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1.  Referrals to chiropractors and osteopaths: a survey of general practitioners in rural and regional New South Wales, Australia 
Background
Chiropractic and osteopathy form a significant part of the healthcare setting in rural and regional Australia, with national registration of practitioners, public subsidies for services and high utilisation by the Australian public. However, despite their significant role in rural and regional Australia, there has been little exploration of the interface between chiropractic and osteopathy and conventional primary health care practitioners in this area. The study aim was to examine the referral practices and factors that underlie referral to chiropractors and osteopaths by rural and regional Australian general practitioners (GPs), by drawing on a sample of GPs in rural and regional New South Wales.
Methods
A 27-item questionnaire was sent to all 1486 GPs currently practising in rural and regional Divisions of General Practice in New South Wales, Australia.
Results
A total of 585 GPs responded to the questionnaire, with 49 questionnaires returned as “no longer at this address” (response rate: 40.7%). The majority of GPs (64.1%) referred to a chiropractor or osteopath at least a few times per year while 21.7% stated that they would not refer to a chiropractor or osteopath under any circumstances. Patients asking the GP about CAM (OR=3.59; CI: 1.12, 11.55), GP’s use of CAM practitioners as a major source of information (OR=4.39; 95% CI: 2.04, 9.41), lack of other treatment options (OR=2.41; 95% CI: 1.18, 5.12), access to a wide variety of medical specialists (OR=12.5; 95% CI: 2.4, 50.0), GP’s belief in the efficacy of chiropractic and osteopathy services (OR=3.39; 95% CI: 2.19, 5.25) and experiencing positive results from patients using these services previously (OR=1.67; CI: 1.02, 2.75) were all independently predictive of increased referral to chiropractic and osteopathy services amongst the rural GPs.
Conclusions
There is a significant interface between chiropractic and osteopathy and Australian rural and regional general practice in New South Wales. Although there is generally high support for chiropractic and osteopathy among Australian GPs, this was not absolute and the heterogeneity of responses suggests that there remain tensions between the professions. The significant interface between chiropractic and osteopathy may be due in part to the inclusion of these professions in the publicly subsidised national healthcare delivery scheme. The significant impact of chiropractic and osteopathy and general practice in rural and regional Australian healthcare delivery should serve as an impetus for increased research into chiropractic and osteopathy practice, policy and regulation in these areas.
doi:10.1186/2045-709X-21-5
PMCID: PMC3599860  PMID: 23369205
Chiropractic; Osteopathy; General practice; Rural healthcare; Health services; Referral; Interdisciplinary care; Primary care
2.  The provision of chiropractic, physiotherapy and osteopathic services within the Australian private health-care system: a report of recent trends 
Background
Chiropractors, physiotherapists, and osteopaths receive training in the diagnosis and management of musculoskeletal conditions. As a result there is considerable overlap in the types of conditions that are encountered clinically by these practitioners. In Australia, the majority of benefits paid for these services come from the private sector. The purpose of this article is to quantify and describe the development in service utilization and the cost of benefits paid to users of these healthcare services by private health insurers. An exploration of the factors that may have influenced the observed trends is also presented.
Methods
A review of data from the Australian Bureau of Statistics, Australian Health Practitioner Regulation Agency, and the Australian Government Private Health Insurance Administration Council was conducted. An analysis of chiropractic, physiotherapy and osteopathic service utilisation and cost of service utilisation trend was performed along with the level of benefits and services over time.
Results
In 2012, the number of physiotherapists working in the private sector was 2.9 times larger than that of chiropractic, and 7.8 times that of the osteopathic profession. The total number of services provided by chiropractors, physiotherapists, and osteopaths increased steadily over the past 15 years. For the majority of this period, chiropractors provided more services than the other two professions. The average number of services provided by chiropractors was approximately two and a half times that of physiotherapists and four and a half times that of osteopaths.
Conclusions
This study highlights a clear disparity in the average number of services provided by chiropractors, physiotherapists, and osteopaths in the private sector in Australia over the last 15 years. Further research is required to explain these observed differences and to determine whether a similar trend exists in patients who do not have private health insurance cover.
doi:10.1186/2045-709X-22-3
PMCID: PMC3896731  PMID: 24428934
Chiropractic; Physiotherapy; Osteopathy; Allied health; Healthcare utilisation
3.  THE JOURNAL OF THE CHIROPRACTIC & OSTEOPATHIC COLLEGE OF AUSTRALASIA 
The first edition of the Journal of the Chiropractic and Osteopathic College of Australasia was known as COMSIG Review and was published in November, 1992 to coincide with a large conference that COCA had organised in Melbourne.
In the first few years the majority of articles were magazine style reviews, similar to these found in the Australian Family Physician. The first Editor was Bruce Walker and subsequent Editors have included John Drinkwater, Stephanie Campbell and John Reggars. The current Editors in Chief, Peter Tuchin and Henry Pollard, are staff members at Macquarie University, Centre of Chiropractic, with a strong background in science and research and both are currently undertaking post-graduate research degrees.
