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1.  Beyond spinal manipulation: should Medicare expand coverage for chiropractic services? A review and commentary on the challenges for policy makers 
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?
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.
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.
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.
PMCID: PMC4111075  PMID: 25067927
Chiropractic; Medicare; Spinal manipulation; Public policy; Health policy; Health care reform
2.  The provision of chiropractic, physiotherapy and osteopathic services within the Australian private health-care system: a report of recent trends 
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.
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.
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.
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.
PMCID: PMC3896731  PMID: 24428934
Chiropractic; Physiotherapy; Osteopathy; Allied health; Healthcare utilisation
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
Introduction: Continuing professional education activities such as professional conferences and passive dissemination of literature appear to have no little or no impact on changing clinicians’ practice. A clinical activities audit was carried out with a group (44) of chiropractors and osteopaths as part of the Chiropractic and Osteopathic College of Australasia’s continuing professional development program to determine whether it was likely to generate improvement in practice.
Methods: The participants gathered data relating to six audit criteria on ten patient records in round 1 and ten in round 2 (six months later). Each participant received a learning guide relating to useful clinical tools for pain and disability measurement immediately after completing the first round. The audit criteria relate to: methods used to assess the site and severity of pain, methods used to assess disability, other investigations performed or ordered, referrals made and outcome measures used for pain and disability. The data were analysed to determine whether the participants increased their use of objective pain and disability and outcome measures over the course of the audit.
Results: Results of the first round of audit were compared with those of the second round. Practitioners’ use of objective measures of pain and disability and outcome measures was significantly higher in the second round of audit.
Conclusion: This indicates that this clinical activities audit is a useful tool for improving practice.
PMCID: PMC2051303  PMID: 17987202
Clinical audit; pain and disability measurement; chiropractic; osteopathic
5.  Patients’ experiences and expectations of chiropractic care: a national cross-sectional survey 
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.
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.
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%).
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.
PMCID: PMC4307916  PMID: 25628858
Chiropractic; Patients’ expectations; Patients’ experiences; Risk; Benefit; Fitness to practice
6.  Pain Research in Complementary and Alternative Medicine in Australia: A Critical Review 
Sixty percent (60%) to 80% of patients who visit chiropractic, osteopathic, or Chinese medicine practitioners are seeking pain relief.
This article aimed to identify the amount, quality, and type of complementary and alternative medicine (CAM) pain research in Australia by systematically and critically reviewing the literature.
PubMed, Scopus, Australasian Medical Index, and Cochrane library were searched from their inception to July 2009. Australian and New Zealand Clinical Trial Registration and National Health and Medical Research Council databases were searched for human studies yet to be completed. Predefined search terms and selection criteria were used for data identification.
Of 204 studies selected, 54% were on chiropractic, 27% on Chinese medicine, 15% about multitherapy, and 4% on osteopathy. Chronic spinal pain was the most studied condition, with visceral pain being the least studied. Half of the articles in Chinese medicine or multitherapy were systematic reviews or randomized control trials. In comparison, only 5% of chiropractic and none of osteopathy studies were in these categories. Government funding was rare, and most studies were self-funded or internally funded. All chiropractic, osteopathic, and Chinese herbal medicine studies were conducted by the researchers of the professions. In contrast, half of the acupuncture studies and all t'ai chi studies were conducted by medical doctors or physiotherapists. Multidisciplinary collaboration was uncommon.
The quantity and the quality of CAM pain research in Australia are inconsistent with the high utilization of the relevant CAM therapies by Australians. A substantial increase in government funding is required. Collaborative research examining the multimodality or multidisciplinary approach is needed.
PMCID: PMC3576897  PMID: 22891634
This article is the second in a series of articles dealing with risk management in the practise of chiropractic and osteopathy, prepared by the COCA Risk Management Subcommittee.
Background: Radiographic examination carries risks that must be weighed against the possible benefits when determining patient care.
Objective: The objective of this article is to propose guidelines for the use of imaging in chiropractic and osteopathic practice.
Discussion: Plain film radiography, CT scan, magnetic resonance imaging (MRI) and other forms of imaging are available for use in chiropractic and osteopathic practice in Australia. The astute practitioner utilises these imaging procedures for clinical decision making in order to make an accurate diagnosis that will determine a patient’s management. This article attempts to guide the practitioner in the proper use of these imaging procedures for different regions of the body.
PMCID: PMC2051318  PMID: 17987210
Chiropractic; risk management; osteopathy
8.  Manual therapy as a conservative treatment for adolescent idiopathic scoliosis: a systematic review 
Scoliosis  2008;3:2.
