FULL TITLE: Chiropractic treatment and the enhancement of sport performance: a narrative literature review.

A literature search and narrative review was carried out with the intent of determining the current level of knowledge regarding the chiropractic treatment of athletes for the purpose of sport performance enhancement. Of the fifty-nine relevant articles retrieved, only 7 articles of variable quality were obtained which specifically investigated/discussed chiropractic treatment and its involvement in sport performance enhancement. The role of the chiropractor in sport, unsubstantiated claims of performance enhancement, theories of how chiropractic treatment may influence sport performance, and the available evidence for the benefit of chiropractic treatment on sport performance are reviewed and discussed. Areas and directions for future studies are postulated. At this time there is insufficient evidence to convincingly support the notion that treatment provided by chiropractors can directly improve sport performance.

J Can Chiropr Assoc. 2010 Dec;54(4):210-21. Miners AL. Assistant Professor/Clinician, Division of Clinical Education, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario M2H 3J1; email: aminers@cmcc.ca.

OBJECTIVE: This case report describes the rare presentation of an osteochondroma arising from the anterior body of C4. This is the first known reported case of an osteochondroma arising from the anterior vertebral body of C4. CLINICAL FEATURES: A 24-year-old male sought consultation with his primary care physician for neck pain. The patient was then referred for cervical radiography and for chiropractic evaluation and treatment. An osseous lesion was noted arising from the C4 vertebra. Osteochondroma was suspected; however, chondrosarcoma could not be ruled out. After orthopedic consultation, osteochondroma was the confirmed diagnosis with the lesion likely incidental to the chief complaint. INTERVENTION AND OUTCOME: The patient underwent 12 chiropractic treatments for 8 weeks including thoracic and cervical high-velocity, low-amplitude spinal manipulation, interferential current, therapeutic ultrasound, stretching, and therapeutic exercise of the paraspinal musculature. Reevaluation revealed the patient experienced no pain with occupational duties, activities of daily living, and improved sleep quality. He was discharged with a home stretching and strengthening regimen targeting the thoracic and cervical paraspinal musculature. Follow-up at 6 months revealed no return of symptoms. CONCLUSION: We described the first case of an osteochondroma arising from the anterior aspect of the C4 vertebral body. The clinical evaluation, differential diagnosis, imaging workup, and treatment are addressed. This case also demonstrates that an asymptomatic osteochondroma of the cervical spine may be a relative, not an absolute, contraindication for high-velocity, low-amplitude spinal manipulation.

J Manipulative Physiol Ther. 2010 Nov-Dec;33(9):711-5. Reckelhoff KE, Green MN, Kettner NW. Department of Radiology, Logan College of Chiropractic, Chesterfield, Mo 63006-1065, USA.

FULL TITLE: Chiropractic utilization in BMX athletes at the UCI World Championships: a retrospective study.

OBJECTIVE: To examine paramedical (chiropractic, physiotherapy and massage therapy) utilization among high-level BMX athletes following sport-related injury at the 2007 UCI World Championships. METHODS: Retrospective analysis was conducted on a dataset from international male and female BMX athletes (n = 110) who sustained injury in training and competition at the 2007 BMX World Championships. RESULTS: Fifty percent of individuals aged 8-17 presented to a chiropractor versus 32% to physiotherapists and 18% to massage therapists. There was a significant difference in paramedical practitioner choice when comparing the sample across the different locations of injury. Specifically, the proportion of individuals presenting for treatment to chiropractors (84%) was much higher than to physiotherapists/massage therapists (16%) for spine or torso complaints. CONCLUSION: Utilization of chiropractors by BMX athletes may be higher than utilization of other paramedical professionals as suggested by this study. Chiropractors appear to be the paramedical practitioner of choice in regards to spine and torso related complaints.

J Can Chiropr Assoc. 2010 Dec;54(4):250-6. Konczak CR. Resident: College of Chiropractic Sports Sciences (Canada), Email: drclarkkonczak@gmail.com.

FULL TITLE: Interprofessional education through shadowing experiences in multi-disciplinary clinical settings.

ABSTRACT: The World Health Organization has recently added Interprofessional Education (IPE) to its global health agenda recognizing it as a necessary component of all health professionals' education. We suggest mandatory interprofessional shadowing experiences as a mechanism to be used by chiropractic institutions to address this agenda. IPE initiatives of other professions (pharmacy and medicine) are described along with chiropractic. This relative comparison of professions local to our jurisdiction in Ontario, Canada is made so that the chiropractic profession may take note that they are behind other health care providers in implementing IPE.Interprofessional shadowing experiences would likely take place in a multi-disciplinary clinical setting. We offer an example of how two separate professions within a Family Health Team (FHT) can work together in such a setting to enhance both student learning and patient care. For adult learners, using interprofessional shadowing experiences with learner-derived and active objectives across diverse health professional groups may help to improve the educational experience. Mandatory interprofessional shadowing experiences for chiropractors during their training can enhance future collaborative practice and provide success in reaching a goal common to each profession - improved patient care.

Chiropr Osteopat. 2010 Dec 2;18:31. Riva JJ, Lam JM, Stanford EC, Moore AE, Endicott AR, Krawchenko IE. Department of Family Medicine, McMaster University, McMaster Innovation Park, 175 Longwood Rd S, Hamilton, ON, Canada. rivaj@mcmaster.ca.

BACKGROUND: Ice hockey is an international sport. Injuries occur in a full body fashion, to a number of tissues, commonly through body contact. There is a lack of literature documenting the scope of sports chiropractic practice. Thus, it was the aim to document the type, scope and severity of conditions presenting to, and the treatment provided by, the New Zealand team chiropractor acting as a primary health provider for the duration of the 2007 World Ice Hockey Championships. METHODS: All conditions presenting were recorded. Diagnosis was recorded along with clinical parameters of injury: injury type, severity, mechanism and whether referral or advanced imaging was required. All treatment provided was continuously recorded, including information on the number of treatments required and the reason, duration, type and location of treatment. RESULTS: Players presented for diagnosis of injury 50 times. Muscle (34%), joint (24%) and tendon injuries (18%) were most common. Players presented with a new injury 76% of the time. Most injuries had been present for less than one week (84%), with 53% occurring through a contact mechanism. Injuries were common at training and match locations. Only two injuries required the player to stop playing or training, both of which were referred for advanced imaging. During the study, 134 treatment consultations were rendered to 45 player injuries. Eighty per-cent of injuries were managed with four or less treatments. Three quarters of treatment was provided at training locations with treatment duration predominantly being between 11-15 minutes (71%) and 16-20 minutes (27%). Most treatment delivered was passive in nature (71%) although combination active and passive care was provided (27%). Treatment typically involved joint (81%) and soft tissue based therapies (81%) and was delivered in a full body manner. CONCLUSIONS: This study documented the injury profile of ice hockey at an international level of competition. It documented the conditions presenting to a chiropractor for diagnosis and the treatment provided. Treatment was consistent with that recommended for chiropractic management of athletic injuries. This documentation of sports chiropractic scope of practice fills a void in the literature and assists in determining a role for sports chiropractors as primary health providers or in multidisciplinary sports management teams.

Chiropr Osteopat. 2010 Dec 3;18:32. Julian C, Hoskins W, Vitiello AL. Department of Surgery, Royal Melbourne Hospital, Grattan St, Parkville 3050, Victoria, Australia. waynehoskins@iinet.net.au.

FULL TITLE: The chiropractic care of children with "growing pains": A case series and systematic review of the literature.

OBJECTIVE: To describe the successful chiropractic care of two pediatric patients with complaints of "growing pain." CLINICAL FEATURES: A 2¾-yr-old female and 3½-yr-old male were presented by their mothers with complaints of "growing pains" that awakened both patients at night. The girl's problem began 3 months prior to care with awakening due to leg pain at 1-2 nights weekly in the first month and progressed to 5-6 nights per week in the month prior to presentation. The boy's growing pain was of "several months" duration that awakened the patient 2-3 nights per week. The parents of both children denied trauma or an "organic" cause to their children's pain complaints. Spinal segmental dysfunctions were noted in both patients at the lumbosacral spine. INTERVENTION AND OUTCOME: Spinal manipulative therapy (SMT) characterized as high velocity, low amplitude thrusts to sites of segmental dysfunction was rendered to both patients. Following a trial of care (i.e., 3 visits scheduled over a 3-week period and 4 visits over a period of 14 weeks), the patient's symptoms resolved and were released from care. CONCLUSION: This case series provides support on the effectiveness of chiropractic SMT for children with complaints of "growing pain." We support further research in the care of similar patients.

