data, there are 74,623 US chiropractors and the per capita supply of chiropractors varies more than 10-fold across the nation. Chiropractors practice in areas with greater supply of primary care physicians (Pearson's correlation 0.17, p-value < 0.001) and appear to be more responsive to market conditions (i.e. more heavily influenced by population characteristics) in regards to practice location than primary care physicians.

CONCLUSION: These findings suggest that chiropractors practice in areas of greater primary care physician supply. Therefore chiropractors may be functioning in more complementary roles to primary care as opposed to an alternative point of access.

Chiropr Man Therap. 2012 Nov 21;20(1):35. Davis MA, Mackenzie TA, Coulter ID, Whedon JM, Weeks WB.

The aim of the present study was to assess the use of complementary and alternative medicine (CAM) treatments in outpatients with cardiovascular disease and their interest in future use. The increasing popularity of CAM therapies highlights the need to explore their use among patients with cardiovascular disease. Data were collected with a prospective, point-of-care, anonymous, 17-question survey about basic medical information and previous use and interest in the future use of dietary supplements and other CAM interventions among patients undergoing outpatient cardiology evaluation at a Midwestern tertiary care center. The survey was completed by 1,055 patients (655 men, 351 women; mean age 63.5 years) of whom 98.1% were white. Of these, 36.8% had cardiac symptoms for >10 years, 48.2% had coronary artery disease, and 82.5% reported use of CAM therapies. Of these patients, 75.4% reported using dietary supplements, 31.5% chiropractic therapy, 23.9% mind-body therapies, and 19.2% massage. Only 14.4% had discussed the use of CAM treatments with their physicians. The top 4 treatments used for cardiac symptoms were relaxation techniques, stress management, meditation, and guided imagery. Also, 48.6% were interested in participating in a future clinical trial of an alternative treatment. The great majority of patients seen in current practice use CAM therapies, and a large proportion expressed an interest in participating in research with CAM therapies. In conclusion, research directed with an integrative approach to cardiovascular care might prove beneficial when designing future studies.

Am J Cardiol. 2012 Nov 24. pii: S0002-9149(12)02287-4. doi: 10.1016/j.amjcard.2012.10.010. Prasad K, Sharma V, Lackore K, Jenkins SM, Prasad A, Sood A. Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota. Electronic address: prasad.kavita@mayo.edu.

Assistant Professor, Department of Family Dentistry, The University of Iowa College of Dentistry, Iowa City, Iowa Private Practice of General Dentistry, Ankeny, Iowa Professor, Department of Pediatric Dentistry and Director of the Biostatistics Unit for the College of Dentistry Professor and Head, Department of Family Dentistry Biostatistician, Dows Institute for Dental Research, The University of Iowa College of Dentistry, Iowa City, Iowa Professor, Department of Internal Medicine, The University of Iowa College of Medicine, Iowa City, Iowa Associate Professor and Director of Dental Pharmacy, The University of Iowa College of Dentistry, Iowa City, Iowa.

This pilot study investigated the prevalence and specific reasons for usage of complementary and alternative medicine (CAM) among patients of a dental school clinic. Four hundred and two patients completed a 30-page survey on CAM usage. A higher rate of CAM usage was found in this dental school clinic population than rates previously reported in a general population. More than three-quarters (76.1%) of the respondents reported using at least one CAM treatment in the past 12 months; 93.3% reported using at least one CAM treatment at some time in their lives. High rates of chiropractic use were found in this population. Tooth pain was the most frequently reported dental condition motivating CAM use. About 10% of dental school clinic patients use topical oral herbal and/or natural products to treat dental conditions, most frequently for preventive/oral health reasons or for tooth pain.

Spec Care Dentist. 2012 Sep;32(5):177-183. doi: 10.1111/j.1754-4505.2012.00273.x. Spector ML, Fischer M, Dawson DV, Holmes DC, Kummet C, Nisly NL, Baker KA.

Arthritis is considered the leading cause of disability among adults in the United States today and contributes substantially to the rising cost of health care. Residents of rural areas are especially affected. The purposes of this article are to describe chiropractic use by rural and nonrural individuals with arthritis and to identify differences in other health care use and health status by those using chiropractic care plus conventional care or conventional care alone. A longitudinal cohort from panel 12 (N = 12440) of the Medical Expenditure Panel Survey spanning 2007 to 2008 was selected for this study to represent changes in health care expenditures and use and outcomes throughout this period. The population was stratified by self-reported physician-diagnosed arthritis and rural status and compared across demographics, health status, and health care use and expenditures, including use of chiropractic services plus conventional care or conventional care alone. Twice as many rural people with arthritis had 1 or more visits with a doctor of chiropractic compared with nonrural persons with arthritis. More rural chiropractic users with arthritis reported their perceived health status as excellent, very good, or good compared with nonrural chiropractic users with arthritis and to rural people with arthritis who reported no chiropractic visits. Health care expenditures for other physician services were higher among rural chiropractic users with arthritis than nonrural users with arthritis. Differences in chiropractic use were observed between rural and nonrural individuals with arthritis. More studies are needed to investigate these differences and the impact on health care use and expenditures and outcomes of individuals with arthritis.

J Manipulative Physiol Ther. 2012 Aug 27. Enyinnaya EI, Anderson JG, Merwin EI, Taylor AG. Postdoctoral Research Fellow, Center for the Study of Complementary and Alternative Therapies, School of Nursing, University of Virginia, Charlottesville, VA.

This case study reported the conservative management of a patient presenting with left sided low back and leg pain diagnosed as a left sided L5-S1 disc prolapse/herniation. A 31-year-old male recreational worker presented with left sided low back and leg pain for the previous 3-4 months that was exacerbated by prolonged sitting. The plan of management included interferential current, soft tissue trigger point and myofascial therapy, lateral recumbent manual low velocity, low amplitude traction mobilizations and pelvic blocking as necessary. Home care included heat, icing, neural mobilizations, repeated extension exercises, stretching, core muscle strengthening, as well as the avoidance of prolonged sitting and using a low back support in his work chair. The patient responded well after the first visit and his leg and back pain were almost completely resolved by the third visit. Conservative chiropractic care appears to reduce pain and improve mobility in this case of a L5-S1 disc herniation. Active rehabilitative treatment strategies are recommended before surgical referral.

J Can Chiropr Assoc. 2012 Sep;56(3):225-32. Howell ER. Ashbridge's Health Centre, 1522 Queen St. East, Toronto, ON M4L 1E3. E-mail: dremilyhowell@hotmail.com .

To assess the significance of adverse events after spinal manipulation therapy (SMT) by replicating and critically reviewing a paper commonly cited when reviewing adverse events of SMT as reported by Ernest (J Roy Soc Med 100:330--338, 2007). Replication of a 2007 Ernest paper to compare the details recorded in this paper to the original source material. Specific items that were assessed included the time lapse between treatment and the adverse event, and the recording of other significant risk factors such as diabetes, hyperhomocysteinemia, use of oral contraceptive pill, any history of hypertension, atherosclerosis and migraine. The review of the 32 papers discussed by Ernest found numerous errors or inconsistencies from the original case reports and case series. These errors included alteration of the age or sex of the patient, and omission or misrepresentation of the long term response of the patient to the adverse event. Other errors included incorrectly assigning spinal manipulation therapy (SMT) as chiropractic treatment when it had been reported in the original paper as delivered by a non-chiropractic provider (e.g. Physician).The original case reports often omitted to record the time lapse between treatment and the adverse event, and other significant clinical or risk factors. The country of origin of the original paper was also overlooked, which is significant as chiropractic is not legislated in many countries. In 21 of the cases reported by Ernest to be chiropractic treatment, 11 were from countries where chiropractic is not legislated. The number of errors or omissions in the 2007 Ernest paper, reduce the validity of the study and the reported conclusions. The omissions of potential risk factors and the timeline between the adverse event and SMT could be significant confounding factors. Greater care is also needed to distinguish between chiropractors and other health practitioners when reviewing the application of SMT and related adverse effects.

