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OBJECTIVES: Patients receiving chiropractic spinal manipulation (CSM) for low back pain (LBP) are less likely to receive any opioid prescription for subsequent pain management. However, the likelihood of specifically being prescribed tramadol, a less potent opioid, has not been explored. We hypothesised that adults receiving CSM for newly diagnosed radicular LBP would be less likely to receive a tramadol prescription over 1-year follow-up, compared with those receiving usual medical care. DESIGN: Retrospective cohort study. SETTING: US medical records-based dataset including >115 million patients attending academic health centres (TriNetX, Inc), queried 9 November 2023. PARTICIPANTS: Opioid-naive adults aged 18-50 with a new diagnosis of radicular LBP were included. Patients with serious pathology and tramadol use contraindications were excluded. Variables associated with tramadol prescription were controlled via propensity matching. INTERVENTIONS: Patients were divided into two cohorts dependent on treatment received on the index date of radicular LBP diagnosis (CSM or usual medical care). PRIMARY AND SECONDARY OUTCOME MEASURES: Risk ratio (RR) for tramadol prescription (primary); markers of usual medical care utilisation (secondary). RESULTS: After propensity matching, there were 1171 patients per cohort (mean age 35 years). Tramadol prescription was significantly lower in the CSM cohort compared with the usual medical care cohort, with an RR (95% CI) of 0.32 (0.18 to 0.57; p

BACKGROUND: Acupuncture and chiropractic care are evidence-based pain management alternatives to opioids. The Veterans Health Administration (VA) provides this care in some VA facilities, but also refers patients to community providers. We aimed to determine if patient-reported outcomes differ for acupuncture and chiropractic care from VA versus community providers. MATERIALS AND METHODS: We conducted an observational study using survey outcome data and electronic medical record utilization data for acupuncture and chiropractic care provided in 18 VA facilities or in community facilities reimbursed by VA. Study participants were users of VA primary care, mental health, pain clinic, complementary and integrative therapies, coaching or education services in 2018-2019. Patients received 1) 4+ acupuncture visits (N = 201) or 4+ chiropractic care visits (N = 178) from a VA or community provider from 60 days prior to baseline to six-months survey and 2) no acupuncture or chiropractic visits from 1 year to 60 days prior to baseline. Outcomes measured included patient-reported pain (PEG) and physical health (PROMIS) at baseline and six-month surveys. Multivariate analyses examined outcomes at six months, adjusting for baseline outcomes and demographics. RESULTS: In unadjusted analyses, pain and physical health improved for patients receiving community-based acupuncture, while VA-based acupuncture patients experienced no change. Unadjusted analyses also showed improvements in physical health, but not pain, for patients receiving VA-based chiropractic care, with no changes for community-based chiropractic care patients. Using multivariate models, VA-based acupuncture was no different from community-based acupuncture for pain (-0.258, p = 0.172) or physical health (0.539, p = 0.399). Similarly, there were no differences between VA- and community-based chiropractic care in pain (-0.273, p = 0.154) or physical health (0.793, p = 0.191). CONCLUSIONS: Acupuncture and chiropractic care were associated with modest improvements at six months, with no meaningful differences between VA and community providers. The choice to receive care from VA or community providers could be based on factors other than quality, like cost or convenience.

BACKGROUND: Cauda equina syndrome (CES) is a lumbosacral surgical emergency that has been associated with chiropractic spinal manipulation (CSM) in case reports. However, identifying if there is a potential causal effect is complicated by the heightened incidence of CES among those with low back pain (LBP). The study hypothesis was that there would be no increase in the risk of CES in adults with LBP following CSM compared to a propensity-matched cohort following physical therapy (PT) evaluation without spinal manipulation over a three-month follow-up period. METHODS: A query of a United States network (TriNetX, Inc.) was conducted, searching health records of more than 107 million patients attending academic health centers, yielding data ranging from 20 years prior to the search date (July 30, 2023). Patients aged 18 or older with LBP were included, excluding those with pre-existing CES, incontinence, or serious pathology that may cause CES. Patients were divided into two cohorts: (1) LBP patients receiving CSM or (2) LBP patients receiving PT evaluation without spinal manipulation. Propensity score matching controlled for confounding variables associated with CES. RESULTS: 67,220 patients per cohort (mean age 51 years) remained after propensity matching. CES incidence was 0.07% (95% confidence intervals [CI]: 0.05-0.09%) in the CSM cohort compared to 0.11% (95% CI: 0.09-0.14%) in the PT evaluation cohort, yielding a risk ratio and 95% CI of 0.60 (0.42-0.86; p = .0052). Both cohorts showed a higher rate of CES during the first two weeks of follow-up. CONCLUSIONS: These findings suggest that CSM is not a risk factor for CES. Considering prior epidemiologic evidence, patients with LBP may have an elevated risk of CES independent of treatment. These findings warrant further corroboration. In the meantime, clinicians should be vigilant to identify LBP patients with CES and promptly refer them for surgical evaluation.

BackgroundPatients who undergo lumbar discectomy may experience ongoing lumbosacral radiculopathy (LSR) and seek spinal manipulative therapy (SMT) to manage these symptoms. We hypothesized that adults receiving SMT for LSR at least one year following lumbar discectomy would be less likely to undergo lumbar spine reoperation compared to matched controls not receiving SMT, over two years' follow-up.MethodsWe searched a United States network of health records (TriNetX, Inc.) for adults aged ≥ 18 years with LSR and lumbar discectomy ≥ 1 year previous, without lumbar fusion or instrumentation, from 2003 to 2023. We divided patients into two cohorts: (1) chiropractic SMT, and (2) usual care without chiropractic SMT. We used propensity matching to adjust for confounding variables associated with lumbar spine reoperation (e.g., age, body mass index, nicotine dependence), calculated risk ratios (RR), with 95% confidence intervals (CIs), and explored cumulative incidence of reoperation and the number of SMT follow-up visits.ResultsFollowing propensity matching there were 378 patients per cohort (mean age 61 years). Lumbar spine reoperation was less frequent in the SMT cohort compared to the usual care cohort (SMT: 7%; usual care: 13%), yielding an RR (95% CIs) of 0.55 (0.35-0.85; P = 0.0062). In the SMT cohort, 72% of patients had ≥ 1 follow-up SMT visit (median = 6).ConclusionsThis study found that adults experiencing LSR at least one year after lumbar discectomy who received SMT were less likely to undergo lumbar spine reoperation compared to matched controls not receiving SMT. While these findings hold promise for clinical implications, they should be corroborated by a prospective study including measures of pain, disability, and safety to confirm their relevance. We cannot exclude the possibility that our results stem from a generalized effect of engaging with a non-surgical clinician, a factor that may extend to related contexts such as physical therapy or acupuncture.RegistrationOpen Science Framework ( https://osf.io/vgrwz ).

