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1.  Use of Chiropractic Spinal Manipulation in Older Adults is Strongly Correlated with Supply 
Spine  2012;37(20):1771-1777.
Study Design
Retrospective cross-sectional analysis of administrative data.
Objective
To examine the relationship between regional chiropractic supply and both use and utilization intensity of chiropractic services among Medicare beneficiaries.
Summary of Background Data
Numerous studies have documented trends and patterns in the utilization of chiropractic services in the United States, but little is known about geographic variation in the relationship between chiropractic supply and utilization.
Methods
We analyzed Medicare claims data for services provided by chiropractic physicians in 2008. We aggregated the data to the hospital referral region level and employed small area analysis techniques to generate descriptive statistics. We mapped geographic variations in chiropractic supply, use and utilization intensity (treatments per user) and quantified the variation by coefficient of variation and extremal ratio. We employed Spearman’s rank correlation coefficient to correlate use with supply. We employed a logistic regression model for chiropractic use and a multiple linear regression model for chiropractic utilization intensity.
Results
The average regional supply of chiropractic physicians was 21.5 per 100,000 adult capita. The average percentage of beneficiaries who used chiropractic was approximately 7.6 (SD 3.9). The average utilization intensity was 10.6 (SD 1.8). Regional chiropractic supply varied more than 14 fold, and chiropractic use varied more than 17 fold. Chiropractic supply and use were positively correlated (Spearman’s rho 0.68; p<.001). A low back or cervical spine problem was strongly associated with chiropractic use (OR 21.6 and 14.3, respectively). Increased chiropractic supply was associated with increased chiropractic use (OR 1.04), but not with increased chiropractic utilization intensity.
Conclusion
Both the supply of chiropractors and the utilization of chiropractic by older US adults varied widely by region. Increased chiropractic supply was associated with increased chiropractic use, but not with increased chiropractic utilization intensity. Utilization of chiropractic care is likely sensitive to both supply and patient preference.
doi:10.1097/BRS.0b013e31825762b7
PMCID: PMC3414681  PMID: 22487711
Chiropractic; Spinal Manipulation; Medicare
2.  Australian chiropractic sports medicine: half way there or living on a prayer? 
Sports chiropractic within Australia has a chequered historical background of unorthodox individualistic displays of egocentric treatment approaches that emphasise specific technique preference and individual prowess rather than standardised evidence based management. This situation has changed in recent years with the acceptance of many within sports chiropractic to operate under an evidence informed banner and to embrace a research culture. Despite recent developments within the sports chiropractic movement, the profession is still plagued by a minority of practitioners continuing to espouse certain marginal and outlandish technique systems that beleaguer the mainstream core of sports chiropractic as a cohesive and homogeneous group. Modern chiropractic management is frequently multimodal in nature and incorporates components of passive and active care. Such management typically incorporates spinal and peripheral manipulation, mobilisation, soft tissue techniques, rehabilitation and therapeutic exercises. Externally, sports chiropractic has faced hurdles too, with a lack of recognition and acceptance by organized and orthodox sports medical groups. Whilst some arguments against the inclusion of chiropractic may be legitimate due to its historical baggage, much of the argument appears to be anti-competitive, insecure and driven by a closed-shop mentality.sequently, chiropractic as a profession still remains a pariah to the organised sports medicine world. Add to this an uncertain continuing education system, a lack of protection for the title 'sports chiropractor', a lack of a recognized specialist status and a lack of support from traditional chiropractic, the challenges for the growth and acceptance of the sports chiropractor are considerable. This article outlines the historical and current challenges, both internal and external, faced by sports chiropractic within Australia and proposes positive changes that will assist in recognition and inclusion of sports chiropractic in both chiropractic and multi-disciplinary sports medicine alike.
doi:10.1186/1746-1340-15-14
PMCID: PMC2042981  PMID: 17880724
3.  Canadian Chiropractic Resources Databank (CCRD): a profile of Canadian chiropractors 
Objective:
To establish a data bank which will serve as a comprehensive inventory of data and document practical information on Canada’s licensed chiropractors and to produce a summary report of this information.
Design:
A national census mail survey.
Setting:
Canada. The survey administration timeline during which information was collected was the period of August 1995 to July 1996.
Participants:
All chiropractors licensed to practice chiropractic in Canada, excluding chiropractors practising in the Yukon and Northwest Territories. A total of 4,246 questionnaires were mailed, of which 121 were ineligible. There were 2,905 valid responses (response rate 70.4%).
Main outcome measures:
Background information (demographics), professional activity, educational, training and affiliations, practice characteristics, finances and income.
