Abstract Background The prevalence of headache disorders is imposing a growing burden on public health. Although most patients are seen in primary care, there is an absence of validated questionnaires designed to describe how clinicians manage patients with headache in primary care. The aim of this study was to develop a standardised headache questionnaire for use by primary care clinicians, covering diagnostic procedures, management strategies, and treatment modalities, and to assess the prevalence of consultations for headache in primary care. Methods The Danish Headache Questionnaire was developed through a three-phase process: a development phase, a content validation phase via iterative feedback, and a phase to create a generic English version. The Danish Headache Questionnaire includes a survey that covers diagnostic procedures, management strategies, and treatment modalities, and a logbook for tracking the prevalence of consultations for headaches. The questionnaire was tested by Danish chiropractors in primary care from 2020 to 2022. Results The Danish Headache Questionnaire underwent several modifications. The survey was expanded to include questions about the Danish profession-specific guideline for managing headaches, different headache types, medical history, radiographic imaging, and potential side effects. The logbook was revised to allow for the documentation of multiple headaches and included a separate form for recording the total number of consultations. The generic version was adapted by removing or adjusting profession-specific terms and questions to suit other clinical environments. The final Danish Headache Questionnaire is available in a generic and a chiropractic-specific format, and was translated to English through a cross-cultural adaptation process. Conclusions The Danish Headache Questionnaire has good content validity and is a feasible tool for assessing clinicians’ knowledge in managing patients with headaches and gathering data on headache prevalence in primary care. The generic version promotes a uniform approach and enables comparative analysis across different settings. The Danish Headache Questionnaire may be a valuable instrument guiding teaching a standardised assessment and for clinical assessment in primary care. Furthermore, it may have the potential to fill in gaps of knowledge which could improve the management of headache disorders in primary care.

Abstract Introduction Limited adoption of first line treatments for low back pain (LBP) in primary care settings may contribute to an overreliance on pain medications by primary care providers (PCPs). While chiropractic care typically includes recommended nonpharmacologic approaches (e.g., manual therapy, exercise instruction, advice on self-care), implementation strategies to increase adoption of chiropractic care for LBP in primary care clinics are understudied, particularly in underserved communities. Methods We will use a stepped-wedge cluster randomized controlled pilot trial design to evaluate the feasibility of a multi-level implementation strategy to increase adoption of chiropractic care for LBP in primary care clinics at community health centers. Key barriers and facilitators identified by site champions and other key stakeholders will help us to develop and tailor implementation strategies including educational materials and meetings, developing a network of local chiropractors, and modifying the electronic health record to facilitate referrals. Three primary care clinics will be randomized to receive the implementation strategy first, second, or third over a fourteen-month study period. At our first clinic, we will have a four-month pre-implementation period, a two-month implementation deployment period, and a subsequent eight-month follow-up period. We will stagger the start of our implementation strategy, beginning in a new clinic every two months. We will evaluate the proportion of patients with LBP who receive a referral to chiropractic care in the first 21 days after their index visit with PCP. We will also evaluate adoption of other guideline concordant care (e.g., other nonpharmacologic treatments) and non-guideline concordant care (e.g., opioids, imaging) over the study period. Discussion LBP is currently the leading cause of disability worldwide. While there are several treatment options available for individuals with LBP, patients in underserved populations do not often access recommended nonpharmacologic treatment options such as chiropractic care. The results from this study will inform the development of practical implementation strategies that may improve access to chiropractic care for LBP in the primary care context. Furthermore, results may also inform policy changes needed to expand access to chiropractic care in underserved communities. Clintrials.gov NCT# NCT06104605.

Abstract Background Evidence has been reported that spinal manipulation therapy (SMT) leads to spine segmental hypoalgesia through neurophysiological and peripheral mechanisms related to regulating inflammatory biomarker function. However, these studies also showed substantial inter-individual variability in the biomarker responses. Such variability may be due to the incomplete understanding of the fundamental effects of force-based manipulations (e.g., patient-specific force-time characteristics) on a person’s physiology in health and disease. This study investigated the short-term effects of distinct SMT force-time characteristics on blood oxidative stress and pro-resolution of inflammation biomarkers. Methods Nineteen healthy adults between 18 and 45 years old were recruited between February and March 2020 before the COVID-19 pandemic and clustered into three groups: control (preload only), target total peak force of 400 N, and 800 N. A validated force-sensing table technology (FSTT®) determined the SMT force-time characteristics. Blood samples were collected at pre-intervention, immediately after SMT, and 20 min post-intervention. Parameters of the oxidant system (total oxidant status, lipid peroxidation and lipid hydroperoxide), the antioxidant system (total antioxidant capacity and bilirubin), and lipid-derived resolvin D1 were evaluated in plasma and erythrocytes through enzyme-linked immunosorbent assay and colorimetric assays. Results The COVID-19 global pandemic impacted recruitment, and our pre-established target sample size could not be reached. As a result, there was a small sample size, which decreased the robustness of the statistical analysis. Despite the limitations, we observed that 400 N seemed to decrease systemic total oxidant status and lipid peroxidation biomarkers. However, 800 N appeared to transitorily increase these pro-oxidant parameters with a further transitory reduction in plasma total antioxidant capacity and resolvin D1 mediator. Conclusion Despite the small sample size, which elevates the risk of type II error (false negatives), and the interruption of recruitment caused by the pandemic, our findings appeared to indicate that different single SMT force-time characteristics presented contrasting effects on the systemic redox signalling biomarkers and pro-resolution of inflammation mediators in healthy participants. The findings need to be confirmed by further research; however, they provide baseline information and guidance for future studies in a clinical population.