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 FROM AUTHOR]

Chiropractors diagnose and manage musculoskeletal disorders, commonly using spinal manipulative therapy (SMT). Over the past half-century, the chiropractic profession has seen increased utilization in the United States following Medicare authorization for payment of chiropractic SMT in 1972. We reviewed chiropractic research trends since that year and recent clinical practice guideline (CPG) recommendations regarding SMT. We searched Scopus for articles associated with chiropractic (spanning 1972–2024), analyzing publication trends and keywords, and searched PubMed, Scopus, and Web of Science for CPGs addressing SMT use (spanning 2013–2024). We identified 6286 articles on chiropractic. The rate of publication trended upward. Keywords initially related to historical evolution, scope of practice, medicolegal, and regulatory aspects evolved to include randomized controlled trials and systematic reviews. We identified 33 CPGs, providing a total of 59 SMT-related recommendations. The recommendations primarily targeted low back pain (n = 21) and neck pain (n = 14); of these, 90% favored SMT for low back pain while 100% favored SMT for neck pain. Recent CPG recommendations favored SMT for tension-type and cervicogenic headaches. There has been substantial growth in the number and quality of chiropractic research articles over the past 50 years, resulting in multiple CPG recommendations favoring SMT. These findings reinforce the utility of SMT for spine-related disorders. [ABSTRACT FROM AUTHOR]

This study evaluates biopsychosocial factors as mediators of the effect of chiropractic care on low back pain (LBP) intensity and interference for active-duty military members. Data from a multi-site, pragmatic clinical trial comparing six weeks of chiropractic care plus usual medical care to usual medical care alone for 750 US active-duty military members with LBP were analyzed using natural-effect, multiple-mediator modeling. Mediation of the adjusted mean effect difference on 12-week outcomes of PROMIS-29 pain interference and intensity by 6-week mediators of other PROMIS-29 physical, mental, and social health subdomains was evaluated. The effect difference on pain interference occurring through PROMIS-29 biopsychosocial factors (natural indirect effect = -1.59, 95% CI = -2.28 to -0.88) was 56% (95% CI = 35 to 96) of the total effect (-2.82, 95% CI = -3.98 to -1.53). The difference in effect on pain intensity occurring through biopsychosocial factors was smaller (natural indirect effect = -0.32, 95% CI = -0.50 to -0.18), equaling 26% (95% CI = 15 to 42) of the total effect (-1.23, 95% CI = -1.52 to -0.88). When considered individually, all physical, mental, and social health factors appeared to mediate the effect difference on pain interference and pain intensity with mental health factors having smaller effect estimates. In contrast with effects on pain interference, much of the effect of adding chiropractic care to usual medical care for US military members on pain intensity did not appear to occur through the PROMIS-29 biopsychosocial factors. Physical and social factors appear to be important intermediate measures for patients receiving chiropractic care for low back pain in military settings. Further study is needed to determine if the effect of chiropractic care on pain intensity for active-duty military occurs through other unmeasured factors, such as patient beliefs, or if the effect occurs directly. [ABSTRACT FROM AUTHOR]

Background Health issues caused and/or exacerbated by work are common in patients seeking primary health care. Yet, primary care providers generally receive little or no training in the assessment and management of occupational injuries and illnesses. Aims To conduct a pilot project to develop, implement and evaluate a programme to teach occupational and environmental medicine to primary healthcare providers. Methods We followed the Extensions for Community Healthcare Outcomes (ECHO) model to connect primary healthcare providers with experts in Occupational and Environmental Medicine (OEM). We employed an observational pre–post study design to assess changes in self-efficacy, knowledge, attitudes and beliefs towards OEM. Results From September 2021 to June 2022, we offered two cycles of 12 sessions each. Participants came from medicine, nursing, psychology, occupational and physical therapy, chiropractic, kinesiology, social work, and pharmacy. Sixty-seven participants completed both pre- and post-ECHO questionnaires. Self-efficacy and knowledge ratings significantly increased after attendance at ECHO compared to the pre-ECHO responses. Attitudes and beliefs were unchanged in most of the items assessed. Participants rated their satisfaction with ECHO between 59% and 97%. Conclusions Our pilot study demonstrated the challenges in implementing the first ECHO OEM in Canada. Findings show acceptability and satisfaction, improved self-efficacy, and small increases in knowledge, but not overall attitudes and beliefs. There is a need to understand barriers to participation and to target participants with less knowledge and experience in occupational and environmental medicine. [ABSTRACT FROM AUTHOR]

Providing video recordings of lecture material may enhance student flexibility, but does it alter attendance or influence their grade? This project assessed the extent and purpose of video usage by students and evaluated their impact on course performance within first-year basic science courses in a chiropractic curriculum. All first-year students enrolled at a chiropractic college based in the United States were invited to complete a retrospective survey regarding video usage, attendance, and study behaviors for basic science courses they were enrolled during the previous term. Grades were third-party obtained for each consenting student. Statistical analysis included descriptive statistics and independent t tests for each course. Effect size using Cohen's d was calculated for all statistically significant courses (p <.05). Overall, 260 students completed the questionnaire assessing 18 courses in total. The perceived helpfulness of video recordings was associated with heavier usage, primarily to study for exams. Shorter summary videos were preferred by 78% of students over full lecture recordings. Use of videos to replace lectures increased from 21.9% to 53.2% in first through third trimester, respectively. Video use in Neuroanatomy I, Neuroanatomy II, Gross Anatomy II, Organ Histology, and Endocrinology were associated with lower exam scores and overall grades (p <.05), yielding moderate to large effect sizes. Videos were used < 1 hour per week, primarily to study for exams. When used as a study tool, video use decreased course performance. Rewatching videos to prepare for exams may be mistaken for mastery of material. [ABSTRACT FROM AUTHOR]