Results:
Background information: 82.8% of all respondents were male. On January 1, 1997, the mean age of all respondents was 41.9 years. 88.6% of all respondents were born in Canada and 74.8% graduated from the Canadian Memorial Chiropractic College. The mean number of years in practice by all respondents was 13.7 years. 17.5% of all respondents had more than one practice location. Professional activity: A total of 96.2% of the respondents were active chiropractors (a chiropractor in active practice was one whose level of activity was self-described as full-time, part-time or semi-retired and who was in practice at least 10 hours per week). 85% reported being in full-time practice, 8.7% in part-time practice and 2.5% reported being semi-retired. Full-time chiropractors reported working on average 41.3 hours per week, 49.1 weeks per year and receiving 158.6 total patient visits per week. Active chiropractors reported spending on average 75.1% of their work time on direct patient care. 39.6% of active chiropractors reported that their practice had decreased over the last three years (in terms of number of patient visits). Education, training and affiliations: 42.1% of all respondents had obtained a baccalaureate degree prior to attending chiropractic college. 3.7% of all respondents held a CCA recognized specialty certification. 15.5% of all respondents held a certification or were registered to practice naturopathy, homeopathy, acupuncture, massage therapy or other related discipline. Practice Characteristics: 69.1% of active chiropractors reported being in sole proprietorship, and 85.3% reported working in a private chiropractic office. On an aggregate basis, active chiropractors reported using diversified techniques on 77.3% of their patients. Chiropractors in active practice reported treating on average 86.3% of their patients for primary conditions of a neuromusculoskeletal nature. Active chiropractors reported that their current patients were their greatest source of patient referrals, accounting for on average 58.5% of all their patients. Finances and Income: In provinces with public insurance for chiropractic services (Ontario, Manitoba, Saskatchewan, Alberta, British Columbia) active chiropractors reported deriving on average 39.7% of their practice income from the provincial plan, 44.7% directly from the patient, 9.6% from a third party payer and 6.1% from workers’ compensation boards. 56.2% of active chiropractors reported a gross annual practice income of less than $150,000 whereas 14.1% reported earning $250,000 or more. 49.5% of active chiropractors reported a net annual practice income of less than $60,000 whereas 21.4% reported earning $100,000 or more. In aggregate, active chiropractors reported that 37.3% of their patients exhausted their public insurance coverage for chiropractic care (in provinces where public insurance is available), and of those patients 35.3% discontinued care.
Conclusions:
This report is a first attempt to document a statistical portrait of Canada’s chiropractors. The report has been prepared by using data derived from the Canadian Chiropractic Resource Databank (CCRD), a data bank (housed at the CCA) which now holds a comprehensive inventory of data and practical information on Canada’s licensed chiropractors. The data is now available for use internally by the CCA or by external audiences who may need statistical information from time to time. It is hoped that the survey which led to the establishment of the CCRD will be repeated on a periodic basis, with requisite modifications, to update the data bank and to determine longitudinal trends regarding the chiropractic profession in Canada. The CCRD can be an important source of information for decision making and planning.
PMCID: PMC2485158
chiropractor; survey statistics; data bank
4.  Straight chiropractic philosophy as a barrier to Medicare compliance: a discussion of 5 incongruent issues 
Objective
The purpose of this commentary is to discuss potential 5 factors within straight chiropractic philosophy and practice that may prevent Medicare compliance.
Discussion
The national Medicare Benefit Policy Manual and the Florida Local Coverage Determination were reviewed to identify documentation and conceptual issues regarding chiropractic practice. Five Medicare positions were contrasted with tenets of straight chiropractic philosophy. Based on Medicare’s documentation requirements, Medicare defines subluxation and chiropractic practice from the perspective of treating spinal pain and related functional disability. In contrast, traditional straight chiropractic philosophy is not based on the treatment of spinal pain and disability or other symptomatic presentations. In this context, 5 potential areas of conflict are discussed.
Conclusion
The Medicare version of chiropractic practice is not consistent with traditional straight chiropractic philosophy, which may play a role in preventing Medicare compliance. The chiropractic profession may need to consider the fashion in which “philosophy” as it relates to technique and practice is presented to students and doctors to facilitate compliance with the documentation requirements of Medicare.
doi:10.1016/j.echu.2013.09.001
PMCID: PMC4111077  PMID: 25067928
Medicare; Chiropractic; Back pain; Manipulation; Spinal; Philosophy
5.  Gimme that old time religion: the influence of the healthcare belief system of chiropractic’s early leaders on the development of x-ray imaging in the profession 
Background
Chiropractic technique systems have been historically documented to advocate overutilization of radiography. Various rationales for this have been explored in the literature. However, little consideration has been given to the possibility that the healthcare belief system of prominent early chiropractors may have influenced the use of the diagnostic modality through the years. The original rationale was the visualisation of chiropractic subluxations, defined as bones slightly out of place, pressing on nerves, and ultimately causing disease. This paradigm of radiography has survived in parts of the chiropractic profession, despite lacking evidence of clinical validity. The purpose of this paper is to compare the characteristics of the chiropractic technique systems that have utilised radiography for subluxation detection with the characteristics of religion, and to discover potential historical links that may have facilitated the development of those characteristics.
Discussion
Twenty-three currently or previously existing technique systems requiring radiography for subluxation analysis were found using a search of the internet, books and consultation with experts. Evidence of religiosity from the early founders’ writings was compared with textbooks, published papers, and websites of subsequently developed systems. Six criteria denoting religious thinking were developed using definitions from various sources. They are: supernatural concepts, claims of supremacy, rules and rituals, sacred artefacts, sacred stories, and special language. All of these were found to a greater or lesser degree in the publicly available documents of all the subluxation-based chiropractic x-ray systems.