Chiropr Man Therap. 2012 Sep 21;20(1):30. Tuchin P.

Full title: A Literature Review of Pediatric Spinal Manipulation and Chiropractic Manipulative Therapy: Evaluation of Consistent Use of Safety Terminology.

The purpose of this study was to perform a literature search to identify relevant studies on pediatric spinal manipulation and chiropractic manipulative therapy and to assess if safety terminology was consistent with the International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH). A literature search was performed in PubMed using the following terms: spinal manipulation pediatric, chiropractic safety pediatric, and manual therapy safety pediatric. PubMed was searched from inception to April 2012 with no language limitations. The international standards included the terminology of the World Health Organization on side effects, adverse reactions, adverse events and the ICH guideline templates that were adapted for manual therapy for this study. Of the 9 relevant articles identified in this study, 3 reported methodology for classifying safety incidents, and all 9 used safety terminology (adverse effects or adverse events). However, terminology was not used consistently. Most of the articles identified in this literature review did not use terminology consistent with the standards established by the ICH when reporting on safety incidents following pediatric spinal manipulation or chiropractic manipulative therapy. More efforts should be taken to include consistent terminology for studies of spinal manipulation and chiropractic manipulative therapy for children.

J Manipulative Physiol Ther. 2012 Aug 27. Marchand AM.

Full title: Precompetition manipulative treatment and performance among virginia tech athletes during 2 consecutive football seasons: a preliminary, retrospective report.

One of the goals of providing manipulative treatment such as osteopathic manipulative treatment (OMT) is to restore maximal, pain-free movement of the musculoskeletal system and to enhance neuromuscular function. Anecdotally, some athletes have reported that their athletic performance improves after manipulative treatment. To develop preliminary data to gain more understanding about the association between precompetition manipulative treatments provided to Division I football players and their athletic performance during each game for 2 consecutive football seasons. The study design was a retrospective cohort study. Participants were football athletes at Virginia Polytechnic Institute and State University (Virginia Tech). Board-certified osteopathic physicians who were trained in osteopathic manipulative medicine and sports medicine performed OMT and determined the type of OMT techniques used and the spinal segments treated. One chiropractor provided chiropractic manipulative therapy. Prior to each game, the athletes who elected to receive precompetition manipulative treatment (ie, OMT or chiropractic manipulative therapy) underwent a focused physical examination and received manipulative treatment on the basis of clinical findings. After each game, the coaching staff "graded" the players by using a standard coaching algorithm. Offensive players received a percentile score (0 to 100) and defensive players received a numeric score (>30 was considered "very good"). A total of 1976 manipulative treatments were provided to 115 football players in 2 consecutive football seasons. Sixty-two offensive players received 985 manipulative treatments, and 53 defensive players received 991 manipulative treatments. Treatments were applied to the affected regions of the spine: cervical, thoracic, lumbar, and sacral sections. Mean (standard deviation) performance scores were 67.8% (22.8%) and 11.1 (9.9) points among offensive and defensive players, respectively. The correlation coefficients between the numbers of the manipulative treatments and the performance scores were 0.107 (P=.407) among the offensive players and 0.218 (P=.117) among the defensive players. Precompetition manipulative treatment was positively associated with improved performance among both offensive and defensive Virginia Tech football players. Although the associations between these 2 factors were relatively small and not statistically significant, we found positive correlations in performance of the offensive and defensive players.

J Am Osteopath Assoc. 2012 Sep;112(9):607-15. Brolinson PG, Smolka M, Rogers M, Sukpraprut S, Goforth MW, Tilley G, Doolan KP. Associate Dean for Clinical Research, VCOM, 2265 Kraft Dr, Blacksburg, VA 24060-6360. pbrolins@vcom.vt.edu.

Full title: Precompetition manipulative treatment and performance among virginia tech athletes during 2 consecutive football seasons: a preliminary, retrospective report.

One of the goals of providing manipulative treatment such as osteopathic manipulative treatment (OMT) is to restore maximal, pain-free movement of the musculoskeletal system and to enhance neuromuscular function. Anecdotally, some athletes have reported that their athletic performance improves after manipulative treatment. To develop preliminary data to gain more understanding about the association between precompetition manipulative treatments provided to Division I football players and their athletic performance during each game for 2 consecutive football seasons. The study design was a retrospective cohort study. Participants were football athletes at Virginia Polytechnic Institute and State University (Virginia Tech). Board-certified osteopathic physicians who were trained in osteopathic manipulative medicine and sports medicine performed OMT and determined the type of OMT techniques used and the spinal segments treated. One chiropractor provided chiropractic manipulative therapy. Prior to each game, the athletes who elected to receive precompetition manipulative treatment (ie, OMT or chiropractic manipulative therapy) underwent a focused physical examination and received manipulative treatment on the basis of clinical findings. After each game, the coaching staff "graded" the players by using a standard coaching algorithm. Offensive players received a percentile score (0 to 100) and defensive players received a numeric score (>30 was considered "very good"). A total of 1976 manipulative treatments were provided to 115 football players in 2 consecutive football seasons. Sixty-two offensive players received 985 manipulative treatments, and 53 defensive players received 991 manipulative treatments. Treatments were applied to the affected regions of the spine: cervical, thoracic, lumbar, and sacral sections. Mean (standard deviation) performance scores were 67.8% (22.8%) and 11.1 (9.9) points among offensive and defensive players, respectively. The correlation coefficients between the numbers of the manipulative treatments and the performance scores were 0.107 (P=.407) among the offensive players and 0.218 (P=.117) among the defensive players. Precompetition manipulative treatment was positively associated with improved performance among both offensive and defensive Virginia Tech football players. Although the associations between these 2 factors were relatively small and not statistically significant, we found positive correlations in performance of the offensive and defensive players.

J Am Osteopath Assoc. 2012 Sep;112(9):607-15. Brolinson PG, Smolka M, Rogers M, Sukpraprut S, Goforth MW, Tilley G, Doolan KP. Associate Dean for Clinical Research, VCOM, 2265 Kraft Dr, Blacksburg, VA 24060-6360. pbrolins@vcom.vt.edu.

To describe two patients with lumbar facet synovial cysts causing sciatica and progressive neurological deficit. A 52-year-old female with bilateral sciatica and a neurological deficit that progressed to a foot drop; and a 54-year-old female with worsening sciatica and progressive calf weakness were seen at a major tertiary care centre. Diagnostic imaging studies revealed the presence of spinal nerve root impingement by large facet synovial cysts. Activity modification, gabapentinoid and non-steroidal anti-inflammatory medications were unsuccessful in ameliorating either patient's symptoms. One patient had been receiving ongoing lumbar chiropractic spinal manipulative therapy despite the onset of a progressive neurological deficit. Both patients eventually required surgery to remove the cyst and decompress the affected spinal nerve roots. Patients with acute sciatica who develop a progressive neurological deficit while under care, require prompt referral for axial imaging and surgical consultation. Primary care spine clinicians need to be aware of lumbar facet synovial cysts as a possible cause of acute sciatica and the associated increased risk of the patient developing a progressive neurological deficit.

