This paper presents a proposed quality assurance (QA) program for chiropractors using surface electromyography (SEMG) in their offices. The paper examines in detail the various aspects of the program including both the technical and professional components. The technical component has three sub topics: equipment, technical procedures and data processing; as does the professional component: qualification/certification, compliance/peer review and patient selection. These are also further broken down to discuss the aspects dealing with quality and also other basic components necessary to understand the effective use of SEMG in the chiropractic office. The rationale for such a program is presented first and the details of the various aspects later. The complete program is represented in a number of charts which form a blueprint for the total QA program. As this is a proposed program, the authors invite feedback and criticism so that it may be optimized.
chiropractic; electromyography; quality assurance
The purpose of this article is to present select concepts and theories of bureaucratic structures and functions so that chiropractic physicians and other health care professionals can use them in their respective practices. The society-culture-personality model can be applied as an organizational instrument for assisting chiropractors in the diagnosis and treatment of their patients irrespective of locality.
Society-culture-personality and social meaningful interaction are examined in relationship to the structural and functional aspects of bureaucracy within the health care institution of a society. Implicit in the examination of the health care bureaucratic structures and functions of a society is the focus that chiropractic physicians and chiropractic students learn how to integrate, synthesize, and actualize values and virtues such as empathy, integrity, excellence, diversity, compassion, caring, and understanding with a deep commitment to self-reflection.
It is essential that future and current chiropractic physicians be aware of the structural and functional aspects of an organization so that chiropractic and other health care professionals are able to deliver care that involves the ingredients of quality, affordability, availability, accessibility, and continuity for their patients.
Improving the health of Indigenous Australians remains a major challenge. A chiropractic service was established to evaluate this treatment option for musculoskeletal illness in rural Indigenous communities, based on the philosophy of keeping the community involved in all the phases of development, implementation, and evaluation. The development and integration of this service has experienced many difficulties with referrals, funding and building sustainability. Evaluation of the program was a key aspect of its implementation, requiring an appropriate process to identify specific problems and formulate solutions to improve the service.
We used the normalisation process model (May 2006) to order the data collected in consultation meetings and to inform our strategy and actions. The normalisation process model provided us with a structure for organising consultation meeting data and helped prioritise tasks. Our data was analysed as it applied to each dimension of the model, noting aspects that the model did not encompass. During this process we reworded the dimensions into more everyday terminology. The final analysis focused on to what extent the model helped us to prioritise and systematise our tasks and plans.
We used the model to consider ways to promote the chiropractic service, to enhance relationships and interactions between clinicians and procedures within the health service, and to avoid disruption of the existing service. We identified ways in which chiropractors can become trusted team members who have acceptable and recognised knowledge and skills. We also developed strategies that should result in chiropractic practitioners finding a place within a complex occupational web, by being seen as similar to well-known occupations such as physiotherapy. Interestingly, one dimension identified by our data, which we have labelled ‘emancipatory’, was absent from the model.
The normalisation process model has resulted in a number of new insights and questions. We have now established thriving weekly chiropractic clinics staffed by a team of volunteer chiropractors. We identified an ‘emancipatory’ dimension that requires further study. We provide a worked example of using this model to establish, integrate and evaluate a chiropractic service in an Indigenous Australian community.
To describe a common musculoskeletal disorder from a chiropractic management prospective, subsequently to stimulate further research into the chiropractic therapeutic effects on such cases and to contribute to chiropractic literature.
A 27-year-old, 76” male student often involved in athletic activities, had a sudden onset of continuous localized pain in the medial aspect of the mid and forefoot on the right side for 1-and-a half months. The onset of pain was related to an accidental injury while playing basketball. The pain worsened every time during and after playing basketball and other weight-bearing activities such as walking upstairs and is palliated with physical rest. He tried Biofreeze and ice application for several times immediately after the injuries which help to some extent to relieve pain and swelling, but he did not seek any other professional care. The condition had been improving slowly even before he came to the clinic although the patient described the pain as 5/10 on the Borg pain scale when he came to the clinic for the first time. The characteristic local findings were a mildly hyper-pronated right foot, mildly asymmetric soft-tissue and bony contours, tenderness, stiffness and decreased range of motion (ROM) at the first metatarsophalangel and adjacent joints on the medial aspect of the midfoot decreased fluid motions in the concerned joints on the chiropractic evaluation and some abnormal wearing in the shoes.
Intervention and Outcome
He was managed with chiropractic manipulation combined with other conservative measures. Range of motion (ROM), Borg Pain Scale and an orthopedic test (Morton's Test) were used as the outcome measures. The subject showed a favorable response to the conservative (chiropractic) care.
