Dana J. Lawrence

Chiropractic as spine care: a model for the profession

BackgroundMore than 100 years after its inception the chiropractic profession has failed to define itself in a way that is understandable, credible and scientifically coherent. This failure has prevented the profession from establishing its cultural authority over any specific domain of health care.ObjectiveTo present a model for the chiropractic profession to establish cultural authority and increase market share of the public seeking chiropractic care.DiscussionThe continued failure by the chiropractic profession to remedy this state of affairs will pose a distinct threat to the future viability of the profession. Three specific characteristics of the profession are identified as impediments to the creation of a credible definition of chiropractic: Departures from accepted standards of professional ethics; reliance upon obsolete principles of chiropractic philosophy; and the promotion of chiropractors as primary care providers. A chiropractic professional identity should be based on spinal care as the defining clinical purpose of chiropractic, chiropractic as an integrated part of the healthcare mainstream, the rigorous implementation of accepted standards of professional ethics, chiropractors as portal-of-entry providers, the acceptance and promotion of evidence-based health care, and a conservative clinical approach.ConclusionThis paper presents the spine care model as a means of developing chiropractic cultural authority and relevancy. The model is based on principles that would help integrate chiropractic care into the mainstream delivery system while still retaining self-identity for the profession.

Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis.

OBJECTIVES The purpose of this project was to review the literature for the use of spinal manipulation for low back pain (LBP). METHODS A search strategy modified from the Cochrane Collaboration review for LBP was conducted through the following databases: PubMed, Mantis, and the Cochrane Database. Invitations to submit relevant articles were extended to the profession via widely distributed professional news and association media. The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. RESULTS A total of 887 source documents were obtained. Search results were sorted into related topic groups as follows: randomized controlled trials (RCTs) of LBP and manipulation; randomized trials of other interventions for LBP; guidelines; systematic reviews and meta-analyses; basic science; diagnostic-related articles, methodology; cognitive therapy and psychosocial issues; cohort and outcome studies; and others. Each group was subdivided by topic so that team members received approximately equal numbers of articles from each group, chosen randomly for distribution. The team elected to limit consideration in this first iteration to guidelines, systematic reviews, meta-analyses, RCTs, and coh ort studies. This yielded a total of 12 guidelines, 64 RCTs, 13 systematic reviews/meta-analyses, and 11 cohort studies. CONCLUSIONS As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence. There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.

Chiropractic and CAM Utilization: A Descriptive Review

ObjectiveTo conduct a descriptive review of the scientific literature examining use rates of modalities and procedures used by CAM clinicians to manage chronic LBP and other conditionsData SourcesA literature of PubMed and MANTIS was performed using the key terms Chiropractic; Low Back Pain; Utilization Rate; Use Rate; Complementary and Alternative Medicine; and Health Services in various combinations.Data SelectionA total of 137 papers were selected, based upon including information about chiropractic utilization, CAM utilization and low back pain and other conditions.Data SynthesisInformation was extracted from each paper addressing use of chiropractic and CAM, and is summarized in tabular form.ResultsThematic analysis of the paper topics indicated that there were 5 functional areas covered by the literature: back pain papers, general chiropractic papers, insurance-related papers, general CAM-related papers; and workers compensation papers.ConclusionStudies looking at chiropractic utilization demonstrate that the rates vary, but generally fall into a range from around 6% to 12% of the population, most of whom seek chiropractic care for low back pain and not for organic disease or visceral dysfunction. CAM is itself used by people suffering from a variety of conditions, though it is often used not as a primary intervention, but rather as an additional form of care. CAM and chiropractic often offer lower costs for comparable results compared to conventional medicine.

Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: results of a pragmatic randomized comparative effectiveness study.

Study Design. Randomized controlled trial. Objective. To assess changes in pain levels and physical functioning in response to standard medical care (SMC) versus SMC plus chiropractic manipulative therapy (CMT) for the treatment of low back pain (LBP) among 18 to 35-year-old active-duty military personnel. Summary of Background Data. LBP is common, costly, and a significant cause of long-term sick leave and work loss. Many different interventions are available, but there exists no consensus on the best approach. One intervention often used is manipulative therapy. Current evidence from randomized controlled trials demonstrates that manipulative therapy may be as effective as other conservative treatments of LBP, but its appropriate role in the healthcare delivery system has not been established. Methods. Prospective, 2-arm randomized controlled trial pilot study comparing SMC plus CMT with only SMC. The primary outcome measures were changes in back-related pain on the numerical rating scale and physical functioning at 4 weeks on the Roland-Morris Disability Questionnaire and back pain functional scale (BPFS). Results. Mean Roland-Morris Disability Questionnaire scores decreased in both groups during the course of the study, but adjusted mean scores were significantly better in the SMC plus CMT group than in the SMC group at both week 2 (P < 0.001) and week 4 (P = 0.004). Mean numerical rating scale pain scores were also significantly better in the group that received CMT. Adjusted mean back pain functional scale scores were significantly higher (improved) in the SMC plus CMT group than in the SMC group at both week 2 (P < 0.001) and week 4 (P = 0.004). Conclusion. The results of this trial suggest that CMT in conjunction with SMC offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care, for men and women between 18 and 35 years of age with acute LBP.