Complement Ther Clin Pract. 2011 Feb;17(1):28-32. Alcantara J, Davis J. International Chiropractic Pediatric Association, 327N Middletown Rd, Media, PA 19063, USA.

ABSTRACT: BACKGROUND: Longitudinal patterns of chiropractic use in the United States, particularly among Medicare beneficiaries, are not well documented. Using a nationally representative sample of older Medicare beneficiaries we describe the use of chiropractic over fifteen years, and classify chiropractic users by annual visit volume. We assess the characteristics that are associated with chiropractic use versus nonuse, as well as between different levels of use. METHODS: We analyzed data from two linked sources: the baseline (1993-1994) interview responses of 5,510 self-respondents in the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD), and their Medicare claims from 1993 to 2007. Binomial logistic regression was used to identify factors associated with chiropractic use versus nonuse, and conditional upon use, to identify factors associated with high volume relative to lower volume use. RESULTS: There were 806 users of chiropractic in the AHEAD sample yielding a full period prevalence for 1993-2007 of 14.6%. Average annual prevalence between 1993 and 2007 was 4.8% with a range from 4.1% to 5.4%. Approximately 42% of the users consumed chiropractic services only in a single calendar year while 38% used chiropractic in three or more calendar years. Chiropractic users were more likely to be women, white, overweight, have pain, have multiple comorbid conditions, better self-rated health, access to transportation, higher physician utilization levels, live in the Midwest, and live in an area with fewer physicians per capita. Among chiropractic users, 16% had at least one year in which they exceeded Medicare's "soft cap" of 12 visits per calendar year. These over-the-cap users were more likely to have arthritis and mobility limitations, but were less likely to have a high school education. Additionally, these over-the-cap individuals accounted for 58% of total chiropractic claim volume. High volume users saw chiropractors the most among all types of providers, even more than family practice and internal medicine combined. CONCLUSION: There is substantial heterogeneity in the patterns of use of chiropractic services among older adults. In spite of the variability of use patterns, however, there are not many characteristics that distinguish high volume users from lower volume users. While high volume users accounted for a significant portion of claims, the enforcement of a hard cap on annual visits by Medicare would not significantly decrease overall claim volume. Further research to understand the factors causing high volume chiropractic utilization among older Americans is warranted to discern between patterns of "need" and patterns of "health maintenance".

Chiropr Osteopat. 2010 Dec 21;18(1):34. Weigel P, Hockenberry JM, Bentler SE, Obrizan M, Kaskie B, Jones MP, Ohsfeldt RL, Rosenthal GE, Wallace RB, Wolinsky FD.

INTRODUCTION: The high prevalence of low back pain (LBP) in helicopter pilots has been well documented, although the reason behind it remains unclear. To date, little research exists comparing the Royal Air Force (RAF) to civilian pilots.

METHODS: A questionnaire inquiring into participant demographics, flying experience, and back pain was distributed to RAF pilots based at units around the United Kingdom and civilian pilots working for groups such as Air Ambulance and Her Majesty's Coastguards.

RESULTS: RAF pilots were significantly younger than civilian pilots (mean age 38.9 +/- 8.8 yr and 47.1 +/- 9.2 yr, respectively) and had been flying for a mode length of 6-10 yr compared with +26 yr in civilian pilots. Of civilian pilots, 40% had previously served as a pilot in the military. Neither RAF (83%) nor civilian (81%) pilots were significantly more likely to suffer from LBP and the nature of the pain experienced was similar. There were 33% of RAF and 55% of civilian pilots who used a back support.

DISCUSSION: The high prevalence of back pain reported by civilian and RAF pilots may be due to several factors. To investigate this further would require responses from a greater number of civilian pilots, particularly those who do not have previous military experience. In the meantime, further use of lumbar support may go some of the way to alleviating the problem.

Cunningham LK, Docherty S, Tyler AW. Aviat Space Environ Med. 2010 Aug;81(8):774-8. Anglo-European College of Chiropractic, Bournemouth, Dorset, UK. laura_catseyes@hotmail.com

Full Title Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic profession?

ABSTRACT: The understanding of the relationship between cervical manipulative therapy (CMT) and vertebral artery dissection and stroke (VADS) has evolved considerably over the years. In the beginning the relationship was seen as simple cause-effect, in which CMT was seen to cause VADS in certain susceptible individuals. This was perceived as extremely rare by chiropractic physicians, but as far more common by neurologists and others. Recent evidence has clarified the relationship considerably, and suggests that the relationship is not causal, but that patients with VADS often have initial symptoms which cause them to seek care from a chiropractic physician and have a stroke some time after, independent of the chiropractic visit.This new understanding has shifted the focus for the chiropractic physician from one of attempting to "screen" for "risk of complication to manipulation" to one of recognizing the patient who may be having VADS so that early diagnosis and intervention can be pursued. In addition, this new understanding presents the chiropractic profession with an opportunity to change the conversation about CMT and VADS by taking a proactive, public health approach to this uncommon but potentially devastating disorder.

Murphy DR. Chiropr Osteopat. 2010 Aug 3;18:22. Rhode Island Spine Center, 600 Pawtucket Avenue, Pawtucket, RI 02860, USA. rispine@aol.com.

Full Title A descriptive study of a manual therapy intervention within a randomised controlled trial for hamstring and lower limb injury prevention.

BACKGROUND: There is little literature describing the use of manual therapy performed on athletes. It was our purpose to document the usage of a sports chiropractic manual therapy intervention within a RCT by identifying the type, amount, frequency, location and reason for treatment provided. This information is useful for the uptake of the intervention into clinical settings and to allow clinicians to better understand a role that sports chiropractors offer.

METHODS: All treatment rendered to 29 semi-elite Australian Rules footballers in the sports chiropractic intervention group of an 8 month RCT investigating hamstring and lower-limb injury prevention was recorded. Treatment was pragmatically and individually determined and could consist of high-velocity, low-amplitude (HVLA) manipulation, mobilization and/or supporting soft tissue therapies. Descriptive statistics recorded the treatment rendered for symptomatic or asymptomatic benefit, delivered to joint or soft tissue structures and categorized into body regions. For the joint therapy, it was recorded whether treatment consisted of HVLA manipulation, HVLA manipulation and mobilization, or mobilization only. Breakdown of the HVLA technique was performed.

RESULTS: A total of 487 treatments were provided (mean 16.8 consultations/player) with 64% of treatment for asymptomatic benefit (73% joint therapies, 57% soft tissue therapies). Treatment was delivered to approximately 4 soft tissue and 4 joint regions each consultation. The most common asymptomatic regions treated with joint therapies were thoracic (22%), knee (20%), hip (19%), sacroiliac joint (13%) and lumbar (11%). For soft tissue therapies it was gluteal (22%), hip flexor (14%), knee (12%) and lumbar (11%). The most common symptomatic regions treated with joint therapies were lumbar (25%), thoracic (15%) and hip (14%). For soft tissue therapies it was gluteal (22%), lumbar (15%) and posterior thigh (8%). Of the joint therapy, 56% was HVLA manipulation only, 36% high-HVLA and mobilization and 9% mobilization only. Of the HVLA manipulation, 63% was manually performed and 37% mechanically assisted.

CONCLUSIONS: The intervention applied was multimodal and multi-regional. Most treatment was for asymptomatic benefit, particularly for joint based therapies, which consisted largely of HVLA manipulation techniques. Most treatment was applied to non-local hamstring structures, in particular the knee, hip, pelvis and spine.

Hoskins W, Pollard H. Chiropr Osteopat. 2010 Aug 9;18:23. Department of Chiropractic, Faculty of Science, Macquarie University, NSW 2109, Australia. waynehoskins@iinet.net.au.

Full Title Standardization of adverse event terminology and reporting in orthopaedic physical therapy: application to the cervical spine.