The treatment of adolescent idiopathic scoliosis is contingent upon many variables. Simple observation is enough for less serious curvatures, but for very serious cases surgical intervention could be proposed. Between these there is a wide range of different treatments. Manual therapy is commonly used: the aim of this paper is to verify the data existing in the literature on the efficacy of this approach.
A systematic review of the scientific literature published internationally has been performed. We have included in the term manual therapy all the manipulative and generally passive techniques performed by an external operator. In a more specific meaning, osteopathic, chiropractic and massage techniques have been considered as manipulative therapeutic methods. We performed our systematic research in Medline, Embase, Cinhal, Cochrane Library, Pedro with the following terms: idiopathic scoliosis combined with chiropractic; manipulation; mobilization; manual therapy; massage; osteopathy; and therapeutic manipulation. The criteria for inclusion were as follows: Any kind of research; diagnosis of adolescent idiopathic scoliosis; patients treated exclusively by one of the procedures established as a standard for this review (chiropractic manipulation, osteopathic techniques, massage); and outcome in Cobb degrees.
We founded 145 texts, but only three papers were relevant to our study. However, no one of the three satisfied all the required inclusion criteria because they were characterized by a combination of manual techniques and other therapeutic approaches.
The lack of any kind of serious scientific data does not allow us to draw any conclusion on the efficacy of manual therapy as an efficacious technique for the treatment of Adolescent idiopathic scoliosis.
PMCID: PMC2262872  PMID: 18211702
9.  Chiropractic identity, role and future: a survey of North American chiropractic students 
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.
The purpose of this study is to investigate North American chiropractic students’ opinions concerning professional identity, role and future.
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.
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.
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.
PMCID: PMC4313466  PMID: 25646145
Chiropractic; Cross-sectional survey
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
Two recent studies that examined National Health Interview Survey data reported divergent findings regarding the propensity of adult chiropractic users to receive seasonal influenza immunization. Although one study found a statistically significant negative association between chiropractic use and influenza vaccination, another found that chiropractic users were significantly more likely to be vaccinated. The purpose of this study is to extend previous works by delving more deeply into recent data to identify adult chiropractic users at high risk and high priority for vaccination against influenza and pneumococcal disease.
We used data from the 2007 National Health Interview Survey in an attempt to replicate previous methodologies and further examine vaccination among adult chiropractic users (age ≥18 years) who, according to the Center for Disease Control and Prevention guidelines, should receive influenza and/or pneumococcal vaccination. We used complex survey design methods to make national estimates and used logistic regression to determine if having used chiropractic care predicted vaccination.
We found major methodological differences between the prior studies. In our analyses, we found that chiropractic users were significantly less likely than nonusers to have received the pneumococcal vaccine, and we found no significant difference between chiropractic users and nonusers relative to having received the seasonal flu vaccine.
Methodological differences in previous studies that investigated the association between chiropractic care and adult vaccination likely explain divergent findings reported in the literature. Future studies should consider these differences.
PMCID: PMC3586316  PMID: 21943651
Chiropractic; Vaccination; Health Surveys; Preventive Health Services
12.  Assessing the evidence for the use of chiropractic manipulation in paediatric health conditions: A systematic review 
Paediatrics & Child Health  2005;10(3):157-161.
To review the biomedical literature up to and including 2003, and determine the extent of the evidence related to the therapeutic application of chiropractic manipulation for paediatric health conditions. No critical appraisal of the evidence is undertaken.
The indexed manual therapy sector including medical, chiropractic, physiotherapy, naturopathic and osteopathic literature was searched. This included PubMed; the Manual, Alternative, and Natural Therapy Index System; the Cumulative Index to Nursing and Allied Health Literature; the Index to Chiropractic Literature; the Paediatric Economic Database Evaluation Project; the Cochrane Library; the Canadian Coordinating Office for Health Technology Assessment database; and the Agency for Healthcare Research and Quality database. Other resources included research conference and symposium proceedings, and the references of identified studies.
The search identified 1731 articles, of which 166 met the eligibility criteria. Two reviewers determined by consensus each citation’s appropriate level on the strength of evidence scale. There was one systematic review, nine randomized controlled trials, one observational study, 141 descriptive case studies and 14 conference abstracts.
Health claims made by practitioners regarding the application of chiropractic manipulation as a health care intervention for paediatric health conditions are, for the most part, supported by low levels of scientific evidence. Chiropractors, in particular, employ manipulation for the treatment of a wide variety of paediatric health conditions. The evidence rests primarily with clinical experience, descriptive case studies and a few randomized controlled trials. There is a need for more rigorous scientific inquiry to examine the value of manipulative therapy in the treatment of paediatric conditions. To advance the health interests of paediatric patients, health care decisions made on the basis of expert opinion or clinical experience must integrate the best research evidence available from high-quality, scientific studies.