Summary
The founders and early pioneers of chiropractic did not benefit from the current understanding of science and research, and therefore substituted deductive and inductive reasoning to arrive at conclusions about health and disease in the human body. Some of this thinking and rationalisation demonstrably followed a religion-like pattern, including BJ Palmer’s use of radiography. Although access to scientific methods and research education became much advanced and more accessible during the past few decades, the publicly available documents of technique systems that used radiography for chiropractic subluxation detection examined in this paper employed a historically derived paradigm for radiography that displayed characteristics in common with religion.
Electronic supplementary material
The online version of this article (doi:10.1186/s12998-014-0036-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s12998-014-0036-5
PMCID: PMC4228104  PMID: 25392731
Chiropractic; X-ray; Subluxation; History; Evidence-based practice; Religion
6.  The ABC's of health promotion and disease prevention in chiropractic practice 
Journal of Chiropractic Medicine  2003;2(3):107-110.
Abstract
Objective
To describe the importance of health promotion techniques and use of active disease prevention techniques as part of chiropractic practice through a selective review of literature using a mnemonic device.
Discussion
There is evidence that doctors of chiropractic use some health promotion techniques in practice such as instruction on exercise, dietary advice, smoking cessation recommendations and the encouraging of preventive chiropractic visits. Healthy People goals for the nation suggest that providers encourage preventive services, work toward better access to care and stress disease prevention. However, information on how this can be routinely done in chiropractic practice is fragmented. This article suggests ways to implement health promotion into the everyday management of the chiropractic patient.
Conclusion
Health promotion and disease prevention can be easily performed in chiropractic practice. The nature of the chiropractic supportive or maintenance visit gives doctors a unique platform on which they can launch full-scale health promotion efforts on their patients.
doi:10.1016/S0899-3467(07)60054-8
PMCID: PMC2646969  PMID: 19674604
Health Promotion; Disease Prevention; Chiropractic; Wellness
7.  Chiropractic treatment approaches for spinal musculoskeletal conditions: a cross-sectional survey 
Background
There are several chiropractic spinal manipulative technique systems. However, there is limited research differentiating the efficacy of these techniques. Additionally, chiropractors may also use ancillary procedures in the treatment of musculoskeletal pain, a variable that also needs to be considered when measuring the efficacy of chiropractic therapy. No data is currently available regarding the frequency of usage of chiropractic technique systems or ancillary procedures for the treatment of specific musculoskeletal conditions. Knowing which technique systems and ancillary procedures are used most frequently may help to direct future research. The aim of this research was to provide insight into which treatment approaches are used most frequently by Australian chiropractors to treat spinal musculoskeletal conditions.
Methods
Cross-sectional survey design. The survey was sent online to the members of the two main Australian chiropractic associations between 30th June 2013 and 7th August 2013. The participants were asked to provide information on treatment choices for specific spinal musculoskeletal conditions.
Results
280 respondents. Diversified manipulative technique was the first choice of treatment for most of the included conditions. Diversified was used significantly less in 4 conditions; cervical disc syndrome with radiculopathy and cervical central stenosis were more likely to be treated with Activator; flexion distraction technique was used almost as much as Diversified in the treatment of lumbar disc syndrome with radiculopathy and lumbar central stenosis. More experienced Australian chiropractors use more Activator and soft tissue therapy and less Diversified technique compared to their less experienced peers. The majority of responding chiropractors used ancillary procedures such as soft tissue techniques and exercise prescription in the treatment of spinal musculoskeletal conditions.
Conclusion
This survey provides information on commonly used treatment choices to the chiropractic profession. Treatment choices changed based on the region of disorder and whether neurological symptoms were present rather than with specific diagnoses. Diversified technique was the most commonly used spinal manipulative therapy, however, ancillary procedures such as soft tissue techniques and exercise prescription were also commonly utilised. This information may help direct future studies into the efficacy of chiropractic treatment for spinal musculoskeletal disorders.
Electronic supplementary material
The online version of this article (doi:10.1186/s12998-014-0033-8) contains supplementary material, which is available to authorized users.
doi:10.1186/s12998-014-0033-8
PMCID: PMC4193988  PMID: 25309722
Chiropractic; Technique systems; Manipulation; Manual therapy; Musculoskeletal; Treatment; Prevalence
8.  Chiropractic approach to the management of children 
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.
doi:10.1186/1746-1340-18-16
PMCID: PMC2887887  PMID: 20525200
9.  The prevalence of the term subluxation in North American English-Language Doctor of chiropractic programs 
Background
The subluxation construct has been a divisive term in the chiropractic profession. There is a paucity of evidence to document the subluxation. Some authors have questioned the propriety of continuing to use the term.
Aim
The purpose of this study is to examine current North American English language chiropractic college academic catalogs and determine the prevalence of the term subluxation in the respective chiropractic program curricula.
Methods
Sixteen current English-language North American chiropractic college academic catalogs were studied. The term subluxation was searched for in each of the catalogs. Categories were developed for the usage of the term. These included "total times mentioned", "subluxation mentioned in a course description", "subluxation mentioned in a course title", "subluxation mentioned in a technique course description", and "subluxation mentioned in a philosophy course description." The prevalence of the "subluxation mentioned in a course description" was compared to the total programmatic curriculum.