Over several years the magazine review style was changed in keeping with a more full journal format. An Editorial Board was formed, comprised of chiropractors, osteopaths and medical practitioners, some of whom are world renowned in their particular field of research.
By March, 1996 it was decided to change the name of the journal to Australasian Chiropractic and Osteopathy (ACO). This was a purposeful move to reflect the maturing of the journal and also the growth of the College and in the five years since November 1992, seventy-nine scientific articles have been published.
It is anticipated that the journal will continue to be widely distributed throughout the world, with current subscriptions from all Australian undergraduate chiropractic and osteopathic institutions and the vast majority of international undergraduate institutions.
ACO is currently indexed with Mantis (formerly Chirolars). The Editorial Panel continue to strive for Australasian Chiropractic and Osteopathy inclusion into Index Medicus and thereby Medline. However, it is recognised that readership of chiropractic journals is very low throughout the world and it is unlikely in the near future that any chiropractic journal other than the Journal of Manipulative and Physiological Therapeutics will be included in Index Medicus.
The lack of mainstream international indexing will not stop or prevent the College from producing a first rate journal into the future years of the professions. In fact with the now steady growth in Australian chiropractic and osteopathic research, it is envisaged that ACO will be Australia's leading professional journal. We trust our membership enjoy reading the journal and find many of its articles instructional.
We look forward to any comments from members relating to the production of the journal and any suggestions will be welcomed.
PMCID: PMC2050635  PMID: 17989763
Australasian Chiropractic Osteopathy; journal
4.  Testing the effectiveness of an innovative information package on practitioner reported behaviour and beliefs: The UK Chiropractors, Osteopaths and Musculoskeletal Physiotherapists Low back pain ManagemENT (COMPLeMENT) trial [ISRCTN77245761] 
Background
Low back pain (LBP) is a common and costly problem. Initiatives designed to assist practitioner and patient decisions about appropriate healthcare for LBP include printed evidence-based clinical guidelines. The three professional groups of chiropractic, osteopathy and musculoskeletal physiotherapy in the UK share common ground with their approaches to managing LBP and are amongst those targeted by LBP guidelines. Even so, many seem unaware that such guidelines exist. Furthermore, the behaviour of at least some of these practitioners differs from that recommended in these guidelines.
Few randomised controlled trials evaluating printed information as an intervention to change practitioner behaviour have utilised a no-intervention control. All these trials have used a cluster design and most have methodological flaws. None specifically focus upon practitioner behaviour towards LBP patients. Studies that have investigated other strategies to change practitioner behaviour with LBP patients have produced conflicting results. Although numerous LBP guidelines have been developed worldwide, there is a paucity of data on whether their dissemination actually changes practitioner behaviour. Primarily because of its low unit cost, sending printed information to large numbers of practitioners is an attractive dissemination and implementation strategy. The effect size of such a strategy, at an individual practitioner level, is likely to be small. However, if large numbers of practitioners are targeted, this strategy might achieve meaningful changes at a population level.
Methods
The primary aim of this prospective, pragmatic randomised controlled trial is to test the short-term effectiveness (six-months following intervention) of a directly-posted information package on the reported clinical behaviour (primary outcome), attitudes and beliefs of UK chiropractors, osteopaths and musculoskeletal physiotherapists. We sought to randomly allocate a combined sample of 1,800 consenting practitioners to receive either the information package (intervention arm) or no information above that gained during normal practice (control arm). We collected questionnaire data at baseline and six-months post-intervention. The analysis of the primary outcome will assess between-arm differences of proportions of responses to questions on recommendations about activity, work and bed-rest, that fall within categories previously defined by an expert consensus exercise as either 'guideline-consistent' and 'guideline-inconsistent'.
doi:10.1186/1471-2474-6-41
PMCID: PMC1208895  PMID: 16033646
5.  RISK MANAGEMENT FOR CHIROPRACTORS AND OSTEOPATHS 
Although rare, vertebrobasilar stroke is the best known of the possible side effects of cervical manipulation. Due to the serious sequelae that may result from cervical manipulation, chiropractors and osteopaths must take the appropriate steps to ensure the risk is minimised. This article outlines how the astute practitioner can minimise this risk. Practitioners must decide on the options for treatment of a patient with neck problems. Practitioners must also advise the patient of these options as part of an appropriate informed consent.
PMCID: PMC2051301  PMID: 17987199
Chiropractic; stroke; manipulation
6.  Chiropractors & Osteopaths Musculo-Skeletal Interest Group (COMSIG) 
COMSIG Review  1992;1(1):2.