SYNOPSIS: Orthopaedic physical therapy is considered safe, based on a lack of reported harms. Most of the research until now has focused on benefits. Consideration of benefits and harm involves informed consent, clinical decision making, and cost-benefit analyses. Benefits and harms are treatment and dosage specific. There is currently an insufficient number of dosage trials in orthopaedic physical therapy to identify optimal dosage for common interventions, including exercise and manual therapy. Published cases of severe adverse events following chiropractic manipulation illustrate the need for physical therapy to have high-quality data documenting the safety of orthopaedic physical therapy, including cervical manipulation. A recent systematic review identified poor reporting standards of harms within clinical research in this area. Lack of standardization of terminology has contributed to this problem. Pharmacovigilence provides a framework for terms that orthopaedic physical therapy can adapt and thereafter adopt into clinical practice and research. Adverse events are unexpected events that occur following an intervention without evidence of causality. Where temporality of an event is highly suggestive of causality, the term "adverse reaction" may be more appropriate. Future studies in orthopaedic physical therapy should adopt the CONSORT statement extension on the reporting of harms, published in 2004, to ensure better reporting. Consistent reporting of harms in both research and clinical practice requires professional consensus on terminology pertaining to harms, as well as defining what constitutes an adverse event or an adverse reaction. Widespread consultation and consensus should support optimal definitions and processes and facilitate their implementation into practice. This paper is focused on theoretical considerations and evidence in terms of harm reporting within physical therapy using cervical manual therapy as an example.

Carlesso LC, Macdermid JC, Santaguida LP. J Orthop Sports Phys Ther. 2010 Aug;40(8):455-463

Social justice in public health involves the process and product of a community acting to fairly distribute advantages and burdens to improve the health of its population and to reasonably take care of the disadvantaged. Although publications are available about chiropractic public health history, programs, and policy, the potential role of chiropractic in social justice has received little attention. This article discusses Beauchamp's 4 principles of social justice and suggests actions that the chiropractic profession may consider to participate in the practice of social justice in the field of public health.

Green BN, Johnson C. J Manipulative Physiol Ther. 2010 Jul-Aug;33(6):407-11.

Full Title Chiropractic and medical use of health promotion in the management of arthritis: analysis of the 2006 National Health Interview Survey.

OBJECTIVE: The importance of integrating healthy behavior counseling into routine health care is universal but may depend on the type of medical care provider as well as the conditions presented by patients. The purpose of this study was to evaluate whether health promotion (HP) recommendations for known risk factors of arthritis differed between general medical doctors and doctors of chiropractic (DCs) in a nationally representative US population with arthritis.

METHODS: Multiple logistic regression models were used for analyses of data from the Sample Adult Core component of the 2006 National Health Interview Survey (n = 6374 diagnosed with arthritis). Analyses were performed separately for recommendation of weight loss and increase in exercise by health profession subtype (chiropractor and medical doctor).

RESULTS: Comparing the reported HP efforts between DCs and medical doctors (MDs), while adjusting for the effect of physical therapist and body mass index, we observed no significant differences (weight loss: adjusted odds ratio [95% confidence interval] = 0.76 [0.50-1.18]; increased exercise: adjusted odds ratio [95% confidence interval] = 0.87 [0.59-1.29]).

CONCLUSION: Health promotion efforts to patients with arthritis do not differ significantly between MDs and DCs, as reported by National Health Interview Survey 2006. This investigation makes it difficult to suggest that DCs or MDs are doing all they can do to manage arthritis through suggested modification of lifestyle in their patients. More research specific to what is and can be recommended to those with arthritis should be conducted particularly because it relates to health-promoting behaviors. Given the recent implementation of required clinical competencies in HP into chiropractic college curriculums, future studies regarding translation of HP messages into public practice should be more informative.

Ndetan H, Evans MW Jr, Felini M, Bae S, Rupert R, Singh KP. J Manipulative Physiol Ther. 2010 Jul-Aug;33(6):419-24. Parker College of Chiropractic, Research Institute, Dallas, TX 75229, USA. hndetan@parkercc.edu

OBJECTIVE: As the chiropractic profession delineates its role in the emerging health care marketplace, it will become increasingly important that the scope of appropriate chiropractic care is clearly defined relative to overall patient case management. Therefore, the Council on Chiropractic Guidelines and Practice Parameters engaged in a multidisciplinary consensus process addressing the terminology related to "levels of care."

METHODS: A formal consensus process was conducted in early 2009, following the RAND/UCLA method for rating appropriateness. Panelists were selected to provide a broad representation of the profession in terms of geographic location and organizational affiliation, and an attempt was made to include members of other professions, including representation from third-party payors. The Delphi process was conducted electronically in January-February 2009. A nominal group panel was conducted through an online meeting service using an experienced group facilitator. Twenty-seven panelists were selected; all but 3 were doctors of chiropractic. Six of the panelists had experience as consultants with third-party payors.

RESULTS: Fifteen seed statements were circulated to the Delphi panel. Consensus was reached on all statements after 3 Delphi rounds, with further refinements made through the nominal group panel.

CONCLUSIONS: By using a recognized formal consensus process, the Council on Chiropractic Guidelines and Practice Parameters has endeavored to establish a set of terms that are acceptable to the chiropractic community in order to facilitate their use within the broader health care community.

Dehen MD, Whalen WM, Farabaugh RJ, Hawk C. J Manipulative Physiol Ther. 2010 Jul-Aug;33(6):458-63. Council on Chiropractic Guidelines and Practice Parameters, Lexington, SC, USA

OBJECTIVE: At this time, the scientific evidence base supporting the effectiveness of chiropractic care for musculoskeletal conditions has not yet definitively addressed its appropriateness for older adults. Expert consensus, as a form of evidence, must be considered when higher levels of evidence are lacking. The purpose of this project was to develop a document with evidence-based recommendations on the best practices for chiropractic care of older adults.

METHODS: A set of 50 seed statements was developed, based on the clinical experience of the multidisciplinary steering committee and the results of an extensive literature review. A formal Delphi process was conducted, following the rigorous RAND-UCLA (University of California, Los Angeles) methodology. The statements were circulated electronically to the Delphi panel until consensus was reached. Consensus was defined as agreement by at least 80% of the panelists. There were 28 panelists from 17 US states and Canada, including 24 doctors of chiropractic, 1 physical therapist, 1 nurse, 1 psychologist, and 1 acupuncturist.

RESULTS: The Delphi process was conducted in January-February 2010; all 28 panelists completed the process. Consensus was reached on all statements in 2 rounds. The resulting best practice document defined the parameters of an appropriate approach to chiropractic care for older adults, and is presented in this article.

CONCLUSION: A multidisciplinary panel of experienced chiropractors was able to reach a high level (80%) of consensus on evidence-informed best practices for the chiropractic approach to evaluation, management, and manual treatment for older adult patients.

Hawk C, Schneider M, Dougherty P, Gleberzon BJ, Killinger LZ. J Manipulative Physiol Ther. 2010 Jul-Aug;33(6):464-73. Cleveland Chiropractic College, Overland Park, KS 66210, USA. cheryl.hawk@cleveland.edu

Full Title Chiropractic management of the kinetic chain for the treatment of hip osteoarthritis: an Australian case series.

OBJECTIVE: Osteoarthritis is the most common musculoskeletal disorder, estimated to affect 3 million Australians. Previous studies support structured exercise programs and manipulation for hip osteoarthritis; however, no trials have examined treatment of the lower limb kinetic chain. The purpose of this case series was to report hip range of motion and pain scale outcomes in 4 patients diagnosed with hip osteoarthritis who were treated with chiropractic management of the lower limb kinetic chain.

METHODS: Four subjects (mean age 59.5; SD +/- 6.7) were provided with 9 sessions of chiropractic treatment. This included long-axis traction pulls and pre/post adjustment stretching of the symptomatic hip, with additional manipulation and mobilization of the lumbar spine, sacroiliac, knee, and ankle joints. Outcome measures included range of motion as measured and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

RESULTS: All 4 subjects had improvements in WOMAC scores, with a mean group reduction of 382.5 (SD +/- 115.8) and overall improvement of 68.1%. As a group, there were improvements in internal rotation (51.7%, mean 7.3 degrees; SD +/- 6.2 degrees), adduction (26.7%, mean 5.3 degrees; SD +/- 5.0 degrees), abduction (21.1%, mean 6.8 degrees; SD +/- 5.4 degrees), flexion (15.3%, mean 15 degrees; SD +/- 4.8 degrees) and external rotation (8.5%, mean 8.5 degrees; SD +/- 6.0 degrees).

