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Purpose To develop an evidence-based guideline for the management of grades I–III neck pain and associated disorders (NAD). Methods This guideline is based on recent systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences (obtained from qualitative research) when formulating recommendations. Target audience includes clinicians; target population is adults with grades I–III NAD <6 months duration. Recommendation 1 Clinicians should rule out major structural or other pathologies as the cause of NAD. Once major pathology has been ruled out, clinicians should classify NAD as grade I, II, or III. Recommendation 2 Clinicians should assess prognostic factors for delayed recovery from NAD. Recommendation 3 Clinicians should educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I–III and the importance of maintaining activity and movement. Patients with worsening symptoms and those who develop new physical or psychological symptoms should be referred to a physician for further evaluation at any time during their care. Recommendation 4 For NAD grades I–II ≤3 months duration, clinicians may consider structured patient education in combination with: range of motion exercise, multimodal care (range of motion exercise with manipulation or mobilization), or muscle relaxants. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, strain-counterstrain therapy, relaxation massage, cervical collar, electroacupuncture, electrotherapy, or clinic-based heat. Recommendation 5 For NAD grades I–II >3 months duration, clinicians may consider structured patient education in combination with: range of motion and strengthening exercises, qigong, yoga, multimodal care (exercise with manipulation or mobilization), clinical massage, low-level laser therapy, or non-steroidal anti-inflammatory drugs. In view of evidence of no effectiveness, clinicians should not offer strengthening exercises alone, strain-counterstrain therapy, relaxation massage, relaxation therapy for pain or disability, electrotherapy, shortwave diathermy, clinic-based heat, electroacupuncture, or botulinum toxin injections. Recommendation 6 For NAD grade III ≤3 months duration, clinicians may consider supervised strengthening exercises in addition to structured patient education. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, cervical collar, low-level laser therapy, or traction. Recommendation 7 For NAD grade III >3 months duration, clinicians should not offer a cervical collar. Patients who continue to experience neurological signs and disability more than 3 months after injury should be referred to a physician for investigation and management. Recommendation 8 Clinicians should reassess the patient at every visit to determine if additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged.

Background Health inequities disproportionately impact equity-deserving groups, which include individuals marginalized due to race, ethnicity, Indigenous identity, sex and gender, socioeconomic status, and other social determinants of health. This qualitative study aimed to explore Canadian chiropractors’ experiences and perceptions in delivering care to equity-deserving groups and identify individual and institutional factors that may influence care delivery. Methods We utilized interpretive description for data development, sampling, collection, and analysis. Participants were recruited as part of a larger mixed-methods research study, where we conducted a cross-sectional survey assessing Canadian chiropractors' diversity and cultural competency. We used maximum variation sampling to recruit chiropractors who indicated their interest in participating in the qualitative study. Results Fourteen participants (N = 7, female) were included in this study, ranging from 28–64 years of age. We identified three major themes: 1) Perceived role of institutions to advance cultural competency , describing the approaches and strategies of professional associations and educational institutions in making changes concerning diversity, equity, and inclusion (DEI), 2) Fostering a culturally responsive clinical practice, describing factors that impact the delivery of care to equity-deserving groups (e.g. ensuring clinicians’ cultural awareness and sensitivity, promoting culturally competent behaviours, and understanding patients’ cultural values), and 3) Understanding the contextual determinants in accessing care (e.g., socioeconomic status, lack of accessibility, patient advocacy). Conclusion The results suggest that culturally congruent care involves top-down and bottom-up approaches that integrate DEI practices at institutional and clinician levels. Specifically, the incorporation of DEI training within curricula, the development of policies that foster diversity, the engagement of equity-deserving groups to understand unique cultural needs, and tailoring treatments to each patient rather than a one-size-fits-all approach.

Background Little is known about the diversity of the chiropractic profession with respect to gender, sexual orientation, race, ethnicity and community of practice. This knowledge is important as profession representation of key equity seeking groups may impact quality of care and access for vulnerable communities. The aim of this cross-sectional survey was to explore the diversity of the chiropractic profession in Canada. Methods All registered members of the Canadian Chiropractic Association ( N  = 7721) were invited to participate in a web-based survey between May and June 2021. Survey questions explored diversity with respect to personal demographics (age, sex, gender, sexual orientation, race, ethnicity, language) and practice characteristics (community setting, practice type). Where possible, survey data was compared to data from the 2016 Census of the Canadian population. Results We received a total of 3143 survey responses (response rate—41%). The average age of our sample was 44.7 years (standard deviation 12.7). Forty-five percent were female with the same proportion (45.2%) self-identifying as women. Ninety-one percent of the sample self-identified as heterosexual. With respect to race, 80% of respondents were Caucasian. Seventy percent of chiropractors in our sample identified with Canadian ancestry and 29% with European ancestry. In comparison to the Canadian population, some visible minorities were underrepresented. The greatest discrepancy between the Canadian population and our sample was in the proportion of Black and Indigenous chiropractors. With respect to ethnicity, chiropractors identifying themselves with Canadian ancestry were overrepresented in our sample compared to others, specifically those with North American Indigenous and South, Central and Latin American ancestry. Sixty-one percent of chiropractors practiced in major cities and most work in interdisciplinary clinics (42% Complementary and Alternative Medicine and 33% rehabilitation). Conclusions This study provides an initial description of diversity within the chiropractic profession in Canada. Women represent less than 50% of the profession nationally. Overall, there is little racial and ethnic diversity in the chiropractic profession compared to the Canadian population, with Black and Indigenous peoples being underrepresented. Future work should focus strategies to foster the development of a more diverse chiropractic workforce.