To evaluate the association between basic science curriculum delivery method with other academic and demographic factors on National Board of Chiropractic Examiners (NBCE) part I pass rates. This was a retrospective cohort study of students from 3 campuses of 1 chiropractic institution who matriculated in 2018 or 2020. COVID-19 regulations required online delivery of a basic science curriculum for students in the 2020 cohorts, whereas students in the 2018 cohorts experienced a traditional classroom delivery. A general linear model estimated odds ratios for passing NBCE part I, comparing individual online cohorts with the combined classroom cohort while adjusting for academic and demographic variables. A total of 968 students were included, 55% from the classroom cohort. The spring 2020 cohort had the fewest students with bachelors' degrees (59%) and more students with high in-program grade point averages (GPA; 61%) along with the lowest estimated odds ratio [0.80 (95% CI: 0.73–0.87)] for passing vs the classroom cohort. The fall 2020 cohort had significantly higher odds [1.06 (95% CI: 1.00–1.03)] of passing vs the classroom cohort. Additional predictors included main campus matriculation, white ethnicity, bachelors' degree, no alternative admission status, and in-program GPA. Students with high in-program GPA (vs low) had a 36% increased odds of passing. Compared to the classroom cohort, the spring 2020 cohort had the lowest odds while the fall 2020 cohort had the highest odds of passing part I. In-program GPA had the highest association with passing. These results provide information on how curriculum delivery impacts board exam performance. [ABSTRACT FROM AUTHOR]

This conference was convened by the World Federation of Chiropractic from October 30 to November 2, 2024, in Kuala Lumpur, Malaysia. The 2024 program focused on the delivery of technology in chiropractic education. [ABSTRACT FROM AUTHOR]

Higher stress levels may be associated with decreased academic success and physical and psychological well-being in chiropractic students. This study aimed to determine the perceived stress and burnout of chiropractic students at the University of Johannesburg during the COVID-19 pandemic. This was a quantitative, exploratory study utilizing a self-administered online questionnaire distributed to chiropractic students (n = 246) at the university. The questionnaire consisted of 3 main components: demographics, the Perceived Stress Scale (PSS-10), and the Maslach Burnout Inventory–Student Survey (MBI-SS). Data were analyzed utilizing exploratory factor analysis, Cronbach alpha for reliabilities, and descriptive statistics for mean scores being interpreted using subscales pertaining to the 2 survey tools. The response rate was 63.82% (n = 157) with the PSS-10 indicating participants obtained a total mean score of 25.08 (average stress). For the MBI-SS categories, participants scored 18.96 out of 30 for exhaustion, 10.31 out of 30 for cynicism, and 22.46 out of 36 for professional efficiency; higher scores of exhaustion and cynicism and lower scores of professional efficiency are indicative of higher degrees of burnout. Statistically significant differences for both tools were noted in relation to age and academic year with higher values indicated with increased age and progression in the program. The results indicate that chiropractic students experienced moderate levels of stress but higher burnout than other health sciences student populations when compared to current literature. Age and progression in the program appear to have a negative influence on both these factors. [ABSTRACT FROM AUTHOR]

Entrustable professional activities (EPAs) have seen widespread adoption in medical education and other health professions education. EPAs aim to provide a bridge between competency-based education and clinical practice by translating competencies into fundamental profession-specific tasks associated with clinical practice. Despite the extensive use of EPAs in health professions education, EPAs have yet to be introduced into chiropractic education. The purpose of this paper is to describe the development and introduction of EPAs as part of 2 community-based chiropractic student preceptorship education programs in the United States. EPAs were developed and introduced at 2 community-based chiropractic preceptorship sites in 5 distinct steps: (1) differentiating EPAs from competencies, learning objectives, and knowledge, skills, and attitudes; (2) identifying EPAs; (3) mapping EPAs to competencies and necessary experience, knowledge, and skills; (4) designing EPA assessment strategies; and (5) implementing the use of EPAs. A total of 13 individual EPAs were developed and mapped to Council on Chiropractic Education meta-competency outcomes and underlying experience, knowledge, and skills. Three assessment tools were created to evaluate student entrustability for EPAs and enhance student self-assessment. The EPAs and assessment tools were integrated into chiropractic student preceptorships at each site. This paper describes the development and introduction of EPAs at 2 community-based chiropractic preceptorship sites. Future research is needed to develop and standardize EPA use and assessment, and to evaluate outcomes associated with EPA use. [ABSTRACT FROM AUTHOR]

Since 1963 the Canadian Chiropractic Examining Board has conducted competency examinations for individuals seeking licensure to practice chiropractic in Canada. To maintain currency with changes in practice, examination content and methodology have been regularly updated since that time. This paper describes the process used by the Canadian Chiropractic Examining Board to restructure the examination to ensure it was current and to align it with the 2018 Federation of Canadian Chiropractic's Canadian Chiropractic Entry-to-Practice Competency Profile. A subject-matter-expert committee developed proposed candidate outcomes (indicators) for a new examination, derived from the competency profile. A national survey of practice was undertaken to determine the importance and frequency-of-use of the profile's enabling competencies. Survey results, together with other practice-based data and further subject-matter-expert input, were used to validate indicators and to create a new structure for the examination. The new examination is a combination of single-focus and case-based multiple-choice questions, and OSCE (objective, structured, clinical examination) methodology. Content mapping and item weighting were determined by a blueprinting committee and are provided. Administration of the new examination commenced in early 2024. [ABSTRACT FROM AUTHOR]