The Chiropractors & Osteopaths Musculo-Skeletal Interest Group evolved from regular clinical meetings at Ringwood Clinic, a multi-disciplinary clinic in Melbourne
In 1987 the Directors of the clinic Bruce F. Walker D.C. and Alison Hogg MB.BS. (Hons), FRACGP. Decided to invite a range of guest speakers (on musculo-skeletal topics) to give an address every 6 weeks
Local practitioners of all persuasions were invited to attend these meetings. Although all groups were represented, by far the greatest interest shown by the chiropractors and osteopaths
In 1989 Peter D. Werth B.App.Sc.(Chiro) joined the team and together with the writer formulated a plan to broaden the list of invited guests to all registered chiropractors and osteopaths in Melbourne
Naturally, this required a larger venue and organisation. After several successful meetings attracting groups of 60 to 70 practitioners we formalised the COMSIG organisation and gained the invaluable assistance of David de l Harpe B.Sc., B.App.Sc.(Chiro), MB.,BS., Shane Carter B.App.Sc.(Chiro) and Simon Clement D.O. on our committee. More recently Shane Carter left for overseas and was ably replaced by Miriam Bourke B.App.Sc.(Chiro)
This year COMSIG incorporated under the name of the long established Chiropractic & Osteopathic College of Australasia
So, what is COMSIG and what are it’s objectives? COMSIG is a special interest group of the Chiropractic & Osteopathic College of Australasia. More specifically, it is an affiliation of Chiropractors and Osteopaths with interests pertaining to the musculo-skeletal system
The objectives for which COMSIG was established are: to promote knowledge of disorders of the musculo-skeletal system.to provide a forum for the interchange of ideas related to such disorders.to educate chiropractors, osteopaths and other health professionals about the diagnosis and management of such disorders.to encourage the diagnosis and management of musculo-skeletal disorders in a scientific and ethical manner.to conduct, promote, and arrange meetings, seminars, symposia, conferences, and lectures on musculo-skeletal disorders.to foster research into musculo-skeletal disorders.
Importantly, COMSIG is not a political organisation but rather an academic organisation arising from the practitioner ranks of the professions
We encourage all those with an interest in musculo-skeletal disorders to join COMSIG and participate in its development. An application form is enclosed, or available from the Secretary…
PMCID: PMC2050005  PMID: 17989738
Chiropractic; osteopathy; Australia; education
7.  The establishment of the Chiropractic & Osteopathic College of Australasia in Queensland (1996–2002) 
Introduction
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.
Methods
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.
Results
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.
Discussion
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.
doi:10.1186/1746-1340-13-3
PMCID: PMC1151651  PMID: 15967046
Chiropractic; osteopathy; continuing education; vocational education; evidence-based practice; Queensland
8.  Osteopathic intervention in chronic non-specific low back pain: a systematic review 
Background
Chronic Non Specific Low Back Pain (CNSLBP) is a common, complex and disabling condition that has been present for longer than three months and is not caused by a serious pathology. Osteopaths are health practitioners who commonly diagnose and treat CNSLBP patients using a complex set of interventions that includes manual therapy. The study aimed to complete a Systematic Review of clinical research into osteopathic intervention in CNSLBP using a rigorous assessment of study quality.
Methods
The literature was searched to August 2011 using the following databases: AMED, CINAHL Plus, Cochrane Central Register of Clinical Trials, MEDLINE Plus, EMBASE, MANTIS, OSTMED, PEDro, ScienceDirect. Multiple search terms were used in various combinations: osteopathy/osteopathic, osteopathic manipulative technique, OMT, Spinal Manipulative Therapy, SMT, clinical trial, back pain, chronic back pain. The inclusion criteria were papers that: reported clinical trials; had adult participants; tested the effectiveness and/or efficacy of osteopathic manual therapy intervention applied by osteopaths, and had a study condition of CNSLBP. The quality of the papers was assessed using the Cochrane Back Review Risk of Bias criteria. A meta-analysis would proceed if the studies had adequate clinical and methodological homogeneity.
Results
Initial searches revealed 809 papers, 772 of which were excluded on the basis of abstract alone. The remaining 37 trial papers were subjected to a more detailed analysis of the full text, which resulted in 35 being excluded. The two remaining trials had a lack of methodological and clinical homogeneity, precluding a meta-analysis. The trials used different comparators with regards to the primary outcomes, the number of treatments, the duration of treatment and the duration of follow-up.
Conclusion
There are only two studies assessing the effect of the manual therapy intervention applied by osteopathic clinicians in adults with CNSLBP. One trial concluded that the osteopathic intervention was similar in effect to a sham intervention, and the other suggests similarity of effect between osteopathic intervention, exercise and physiotherapy. Further clinical trials into this subject are required that have consistent and rigorous methods. These trials need to include an appropriate control and utilise an intervention that reflects actual practice.
doi:10.1186/1471-2474-14-129
PMCID: PMC3623881  PMID: 23570655
Systematic review; Osteopathy; Osteopathic manipulative treatment; Low back pain; Chronic low back pain; Non-specific low back pain; Manual therapy; Clinical trial methodology
9.  Beyond spinal manipulation: should Medicare expand coverage for chiropractic services? A review and commentary on the challenges for policy makers 
Objectives
Private insurance plans typically reimburse doctors of chiropractic for a range of clinical services, but Medicare reimbursements are restricted to spinal manipulation procedures. Medicare pays for evaluations performed by medical and osteopathic physicians, nurse practitioners, physician assistants, podiatrists, physical therapists, and occupational therapists; however, it does not reimburse the same services provided by chiropractic physicians. Advocates for expanded coverage of chiropractic services under Medicare cite clinical effectiveness and patient satisfaction, whereas critics point to unnecessary services, inadequate clinical documentation, and projected cost increases. To further inform this debate, the purpose of this commentary is to address the following questions: (1) What are the barriers to expand coverage for chiropractic services? (2) What could potentially be done to address these issues? (3) Is there a rationale for Centers for Medicare and Medicaid Services to expand coverage for chiropractic services?