Abstract Background Chronic low back pain (CLBP) presents a significant challenge for manual therapists. Recent advancements in pain research have highlighted the limitations of the traditional biomedical and biopsychosocial models, prompting the exploration of alternatives. The biopsychosocial-enactive (BPS-E) model has emerged as a promising alternative. This study aims to explore the application of the BPS-E model by manual therapists in managing CLBP and to initiate a meaningful dialogue about its use. Methods This study adhered to the Standards for Reporting Qualitative Research. Guided by constructivist grounded theory, we conducted semi-structured interviews with ten manual therapists who are experts in the BPS-E model. Data collection, conceptualization, and analysis were systematically carried out to identify key themes and insights. Results The core theme identified was “The person-centred approach,” with three subthemes: “Opportunities in implementing the model”, “Utilizing and Integrating Diverse Skills for Holistic Care”, and “Challenges in implementing the model”. Conclusion This study provides insights into how manual therapists incorporate the BPS-E model in their practice, demonstrating its advantages over the traditional biopsychosocial model. The findings highlight the need for further research and training to effectively implement the BPS-E model in clinical settings. This research begins an essential discussion on the potential of the BPS-E model to enhance care for CLBP patients.

Abstract Background There is limited high-quality research examining conservative treatments for back-related leg pain (BRLP). This feasibility study was done in preparation for a full-scale trial comparing a whole-person supported self-management intervention to medical care for chronic BRLP. Methods Participants were randomized to 12 weeks of individualized supported self-management delivered by physical therapists and chiropractors or medical care consisting of guideline-based pharmacologic care. Supported self-management was based on a behavioral model that used a whole person approach to enhance participants capabilities, opportunities, and motivations to engage in self-care. It combined BRLP education with psychosocial strategies (e.g., relaxed breathing, progressive muscle relaxation, guided imagery, communication skills) and physical modalities such as exercise and spinal manipulation therapy. Providers were trained to address participants’ individualized needs and use behavior change and motivational communication techniques to develop a therapeutic alliance to facilitate self-management. Feasibility was assessed using pre-specified targets for recruitment and enrollment, intervention delivery, and data collection over the six-month study period. In addition, areas for potential refinement and optimization of processes and protocols for the full-scale trial were assessed. Results We met or exceeded nearly all feasibility targets. Forty-two participants were enrolled over a six-month period in 2022 and very few individuals declined participation due to preferences for one treatment. All but one participant received treatment and 95% of participants attended the minimum number of visits (self-management = 6, medical care = 2). At 12 weeks, 95% of participants in the self-management group reported engaging in self-management practices learned in the program and 77% of medical care participants reported taking medications as prescribed. Satisfaction with the self-management intervention was high with 85% of participants reporting satisfaction with the program overall. Self-management intervention providers delivered all required activities at 72% of visits. Providers also noted some challenges navigating the shared decision-making process and deciding what self-management tools to prioritize. Over the six-month study period, completion rates were 91% for monthly surveys and 86% for weekly surveys. Conclusion We were able to demonstrate that a full-scale randomized trial comparing a whole-person supported self-management intervention to medical care for chronic BRLP is feasible and identified important areas for optimization.

Abstract Background A significant body of research has examined how the attire of physicians and nurses affects patients’ perceptions, preferences, and outcomes. However, limited research has focused on the clothing worn by other health professionals, such as chiropractors. The present study aims to explore patients’ preferences and perceptions of chiropractors’ attire. Methods Using a cross-sectional image-based procedure, new patients to a university clinic were questioned regarding their preferences for four different attires (casual, formal, scrub, and white coat) worn by both a male and a female chiropractor. Patients also reported their perceptions in terms of chiropractors’ knowledge, trustworthiness, competence, professionalism, and comfortable for each photograph. Results From August 10, 2022, to January 23, 2023, 75 new patients participated in the study. Results indicated a strong preference for scrubs for both male and female chiropractors. Chiropractors in scrubs were also seen as more knowledgeable, trustworthy, competent, and professional, and comfortable. This was closely followed by those wearing white coats and formal attire. Notably, the white coat worn by the female chiropractor received significantly more positive ratings than when worn by her male counterpart. Conclusion In conclusion, our findings suggest that chiropractors’ attire influences patients’ perceptions and should be considered in the development of dress codes for public and private clinics. Further research is essential to understand better how the gender and age of care providers affect patient evaluations.