Evidence-based radiographic guidelines are used to justify the need for radiographs and prevent their overuse. This study aimed to assess whether 4th-year chiropractic interns at the International Medical University plan to use x-ray imaging in their future private practice in line with the principles taught throughout their chiropractic program and the evidence-based imaging guidelines. A survey questionnaire was distributed to 74 final year chiropractic interns, with 62 completed responses. The questionnaire consisted of 8 case scenarios representing potential chiropractic patients. The interns were asked to decide whether to x-ray the patient or not, and which x-ray views to request if they chose to x-ray the patient. Results were compared with the gold standard using percentage agreement. The findings revealed that the chiropractic students adhered to the gold standard answers for 6 out of 8 cases. However, they did not perform well in selecting the correct x-ray views for the 3 cases where radiography was indicated by the gold standard. Results suggest that while the interns have a good understanding of when radiography is necessary, they may need additional training in selecting the appropriate x-ray views for each case. [ABSTRACT FROM AUTHOR]

This study sought to determine whether chiropractic faculty were extrinsically, introjectedly, or intrinsically motivated to pursue scholarship; if satisfaction of a faculty member's work-related needs of autonomy, competence, and relatedness correlated with intrinsic motivation to pursue scholarly activities; and to identify barriers to faculty participation in scholarship. An anonymous online survey was administered to full-time faculty at 2 chiropractic institutions in the United States. Survey items assessed whether faculty perceived their work-related needs as met, which motivation type they displayed, and perceived barriers to performing scholarly work. Pearson correlation was used to measure the relationships between satisfaction of the work-related needs and intrinsic motivation. Content analysis was used to analyze faculty responses regarding perceived barriers. On average, survey items indicating extrinsic motivation received 52.2% of positive responses, those indicating intrinsic motivation received 47.8% of positive responses, and those indicating introjected motivation received 26.7%. Intrinsic motivation was positively correlated with each of the work-related needs (autonomy: r =.34, p =.067; competence: r =.52, p =.004; relatedness: r = 0.34, p =.063). Four categories of barriers were reported: time constraints, lack of knowledge, lack of support, and lack of interest. In this sample, chiropractic faculty most frequently identified with survey items indicating extrinsic motivation. Satisfaction of each of the 3 work-related needs was positively correlated with intrinsic motivation; however, competence showed a significant correlation indicating as competence is satisfied faculty are more likely to be intrinsically motivated to pursue scholarship. Perceived lack of time, knowledge, and support were reported barriers to the pursuit of scholarship. [ABSTRACT FROM AUTHOR]

To describe student loan debt and income of doctors of chiropractic (DC) who sought private student loan counseling. A descriptive analysis of de-identified client records from a student debt consulting firm (Student Loan Planner®) was conducted. Data regarding chiropractic programs, cumulative student loan amounts, and current incomes at the time of consultation were abstracted. Descriptive statistics were reported. Consultations (n = 448) were completed with DCs between March 2017 and August 2023. Nearly half (44.2%) reported student loan indebtedness between $150,000 and $249,999 with another 35.7% indicating between $250,000 and $349,999. The mean student loan debt was $249,149 (SD: $82,892) with a median of $240,000 (interquartile range [IQR]: $199,507–$295,390). The mean income for DCs in this sample was $81,305 (SD: $47,495) with a median income of $75,000 (IQR: $50,000–$100,000). The mean debt-to-income ratio was 4.11 (SD: 2.93) with a median of 3.38 (IQR: 2.21–5.16). Sixteen consultees possessed a debt-to-income ratio below 1.00, whereas more than a quarter (26.3%) of consultees reported a debt-to-income ratio greater than 5.00. DCs seeking debt guidance commonly carry substantial student loan debt that far exceeds their income. Our findings highlight that the student loan debt crisis includes DCs. [ABSTRACT FROM AUTHOR]

Racial and ethnic minority groups are underrepresented in chiropractic education and the profession, and are less likely than individuals identifying as White to have access to or use chiropractic care. Stakeholders with leadership positions in USA-based chiropractic colleges and organizations participated in 3 online diversity, equity, and inclusion (DEI) summit meetings to foster a deeper understanding of DEI, identify DEI objectives, and develop action steps and drive change. Summit I (51 attendees) comprised 3 presentations that provided background about DEI in chiropractic education and practice. Summit II (32 attendees), comprised 4 breakout sessions addressing organizational issues in DEI. Summit III (65 attendees) comprised 5 collaborative sessions focused on implementation of DEI objectives. We use aggregate data and qualitative summaries to provide a descriptive narrative. Data sources include pre/post-summit quantitative surveys, items from open-ended questionnaires, and a spreadsheet of recommendations for increasing organizational DEI. Before attending Summit I, 48% rated their understanding of DEI issues as "moderately" or "very" high, compared with 74% afterward. Summit II participants suggested actions that should be taken by their institutions and the profession. Summit III participants stressed the need for DEI-supportive data, policies, and resources. They identified > 150 action steps to address DEI objectives. A listserv was established to facilitate ongoing institutional collaboration. Summit participants recognized the importance of developing a diverse, culturally aware chiropractic workforce. The summits provided structure and support for stakeholders to effectively plan for and implement DEI in their organizations and institutions. [ABSTRACT FROM AUTHOR]

This study investigated patient satisfaction with care provided by chiropractic students under supervision vs supervisors in a Danish hospital setting. A cross-sectional observational study of patient satisfaction was conducted at the Spine Center of Southern Denmark, where chiropractic students from the University of Southern Denmark complete an 8-week internship in their final year of pregraduate training. Patients were assigned to students or supervisors based on administrative convenience (ie, natural allocation). Blinded from the aim of the study, all patients seen by a chiropractor (with or without a student) were invited to answer a questionnaire rating satisfaction with the clinical encounter. Results were analyzed using ordinal logistic regression with group allocation blinded by the investigators. Results from 438 participants (response rate = 88%) showed no significant difference in patient satisfaction between the student and supervisor groups. Although a small difference favored the supervisor group, the student group had a higher proportion of high and very high satisfaction combined. Satisfaction differed minimally whether patient care was administered by students under the supervision of a licensed chiropractor or by licensed chiropractors alone. Our findings suggest that patients do not negatively view student involvement in clinical consultations at a Danish hospital. [ABSTRACT FROM AUTHOR]