Background The Canadian Chiropractic Association (CCA) initiated a quality improvement project to develop best practices aimed at enhancing the patient experience . Objectives (1) Identify and prioritise the key moments in the new patient experience that could be improved by providing chiropractors with focused support and resources; (2) explore views, barriers, and enablers to implementing these best practices ; and (3) develop recommendations to facilitate the adoption of these practices. Methods We conducted a qualitative needs assessment using a human-centred design approach, focused on understanding the needs and experiences of end-users to create tailored solutions. The Theoretical Domains Framework (TDF) was employed to explore chiropractors’ knowledge use and behaviour change, and TDF domains were mapped to Behaviour Change Techniques (BCTs) to develop targeted strategies for addressing identified barriers and enablers. Thirteen chiropractors from across Canada participated in semi-structured interviews and related activities. Results The key moments where participants felt they needed the most support were “treatment”, “report of findings”, “informed consent”, “physical examination”, and “before the appointment”. All participants agreed with the best practices seed statements. Key barriers included gaps in knowledge, communication skills, and resource availability, particularly in rural areas. Enablers included collaboration with other health professionals, mentorship, and access to practice tools. Recommendations include enhanced training in communication and treatment planning, increased access to resources in rural areas, and fostering collaborative relationships among health professionals. Conclusion Understanding the barriers and enablers to implementing best practices can inform targeted strategies to improve patient-centred care in chiropractic practice across Canada.

Background There is a paucity of research assessing cultural competency among Canadian chiropractors. Therefore, the aims of this study were to (1) measure cultural competency among Canadian chiropractors, (2) understand chiropractors’ perspectives of challenges and attitudes regarding the delivery of chiropractic services to equity-seeking communities, and (3) assess contextual factors associated with cultural competency. Methods We conducted a cross-sectional survey of members of the Canadian Chiropractic Association (CCA) (May–July 2021). The survey instrument consisted of 57 questions related to demographics, cultural competency, perceptions about health disparities, and challenges in delivery of rehabilitation. Cultural competency was measured using the Cultural Awareness and Sensitivity and Cultural Competence Behaviours subscales of the Cultural Competence Assessment Instrument. We conducted a multivariate linear regression to assess factors that may be associated with cultural competency. Results A total of 3143 CCA members responded (response rate of 41%). Mean scores for the Cultural Awareness and Sensitivity subscale were 5.8/7 (95% CI 5.7; 5.8) and 4.2/7 (95% CI 4.1; 4.2) for the Cultural Competence Behaviour subscale. Most chiropractors (72–78%) reported observing important cultural health disparities across various care-related outcomes. Cost of services and language were identified as barriers to providing care to equity-seeking communities. Cultural Awareness and Sensitivity scores were weakly associated with gender (men), years of clinical practice, cultural health disparities, the statement “I think some people have an agenda to look for discrimination even where it does not exist (DEI attitudes),” race (Caucasian), and prior DEI training, (R 2  = 0.15, p  < 0.0001). Cultural Competence Behaviour scores were weakly associated with race (Caucasian), cultural health disparities, prior DEI training, increased years of clinical experience, and higher Cultural Awareness and Sensitivity scores (R 2  = 0.19, p  < 0.0001). Conclusion This study provides the first description of cultural competency within the chiropractic profession in Canada. Findings suggest a gap between knowledge and behaviour and uncover several barriers and challenges that may inform the development of profession-specific training in cultural competence.

