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Background Previous research has investigated utilization rates, who sees chiropractors, for what reasons, and the type of care that chiropractors provide. However, these studies have not been comprehensively synthesized. We aimed to give a global overview by summarizing the current literature on the utilization of chiropractic services, reasons for seeking care, patient profiles, and assessment and treatment provided. Methods Systematic searches were conducted in MEDLINE, CINAHL, and Index to Chiropractic Literature using keywords and subject headings (MeSH or ChiroSH terms) from database inception to January 2016. Eligible studies: 1) were published in English or French; 2) were case series, descriptive, cross-sectional, or cohort studies; 3) described patients receiving chiropractic services; and 4) reported on the following theme(s): utilization rates of chiropractic services; reasons for attending chiropractic care; profiles of chiropractic patients; or, types of chiropractic services provided. Paired reviewers independently screened all citations and data were extracted from eligible studies. We provided descriptive numerical analysis, e.g. identifying the median rate and interquartile range (e.g., chiropractic utilization rate) stratified by study population or condition. Results The literature search retrieved 14,149 articles; 328 studies (reported in 337 articles) were relevant and reported on chiropractic utilization (245 studies), reason for attending chiropractic care (85 studies), patient demographics (130 studies), and assessment and treatment provided (34 studies). Globally, the median 12-month utilization of chiropractic services was 9.1% (interquartile range (IQR): 6.7%-13.1%) and remained stable between 1980 and 2015. Most patients consulting chiropractors were female (57.0%, IQR: 53.2%-60.0%) with a median age of 43.4 years (IQR: 39.6-48.0), and were employed (median: 77.3%, IQR: 70.3%-85.0%). The most common reported reasons for people attending chiropractic care were (median) low back pain (49.7%, IQR: 43.0%-60.2%), neck pain (22.5%, IQR: 16.3%-24.5%), and extremity problems (10.0%, IQR: 4.3%-22.0%). The most common treatment provided by chiropractors included (median) spinal manipulation (79.3%, IQR: 55.4%-91.3%), soft-tissue therapy (35.1%, IQR: 16.5%-52.0%), and formal patient education (31.3%, IQR: 22.6%-65.0%). Conclusions This comprehensive overview on the world-wide state of the chiropractic profession documented trends in the literature over the last four decades. The findings support the diverse nature of chiropractic practice, although common trends emerged.

Following publication of the original article [1], we have been notified that the copyright holder needs to be changed from ©The Author(s) to ©Crown.Following publication of the original article [1], we have been notified that the copyright holder needs to be changed from ©The Author(s) to ©Crown.

Background Research funds are limited and a healthcare profession that supports research activity should establish research priority areas. The study objective was to identify research priority areas for the Canadian chiropractic profession, and for stakeholders in the chiropractic profession to rank these in order of importance. Methods We conducted a modified Delphi consensus study between August 2015 and May 2017 to determine the views of Canadian chiropractic organisations (e.g. Canadian Chiropractic Association; provincial associations) and stakeholder groups (e.g. chiropractic educational institutions; researchers). Participants completed three online Delphi survey rounds. In Round 1, participants suggested research areas within four broad research themes: 1) Basic science; 2) Clinical; 3) Health services; and 4) Population health. In Round 2, researchers created sub-themes by categorising the areas suggested in Round 1, and participants judged the importance of the research sub-themes. We defined consensus as at least 70% of participants agreeing that a research area was “essential” or “very important”. In Round 3, results from Round 2 were presented to the participants to re-evaluate the importance of sub-themes. Finally, participants completed an online pairwise ranking activity to determine the rank order of the list of important research sub-themes. Results Fifty-seven participants, of 85 people invited, completed Round 1 (response rate 67%). Fifty-six participants completed Round 2, 55 completed Round 3, and 53 completed the ranking activity. After three Delphi rounds and the pairwise ranking activity was completed, the ranked list of research sub-themes considered important were: 1) Integration of chiropractic care into multidisciplinary settings; 2) Costs and cost-effectiveness of chiropractic care; 3) Effect of chiropractic care on reducing medical services; 4) Effects of chiropractic care; 5) Safety/side effects of chiropractic care; 6) Chiropractic care for older adults; 7) Neurophysiological mechanisms and effects of spinal manipulative therapy; 8) General mechanisms and effects of spinal manipulative therapy. Conclusions This project identified research priority areas for the Canadian chiropractic profession. The top three priority areas were all in the area of health services research: 1) Integration of chiropractic care into multidisciplinary settings; 2) Costs and cost-effectiveness of chiropractic care; 3) Effect of chiropractic care on reducing medical services.