To compare unproctored and proctored online exams among chiropractic students. Pre-existing data of 234 students across 4 consecutive endocrinology classes were analyzed for this study. The course was comprised of 3 lectures (50 minutes per lecture) each week. Student performance was evaluated by midterm exam and summative exam (S1). The students from 3 classes were asked to take a voluntary second summative exam (S2) approximately 7 months after the S1. Since this study was partially conducted during the COVID pandemic, some classes took the midterm and the S1 proctored in the classroom while others took them unproctored from a remote location. The mean midterm exam (p <.001) and S1 scores (p =.01) for the unproctored group (93.6 ± 7.0 and 88.8 ± 8.2) were significantly higher than the proctored group (88.1 ± 8.2 and 83.9 ± 11.2). The mean time taken by students was much greater for the unproctored exams than for the proctored exams (midterm: 40.7 ± 10.2 versus 16.7 ± 7.0, p <.001; S1: 47.0 ± 8.7 versus 21.5 ± 9.0, p <.001). By contrast, the mean unproctored S2 scores were lower than the proctored group (60.2 ± 14.7 versus 88.1 ± 8.2, p <.001). A linear regression test showed that the final exam was a statistically significant predictor of the recall exam (p <.01, R2 = 28.3%). The findings suggest that student performance is significantly altered by test format. [ABSTRACT FROM AUTHOR]

To examine chiropractic students' attitudes regarding knowledge of pain neuroscience, chronic pain, and patient-centered care before and after educational interventions. Secondarily, this study aimed to compare measures of these skills between cohorts at different timepoints throughout training programs. Using stratified randomization, 281 Year 3 chiropractic students at 2 institutions were allocated into 1 of 3 educational interventions and served as active-control comparison groups: pain neuroscience education, chronic pain education, or patient-centered care. Participants completed validated surveys regarding their experience with the education interventions immediately pre- and post-lecture and 12 weeks after completion. For further comparison, surveys were also completed by 160 Year 1 students and 118 Year 2 students at 1 of the institutions. Independent sample t tests and 1-way analysis of variance were used for data analysis. All Year 3 lecture groups showed immediate improvements (pain neuroscience education: 3.99 + 3.09/100, p =.18 [95% CI: 10.10 to −1.77]; chronic pain education: 0.42 + 0.74/7, p =.02 [95% CI: 0.72 to 0.07]; patient-centered care: 0.25 + 0.12/6, p =.05 [95% CI: 0.12–0.51]), but these were not sustained at the 12-week follow-up (pain neuroscience education: −6.25 + 4.36/100, p =.15 [95% CI: 14.93 to −2.42]; chronic pain education: 0.33 + 0.16/7, p =.19 [95% CI, 0.66 to 0.01]; patient-centered care: 0.13 + 0.13/6, p =.30 [95% CI: 0.41 to −0.13]). Compared to active controls, only the patient-centered care group showed an immediate statistically significant difference. While this study found that immediate improvement in targeted competencies is possible with focused interventions, they were not sustained long term. [ABSTRACT FROM AUTHOR]

The objective was to compare the average number of mistakes made on multiple-choice (MCQ) and fill-in-the-blank (FIB) questions in anatomy lab exams. The study was conducted retrospectively; every exam had both MCQs and FIBs. The study cohorts were divided into 3 tiers based on the number and percentage of mistakes in answering sheets: low (21–32, >40%), middle (11–20, 40%–20%), and high (1–9, <20%) tiers. The study used an independent 2-sample t test to compare the number of mistakes between MCQs and FIBs overall and per tier and a 1-way analysis of variance to compare the number of mistakes in both formats across the 3 tiers. The results show that there was a significant difference in the number of mistakes between the 2 formats overall with more mistakes found on FIBs (p <.001). The number of mistakes made in the high and middle tiers had a statistical difference, being higher on MCQs (p <.001). There was no significant difference in the number of mistakes made in the low tier between formats (p >.05). Furthermore, the study found significant differences in the number of mistakes made on MCQs and FIBs across the 3 tiers, being highest in the low-tier group (p <.001). There were fewer mistakes on the MCQ than the FIB format in exams. It also suggests that, in the low tier answering sheets, both formats could be used to identify students at academic risk who need more attention. [ABSTRACT FROM AUTHOR]

Background/Objectives: Scoliosis is a condition that involves deformation of the spine in the coronal plane and commonly appears in childhood or adolescence, significantly limiting a person's life. The cause is multifactorial, and treatment aims to improve the spinal curvature, prevent major pathologies, and enhance aesthetics. The objective of this review was to determine whether high-velocity low-amplitude (HVLA) spinal manipulation is more effective than other treatments for children with idiopathic scoliosis (IS). Methods: The PubMed, Web of Science, Scopus and PEDro databases were searched for both clinical trials and cohort studies. Methodological quality was assessed via the PEDro scale (for clinical trials) and the Newcastle–Ottawa scale (for observational studies). The protocol of this systematic review was registered in PROSPERO (CRD42024532442). Results: Five studies were selected for review. The results indicated moderate improvements in pain and the Cobb angle and limited improvements in quality of life. Conclusions: HVLA spinal manipulation does not seem to have significant effects on reducing spinal deformity in IS patients, nor does it significantly impact quality of life. However, this therapy may have significant effects on reducing pain in these patients. [ABSTRACT FROM AUTHOR]