CONCLUSIONS: Four patients diagnosed with hip osteoarthritis had decreases in WOMAC scores and increases in hip range of motion after chiropractic management. Further research in the form of large scale randomized controlled trials is needed to investigate the effectiveness and clinical significance of chiropractic management for hip osteoarthritis.

de Luca K, Pollard H, Brantingham J, Globe G, Cassa T. J Manipulative Physiol Ther. 2010 Jul-Aug;33(6):474-9. Private Practice, 32 Elizabeth St, Parramatta NSW 2150, Australia. katie_hardy@hotmail.com

This study will define a normal range of values for the cross-sectional area (CSA) of the C5-C8 ventral rami in normal subjects and will assess the interexaminer reliability of the CSA measurements. We also describe the normal sonoanatomy of the C5-C8 ventral rami. Thirty-three normal subjects (20 female) were scanned bilaterally. The mean CSA and reference ranges for the C5, C6, C7 and C8 ventral rami were 7.1 +/- 4.1 mm(2), 10.6 +/- 4.3 mm(2), 12.1 +/- 4.1 mm(2) and 10.7 +/- 4.8 mm(2), respectively. The intraclass correlation coefficient (ICC) demonstrated good reliability with a coefficient of 0.76 overall, with individual level coefficients at C5, C6, C7 and C8 of 0.69, 0.71, 0.76 and 0.72, respectively. This is the first study to obtain normative CSA measurements of the C5-C8 ventral rami.

Haun DW, Cho JC, Kettner NW. Ultrasound Med Biol. 2010 Sep;36(9):1422-30. Department of Radiology, Logan College of Chiropractic, Chesterfield, MO, USA. daniel.haun@logan.edu

Full Title Chiropractic in North America: toward a strategic plan for professional renewal--outcomes from the 2006 Chiropractic Strategic Planning Conference.

OBJECTIVE: This report describes the process, participation, and recommendations of a set of consensus conferences on strategy for professional growth that emphasized elements of public trust and alignment between the chiropractic profession and its stakeholders.

METHODS: In February and August 2006, an invitational group of leaders in the chiropractic profession convened an ad hoc Chiropractic Strategic Planning Conference. Public notice was given and support solicited through the Foundation of Chiropractic Education and Research. A series of international and interdisciplinary speakers gave presentations on the shifting of external social dynamics and medical culture, illuminating opportunities for the profession to extend its privilege and service. A systematic round-robin discussion was followed by group breakout sessions to develop recommendations on priorities for the profession to respond to challenges and opportunities. Recommendations were reviewed by the group as a whole and voted to consensus requiring more than 70% agreement.

RESULTS: Participants determined a series of recommendations within 5 key domains for improving health professions practice: education, research, regulation, workplace, and leadership.

CONCLUSION: The action steps proposed by the Strategic Planning Committee are first steps to provide better service to the public while making use of the inherent strengths of the profession.

Triano JJ, Goertz C, Weeks J, Murphy DR, Kranz KC, McClelland GC, Kopansky-Giles D, Morgan W, Nelson CF. J Manipulative Physiol Ther. 2010 Jun;33(5):395-405. Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario, Canada. jtriano@cmcc.ca

OBJECTIVE: To determine whether neck manipulation is more effective for neck pain than mobilization.

DESIGN: Randomized controlled trial with blind assessment of outcome.

SETTING: Primary care physiotherapy, chiropractic, and osteopathy clinics in Sydney, Australia.

PARTICIPANTS: Patients (N=182) with nonspecific neck pain less than 3 months in duration and deemed suitable for treatment with manipulation by the treating practitioner.

INTERVENTIONS: Participants were randomly assigned to receive treatment with neck manipulation (n=91) or mobilization (n=91). Patients in both groups received 4 treatments over 2 weeks.

MAIN OUTCOME MEASURE: The number of days taken to recover from the episode of neck pain.

RESULTS: The median number of days to recovery of pain was 47 in the manipulation group and 43 in the mobilization group. Participants treated with neck manipulation did not experience more rapid recovery than those treated with neck mobilization (hazard ratio=.98; 95% confidence interval, .66-1.46).

CONCLUSIONS: Neck manipulation is not appreciably more effective than mobilization. The use of neck manipulation therefore cannot be justified on the basis of superior effectiveness.

Leaver AM, Maher CG, Herbert RD, Latimer J, McAuley JH, Jull G, Refshauge KM. Arch Phys Med Rehabil. 2010 Sep;91(9):1313-8. University of Sydney, Sydney, Australia. leaver@sydney.edu.au

OBJECTIVE: Muscle thickness is a widely used parameter for quantifying muscle function in ultrasound imaging. However, current measurement techniques generally rely on manual digitization, which is subjective, time consuming, and prone to error. The primary purposes of this study were to develop an automated muscle boundary tracking algorithm to overcome these limitations and to report its intraexaminer reliability on pectoralis major muscle.

METHODS: Real-time B-mode ultrasound images of the pectoralis major muscles were acquired by an integrated data acquisition system. A transducer placement protocol was developed to facilitate better repositioning of an ultrasound transducer. Intraexaminer reliability of the tracking algorithm for static measurements was studied using intraclass correlation coefficient based on the thickness data from 11 healthy subjects recruited from a chiropractic college measured at 3 independent sessions. Standard error of measurement and minimal detectable change were calculated. Feasibility of using the tracking algorithm for dynamic measurements was also evaluated.

RESULTS: All calculated intraclass correlation coefficients were larger than 0.96, indicating excellent reliability of the sonomyographic measurements. Minimal detectable changes were 9.7%, 6.7%, and 6.8% of the muscle thickness at the lateral, central, and medial aspects, respectively. For a 400-frame image stack with 3 pairs of 40 x 40 pixels tracking windows, the tracking took about 80 seconds to complete.

CONCLUSIONS: The tracking algorithm offers precise and reliable measurements of muscle thickness changes in clinical settings with potential to quantify the effects of a wide variety of chiropractic techniques on muscle function.

Koo TK, Wong C, Zheng Y. J Manipulative Physiol Ther. 2010 Jun;33(5):386-94. Foot Levelers Biomechanics Research Laboratory, New York Chiropractic College, Seneca Falls, NY 13148, USA. tkoo@nycc.edu

Although not typical, there appears to be a growing trend of chiropractors working within collaborative care settings. We use a case report to highlight features of patient care and education related to chiropractic practice within a collaborative care model. This paper hopes to offer some insight into how a chiropractor might fit into a collaborative setting and what training might help them to function effectively. The case report used is an example where a chiropractor provided a secondary diagnosis and complementary care not previously considered by the allied team resulting in symptom control and return to work by the patient. By the nature of a chiropractor's ability to provide a primary or secondary musculoskeletal diagnosis, they have the capacity to offer an additive approach to patient care within collaborative care models. However, chiropractors wishing to work in these environments, such as a family health team, would benefit from further education.

Riva JJ, Muller GD, Hornich AA, Mior SA, Gupta A, Burnie SJ. J Can Chiropr Assoc. 2010 Sep;54(3):147-54. Department of Family Medicine, McMaster University, Hamilton, Ontario

Full Title Physical examination and self-reported pain outcomes from a randomized trial on chronic cervicogenic headache.

OBJECTIVE: Objective clinical measures for use as surrogate markers of cervicogenic headache (CGH) pain have not been established. In this analysis, we investigate relationships between objective physical examination (PE) measures with self-reported CGH outcomes.

METHODS: This is an exploratory analysis of data generated by attention control PE from an open-label randomized clinical trial. Of 80 subjects, 40 were randomized to 8 treatments (spinal manipulative therapy or light massage control) and 8 PE over 8 weeks. The remaining subjects received no PE. Physical examination included motion palpation of the cervical and upper thoracic regions, active cervical range of motion (ROM) and associated pain, and algometric pain threshold evaluated over articular pillars. Self-reported outcomes included CGH and neck pain and disability, number of CGH headaches, and related disability days. Associations between PE and self-reported outcomes were evaluated using generalized linear models, adjusting for sociodemographic differences and study group.