Abstract Background Blinding is essential for mitigating biases in trials of low back pain (LBP). Our main objectives were to assess the feasibility of blinding: (1) participants randomly allocated to active or placebo spinal manual therapy (SMT), and (2) outcome assessors. We also explored blinding by levels of SMT lifetime experience and recent LBP, and factors contributing to beliefs about the assigned intervention. Methods A two-parallel-arm, single-centre, placebo-controlled, blinding feasibility trial. Adults were randomised to active SMT (n = 40) or placebo SMT (n = 41). Participants attended two study visits for their assigned intervention, on average seven days apart. The primary outcome was participant blinding (beliefs about assigned intervention) using the Bang blinding index (BI) at two study visits. The Bang BI is arm-specific, chance-corrected, and ranges from − 1 (all incorrect beliefs) to 1 (all correct beliefs), with 0 indicating equal proportions of correct and incorrect beliefs. Secondary outcomes included factors contributing to beliefs about the assigned intervention. Results Of 85 adults screened, 81 participants were randomised (41 [51%] with SMT lifetime experience; 29 [39%] with recent LBP), and 80 (99%) completed follow-up. At study visit 1, 50% of participants in the active SMT arm (Bang BI: 0.50 [95% confidence interval (CI), 0.26 to 0.74]) and 37% in the placebo SMT arm (0.37 [95% CI, 0.10 to 0.63]) had a correct belief about their assigned intervention, beyond chance. At study visit 2, BIs were 0.36 (0.08 to 0.64) and 0.29 (0.01 to 0.57) for participants in the active and placebo SMT arms, respectively. BIs among outcome assessors suggested adequate blinding at both study visits (active SMT: 0.08 [− 0.05 to 0.20] and 0.03 [− 0.11 to 0.16]; placebo SMT: − 0.12 [− 0.24 to 0.00] and − 0.07 [− 0.21 to 0.07]). BIs varied by participant levels of SMT lifetime experience and recent LBP. Participants and outcome assessors described different factors contributing to their beliefs. Conclusions Adequate blinding of participants assigned to active SMT may not be feasible with the intervention protocol studied, whereas blinding of participants in the placebo SMT arm may be feasible. Blinding of outcome assessors seemed adequate. Further methodological work on blinding of SMT is needed. Trial registration number NCT05778396.

Abstract Objectives To describe the structure and development of a new international, chiropractic, practice-based research network (PBRN), the Chiropractic International Research Collaborative (CIRCuit), as well as the demographic, practice, and clinical management characteristics of its clinician participants. An electronic survey was used to collect information on their demographics, practice, and clinical management characteristics from clinicians from 17 October through 28 November 2022. Descriptive statistics were used to report the results. Background PBRNs are an increasingly popular way of facilitating clinic-based studies. They provide the opportunity to collaboratively develop research projects involving researchers, clinicians, patients and support groups. We are unaware of any international PBRNs, or any that have a steering group comprised of equal numbers of clinicians representing the different international regions. Results 77 chiropractors responded to the survey (0.7% of EBCN-FB members). 48 were men (62%), 29 women (38%). Thirty-six (47%) were in North America, 18 (23%) in Europe, and 15 (19%) in Oceania. Participants reported predominantly treating musculoskeletal issues, often with high-velocity, low-amplitude spinal manipulation (95%), but also with soft tissue therapy (95%), exercise (95%), and other home care (up to 100%). Methods The development of CIRCuit is described narratively. Members of the Evidence-Based Chiropractic Network Facebook group (EBCN-FB) were invited to become clinician participants by participating in the survey. Conclusions This paper describes the development of a new PBRN for chiropractors. It offers a unique opportunity to facilitate the engagement of clinical chiropractors with research, as well as for academics to readily be able to access an international cohort of clinicians to collaboratively develop and conduct research. Although the results of the survey are not statistically generalisable, the initial cohort of CIRCuit clinician participants use similar techniques on similar types of conditions as the profession at large. The international structure is unique among PBRNs and offers the opportunity to help develop innovative research projects.

Abstract Background Some chiropractors use spinal x-rays to inform care, but the relationship between radiographic findings and outcomes is unclear. This study examined the association between radiographic findings and 30% improvement in back-related disability in older adults after receiving 12 weeks of chiropractic spinal manipulation and home exercise instruction. Methods This IRB-approved secondary analysis used randomized trial data of community-dwelling adults age ≥ 65 with chronic spinal pain and disability. Data were collected during the parent trial between January 2010-December 2014. The primary outcome of the parent study was ≥ 30% improvement in Oswestry Disability Index (ODI) at 12 weeks, a clinically important response to care. In this secondary analysis, two chiropractic radiologists independently assessed digital lumbar radiographs for pre-specified anatomic, degenerative, and alignment factors; differences were adjudicated. The unadjusted association between baseline radiographic factors and 30% ODI improvement was determined using chi-square tests. Results From the parent trial, 120 adults with baseline lumbar radiographs were included in this study. Mean age was 70.4 years (range 65–81); 59.2% were female. Mean baseline disability (ODI = 25.6) and back pain (5.2, 0–10 scale) were moderate. Disc degeneration (53.3% moderate, 13.3% severe), anterolisthesis (53.3%), retrolisthesis (36.6%) and scoliosis (35.0%) were common among the participant sample. After 12-weeks of treatment, 51 (42.5%) participants achieved 30% improvement in back disability. No alignment, degenerative, or anatomic factors were associated with ODI improvement at 12 weeks (all p > 0.05), regardless of severity of radiographic findings. Conclusion We found no association between a predetermined subset of radiographic findings and improvement in back-related disability among this sample of older adults. As such, this study provides preliminary data suggesting that imaging may be unhelpful for predicting response to chiropractic spinal manipulation and home exercise.