The purpose of this review was to identify assessment instruments and their measurement properties for assessing evidence-based practice (EBP) knowledge, skills, attitudes, and behavior among students of manual therapy education programs. 7 electronic databases were systematically searched from inception to May 19, 2023. (MEDLINE, EMBASE, CINAHL, ERIC, EBSCO Discovery, LISA, Google Scholar.) Search terms were subject headings specific to each database (MeSH in MEDLINE) and relevant to evidence-based practice, assessment tools/instruments, and manual therapy healthcare professions. Eligible studies included students of manual therapy education programs (chiropractic, physiotherapy, occupational therapy, osteopathy) and provided evidence supporting instrument measurement properties (reliability, validity). Titles and abstracts were screened by 2 reviewers. Data on each instrument and its properties were extracted and tabulated by 2 reviewers. Instruments were compared using the Classification Rubric for EBP Assessment Tools in Education (CREATE) framework including the 5 steps in the EBP model. Joanna Briggs Institute methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist were followed. 5 studies were identified, (3 physiotherapy, 2 chiropractic) Two studies used a physiotherapy-focused modification of the Fresno test. One study presented the Knowledge of Research Evidence Competencies instrument. Two studies presented original instruments. Instruments focused on the knowledge domain and did not assess all 5 EBP model steps. The current literature does not address all 5 steps of the EBP model. The identified instruments have the potential to ensure chiropractic institutions are graduating chiropractors who are highly skilled in evidence-based practice. [ABSTRACT FROM AUTHOR]

The Chiropractic Educators Research Forum convened a conference on June 22, 2024. During this meeting, attendees shared what chiropractic programs are doing, specifically focusing on education research related to technology. Presenters and panelists discussed what technology chiropractic programs should be using to educate chiropractors for the future. [ABSTRACT FROM AUTHOR]

Background: Back pain is very common and a leading cause of disability worldwide. Due to health care system inequalities, Indigenous communities have a disproportionately higher prevalence of injury and acute and chronic diseases compared to the general Canadian population. Indigenous communities, particularly in northern Canada, have limited access to evidence-based spine care. Strategies established in collaboration with Indigenous peoples are needed to address unmet healthcare needs, including spine care (chiropractic and movement program) services. This study aimed to understand the views and perspectives of Cross Lake community leaders and clinicians working at Cross Lake Nursing Station (CLNS) in northern Manitoba regarding the implementation of the Global Spine Care Initiative (GSCI) model of spine care (MoC) and related implementation strategies. Method: A qualitative exploratory design using an interpretivist paradigm was used. Twenty community partners were invited to participate in semi-structured interviews underpinned by the Theoretical Domains Framework (TDF) adapted to capture pertinent information. Data were analyzed deductively and inductively, and the interpretation of findings were explored in consultation with community members and partners. Results: Community leaders (n = 9) and physicians, nurses, and allied health workers (n = 11) emphasized: 1) the importance of contextualizing the MoC (triaging and care pathway) and proposed new services through in-person community engagement; 2) the need and desire for local non-pharmacological spine care approaches; and 3) streamlining patient triage and CLNS workflow. Recommendations for the streamlining included reducing managerial/administrative duties, educating new incoming clinicians, incorporating follow-up appointments for spine pain patients, and establishing an electronic medical record system along with a patient portal. Suggestions regarding how to sustain the new spine care services included providing transportation, protecting allocated clinic space, resolving insurance coverage discrepancies, addressing misconceptions about chiropractic care, instilling the value of physical activity for self-care and pain relief, and a short-term (30-day) incentivised movement program which considers a variety of movement options and offers a social component after each session. Conclusion: Community partners were favorable to the inclusion of a refined GSCI MoC. Adapting the TDF to unique Indigenous needs may help understand how best to implement the MoC in communities with similar needs. [ABSTRACT FROM AUTHOR]

Background: In recent studies, receipt of chiropractic care has been associated with lower odds of receiving prescription opioids and, among those already prescribed, reduced doses of opioids among patients with non-cancer spine pain. These findings suggest that access to chiropractic services may reduce reliance on opioids for musculoskeletal pain. Objective: To assess the impact of chiropractic care on initiation, or continued use, of prescription opioids among patients with non-cancer spine pain. Methods: We will search for eligible randomized controlled trials (RCTs) and observational studies indexed in MEDLINE, Embase, AMED, CINAHL, Web of Science, and the Index to Chiropractic Literature from database inception to June 2024. Article screening, data extraction, and risk-of-bias assessment will be conducted independently by pairs of reviewers. We will conduct separate analyses for RCTs and observational studies and pool binary outcomes (e.g. prescribed opioid receipt, long-term opioid use, and higher versus lower opioid dose) as odds ratios (ORs) with associated 95% confidence intervals (CIs). When studies provide hazard ratios (HRs) or relative risks (RRs) for time-to-event data (e.g. time-to-first opioid prescription) or incidence rates (number of opioid prescriptions over time), we will first convert them to an OR before pooling. Continuous outcomes such as pain intensity, sleep quality, or morphine equivalent dose will be pooled as weighted mean differences with associated 95% CIs. We will conduct meta-analyses using random-effects models and explore sources of heterogeneity using subgroup analyses and meta-regression. We will evaluate the certainty of evidence of all outcomes using the GRADE approach and the credibility of all subgroup effects with ICEMAN criteria. Our systematic review will follow the PRISMA statement and MOOSE guidelines. Discussion: Our review will establish the current evidence informing the impact of chiropractic care on new or continued prescription opioid use for non-cancer spine pain. We will disseminate our results through peer-reviewed publication and conference presentations. The findings of our review will be of interest to patients, health care providers, and policy-makers. Trial registration: Systematic review registration: PROSPERO CRD42023432277. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Cam-type deformities of the proximal femur have long been associated with femoroacetabular impingement (FAI); an orthopedic condition recognized in the etiology of early osteoarthritis (OA) in the non-dysplastic adult hip. However, the optimal clinical management (including the long-term prognosis) of patients with cam-type deformities with or without FAI symptoms remains uncertain. In this imaging case review (ICR), we present the 10-year follow-up of a retired chiropractor with bilateral cam-type femoral deformities who initially underwent total right hip joint arthroplasty for advanced hip joint OA, and subsequently developed advanced hip joint OA on the contralateral side. [ABSTRACT FROM AUTHOR]