RESULTS: At baseline, number of CGH and disability days were strongly associated with cervical active ROM (P < .001 to .037). Neck pain and disability were strongly associated with ROM-elicited pain (P < .001 to .035) but not later in the study. After the final treatment, pain thresholds were strongly associated with week 12 neck pain and disability and CGH disability and disability days (P < or = .001 to .048).

CONCLUSIONS: Cervical ROM was most associated with the baseline headache experience. However, 4 weeks after treatment, algometric pain thresholds were most associated. No one PE measure remained associated with the self-reported headache outcomes over time.

Vavrek D, Haas M, Peterson D. J Manipulative Physiol Ther. 2010 Jun;33(5):338-48. Center for Outcomes Studies, Western States Chiropractic College, 2900 132nd Avenue, Portland, OR 97230-3009, USA. dvavrek@wschiro.edu

OBJECTIVE: To familiarize the chiropractic clinician with the clinical presentation, radiographic features, and conservative versus surgical treatment options for managing femoroacetabular impingement (FAI) syndrome. BACKGROUND: FAI syndrome is a relatively new clinical entity to be described in orthopedics, and has been strongly linked with pain and early osteoarthritis of the hip in young adults. Hip joint radiographs in these patients often appear normal at first-particularly if the clinician is unfamiliar with FAI. The role of conservative therapy in managing this disorder is questionable. Surgical treatment ultimately addresses any acetabular labral or articular cartilage damage, as well as the underlying osseous abnormalities associated with FAI. The most commonly used approach is open surgical hip dislocation; however, more recent surgical procedures also involve arthroscopy. CONCLUSION: In FAI syndrome-a condition unknown to many clinicians (including medical)-chiropractors can play an important role in its diagnosis and referral for appropriate management.

J Can Chiropr Assoc. 2010 Sep;54(3):164-76. Emary P. Private practice: Parkway Back Clinic, 201C Preston Parkway, Cambridge, Ontario, N3H 5E8.

The following case describes a 68 year-old woman with a 7(1/2) year history of worsening head and neck pain diagnosed as trigeminal neuralgia following surgical resection of a brain tumor. After years of unsuccessful management with medication and physical therapies, a therapeutic trial of chiropractic was carried out. Chiropractic care included ultrasound, manual therapies (manipulation and mobilization), soft tissue therapies, and home stretching exercises.

After an initial treatment period followed by 18 months of supportive care the patient reported satisfactory improvement. It became evident that there were at least three sources of her symptoms: mechanical and/or degenerative neck pain, temporomandibular joint syndrome, and trigeminal neuralgia. While never completely pain-free, the patient continued to report that her pains reduced to minimal at times. At the most recent follow-up, the pain had not returned to pre-treatment intractable levels. This case study demonstrates the importance of diagnosing and treating multiple sources of pain and the positive role chiropractic care can have in the management of patients with these clinical conditions. The potential for convergence of sensory input from the upper three cervical segments and the trigeminal nerve via the trigeminocervical nucleus is discussed.

J Can Chiropr Assoc. 2010 Sep;54(3):177-86. Rodine RJ, Aker P. Graduate Student, Graduate Education and Research Programs Canadian Memorial Chiropractic College, Toronto, Ontario Private Practice, Smiths Falls, Ontario.

Full Title Relative effectiveness and adverse effects of cervical manipulation, mobilisation and the activator instrument in patients with sub-acute non-specific neck pain: results from a stopped randomised trial.

BACKGROUND: Neck pain of a mechanical nature is a common complaint seen by practitioners of manual medicine, who use a multitude of methods to treat the condition. It is not known, however, if any of these methods are superior in treatment effectiveness. This trial was stopped due to poor recruitment. The purposes of this report are (1) to describe the trial protocol, (2) to report on the data obtained from subjects who completed the study, (3) to discuss the problems we encountered in conducting this study.

METHODS: A pragmatic randomised clinical trial was undertaken. Patients who met eligibility criteria were randomised into three groups. One group was treated using specific segmental high velocity low amplitude manipulation (diversified), another by specific segmental mobilisation, and a third group by the Activator instrument. All three groups were also treated for any myofascial distortions and given appropriate exercises and advice. Participants were treated six times over a three-week period or until they reported being pain free. The primary outcome measure for the study was Patient Global Impression of Change (PGIC); secondary outcome measures included the Short-Form Health Survey (SF-36v2), the neck Bournemouth Questionnaire, and the numerical rating scale for pain intensity. Participants also kept a diary of any pain medication taken and noted any perceived adverse effects of treatment. Outcomes were measured at four points: end of treatment, and 3, 6, and 12 months thereafter.

RESULTS: Between January 2007 and March 2008, 123 patients were assessed for eligibility, of these 47 were considered eligible, of which 16 were allocated to manipulation, 16 to the Activator instrument and 15 to the mobilisation group. Comparison between the groups on the PGIC adjusted for baseline covariants did not show a significant difference for any of the endpoints. Within group analyses for change from baseline to the 12-month follow up for secondary outcomes were significant for all groups on the Bournemouth Questionnaire and for pain, while the mobilisation group had a significant improvement on the PCS and MCS subscales of the SF-36v2. Finally, there were no moderate, severe, or long-lasting adverse effects reported by any participant in any group.

CONCLUSIONS: Although the small sample size must be taken into consideration, it appears that all three methods of treating mechanical neck pain had a long-term benefit for subacute neck pain, without moderate or serious adverse events associated with any of the treatment methods. There were difficulties in recruiting subjects to this trial. This pragmatic trial should be repeated with a larger sample size.

Gemmell H, Miller P. Chiropr Osteopat. 2010 Jul 9;18:20. Principal Lecturer Chiropractic Sciences, Department of Academic Affairs Anglo-European College of Chiropractic Bournemouth, Dorset, UK. hgemmell@aecc.ac.uk.

Full Title: Effects of chiropractic care on pain and function in patients with hip osteoarthritis waiting for arthroplasty: a clinical pilot trial.

OBJECTIVE: The purpose of this study was to explore the short-term effects of chiropractic care on pain and function in patients with hip osteoarthritis.

METHODS: A convenience sample of 14 patients waiting to undergo unilateral hip arthroplasty at a large university hospital received either chiropractic care (n = 7) or no additional treatment (n = 7) during a 3-week period. The main outcome was the change in self-rated hip pain on a 100 mm Visual Analogue Scale (VAS, 0-100). Secondary outcomes were the change in the five Hip disability and Osteoarthritis Outcome Subscales (HOOS, 0-100), which include pain, other symptoms, function in daily living, function in sport and recreation and hip related quality of life. Nonparametric statistics were used to explore outcome changes from baseline to follow-up after three weeks within and between the groups.

RESULTS: Patients receiving chiropractic care, on average 4.4 (SD +/-1.0) treatments over 3 weeks, showed a clinically and statistically significant improvement in self-rated hip pain, VAS - 26.0 (SD +/-28.4), P = .043. The chiropractic patients also had clinically important, but not statistically significant, improvement scores in HOOS function in daily living 18.6 (SD +/-18.5), pain 15.4 (SD +/-17.2), and hip-related quality of life 12.4 (SD +/-19.6). The waiting list controls had no statistically significant improvements in any outcome measured, but a clinically relevant improvement in HOOS Pain 12.2 (SD +/-18.2), P = .051 was observed. There were no statistically significant differences between the groups due to the small sample size. Approximately 25 patients per arm would be required to adequately power a full scale randomized controlled trial with VAS for hip pain as the main outcome measure.

CONCLUSIONS: Chiropractic care may provide a short-term benefit in decreasing hip pain for patients with hip osteoarthritis waiting for hip arthroplasty. The pilot findings warrant larger scale randomized controlled trials with longer-term follow-ups.