PMCID: PMC2722516  PMID: 19675828
Adolescent; Child; Evidence-based medicine; Infant; Chiropractic manipulation; Newborn; Paediatrics
13.  Referrals to chiropractors and osteopaths: a survey of general practitioners in rural and regional New South Wales, Australia 
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.
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.
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.
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.
PMCID: PMC3599860  PMID: 23369205
Chiropractic; Osteopathy; General practice; Rural healthcare; Health services; Referral; Interdisciplinary care; Primary care
14.  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 provide a forum for the interchange of ideas related to such educate chiropractors, osteopaths and other health professionals about the diagnosis and management of such encourage the diagnosis and management of musculo-skeletal disorders in a scientific and ethical conduct, promote, and arrange meetings, seminars, symposia, conferences, and lectures on musculo-skeletal 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
15.  A review of the literature on chiropractic and insomnia 
Journal of Chiropractic Medicine  2010;9(3):121-126.
The purpose of this literature review is to critically review the evidence for chiropractic as a treatment of primary insomnia.
A search of the following databases up to October 2006 was conducted: PubMed, PEDro, MANTIS, CINAHL, and the specialized register of the Cochrane review group. We also performed hand searching of relevant journals. Randomized clinical trials, clinical trials, and case studies of chiropractic treatment of insomnia were included. It was required that each study used at least one form of standard patient outcome measure. Treatment strategies included manual therapy such as spinal manipulative therapy or muscle relaxation techniques. The review focused on articles published in indexed, peer-reviewed journals.
Fifteen studies met the selection criteria. There were no randomized clinical trials specific to chiropractic and insomnia. One study was a survey of opinion for treatment regimens for insomnia, which had low methodological scores. Another study assessed osteopathic cranial manipulation for insomnia, which appeared to have positive effects. Four studies identified physiotherapy treatment and manual therapy. A further 9 studies related to mind-body medical therapies and impaired health status, sleep disorders, and pain in the craniomandibular and cervical spinal regions.
Some studies have noted improvement in insomnia following manual therapy; however, based on clinical trials, there is minimal evidence of support for chiropractic in insomnia. Further studies with high methodological scores need to be conducted.
PMCID: PMC3188343  PMID: 22027034
Chiropractic; Insomnia; Neck pain
16.  Acupuncture, chiropractic and osteopathy use in Australia: a national population survey 
BMC Public Health  2008;8:105.
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.
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.
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.
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.
PMCID: PMC2322980  PMID: 18377663
17.  Patients’ expectations of private osteopathic care in the UK: a national survey of patients 
Patients’ expectations of osteopathic care have been little researched. The aim of this study was to quantify the most important expectations of patients in private UK osteopathic practices, and the extent to which those expectations were met or unmet.
The study involved development and application of a questionnaire about patients’ expectations of osteopathic care. The questionnaire drew on an extensive review of the literature and the findings of a prior qualitative study involving focus groups exploring the expectations of osteopathic patients. A questionnaire survey of osteopathic patients in the UK was then conducted. Patients were recruited from a random sample of 800 registered osteopaths in private practice across the UK. Patients were asked to complete the questionnaire which asked about 51 aspects of expectation, and post it to the researchers for analysis.
The main outcome measures were the patients-perceived level of expectation as assessed by the percentage of positive responses for each aspect of expectation, and unmet expectation as computed from the proportion responding that their expectation “did not happen”.
1649 sets of patient data were included in the analysis. Thirty five (69%) of the 51 aspects of expectation were prevalent, with listening, respect and information-giving ranking highest. Only 11 expectations were unmet, the most often unmet were to be made aware that there was a complaints procedure, to find it difficult to pay for osteopathic treatment, and perceiving a lack of communication between the osteopath and their GP.
The findings reflected the complexity of providing osteopathic care and meeting patients’ expectations. The results provided a generally positive message about private osteopathic practice. The study identified certain gaps between expectations and delivery of care, which can be used to improve the quality of care. The questionnaire is a resource for future research.
PMCID: PMC3679882  PMID: 23721054
Questionnaires; Survey; Expectations; Musculoskeletal manipulations; Osteopathic medicine
18.  Possible adverse events in children treated by manual therapy: a review 
Pediatric manual therapy is controversial within the medical community particularly with respect to adverse events. Pediatric manual therapy (Ped MT) is commonly used by a number of professions such as chiropractors, osteopaths and naturopaths for a variety of treatments in children. Ped MT interventions range from advice, light touch, massage, through to mobilisation and high velocity spinal manipulation. However, current evidence related to adverse events associated with Ped MT is not well understood.