Human Subject Research: Reporting Ethics Approval and Informed Consent in 3 Chiropractic Journals

OBJECTIVE To date, there have been no reports of ethics board approval or informed consent within the chiropractic literature or within chiropractic research. The purpose of this study was to assess the reporting of ethics approval and informed consent in articles published during the 2008 volume year of 3 chiropractic research journals included in PubMed. METHODS A quantitative assessment of the articles published in each journal for the 2008 volume year was performed. Information collected included if the article involved human subject research, if it reported ethics board approval, and if informed consent was given to subjects. Data were collected as descriptive statistics (frequency counts and percentages). RESULTS In aggregate, 50 articles of a total of 143 published involved human subject research (35%). 44 reported ethics board approval (88%), and 28 reported that informed consent had been obtained (56%). Forty-five percent of articles published in the Journal of Manipulative and Physiological Therapeutics involved human subject research (39/87), of which 95% reported ethics board approval (37/39) and 64% reported informed consent (25/39); 12.5% of articles from the Journal of the Canadian Chiropractic Association involved human subject research (5/40), of which 80% reported ethics board approval (4/5) and 40% reported informed consent (2/5); and 37.5% of articles published in Chiropractic and Osteopathy involved human subject research (6/16), of which 50% reported ethics board approval (3/6) and 17% reported informed consent (1/6). CONCLUSION Overall, most articles reported ethics approval, and more than half reported consent. This was harmonious with research on this topic from other disciplines. This situation indicates a need for continued quality improvement and for better instruction and dissemination of information on these issues to researchers, to manuscript reviewers, to journal editors, and to the readers.

Attitudes toward evidence-based clinical practice among doctors of chiropractic with diplomate-level training in orthopedics

BackgroundEvidence-based clinical practice (EBCP) is a practice model gaining prominence within healthcare, including the chiropractic profession. The status of EBCP has been evaluated in a variety of healthcare disciplines, but little is known regarding the attitudes doctors of chiropractic (DCs) hold toward this model of healthcare. This project examines the attitudes toward EBCP within a specialty discipline of DCs.MethodsWe identified a survey questionnaire previously used to evaluate EBCP among non-chiropractic complementary and alternative practitioners. We adapted this questionnaire for use among DCs and pretested it in 5 chiropractic college faculty. The final version was administered to DCs with diplomate-level training in orthopedics. The survey was emailed to 299 potential participants; descriptive results were calculated.Results144 surveys were returned, resulting in a 48% response rate. The majority of respondents perceived EBCP as an important aspect of chiropractic practice. Respondents also believed themselves to have an above average skill level in EBCP, reported that training originated from their diplomate education, and based the majority of their practice on clinical research.ConclusionDoctors of chiropractic with an orthopedic diplomate appear to have favorable attitudes toward EBCP. Further study will help understand EBCP perceptions among general field DCs. A logical next step includes validation of this questionnaire.

Do chiropractic college faculty understand informed consent: a pilot study

BackgroundThe purpose of this study was to survey full-time faculty at a single chiropractic college concerning their knowledge of Institutional Review Board (IRB) policies in their institution as they pertain to educational research.MethodsAll full-time faculty were invited to participate in an anonymous survey. Four scenarios involving educational research were described and respondents were asked to select from three possible courses of action for each. In addition, respondents were queried about their knowledge of IRB policies, how they learned of these policies and about their years of service and departmental assignments.ResultsThe response rate was 55%. In no scenario did the level of correct answers by all respondents score higher than 41% and in most, the scores were closer to just under 1 in 3. Sixty-five percent of respondents indicated they were unsure whether Palmer had any policies in place at all, while 4% felt that no such policies were in place. Just over one-quarter (27%) were correct in noting that students can decline consent, while more than half (54%) did not know whether there were any procedures governing student consent.ConclusionPalmer faculty have only modest understanding about institutional policies regarding the IRB and human subject research, especially pertaining to educational research. The institution needs to develop methods to provide knowledge and training to faculty. The results from this pilot study will be instrumental in developing better protocols for a study designed to survey the entire chiropractic academic community.

A focus group study of chiropractic students following international service learning experiences.