Methods
A literature search was conducted of Google and PubMed for peer-reviewed articles and US government reports relevant to the provision of chiropractic care under Medicare. We reviewed relevant articles and reports to identify key issues concerning the expansion of coverage for chiropractic under Medicare, including identification of barriers and rationale for expanded coverage.
Results
The literature search yielded 29 peer-reviewed articles and 7 federal government reports. Our review of these documents revealed 3 key barriers to full coverage of chiropractic services under Medicare: inadequate documentation of chiropractic claims, possible provision of unnecessary preventive care services, and the uncertain costs of expanded coverage. Our recommendations to address these barriers include the following: individual chiropractic physicians, as well as state and national chiropractic organizations, should continue to strengthen efforts to improve claims and documentation practices; and additional rigorous efficacy/effectiveness research and clinical studies for chiropractic services need to be performed. Research of chiropractic services should target the triple aim of high-quality care, affordability, and improved health.
Conclusions
The barriers that were identified in this study can be addressed. To overcome these barriers, the chiropractic profession and individual physicians must assume responsibility for correcting deficiencies in compliance and documentation; further research needs to be done to evaluate chiropractic services; and effectiveness of extended episodes of preventive chiropractic care should be rigorously evaluated. Centers for Medicare and Medicaid Services policies related to chiropractic reimbursement should be reexamined using the same standards applicable to other health care providers. The integration of chiropractic physicians as fully engaged Medicare providers has the potential to enhance the capacity of the Medicare workforce to care for the growing population. We recommend that Medicare policy makers consider limited expansion of Medicare coverage to include, at a minimum, reimbursement for evaluation and management services by chiropractic physicians.
doi:10.1016/j.echu.2013.07.001
PMCID: PMC4111075  PMID: 25067927
Chiropractic; Medicare; Spinal manipulation; Public policy; Health policy; Health care reform
10.  CHIROPRACTIC AND OSTEOPATHIC EDUCATION AT ROYAL MELBOURNE INSTITUTE TECHNOLOGY 
Objective: To assess the attitudes of undergraduate chiropractic and osteopathic students at Royal Melbourne Institute of Technology (RMIT) in 1992 on the education they are receiving and on the effectiveness of chiropractic and osteopathic care.
Design: Cross-sectional descriptive survey.
Participants: Undergraduate chiropractic and osteopathic students enrolled at RMIT School of Chiropractic and Osteopathy in 1992.
Results: This study surveyed 272 students, 196 who were chiropractic students and 76 who were osteopathic students from RMIT School of Chiropractic and Osteopathy in Melbourne, Australia. The students that responded represented 73.4% of chiropractic students and 85.4% of osteopathic students currently enrolled in their respective courses. Chiropractic and osteopathic students entered their respective courses from non-chiropractic/non-osteopathic families. More chiropractic students than osteopathic students (1.3:1.0) had their respective course as their first choice when applying for tertiary education. A majority (95.8 chiropractic students and 94.8% osteopathic students) of both groups surveyed were pleased with their choice of course. Students from both disciplines held considerable respect for each other in the care of certain conditions, but did not see the other profession’s care as effective as their own. A greater percentage of osteopathic students believed there was sufficient difference between chiropractic and osteopathy to justify two separate professions (57.6% compared to 97.2%).
Discussion: High quality education is a major aim in our schools and colleges. For this standard to be maintained it requires continual re-evaluation and assessment. Surveys such as this should be performed regularly as a method of evaluating student attitude and how these attitudes change during the course. This would also allow administrators to determine whether they are achieving their academic intentions. An immediate follow up survey asking the same questions is suggested to ascertain whether the same attitudes exist today.
PMCID: PMC2051086  PMID: 17987188
Chiropractic; osteopathic medicine; education; students; attitude
11.  A COMPARISON OF THE PATIENT DEMOGRAPHICS OF VICTORIAN CHIROPRACTIC AND OSTEOPATHIC CLINICS 
COMSIG review  1994;3(2):48-53.
While there are studies that describe the patient demographics of both Australian and American chiropractic clinics, such information appears difficult to find for physiotherapy or osteopathic clinics comparative data of any kind doesn't appear to exist. This study attempted to provide this data for Australian practices and to analyse any similarities or differences between populations.
Results obtained for chiropractors and osteopaths would appear to suggest that there may be significant differences between the diagnostic profiles of the two professions. Physiotherapists withdrew from the - process during data collection.
Suggestions are made relating to possible modifications I to the survey instrument and possible directions any future study might take.