ObjectivesThere is no current detailed profile of people seeking chiropractic care in Canada. We describe the profiles of chiropractors’ practice and the reasons, nature of the care provided to their patients and extent of interprofessional collaborations in Ontario, Canada.DesignCross-sectional observational study.SettingPrimary care setting in Ontario, Canada.ParticipantsWe randomly recruited chiropractors from a list of registered chiropractors (n=3978) in active practice in 2015. Of the 135 randomly selected chiropractors, 120 were eligible, 43 participated and 42 completed the study.Outcome measuresEach chiropractor recorded information for up to 100 consecutive patient encounters, documenting patient health profiles, reasons for encounter, diagnoses and care provided. Descriptive statistics summarised chiropractor, patient and encounter characteristics, with analyses accounting for clustering and design effects.ResultsChiropractors provided data on 3523 chiropractor-patient encounters. More than 65% of participating chiropractors were male, mean age 44 years and had practised on average 15 years. The typical patient was female (59% of encounters), between 45 and 64 years (43%) and retired (21%) or employed in business and administration (13%). Most (39.4%) referrals were from other patients, with 6.8% from physicians. Approximately 68% of patients paid out of pocket or claimed extended health insurance for care. Most common diagnoses were back (49%, 95% CI 44 to 56) and neck (15%, 95% CI 13 to 18) problems, with few encounters related to maintenance/preventive care (0.86%, 95% CI 0.2 to 3.9) and non-musculoskeletal problems (1.3%, 95% CI 0.7 to 2.3). The most common treatments included spinal manipulation (72%), soft tissue therapy (70%) and mobilisation (35%).ConclusionsThis is the most comprehensive profile to date of chiropractic practice in Canada. People who present to Ontario chiropractors are mostly adults with a musculoskeletal condition. Our results can be used by stakeholders to make informed decisions about workforce development, education and healthcare policy related to chiropractic care.

Background Past mental disorders predict future disorders, both in the presence and absence of trauma exposure. However, it is not clear whether those with past mental disorders are disproportionately vulnerable to the negative effects of a given level of trauma. Methods The data source was the 2013 Canadian Forces Mental Health Survey (CFMHS), of which 1820 respondents had deployed only once in their military careers—all in support of the mission in Afghanistan. The primary outcomes were past 12-month depression and past 12-month PTSD. Multivariate logistic regression was performed for each outcome variable, looking primarily for differences in the marginal effect of deployment-related trauma in those with and without a pre-deployment history of each disorder. Results A history of each pre-deployment disorder did indeed interact with deployment-related trauma with respect to the corresponding past 12-month disorder. In addition, pre-deployment history of depression and of PTSD interacted with each other, though only for the outcome of past 12-month PTSD. The average marginal effect of deployment-related trauma on past 12-month PTSD was highest in those with a pre-deployment history of depression in the absence of a pre-deployment history of PTSD. This group was twice as vulnerable to post-deployment PTSD relative to those without a pre-deployment history of both disorders and four times as vulnerable to post-deployment PTSD relative to those with a pre-deployment history of both disorders. No significant differences were seen in the marginal effects of trauma on past 12-month depression in the presence or absence of a pre-deployment history of that disorder. Conclusion There is modest differential vulnerability to past 12-month PTSD as a function of deployment-related trauma in those who had a pre-deployment history of PTSD or depression when compared to those who did and did not have a pre-deployment history of one or both disorders.

