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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 well-known benefits of physical activity, physical inactivity is presently a global health pandemic. Allied healthcare providers, such as chiropractors, knowingly recognise the importance of physical activity and are prepared to routinely discuss and/or counsel patients on this topic; however, little is known about Australian chiropractors in the physical activity setting. Our aim was to explore and identify factors associated with physical activity promotion among Australian chiropractors, including their knowledge of the physical activity and sedentary behaviour guidelines and their own levels of physical activity. Methods From February to May 2021, a convenience sample of Australian chiropractors completed an online survey. Items assessed by Likert scale included: physical activity promotion frequency, with the type, quantity, barriers, perceptions, and feasibility. We asked questions about their familiarity with, and knowledge of, Australian Physical Activity and Sedentary Behaviour Guidelines, chiropractors’ own physical activity, and whether the chiropractors met activity guidelines. Survey responses were descriptively reported. Univariable logistic regression models explored factors explaining frequent physical activity promotion. Results Of 217 respondents, 64% reported that they frequently (≥ 70%) recommended a more physically active lifestyle. Only 15% often performed pre-exercise screening, 73% frequently prescribed resistance exercise, 19% reported time as the most frequent barrier, while 37% reported being not at all familiar with the guidelines. Univariable logistic regression models found male chiropractors were more likely to promote physical activity, [odds ratio (OR) = 2.33; 95% confidence interval (CI): 1.32–4.12)], while chiropractors who frequently treat children 0–3 years (OR = 0.5; 95% CI: 0.28–0.87), children 4–18 years (OR = 0.42; 95% CI: 0.21–0.86), and pregnant women (OR = 0.5; 95% CI: 0.26–0.94) were less likely. Chiropractors were more likely to promote physical activity if they were familiar with the activity guidelines (OR = 2.9; 95% CI: 1.32–6.41), were confident promoting (OR = 11.6; 95% CI: 1.37–98.71) and prescribing physical activity programs (OR = 4.5; 95% CI: 2.03–9.99). Conclusion Most chiropractors confidently and regularly integrate physical activity into practice. Yet, despite acknowledging its importance, one third of chiropractors reported poor knowledge of the Physical Activity and Sedentary Behaviour Guidelines. Identifying barriers to the awareness, and implementation of physical activity guidelines should be further explored within chiropractic clinical settings.

Abstract Background Pregnancy-related low back and/or pelvic girdle pain is common, with a prevalence rate of up to 86% in pregnant women. Although 19.5% of Australian pregnant women visit a chiropractor for pelvic girdle pain, little is known about the experience of pregnant women who seek this care. The aim of this study was to describe and explore the experiences of Australian pregnant women who seek chiropractic care for their current pregnancy-related low back and/or pelvic girdle pain. Methods A qualitative case study approach with purposive sampling from 27 chiropractic practices was used. A grounded theory approach was informed by a constructivist and interpretivist stance, which provided understanding and meaning to the pregnant women’s experiences. Online unstructured interviews were recorded, transcribed, and anonymised. A thematic analysis was subsequently conducted on the primary data. Codes and major themes were developed with the use of critical self- reflection (memos), survey finding triangulation and respondent validation. Results Sixteen potential respondents expressed interest in participating. After eligibility screening and data saturation, nine interviews were undertaken. Four key themes were identified: “Care drivers: what drives care seeking?”, “Care barriers: what barriers are encountered?”, “Chiropractic treatment: what does treatment consist of?” and “Response to care: what response was there to care?”. Conclusion Four key themes: care drivers, care barriers, chiropractic treatment, and response to care support an emergent substantive-level theory in women’s care seeking experiences for pregnancy-related back pain and chiropractic care. This theory is that chiropractic care for pregnant women experiencing low back pain and pelvic girdle pain may improve pain and function, while reducing pregnancy-related biopsychosocial concerns. The findings may inform antenatal health providers and the chiropractic profession about pregnant women’s experience seeking chiropractic care as well as directing future research.