PMCID: PMC2050142
Patients; statistics and numerical dam demography; utilisation; chiropractic; osteopathy; databases
12.  Risk Management for Chiropractors and Osteopaths. Informed consent 
Obtaining the informed consent of a patient before undertaking chiropractic or osteopathic treatment is a common law requirement in Australia. This paper outlines the essential elements of informed consent and provides some practice tips on streamlining the process.
PMCID: PMC2051308  PMID: 17987206
Chiropractic; osteopathy; informed consent; risk management
13.  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
14.  Patients’ experiences and expectations of chiropractic care: a national cross-sectional survey 
Background
Not enough is understood about patients’ views of chiropractic care. The aims of this research were to explore patients’ experiences and expectations, their perceptions of benefits and risks, and the implications for chiropractors’ continuing fitness to practise.
Methods
Survey questions were formulated from existing literature, published guidance on good practice from the General Chiropractic Council, and from 28 telephone interviews and a small focus group with chiropractic patients using a semi-structured topic guide. In its final form, the survey elicited patients’ ratings on expectations regarding 33 aspects of care. In a national cross-sectional survey, a number of sampling methods were required as a consequence of the low practitioner response rate.
Results
In total, 544 completed questionnaires were received from chiropractic patients, a lower response rate than expected (8%). The two main benefits that patients reported regarding their chiropractic care were reduced pain (92%) and increased mobility (80%). Of respondents, 20% reported unexpected or unpleasant reactions to their treatment, most commonly tiredness or fatigue (32%), and extra pain (36%). In most cases they expressed low levels of concern about these reactions. Patients’ expectations were met for most aspects of care. The four aspects of practice where expectations were least well met comprised: having more information on the cost of the treatment plan at the first consultation (80%); the chiropractor contacting the patient’s general practitioner if necessary (62%); having a discussion about a referral to another healthcare practitioner (62%); and providing a method for confidential feedback (66%).
Conclusions
Overall, patients reported a high level of satisfaction with the benefits of their chiropractic care, although there is a likelihood of bias towards patients with a positive experience of chiropractic. There were no serious adverse reactions; however, patients reported concern about pain, tingling and numbness in the limbs after chiropractic. In general, patients’ expectations were being well met.
Electronic supplementary material
The online version of this article (doi:10.1186/s12998-014-0049-0) contains supplementary material, which is available to authorized users.
doi:10.1186/s12998-014-0049-0
PMCID: PMC4307916  PMID: 25628858
Chiropractic; Patients’ expectations; Patients’ experiences; Risk; Benefit; Fitness to practice
15.  Osteopathic Manipulative Treatment as a Useful Adjunctive Tool for Pneumonia 
Pneumonia, the inflammatory state of lung tissue primarily due to microbial infection, claimed 52,306 lives in the United States in 20071 and resulted in the hospitalization of 1.1 million patients2. With an average length of in-patient hospital stay of five days2, pneumonia and influenza comprise significant financial burden costing the United States $40.2 billion in 20053. Under the current Infectious Disease Society of America/American Thoracic Society guidelines, standard-of-care recommendations include the rapid administration of an appropriate antibiotic regiment, fluid replacement, and ventilation (if necessary). Non-standard therapies include the use of corticosteroids and statins; however, these therapies lack conclusive supporting evidence4. (Figure 1)
Osteopathic Manipulative Treatment (OMT) is a cost-effective adjunctive treatment of pneumonia that has been shown to reduce patients’ length of hospital stay, duration of intravenous antibiotics, and incidence of respiratory failure or death when compared to subjects who received conventional care alone5. The use of manual manipulation techniques for pneumonia was first recorded as early as the Spanish influenza pandemic of 1918, when patients treated with standard medical care had an estimated mortality rate of 33%, compared to a 10% mortality rate in patients treated by osteopathic physicians6. When applied to the management of pneumonia, manual manipulation techniques bolster lymphatic flow, respiratory function, and immunological defense by targeting anatomical structures involved in the these systems7,8, 9, 10.
The objective of this review video-article is three-fold: a) summarize the findings of randomized controlled studies on the efficacy of OMT in adult patients with diagnosed pneumonia, b) demonstrate established protocols utilized by osteopathic physicians treating pneumonia, c) elucidate the physiological mechanisms behind manual manipulation of the respiratory and lymphatic systems. Specifically, we will discuss and demonstrate four routine techniques that address autonomics, lymph drainage, and rib cage mobility: 1) Rib Raising, 2) Thoracic Pump, 3) Doming of the Thoracic Diaphragm, and 4) Muscle Energy for Rib 1.5,11
doi:10.3791/50687
PMCID: PMC4173698  PMID: 24836893
Medicine; Issue 87; Pneumonia; osteopathic manipulative medicine (OMM) and techniques (OMT); lymphatic; rib raising; thoracic pump; muscle energy; doming diaphragm; alternative treatment
16.  Extending ICPC-2 PLUS terminology to develop a classification system specific for the study of chiropractic encounters 
Background
Typically a large amount of information is collected during healthcare research and this information needs to be organised in a way that will make it manageable and to facilitate clear reporting. The Chiropractic Observation and Analysis STudy (COAST) was a cross sectional observational study that described the clinical practices of chiropractors in Victoria, Australia. To code chiropractic encounters COAST used the International Classification of Primary Care (ICPC-2) with the PLUS general practice clinical terminology to code chiropractic encounters. This paper describes the process by which a chiropractic-profession specific terminology was developed for use in research by expanding the current ICPC-2 PLUS system.