This case study documents the case of a 27-year-old female who presented with a complaint of left anterolateral thigh numbness, initially diagnosed as meralgia paresthetica with a differential diagnosis of lumbar radiculopathy. Over a span of two weeks, the patient endured emotional trauma and subsequently developed lesions in the area of complaint. The patient was diagnosed at a medical clinic with herpes zoster and was prescribed anti-viral medication which resulted in complete resolution. This case highlights the importance of considering herpes zoster as a differential diagnosis for nerve-related symptoms. Features of lumbar radiculopathy, meralgia paresthetica, varicella zoster and herpes zoster are discussed, as well as the defining characteristics and treatment options. Practitioners must remain vigilant in suspicion of viral infections such as herpes zoster even with lower incidence due to approved vaccines. [ABSTRACT FROM AUTHOR]

Objective: Technique description and verification of L5 pars interarticularis (L5PI) using diagnostic ultrasound (DUS). Methods: Asymptomatic 10-year-old male subject was scanned with diagnostic ultrasound applying a linear array transducer (8-13 MHz) over L5/S1 facets; longaxis slide cephalad to capture both superior (SAP) and inferior articulating process (IAP) of L5. Contiguous hyperechoic cortex with deep acoustic shadowing between the SAP and IAP was assumed to be L5PI. To confirm in vivo technique representing L5PI, two spine models (plastic, human spine) were scanned to verify authors' assumption. Metallic paperclip was placed over L5PI then DUS image captured. Lastly, a subject with known spondylolysis was imaged and sonographic appearance of L5PI compared. Results: The structures localized with the metal paperclip on L5PI models were equivalent to the in vivo DUS image. Spondylolysis demonstrates an abrupt stepoff defect at L5PI. Conclusion: We report the first technique description and verification of the L5PI using DUS. [ABSTRACT FROM AUTHOR]

Background: Clinicians make clinical decisions using the dual process theory. The dual process theory comprises two approaches, System 1, based on heuristics, and System 2, involving an analytical and effortful thought process. However, there are inherent limitations to the dual process theory, such as relying on inaccurate memory or misinterpreting cues leading to inappropriate clinical management. As a result, clinicians may utilize mental shortcuts, termed heuristics, and be susceptible to clinical errors and biases that may lead to flawed decision making and diagnosis. Methods: This case series describes four clinical cases whereby the clinicians use distinct strategies to assess and manage complex clinical presentations. Discussion: Through the use of self-reflection and acknowledging diagnostic uncertainty, the clinicians were able to reduce common cognitive biases and provide effective and timely patient care. We discuss strategies that clinicians can implement in their daily practice to improve clinical decision-making processes and deliver quality care. [ABSTRACT FROM AUTHOR]

Objectives: This sequential explanatory mixed-method study aimed to explore chiropractic students' attitudes toward incorporating maintenance care (MC) focused evidence. Methods: Attitudes towards using an evidence-based clinical protocol for maintenance care (MC), the MAINTAIN instrument, were assessed via surveys, monologue responses, dialogues, and qualitative feedback. Participants from a single chiropractic educational institution completed questionnaires evaluating their perspectives on patient-centeredness, chronic pain, and evidence incorporation. Descriptive statistics summarized quantitative data, while content analysis was used for qualitative data. Results: 74.4% (n=419) of students participated, mostly male (57.5%), with an average GPA of 3.15 (out of a maximum of 4.0). Qualitative analysis identified the need to clarify MC terminology and factors motivating students to adopt new evidence, such as quality and alignment with healthcare beliefs. Conclusions: This study's findings emphasize the importance of refining healthcare training strategies, including defining terminology and addressing motivators for evidence incorporation, as evidence for MC for low back pain evolves. [ABSTRACT FROM AUTHOR]

Concussions are increasingly recognized as a public health concern. This paper evaluates Canadian concussion care guidelines, advocating for the inclusion of a broader range of healthcare professionals (HCPs) in concussion assessment, diagnosis, and management. It emphasizes the role of chiropractors, in addition to medical doctors (MDs) and nurse practitioners (NPs), highlighting their extensive training in musculoskeletal and neurological disorders. Chiropractors are adept at managing symptoms like headache, neck pain, and dizziness, and employing evidence-based, comprehensive interventions including patient education, exercise therapy, manual therapy, cervicovestibular rehabilitation, and return-to-sport (RTS) protocols. The paper also addresses regional variations in chiropractors' roles, focusing on Ontario's "Rowan's Law," and argues that limiting aspects of concussion care (assessment, diagnosis, RTS clearance) to MDs and NPs may result in healthcare inefficiencies and inequities. The findings are significant for policymakers and healthcare leaders, indicating a need for updated concussion care guidelines that integrate and utilize diverse HCPs. This could lead to improved patient outcomes, healthcare efficiency, and equity in concussion management across Canada. [ABSTRACT FROM AUTHOR]

Background: Many clinical practice guidelines for management of pain disorders now favor first-line use of nonpharmacological therapies (NPT). However, Medicare coverage of NPT is limited. Methods: Using a serial cross-sectional design, we examined temporal trends in the utilization and cost of NPT procedures commonly used to treat pain under Medicare. Results: Utilization and costs for physical therapy increased while those for spinal and osteopathic manipulation declined. Discussion: Future research on NPT under Medicare should focus on equity of patient access and comparative outcomes. [ABSTRACT FROM AUTHOR]