Abstract Background In Australian emergency departments, 30% of all back pain presentations are for older adults. Relatively little is known about the care that this population receives during an emergency department stay, including admission to hospital. The aim of this study is to describe emergency department management of older adults diagnosed with a lumbar spine condition and to determine predictors of healthcare use in this population. Methods A retrospective analysis of electronic medical record data of adults aged ≥ 65 years with a lumbar spine discharge diagnosis. Demographic, clinical care (date and time of presentation and discharge, length of stay in the emergency department, mode of arrival, triage category, re-presentations to the emergency department (within 48 h), discharge mode, the administration of pain-relieving medicines, lumbar imaging, and laboratory tests) and costs data were extracted from the electronic medical record system. Descriptive analyses and multilevel mixed-effects logistic regression models were performed. Results Over the period January 2016 to December 2019 there were 4,093 presentations to emergency departments by older adults with a lumbar spine discharge diagnosis (82.0% were non-specific low back pain). Most were female (58.3%), 39.9% had some form of lumbar imaging, and 34.1% were admitted to hospital. The most administered pain medicines were opioid analgesics (67.1%), followed by paracetamol (63.9%) and NSAIDs (33.0%). Predictors of healthcare use and hospital inpatient admission were receiving a laboratory test and receiving any opioid. For the financial period 2019-20, the mean (SD) total cost of care per presentation was $5,629 ($11,982). Conclusion In the emergency department, more than two thirds of older adults with a lumbar spine condition received opioid analgesics. They often received imaging and laboratory tests, had high costs and were admitted to hospital. Alternative pathways of care are needed to support older adults with low back pain, to receive guideline-concordant emergency department care and have good health outcomes.

Abstract Background Physical inactivity is a global health pandemic. Allied healthcare providers, including chiropractors, are well placed to integrate individual physical activity (PA) promotion into routine care. A previous systematic review identified that approximately 90% of chiropractors held a positive opinion towards healthier patient lifestyles; however, the extent to which chiropractors promote PA to their patients within routine care is unclear. This systematic review aimed to describe chiropractors' attitudes towards and current practice in advising, counselling, discussing, supporting, or recommending PA to patients. Methods Five databases were searched from inception to December 2021 for cross-sectional surveys that explored PA promotion by chiropractors in practice. We assessed the risk of bias of the included studies with the ‘Risk of Bias in Cross-Sectional Surveys of Attitudes and Practices’ tool. Descriptive data were extracted, grouping similar survey questions and responses into emerging categories. Chiropractors’ views regarding the perceived importance and/or their preparedness to counsel and provide PA or exercise information are reported. Results From 661 studies, 15 met the selection criteria. Surveys included 7999 chiropractors primarily from the USA, UK, Australia, and Sweden. All studies were rated as moderate-to-high risk of bias, with methodological weaknesses characterised by inconsistent reporting of missing data, non-representative samples, low response rates (i.e., less than 60%), and unknown validity of survey instruments. Chiropractors frequently recognised the importance of PA promotion, as demonstrated by the proportion of respondents reporting that they: (1) support the importance of providing PA or exercise information and counselling (64% to 100%); (2) are prepared to provide PA or exercise information and/or counselling to patients (91% to 92%,); (3) frequently obtain PA or exercise information from patients (87% to 97%,); 4) frequently discuss PA or exercise and/or provide PA or exercise information to patients (68% to 99%); and 5) frequently provide PA counselling to patients (50% to 81%.). Conclusion A large majority of practising chiropractors actively engage with PA promotion. However, the results should be interpreted with caution owing to the moderate-to-high risk of bias of the included studies. Forthcoming research initiatives should explore unbiased surveys, further PA education and training as well as capitalising on chiropractors’ own PA participation.