OBJECTIVE One objective of chiropractic education is to cultivate clinical confidence in novice practitioners. The purpose of this qualitative study was to describe how participation in a short-term international service learning experience changed perceptions of clinical confidence in senior chiropractic students. METHODS Seventeen senior chiropractic students participated in 4 moderated focus group sessions within 4 months after a clinical educational opportunity held in international settings. Participants answered standard questions on how this educational experience may have changed their clinical confidence. Two investigators performed qualitative thematic analysis of the verbatim transcripts to identify core concepts and supporting themes. RESULTS The core concept was transformation from an unsure student to a confident doctor. The service learning experience allowed students to deliver chiropractic treatment to patients in a real-world setting, engage in frequent repetitions of technical skills, perform clinical decision-making and care coordination, and communicate with patients and other health professionals. Students described increased clinical confidence in 9 competency areas organized within 3 domains: (1) chiropractic competencies including observation, palpation, and manipulation; (2) clinical competencies including problem solving, clinic flow, and decision-making; and (3) communication competencies, including patient communication, interprofessional communication, and doctor-patient relationship. Students recommended that future service learning programs include debriefing sessions similar to the experience offered by these focus groups to enhance student learning. CONCLUSION Senior chiropractic students who participated in an international service learning program gained confidence and valuable practical experience in integrating their chiropractic, clinical, and communication skills for their future practices.

Do informed consent documents for chiropractic clinical research studies meet readability level recommendations and contain required elements: a descriptive study

BackgroundInformed consent documents (ICD) in research are designed to educate research participants about the nature of the research project in which he or she may participate. United States (US) law requires the documents to contain specific elements present and be written in a way that is understandable to research participants. The purpose of this research is to determine if ICDs from randomized controlled trials conducted at chiropractic colleges meet recommended readability standards and contain the 13 content items required by US law.MethodsThis study was approved by Palmer College of Chiropractic’s IRB #2012-12-3-T and was conducted between December 3, 2012 and February 14, 2013. We contacted the research directors of five chiropractic colleges that have received federal funding supporting their clinical research. A total of 13 informed consent documents from four chiropractic colleges were analyzed using the Flesch-Kincaid measurement. We assigned a grade-level readability score to the document based on the average of three separate grade level scores conducted on the three largest uninterrupted blocks of text. Content of the 13 ICDs was assessed using a 13-element checklist. A point was given for every element present in the document, giving a score range of “0, no elements are present”, to “13, all elements are present.”ResultsThe mean Flesch-Kincaid grade level readability was 10.8 (range 7.2 -14.0). Our sample had a mean readability score 2.8 grade levels above the generally-accepted US average reading level. Content varied among the 13 informed consent forms, ranging from only nine elements present in one document to all 13 required in five documents. Additionally, we collated the risks presented in each document.ConclusionThese results strongly suggest that chiropractic clinical researchers are not developing ICDs at a readability level congruent with the national average acceptable level. The low number of elements in some of the informed consent documents raises concern that not all research participants were fully informed when given the informed consent, and it may suggest that some documents may not be in compliance with federal requirements. Risk varies among institutions and even within institutions for the same intervention.

Radiographic analysis of the anterior to posterior open mouth (APOM) cervical spine view: frequency of atlas transverse process overlap of the inferior tip of the mastoid process.

OBJECTIVE The purpose of this study was to measure the frequency with which the atlas transverse process is overlapped by the inferior tip of the mastoid process based upon radiographic analysis of the anterior to posterior open mouth (APOM) cervical spine view. METHODS This is a retrospective study. Anterior to posterior open mouth radiographs (N = 120) were obtained from patient files at a chiropractic clinic. Dimensions were bilaterally measured: the vertical distance from the inferior mastoid to the superior margin of the C1 transverse process (C1TP) and the vertical distance from the inferior mastoid to the inferior margin of the C1TP. The percentage of the C1TP occluded by the mastoid process was calculated by determining the occlusal distance. These percentages were grouped into 4 categories: no occlusion, 1% to 50%, 50% to 99%, and 100%. RESULTS The occlusal distance for the left and right ranged from -7.1 to 19.0 mm and -7.5 to 19.5 mm, respectively. The mean occlusal distance was identical on the left and right sides (4.6 [SD, 5.1 mm] and 4.7 mm [SD, 5.0 mm], respectively). The percentage of occlusion for the left and right transverse processes ranged from 0% to 80% and 0% to 100%, respectively. The mean percentage was 6.4% (SD, 16.4) on the left and 6.2% (SD, 16.3) on the right. CONCLUSION This study shows that the occlusal distance for the left and right ranged from -7.1 to 19.0 mm and -7.5 to 19.5 mm, respectively. A total occlusion of the C1TP occurred in 1 side of 120 participants in this sample.