Results
Palmer College in Florida devoted 22.72% of its curriculum to courses mentioning the subluxation followed by Life University (Marietta, GA) and Sherman College with 16.44% and 12.80% respectively. As per specific coursework or subjects, an average of 5.22 courses or subjects have descriptions mentioning the term subluxation. Three schools made no mention of the term subluxation in their academic catalogs; they were National University of Health Sciences, Canadian Memorial Chiropractic College, and Southern California University of Health Sciences.
Conclusion
Despite the controversies and paucity of evidence the term subluxation is still found often within the chiropractic curricula of most North American chiropractic programs. Future research should determine if changes in accreditation standards and research on evidence based practice will affect this prevalence.
doi:10.1186/2045-709X-19-14
PMCID: PMC3143079  PMID: 21682859
10.  Chiropractors in Finland – a demographic survey 
Background
The Finnish chiropractic profession is young and not fully accepted by Finnish healthcare authorities. The demographic profile and style of practice has not been described to date. However, as the profession seems to be under rapid development, it would be of interest to stakeholders, both chiropractic and political, to obtain a baseline description of this profession with a view to the development of future goals and strategies for the profession. The purpose of this study was to describe the chiropractic profession in Finland in relation to its demographic background, the demographics of their clinics, practice patterns, interactions with other health care practitioners and some of the professions' plans for the future.
Methods
A structured questionnaire survey was conducted in 2005, in which all 50 members of the Finnish Chiropractic Union were invited to participate.
Results
In all, 44 questionnaires were returned (response rate 88%). Eighty percent of the respondents were men, and 77% were aged 30 to 44 years old, most of whom graduated after 1990 with either a university-based bachelors' or masters' degree in chiropractic. Solo practice was their main practice pattern. The vast majority described their scope of practice to be based on a musculoskeletal approach, using the Diversified Technique, performing Soft Tissue Therapy and about two-thirds also used an Activator Instrument (mechanical adjusting instrument). The mean number of patient visits reported to have been seen weekly was 59 of which nine were new patients. Most practitioners found this number of patients satisfactory. At the initial consultation, 80% of respondents spent 30–45 minutes with their patients, 75% spent 20–30 minutes with "new old" patients and on subsequent visits 80% of respondents spent 15–30 minutes. Interactions with other health care professions were reasonably good and most of chiropractors intended to remain within the profession.
Conclusion
The Finnish chiropractic profession is relatively young. Consequently, many of the practitioners have a university-degree, which reflects recent developments in undergraduate chiropractic education. Their practice profile and the manner in which they practice appear to be fairly traditional.
doi:10.1186/1746-1340-16-9
PMCID: PMC2535588  PMID: 18752685
11.  Evidence-based protocol for structural rehabilitation of the spine and posture: review of clinical biomechanics of posture (CBP®) publications 
BACKGROUND
Although practice protocols exist for SMT and functional rehabilitation, no practice protocols exist for structural rehabilitation. Traditional chiropractic practice guidelines have been limited to acute and chronic pain treatment, with limited inclusion of functional and exclusion of structural rehabilitation procedures.
OBJECTIVE
(1) To derive an evidence-based practice protocol for structural rehabilitation from publications on Clinical Biomechanics of Posture (CBP®) methods, and (2) to compare the evidence for Diversified, SMT, and CBP®.
METHODS
Clinical control trials utilizing CBP® methods and spinal manipulative therapy (SMT) were obtained from searches in Mantis, CINAHL, and Index Medicus. Using data from SMT review articles, evidence for Diversified Technique (as taught in chiropractic colleges), SMT, and CBP® were rated and compared.
RESULTS
From the evidence from Clinical Control Trials on SMT and CBP®, there is very little evidence support for Diversified (our rating = 18), as taught in chiropractic colleges, for the treatment of pain subjects, while CBP® (our rating = 46) and SMT for neck pain (rating = 58) and low back pain (our rating = 202) have evidence-based support.
CONCLUSIONS
While CBP® Technique has approximately as much evidence-based support as SMT for neck pain, CBP® has more evidence to support its methods than the Diversified technique taught in chiropractic colleges, but not as much as SMT for low back pain. The evolution of chiropractic specialization has occurred, and doctors providing structural-based chiropractic care require protocol guidelines for patient quality assurance and standardization. A structural rehabilitation protocol was developed based on evidence from CBP® publications.
PMCID: PMC1840024  PMID: 17549209
chiropractic; spinal manipulation; rehabilitation
12.  Upper cervical chiropractic care for a 25-year-old woman with myoclonic seizures 
Objective
The purpose of this case report is to describe the chiropractic management using upper cervical techniques of a 25-year-old woman diagnosed with juvenile myoclonic epilepsy (JME).
Clinical Features
A 25-year-old woman had a history of JME, which was diagnosed at the age of 14 years. Her seizure episodes began shortly after trauma to her cervical spine and the onset of menarche.