Introduction The increasing prevalence of coexisting health conditions poses a challenge to healthcare providers and healthcare systems. Spinal pain (eg, neck and back pain) and spinal pathologies (eg, osteoporotic fractures and degenerative spinal disease) exist concurrently with other non-spinal health conditions (NSHC). However, the scope of what associations may exist among these co-occurring conditions is unclear. Therefore, this scoping review aims to map the epidemiological literature that reports associations between spine-related pain and pathologies (SPPs) and NSHCs.Methods and analysis This scoping review will follow the JBI protocol and Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. We will systematically search the literature using key words and MeSH terms for SPPs and NSHCs. Terminology/vocabulary for NSHCs will include those for communicable and non-communicable diseases as reported by WHO Global Burden of Disease reports. Five databases will be searched from inception: MEDLINE, EMBASE, APA PsycInfo, Scopus and Web of Science Core Collection. Papers published in English, in peer-reviewed journals, including measures of association between SPPs and NSHCs and using observational epidemiologic study designs will be included. Excluded will be studies of cadaveric, animal or health behaviours; studies with no measures of association and non-observational epidemiologic studies. Results will include the number of studies, the studies that have evaluated the measures of association and the frequency of the studied associations between SPPs and NSHCs. Results will be reported in tables and diagrams. Themes of comorbidities will be synthesised into a descriptive report.Ethics and dissemination This scoping review was deemed exempt from ethics review. This review will provide a comprehensive overview of the literature that reports associations between SPPs and NSHCs to inform future research initiatives and practices. Results will be disseminated through publication in peer-reviewed journals and research conferences.Registration details https://osf.io/w49u3.

Objectives Developing a research agenda is one method to facilitate broad research planning and prioritise research within a discipline. Despite profession-specific agendas, none have specifically addressed the research needs of the specialty of sports chiropractic. This study determined consensus on research priorities to inform a global sports chiropractic research agenda.Methods A Delphi consensus methodology was used to integrate expert opinions. Clinicians, academics and leaders from the international sports chiropractic specialty were recruited using purposive sampling to participate in (1) a Delphi panel involving three voting rounds to determine consensus on research priorities and (2) a priority importance ranking of the items that reached consensus.Results We identified and contacted 141 participants, with response rates for rounds 1, 2 and 3, of 44%, 31% and 34%, respectively. From the original 149 research priorities, 66 reached consensus in round 1, 63 in round 2 and 45 items in round 3. Research priorities reaching consensus were collapsed by removing redundancies, and priority ranking identified 20 research priorities, 11 related to collaboration and 6 to research themes.Conclusions The top-ranked items for research priorities, research themes and collaborations included the effects of interventions on performance, recovery and return to play; clinical research in sport; and collaborations with researchers in chiropractic educational institutions, respectively.Implications The prioritisation of research items can be evaluated by key stakeholders (including athletes) and implemented to develop the first international research agenda for sports chiropractic.

Abstract Background The prevalence of low back pain increases with age and has a profound impact on physical and psychosocial health. With increasing age comes increasing comorbidity, and this also has pronounced health consequences. Whilst exercise is beneficial for a range of health conditions, trials of exercise for low back pain management often exclude older adults. It is currently unknown whether an exercise program for older adults with low back pain, tailored for the presence of comorbidities, is acceptable for participants and primary healthcare providers (PHCPs). Therefore, this mixed-methods study will assess the feasibility of an 8-week comorbidity-adapted exercise program for older people with low back pain and comorbid conditions. Methods The 3-phased feasibility study will be performed in a primary healthcare setting. PHCPs will be trained to deliver a comorbidity-adapted exercise program for older people with low back pain and comorbidities. Healthcare-seeking adults > 65 will be screened for eligibility over telephone, with a recruitment target of 24 participants. Eligible participants will attend an initial appointment (diagnostic phase). During this initial appointment, a research assistant will collect patient demographics, self-reported outcome measurement data, and perform a physical and functional examination to determine contraindications and restrictions to an exercise program. During the development phase, PHCPs will adapt the exercise program to the individual and provide patient education. During the intervention phase, there will be two supervised exercise sessions per week, over 8 weeks (total of 16 exercise sessions). Each exercise session will be approximately 60 min in duration. A qualitative evaluation after the last exercise program session will explore the feasibility of the exercise program for participants and PHCPs. Progression criteria will determine the suitability for a fully powered randomised controlled trial. Discussion This mixed-methods feasibility study will assess an exercise program for older adults with low back pain and comorbidities. Once assessed for feasibility, the exercise program may be tested for effectiveness in a larger, fully powered randomised controlled trial. This information will add to the sparse evidence base on appropriate options for managing back pain in older adults. Trial registration Australian and New Zealand Clinical Trials Registry registration number: ACTRN12621000379819p (06/04/2021; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12621000379819p ). Trial sponsor Macquarie University, Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW 2109, Australia.