Methods
The coder referred to the ICPC-2 PLUS system when coding chiropractor recorded encounter details (reasons for encounter, diagnoses/problems and processes of care). The coder used rules and conventions supplied by the Family Medicine Research Unit at the University of Sydney, the developers of the PLUS system. New chiropractic specific terms and codes were created when a relevant term was not available in ICPC-2 PLUS.
Results
Information was collected from 52 chiropractors who documented 4,464 chiropractor-patient encounters. During the study, 6,225 reasons for encounter and 6,491 diagnoses/problems were documented, coded and analysed; 169 new chiropractic specific terms were added to the ICPC-2 PLUS terminology list. Most new terms were allocated to diagnoses/problems, with reasons for encounter generally well covered in the original ICPC 2 PLUS terminology: 3,074 of the 6,491 (47%) diagnoses/problems and 274 of the 6,225 (4%) reasons for encounter recorded during encounters were coded to a new term. Twenty nine new terms (17%) represented chiropractic processes of care.
Conclusion
While existing ICPC-2 PLUS terminology could not fully represent chiropractic practice, adding terms specific to chiropractic enabled coding of a large number of chiropractic encounters at the desired level. Further, the new system attempted to record the diversity among chiropractic encounters while enabling generalisation for reporting where required. COAST is ongoing, and as such, any further encounters received from chiropractors will enable addition and refinement of ICPC-2 PLUS (Chiro). More research is needed into the diagnosis/problem descriptions used by chiropractors.
doi:10.1186/2045-709X-21-4
PMCID: PMC3563572  PMID: 23311664
Chiropractic; International classification of primary care; Classification; Clinical coding
17.  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
18.  Who uses Australian chiropractic services? 
Background
The use of chiropractic services is widespread, however, little is known about the characteristics of people who seek chiropractic care in Australia. This study compared the characteristics of users and non-users of chiropractic services from a cohort of patients sourced from general medical practice in Victoria, Australia.
Methods
This is a secondary analysis of baseline screening data from a prospective adult cohort study beginning in 2005. Thirty randomly selected Australian general medical practices mailed out surveys to 17,780 of their patients. Differences were examined between chiropractic users and others, and between chiropractic users who reported a back problem to those who did not.
Results
Of 7,519 respondents, 15% indicated they had visited a chiropractor in the last 12 months. Chiropractic users were more likely to have their GP located in a rural location and to be born in Australia; they were less likely to be in the older age group (55–76), to be unemployed or to have a pension/benefit as their main source of income. Chiropractic users were more likely to: have a back problem; use complementary or alternative medication; visit another type of complementary health practitioner or a physiotherapist. They were less likely to take medication for certain health problems (e.g. for high blood pressure, high cholesterol or asthma). No important differences were seen between chiropractic users and non-users for other health problems. People who visited a chiropractor and reported a back problem were more likely to: be a current smoker; have a number of other chronic conditions, including arthritis, hypertension, chronic sinusitis, asthma, dermatitis, depression and anxiety; report taking medications, including antidepressants, analgesics (painkillers and arthritis medication) and complementary or alternative medications.
Conclusions
This large cross-sectional study of general medical practice attendees suggests that chiropractors are the most commonly consulted complementary health profession. Chiropractors should ensure they are aware of their patients’ health conditions other than musculoskeletal problems and should ensure they are appropriately managed.
doi:10.1186/2045-709X-21-31
PMCID: PMC3849188  PMID: 24295295
19.  A review of the use of likelihood ratios in the chiropractic literature 
Abstract
Objective
The objective of this review is to determine how frequently likelihood ratios (LRs) have been used or described in the chiropractic literature and to depict their appropriate use in the clinical setting.
Methods
A literature search was conducted of the MEDLINE, Manual Alternative and Natural Therapy Index System, and Index to Chiropractic Literature databases, with search years encompassing 1966 through June 2006. Citations in the English language that addressed the following search terms were retrieved: likelihood ratio in combination with manipulation and chiropractic.
Results
The searches netted a total of 64 citations: 10 in MEDLINE, 34 in the Manual Alternative and Natural Therapy Index System, and 20 in the Index to Chiropractic Literature. After eliminating articles from journals that were not focused specifically on chiropractic, duplicates, and those that did not involve LRs, 3 articles remained and were reviewed. None of the reviewed articles provided a description of LRs, and only 2 used them in a clinical context.