Intervention and Outcome
After case history and physical examination, the patient received high-velocity, low-amplitude chiropractic spinal manipulation to her upper cervical spine using the Blair upper cervical chiropractic technique protocol. There was improvement in her seizure episodes and menstrual cycles following 12 weeks of chiropractic care.
Conclusion
This case study demonstrated improvement in a young woman with a seizure disorder after she received upper cervical chiropractic manipulation. This case suggests the need for more rigorous research to examine how upper cervical chiropractic techniques may provide therapeutic benefit to patients with seizure disorders.
doi:10.1016/j.jcm.2010.03.001
PMCID: PMC2943656  PMID: 21629556
Manipulation, Chiropractic; Myoclonic epilepsy, Juvenile; Cervical, Atlas; Menstrual cycle
13.  The Chiropractic Care of Children 
Abstract
Objective
The objective of this study was to characterize the practice of pediatric chiropractic.
Design
The study design was a cross-sectional descriptive survey.
Settings/location
The settings were private practices throughout the United States, Canada, and Europe.
Participants
The participants were 548 chiropractors, the majority of whom are practicing in the United States, Canada, and Europe.
Main outcome measures
Practitioner demographics (i.e., gender, years in practice, and chiropractic alma mater), practice characteristics (i.e., patient visits per week, practice income reimbursement), and chiropractic technique were surveyed. The practitioners were also asked to indicate common indicators for pediatric presentation, their practice activities (i.e., use of herbal remedies, exercise and rehabilitation, prayer healing, etc.), and referral patterns.
Results
A majority of the responders were female with an average practice experience of 8 years. They attended an average of 133 patient visits per week, with 21% devoted to the care of children (<18 years of age). Practice income was derived primarily from out-of-pocket reimbursement with charges of an average of $127 and $42 for the first and subsequent visits, respectively. These visits were reimbursed to address common conditions of childhood (i.e., asthma, ear infections, etc.). Approach to patient care was spinal manipulative therapy (SMT) augmented with herbal remedies, exercises, rehabilitation, and so on. Wellness care also figured prominently as a motivator for chiropractic care. Fifty-eight percent (58%) indicated an established relationship with an osteopathic or medical physician. Eighty percent (80%) of the responders indicated referring patients to medical practitioners while only 29% indicated receiving a referral from a medical/osteopathic physician.
Conclusions
The chiropractic care of children is a significant aspect of the practice of chiropractic. Further research is warranted to examine the safety and effectiveness of this popular nonallopathic approach to children's health.
doi:10.1089/acm.2009.0369
PMCID: PMC3151461  PMID: 20569028
14.  Outcomes of usual chiropractic, harm & efficacy, the ouch study: study protocol for a randomized controlled trial 
Trials  2011;12:235.
Background
Previous studies have demonstrated that adverse events occur during chiropractic treatment. However, because of these studies design we do not know the frequency and extent of these events when compared to sham treatment. The principal aims of this study are to establish the frequency and severity of adverse effects from short term usual chiropractic treatment of the spine when compared to a sham treatment group. The secondary aim of this study is to establish the efficacy of usual short term chiropractic care for spinal pain when compared to a sham intervention.
Methods
One hundred and eighty participants will be randomly allocated to either usual chiropractic care or a sham intervention group. To be considered for inclusion the participants must have experienced non-specific spinal pain for at least one week. The study will be conducted at the clinics of registered chiropractors in Western Australia. Participants in each group will receive two treatments at intervals no less than one week. For the usual chiropractic care group, the selection of therapeutic techniques will be left to the chiropractors' discretion. For the sham intervention group, de-tuned ultrasound and de-tuned activator treatment will be applied by the chiropractors to the regions where spinal pain is experienced. Adverse events will be assessed two days after each appointment using a questionnaire developed for this study. The efficacy of short term chiropractic care for spinal pain will be examined at two week follow-up by assessing pain, physical function, minimum acceptable outcome, and satisfaction with care, with the use of the following outcome measures: Numerical Rating Scale, Functional Rating Index, Neck Disability Index, Minimum Acceptable Outcome Questionnaire, Oswestry Disability Index, and a global measure of treatment satisfaction. The statistician, outcome assessor, and participants will be blinded to treatment allocation.
Trial registration
Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12611000542998
doi:10.1186/1745-6215-12-235
PMCID: PMC3224760  PMID: 22040597
15.  CHIROPRACTIC MANAGEMENT OF MIGRAINE WITHOUT AURA 
Objective: To assess the response of a patient with chronic migraines to a short program of chiropractic care (diversified technique).
Method: The study was run over a 13 week period with chiropractic spinal manipulative therapy (CSMT) on a once weekly schedule for 5 weeks, followed by an 8 week re-evaluation.
Outcome Measures: To measure the effect of treatment, a previously reported diary system was used which noted the intensity of a range of symptoms that are recorded following each migraine episode.
Results: The results attained showed there was a marked improvement in the migraine symptoms following the chiropractic care. The patient reported an improvement in frequency, intensity, duration and use of medication. These findings appear to also confirm other evidence which documented similar changes following a large randomised controlled trial of chiropractic treatment of migraine.
Discussion: The case is presented as further support for CSMT in the treatment of migraine. The outcome of this case is also discussed in relation to recent research that concludes that CSMT is a very effective treatment for some people with non-neuromusculoskeletal conditions.