Thorman P, Dixner A, Sundberg T. J Manipulative Physiol Ther. 2010 Jul-Aug;33(6):438-44. Scandinavian College of Chiropractic, Solna, Sweden. thorman@kiropraktik.edu

BACKGROUND AND OBJECTIVE: Low level light (or laser) therapy (LLLT) is a rapidly growing modality used in physical therapy, chiropractic, sports medicine and increasingly in mainstream medicine. LLLT is used to increase wound healing and tissue regeneration, to relieve pain and inflammation, to prevent tissue death, to mitigate degeneration in many neurological indications. While some agreement has emerged on the best wavelengths of light and a range of acceptable dosages to be used (irradiance and fluence), there is no agreement on whether continuous wave or pulsed light is best and on what factors govern the pulse parameters to be chosen.

STUDY DESIGN/MATERIALS AND METHODS: The published peer-reviewed literature was reviewed between 1970 and 2010.

RESULTS: The basic molecular and cellular mechanisms of LLLT are discussed. The type of pulsed light sources available and the parameters that govern their pulse structure are outlined. Studies that have compared continuous wave and pulsed light in both animals and patients are reviewed. Frequencies used in other pulsed modalities used in physical therapy and biomedicine are compared to those used in LLLT.

CONCLUSION: There is some evidence that pulsed light does have effects that are different from those of continuous wave light. However further work is needed to define these effects for different disease conditions and pulse structures.

Hashmi JT, Huang YY, Sharma SK, Kurup DB, De Taboada L, Carroll JD, Hamblin MR. Lasers Surg Med. 2010 Aug;42(6):450-66. Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts, USA.

Abstract 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 1. Votova K, Penning MJ, Zheng C, Brackley ME. Department of Sociology and Centre on Aging, University of Victoria , Victoria, BC, Canada .

OBJECTIVE: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death. DESIGN: This study is a systematic review of case reports. METHODS: Literature searches in four electronic databases with no restrictions of time or language. MAIN OUTCOME MEASURE: Death. RESULTS: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery. CONCLUSION: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit.

Int J Clin Pract. 2010 Jul;64(8):1162-5. Ernst E. Complementary Medicine, Peninsula Medical School, University of Exeter, Exeter, UK. Edzard.Ernst@pms.ac.uk

ABSTRACT: BACKGROUND: Chiropractic (Greek: done by hand) is a health care profession concerned with the diagnosis, treatment and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health. There is an emphasis on manual techniques, including joint adjustment and/or manipulation, with a particular focus on joint subluxation (World Health Organization 2005) or mechanical lesion and restoring function. The chiropractor's role in wellness care, prevention and treatment of injury or illness is based on education in anatomy and physiology, nutrition, exercise and healthy lifestyle counseling as well as referral to other health practitioners. Depending on education, geographic location, scope of practice, as well as consumer preference, chiropractors may assume the role of primary care for families who are pursuing a more natural and holistic approach to health care for their families. OBJECTIVE: To present a perspective on current management of the paediatric patient by members of the chiropractic profession and to make recommendations as to how the profession can safely and effectively manage the paediatric patient. DISCUSSION: The chiropractic profession holds the responsibility of ethical and safe practice and requires the cultivation and mastery of both an academic foundation and clinical expertise that distinguishes chiropractic from other disciplines.Research into the effectiveness of chiropractic care for paediatric patients has lagged behind that of adult care, but this is being addressed through educational programs where research is now being incorporated into academic tracks to attain advanced chiropractic degrees. CONCLUSION: Studies in the United States show that over the last several decades, chiropractors are the most common complementary and alternative medicine providers visited by children and adolescents. Chiropractors continue to seek integration with other healthcare providers to provide the most appropriate care for their paediatric patients.In the interest of what is best for the paediatric population in the future, collaborative efforts for research into the effectiveness and safety of chiropractic care as an alternative healthcare approach for children should be negotiated and are welcomed.

Chiropr Osteopat. 2010 Jun 2;18:16. Vallone SA, Miller J, Larsdotter A, Barham-Floreani J. Private Practice, Connecticut, USA. svallonedc@aol.com.

Full Title: The evidence base for chiropractic treatment of musculoskeletal conditions in children and adolescents: The emperor's new suit?

ABSTRACT: Five to ten percent of chiropractic patients are children and adolescents. Most of these consult because of spinal pain, or other musculoskeletal complaints. These musculoskeletal disorders in early life not only affect the quality of children's lives, but also seem to have an impact on adult musculoskeletal health. Thus, this is an important part of the chiropractors' scope of practice, and the objective of this review is to assess the evidence base for manual treatment of musculoskeletal disorders in children and adolescents.Randomized, quasi-randomized and non-randomized clinical studies were included if they investigated the effect of manual therapy on musculoskeletal disorders in children and/or adolescents. The MEDLINE and MANTIS databases were searched, and studies published in English, Danish, Swedish or Norwegian were included.Only three studies were identified that in some way attempted to look at the effectiveness of manual therapy for children or adolescents with spinal problems, and none of these was a randomized controlled clinical trial. As for the rest of the musculoskeletal system, only one study of temporomandibular disorder was identified.With this review, we have detected a paradox within the chiropractic profession: Although the major reason for pediatric patients to attend a chiropractor is spinal pain, no adequate studies have been performed in this area. It is time for the chiropractic profession to take responsibility and systematically investigate the efficiency of joint manipulation of problems relating to the developing musculoskeletal system.

Chiropr Osteopat. 2010 Jun 2;18:15. Hestbaek L, Stochkendahl MJ. Nordic Institute of Chiropractic and Clinical Biomechanics, Forskerparken 10, DK-5230 Odense M, Denmark. l.hestbaek@nikkb.dk.11

OBJECTIVES: To describe the extent to which chiropractors utilize standardized outcome and various clinical measures to systematically document patients' baseline health status and responses to treatment, with particular consideration being given towards quantifiable outcome instruments. STUDY DESIGN: Cross-sectional mailed survey. PARTICIPANTS: Registered chiropractors in the province of Saskatchewan. METHODS: A survey was mailed to all registrants of the Chiropractors' Association of Saskatchewan. Respondents graded their frequency of using various standardized pencil-and-paper instruments and functional chiropractic, orthopaedic and neurological tests in the contexts of both the initial intake assessment ('always,' 'commonly,' 'occasionally,' or 'never') and the course of subsequent treatment (after 'each visit,' after '9-12 visits,' 'annually,' when patient 'not responding,' on 'dismissal/discharge,' 'never' or for some 'other' reason). Data were tabulated for all item and response category combinations as frequencies and percentages using the total sample size as the denominator. RESULTS: Of 164 registered chiropractors, 62 (38%) returned a completed questionnaire. A pain diagram was the most commonly used subjective outcome measure and was administered routinely (either "always" or "commonly") by 75% of respondents, at either the initial consultation or during a subsequent visit. Numerical rating and visual analogue scales were less popular (routinely used by 59% and 42% respectively). The majority of respondents (80%) seldom ("occasionally" or "never") used spine pain-specific disability indices such as the Low Back Revised Oswestry, Neck Disability Index or the Roland-Morris Questionnaire. As well, they did not use standardized psychosocial instruments such as the Beck Depression Index, or general health assessment measures such as the SF-36 or SF-12 questionnaire. Neurological testing was the most commonly used objective outcome measure. Most respondents (84% to 95%) indicated that they continually monitored neurological status through dermatomal, manual muscle strength and deep tendon reflex testing. Ranges of motion were routinely measured by 95% of respondents, usually visually (96%) rather than goniometrically or by some other specialized device (7%). CONCLUSIONS: Our findings suggest that the majority of chiropractors do not use psychosocial questionnaires or condition-specific disability indices to document baseline or subsequent changes in health status. Chiropractors are more likely to rely on medical history taking and pain drawings during an initial intake assessment, as well as neurological and visually estimated range of motion testing during both initial intake and subsequent treatment visits.