Abstract Background The unprecedented impact of COVID-19 on healthcare professionals has implications for healthcare delivery, including the public health guidance provided to patients. This study aims to assess the response and impact of COVID-19 on chiropractors internationally, and examines the public health response of chiropractors to the COVID-19 pandemic practising under a musculoskeletal spine-care versus subluxation-based care paradigm. Methods A survey was distributed to chiropractors in Australia, Canada, Denmark, Hong Kong, United Kingdom and United States (Oct. 2nd–Dec. 22nd, 2020) via professional bodies/publications, and social media. Questions were categorised into three domains: socio-demographic, public health response and business/financial impact. Multivariable logistic regression explored survey items associated with chiropractors practising under different self-reported paradigms. Results A total of 2061 chiropractors representing four global regions completed the survey. Our recruitment method did not allow the calculation of an accurate response rate. The vast majority initiated COVID-19 infection control changes within their practice setting, including increased disinfecting of treatment equipment (95%), frequent contact areas (94%) and increased hand hygiene (94%). While findings varied by region, most chiropractors (85%) indicated that they had implemented regulator advice on the use of personal protective equipment (PPE). Suspension of face-to-face patient care during the peak of the pandemic was reported by 49% of the participants with 26% implementing telehealth since the pandemic began. Chiropractors practising under a musculoskeletal spine-care paradigm were more likely to implement some/all regulator advice on patient PPE use (odds ratio [OR] = 3.25; 95% confidence interval [CI]: 1.57, 6.74) and practitioner PPE use (OR = 2.59; 95% CI 1.32, 5.08); trust COVID-19 public health information provided by government/World Health Organisation/chiropractic bodies (OR = 2.47; 95% CI 1.49, 4.10), and initiate patient telehealth in response to COVID-19 (OR = 1.46; 95% CI 1.02, 2.08) compared to those practising under a subluxation-based paradigm. Conclusions Chiropractors who responded to our survey made substantial infectious control changes in response to COVID-19. However, there was regional variation in the implementation of the advised practitioner and patient use of PPE and limited overall use of telehealth consultations by chiropractors during COVID-19. Musculoskeletal spine-care chiropractors were more adaptive to certain COVID-19 public health changes within their practice setting than subluxation-based chiropractors.

Abstract Background To report the national prevalence, years lived with disability (YLDs) and attributable risk factors for all musculoskeletal conditions and separately for low back pain (LBP), as well as compare the disability burden related to musculoskeletal with other health conditions in Australia in 2019. Methods Global Burden of Disease (GBD) 2019 study meta-data on all musculoskeletal conditions and LBP specifically were accessed and aggregated. Counts and age-standardised rates, for both sexes and across all ages, for prevalence, YLDs and attributable risk factors are reported. Results In 2019, musculoskeletal conditions were estimated to be the leading cause of YLDs in Australia (20.1%). There were 7,219,894.5 (95% UI: 6,847,113–7,616,567) prevalent cases of musculoskeletal conditions and 685,363 (95% UI: 487,722–921,471) YLDs due to musculoskeletal conditions. There were 2,676,192 (95% UI: 2,339,327–3,061,066) prevalent cases of LBP and 298,624 (95% UI: 209,364–402,395) YLDs due to LBP. LBP was attributed to 44% of YLDs due to musculoskeletal conditions. In 2019, 22.3% and 39.8% of YLDs due to musculoskeletal conditions and LBP, respectively, were attributed to modifiable GBD risk factors. Conclusions The ongoing high burden due to musculoskeletal conditions impacts Australians across the life course, and in particular females and older Australians. Strategies for integrative and organisational interventions in the Australian healthcare system should support high-value care and address key modifiable risk factors for disability such as smoking, occupational ergonomic factors and obesity.