Conclusion: It now appears clear that chiropractic care may be used to assist patients with migraine. Research is currently being undertaken to investigate the potential mechanisms of chiropractic in the treatment of migraine. This research should also assess what (if any) prognostic signs can be identified to assist practitioners making a more informed decision on the treatment of choice for migraine.
PMCID: PMC2051094  PMID: 17987195
Classic Migraine; chiropractic; manipulation; spinal; case report
16.  TREATMENT OF ACUTE ATOPIC ECZEMA BY CHIROPRACTIC CARE 
Objective: To investigate a patient with atopic eczema and assess how they responded to chiropractic care.
Method: The study was run over a 7 week period with chiropractic treatments (diversified technique) on a once weekly schedule.
Outcome Measures: To measure the effect of treatment, a rating system was developed and the intensity of a range of symptoms was recorded (through a questionnaire) on a twice weekly basis.
Results: The results attained showed there was a marked improvement in the eczema symptoms following the chiropractic care. The patient reported an improvement in eczematous symptoms of excoriation, pruritus, oedema and general psychological ease. These findings were also confirmed by photographic evidence which documented the change in the lesions.
Discussion: The case is presented to assist practitioners making a more informed decision on the treatment of choice for eczema. The outcome of this case is also discussed in relation to recent research that concludes that chiropractic spinal manipulative therapy has a role in the treatment for some people with non-neuromusculoskeletal conditions.
Conclusion: It appears that chiropractic care may have assisted this patient with eczema. However, more research is required to investigate the role that chiropractic has in the treatment of patients with eczema, and the potential mechanisms that could explain the improvement.
PMCID: PMC2051093  PMID: 17987197
Eczema; dermatitis; atopic; chiropractic; case report
17.  Chiropractic care of a six-year-old child with congenital torticollis 
Abstract
Objective
To discuss the care of a patient with congenital torticollis who was treated with chiropractic diversified technique and a chiropractic technique proposed by Frogley and Wallace in a previously published article.
Clinical Features
A 6-year-old female suffered from congenital torticollis with a left head-tilt subsequent to a difficult birth that culminated in a Caesarian section. Computerized tomography of the brain revealed plagiocephaly. Left facial asymmetry was demonstrated on visual observation.
Intervention and Outcome
The patient was treated with a chiropractic adjusting protocol as suggested by Frogley and Wallace and by diversified chiropractic technique. She tolerated the care well and experienced substantial changes in clinical presentation including a distinct improvement in head-tilt. The improvement in head-tilt has been maintained for a period of 1 year.
Conclusion
The conservative chiropractic methodology postulated by Frogley and Wallace in the care of headache patients should be investigated further in its use for congenial torticollis. The positive results observed with this patient lead the authors to recommend that additional studies be undertaken to assess whether these clinical observations can be replicated in other cases of congenital torticollis.
doi:10.1016/S0899-3467(07)60135-9
PMCID: PMC2647060  PMID: 19674674
Chiropractic; Torticollis
18.  Chiropractic treatment of chronic episodic tension type headache in male subjects: a case series analysis 
Objective:
To assess effectiveness of chiropractic management, primarily cervical adjustment, in the treatment of chronic episodic muscle tension type headache in male patients.
Design:
Prospective case series analysis with pre-treatment baseline. Sixteen sessions of chiropractic care were provided to each patient over an eight week period. Data was also collected during a two week no-treatment baseline period prior to initiation of care. The subjects took no pain medication or had any other treatment for the entire duration of the study.
Setting:
A large chiropractic teaching clinic: Palmer College of Chiropractic-West Outpatient Clinic.
Participants:
Eleven male outpatients between the ages of 18-40 years old with a self-reported history of chronic headache at least six months duration and an average of at least weekly headache episodes were recruited. There was one dropout due to moving out of the area before study completion.
Interventions:
Primary: high velocity, short lever cervical adjustment (Diversified technique). Secondary: myofascial trigger point therapy using ischemic compression to the cervical and thoracic musculature; thoracic and lumbar adjustment if indicated (Diversified technique); moist hot packs to cervical and thoracic spine regions.
Outcome measures:
Pain diary measuring frequency, duration, and intensity of head/neck pain; and McGill Pain Questionnaires.
Results:
Mean pre-treatment to post-treatment headache frequency changed from 6.4 episodes per two week period to 3.1, a statistically significant change (p < 0.01). Mean pre-treatment to post-treatment headache duration changed from 6.7 hours per episode to 3.88 hours which was statistically significant (p < 0.05). Mean anchored pain scale intensity ratings changed from 5.05 to 3.37 but this was just beyond statistical significance (p = 0.059). There were no significant changes in any McGill pain questionnaire scores pre and post treatment.
Conclusions:
In this case series analysis of episodic tension headache in 10 male patients, typical chiropractic interventions of adjusting, muscle work and moist heat significantly reduced self-reported frequency and duration of headache episodes following 12 treatments over an 8 week period. No significant effect was observed in self-reported pain intensity, however a trend of reduction may indicate that a larger sample size might show increased significance. The McGill Pain Questionnaire did not appear to provide any useful information in assessing change in this sample. This may lend support to the result that little or no effect is obtained in reducing intensity of individual headache episodes with this treatment approach. These findings are limited by the small sample size and suggest a need for a larger study population as well as specific treatment comparison studies. These results may further be limited in that all subjects were male.