Abstract Background Spinal manipulation (MAN) and mobilization (MOB) are biomechanically different yet both elicit pain reduction and increased range of motion. Previous investigations have focused on quantifying kinetics (e.g., applied forces) or, recipient kinematics (i.e., movements) during MAN and MOB. While these studies provide valuable information, they do not report on the strategies adopted by providers when performing the complex motor tasks of MAN and MOB. This review sought to synthesise the literature reporting on provider kinematics during the delivery of MAN and MOB. Methods This scoping literature review is reported following the Preferred Reporting Items for Scoping Reviews (PRISMA-ScR) statement. MEDLINE (Ovid), PsychINFO, Cochrane Library, Web of Science, Embase, Scopus, PEDro, ICL and CINAHL databases were searched from inception to September 2023 for terms relating to provider kinematics during the delivery of MAN and MOB. Data were extracted and reported descriptively, including: general study characteristics, number and characteristics of individuals who delivered/received MAN and/or MOB, region treated, equipment used and kinematic parameters of the individual delivering the procedure. Results Of 4,844 records identified, five (0.1%) fulfilled the eligibility criteria and were included in the analysis. Of these, provider kinematics were reported for the delivery of MAN in four (80%) and for the delivery of MOB in one (20%) article. Practitioners applied the procedure in all (100%) and students in one (20%) study. Spinal regions treated were: lumbar (n = 4), thoracic (n = 2) and cervical (n = 1). Data were reported heterogeneously but were most commonly captured using either video or motion capture equipment (n = 4, 80%). The direction of applied force was fully reported in one (20%) and only partially reported (one spinal region) in another study. Conclusions There are a small number of studies reporting heterogeneously on provider kinematics during the delivery of MAN and MOB. Clear reporting of the procedure from a biomechanical perspective and of the measurement equipment used could enable future meta-analysis of provider kinematic data, the use of provider kinematic data in the development of technique skills curricula and could feasibly be used to mitigate risk of injury for providers.

Abstract Background Diagnostic imaging is commonly used in the management of low back pain (LBP), with approximately one-quarter of those who present to primary care referred for imaging. Current estimates of imaging frequency commonly exclude older adults; however, pathology detected with imaging (e.g., osteoporosis, cancer) may occur more frequently in older populations. The aims of this study were to: (i) determine the frequency and forms of diagnostic imaging use in older adults presenting for chiropractic care for LBP in Australia; (ii) describe participant characteristics associated with imaging use; and (iii) describe the types of radiographic findings. Methods Data were collected from the BAck Complaints in Elders: Chiropractic-Australia (BACE: C-A) study, a 12-month, prospective cohort study of adults aged ≥ 55 years with a new episode of LBP. Self-reported frequency of imaging use (baseline, 2 and 6 weeks, 3, 6, 9, and 12 months) was reported descriptively by imaging modality. Imaging reports were obtained, and imaging findings were independently extracted and categorised. Baseline characteristics were assessed for differences in those who received imaging compared to those who did not. Proportions of imaging use and imaging findings were presented descriptively with 95% confidence intervals. Results The BACE: C-A cohort comprised 217 participants of whom 60.8% reported receiving diagnostic imaging for their current episode of LBP. X-ray was performed most (44.7%), followed by computed tomography (CT) (30.8%). Participants receiving imaging reported higher low back disability, more healthcare use for LBP, more frequent leg pain, more suspected serious pathology, and stronger beliefs that imaging was important. Degenerative changes were the most common imaging finding (96.6%). Pathology of possible clinical significance, including compression fracture or suspected osteoporosis, was present in 15.5% of participants. Conclusion Three out of five older adults with LBP who sought chiropractic care received imaging over one-year. Participants receiving imaging tended to have more complex presentations (e.g., more disability, suspected underlying pathology) or stronger beliefs that imaging was necessary for the management of LBP. Degenerative changes were the most common imaging finding. Pathology of potential clinical relevance was present on approximately 15% of imaging reports received. No conditions requiring immediate medical attention were reported.

Abstract Background Despite the progress made in better understanding the potential mechanisms of spinal manipulative therapy (SMT) and its treatment effects, a knowledge gap continues to exist when identifying the specific factors that contribute to the perceived treatment effect associated with SMT. The purpose of the study was to explore the perceptions of chiropractic clinicians, interns, and patients regarding what factors during a doctor-patient encounter contribute to the perceived treatment effect associated with SMT. Methods This study used convenience sampling to enroll participants from a chiropractic teaching clinic in the United States. Semi-structured interviews were used as the main form of data collection, which took place from January-April 2024. The data was subsequently analyzed using thematic analysis and organized into themes through an iterative open coding process. Results Six rounds of interviews were conducted for a total of 18 interviews. Each round consisted of one patient who received treatment including SMT, one intern who performed the treatment, and one clinician who oversaw the treatment. After analyzing the interview data, the following five themes were identified: Treatment Outcome, Therapeutic Alliance, Adjunctive Therapies, Significance of Cavitation, and Psychomotor Skills. Each theme consisted of multiple subthemes which were mentioned by the participant groups at varying frequencies. Patients frequently mentioned the importance of improvement in symptoms following treatment, as well as good communication skills and the use of adjunctive therapies. Interns valued functional change following treatment, while clinicians focused on confidence levels and psychomotor skills. There were differing views on the significance of cavitation, ranging from indifference to an indication of a successful treatment. Conclusion This qualitative study identified several themes which describe factors that may contribute to the perceived effect associated with SMT. In addition to the psychomotor skills required to perform SMT, educators and practitioners should consider factors such as the therapeutic alliance between patient and provider, use of adjunctive therapies, and assessment of the outcome associated with the intervention.