J Can Chiropr Assoc. 2012 Sep;56(3):173-8. Arthur B, Lewkonia P, Quon JA, Street J, Bishop PB. Combined Neurosurgical and Orthopaedic Spine Program, Vancouver General Hospital, Division of Spine, Department of Orthopaedics & I.C.O.R.D. (International Collaboration on Repair Discoveries), University of British Columbia, Vancouver, Canada.

To describe two patients with lumbar facet synovial cysts causing sciatica and progressive neurological deficit. A 52-year-old female with bilateral sciatica and a neurological deficit that progressed to a foot drop; and a 54-year-old female with worsening sciatica and progressive calf weakness were seen at a major tertiary care centre. Diagnostic imaging studies revealed the presence of spinal nerve root impingement by large facet synovial cysts. Activity modification, gabapentinoid and non-steroidal anti-inflammatory medications were unsuccessful in ameliorating either patient's symptoms. One patient had been receiving ongoing lumbar chiropractic spinal manipulative therapy despite the onset of a progressive neurological deficit. Both patients eventually required surgery to remove the cyst and decompress the affected spinal nerve roots. Patients with acute sciatica who develop a progressive neurological deficit while under care, require prompt referral for axial imaging and surgical consultation. Primary care spine clinicians need to be aware of lumbar facet synovial cysts as a possible cause of acute sciatica and the associated increased risk of the patient developing a progressive neurological deficit.

J Can Chiropr Assoc. 2012 Sep;56(3):173-8. Arthur B, Lewkonia P, Quon JA, Street J, Bishop PB. Combined Neurosurgical and Orthopaedic Spine Program, Vancouver General Hospital, Division of Spine, Department of Orthopaedics & I.C.O.R.D. (International Collaboration on Repair Discoveries), University of British Columbia, Vancouver, Canada.

OBJECTIVE: The purpose of this study was to investigate whether a computer interviewing system (CIS) could be used as part of the periodic patient reassessment process, if patients and practitioners perceived that the CIS enhanced communication, and if the CIS could be used to identify patients with possible anxiety and/or depression. METHODS: An observational method was used, whereby the CIS was used to augment the usual patient reassessment routine in a chiropractic clinic. One clinic in the Dundee region, with 3 chiropractors, collected information from 60 patients using a CIS directly before the patient treatment session. The patients were then asked to rate whether they had disclosed new information relative to their care, if they felt better prepared, or if it had helped them to formulate questions. The chiropractors reported whether the interview transcript was useful, if it helped to identify communication issues, and if it had altered the treatment session. RESULTS: The doctors of chiropractic rated the interview transcript as useful for 83% of patients, they altered the treatment session for 20% of patients, and the CIS helped to identify communication difficulties for 13% of patients. The chiropractors were surprised by the Hospital Anxiety and Depression Scale results for 23% of patients. The patients were positive about the inclusion of the CIS, with 42% saying that they disclosed new information and 33% saying that they felt better prepared for the session with the chiropractor after having used the CIS. The CIS was acceptable to 90% of patients. CONCLUSIONS: The inclusion of the CIS at this one clinic appeared to be a useful addition to the periodic patient reassessment process and was perceived to be an efficient media to evaluate Hospital Anxiety and Depression Scale scores.

J Manipulative Physiol Ther. 2011 Sep;34(7):468-75. Hands KA, Cashley M, McWilliam R, Steen L. PhD Student, School of Computing, University of Dundee, Dundee, Scotland, UK. katrina.hands@tiscali.co.uk

Traditional Chinese spinal manipulative therapy (TCSMT) and Chiropractic are similar in treating related with spinal disease, but they keep different characteristics of themselves. Although Chiropractic's "Subluxation" and TCSMT's "Jin Chu Cao and Gu Cuo Feng" theory have not be widely recognized, yet Chiropractic has already have official cooperation with WHO,and has launched "WHO Basis of Chiropractic Training and Security Guide" which would promote the project further research. Comparatively, TCSMT has mature theoretical system and satisfactory clinical effectiveness, but it's hard to global spreading formally and legally. By means of cogitation of the TCSMT'S basic theories and clinical applications, this paper aims to analyze the inadequacy aspects of it, and hope to borrow some Chiropractic's advantage to TCSMT's global spreading. And I wish this paper could be helpful for relative doctors and researchers.

Zhongguo Gu Shang. 2011 Aug;24(8):662-6. Wang HH, Zhang MC, Zhan HS. Hospital Affiliated to Shanghai University of TCM, Insititue of Orthopedics and Traumatology, Shanghai Academy of Traditional Chinese Medicine, Shanghai 201203, China.

OBJECTIVE: Two recent studies that examined National Health Interview Survey data reported divergent findings regarding the propensity of adult chiropractic users to receive seasonal influenza immunization. Although one study found a statistically significant negative association between chiropractic use and influenza vaccination, another found that chiropractic users were significantly more likely to be vaccinated. The purpose of this study is to extend previous works by delving more deeply into recent data to identify adult chiropractic users at high risk and high priority for vaccination against influenza and pneumococcal disease. METHODS: We used data from the 2007 National Health Interview Survey in an attempt to replicate previous methodologies and further examine vaccination among adult chiropractic users (age =18 years) who, according to the Center for Disease Control and Prevention guidelines, should receive influenza and/or pneumococcal vaccination. We used complex survey design methods to make national estimates and used logistic regression to determine if having used chiropractic care predicted vaccination. RESULTS: We found major methodological differences between the prior studies. In our analyses, we found that chiropractic users were significantly less likely than nonusers to have received the pneumococcal vaccine, and we found no significant difference between chiropractic users and nonusers relative to having received the seasonal flu vaccine. CONCLUSIONS: Methodological differences in previous studies that investigated the association between chiropractic care and adult vaccination likely explain divergent findings reported in the literature. Future studies should consider these differences.

J Manipulative Physiol Ther. 2011 Sep 22. Smith M, Davis MA. Adjunct Faculty, National University of Health Sciences, Pinellas Park, FL.

Full Title: A survey of accessibility and utilisation of chiropractic services for wheelchair-users in the United Kingdom: What are the issues?

BACKGROUND: People with physical disabilities experience barriers to healthcare across all services despite a legal and moral obligation to the contrary. Complementary medicine is considered as supplementary to conventional care and integration of these approaches is essential to achieve optimal care. This paper explores the utilization of chiropractic services and practitioner experiences of treating wheelchair-users which appears under-reported. METHODS: A 20 item questionnaire was posted to 250 randomly selected chiropractors registered with the General Chiropractic Council. Follow-up questionnaires were sent 7 days after the initial return date. Quantitative data were subjected to frequency analysis. RESULTS: The response rate was 64% (n = 161). The majority (66%) of chiropractors had been in practice less than 10 years and were practice owners (50%). Fifty-two percent of chiropractors sampled had treated a patient in a wheelchair in the previous 5 years. The majority (87%) had treated between 1 and 5 such patients. Patients with multiple sclerosis, stroke and cerebral palsy most commonly presented for treatment. The majority of patients' presenting complaint was musculoskeletal in origin, primarily for pain control. Only 13% of respondents worked in a fully accessible clinic. Impracticality of alterations was the most common reason for inaccessibility. CONCLUSIONS: Wheelchair-users seem to be an underserved patient group in relation to chiropractic services. Chiropractic management is primarily utilised for pain control in patients with physical disabilities in which mobility may be improved or maintained. Co-management of wheelchair-users with GPs appears to be desirable in order to achieve optimal patient care however more research is required regarding the efficacy of chiropractic treatment for a range of disabling conditions. Physical access was identified as a key barrier to accessing care.