Although hallux rigidus is one of the most common musculoskeletal degenerative conditions, our conservative management received a favorable response but there has been little discussion about it in chiropractic literature. It can be hypothesized that the progress of Hallux Rigidus (HR) can be reversed or halted by chiropractic management provided it is started at the early stage of the disease.
Hallux Rigidus; Degenerative Joint Disease; First Metatarsophalangeal Disorders; Chiropractic Manipulation; Rehabilitation
The 1998 Nobel Prize in Physiology or Medicine recognized the biological significance of nitric oxide. Nitric oxide is derived from the amino acid arginine. It is intimately involved with circulatory vessel dilation where, for example, it protects against heart attacks, and is the basis for new medications such as Sildenafil (Viagra). Nitric oxide acts as a neurotransmitter and can modulate many neurological reactions. The immune system uses nitric oxide to destroy pathogens by interfering with key enzymes. Nitric oxide is responsible for both osteoclastic and osteoblastic responses in bone and is a key player in the degenerative aspects of arthritis. The process of apoptosis employs nitric oxide in the orderly removal of unneeded cells. There is clear evidence that major signaling and control mechanisms exist in the body apart from the nervous system. Chiropractic is thus faced with the challenge of how to incorporate this new knowledge which conflicts with traditional chiropractic concepts.
nitric oxide; chiropractic
The philosophy of chiropractic has always been regarded as an integral and indispensable component of the curriculum at chiropractic colleges. This study describes a review process in which instruments were designed to survey students and faculty to obtain information concerning curricular aspects of philosophy at the Canadian Memorial Chiropractic College. Approximately one half of the student body (N = 292) and sixty percent of the full-time and part-time faculty members (N = 66) responded to the surveys. The students who were surveyed indicated that philosophy was a very important part of their chiropractic education and they felt that their needs in this regard were not being met by the present program. Further, they perceived most faculty as being unappreciative of philosophy. The results from the faculty survey were at odds with the students’ perceptions and indicated that the faculty members were favourably disposed towards philosophy and felt that it should be an integral part of the students’ educational experience. The information gained from these surveys was subsequently used as a catalyst to stimulate discussion in a series of student/faculty focus groups on philosophy. These discussions helped to clarify some curricular philosophical issues and resulted in specific modifications to the philosophy program in the areas of content, format, faculty, and evaluation methods.
chiropractic; philosophy; curriculum
Current provincial legislation in various jurisdictions across Canada, serves to impede the utilization of the diagnostic laboratory by doctors of chiropractic. Chiropractic students both in Canada and the United States, are required to successfully complete an intensive course of study in the area of laboratory diagnosis, as a necessary aspect of the undergraduate educational curriculum. Unfortunately, Canadian graduate doctors of chiropractic and their patients, are not currently afforded the privilege of direct referral to a community diagnostic laboratory. Rather, chiropractors must enlist the assistance of other health care providers, namely medical doctors, to acquire various laboratory testing procedures. The premise of this paper is intended to demonstrate the necessity of revising such laws, in order to address the needs of those health care consumers who seek the services of the rapidly growing profession of chiropractic. Two clinical cases are presented as illustrative examples.
chiropractic; manipulation; legislation; laboratory; diagnosis
A cardinal characteristic of any profession is self-regulation. It is argued in the present paper that chiropractic has now reached a level of professional maturity that indicates the need for the final aspect of self-regulation: a standardized selection approach into professional schools or colleges. Quality control of membership can then begin at the entry point into the profession. An admission test - the Chiropractic College Admission Test (CCAT) - is proposed and outlined for use for the selection of candidates into chiropractic colleges. Such a test would be beneficial for students applying to the colleges, regulatory and licensing boards, to the profession as a whole, to the chiropractic colleges, to other professions, and to government as well as the general public. The proposed CCAT contains elements that are general to many health professions such as knowledge of the biological and physical sciences, verbal and linguistic reasoning and visual perceptual ability. The test, however, is proposed to have elements that are unique to chiropractic. Based on the performance of other admission tests (e.g. Dental Admission Test, Medical College Admission Test), it is argued that the CCAT could be constructed and used to have the highest technical properties of validity and reliability. Such a test would become an integral tool in maintaining quality assurance, beginning at the earliest point of the profession.
chiropractic; education; admission tests; test validity
This editorial provides an overview of this Thematic Series of the journal titled Chiropractic Care for Children. In commissioning this series of articles we aimed to bring the busy clinician up to date with the current best evidence in key aspects of evaluation and management of chiropractic care for children. Individual articles address a chiropractic approach to the management of children, chiropractic care of musculoskeletal conditions in children and adolescents, chiropractic care of non-musculoskeletal conditions in children and adolescents, chiropractic care for attention-deficit/hyperactivity disorder and possible adverse effects from chiropractic management of children. The final article by Charlotte Leboeuf-Yde and Lise Hestbæk is an overview of the current state of the evidence and future research opportunities for chiropractic care for children. We conclude this editorial discussing the strengths and weaknesses of contemporary research relevant to chiropractic care of children and the implications for chiropractic practice.