Abstract Background Rotator cuff repair (RCR) is one of the most prevalent procedures to manage rotator cuff tears (RCT). Postoperative shoulder pain is a common complication following RCR and may be aggravated by activation of myofascial trigger points (MTrP) associated with the injury to the soft tissues surrounding the surgical incision. This study aimed to describe a preliminary, randomized, sham-controlled trial to evaluate the effectiveness of implementing 4 sessions of myofascial trigger point dry needling (MTrP-DN) as a muscle treatment approach along with 10 sessions of multimodal rehabilitation protocol (MRh) consisting of therapeutic exercise, manual therapy, and electrotherapy on postoperative shoulder pain, range of motion (ROM), strength, and functional outcome scores for patients following RCR surgery. Methods Forty-six patients aged 40–75 following RCR surgery were recruited and randomly allocated into 2 groups: (1) MTrP-DN plus MRh (experimental group), and (2) sham dry needling (S-DN) plus MRh (control group). This trial had a 4-week intervention period. The primary outcome was the Numeric Pain Rating Scale (NPRS) for postoperative shoulder pain. Secondary outcomes were the Shoulder Pain and Disability Index (SPADI), ROM, and strength. The mentioned outcomes were measured at baseline and week 4. In the current study, adverse events were recorded as well. Results No statistically significant differences were observed between groups when adding MTrP-DN to MRh for postoperative shoulder pain after 4 weeks of intervention (mean difference 0.32, [95% CI -0.41,1.05], p = 0.37). However, this trial found a small effect size for postoperative shoulder pain. No significant between-group differences were detected in any of the secondary outcomes (p > 0.05) either. We found significant within-group changes in all studied outcome measures. (p < 0.001). This study also reported minor adverse events. following the needling approach. Conclusion The lack of statistically significant differences in the outcomes and small clinical significance in shoulder pain highlights the complexity of pain management, suggesting that alternative methodologies may be needed for meaningful clinical benefits. Future studies should consider different control groups, long-term follow ups, larger sample sizes, and more MTrP-DN sessions to better understand their potential impact. Trial registration This trial was registered at (https://www.irct.ir), (IRCT20211005052677N1) on 19/02/2022.

Abstract Background The Foot Function Index (FFI) is a reliable and widely used standardized questionnaire that measures the impact of foot pathology on function. With 571 million Hindi-speaking people living globally and an increasing incidence of foot-related pathologies, it is imperative to cross-culturally translate and adapt a Hindi version of the FFI (FFI-Hi). We aimed to translate, cross-cultural adapt, and psychometrically test the FFI-Hi for use in Hindi-speaking individuals with foot conditions. Methods The translation of FFI-Hi was performed according to guidelines given by MAPI Research Trust. A total of 223 Hindi-speaking participants afflicted with foot conditions completed the FFI-Hi alongside the Short Form 36 (SF-36) questionnaire. The study duration spanned between October 2023 and January 2024. The initial phase was the translation and adaptation of FFI to cultural context. Followed by testing of psychometric properties involving of 133 participants for the test-retest reliability of FFI-Hi after a 7-day interval. Results The mean age of the participants was 47.10 (± 8.1) years. The majority of the participants were male (n = 148, 66.4%) and the most common foot condition was plantar fasciopathy (n = 91, 40.8%). The mean score of FF-Hi was 33.7 ± 11.7. The internal consistency of FFI-Hi was good with the Cronbach’s alpha (α) value of 0.891 and excellent reproducibility with the intra-class correlation of 0.90. The 95% minimal detectable change (MCD) and the standard error of measurement of the FFI-Hi was 22.02 and 7.94 respectively. Convergent validity between FFI-Hi subscales and SF-36 domains was moderate. Factor analysis corroborated the multidimensional nature of the FFI-Hi. Conclusion The FFI-Hindi version was successfully cross-culturally adapted, translated and demonstrated acceptable psychometric properties to be used in clinical practice and research. Further, the context-specific Hindi language version of FFI will enhance the utility of FFI in foot function evaluation and remove language barrier in patients reporting disability and activity limitation related to foot conditions. Registration Clinical Trials Registry of India (CTRI/2023/07/055734).

Abstract Background The Canadian Chiropractic Association (CCA) initiated a quality improvement project to develop best practices aimed at enhancing the patient experience. Objectives (1) Identify and prioritise the key moments in the new patient experience that could be improved by providing chiropractors with focused support and resources; (2) explore views, barriers, and enablers to implementing these best practices; and (3) develop recommendations to facilitate the adoption of these practices. Methods We conducted a qualitative needs assessment using a human-centred design approach, focused on understanding the needs and experiences of end-users to create tailored solutions. The Theoretical Domains Framework (TDF) was employed to explore chiropractors’ knowledge use and behaviour change, and TDF domains were mapped to Behaviour Change Techniques (BCTs) to develop targeted strategies for addressing identified barriers and enablers. Thirteen chiropractors from across Canada participated in semi-structured interviews and related activities. Results The key moments where participants felt they needed the most support were “treatment”, “report of findings”, “informed consent”, “physical examination”, and “before the appointment”. All participants agreed with the best practices seed statements. Key barriers included gaps in knowledge, communication skills, and resource availability, particularly in rural areas. Enablers included collaboration with other health professionals, mentorship, and access to practice tools. Recommendations include enhanced training in communication and treatment planning, increased access to resources in rural areas, and fostering collaborative relationships among health professionals. Conclusion Understanding the barriers and enablers to implementing best practices can inform targeted strategies to improve patient-centred care in chiropractic practice across Canada.