Chiropr Man Therap. 2011 Sep 13;19(1):20. McKay ND, Langworthy J. Anglo-European College of Chiropractic, 13-15 Parkwood Road, Bournemouth, UK. naomi.chiro@gmail.com.

Full Title: Attitudes towards Chiropractic: An Analysis of Written Comments from a Survey of North American Orthopaedic Surgeons.

BACKGROUND: There is increasing interest by chiropractors in North America regarding integration into mainstream healthcare; however, there is limited information about attitudes towards the profession among conventional healthcare providers, including orthopaedic surgeons. METHODS: We administered a 43-item cross-sectional survey to 1000 Canadian and American orthopaedic surgeons that inquired about demographic variables and their attitudes towards chiropractic. Our survey included an option for respondents to include written comments, and our present analysis is restricted to these comments. Two reviewers, independently and in duplicate, coded all written comments using thematic analysis. RESULTS: 487 surgeons completed the survey (response rate 49%), and 174 provided written comments. Our analysis revealed 8 themes and 24 sub-themes represented in surgeons' written comments. Reported themes were: variability amongst chiropractors (n=55); concerns with chiropractic treatment (n=54); areas where chiropractic is perceived as effective (n=43); unethical behavior (n=43); patient interaction (n=36); the scientific basis of chiropractic (n=26); personal experiences with chiropractic (n=21); and chiropractic training (n=18). Common sub-themes endorsed by surgeon's were diversity within the chiropractic profession as a barrier to increased interprofessional collaboration, endorsement for chiropractic treatment of musculoskeletal complaints, criticism for treatment of non-musculoskeletal complaints, and concern over whether chiropractic care was evidence-based. CONCLUSIONS: Our analysis identified a number of issues that will have to be considered by the chiropractic profession as part of its efforts to further integrate chiropractic into mainstream healthcare.

Chiropr Man Therap. 2011 Oct 4;19(1):25. Busse JW, Jim J, Jacobs C, Ngo T, Rodine R, Torrance D, Kulkarni AV, Petrisor B, Drew B, Bhandari M.

Full Title: Management of primary chronic headache in the general population: the Akershus study of chronic headache.

Primary chronic headaches cause more disability and necessitate high utilisation of health care. Our knowledge is based on selected populations, while information from the general population is largely lacking. An age and gender-stratified cross-sectional epidemiological survey included 30,000 persons aged 30-44 years. Respondents with self-reported chronic headache were interviewed by physicians. The International Classification of Headache Disorders was used. Of all primary chronic headache sufferers, 80% had consulted their general practitioner (GP), of these 19% had also consulted a neurologist and 4% had been hospitalised. Co-occurrence of migraine increased the probability of contact with a physician. A high Severity of Dependence Scale score increased the probability for contact with a physician. Complementary and alternative medicine (CAM) was used by 62%, most often physiotherapy, acupuncture and chiropractic. Contact with a physician increased the probability of use of CAM. Acute headache medications were taken by 87%, while only 3% used prophylactic medication. GPs manage the majority of those with primary chronic headache, 1/5 never consults a physician for their headache, while approximately 1/5 is referred to a neurologist or hospitalised. Acute headache medication was frequently overused, while prophylactic medication was rarely used. Thus, avoidance of acute headache medication overuse and increased use of prophylactic medication may improve the management of primary chronic headaches in the future.

J Headache Pain. 2011 Oct 13. Kristoffersen ES, Grande RB, Aaseth K, Lundqvist C, Russell MB. Head and Neck Research Group, Research Centre, Akershus University Hospital, 1478 Lørenskog, Oslo, Norway.

OBJECTIVE: The purpose of this study was to investigate if Canadian doctors of chiropractic consider using wellness strategies after functional recovery in acute and chronic conditions. This study also attempted to determine if there is a difference in the use of wellness management strategies between broad and narrow scope practitioners. METHODS: Forty-one practicing, licensed chiropractors were recruited to complete an interview survey regarding 2 mock clinical case presentations. Interviews were recorded, and influential words or word pairings were identified. Investigators formulated criteria to divide practitioners into broad scope (mixers) and narrow scope (straights). Data were analyzed using Crawdad Analysis Software (version 1.2). RESULTS: All subjects indicated that they would provide information regarding public health and wellness strategies to a patient after functional resolution of the presenting chronic or acute complaints. The responses of broad scope (mixer) chiropractors appeared to be focused on the patient specifically, whereas narrow scope (straight) responses appeared to be more varied when analyzed for noun and noun-pair influence. CONCLUSION: This study of practicing, licensed Canadian chiropractors suggests that wellness strategies may be commonly considered in practice. All subjects in this study reported a number of strategies to educate patients regarding wellness after functional recovery of a complaint.

J Manipulative Physiol Ther. 2011 Jul-Aug;34(6):388-93. Stainsby BE, Porr JT, Kim P, Collinge AM, Hunter JC. Canadian Memorial Chiropractic College, Toronto, ON, Canada. bstainsby@cmcc.ca

Full Title: Spinal manipulative therapy for elderly patients with chronic obstructive pulmonary disease: a case series.

OBJECTIVE: The objective of this case series is to report the results of spinal manipulative therapy (SMT) for people with chronic obstructive pulmonary disease (COPD) who were older than 65 years. METHODS: The study design was a prospective case series. Six patients of a long-term care center who were older than 65 years and having COPD underwent a course of 12 SMT sessions over a 4-week period. Each SMT session consisted of manually applied spinal manipulation and instrument-assisted spinal manipulation delivered by a doctor of chiropractic. Lung function measurements were recorded at baseline and at 2 and 4 weeks. The occurrence and type of any adverse events (AEs) related to SMT were recorded at each SMT session. RESULTS: One male and 5 female patients took part in the study. The average age was 79.1 years (range, 68-89 years). There was a clinically significant increase in forced expiratory volume in the first second after SMT in 4 of the 6 patients at 2 weeks. This was sustained in only 1 patient at 4 weeks. No clinically significant changes were observed for forced vital capacity at 2 or 4 weeks. One hundred forty-four manually applied spinal manipulations and 72 instrument-assisted spinal manipulations were administered during the intervention period. No major or moderate AEs were reported. Only minor AEs were reported after 29% of the intervention sessions, with 1 AE being reported for each patient. All AEs resolved within 48 hours. CONCLUSIONS: This case series offers preliminary evidence that SMT may have the potential to benefit lung function in patients with COPD who are older than 65 years.

J Manipulative Physiol Ther. 2011 Jul-Aug;34(6):413-7. Dougherty PE, Engel RM, Vemulpad S, Burke J. New York Chiropractic College, Seneca Falls, NY 13148, USA. pdougherty@nycc.edu

ABSTRACT: 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 has hindered the growth and prosperity 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 coming 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 certain 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.

Chiropr Man Therap. 2011 May 21;19(1):11. Reggars JW.