BACKGROUND: Some chiropractors and their associations claim that chiropractic is effective for conditions that lack sound supporting evidence or scientific rationale. This study therefore sought to determine the frequency of World Wide Web claims of chiropractors and their associations to treat, asthma, headache/migraine, infant colic, colic, ear infection/earache/otitis media, neck pain, whiplash (not supported by sound evidence), and lower back pain (supported by some evidence). METHODS: A review of 200 chiropractor websites and 9 chiropractic associations' World Wide Web claims in Australia, Canada, New Zealand, the United Kingdom, and the United States was conducted between 1 October 2008 and 26 November 2008. The outcome measure was claims (either direct or indirect) regarding the eight reviewed conditions, made in the context of chiropractic treatment. RESULTS: We found evidence that 190 (95%) chiropractor websites made unsubstantiated claims regarding at least one of the conditions. When colic and infant colic data were collapsed into one heading, there was evidence that 76 (38%) chiropractor websites made unsubstantiated claims about all the conditions not supported by sound evidence. Fifty-six (28%) websites and 4 of the 9 (44%) associations made claims about lower back pain, whereas 179 (90%) websites and all 9 associations made unsubstantiated claims about headache/migraine. Unsubstantiated claims were made about asthma, ear infection/earache/otitis media, neck pain, CONCLUSIONS: The majority of chiropractors and their associations in the English-speaking world seem to make therapeutic claims that are not supported by sound evidence, whilst only 28% of chiropractor websites promote lower back pain, which is supported by some evidence. We suggest the ubiquity of the unsubstantiated claims constitutes an ethical and public health issue.

BACKGROUND: Chiropractors commonly use a combination of interventions to treat people with low-back pain (LBP). OBJECTIVES: To determine the effects of combined chiropractic interventions (that is, a combination of therapies, other than spinal manipulation alone) on pain, disability, back-related function, overall improvement, and patient satisfaction in adults with LBP, aged 18 and older. SEARCH STRATEGY: We searched: The Cochrane Back Review Group Trials Register (May 2009), CENTRAL (The Cochrane Library 2009, Issue 2), and MEDLINE (from January 1966), EMBASE (from January 1980), CINAHL (from January 1982), MANTIS (from Inception) and the Index to Chiropractic Literature (from Inception) to May 2009. We also screened references of identified articles and contacted chiropractic researchers. SELECTION CRITERIA: All randomised trials comparing the use of combined chiropractic interventions (rather than spinal manipulation alone) with no treatment or other therapies. DATA COLLECTION AND ANALYSIS: At least two review authors selected studies, assessed the risk of bias, and extracted the data using standardised forms. Both descriptive synthesis and meta-analyses were performed. MAIN RESULTS: We included 12 studies involving 2887 participants with LBP. Three studies had low risk of bias. Included studies evaluated a range of chiropractic procedures in a variety of sub-populations of people with LBP.No trials were located of combined chiropractic interventions compared to no treatment. For acute and subacute LBP, chiropractic interventions improved short- and medium-term pain (SMD -0.25 (95% CI -0.46 to -0.04) and MD -0.89 (95%CI -1.60 to -0.18)) compared to other treatments, but there was no significant difference in long-term pain (MD -0.46 (95% CI -1.18 to 0.26)). Short-term improvement in disability was greater in the chiropractic group compared to other therapies (SMD -0.36 (95% CI -0.70 to -0.02)). However, the effect was small and all studies contributing to these results had high risk of bias. There was no difference in medium- and long-term disability. No difference was demonstrated for combined chiropractic interventions for chronic LBP and for studies that had a mixed population of LBP. AUTHORS' CONCLUSIONS: Combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions. Future research is very likely to change the estimate of effect and our confidence in the results.

Cochrane Database Syst Rev. 2010 Apr 14;4:CD005427. Walker BF, French SD, Grant W, Green S. School of Chiropractic and Sports Science, Murdoch University, Faculty of Health Sciences, Murdoch, Australia, 6150.

ABSTRACT: BACKGROUND: When conservative therapies for low back pain (LBP) are not effective, elective surgery may be proposed to these patients. Over the last 20 years, a new technology, disc replacement, has become increasingly popular because it is believed to maintain or restore the integrity of spinal movement and minimize the side-effects compared to fusion. Although disc replacement may relieve a patient from pain and related disability, soreness and stiffness of the lumbopelvic region seem to be common aftermaths of the surgery. This prospective case series was undertaken to identify and describe potential adverse events of lumbar spinal manipulation, a common therapy for low back pain, in a group of patients with symptoms after disc prostheses. CASES PRESENTATION: Eight patients who underwent lumbar spine total disc replacement were referred by an orthopaedic surgeon for chiropractic treatments. These patients had 1 or 2 total lumbar disc replacements and were considered stable according to the surgical protocol but presented persistent, post-surgical, non-specific LBP or pelvic pain. They were treated with lumbar spine side posture manipulations only and received 8 to 10 chiropractic treatments based on the clinical evolution and the chiropractor's judgment. Outcome measures included benign, self-limiting, and serious adverse events after low back spinal manipulative therapy. The Oswestry Disability Index, a pain scale and the fear avoidance belief questionnaire were administered to respectively assess disability, pain and fear avoidance belief about work and physical activity. This prospective case series comprised 8 patients who all had at least 1 total disc replacement at the L4/L5 or L5/S1 level and described persistent post-surgical LBP interfering with their daily activities. Commonly-reported side-effects of a benign nature included increased pain and/or stiffness of short duration in nearly half of the chiropractic treatment period. No major or irreversible complication was noted. CONCLUSIONS: During the short treatment period, no major complication was encountered by the patients. Moreover, the benign side-effects reported after lumbar spine manipulation were similar in nature and duration to those frequently experienced by the general population.

Chiropr Osteopat. 2010 Apr 21;18:7. O'Shaughnessy J, Drolet M, Roy JF, Descarreaux M. Département de chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada. martin.descarreaux@uqtr.ca.

Full Title: Management of Operation Iraqi Freedom and Operation Enduring Freedom veterans in a Veterans Health Administration chiropractic clinic: a case series

Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans commonly seek care for musculoskeletal complaints in Veterans Health Administration (VHA) facilities. Chiropractic services for musculoskeletal conditions have recently been introduced to VHA. No reports have been published on chiropractic care for OIF/OEF veterans. This study was designed to describe elements of the processes and outcomes of care for OIF/OEF veterans in a VHA chiropractic clinic. A retrospective review of consecutive cases consulted to one VHA chiropractic clinic was conducted. Thirty-one cases were identified. Consultations originated in primary care and specialty clinics that commonly manage musculoskeletal conditions. Military traumatic injury and posttraumatic stress disorder were common. Adverse effects of treatment were mild and transitory. In 19 cases (61%), a pain decrease above the threshold for minimally important change was reported. This article is the first description of health services delivered to OIF/OEF veterans in a VHA chiropractic clinic. Chiropractic management was safe in these cases, and results support the hypothesis that such management may be effective in certain OIF/OIF veterans. A better understanding of the characteristics of these particular patients and the processes of care received in VHA chiropractic clinics is needed to improve the clinical care of these veterans.

J Rehabil Res Dev. 2010;47(1):1-6. Lisi AJ. Department of Veterans Affairs Connecticut Healthcare System, West Haven, CT 06516, USA. Anthony.lisi@va.gov

Full Title: The chiropractic care of children with attention-deficit/hyperactivity disorder: a retrospective case series