Conclusions
The use of LRs can be very helpful in patient management; however, LRs are rarely reported in the chiropractic literature. Accordingly, chiropractic practitioners are most likely uninformed on the subject and may not have the capacity to use them in formulating diagnoses. It is suggested that researchers increase the reporting of LRs and that chiropractic clinicians begin to make use of them in day-to-day practice.
doi:10.1016/j.jcme.2007.04.008
PMCID: PMC2647089  PMID: 19674703
Chiropractic; Likelihood function; Sensitivity; Specificity; Nomogram
20.  Chiropractic identity, role and future: a survey of North American chiropractic students 
Background
The literature pertaining to chiropractic students’ opinions with respect to the desired future status of the chiropractic physician is limited and is an appropriate topic worthy of study. A previous pilot study was performed at a single chiropractic college. This current study is an expansion of this pilot project to collect data from chiropractic students enrolled in colleges throughout North America.
Objective
The purpose of this study is to investigate North American chiropractic students’ opinions concerning professional identity, role and future.
Methods
A 23-item cross-sectional electronic questionnaire was developed. A total of 7,455 chiropractic students from 12 North American English-speaking chiropractic colleges were invited to complete the survey. Survey items encompassed demographics, evidence-based practice, chiropractic identity and setting, and scope of practice. Data were collected and descriptive statistical analysis was performed.
Results
A total of 1,247 (16.7% response rate) questionnaires were electronically submitted. Most respondents agreed (34.8%) or strongly agreed (52.2%) that it is important for chiropractors to be educated in evidence-based practice. A majority agreed (35.6%) or strongly agreed (25.8%) the emphasis of chiropractic intervention is to eliminate vertebral subluxations/vertebral subluxation complexes. A large number of respondents (55.2%) were not in favor of expanding the scope of the chiropractic profession to include prescribing medications with appropriate advanced training. Most respondents estimated that chiropractors should be considered mainstream health care practitioners (69.1%). Several respondents (46.8%) think that chiropractic research should focus on the physiological mechanisms of chiropractic adjustments.
Conclusion
The chiropractic students in this study showed a preference for participating in mainstream health care, report an exposure to evidence-based practice, and desire to hold to traditional chiropractic theories and practices. The majority of students would like to see an emphasis on correction of vertebral subluxation, while a larger percent found it is important to learn about evidence-based practice. These two key points may seem contradictory, suggesting cognitive dissonance. Or perhaps some students want to hold on to traditional theory (e.g., subluxation-centered practice) while recognizing the need for further research to fully explore these theories. Further research on this topic is needed.
Electronic supplementary material
The online version of this article (doi:10.1186/s12998-014-0048-1) contains supplementary material, which is available to authorized users.
doi:10.1186/s12998-014-0048-1
PMCID: PMC4313466  PMID: 25646145
Chiropractic; Cross-sectional survey
21.  Management of people with acute low-back pain: a survey of Australian chiropractors 
Introduction
Chiropractors commonly provide care to people with acute low-back pain (LBP). The aim of this survey was to determine how chiropractors intend to support and manage people with acute LBP and if this management is in accordance with two recommendations from an Australian evidence-based acute LBP guideline. The two recommendations were directed at minimising the use of plain x-ray and encouraging the patient to stay active.
Methods
This is a cross sectional survey of chiropractors in Australia. This paper is part of the ALIGN study in which a targeted implementation strategy was developed to improve the management of acute LBP in a chiropractic setting. This implementation strategy was subsequently tested in a cluster randomised controlled trial. In this survey phase of the ALIGN study we approached a random sample of 880 chiropractors in three States of Australia. The mailed questionnaire consisted of five patient vignettes designed to represent people who would typically present to chiropractors with acute LBP. Four vignettes represented people who, according to the guideline, would not require a plain lumbar x-ray, and one vignette represented a person with a suspected vertebral fracture. Respondents were asked, for each vignette, to indicate which investigation(s) they would order, and which intervention(s) they would recommend or undertake.
Results
Of the 880 chiropractors approached, 137 were deemed ineligible to participate, mostly because they were not currently practising, or mail was returned to sender. We received completed questionnaires from 274 chiropractors (response rate of 37%). Male chiropractors made up 66% of respondents, 75% practised in an urban location and their mean number of years in practice was 15. Across the four vignettes where an x-ray was not indicated 68% (95% Confidence Intervals (CI): 64%, 71%) of chiropractors responded that they would order or take an x-ray. In addition 51% (95%CI: 47%, 56%) indicated they would give advice to stay active when it was indicated. For the vignette where a fracture was suspected, 95% (95% CI: 91%, 97%) of chiropractors would order an x-ray.
Conclusion
The intention of chiropractors surveyed in this study shows low adherence to two recommendations from an evidence-based guideline for acute LBP. Quality of care for these patients could be improved through effective implementation of evidence-based guidelines. Further research to find cost-effective methods to increase implementation is warranted.
doi:10.1186/2045-709X-19-29
PMCID: PMC3265419  PMID: 22171632
22.  A psychological profile of chiropractic patients: an australian case study 
Journal of Chiropractic Medicine  2002;1(3):107-112.