OBJECTIVE: The purpose of this manuscript is to provide evidence-informed practice recommendations for the chiropractic treatment of headache in adults. METHODS: Systematic literature searches of controlled clinical trials published through August 2009 relevant to chiropractic practice were conducted using the databases MEDLINE; EMBASE; Allied and Complementary Medicine; the Cumulative Index to Nursing and Allied Health Literature; Manual, Alternative, and Natural Therapy Index System; Alt HealthWatch; Index to Chiropractic Literature; and the Cochrane Library. The number, quality, and consistency of findings were considered to assign an overall strength of evidence (strong, moderate, limited, or conflicting) and to formulate practice recommendations. RESULTS: Twenty-one articles met inclusion criteria and were used to develop recommendations. Evidence did not exceed a moderate level. For migraine, spinal manipulation and multimodal multidisciplinary interventions including massage are recommended for management of patients with episodic or chronic migraine. For tension-type headache, spinal manipulation cannot be recommended for the management of episodic tension-type headache. A recommendation cannot be made for or against the use of spinal manipulation for patients with chronic tension-type headache. Low-load craniocervical mobilization may be beneficial for longer term management of patients with episodic or chronic tension-type headaches. For cervicogenic headache, spinal manipulation is recommended. Joint mobilization or deep neck flexor exercises may improve symptoms. There is no consistently additive benefit of combining joint mobilization and deep neck flexor exercises for patients with cervicogenic headache. Adverse events were not addressed in most clinical trials; and if they were, there were none or they were minor. CONCLUSIONS: Evidence suggests that chiropractic care, including spinal manipulation, improves migraine and cervicogenic headaches. The type, frequency, dosage, and duration of treatment(s) should be based on guideline recommendations, clinical experience, and findings. Evidence for the use of spinal manipulation as an isolated intervention for patients with tension-type headache remains equivocal.

J Manipulative Physiol Ther. 2011 Jun;34(5):274-89. Bryans R, Descarreaux M, Duranleau M, Marcoux H, Potter B, Ruegg R, Shaw L, Watkin R, White E. Guidelines Development Committee Chair and Chiropractor, Private Practice, Clarenville, Newfoundland and Labrador, Canada.

OBJECTIVE: The purpose of this study was to conduct a systematic review on manual and manipulative therapy (MMT) for common shoulder pain and disorders. METHODS: A search of the literature was conducted using the Cumulative Index of Nursing Allied Health Literature; PubMed; Manual, Alternative, and Natural Therapy Index System; Physiotherapy Evidence Database; and Index to Chiropractic Literature dating from January 1983 to July 7, 2010. Search limits included the English language and human studies along with MeSH terms such as manipulation, chiropractic, osteopathic, orthopedic, musculoskeletal, physical therapies, shoulder, etc. Inclusion criteria required a shoulder peripheral diagnosis and MMT with/without multimodal therapy. Exclusion criteria included pain referred from spinal sites without a peripheral shoulder diagnosis. Articles were assessed primarily using the Physiotherapy Evidence Database scale in conjunction with modified guidelines and systems. After synthesis and considered judgment scoring were complete, with subsequent participant review and agreement, evidence grades of A, B, C, and I were applied. RESULTS: A total of 211 citations were retrieved, and 35 articles were deemed useful. There is fair evidence (B) for the treatment of a variety of common rotator cuff disorders, shoulder disorders, adhesive capsulitis, and soft tissue disorders using MMT to the shoulder, shoulder girdle, and/or the full kinetic chain (FKC) combined with or without exercise and/or multimodal therapy. There is limited (C) and insufficient (I) evidence for MMT treatment of minor neurogenic shoulder pain and shoulder osteoarthritis, respectively. CONCLUSIONS: This study found a level of B or fair evidence for MMT of the shoulder, shoulder girdle, and/or the FKC combined with multimodal or exercise therapy for rotator cuff injuries/disorders, disease, or dysfunction. There is a fair or B level of evidence for MMT of the shoulder/shoulder girdle and FKC combined with a multimodal treatment approach for shoulder complaints, dysfunction, disorders, and/or pain.

J Manipulative Physiol Ther. 2011 Jun;34(5):314-46. Brantingham JW, Cassa TK, Bonnefin D, Jensen M, Globe G, Hicks M, Korporaal C. Director of Research and Associate Professor, Department of Research, Cleveland Chiropractic College, Los Angeles, CA.

Full title: Attitudes of clinicians at the Canadian Memorial Chiropractic College towards the chiropractic management of non-musculoskeletal conditions.

OBJECTIVE: The objective of this study was to determine the attitudes of clinical faculty during the 2009-2010 academic year at the Canadian Memorial Chiropractic College towards the treatment of various non-musculoskeletal disorders. METHODS: A confidential survey was distributed to the clinical faculty via email. It consisted of several questions polling the demographic of the respondent such as years in clinical practice, and a list of 29 non-musculoskeletal conditions. Clinicians were asked to indicate their opinions on each condition on rating scale ranging from strongly agree to strongly disagree. RESULTS: Twenty of 22 clinicians responded. The conditions garnering the greatest positive ratings include: asthma, constipation, chronic pelvic pain, dysmenorrhea, infantile colic, and vertigo. The options regarding vertigo and asthma, while demonstrating an overall positive attitude towards the benefits of chiropractic care, were stratified amongst clinicians with varying years in clinical practice. CONCLUSION: This study suggests clinicians at this college are moderately open towards the chiropractic treatment of some non-musculoskeletal disorders.

J Can Chiropr Assoc. 2011 Jun;55(2):107-19. Parkinson J, Lau J, Kalirah S, Gleberzon BJ. Professor and Chair, Department of Applied Chiropractic, Canadian Memorial Chiropractic College, 6100 Leslie St. Toronto, ON M2H 3J1, E-mail: bgleberzon@cmcc.ca.

Full title: Complementary and alternative medicine: Perception and use by physiotherapists in the management of low back pain.

BACKGROUND AND PURPOSE: The aim of this survey was to investigate complementary and alternative medicine (CAM) use by physiotherapists for the treatment of low back pain (LBP). METHODS: Questionnaires (n=1000) were distributed to physiotherapists randomly selected from the UK's Organisation of Chartered Physiotherapists in Private Practice (OCPPP). Results were analysed by SPSS. RESULTS: A response rate of 46% was obtained (n=459). 94.3% of respondents stated that they currently treated LBP; the most common CAMs used by physiotherapists were acupuncture (46.9%) and massage (2.1%). Physiotherapists perceived acupuncture, massage, osteopathy, chiropractic and yoga to be effective in the treatment of LBP, but were unsure about the effectiveness of other CAMs. DISCUSSION AND CONCLUSION: Physiotherapists in this sample often use acupuncture and massage to treat LBP, but appear to have little knowledge of other CAMs. Physiotherapists use mainstream methods such as mobilization and massage which could be perceived as CAM depending on the physiotherapists' perceptions and training, as these therapies have also been used and investigated by CAM practitioners. More research is required on the use of CAM as little is known regarding the effectiveness of these therapies on LBP.

Complement Ther Med. 2011 Jun;19(3):149-54. Epub 2011 Apr 27. Hughes CM, Quinn F, Baxter GD. School of Health Sciences, University of Ulster, Shore Road, Newtownabbey, Co., Antrim BT37 OQB, United Kingdom.

