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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.

Background Arthritis covers a range of chronic diseases presenting as joint pain and inflammation with prevalence of 20% in Canadians. Treatment guidelines for arthritis depend upon the type of arthritis but most include recommendations for rehabilitation interventions designed to optimize functioning and reduce disability. We set out to estimate the prevalence of healthcare utilization with different providers and to explore factors associated with utilization of different providers among Canadians with arthritis. Methods This population-based study used Canadian Community Health Survey data (2001–2018) restricted to respondents with arthritis (≥12 years). We used self-reported consultation with healthcare providers (medical doctor, chiropractor, physiotherapist, nurse, psychologist) (2001–2010), and self-reported regular healthcare provider (2015–2018). We calculated the 12-month prevalence of utilization with providers, and used modified Poisson regression to assess predisposing (e.g. age, sex, education), enabling (e.g. income, province) and need (e.g. self-percieved health) factors associated with utilization of providers. Results From 2001–2010 and 2015–2018, respectively, prevalence of utilization of medical doctors was 92.0% (95%CI: 91.7–92.2%) and 91.0% (95%CI: 90.5–91.5%); chiropractors 13.1% (12.8–13.4%) and 9.6% (9.1–10.1%); physiotherapists 14.5% (14.1–14.8%) and 9.4% (8.9–9.9%); nurses 14.2% (13.9–14.5%) and 7.5% (7.2–7.9%); psychologists 3.0% (2.8–3.1%) and 3.9% (3.5–4.2%). Females were more likely to see any provider. Users of chiropractic care were less likely to be smokers and more physically active with greater utilization in the western provinces than in the east. Those with poorer self-perceived health were more likely to see physiotherapists, nurses and psychologists. Consultation with a nurse (2001–2010) was more likely in the northern territories, while regular care from a nurse (2015–2018) was more likely in older age groups. Conclusions Canadians with arthritis were most likely to see medical doctors. Characteristics of healthcare utilizers varied by provider type. Geographical variation in utilization of chiropractors and physiotherapists likely related to differences by province and over time in what provincial health insurance covered while geographical variation in utilization of nurses was likely related to the lack of availability of medical doctors. Findings inform the need to strengthen healthcare delivery for Canadians, perhaps providing better access to providers of rehabilitation interventions.

Background Musculoskeletal disorders are common in the active military and are associated with significant lost duty days and disability. Implementing programs of care to manage musculoskeletal disorders can be challenging in complex healthcare systems such as in the military. Understanding how programs of care for musculoskeletal disorders have been implemented in the military and how they impact outcomes may help to inform future implementation interventions in this population. Methods We conducted a scoping review using the modified Arksey and O’Malley framework to identify literature on (1) implementation interventions of musculoskeletal programs of care in the active military, (2) barriers and facilitators of implementation, and (3) implementation outcomes. We identified studies published in English by searching MEDLINE, CINAHL, Embase, and CENTRAL (Cochrane) from inception to 1 June 2018 and hand searched reference lists of relevant studies. We included empirical studies. We synthesized study results according to three taxonomies: the Effective Practice and Organization of Care (EPOC) taxonomy to classify the implementation interventions; the capability, opportunity, motivation-behavior (COM-B) system to classify barriers and facilitators of implementation; and Proctor et al.’s taxonomy (Adm Policy Ment Health 38:65–76, 2011) to classify outcomes in implementation research. Results We identified 1785 studies and 16 were relevant. All but two of the relevant studies were conducted in the USA. Implementation interventions were primarily associated with delivery arrangements (e.g., multidisciplinary care). Most barriers or facilitators of implementation were environmental (physical or social). Service and client outcomes indicated improved efficiency of clinical care and improved function and symptomology. Studies reporting implementation outcomes indicated the programs were acceptable, appropriate, feasible, or sustainable. Conclusion Identification of evidence-based approaches for the management of musculoskeletal disorders is a priority for active-duty military. Our findings can be used by military health services to inform implementation strategies for musculoskeletal programs of care. Further research is needed to better understand (1) the components of implementation interventions, (2) how to overcome barriers to implementation, and (3) how to measure implementation outcomes to improve quality of care and recovery from musculoskeletal disorders.