PMCID: PMC2485120
tension-type headache; muscle contraction headache; vertebrogenic headache; chiropractic; spinal manipulation
19.  Multinational survey of chiropractic patients: reasons for seeking care 
Introduction
This study explores the extent to which consumers seek wellness care when choosing chiropractors whose practice methods are known to include periodic evaluative and interventional methods to maintain wellness and prevent illness.
Methods
Using an international convenience sample of Sacro-Occipital Technique (SOT) practitioners, 1316 consecutive patients attending 27 different chiropractic clinics in the USA, Europe and Australia completed a one-page survey on intake to assess reason for seeking care. A forced choice response was obtained characterizing the patient’s reason for seeking chiropractic care.
Results
More than 40% of chiropractic patient visits were initiated for the purposes of health enhancement and/or disease prevention.
Conclusion
Although prudence dictates great caution when generalizing from this study, if confirmed by subsequent research among other similar cohorts, the present results may lend support to continued arguments of consumer demand for a more comprehensive paradigm of chiropractic care, beyond routine musculoskeletal complaints, that conceptualizes the systemic, nonspecific effects of the chiropractic encounter in much broader terms.
PMCID: PMC2528271  PMID: 18769601
chiropractic; wellness; care
20.  Demanding excellence in the 21st century 1 
Chiropractic theory and development is briefly explored and compared with contemporary medical theory. Theoretical and philosophical assumptions in chiropractic, this writer predicts, may be challenged and altered in the 21st century. Technological advances and a slow trend in chiropractic toward a more scientific basis may result in improved theory, practice, and utilization in the next century. In order for such advances to occur, however, the profession must change some deeply rooted attitudes regarding scientific research and practice, adopt new attitudes regarding the need for clinical research, and ultimately become consumers of chiropractic research and of chiropractic techniques that have been subject to research.
PMCID: PMC2484617
chiropractic philosophy; clinical research; manipulation
21.  Practice patterns of doctors of chiropractic with a pediatric diplomate: a cross-sectional survey 
Background
Complementary and alternative medicine (CAM) is growing in popularity, especially within the pediatric population. Research on CAM practitioners and their specialties, such as pediatrics, is lacking. Within the chiropractic profession, pediatrics is one of the most recently established post-graduate specialty programs. This paper describes the demographic and practice characteristics of doctors of chiropractic with a pediatric diplomate.
Methods
218 chiropractors with a pediatric diplomate were invited to complete our survey using either web-based or mailed paper survey methods. Practitioner demographics, practice characteristics, treatment procedures, referral patterns, and patient characteristics were queried with a survey created with the online survey tool, SurveyMonkey©®.
Results
A total of 135 chiropractors responded (62.2% response rate); they were predominantly female (74%) and white (93%). Techniques most commonly used were Diversified, Activator ®, and Thompson with the addition of cranial and extremity manipulation to their chiropractic treatments. Adjunctive therapies commonly provided to patients included recommendations for activities of daily living, corrective or therapeutic exercise, ice pack\cryotherapy, and nutritional counseling. Thirty eight percent of respondents' patients were private pay and 23% had private insurance that was not managed care. Pediatrics represented 31% of the survey respondents' patients. Chiropractors also reported 63% of their work time devoted to direct patient care. Health conditions reportedly treated within the pediatric population included back or neck pain, asthma, birth trauma, colic, constipation, ear infection, head or chest cold, and upper respiratory infections. Referrals made to or from these chiropractors were uncommon.
Conclusions
This mixed mode survey identified similarities and differences between doctors of chiropractic with a pediatric diplomate to other surveys of doctors of chiropractic, CAM professionals, and pediatric healthcare providers. The pediatric diplomate certificate was established in 1993 and provides didactic education over a 2 to 3 year span. The results of this study can be used for historical information as this specialty continues to grow.
doi:10.1186/1472-6882-10-26
PMCID: PMC2898809  PMID: 20546582
22.  Triad of spinal pain, spinal joint dysfunction, and extremity pain in 4 pediatric cases of “Wii-itis”: a 21st century pediatric condition 
Objective
This article describes 4 pediatric cases of overuse injuries related to playing Nintendo Wii (Nintendo, Redmond, WA). A brief discussion is also presented regarding other 21st century problems found in the literature, such as problems associated with playing the Nintendo DS portable electronic device, text messaging, and Blackberry (Research in Motion, Waterloo, Ontario) thumb.
Clinical Features
Four pediatric patients, ranging from 3 to 9 years old, who had injuries causally related to what has been described in the literature as “Wii-itis” (spinal pain, spinal joint dysfunction [chiropractic subluxation], and related extremity pain), presented to a chiropractic clinic.
Intervention and Outcomes
Each of the 4 pediatric cases was evaluated and managed using chiropractic techniques. All patients successfully had their complaints resolve with 1 chiropractic visit.