Abstract Background Musculoskeletal conditions are the primary reason older adults seek general medical care, resulting in older adults as the highest consumers of health care services. While there is high use of chiropractic care by older adults, there is no recent, specific data on why older adults seek chiropractic care and how chiropractors manage conditions. Therefore, the purpose of this study was to describe the demographic characteristics of older adults seeking chiropractic care, and to report problems diagnosed by chiropractors and the treatment provided to older adults who seek chiropractic care. Methods A secondary data analysis from two, large cross-sectional observational studies conducted in Australia (COAST) and Canada (O-COAST). Patient encounter and diagnoses were classified using the International Classification of Primary Care, 2nd edition (ICPC-2), using the Australian ICPC-2 PLUS general practice terminology and the ICPC-2 PLUS Chiro terminology. Descriptive statistics were used to summarize chiropractor, patient and encounter characteristics. Encounter and patient characteristics were compared between younger ( 65 years (16%), from 897 unique older patients. The most common diagnosis within older adult encounters was a back problem (56%), followed by neck problems (10%). Soft tissue techniques were most frequently used for older patients (85 in every 100 encounters) and in 29 of every 100 encounters, chiropractors recommended exercise to older patients as a part of their treatment. Conclusions From 6781 chiropractor–adult patient encounters across two countries, one in seven adult chiropractic patients were > 65 years. Of these, nearly 60% presented with a back problem, with neck pain and lower limb problems the next most common presentation to chiropractors. Musculoskeletal conditions have a significant burden in terms of disability in older adults and are the most commonly treated conditions in chiropractic practice. Future research should explore the clinical course of back pain in older patients seeking chiropractic care and compare the provision of care to older adults across healthcare professions.

Abstract The Chiropractic Academy for Research Leadership (CARL) was formed in 2016 in response to a need for a global network of early career researchers and leaders in the chiropractic profession. Thirteen fellows were accepted competitively and have since worked together at residentials and virtually on many research and leadership projects. In 2020, the CARL program ended for this first cohort, and it is now timely to take stock and reflect on the achievements and benefits of the program. In this paper we present the structure of CARL, the scientific and leadership outputs as well as the personal value of CARL for the participating fellows. As a result of the success of the first CARL cohort, organizations from Europe, North America, and Australia have supported a second cohort of 14 CARL fellows, who were competitively accepted into the program in early 2020.

Abstract Background Chiropractic students demonstrate philosophically opposing views about the chiropractic profession. The primary aim was to describe chiropractic students’ responses to statements about chiropractic identity, role, setting, and future direction. A secondary aim was to describe the frequency of internally conflicting responses. Methods Three datasets from Europe, North America, and Australia/New Zealand were pooled in a secondary data analysis. Chiropractic students from 25 chiropractic training institutions completed interrelating surveys (combined response rate 21.9%) between 2013 and 2018. The survey instrument investigated student viewpoints about chiropractic professional identity, role, practice setting and future direction of chiropractic practice. Student attitudes about chiropractic were described using weighted proportions to adjust for unequal population sampling across the three geographical regions. The frequency of concordant and discordant student responses was described by combining identity items with items that explored responses about practice role, setting and future direction. The relationship between student characteristics (age, sex, education, association membership and geographical region) and ideologically conflicting responses were assessed using the Chi-squared test and Cramér’s V. Results Data from 2396 student chiropractors (50.8% female; from Europe 36.2%, North America 49.6% and Australia/New Zealand 14.5%) were analysed. For identity, nearly half of the chiropractic students (weighted 45.1%) agreed that it is important for chiropractors to hold strongly to the traditional chiropractic theory that adjusting the spine corrects “dis-ease” and agreed (weighted 55.5%) that contemporary and evolving scientific evidence is more important than traditional chiropractic principles. The frequency of discordant (ideologically conflicting) student responses ranged from 32.5% for statements about identity versus role, to 51.4% for statements about identity versus future. There was no association between student age, sex and internally conflicting responses. Chiropractic students’ professional association membership status, pre-chiropractic education and geographical region were associated with ideologically conflicting responses. Conclusions Chiropractic students in this analysis show traditional and progressive attitudes towards the chiropractic profession. Individual student responses frequently contradict in terms of professional ideology, but most (approximately half) students demonstrate concordant progressive and mainstream attitudes. Ideological conflict may raise concerns about some students’ ability to learn and make clinical judgements, and potential for disharmony in the chiropractic fraternity.