Abstract Background Chiropractors and chiropractic students commonly report low back pain (LBP). However, the burden of LBP in this occupational group has not been synthesized in the literature. This systematic review aims to describe the epidemiology of LBP in chiropractors and chiropractic students. Methods We searched MEDLINE, Embase, CINAHL, and PsycINFO from inception to May 1, 2023. Eligible studies were cross-sectional, cohort, or case–control studies investigating the prevalence, incidence, associated factors, or risk factors of LBP in chiropractors or chiropractic students. Reviewers independently screened articles and assessed risk of bias using the appropriate JBI Checklists for the observational study design. We descriptively synthesized studies that were rated as low or moderate risk of bias. Results Of 2012 citations screened, we included 2 cross-sectional studies in the evidence synthesis (1 study rated as moderate risk of bias on chiropractors, and 1 rated as low risk of bias on chiropractic students). For chiropractors, the 12-month prevalence of work-related overuse injuries to the low back was 35.6% (95% CI 29.1, 42.0) in women and 22.4% (95% CI 16.3, 29.6) in men. The 12-month prevalence of work-related acute physical injuries to the low back in chiropractors were 3.4% (95% CI 1.6, 6.8) for women and 0.7% (95% CI 0.1, 3.7) for men. Among chiropractic students, the 1-week prevalence of LBP was 69% (95% CI 64.8, 73.0). This was higher among female students (72.5%, 95% CI 67.1, 77.4) and lower among male students (64%, 95% CI 57.0, 70.6). Conclusion There is limited high-quality evidence on the epidemiology of LBP in chiropractors and chiropractic students. Our systematic review provides a synthesis of the body of literature, highlighting that chiropractors and chiropractic students commonly report LBP. Future high-quality research is needed to address the incidence, associated factors, and risk factors of LBP.

Abstract Background Research enables a profession to establish its cultural authority, validate its professional roles and ensure ongoing improvement in the quality of its academic programming. Despite the clear importance of research, a mature research culture has eluded the chiropractic profession. A fostering institutional culture that enables, values, and supports research activity is essential to building research capacity. Our study aimed to collect information about the existing research capacity and culture at the Canadian Memorial Chiropractic College (CMCC) and explore the views, attitudes and experiences of faculty members regarding research. Methods We conducted a sequential explanatory mixed methods study with quantitative priority between April and July, 2023. Quantitative data were collected using the Research Capacity and Culture (RCC) tool. Survey results guided the qualitative data collected from four faculty focus groups with varying levels of research experience. Quantitative data were analyzed using descriptive statistics by domain and stratified by research education and workload. The qualitative data were thematically analyzed and then integrated with the quantitative results to provide deeper meaning to the results. Results The faculty survey response rate was 42% (59/144). Attributes at the organization or department level were consistently rated as either moderate or high; however, research skills at an individual level were more variable and influenced by factors such as research workload and highest research-related academic qualification. Qualitative focus group data were categorized under four themes: institutional factors, resource allocation, career pathways and personal factors. Lower scores for survey items related to mentorship, research planning and ensuring faculty research career pathways, as well as the identified workload and time-related barriers (e.g., other work roles and desire for work/life balance) for engaging in research were supported by each of the four themes. Research motivators included keeping the brain stimulated, developing skills and increasing job satisfaction. Conclusion The quantitative and qualitative information in this study provides a baseline evaluation for RCC and identifies key factors impacting RCC at the CMCC. This information is critical for planning, developing, implementing, and evaluating future interventions to enhance research capacity. Ultimately, these efforts are aimed at maturing the research culture of the chiropractic profession.

Abstract Background As part of multimodal therapy, spinal manipulation (SM) is a recommended and effective treatment for musculoskeletal pain. However, the underlying physiological mechanisms for pain relief are largely unknown. SM thrusts can be described and quantified using force–time characteristics (e.g. preload force, peak force, thrust speed, thrust duration, and thrust impulse). If these biomechanical parameters of SM are important for clinical outcomes, a large variability in the delivery of SM could lead to inconsistent responses and could thereby potentially mask a significant clinical effect. Our goal was to determine variability, and repeatability of thoracic spinal manipulation (SM) force–time profiles in a sample of Swiss chiropractors. Methods All interventions were performed on a human analogue manikin. Participating chiropractors received three case scenarios with the following scenarios: 50-year-old male patient, 30-year-old male athlete, and a 70-year-old female patient, each presenting with uncomplicated musculoskeletal thoracic pain. Clinicians were asked to perform three consecutive thoracic SM thrusts for each of the scenarios and repeated the same interventions after 24–48 h. Results Eighty-one chiropractors participated in the study, including 32 females (39.5%) with a mean age of 45.22 ± 12.96 years. The variability in SM force–time characteristics between clinicians was substantial, with preload forces ranging from 4.50 to 450.25 N and peak forces ranging from 146.08 to 1285.17 N. Significant differences between case scenarios were observed for peak force (p < 0.0001), maximum thrust speed (p = 0.0002), and thrust impulse (p = 0.0004). Except for thrust duration, repeatability within and between sessions was fair to excellent (ICCs between 0.578 and 0.957). Conclusion Substantial variability in application of SM was evident across clinicians and between case scenarios. Despite substantial clinician-dependent variability, the high repeatability of thoracic SM thrusts suggests a level of standardization in SM delivery, indicating that chiropractors might have ‘their’ individual force–time profile that they are capable to reproduce. Further research based on these findings should explore how to enhance the consistency, effectiveness, and safety of thoracic SM delivered clinically to humans.