Full title: Conservative management of post-surgical urinary incontinence in an adolescent using applied kinesiology: a case report.

INTRODUCTION: This case report describes the successful treatment of an adolescent female suffering daily stress and occasional total urinary incontinence with applied kinesiology methods and chiropractic manipulative therapy. PATIENT PRESENTATION: A 13-year-old female developed unpredictable urinary incontinence and right hip pain immediately following emergency open appendectomy surgery. The patient was forced to wear an incontinence pad throughout the day and night for 10 months because of unpredictable urinary incontinence. ASSESSMENT AND INTERVENTION: Chiropractic and applied kinesiology (AK) methods - a multi-modal diagnostic technique that utilizes manual muscle tests (MMT) for the detection of musculoskeletal impairments and specific AK techniques for correction of identified issues - were utilized to diagnose and treat this patient for muscle impairments in the lumbar spine and pelvis. RESULTS: Patient experienced a rapid resolution of her urinary incontinence and hip pain. A six-year follow-up confirmed complete resolution of symptoms. DISCUSSION: In this case, utilization of MMT allowed for the identification of several inhibited muscles. Utilizing the appropriate corrective techniques improved the strength of these muscles and resulted in their being graded as facilitated. Symptoms of urinary incontinence and hip pain resolved with this diagnostic and treatment approach. CONCLUSION: AK methods were useful for the discovery of a number of apparent causative factors underlying this patient's urinary incontinence and hip pain. Treatment for these pelvic-floor muscle and joint abnormalities resulted in rapid, long-lasting resolution of her urinary incontinence and hip pain.

Altern Med Rev. 2011 Jun;16(2):164-71. Cuthbert SC, Rosner AL. cranialdc@hotmail.com.

Full title: Factors Associated With Care Seeking From Physicians, Physical Therapists, or Chiropractors by Persons With Spinal Pain: A Population-Based Study.

STUDY DESIGN: Secondary analysis of longitudinal population-based survey data. OBJECTIVES: To investigate factors associated with care seeking for physician referred physical therapy (MD/PT) as compared to physician only (MD) or chiropractic only (DC) care for spinal pain. BACKGROUND: Although a large proportion of ambulatory physical therapy visits are related to spinal pain, physical therapists are not the most commonly seen provider. The majority of visits are to physicians followed by chiropractors. We attempted to understand more about this disparity by examining social and demographic factors that differentiate between persons who see these providers. METHODS: Episodes of care were constructed from participants in 2 panels from the Medical Expenditure Panel Survey who had spinal pain. The provider of care was identified for each episode and logistic regression was used to determine factors associated with MD/PT use compared to MD use; and MD/PT use compared to DC use. RESULTS: MDs see the majority [61%] of patients with spinal pain followed by DC [28%] and MD/PT [11%]. Female sex, higher levels of education, and higher income were significantly associated with MD/PT over MD care. Increased age, female sex, lower self health rating, and presence of at least 1 disability day were all significantly associated with MD/PT care over DC care. CONCLUSION: Socio-demographic and clinical factors are associated with who gets care via an MD/PT route as compared to MD or DC care seeking. We found evidence of an access disparity for physical therapy and identified population characteristics that both increase and reduce the likelihood of physical therapy service use.

J Orthop Sports Phys Ther. 2011 Jun 7. Chevan J, Riddle DL.

The mechanisms for developing long-lasting neck pain after whiplash injuries are still largely unrevealed. In the present study it was investigated whether a kyphotic deformity of the cervical spine, as opposed to a straight or a lordotic spine, was associated with the symptoms at baseline, and with the prognosis one year following a whiplash injury. MRI was performed in 171 subjects about 10 d after the accident, and 104 participated in the pain recording at 1-year follow-up. It was demonstrated that postures as seen on MRI can be reliably categorized and that a straight spine is the most frequent appearance of the cervical spine in supine MRI. In relation to symptoms it was seen that a kyphotic deformity was associated with reporting the highest intensities of headache at baseline, but not with an increased risk of long-lasting neck pain or headache. In conclusion, a kyphotic deformity is not significantly associated with chronic whiplash associated pain. Moreover, it is a clear clinical implication that pain should not be ascribed to a straight spine on MRI. We suggest that future trials on cervical posture focus upon the presence of kyphotic deformity rather than just on the absence of lordosis.

Man Ther. 2011 Aug;16(4):378-83. Epub 2011 Feb 3. Johansson MP, Baann Liane MS, Bendix T, Kasch H, Kongsted A. Private Chiropractic Clinic, Godthaabsvej, Frederiksberg, Denmark.

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.

Can J Gastroenterol. 2011 Jan;25(1):39-40. Ernst E. Department of Complementary Medicine, Peninsula Medical School, University of Exeter, UK. edzard.ernst@pms.ac.uk

OBJECTIVE: The aims of this study were to identify the types and frequencies of pain treatments used by individuals with cerebral palsy, examine the perceived effectiveness of these treatments, and identify the types of healthcare providers that were accessed for pain-related services. DESIGN: A cross-sectional survey design was used. A total of 83 adults (mean [SD] age, 40.3 [13.6] yrs) with cerebral palsy indicated their pain location and intensity during the past 3 mos. Next, they indicated their use of 24 different pain treatments and the effectiveness of each. Finally, participants indicated the frequency of pain-related healthcare visits to specific providers over the past 6 mos. RESULTS: Of the participants, 63% reported experiencing chronic pain and rated their pain intensity over the past week as 5.1 of 10, on average. The most common pain locations were the lower back, hips, and legs. Physical interventions (e.g., physical therapy, strengthening) were the most common pain treatments reportedly used and were rated as moderately effective. Many other treatments were also used, and participants sought pain-related care from a variety of providers. CONCLUSIONS: Although participants reportedly accessed pain care from a variety of providers and perceived that several types of treatments were effective, many of the treatments rated as effective were rarely used or provided. Future research using clinical trial methods would further elucidate the specific pain treatments that are most beneficial for adults with cerebral palsy.

Am J Phys Med Rehabil. 2011 Mar;90(3):207-16. Hirsh AT, Kratz AL, Engel JM, Jensen MP. Department of Psychology, Indiana University-Purdue University Indianapolis, 402 N. Blackford Street, Indianapolis, IN 46202, USA.

Full title: Acute spinal epidural haematoma causing cord compression after chiropractic neck manipulation: an under-recognised serious hazard

Spinal manipulative therapy performed by chiropractors is increasingly common in the United Kingdom. Spinal epidural haematoma is a rare complication of such physical therapy but when identified represents a neurological emergency. We describe the case of a 64 year-old man who presented with a dense hemiplegia due to a spinal epidural haematoma following cervical spine manipulation performed for acute neck pain. The clinical features and surgical management of the case are discussed and we stress the importance of recognition of chiropractic manipulation as a potential cause of neurological sequelae and discuss the potential pitfalls of such therapy as it becomes more widespread.