Introduction: Individuals with participation and activity limitations face important healthcare challenges. Objectives: We investigated healthcare utilization and characteristics of Canadians living with participation and activity limitations between 2001 and 2010. Methods: We pooled data from 5 cycles of the Canadian Community Health Survey (2001-2010 CCHS). The multistage stratified cluster-sampling method used covered approximately 98% of Canadians, aged 12 years and older residing in private dwellings. We described sociodemographic, behavioral, and health-related characteristics of participants with participation and activity limitations and reported their annual utilization (prevalence; 95% CI) of 7 healthcare providers. Multivariable modified Poisson regression identified individual characteristics associated with healthcare utilization and examined the trends over time. Results: Annually, 8.1 million Canadians aged 12 years and older (29.8%) reported participation and activity limitations. Most common health conditions were back problems (37%) and arthritis (34%). Predominant healthcare providers were medical doctors (88.8%; 95% CI = 88.6-89.0), nurses (16.3%; 95% CI = 16.1-16.6), physiotherapists (15.0%; 95% CI = 14.7-15.2), and chiropractors (14.4%; 95% CI = 14.2-14.7). Overall, males, older adults, immigrants, those with lower education, lower income, recent employment, and better general health were less likely to consult providers. Over time, utilization of most non-medical providers increased. Conclusion: Participation and activity limitations are prevalent in Canada, and most consulted medical doctors. Disadvantaged groups reported lower utilization of most providers, emphasizing access challenges and the need for equitable and integrated healthcare policies. Improving access to rehabilitation services and their inclusion within universal healthcare coverage should be a priority.

Introduction The effectiveness of spinal manipulative therapy (SMT) for improving athletic performance in healthy athletes is unclear. Assessing the effect of SMT on other performance outcomes in asymptomatic populations may provide insight into the management of athletes where direct evidence may not be available. Our objective was to systematically review the literature on the effect of SMT on performance-related outcomes in asymptomatic adults. Methods MEDLINE, CINAHL, SPORTDiscus, and Cochrane Central Register of Controlled Trials were systematically searched from 1990 to March 23, 2018. Inclusion criteria was any study examining a performance-related outcome of SMT in asymptomatic adults. Methodological quality was assessed using the SIGN criteria. Studies with a low risk of bias were considered scientifically admissible for a best evidence synthesis. We calculated the between group mean change and 95% confidence intervals. Results Of 1415 articles screened, 20 studies had low risk of bias, seven were randomized crossover trials, 10 were randomized controlled trials (RCT) and three were RCT pilot trials. Four studies showed SMT had no effect on physiological parameters at rest or during exercise. There was no effect of SMT on scapular kinematics or transversus abdominus thickness. Three studies identified changes in muscle activation of the upper or lower limb, compared to two that did not. Five studies showed changes in range of motion (ROM). One study showed an increase lumbar proprioception and two identified changes in baropodometric variables after SMT. Sport-specific studies show no effect of SMT except for a small increase in basketball free-throw accuracy. Conclusion The preponderance of evidence suggests that SMT in comparison to sham or other interventions does not enhance performance-based outcomes in asymptomatic adult population. All studies are exploratory with immediate effects. In the few studies suggesting a positive immediate effect, the importance of such change is uncertain. Further high-quality performance specific studies are required to confirm these preliminary findings.

Background Chiropractors have diverse views of practice, but the impact on their patient profiles and treatment approaches remains unclear. We assessed the association between chiropractors’ view of practice (unorthodox versus orthodox) and patient encounter-level characteristics among chiropractors who practice in Ontario, Canada. Methods We conducted a cross-sectional study using Ontario Chiropractic Observation and Analysis STudy (O-COAST) data. In O-COAST, Ontario chiropractors were randomly recruited from a list of registered chiropractors in 2015 and recorded up to 100 consecutive patient encounters. We classified chiropractors’ response regarding their views of practice as unorthodox when viewing “vertebral subluxation as an encumbrance to health that is corrected to benefit overall well-being”; other views were considered orthodox. Patient encounter-level characteristics included: (1) non-musculoskeletal reason-for-encounter; (2) subluxation as diagnosis; (3) duration of encounter (log-transformed for modeling); (4) unimodal manipulative treatment; and (5) patient health characteristics (good health status, some activity limitations). We conducted multilevel logistic regression to assess the association between view of practice and aforementioned characteristics, accounting for potential confounders and clustering of encounters within chiropractors. The multilevel models had two levels (level 1—patient encounter level; level 2—chiropractor level), with level 1 patient encounters nested within level 2 chiropractors. Results We included 40 chiropractors (mean age = 43.4 years, SD = 11.5) and 3,378 chiropractor-patient encounters. The 2,332 unique patients identified had a mean age of 48.5 years (SD = 18.5). Chiropractors with unorthodox views had higher odds of having patients with a non-musculoskeletal reason-for-encounter (adjusted odds ratio (aOR) 16.5, 95% CI 3.2–84.0) and subluxation as diagnosis (aOR 63.0, 95% CI 4.2–949.1). Encounters of chiropractors with unorthodox views were 0.6 times shorter than those with orthodox views (95% CI 0.4–0.9). Chiropractor level explained 32%, 75%, and 49% of the variability in non-musculoskeletal reason-for-encounter, subluxation as diagnosis, and encounter duration, respectively. We observed no association between unorthodox view and unimodal manipulative treatment or patient health characteristics. Conclusions Chiropractors’ unorthodox view of practice was associated with treating non-musculoskeletal conditions, subluxation as diagnosis, and shorter duration of encounter. Chiropractor level explained a high proportion of variability in these outcomes. Findings have implications for understanding chiropractic practice and informing interprofessional collaboration.