The use of automated text messages has made it possible to identify different courses of low back pain (LBP), and it has been observed that pain often fluctuates and that absolute recovery is rather rare. The purpose of this study was to describe the prevalence of pain-free weeks and pain-free periods in subjects with non-specific LBP treated by chiropractors, and to compare subjects from two different countries in these aspects.
Data were obtained from two practice-based multicentre prospective outcome studies, one Danish and one Swedish, involving subjects being treated by chiropractors for non-specific LBP. Over 18 weeks, subjects answered a weekly automated text message question on the number of days in the past week that they had experienced bothersome LBP, i.e. a number between 0 and 7. The number of weeks in a row without any LBP at all ("zero weeks") as well as the maximum number of zero weeks in a row was determined for each individual. Comparisons were made between the two study samples. Estimates are presented as percentages with 95% confidence intervals.
In the Danish and the Swedish populations respectively, 93/110 (85%) and 233/262 (89%) of the subjects were eligible for analysis. In both groups, zero weeks were rather rare and were most commonly (in 40% of the zero weeks) reported as a single isolated week. The prevalence of pain free periods, i.e. reporting a maximum of 0, 1 or 2, or 3-6 zero weeks in a row, were similar in the two populations (20-31%). Smaller percentages were reported for ≥ 7 zero weeks in a row. There were no significant differences between the two study groups.
It was uncommon that chiropractic subjects treated for non-specific LBP experienced an entire week without any LBP at all over 18 weeks. When this occurred, it was most commonly reported for brief periods only. Hence, recovery in the sense that patients become absolutely pain free is rare, even in a primary care population.
Health practitioners work under fiduciary constraint, and are obligated to favour patient needs over all others and in particular their own. The principles of professionalism demand that professionals take great care to ensure that boundaries are maintained safely to provide an optimal setting in facilitating patient care. Boundary violations cause serious harm to the patient. Any romantic or sexual activity between parties is the most serious form of boundary violation. The chiropractic profession is included in the list of disciplines which are at an increased risk for boundary violations. The authors propose a four stage protocol which is designed to offer all parties maximal protection beginning with undergraduate professional education and then mandatory continuing education for registrants in professional practice. The protocol would affect all aspects of professional life including training in boundaries and jurisdictional regulation.
professionalism; sexual abuse; chiropractic; Professionnalisme; exploitation sexuelle; chiropratique
This commentary discusses the evolving sociocultural roles and sociocultural authority of chiropractic.
The complex interconnectivity of the biological, psychological, and social aspects of our individual and collective well-being has occupied centuries of “nature versus nurture” philosophical debate, creative art, and scientific work. What has emerged is a better understanding of how our human development is affected by the circumstances of what we are born with (ie, nature) and how we are shaped by the circumstances that we are born into (ie, nurture).
In the new millennium, a cumulative challenge to the emerging integrative biopsychosocial health care disciplines is one of reconciling “circumstance versus choice”; that is, advancing individually and collectively the fullest actualization of human potential through the philosophy, art, and science of autonomy and empowerment.
Chiropractic; Health care provider; Professional role
The purpose of this article is to offer aspects of a conceptual model that can be applied as an organizational instrument for aiding preclinical and clinical chiropractic students to develop a thorough understanding of their roles among the next generation of health care providers for the 21st century.
It is necessary for chiropractic physicians to comprehend the basis of the society-culture-personality model as an organizational device in the health care institution. The structure of the family and the socialization process as conceptual components of the model may allow an enriched understanding of their interrelationships and thereby could expand and provide quality care for patients as a whole.
The society-culture-personality model has the potential for synthesizing the features of the socialization process and the family in relation to the institution of health care. This model is particularly appropriate for the needs of the next generation of health care professionals (chiropractic physicians, physicians, dentists, nurses, and osteopathic physicians) who may not have had the chance to be exposed entirely to the behavioral sciences in health care.
Chiropractic; Behavioral sciences; Family; Socialization process
Anecdotal evidence points to variations in individual students’ evolving confidence in clinical and patient communication skills during a clinical internship. A better understanding of the specific aspects of internships that contribute to increasing or decreasing confidence is needed to best support students during the clinical component of their study.
A multi-method approach, combining two large-scale surveys with 269 students and three in-depth individual interviews with a sub-sample of 29 students, was used to investigate the evolution of change in student confidence during a 10-month long internship. Change in levels of confidence in patient communication and clinical skills was measured and relationship to demographic factors were explored. The interviews elicited students’ accounts and reflections on what affected the evolution of their confidence during the internship.