Conclusion
Children in the new era of portable electronic devices are presenting to chiropractic offices with a set of symptoms directly related to overuse or repetitive strain from prolonged play on these systems.
doi:10.1016/j.jcm.2010.02.003
PMCID: PMC2943657  PMID: 21629555
Chiropractic; Children; Electronic equipment and supplies
23.  Chiropractic management of essential tremor and migraine: a case report 
Journal of Chiropractic Medicine  2012;11(2):121-126.
Objective
The purpose of this case report is to describe the chiropractic management of a 39-year-old woman with essential tremors and migraine headaches.
Clinical Features
A 39-year-old woman presented with essential tremors and migraine headaches, which occurred 2 to 3 times per week. The essential tremor was diagnosed in 2000, and migraine headaches with aura were diagnosed when she was 10. Both diagnoses were made by her general medical practitioner. Previous treatments for migraine included propranolol, isometheptene, dichloralphenazone, acetaminophen, sumatriptan, and over-the-counter pain relievers.
Intervention and Outcome
The patient received high-velocity, low-amplitude chiropractic spinal manipulation to her upper cervical spine using the Blair Upper Cervical chiropractic technique protocol. There was improvement in her tremors and migraine headaches following her initial chiropractic treatment, with a sustained improvement after 4 months of care.
Conclusion
This case study demonstrated improvement in a woman with essential tremors and migraine headaches. This suggests the need for more research to examine how upper cervical specific chiropractic care may help mitigate tremors and migraine headaches.
doi:10.1016/j.jcm.2011.10.006
PMCID: PMC3368974  PMID: 23204956
Tremor; Migraine; Spinal adjustment, Chiropractic
24.  Chiropractic adjustments and orthotics reduced symptoms for standing workers 
Journal of Chiropractic Medicine  2005;4(4):177-181.
Abstract
Objective
This controlled study was designed to explore the effectiveness of foot orthotics in solving problems of the feet and other parts of the lower extremities and to reduce low back pain.
Methods
Thirty-two subjects (24 males) were recruited and randomly assigned into 3 study groups. There were 10 subjects in the chiropractic care plus orthotics group, 14 subjects in the orthotics group, and 8 in the control group. All subjects filled out a patient information sheet and pre-screening foot pain questionnaire. Foot orthotics information was collected and the data was sent to Foot Level-ers, Inc. for orthotic fabrication. Chiropractic treatment was performed using Activator Technique. In-home exercise was prescribed to subjects receiving orthotics and chiropractic care.
Results
The control group did not experience much change during the testing period. The orthotics group showed improvement in symptoms (P = 0.053), activities of daily living (P = 0.058), sport and recreation (P = 0.186) and quality of life (P = 0.085). While trends were apparent, the improvements did not reach statistically significant levels. In contrast, there was no trend with pain (P = 0.492). The orthotics plus chiropractic group showed improvement in the four conditions over the study period. Greater improvement was seen in quality of life (P < 0.05), symptoms (P < 0.05) and activities of daily living (P < 0.05), which were statistically significant. Improvement was also seen in sports and recreation but it did not reach statistical significant level (P = 0.097).
Conclusion
This study showed that a combination of chiropractic care and orthotics improved symptoms, activities of daily living, sport and recreation and quality of life in workers whose job requires them to stand at least 6 hours daily.
doi:10.1016/S0899-3467(07)60148-7
PMCID: PMC2647045  PMID: 19674659
Chiropractic; Orthotic Devices
25.  Therapeutic interventions employed by Greater Toronto Area chiropractors on pregnant patients: results of a cross-sectional online survey 
Introduction:
Due to different biomechanical, nutritional, and hormonal considerations, it is possible that chiropractors may employ different therapeutic interventions and recommendations for pregnant patients than non-pregnant ones. The objective of this study was to determine the therapeutic interventions that chiropractors who are members of the Ontario Chiropractic Association in the Greater Toronto Area most commonly provide to pregnant patients.
Methods:
An introductory e-mail was sent in October 2011 to 755 members of the Ontario Chiropractic Association within the Greater Toronto Area five days prior to a 15 question survey being distributed via e-mail. Reminder e-mails were sent 13 days and 27 days later. Using descriptive statistics, demographic information was reported along with reported use of different treatments and recommendations for pregnant patients
Results:
A response rate of 23% was obtained. The majority of the respondents (90%) reported using the Diversified technique on pregnant patients, followed by soft tissue therapy (62%) and Activator (42%). The most common adjunctive therapy recommended to pregnant patients was referral to massage therapy (90%). Most of the respondents (92%) indicated that they prescribe stretching exercises to pregnant patients and recommend a multivitamin (84%) or folic acid (81%) to pregnant patients.
Conclusion:
In agreement with previous research on chiropractic technique usage on non-pregnant patients, the majority of respondents indicated treating pregnant patients with the Diversified technique, with other chiropractic techniques being utilized at varying rates on pregnant patients. Most respondents indicated prescribing exercise, and making adjunctive and nutritional recommendations frequently for their pregnant patients.
PMCID: PMC3661180  PMID: 23754858
chiropractic; pregnancy; interventions; therapy; chiropratique; grossesse; interventions; thérapie

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