Abstract Background Spinal manipulative therapy (SMT) is a guideline-recommended care for musculoskeletal pain taught in various undergraduate programs. Visual feedback through force-sensing tables can improve modulation of SMT force–time characteristics and, potentially, students’ confidence, both factors important for clinical competence and patient outcomes. However, it is unclear if a link exists between students’ confidence and ability in SMT force–time modulation. We aim to investigate this relationship and whether it was moderated by experience. Methods This cross-sectional study recruited first- to third-year Canadian Memorial Chiropractic College students. Participants provided information about their confidence in performing SMT using different impulse forces of 200N, 400N, and 800N with a pre-established pre-load and a time-to-peak force < 150ms. SMT impulse forces of 200N, 400N, and 800N were targeted on a Human Analogue Mannequin positioned prone on a force-sensing table. We described the confidence levels and SMT force–time characteristics and assessed their association using linear mixed models. We re-ran the models interacting with SMT experience. The order of the three SMT impulse forces was randomly performed. Participants and outcome assessors were blinded to force–time characteristics recordings. Results One-hundred-and-forty-nine participants provided usable data. Participants were confident in delivering 200N and 400N impulse forces. However, confidence decreased for 800N forces. Accordingly, participants performed impulse forces close to the 200N and 400N but had difficulty accurately modulating to 800N forces. A positive association was found between confidence and the ability to modulate their force–time characteristics, especially keeping the same pre-load force, keeping the time to peak force < 150ms, and providing the 800N impulse force. This association was not moderated by experience. Conclusions Students were more confident in their abilities to perform lower SMT forces but lacked confidence in their abilities to perform higher (800N) forces. This aligned with their skills, as many struggled to apply 800N force. However, students who had higher confidence levels generally performed better overall. There was substantial variability in SMT force–time characteristics, which may have implications for adverse events and patient satisfaction. Some of this variability could be attributed to students’ confidence. Thus, further investigations are necessary in undergraduate settings to implement and optimize these findings. Registration https://osf.io/6f7d5

Abstract Background The increasing prevalence of mental health disorders in the United Kingdom necessitates the exploration of novel treatment modalities. This study aimed to assess the feasibility and acceptability of conducting a randomised controlled trial (RCT) evaluating the efficacy of four osteopathic interventions on psychophysiological and mental health outcomes. Methods A mixed-methods feasibility study with an explanatory sequential design was implemented. The quantitative phase involved randomising 42 participants into four intervention groups: (1) high-velocity and articulation techniques (HVAT), (2) soft-tissue massage (STM), (3) craniosacral therapy (CST), and (4) a combination approach. Primary outcome measures encompassed recruitment rate, assessment duration, questionnaire completion, intervention attrition, and adverse events. Secondary outcomes included validated assessments of depression, anxiety, stress, psychological flexibility, heart rate variability (HRV), and interoception, administered pre- and post-intervention. Analysis of variance (ANOVA) was employed to evaluate pre-post intervention changes. The qualitative phase comprised semi-structured interviews analysed using thematic analysis. Results The study achieved a recruitment rate of 21 eligible participants per month, with 54.8% of respondents meeting eligibility criteria. All 33 participants who completed the study underwent interventions and assessments within the allocated one-hour timeframe, with full questionnaire completion. The attrition rate was 21%. No adverse events were reported. Qualitative analysis revealed positive participant experiences, with themes highlighting good practitioner communication, intervention accessibility, and increased bodily awareness. Some participants found the questionnaire battery burdensome. Exploratory quantitative analyses showed variations in effects across interventions for heart rate variability, interoceptive accuracy, and mental health measures, but these results should be interpreted cautiously due to the small sample size. Conclusions This study provides evidence supporting the feasibility and acceptability of a larger-scale RCT investigating osteopathic interventions for individuals presenting with mild psychological symptoms. The preliminary findings suggest potential efficacy in improving mental health outcomes, warranting further investigation. Trial registration NCT05674071, registered 06/01/2023.

Abstract Background To describe the societal costs during one year of follow-up among older adults seeking chiropractic care due to a new episode of low back pain (LBP), and to determine what factors predict high societal costs in this population. Methods Prospective cohort study, within chiropractic private practices (n = 38) in the Netherlands. 223 people ≥ 55 years of age with a new episode of LBP seeking chiropractic care participated. The primary outcome was total societal costs. High societal costs were defined as patients with costs in the top 20th percentile. The final prediction models were obtained using forward selection. Results were presented for the total population and stratified for retirement status. The model’s prognostic accuracy (Hosmer–Lemeshow X2, Nagelkerke’s R2) and discriminative ability [area under the receiver operating curve (AUC)] were assessed, and the models were internally validated using bootstrapping. Results The mean total annual societal cost per patient was €5297 [95% confidence interval (CI): 4191–6403]. The biggest cost driver was presenteeism (65% of total costs), and costs were higher among non-retired participants (€7759; 95% CI 6047–9470) than retired participants (€1892; 95% CI 1088–2695). In the total population, younger age [odds ratio (OR): 0.87 for each additional year; 95% CI 0.80–0.95], being male instead of female (OR 2.96; 95% CI 1.19–7.44), less alcohol intake (OR 0.49; 95% CI 0.20–1.19), working instead of retirement (OR 9.37; 95% CI 1.83–48.04), and more disability at baseline (OR 1.08; 95% CI 1.00–1.16) were found to be predictive of high societal costs. Working was found to be the strongest predictor for high societal costs. After internal validation, the model’s fit was good, it’s explained variance was moderate (28%) and their AUCs could be interpreted as moderate (0.85). For non-pensioners, the same predictive factors were identified as for the entire population. The costs for the retired participants showed too little variation to be able to predict high costs. Conclusions This study estimated the mean total annual societal cost of older adults seeking chiropractic care due to a new episode of LBP at €5297 (95% CI 4191–6403).These costs were mainly due to high levels of presenteeism, and extensively differed based upon work status.