J R Army Med Corps. 2010 Dec;156(4):255-7. Lidder S, Lang KJ, Masterson S, Blagg S. ST3 in Trauma and Orthopaedics, Royal London Hospital, Whitechapel Road, London, UK. surjitlidder@doctors.org.uk

BACKGROUND: Many therapies exist for the treatment of low-back pain including spinal manipulative therapy (SMT), which is a worldwide, extensively practiced intervention. OBJECTIVES: To assess the effects of SMT for chronic low-back pain. SEARCH STRATEGY: An updated search was conducted by an experienced librarian to June 2009 for randomised controlled trials (RCTs) in CENTRAL (The Cochrane Library 2009, issue 2), MEDLINE, EMBASE, CINAHL, PEDro, and the Index to Chiropractic Literature.   SELECTION CRITERIA: RCTs which examined the effectiveness of spinal manipulation or mobilisation in adults with chronic low-back pain were included. No restrictions were placed on the setting or type of pain; studies which exclusively examined sciatica were excluded. The primary outcomes were pain, functional status and perceived recovery. Secondary outcomes were return-to-work and quality of life. DATA COLLECTION AND ANALYSIS: Two review authors independently conducted the study selection, risk of bias assessment and data extraction. GRADE was used to assess the quality of the evidence. Sensitivity analyses and investigation of heterogeneity were performed, where possible, for the meta-analyses. MAIN RESULTS: We included 26 RCTs (total participants = 6070), nine of which had a low risk of bias. Approximately two-thirds of the included studies (N = 18) were not evaluated in the previous review. In general, there is high quality evidence that SMT has a small, statistically significant but not clinically relevant, short-term effect on pain relief (MD: -4.16, 95% CI -6.97 to -1.36) and functional status (SMD: -0.22, 95% CI -0.36 to -0.07) compared to other interventions. Sensitivity analyses confirmed the robustness of these findings. There is varying quality of evidence (ranging from low to high) that SMT has a statistically significant short-term effect on pain relief and functional status when added to another intervention. There is very low quality evidence that SMT is not statistically significantly more effective than inert interventions or sham SMT for short-term pain relief or functional status. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT. AUTHORS' CONCLUSIONS: High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority. Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT, and data related to recovery.

Cochrane Database Syst Rev. 2011 Feb 16;2:CD008112. Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Center, PO Box 7057, Room D518, Amsterdam, Netherlands, 1007 MB.

FULL TITLE: Physical therapy and chiropractic use among childhood cancer survivors with chronic disease: impact on health-related quality of life.

INTRODUCTION: The use of rehabilitation services to address musculoskeletal, neurological and cardiovascular late effects among childhood cancer survivors could improve physical function and health-related quality-of-life (HRQL). We describe physical therapy (PT) and chiropractic utilization among childhood cancer survivors and their association with HRQL. METHODS: The sample included 5+ year survivors from the Childhood Cancer Survivor Study (N?=?9,289). Questions addressing use of PT or chiropractic services and HRQL (Medical Outcomes Survey Short Form (SF-36)) were evaluated. Multivariable regression models compared PT and/or chiropractic utilization between survivors and siblings, and by diagnosis, treatment and demographic characteristics; associations between chronic disease, PT/chiropractic use, and HRQL were similarly evaluated. RESULTS: Survivors were not more likely to use PT (OR 1.0; 95% CI 0.8-1.2) or chiropractic (OR 0.8; 95% CI 0.7-1.0) services than siblings. More survivors reported using chiropractic (12.4%) than PT (9.2%) services. Older age and having health insurance were associated with utilization of either PT or chiropractic services. Grade 3-4 chronic conditions and a CNS tumor or sarcoma history were associated with PT but not with chiropractic service utilization. Survivors with musculoskeletal (OR 1.8; 95% CI 1.1-2.9), neurological (OR 3.4; 95% CI 1.6-6.9), or cardiovascular (OR 3.3; 95% CI 1.6-6.9) chronic conditions who used PT/chiropractic services were more likely to report poor physical health than survivors who did not use services. CONCLUSIONS: The reported prevalence of PT/chiropractic among survivors is consistent with that reported by siblings. Severity of late effects is associated with service use and with reporting poor physical health. IMPLICATIONS FOR CANCER SURVIVORS: Long-term childhood cancer survivors do not appear to utilize rehabilitation services to optimize physical function and support increased HRQL.

J Cancer Surviv. 2010 Oct 5. Montgomery M, Huang S, Cox CL, Leisenring WM, Oeffinger KC, Hudson MM, Ginsberg J, Armstrong GT, Robison LL, Ness KK. Capstone College of Nursing, University of Alabama, Tuscaloosa, AL, USA, mmontgomery1@bama.ua.edu.

FULL TITLE: Utilizing molecular details of the pain system to illustrate biochemical principles.

To capture student interest and show clinical relevance, molecular details from the pain system can be used as supplemental examples to basic biochemistry lectures. Lecture topics include glutamate, substance P, calmodulin-dependent protein kinase II, synaptic proteases, calcitonin gene-related peptide, and neuronal protein synthesis. These topics are utilized to illustrate basic biochemical issues and are linked to pain-related topics such as pain transmission, synaptic plasticity, long-term potentiation, and central sensitization. For analysis, a brief survey was administered to evaluate student attitudes toward a representative lecture segment. Survey results support the premise that utilizing the pain system is an effective tool to engage chiropractic students during basic biochemistry lectures.

J Chiropr Educ. 2010 Fall;24(2):187-93. Boal R, Gillette RG, Borman WH. University of Western States.

FULL TITLE: Trends and predictors of publicly subsidized chiropractic service use among adults age 50+.

OBJECTIVES: This article examines trends in and predictors of publicly subsidized chiropractic use from 1991 to 2000, a decade characterized by health care system reforms throughout North America. SAMPLE: The sample included adults age 50+ who visited a publicly subsidized chiropractor in the Canadian province of British Columbia during the study period. DESIGN: Administrative claims data for chiropractic service use were drawn from the Medical Services Plan (MSP) Master file in the British Columbia Linked Health Data resource. The MSP Master file contains claims reported for every provincially insured medical service and supplementary health benefit including chiropractic visits. RESULTS: Joinpoint regression analyses demonstrate that while annual rates of chiropractic users did not change over the decade, visit rates decreased during this period. Predictors of a greater number of chiropractic visits include increasing age, female gender, urban residence, low to moderate income, and use of chiropractic services earlier in the decade. CONCLUSIONS: The trend toward decreasing visit rates over the 1990s both conflicts with and is consistent with findings from other North American chiropractic studies using similar time periods. Results indicating that low and moderate income and advancing age predict more frequent chiropractic service are novel. However, given that lower income and older individuals were exempted from chiropractic service limits during this period, these results suggest support for the responsive nature of chiropractic use to financial barriers.

J Altern Complement Med. 2010 Sep;16(9):995-1001. Votova K, Penning MJ, Zheng C, Brackley ME. Department of Sociology and Centre on Aging, University of Victoria, Victoria, BC, Canada.

FULL TITLE: Could chiropractors screen for adverse drug events in the community? Survey of US chiropractors.

BACKGROUND: The "Put Prevention into Practice" campaign of the US Public Health Service (USPHS) was launched with the dissemination of the Clinician's Handbook of Preventive Services that recommended standards of clinical care for various prevention activities, including preventive clinical strategies to reduce the risk of adverse drug events. We explored whether nonprescribing clinicians such as chiropractors may contribute to advancing drug safety initiatives by identifying potential adverse drug events in their chiropractic patients, and by bringing suspected adverse drug events to the attention of the prescribing clinicians. METHODS: Mail survey of US chiropractors about their detection of potential adverse drug events in their chiropractic patients. RESULTS: Over half of responding chiropractors (62%) reported having identified a suspected adverse drug event occurring in one of their chiropractic patients. The severity of suspected drug-related events detected ranged from mild to severe. CONCLUSIONS: Chiropractors or other nonprescribing clinicians may be in a position to detect potential adverse drug events in the community. These detection and reporting mechanisms should be standardized and policies related to clinical case management of suspected adverse drug events occurring in their patients should be developed.