To update the clinical research literature from the 2007 report by Vohra, Johnston, Cramer and Humphreys on possible adverse events in children treated by spinal manipulation.
A review of the clinical research literature from June 2004 until January 2010 as reported in MEDLINE, PubMed and PubMed Central for adverse events specifically related to the treatment of pediatric cases by manual therapy.
Only three new clinical studies, one systematic review with meta-analysis and one evidence report were identified. Two clinical studies reported on chiropractic care and one on osteopathic spinal manipulation in children. The systematic review investigated all studies of adverse events and manual therapy and was not specific for pediatric patients. The evidence review focused on effectiveness of spinal manipulation in a variety of musculoskeletal conditions. No serious or catastrophic adverse events were reported in the clinical studies or systematic review. However for adults, it has been estimated that between 0.003% and 0.13% of manual therapy treatments may result in a serious adverse event. Although mild to moderate adverse events are common in adults, an accurate estimate from high quality pediatric studies is currently not available.
There is currently insufficient research evidence related to adverse events and manual therapy. However, clinical studies and systematic reviews from adult patients undergoing manual therapy, particularly spinal manipulation report that mild to moderate adverse events are common and self limiting. However serious adverse events are rare and much less than for medication commonly prescribed for these problems. More high quality research specifically addressing adverse events and pediatric manual therapy is needed.
PMCID: PMC2890687  PMID: 20525194
19.  Osteopathic intervention in chronic non-specific low back pain: a systematic review 
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.
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.
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.
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.
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
20.  Racial Disparities in the Use of Chiropractic Care Under Medicare 
Medicare covers chiropractic care, but the health-care community knows little about the demographic characteristics of older adults who use chiropractic services under the Medicare program. Researchers do not know the demographic composition of chiropractic users under Medicare, how the demographics of chiropractic use and rates of use have changed over time, and how users' characteristics vary geographically across the United States. An understanding of the demographics of chiropractic users can help chiropractic organizations, policy makers, and other stakeholders plan for an equitable allocation of resources to meet the chiropractic health-care needs of all of Medicare's beneficiaries.
The study intended to evaluate Medicare administrative data to determine (1) longitudinal trends in the demographic composition of the population that used chiropractic services, (2) longitudinal trends in rates of chiropractic use by demographic group, and (3) geographic variations in chiropractic use among minorities.
The research team used a serial cross-sectional design to analyze administrative data for beneficiaries of Medicare during the years 2002 to 2008, using a 20% random sample that provided those beneficiaries' racial and geographical characteristics. The team restricted the study's actual sample to adults aged 65 to 99 and defined chiropractic users as beneficiaries who had at least one paid claim for chiropractic care on a date of service in an analyzed calendar year.
Outcome Measure(s)
For each state in the United States and the District of Columbia for each of the 7 years studied, the team determined the number of chiropractic users in total and the number of users in selected demographic categories and calculated percentage estimates and averages for each category. The team analyzed 2008 data for rates of use within racial groups and for geographic variations in those rates and quantified variations in rates by state using the coeffcient of variation (CV). The team mapped race-specific rates for selected minorities, categorized by quintiles, to illustrate geographic variations by state.
Analysis by beneficiary's race showed that the proportion of chiropractic users who were white hovered at 96% to 97% throughout the time period studied, while 1% to 2% were black. Each of the other racial categories comprised 1% or less of users, and the percentages showed little change over time. Rates among racial minorities showed greater geographic variation than did rates for whites. The greatest geographic variations in use by specific racial minorities occurred among Hispanics, Asians, and Native Americans.
The research team's results showed little longitudinal variation in the demographics of chiropractic use under Medicare but a striking difference in rates of use between whites and minorities, and substantial geographic variations in user rates among racial minorities. The research team's findings suggest the possibility that barriers may exist for minorities' access to chiropractic care. As minority populations in the US continue to grow, the health-care community can expect that any impact on population health that these barriers cause will grow as well.
PMCID: PMC3590798  PMID: 23251940
21.  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.
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.
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.
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.
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.