Abstract Background A small proportion of chiropractors, osteopaths, and other manual medicine providers use spinal manipulative therapy (SMT) to manage non-musculoskeletal disorders. However, the efficacy and effectiveness of these interventions to prevent or treat non-musculoskeletal disorders remain controversial. Objectives We convened a Global Summit of international scientists to conduct a systematic review of the literature to determine the efficacy and effectiveness of SMT for the primary, secondary and tertiary prevention of non-musculoskeletal disorders. Global summit The Global Summit took place on September 14–15, 2019 in Toronto, Canada. It was attended by 50 researchers from 8 countries and 28 observers from 18 chiropractic organizations. At the summit, participants critically appraised the literature and synthesized the evidence. Systematic review of the literature We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health, and the Index to Chiropractic Literature from inception to May 15, 2019 using subject headings specific to each database and free text words relevant to manipulation/manual therapy, effectiveness, prevention, treatment, and non-musculoskeletal disorders. Eligible for review were randomized controlled trials published in English. The methodological quality of eligible studies was assessed independently by reviewers using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for randomized controlled trials. We synthesized the evidence from articles with high or acceptable methodological quality according to the Synthesis without Meta-Analysis (SWiM) Guideline. The final risk of bias and evidence tables were reviewed by researchers who attended the Global Summit and 75% (38/50) had to approve the content to reach consensus. Results We retrieved 4997 citations, removed 1123 duplicates and screened 3874 citations. Of those, the eligibility of 32 articles was evaluated at the Global Summit and 16 articles were included in our systematic review. Our synthesis included six randomized controlled trials with acceptable or high methodological quality (reported in seven articles). These trials investigated the efficacy or effectiveness of SMT for the management of infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. None of the trials evaluated the effectiveness of SMT in preventing the occurrence of non-musculoskeletal disorders. Consensus was reached on the content of all risk of bias and evidence tables. All randomized controlled trials with high or acceptable quality found that SMT was not superior to sham interventions for the treatment of these non-musculoskeletal disorders. Six of 50 participants (12%) in the Global Summit did not approve the final report. Conclusion Our systematic review included six randomized clinical trials (534 participants) of acceptable or high quality investigating the efficacy or effectiveness of SMT for the treatment of non-musculoskeletal disorders. We found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function. Governments, payers, regulators, educators, and clinicians should consider this evidence when developing policies about the use and reimbursement of SMT for non-musculoskeletal disorders.

Abstract Background Manual therapy is a cornerstone of chiropractic education, whereby students work towards a level of skill and expertise that is regarded as competent to work within the field of chiropractic. Due to the COVID-19 pandemic, chiropractic programs in every region around the world had to make rapid changes to the delivery of manual therapy technique education, however what those changes looked like was unknown. Aims The aims of this study were to describe the immediate actions made by chiropractic programs to deliver education for manual therapy techniques and to summarise the experience of academics who teach manual therapy techniques during the initial outbreak of COVID-19 pandemic. Methods A qualitative descriptive approach was used to describe the immediate actions made by chiropractic programs to deliver manual therapy technique education during the COVID-19 pandemic. Chiropractic programs were identified from the webpages of the Councils on Chiropractic Education International and the Council on Chiropractic Education – USA. Between May and June 2020, a convenience sample of academics who lead or teach in manual therapy technique in those programs were invited via email to participate in an online survey with open-ended questions. Responses were entered into the NVivo software program and analysed using a reflexive thematic analysis by a qualitative researcher independent to the data collection. Results Data from 16 academics in 13 separate chiropractic programs revealed five, interconnected themes: Immediate response; Move to online delivery; Impact on learning and teaching; Additional challenges faced by educators; and Ongoing challenges post lockdown. Conclusion This study used a qualitative descriptive approach to describe how some chiropractic programs immediately responded to the initial outbreak of the COVID-19 pandemic in their teaching of manual therapy techniques. Chiropractic programs around the world provided their students with rapid, innovative learning strategies, in an attempt to maintain high standards of chiropractic education; however, challenges included maintaining student engagement in an online teaching environment, psychomotor skills acquisition and staff workload.