Objectives: In this study, we explored the effects of chiropractic spinal adjustments on resting-state electroencephalography (EEG) recordings and early somatosensory evoked potentials (SEPs) in Alzheimer's and Parkinson's disease. Methods: In this randomized cross-over study, 14 adults with Alzheimer's disease (average age 67 ± 6 years, 2 females:12 males) and 14 adults with Parkinson's disease (average age 62 ± 11 years, 1 female:13 males) participated. The participants underwent chiropractic spinal adjustments and a control (sham) intervention in a randomized order, with a minimum of one week between each intervention. EEG was recorded before and after each intervention, both during rest and stimulation of the right median nerve. The power-spectra was calculated for restingstate EEG, and the amplitude of the N30 peak was assessed for the SEPs. The source localization was performed on the power-spectra of resting-state EEG and the N30 SEP peak. Results: Chiropractic spinal adjustment significantly reduced the N30 peak in individuals with Alzheimer's by 15% (p = 0.027). While other outcomes did not reach significance, resting-state EEG showed an increase in absolute power in all frequency bands after chiropractic spinal adjustments in individuals with Alzheimer's and Parkinson's disease. The findings revealed a notable enhancement in connectivity within the Default Mode Network (DMN) at the alpha, beta, and theta frequency bands among individuals undergoing chiropractic adjustments. Conclusions: We found that it is feasible to record EEG/SEP in individuals with Alzheimer's and Parkinson's disease. Additionally, a single session of chiropractic spinal adjustment reduced the somatosensory evoked N30 potential and enhancement in connectivity within the DMN at the alpha, beta, and theta frequency bands in individuals with Alzheimer's disease. Future studies may require a larger sample size to estimate the effects of chiropractic spinal adjustment on brain activity. Given the preliminary nature of our findings, caution is warranted when considering the clinical implications. Clinical Trial Registration: The study was registered by the Australian New Zealand Clinical Trials Registry (registration number ACTRN12618001217291 and 12618001218280). [ABSTRACT FROM AUTHOR]

Aim: The aim of this study is to explore and compare experiences of pain management strategies for children with CP from the perspectives of children themselves and their parents. Methods: A secondary inductive analysis of previously collected qualitative data was performed. Fourteen children with CP and one parent of each child were interviewed separately about the management of the child's pain. A dyadic data analysis was used to compare parents' and children's perspectives. Findings: The main thematic categories of pain management identified were self-care, psychological strategies, physical interventions and professional treatment. Experiences described by the child and parent differed within all participating dyads but to different degrees. On a group level, children described more use of psychological strategies than parents did. Parents described more professional treatment strategies. Conclusions: Parents and children described different experiences of pain management strategies, and both perspectives are needed to understand the child's situation. [ABSTRACT FROM AUTHOR]

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 Back pain is very common and a leading cause of disability worldwide. Due to health care system inequalities, Indigenous communities have a disproportionately higher prevalence of injury and acute and chronic diseases compared to the general Canadian population. Indigenous communities, particularly in northern Canada, have limited access to evidence-based spine care. Strategies established in collaboration with Indigenous peoples are needed to address unmet healthcare needs, including spine care (chiropractic and movement program) services. This study aimed to understand the views and perspectives of Cross Lake community leaders and clinicians working at Cross Lake Nursing Station (CLNS) in northern Manitoba regarding the implementation of the Global Spine Care Initiative (GSCI) model of spine care (MoC) and related implementation strategies. Method A qualitative exploratory design using an interpretivist paradigm was used. Twenty community partners were invited to participate in semi-structured interviews underpinned by the Theoretical Domains Framework (TDF) adapted to capture pertinent information. Data were analyzed deductively and inductively, and the interpretation of findings were explored in consultation with community members and partners. Results Community leaders (n = 9) and physicians, nurses, and allied health workers (n = 11) emphasized: 1) the importance of contextualizing the MoC (triaging and care pathway) and proposed new services through in-person community engagement; 2) the need and desire for local non-pharmacological spine care approaches; and 3) streamlining patient triage and CLNS workflow. Recommendations for the streamlining included reducing managerial/administrative duties, educating new incoming clinicians, incorporating follow-up appointments for spine pain patients, and establishing an electronic medical record system along with a patient portal. Suggestions regarding how to sustain the new spine care services included providing transportation, protecting allocated clinic space, resolving insurance coverage discrepancies, addressing misconceptions about chiropractic care, instilling the value of physical activity for self-care and pain relief, and a short-term (30-day) incentivised movement program which considers a variety of movement options and offers a social component after each session. Conclusion Community partners were favorable to the inclusion of a refined GSCI MoC. Adapting the TDF to unique Indigenous needs may help understand how best to implement the MoC in communities with similar needs.

Abstract Background In recent studies, receipt of chiropractic care has been associated with lower odds of receiving prescription opioids and, among those already prescribed, reduced doses of opioids among patients with non-cancer spine pain. These findings suggest that access to chiropractic services may reduce reliance on opioids for musculoskeletal pain. Objective To assess the impact of chiropractic care on initiation, or continued use, of prescription opioids among patients with non-cancer spine pain. Methods We will search for eligible randomized controlled trials (RCTs) and observational studies indexed in MEDLINE, Embase, AMED, CINAHL, Web of Science, and the Index to Chiropractic Literature from database inception to June 2024. Article screening, data extraction, and risk-of-bias assessment will be conducted independently by pairs of reviewers. We will conduct separate analyses for RCTs and observational studies and pool binary outcomes (e.g. prescribed opioid receipt, long-term opioid use, and higher versus lower opioid dose) as odds ratios (ORs) with associated 95% confidence intervals (CIs). When studies provide hazard ratios (HRs) or relative risks (RRs) for time-to-event data (e.g. time-to-first opioid prescription) or incidence rates (number of opioid prescriptions over time), we will first convert them to an OR before pooling. Continuous outcomes such as pain intensity, sleep quality, or morphine equivalent dose will be pooled as weighted mean differences with associated 95% CIs. We will conduct meta-analyses using random-effects models and explore sources of heterogeneity using subgroup analyses and meta-regression. We will evaluate the certainty of evidence of all outcomes using the GRADE approach and the credibility of all subgroup effects with ICEMAN criteria. Our systematic review will follow the PRISMA statement and MOOSE guidelines. Discussion Our review will establish the current evidence informing the impact of chiropractic care on new or continued prescription opioid use for non-cancer spine pain. We will disseminate our results through peer-reviewed publication and conference presentations. The findings of our review will be of interest to patients, health care providers, and policy-makers. Trial registration Systematic review registration: PROSPERO CRD42023432277.

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.