PMCID: PMC3414681  PMID: 22487711
Chiropractic; Spinal Manipulation; Medicare
22.  Should Osteopathic Students Applying to Allopathic Emergency Medicine Programs Take the USMLE Exam? 
Board scores are an important aspect of an emergency medicine (EM) residency application. Residency directors use these standardized tests to objectively evaluate an applicant’s potential and help decide whether to interview a candidate. While allopathic (MD) students take the United States Medical Licensing Examination (USMLE), osteopathic (DO) students take the Comprehensive Osteopathic Medical Licensing Examination (COMLEX). It is difficult to compare these scores. Previous literature proposed an equation to predict USMLE based on COMLEX. Recent analyses suggested this may no longer be accurate. DO students applying to allopathic programs frequently ask whether they should take USMLE to overcome this potential disadvantage. The objective of the study is to compare the likelihood to match of DO applicants who reported USMLE to those who did not, and to clarify how important program directors consider it is whether or not an osteopathic applicant reported a USMLE score.
We conducted a review of Electronic Residency Application Service (ERAS) and National Resident Matching Program (NRMP) data for 2010–2011 in conjunction with a survey of EM residency programs. We reviewed the number of allopathic and osteopathic applicants, the number of osteopathic applicants who reported a USMLE score, and the percentage of successful match. We compared the percentage of osteopathic applicants who reported a USMLE score who matched compared to those who did not report USMLE. We also surveyed allopathic EM residency programs to understand how important it is that osteopathic (DO) students take USMLE.
There were 1,482 MD students ranked EM programs; 1,277 (86%, 95% CI 84.3–87.9) matched. There were 350 DO students ranked EM programs; 181 (52%, 95% CI 46.4–57.0) matched (difference=34%, 95% CI 29.8–39.0, p<0.0001). There were 208 DO students reported USMLE; 126 (61%, 95% CI 53.6–67.2) matched. 142 did not report USMLE; 55 (39%, 95% CI 30.7–47.3) matched (difference=22%, 95% CI 11.2–32.5, p<0.0001). Survey results: 39% of program directors reported that it is extremely important that osteopathic students take USMLE, 38% stated it is somewhat important, and 22% responded not at all important.
DO students who reported USMLE were more likely to match. DO students applying to allopathic EM programs should consider taking USMLE to improve their chances of a successful match.
PMCID: PMC3935778  PMID: 24578773
23.  A longitudinal study of chiropractic use among older adults in the United States 
Longitudinal patterns of chiropractic use in the United States, particularly among Medicare beneficiaries, are not well documented. Using a nationally representative sample of older Medicare beneficiaries we describe the use of chiropractic over fifteen years, and classify chiropractic users by annual visit volume. We assess the characteristics that are associated with chiropractic use versus nonuse, as well as between different levels of use.
We analyzed data from two linked sources: the baseline (1993-1994) interview responses of 5,510 self-respondents in the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD), and their Medicare claims from 1993 to 2007. Binomial logistic regression was used to identify factors associated with chiropractic use versus nonuse, and conditional upon use, to identify factors associated with high volume relative to lower volume use.
There were 806 users of chiropractic in the AHEAD sample yielding a full period prevalence for 1993-2007 of 14.6%. Average annual prevalence between 1993 and 2007 was 4.8% with a range from 4.1% to 5.4%. Approximately 42% of the users consumed chiropractic services only in a single calendar year while 38% used chiropractic in three or more calendar years. Chiropractic users were more likely to be women, white, overweight, have pain, have multiple comorbid conditions, better self-rated health, access to transportation, higher physician utilization levels, live in the Midwest, and live in an area with fewer physicians per capita. Among chiropractic users, 16% had at least one year in which they exceeded Medicare's "soft cap" of 12 visits per calendar year. These over-the-cap users were more likely to have arthritis and mobility limitations, but were less likely to have a high school education. Additionally, these over-the-cap individuals accounted for 58% of total chiropractic claim volume. High volume users saw chiropractors the most among all types of providers, even more than family practice and internal medicine combined.
There is substantial heterogeneity in the patterns of use of chiropractic services among older adults. In spite of the variability of use patterns, however, there are not many characteristics that distinguish high volume users from lower volume users. While high volume users accounted for a significant portion of claims, the enforcement of a hard cap on annual visits by Medicare would not significantly decrease overall claim volume. Further research to understand the factors causing high volume chiropractic utilization among older Americans is warranted to discern between patterns of "need" and patterns of "health maintenance".
PMCID: PMC3019203  PMID: 21176137
24.  The Chiropractic Care of Children 
The objective of this study was to characterize the practice of pediatric chiropractic.
The study design was a cross-sectional descriptive survey.
The settings were private practices throughout the United States, Canada, and Europe.
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.
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.
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.
PMCID: PMC3151461  PMID: 20569028
25.  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 
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.
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.
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.
PMCID: PMC4228104  PMID: 25392731
Chiropractic; X-ray; Subluxation; History; Evidence-based practice; Religion

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