Chiropr Osteopat. 2010 Nov 17;18:30. Smith M, Bero L, Carber L. Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA, USA. monica.smith@palmer.edu.

FULL TITLE: Attitudes of non-practicing chiropractors: a pilot survey concerning factors related to attrition.

BACKGROUND: Research into attitudes about chiropractors who are no longer engaged in active clinical practice is non-existent. Yet non-practicing chiropractors (NPCs) represent a valid sub-group worthy of study. AIM: The purpose of this research was to assess attrition attitudes of NPCs about the chiropractic profession and develop a scale to assess such attitudes. METHODS: A 48 item survey was developed using the PsychData software. This survey included 35 Likert-style items assessing various aspects of the profession namely financial, educational, psychosocial and political. An internet discussion site where NPCs may be members was accessed for recruitment purposes. RESULTS: A total of 70 valid responses were received for analysis. A majority of respondents were male with 66% being in non-practice status for 3 to 5 years and less with 43% indicating that they had graduated since the year 2000. Most respondents were employed either in other healthcare professions and non-chiropractic education. A majority of NPCs believed that business ethics in chiropractic were questionable and that overhead expense and student loans were factors in practice success. A majority of NPCs were in associate practice at one time with many believing that associates were encouraged to prolong the care of patients and that associate salaries were not fair. Most NPCs surveyed believed that chiropractic was not a good career choice and would not recommend someone to become a chiropractor. From this survey, a 12 item scale was developed called the "chiropractor attrition attitude scale" for future research. Reliability analysis of this novel scale demonstrated a coefficient alpha of 0.90. CONCLUSION: The low response rate indicates that findings cannot be generalized to the NPC population. This study nonetheless demonstrates that NPCs attrition attitudes can be assessed. The lack of a central database of NPCs is a challenge to future research. Appropriate investigation of attrition within the chiropractic profession would be helpful in the analysis of attitudes regarding both chiropractic education and practice. Further research is needed in this area.

Chiropr Osteopat. 2010 Nov 4;18:29. Mirtz TA, Hebert JJ, Wyatt LH. Division of Health, Physical Education and Recreation, 414 East Clark Street--Dome 221B, University of South Dakota, Vermillion, South Dakota, 57069, USA. timothy.mirtz@usd.edu.

In recent years so-called Complementary and Alternative Medicine (CAM) practices have made significant political and professional advances particularly in the United Kingdom (UK): osteopathy and chiropractic were granted statutory self-regulation in the 1990s effectively giving them more professional autonomy and independence than health care professions supplementary to medicine; the practice of acupuncture is widespread within the National Health Service (NHS) for pain control; and homoeopathy is offered to patients by a few General Practitioners alongside conventional treatments. These developments have had a number of consequences: one is that both CAM and Conventional and Orthodox Medical (COM) professions have had to reappraise their professional identity. In manual therapy for example, questions have been asked about the differences between physiotherapy, osteopathy and chiropractic, and what the justification is for having separate professions. A wider question concerns the relationship between CAM and COM; are CAM distinct professions or should they, as has happened to a limited extent in the UK, be absorbed into the broader field of 'Medicine' or 'Health Care' as adjunctive therapies. CAM professions have also had to develop, implement and enforce codes of practice for practitioners and clarify the scope of practice within a profession. At the heart of these issues lies the need to identify and clarify professional values. A key claim of CAM professions is that their practice is distinct and the outcome of treatment at least as effective and in many cases more effective than with conventional therapies. In addition, what counts as effective outcome is often different from conventional medical understanding, involving more subtle humanitarian considerations, for example. Three values are identified as being commonly held across CAM professions. These are: offering 'natural' treatment; being patient rather than disease focussed; and being holistic. However, these may not be as distinctive of CAM as is claimed either because the meaning is unclear or because COM professions claim similar values. The paper argues that the values that inform 'good practice' and 'effective outcome' should be seen as distinct components of professional competence. This has implications for establishing professional identity and codes of practice.

Med Health Care Philos. 2010 Nov 23. Tyreman S. Dean of Osteopathic Education Development at the British School of Osteopathy (BSO), 275 Borough High Street, London, SE1 1JE, UK, S.Tyreman@bso.ac.uk.

FULL TITLE: Health promotion practices in two chiropractic teaching clinics: does a review of patient files reflect advice on health promotion?

PURPOSE: To retrospectively review patient files in two teaching clinics in the United States and to assess the documented attempts to deliver health promotion messages when a chart indicated a need for health promotion or a red-flag condition that could be helped with positive behavioral changes. METHODS: Approximately 100 patient files were randomly selected from each of two separate chiropractic teaching clinics, for patients seen after January 2007. Files were assessed for pertinent family history of diseases, personal medical history, and red-flag conditions of patients that would warrant intervention with health promotion. RESULTS: Health promotion advice on at least one occasion was noted in 108 (53.7%) patient charts. Only 7 of 98 overweight or obese patients and none of those with family history of obesity were advised on weight management. Among 23 hypertensive patients, only 5 were advised and 17 of the 97 patients with risk of cardiovascular disease were advised. CONCLUSION: Chiropractic teaching clinics should assess what they are doing to help Americans reach their health goals. There is an opportunity to shape future practitioners so they include primary prevention as a part of what they do if the profession cares to move in that direction. Future research should look at mechanisms of delivery for health promotion, including better tracking of patients who need it and how staff doctors are trained to deliver oversight to interns in the area of primary prevention.

J Chiropr Educ. 2010 Fall;24(2):159-64. Ndetan H, Evans MW, Lo K, Walters D, Ramcharan M, Brandon P, Evans C, Rupert R. Parker College of Chiropractic.

OBJECTIVE: The purpose of this systematic review is to discuss the evidence for manipulative methods of management of shoulder pain and chiropractic management techniques used within the literature. METHODS: A literature search of MEDLINE, CINAHL, MANTIS, the Cochrane Musculoskeletal Group trials register and the Cochrane Controlled Trials Register was conducted. Search terms included chiropractic or manipulative therapy and shoulder pain, impingement, rotator cuff, shoulder instability, shoulder joint, treatment or rehabilitation exercises. Publications were included if they contained shoulder pain or contained a specific clinical diagnosis of a shoulder pain syndrome in the title; a detailed description of the treatment intervention which was typical of the profession; treatment performed by a registered practitioner and outcome measures were included in the studies. Exclusion criteria included the diagnosis of adhesive capsultis or referred/pathological pain. The articles were reviewed and clinical trials ranked on the Physiotherapy Evidence Database scale. RESULTS: From a total of 913 retrieved publications, 22 case reports, 4 case series and 4 randomized, controlled trials met the inclusion and exclusion criteria for this review. CONCLUSIONS: The literature contains 2 articles of reasonably sound methodology. The evidence for chiropractic management of shoulder pain is limited to low level evidence in the form of case reports and case series and 1 small controlled trial. There is a need for more well-designed, trials investigating multi-modal chiropractic management for shoulder pain.

J Manipulative Physiol Ther. 2010 Nov-Dec;33(9):679-89. Pribicevic M, Pollard H, Bonello R, de Luca K. mariochiro@optusnet.com.au