Abstract Background Despite increases in musculoskeletal disorders (MSD) in Canada, evidence suggests utilization of chiropractic services has remained relatively stable over time. Understanding the extent to which chiropractors are consulted and factors associated with their utilization may suggest factors related to accessing care. We assessed the change in prevalence and characteristics of Canadians seeking chiropractic care across two time periods 2001–2010 and 2015–2018. Methods We used national cross-sectional data from seven cycles of the Canadian Community Health Survey between 2001 and 2018. The survey included Canadians aged 12 years and older living in private dwellings in all provinces and territories. National annual weighted prevalence and age-standardized weighted prevalence (and 95% confidence intervals) of chiropractic utilization were calculated. We calculated prevalence of chiropractic utilization stratified by demographic, socioeconomic, lifestyle and health-related variables. Crude linear trends and change in prevalence from 2001 to 2010 were assessed using linear regression models. Results The national annual prevalence of Canadians consulting a chiropractor in the previous 12 months slightly increased from 11.0% (95% CI 10.8, 11.3) in 2001 to 11.4% (95%CI 11.1, 11.7) in 2010, and in those reporting receiving regular health care from a chiropractor from 7.5% (95%CI 7.2, 7.7) in 2015 to 7.9% (95%CI 7.7, 8.2) in 2018. Prevalence of utilization varied by province, highest in the Western provinces but lowest in Atlantic provinces. The age-specific prevalence of chiropractic utilization was highest in those aged 35–49 years and remained stable over time, except for slight increase in those aged 65–79 years. A higher percentage of Canadians identifying as white, Canadian-born, in the highest quintile of household income, overweight, physically active and in excellent health reported seeking chiropractic services. The most common reported chronic conditions measured in the survey among Canadians consulting chiropractors were chronic back problems, arthritis, fibromyalgia and headaches. Conclusion The national prevalence of utilization of chiropractic services among Canadians slightly increased over time but varied by province and respondents’ socioeconomic and health characteristics. Chronic back problems were the most common reported chronic condition. This comprehensive population-based study on chiropractic utilization in Canada can be used to inform decisions concerning health human resources and access to rehabilitation care for MSD.

Abstract Objective The purpose of this scoping review was to summarize the literature pertaining to burnout and chiropractic. Methods A literature review was performed in accordance with Preferred Reporting of Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR). A literature review was performed by combining the term “chiropractic” with terms relevant to professional burnout (e.g., “work-related stress,” “emotional exhaustion”). We included all publications addressing burnout within the chiropractic profession, including all study designs in only peer-reviewed literature. Results Our search yielded 126 citations and 10 met the inclusion criteria. The studies identified consisted of eight surveys and two narrative reviews published from 2011 to 2024. Six of the studies utilized the Maslach Burnout Inventory to assess burnout. Chiropractic students reported greater burnout than the general population. Factors reported to increase burnout risk include higher workload, insurance mandates, and physical demands of daily practice. Factors reported to be protective against burnout included longer duration in clinical practice and philosophy-based practices. Conclusions Research on burnout within the chiropractic profession is limited and may not be generalizable. However, the reported factors contributing to burnout are well-documented. Future research should be conducted to improve understanding of the prevalence and causes of burnout in chiropractic.

Abstract Background Spinal manipulation (SM) has been claimed to change anatomy, either in structure or position, and that these changes may be the cause of clinical improvements. The aim of this systematic review was to evaluate and synthesise the peer-reviewed literature on the current evidence of anatomical changes in response to SM. Methods The review was registered with PROSPERO (CRD42022304971) and reporting was guided by the standards of the PRISMA Statement. We searched Medline, Embase, CINAHL, AMED, Cochrane Library all databases, PEDro, and the Index to Chiropractic Literature from inception to 11 March 2022 and updated on 06 June 2023. Search terms included manipulation, adjustment, chiropractic, osteopathy, spine and spine-related structures. We included primary research studies that compared outcomes with and without SM regardless of study design. Manipulation was defined as high-velocity, low-amplitude thrust delivered by hand to the spine or directly related joints. Included studies objectively measured a potential change in an anatomical structure or in position. We developed a novel list of methodological quality items in addition to a short, customized list of risk of bias (RoB) items. We used quality and RoB items together to determine whether an article was credible or not credible. We sought differences in outcomes between SM and control groups for randomised controlled trials and crossover studies, and between pre- and post-SM outcomes for other study designs. We reported, in narrative form, whether there was a change or not. Results The search retrieved 19,572 articles and 20 of those were included for review. Study topics included vertebral position (n = 3) facet joint space (n = 5), spinal stiffness (n = 3), resting muscle thickness (n = 6), intervertebral disc pressure (n = 1), myofascial hysteresis (n = 1), and further damage to already damaged arteries (n = 1). Eight articles were considered credible. The credible articles indicated that lumbar facet joint space increased and spinal stiffness decreased but that the resting muscle thickness did not change. Conclusion We found few studies on this topic. However, there are two promising areas for future study: facet joint space and spinal stiffness. A research strategy should be developed with funding for high quality research centres.