COPD is responsible for an increasing number of deaths worldwide. Smoking is the most reliable predictor for developing COPD later in life. However, women make up the majority of patients with COPD who have never smoked. There is therefore a need to identify other factors that can predict COPD in women. The aim of this study is to identify factors associated with increasing the risk of developing COPD later in life in women who have never smoked. Data from the Australian Longitudinal Study on Women's Health (ALSWH) cohort born between 1946 and 1951 were used to investigate potential predictors of COPD. Retrospective analyses were performed on data from two of the ALSWH surveys: wave 1 (1996) and wave 9 (2019). There were 3584 women who self-reported as being never-smokers (at waves 1 and 9) and did not have COPD at baseline, of which 109 had developed COPD at wave 9. Logistic regression showed a significant relationship between COPD at wave 9 and baseline breathing difficulties (p

Abstract Background Low back pain is a common condition among older adults that significantly influences physical function and participation. Compared to their younger counterparts, there is limited information available about the clinical course of low back pain in older people, in particularly those presenting for chiropractic care. Improving our understanding of this patient population and the course of their low back pain may provide input for studies researching safer and more effective care than is currently provided. Objectives The primary objectives are to examine the clinical course over one year of pain intensity, healthcare costs and pain, functional status and recovery rates of low back pain in people 55 years and older who visit a chiropractor for a new episode of low back pain. Methods An international prospective, multi-center cohort study with one-year follow-up. Chiropractic practices are to be recruited in the Netherlands, Sweden, United Kingdom and Australia. Treatment will be left to the discretion of the chiropractor. Inclusion/Exclusion criteria: Patients aged 55 and older who consult a chiropractor for a new episode of low back pain, meaning low back pain for the first time or those patients who have not been to a chiropractor in the previous six months. This is independent of whether they have seen another type of health care provider for the current episode. Patients who are unable to complete the web-based questionnaires because of language restrictions or those with computer literacy restrictions will be excluded as well as those with cognitive disorders. In addition, those with a suspected tumor, fracture, infection or any other potential red flag or condition considered to be a contraindication for chiropractic care will be excluded. Data will be collected using online questionnaires at baseline, and at 2 and 6 weeks and at 3, 6, 9 and 12 months. Discussion This study, to our knowledge, is the first large-scale, prospective, multicenter, international cohort study to be conducted in a chiropractic setting to focus on older adults with low back pain consulting a chiropractor. By understanding the clinical course, satisfaction and safety of chiropractic treatment of this common debilitating condition in the aged population, this study will provide input for informing future clinical trials. Trial registration Nederlandse Trial Registrar NL7507 .