BACKGROUND: Characterized with hyperactivity, inattention and impulsivity, attention-deficit/hyperactivity disorder (ADHD) has a prevalence in children, ranging from 2.6% to 11.4%. The medical approach is multimodal, with combination therapies of behavioral modification and pharmacotherapy. With growing concerns regarding the safety of both short-term and long-term use of psychotropic medications, the need for investigating alternative approaches to the care of children is warranted. OBJECTIVE: The aim of this review was to describe the chiropractic care of children with medically diagnosed ADHD. DESIGN: Retrospective case series were reviewed. SETTING: The review was conducted in a private practice of chiropractic with a solo practitioner. PATIENTS/PARTICIPANTS: Pediatric patients (aged < or =18 years) attending chiropractic care for a minimum period of five months following a medical diagnosis of ADHD were included in this review. INTERVENTION: The intervention was chiropractic spinal manipulative therapy augmented by nutritional supplements. RESULTS: Our review found four patient files satisfying the inclusion criteria. All patients were males, ranging in age from nine to 13 years (mean age, 10 years), with three patients having a history of medication use and two patients having prescribed medication at the start of chiropractic care. Using a 15-item parent/teacher ADHD questionnaire, the patients' responses to chiropractic care were monitored. Using the Friedman test to compare observations repeated on the same subjects, our findings found improvement in ADHD symptoms (ie, hyperactivity, impulsivity, and inattentiveness, as well as behavioral, social, or emotional difficulties) and provide supporting evidence on the effectiveness of chiropractic in the treatment of children with ADHD. CONCLUSION: A retrospective case series of ADHD patients under chiropractic care is described. This provides supporting evidence on the benefits of chiropractic spinal manipulative therapy. We encourage further research in this area. Copyright (c) 2010 Elsevier Inc. All rights reserved. BACKGROUND: Characterized with hyperactivity, inattention and impulsivity, attention-deficit/hyperactivity disorder (ADHD) has a prevalence in children, ranging from 2.6% to 11.4%. The medical approach is multimodal, with combination therapies of behavioral modification and pharmacotherapy. With growing concerns regarding the safety of both short-term and long-term use of psychotropic medications, the need for investigating alternative approaches to the care of children is warranted. OBJECTIVE: The aim of this review was to describe the chiropractic care of children with medically diagnosed ADHD. DESIGN: Retrospective case series were reviewed. SETTING: The review was conducted in a private practice of chiropractic with a solo practitioner. PATIENTS/PARTICIPANTS: Pediatric patients (aged < or =18 years) attending chiropractic care for a minimum period of five months following a medical diagnosis of ADHD were included in this review. INTERVENTION: The intervention was chiropractic spinal manipulative therapy augmented by nutritional supplements. RESULTS: Our review found four patient files satisfying the inclusion criteria. All patients were males, ranging in age from nine to 13 years (mean age, 10 years), with three patients having a history of medication use and two patients having prescribed medication at the start of chiropractic care. Using a 15-item parent/teacher ADHD questionnaire, the patients' responses to chiropractic care were monitored. Using the Friedman test to compare observations repeated on the same subjects, our findings found improvement in ADHD symptoms (ie, hyperactivity, impulsivity, and inattentiveness, as well as behavioral, social, or emotional difficulties) and provide supporting evidence on the effectiveness of chiropractic in the treatment of children with ADHD. CONCLUSION: A retrospective case series of ADHD patients under chiropractic care is described. This provides supporting evidence on the benefits of chiropractic spinal manipulative therapy. We encourage further research in this area. Copyright (c) 2010 Elsevier Inc. All rights reserved.

Explore (NY). 2010 May-Jun;6(3):173-82. Alcantara J, Davis J. International Chiropractic Pediatric Association, 327 N. Middletown Road, Media, PA 19063, USA. dr_jalcantara@yahoo.com

Full Title: The Nordic maintenance care program: case management of chiropractic patients with low back pain - defining the patients suitable for various management strategies.

ABSTRACT: BACKGROUND: Maintenance care is a well known concept among chiropractors, although there is little knowledge about its exact definition, its indications and usefulness. As an initial step in a research program on this phenomenon, it was necessary to identify chiropractors' rationale for their use of maintenance care. Previous studies have identified chiropractors' choices of case management strategies in response to different case scenarios. However, the rationale for these management strategies is not known. In other words, when presented with both the case, and different management strategies, there was consensus on how to match these, but if only the management strategies were provided, would chiropractors be able to define the cases to fit these strategies? The objective with this study was to investigate if there is a common pattern in Finnish chiropractors' case management of patients with low back pain (LBP), with special emphasis on long-term treatment. METHODS: Information was obtained in a structured workshop. Fifteen chiropractors, members of the Finnish Chiropractors' Union, and present at the general assembly, participated throughout the entire workshop session. These were divided into five teams each consisting of 3 people. A basic case of a patient with low back pain was presented together with six different management strategies undertaken after one month of treatment. Each team was then asked to describe one (or several) suitable case(s) for each of the six strategies, based on the aspects of 1) symptoms/findings, 2) the low back pain history in the past year, and 3) other observations. After each session the people in the groups were changed. Responses were collected as key words on flip-over boards. These responses were grouped and counted. RESULTS: There appeared to be consensus among the participants in relation to the rationale for at least four of the management strategies and partial consensus on the rationale for the remaining two. In relation to maintenance care, the patient's past history was important but also the doctor-patient relationship. CONCLUSION: These results confirm that there is a pattern among Nordic chiropractors in how they manage patients with LBP. More information is needed to define the "cut-point" for the indication of prolonged care.

Chiropr Osteopat. 2009 Jul 12;17:7. Malmqvist S, Leboeuf-Yde C. Department of Health Studies, Faculty of Social Sciences, University of Stavanger, Stavanger, Norway. stefan.malmqvist@uis.no.

Full Title: A retrospective analysis of self-reported symptoms from 761 consecutive new patients presenting to a Neuro Emotional Technique chiropractic clinic.

PURPOSE: To describe the profile of patients presenting to a private chiropractic clinic specialising in Neuro Emotional Technique (NET) and to identify trends in the presentation of symptoms from these patients. METHODS: 761 consecutive new patients presented to a large, multi-doctor chiropractic clinic in which practitioners all adopt a similar philosophical paradigm and practice NET From January 2005 to December 2005, self-referred patients completed a new patient questionnaire, in which they self-reported one primary complaint for why they were visiting the practitioner. Predetermined patient information was entered manually into a database and basic descriptive statistics extracted. RESULTS: 67.3% of participants were female and 32.6% of the participants were between the ages of 31 and 40. 54.8% of patients presented with a primary musculoskeletal complaint and 36.0% a non-musculoskeletal complaint. Of the musculoskeletal complaints, 40.8% of patients presented with back pain, 20.9% with neck pain and 11.5% with shoulder pain. The most common form of non-musculoskeletal complaint was immune and recurrent infections (13.9%), stress and anxiety (12.8%) and depression (10.9%). 41.4% of participants reported a first time complaint, however, of the patients who had had the presenting complaint before 60.7% reported as having the complaint for greater than 1 year. Musculoskeletal and non-musculoskeletal participants had similar pain profiles. CONCLUSION: This retrospective analysis is the first comprehensive description of the scope of NET patients and their presenting complaints. The patient profile of this NET clinic has a higher degree of non-musculoskeletal patients than that usually reported in non-NET chiropractic offices, and other forms of chiropractic previously described in the literature. Further cross sectional research is required to determine if this particular clinic is indicative of all NET practices and whether the presenting symptoms, especially the non-musculoskeletal, are resolved with NET.

Complement Ther Clin Pract. 2009 Aug;15(3):166-71. Epub 2009 Mar 4. Bablis P, Pollard H, Bonello R. Macquarie Injury Management Group, Department of Health and Chiropractic, Macquarie University, Sydney, NSW 2109, Australia.

Full Title: Chiropractic management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran: a case report.

OBJECTIVE: This case report describes the evaluation and conservative management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran within a Veterans Affairs Medical Center chiropractic clinic. CLINICAL FEATURES: The 43-year-old patient had a 20-year history of mechanical back pain secondary to an injury sustained during active military duty. He had intermittent radiation of numbness and tingling involving the right lower extremity distal to the knee. Radiographs of the lumbosacral region demonstrated a grade I spondylolisthesis of L3 in relation to L4 and a grade II spondylolisthesis of L4 in relation to L5 secondary to bilateral pars interarticularis defects. There was marked narrowing of the L4-5 disk space with associated subchondral sclerosis. INTERVENTION AND OUTCOME: A course of conservative management consisting of 10 treatments including lumbar flexion/distraction and activity modification was provided over an 8-week period. Despite the long-standing nature of the complaint and underlying multiple-level lumbar spondylolysis with spondylolisthesis, there was a 25% reduction in low back pain severity on the numeric rating scale and a 22% reduction in perceived disability related to low back pain on the Revised Oswestry Disability Questionnaire. CONCLUSIONS: Conservative management is considered to be the standard of care for spondylolysis and should be explored in its various forms for symptomatic low back pain patients who present without neurologic deficits and with spondylolisthesis below grade III. The response to treatment for the veteran patient in this case suggests that lumbar flexion/distraction may serve as a safe and effective component of conservative management of mechanical low back pain for some patients with spondylolysis and spondylolisthesis.

J Chiropr Med. 2009 Sep;8(3):125-30. Dunn AS, Baylis S, Ryan D. Staff Chiropractor, VA of Western New York, Buffalo, NY 14215; Adjunct Assistant Professor, New York Chiropractic College, Buffalo, NY 14215.