At the start of their internship, students were more confident in their patient communication skills than their clinical skills but prior experience was significantly related to confidence in both. Initial confidence in patient communication skills was also related to age and prior qualification but not gender whilst confidence in clinical skills was related to gender but not age or prior qualification. These influences were maintained over time. Overall, students’ levels of confidence in patient communication and clinical skills confidence increased significantly over the duration of the internship with evidence that change over time in these two aspects were inter-related. To explore how specific aspects of the internship contributed to changing levels of confidence, two extreme sub-groups of interviewees were identified, those with the least increase and those with the highest increase in professional confidence over time. A number of key factors affecting the development of confidence were identified, including among others, interactions with clinicians and patients, personal agency and maturing as a student clinician.
This study provides insight into the factors perceived by students as affecting the development of professional confidence during internships. One particularly promising area for educational intervention may be the promotion of a pro-active approach to professional learning.
Back problems are often recurring or chronic. It is therefore not surprising that chiropractors wish to prevent their return or reduce their impact. This is often attempted with a long-term treatment strategy, commonly called maintenance care. However, some aspects of maintenance care are considered controversial. It is therefore relevant to investigate the scientific evidence forming the basis for its use.
A review of the literature was performed in order to obtain answers to the following questions: What is the exact definition of maintenance care, what are its indications for use, and how is it practised? How common is it that chiropractors support the concept of maintenance care, and how well accepted is it by patients? How frequently is maintenance care used, and what factors are associated with its use? Is maintenance care a clinically valid method of approach, and is it cost-effective for the patient?
Thirteen original studies were found, in which maintenance care was investigated. The relative paucity of studies, the obvious bias in many of these, the lack of exhaustive information, and the diversity of findings made it impossible to answer any of the questions.
There is no evidence-based definition of maintenance care and the indications for and nature of its use remains to be clearly stated. It is likely that many chiropractors believe in the usefulness of maintenance care but it seems to be less well accepted by their patients. The prevalence with which maintenance care is used has not been established. Efficacy and cost-effectiveness of maintenance care for various types of conditions are unknown. Therefore, our conclusion is identical to that of a similar review published in 1996, namely that maintenance care is not well researched and that it needs to be investigated from several angles before the method is subjected to a multi-centre trial.
For chiropractors and osteopaths after graduation, the learning process continues by way of experience and continuing education (CE). The provision of CE and other vocational services in Queensland between 1996 and 2002 is the subject of this paper.
The Chiropractic & Osteopathic College of Australasia (COCA) implemented a plan, which involved continuing education, with speakers from a broad variety of health provider areas; and the introduction of the concepts of evidence-based practice. The plan also involved building membership.
Membership of COCA in Queensland grew from 3 in June 1996 to 167 in 2002. There were a total of 25 COCA symposia in the same period. Evidence-based health care was introduced and attendees were generally satisfied with the conferences.
The development of a vocational body (COCA) for chiropractors and osteopaths in Queensland was achieved. Registrants in the field have supported an organisation that concentrates on the vocational aspects of their practice.
Chiropractic; osteopathy; continuing education; vocational education; evidence-based practice; Queensland
Recent research on the “embodiment of emotion” implies that experiencing an emotion may involve perceptual, somatovisceral, and motor feedback aspects. For example, manipulations of facial expression and posture appear to induce emotional states and influence how affective information is processed. The present study investigates whether performance monitoring, a cognitive process known to be under heavy control of the dopaminergic system, is modulated by induced facial expressions. In particular, we focused on the error-related negativity, an electrophysiological correlate of performance monitoring.
During a choice reaction task, participants held a Chinese chop stick either horizontally between the teeth (“smile” condition) or, in different runs, vertically (“no smile”) with the upper lip. In a third control condition, no chop stick was used (“no stick”). It could be shown on a separate sample that the facial feedback procedure is feasible to induce mild changes in positive affect. In the ERP sample, the smile condition, hypothesized to lead to an increase in dopaminergic activity, was associated with a decrease of ERN amplitude relative to “no smile” and “no stick” conditions.
Embodying emotions by induced facial expressions leads to a changes in the neural correlates of error detection. We suggest that this is due to the joint influence of the dopaminergic system on positive affect and performance monitoring.
Chiropractic’s demise was regularly predicted but the AMA’s campaign to “contain and then eliminate” it did not succeed. Nor did chiropractic follow osteopathy toward fusion with medicine. D.D. and B.J. Palmer were charismatic outsiders who emphasized the differences between medicine and chiropractic. Chiropractic’s unique evolution and survival owed a lot to BJ’s activity in publishing books and brochures and in part, to motivating his followers to fight for separate and distinct licensure. This paper proposes that in the twenty-first century chiropractic is most likely to become well established as an independent limited medical profession like dentistry, podiatry, optometry, and psychology.