Shoulder pain is a common musculoskeletal condition in the general population. Passive physical modalities are commonly used to treat shoulder pain. However, previous systematic reviews reported conflicting results. The aim of this study was to evaluate the effectiveness of passive physical modalities for the management of soft tissue injuries of the shoulder. MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials were searched from January 1, 1990, to April 18, 2013. Randomized controlled trials (RCTs) and cohort and case-control studies were eligible. Random pairs of independent reviewers screened 1,470 of 1,760 retrieved articles after removing 290 duplicates. Twenty-two articles were eligible for critical appraisal. Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. Of those, 11 studies had a low risk of bias. The lead author extracted data from low risk of bias studies and built evidence tables. A second reviewer independently checked the extracted data. The findings of studies with a low risk of bias were synthesized according to principles of best evidence synthesis. Pretensioned tape, ultrasound, and interferential current were found to be noneffective for managing shoulder pain. However, diathermy and corticosteroid injections led to similar outcomes. Low-level laser therapy provided short-term pain reduction for subacromial impingement syndrome. Extracorporeal shock-wave therapy was not effective for subacromial impingement syndrome but provided benefits for persistent shoulder calcific tendinitis. Non-English studies were excluded. Most passive physical modalities do not benefit patients with subacromial impingement syndrome. However, low-level laser therapy is more effective than placebo or ultrasound for subacromial impingement syndrome. Similarly, shock-wave therapy is more effective than sham therapy for persistent shoulder calcific tendinitis.

Although not typical, there appears to be a growing trend of chiropractors working within collaborative care settings. We use a case report to highlight features of patient care and education related to chiropractic practice within a collaborative care model. This paper hopes to offer some insight into how a chiropractor might fit into a collaborative setting and what training might help them to function effectively. The case report used is an example where a chiropractor provided a secondary diagnosis and complementary care not previously considered by the allied team resulting in symptom control and return to work by the patient. By the nature of a chiropractor's ability to provide a primary or secondary musculoskeletal diagnosis, they have the capacity to offer an additive approach to patient care within collaborative care models. However, chiropractors wishing to work in these environments, such as a family health team, would benefit from further education. (JCCA 2010; 54(3):147-154)

This study examined a wide range of variables relating to the practice patterns of 692 Ontario chiropractors (approximately 30% of all registrants in the province) who subscribed to the Ontario Chiropractic Association's Patient Management Program. It analyzed the 2000-2001 data of these chiropractors and provided important information on such factors as practitioner and patient demographics, practice profiles, and reimbursement patterns.The mean number of chiropractic treatments per patient for the year was 8.6 (sd = 3.4) and the mean treatment fee (above OHIP) per patient visit was $17.60 (sd = 5.0). Nearly one third of patient treatments were for lumbar complaints, and more than one-third of the patients were between 35 and 50 years of age.The mean annual gross income of the chiropractors in this study was $148,824 (sd = $86,391), with the male practitioners having a statistically significantly higher mean income ($161,363) than their female counterparts ($108,126). Practice location was significantly related to income, with postal code 'M' (Toronto) having the lowest mean income level. The overwhelming majority of practitioners (85%) used Diversified Technique as their primary treatment procedure, while 'modalities' was the most commonly selected adjunctive treatment procedure (29%).This study sheds new light on the associations among such factors as practitioner gender, practice location, and level of income.

Low Back Pain (LBP) is one of the most common causes of disability in the working population, and its impact on industry is enormous. The high financial costs of LBP and its apparent relationship with working conditions have led to efforts to prevent this condition. Several reviews have suggested that there is considerable potential for multimodal preventive interventions to cost-effectively reduce the overall burden of illness. The objectives of this study were to assess the feasibility of implementing a multi-faceted back injury prevention program in the community, and to assess the effectiveness of this program. A case study involving 92 firefighters from a suburb north of Toronto, Ontario, Canada. A back education program, called the Back Informed Program, was conducted on-site by a trained chiropractor. It offered employees job-specific education, ergonomic advice, exercises and pain management, as well as hands-on practice sessions. Data on absenteeism due to back injury, and cost of lost work days due to back injury were collected between January 1995 and December 1996. Data were compared to a municipality that received no such program during the same time period. Secondary outcomes, including information attained among the workers were qualitatively assessed. Absenteeism and financial data were used to demonstrate the potential efficacy of such a program. The results showed a significant decrease in the number of days lost due to back injuries in the year following implementation of the program. Upon implementation of the Back Informed program, there was a reduction of 72.4% in days lost reported over the two year period of program implementation. The rate of days lost per worker was 0.64 prior to program implementation and dropped to 0.13 two years later. This resulted in substantial cost-savings in both direct and indirect costs to the municipality. This study suggests that a multi-faceted, occupation-specific back education program may help reduce back injuries and reduce injury-related costs.