Abstract
Background
The efficiency and efficacy of the chiropractic consultation would be enhanced if patients requiring additional psychological assistance could be identified. Distressed patients and those with a low sense of coherence and/or manageability score may benefit from a more prolonged chiropractic consultation or may require specialist referral.
Objective
This exploratory study sought to ascertain whether categorization within a particular chiropractic management group could serve as a red flag to alert the practitioner to the likelihood of special patient needs.
Research Method
A case study to explore the psychological profile of chiropractic patients was undertaken. The DRAM (Distress and Risk Assessment Method) and SOC (Sense of Coherence) questionnaires were used to ascertain the distress and sense of coherence and manageability levels of acute, chronic and maintenance chiropractic patients. Purposive sampling of practitioners and convenience sampling of patients fulfilling the study's inclusion criteria was undertaken. Patients were requested to complete two and chiropractors to complete one questionnaire and an interview.
Results
Ten chiropractors and 142 patients participated in the study. Of participating patients, 38% had a chronic biomechanical problem, 23% were acute, and 39% were maintenance patients. Acute, chronic and maintenance patients were spread along the entire spectrum of the SOC and manageability scale. Of the 130 patients who completed the DRAM section of the questionnaire, over one in five were distressed.
Conclusion
Due to the small sample size and the diversity of results it was not possible to identify particular groups of chiropractic patients who require additional consultation time or referral. This study did however demonstrate that some chiropractic patients are distressed and consequently it is important that chiropractors know when to manage and when to refer anxious or depressed patients.
doi:10.1016/S0899-3467(07)60012-3
PMCID: PMC2646929  PMID: 19674569
Chiropractic; Psychological Profile
23.  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
24.  Practitioner Perceptions of Emotions Associated with Pain: A Survey 
Abstract
Objective
To discover whether chiropractors consider that emotional factors are associated with pain presentations in their patients and if so, what methods they use to investigate these factors and what strategies they use to manage them.
Design
A telephone survey of chiropractors in Australasia (Australia and New Zealand) and North America (America and Canada). A database of practitioners was obtained for each region. A phoning protocol was established in each region to standardize the survey approach.
Setting
Private practice of chiropractic.
Method
Chiropractic centers were telephoned and the attending chiropractor(s) were asked to complete a phone survey. The survey consisted of a series of short questions designed to establish the main techniques used in the practice. Questions focused on whether emotional factors of the patient were recognized and addressed and what role emotional factors play in the management of the patient.
Sample
Subjects were registered/licensed chiropractors listed in a publication of the largest association of practitioners in their region.
Results
In Australasia and North America just under half of practitioners surveyed (45.8% and 50.5% respectively) used a technique to evaluate any impacting emotions on the presenting condition. Additionally, 36.3% of Australasia and 33.3% of North America practitioners had a technique to treat emotional factors in the patient. The study also suggests that over 90% of Australasian chiropractors and 80% of North America chiropractors consider emotional factors important in pain presentations.
Conclusion
This study found that a substantial number (80–90%) of the chiropractors surveyed believe that emotional factors influence pain syndromes. However, less than half of these practitioners report that they are able to evaluate emotional factors and approximately only a third report that they are able to treat them. This study shows there is a need for further research of chiropractors to be able to evaluate emotional factors and techniques that can be used to rectify emotional components of their patients' pain syndromes.
doi:10.1016/S0899-3467(07)60107-4
PMCID: PMC2647028  PMID: 19674641
Chiropractic; Psychology; Emotion; Biopsychosocial Model
25.  Acupuncture, chiropractic and osteopathy use in Australia: a national population survey 
BMC Public Health  2008;8:105.
Background
There have been no published national studies on the use in Australia of the manipulative therapies, acupuncture, chiropractic or osteopathy, or on matters including the purposes for which these therapies are used, treatment outcomes and the socio-demographic characteristics of users.
Methods
This study on the three manipulative therapies was a component of a broader investigation on the use of complementary and alternative therapies. For this we conducted a cross-sectional, population survey on a representative sample of 1,067 adults from the six states and two territories of Australia in 2005 by computer-assisted telephone interviews. The sample was recruited by random digit dialling.
Results
Over a 12-month period, approximately one in four adult Australians used either acupuncture (9.2%), chiropractic (16.1%) or osteopathy (4.6%) at least once. It is estimated that, adult Australians made 32.3 million visits to acupuncturists, chiropractors and osteopaths, incurring personal expenditure estimated to be A$1.58 billion in total. The most common conditions treated were back pain and related problems and over 90% of the users of each therapy considered their treatment to be very or somewhat helpful. Adverse events are reported. Nearly one fifth of users were referred to manipulative therapy practitioners by medical practitioners.
Conclusion
There is substantial use of manipulative therapies by adult Australians, especially for back-related problems. Treatments incur considerable personal expenditure. In general, patient experience is positive. Referral by medical practitioners is a major determinant of use of these manipulative therapies.
doi:10.1186/1471-2458-8-105
PMCID: PMC2322980  PMID: 18377663

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