Abstract Background Approximately 60% of people with low back pain also have associated leg pain symptoms. Guidelines for low back pain recommend non-pharmacological approaches, including spinal manipulation - a therapy provided by chiropractors. However, limited empirical data has examined the characteristics of chiropractors managing patients with low back-related leg pain (LBRLP). Our objective is to describe the prevalence, profile and practice characteristics of Australian chiropractors who often treat LBRLP, compared to those who do not often treat LBRLP. Methods This is a cross-sectional analysis of a nationally representative sample from the Australian Chiropractic Research Network (ACORN). This study investigated the demographic and practice characteristics as well as clinical management of chiropractors who ‘often’ treated patients with LBRLP compared to those who treated LBRLP ‘never/rarely/sometimes’. Multiple logistic regression models identified independent factors associated with chiropractors who ‘often’ treated patients with LBRLP. Results A total of 1907 chiropractors reported treating patients experiencing LBRLP, with 80.9% of them ‘often’ treating LBRLP. Chiropractors who ‘often’ treated LBRLP were more likely to manage patients with multi-site pain including axial low back pain (OR = 21.1), referred/radicular neck pain (OR = 10.8) and referred/radicular thoracic pain (OR = 3.1). While no specific management strategies were identified, chiropractors who ‘often’ treated LBRLP were more likely to discuss medication (OR = 1.8), manage migraine (OR = 1.7) and degenerative spine conditions (OR = 1.5), and treat women during pregnancy (OR = 1.6) and people with work-related injuries (OR = 1.5), compared to those not treating LBRLP frequently. Conclusions Australian chiropractors frequently manage LBRLP, although the nature of specific management approaches for this condition remains unclear. Further research on the management of LBRLP can better inform policy makers and educators interested in upskilling chiropractors to deliver safe and effective treatment of LBRLP.

Abstract Background Musculoskeletal pain frequently occurs in more than one body region, with up to 80% of adults reporting more than one joint pain site in the last 12 months. Older people and females are known to be more susceptible to multiple joint pain sites, however the association of multisite joint pain with physical and psychosocial functions in this population are unknown. Methods Cross-sectional data from 579 women were analyzed. Women were asked “Which of your joints have been troublesome on most days of the past month?” Pain qualities were measured using the McGill Pain Questionnaire (Short Form) and PainDETECT, and health was assessed using the SF-36 and sociodemographic variables. Statistical analysis using generalized ordinal logistic regression included comparison of three joint pain groups: no joint pain, 1–4 sites of joint pain and ≥ 5 sites of joint pain. Results Two thirds of respondents had multisite pain (>1 site), and one third had ≥5 joint pain sites. Compared to women with fewer joint pain sites, women with >5 joint pain sites (multisite joint pain) had significantly poorer physical and emotional health-related quality of life, more severe pain, a higher probability of neuropathic pain, and a longer duration of pain. More than half of women in the multisite joint pain group were still employed, statistically significantly more than women with no joint pain. In the final model, pain duration, the number of medications, pain intensity (discomforting and distressing) and the physical component of health-related quality of life were significantly associated with increased number of joint pain sites. Conclusions Over one-third of older women in our sample had >5 painful joints in the last month. These women demonstrated significantly poorer psychosocial health, and increased medication use, than women with no or fewer sites of joint pain. Many women with multisite joint pain were still in the workforce, even when nearing retirement age. This study has important implications for future research into musculoskeletal pain, particularly in regards to womens health and wellbeing, and for clinical practice where there should be increased awareness of the implications of concurrent, multisite joint pain.

Abstract In an evidence-based health care environment, healthcare professions require a sustainable research culture to remain relevant. At present however, there is not a mature research culture across the chiropractic profession largely due to deficiencies in research capacity and leadership, which may be caused by a lack of chiropractic teaching programs in major universities. As a response to this challenge the Chiropractic Academy for Research Leadership, CARL, was created with the aim of develop a global network of successful early-career chiropractic researchers under the mentorship of three successful senior academics from Australia, Canada, and Denmark. The program centres upon an annual week-long program residential that rotates continental locations over the first three-year cycle and between residentials the CARL fellows work on self-initiated research and leadership initiatives. Through a competivite application process, the first cohort was selected and consists of 13 early career researchers from five professions in seven countries who represent diverse areas of interests of high relevance for chiropractic. The first residential was held in Odense, Denmark, with the second being planned in April 2018 in Edmonton, Canada, and the final residential to be held in Sydney, Australia in 2019.

An amendment to this paper has been published and can be accessed via the original article.

An amendment to this paper has been published and can be accessed via the original article.