ObjectiveCanadian Armed Forces (CAF) personnel who return from certain international deployments are required to complete post-deployment screening (PDS) 90 to 180 days post-deployment; the primary goal of PDS is early detection of mental health problems that aims for reduced delays to care provision. We investigated service members’ compliance with the PDS completion requirement and the factors associated with this compliance; a secondary objective was to investigate completion timing.DesignThe study used a retrospective cohort of CAF personnel (n=28 460) who had deployments over 01 January 2009 to 31 December 2014; inferences were based on a probabilistic sample (n=3004).Primary outcomeThe primary outcome was PDS completion. We assessed the timing of PDS completion, comparing non-compliant (early, late or no completion) with compliant completions (90 to 180 days post-deployment) among deployments that required screening. Kaplan-Meier plots summarised time-to-completion and logistic regression assessed the covariate associations with compliant completion. Covariate-adjusted marginal compliance prevalence differences (MPD) were computed.Results67.3% (95% CI65.0 to 69.6) of deployments that required PDS had one completed; 43.3% (95%CI 40.6 to 46.0) were completed within the compliant period. Compliant completion was higher with lower ranks (MPD=10.6%, relative to officers), combat arms occupations (MPD=8.4%), Afghanistan deployments (MPD=19.2%), longer deployments (MPD=10.1%) and among those without a past mental health problem (MPD=9.7%).ConclusionsOur findings suggest that some selective processes may be occurring where those perceived to be at higher risk for post-deployment mental health problems are more compliant with PDS completion. However, PDS completion and compliant completion were lower than expected and this suggests a need to reinforce instruction on the guidelines and objectives of PDS among service members in the CAF.

In this study, we leveraged machine-learning tools by evaluating expression of genes of pharmacological relevance to standard-AML chemotherapy (ara-C/daunorubicin/etoposide) in a discovery-cohort of pediatric AML patients ( N  = 163; NCT00136084 ) and defined a 5-gene-drug resistance score (ADE-RS5) that was predictive of outcome (high MRD1 positivity p  = 0.013; lower EFS p  < 0.0001 and OS p  < 0.0001). ADE-RS5 was integrated with a previously defined leukemic-stemness signature (pLSC6) to classify patients into four groups. ADE-RS5, pLSC6 and integrated-score was evaluated for association with outcome in one of the largest assembly of ~3600 AML patients from 10 independent cohorts (1861 pediatric and 1773 adult AML). Patients with high ADE-RS5 had poor outcome in validation cohorts and the previously reported pLSC6 maintained strong significant association in all validation cohorts. For pLSC6/ADE-RS5-integrated-score analysis, using Group-1 (low-scores for ADE-RS5 and pLSC6) as reference, Group-4 (high-scores for ADE-RS5 and pLSC6) showed worst outcome (EFS: p  < 0.0001 and OS: p  < 0.0001). Groups-2/3 (one high and one low-score) showed intermediate outcome ( p  < 0.001). Integrated score groups remained an independent predictor of outcome in multivariable-analysis after adjusting for established prognostic factors (EFS: Group 2 vs. 1, HR = 4.68, p  < 0.001, Group 3 vs. 1, HR = 3.22, p  = 0.01, and Group 4 vs. 1, HR = 7.26, p  < 0.001). These results highlight the significant prognostic value of transcriptomics-based scores capturing disease aggressiveness through pLSC6 and drug resistance via ADE-RS5. The pLSC6 stemness score is a significant predictor of outcome and associates with high-risk group features, the ADE-RS5 drug resistance score adds further value, reflecting the clinical utility of simultaneous testing of both for optimizing treatment strategies.