Background Research enables a profession to establish its cultural authority, validate its professional roles and ensure ongoing improvement in the quality of its academic programming. Despite the clear importance of research, a mature research culture has eluded the chiropractic profession. A fostering institutional culture that enables, values, and supports research activity is essential to building research capacity. Our study aimed to collect information about the existing research capacity and culture at the Canadian Memorial Chiropractic College (CMCC) and explore the views, attitudes and experiences of faculty members regarding research. Methods We conducted a sequential explanatory mixed methods study with quantitative priority between April and July, 2023. Quantitative data were collected using the Research Capacity and Culture (RCC) tool. Survey results guided the qualitative data collected from four faculty focus groups with varying levels of research experience. Quantitative data were analyzed using descriptive statistics by domain and stratified by research education and workload. The qualitative data were thematically analyzed and then integrated with the quantitative results to provide deeper meaning to the results. Results The faculty survey response rate was 42% (59/144). Attributes at the organization or department level were consistently rated as either moderate or high; however, research skills at an individual level were more variable and influenced by factors such as research workload and highest research-related academic qualification. Qualitative focus group data were categorized under four themes: institutional factors, resource allocation, career pathways and personal factors. Lower scores for survey items related to mentorship, research planning and ensuring faculty research career pathways, as well as the identified workload and time-related barriers (e.g., other work roles and desire for work/life balance) for engaging in research were supported by each of the four themes. Research motivators included keeping the brain stimulated, developing skills and increasing job satisfaction. Conclusion The quantitative and qualitative information in this study provides a baseline evaluation for RCC and identifies key factors impacting RCC at the CMCC. This information is critical for planning, developing, implementing, and evaluating future interventions to enhance research capacity. Ultimately, these efforts are aimed at maturing the research culture of the chiropractic profession.

Background A significant proportion of children and adolescents experience back pain. However, a comprehensive systematic review on the effectiveness of rehabilitation interventions is lacking. Objectives To evaluate benefits and harms of rehabilitation interventions for non-specific low back pain (LBP) or thoracic spine pain in the pediatric population. Methods Seven bibliographic electronic databases were searched from inception to June 16, 2023. Moreover, reference lists of relevant studies and systematic reviews, three targeted websites, and the WHO International Clinical Trials Registry Platform were searched. Paired reviewers independently conducted screening, assessed risk of bias, and extracted data related to study characteristics, methodology, subjects, and results. Certainty of evidence was evaluated based on the GRADE approach. Results We screened 8461 citations and 307 full-text articles. Ten quantitative studies (i.e., 8 RCTs, 2 non-randomized clinical trials) and one qualitative study were included. With very low to moderate certainty evidence, in adolescents with LBP, spinal manipulation (1–2 sessions/week over 12 weeks, 1 RCT) plus exercise may be associated with a greater likelihood of experiencing clinically important pain reduction versus exercise alone; and group-based exercise over 8 weeks (2 RCTs and 1 non-randomized trial) may reduce pain intensity. The qualitative study found information provided via education/advice and compliance of treatment were related to effective treatment. No economic studies or studies examining thoracic spine pain were identified. Conclusions Spinal manipulation and group-based exercise may be beneficial in reducing LBP intensity in adolescents. Education should be provided as part of a care program. The overall evidence is sparse. Methodologically rigorous studies are needed. Trial registration CRD42019135009 (PROSPERO)

Background context Lumbar spinal stenosis (LSS) leads to diminished blood flow to the spinal nerves causing neurogenic claudication and impaired walking ability. Animal studies have demonstrated increased blood flow to the spinal nerves and spinal cord with superficial para-spinal electrical stimulation of the skin. Purpose The aim of this study was to assess the effectiveness of active para-spinal transcutaneous electrical nerve stimulation (TENS) compared to de-tuned TENS applied while walking, on improving walking ability in LSS. Study design This was a two-arm double-blinded (participant and assessor) randomized controlled trial. Patient sample We recruited 104 participants 50 years of age or older with neurogenic claudication, imaging confirmed LSS and limited walking ability. Outcome measures The primary measure was walking distance measured by the self-paced walking test (SPWT) and the primary outcome was the difference in proportions among participants in both groups who achieved at least a 30% improvement in walking distance from baseline using relative risk with 95% confidence intervals. Methods The active TENS group ( n  = 49) received para-spinal TENS from L3-S1 at a frequency of 65–100 Hz modulated over 3-s intervals with a pulse width of 100–200 usec, and turned on 2 min before the start and maintained during the SPWT. The de-tuned TENS group ( n  = 51) received similarly applied TENS for 30 s followed by ramping down to zero stimulus and turned off before the start and during the SPWT. Study funded by The Arthritis Society ($365,000 CAN) and salary support for Carlo Ammendolia funded by the Canadian Chiropractic Research Foundation ($500,000 CAN over 5 years). Results From August 2014 to January 2016 a total of 640 potential participants were screened for eligibility; 106 were eligible and 104 were randomly allocated to active TENS or de-tuned TENS. Both groups showed significant improvement in walking distance but there was no significant difference between groups. The mean difference between active and de-tuned TENS groups was 46.9 m; 95% CI (− 118.4 to 212.1); P  = 0.57. A total of 71% (35/49) of active TENS and 74% (38/51) of de-tuned TENS participants achieved at least 30% improvement in walking distance; relative risk (RR), 0.96; 95% CI, (0.7 to 1.2) P  = 0.77. Conclusions Active TENS applied while walking is no better than de-tuned TENS for improving walking ability in patients with degenerative LSS and therefore should not be a recommended treatment in clinical practice. Registration ClinicalTrials.gov ID: NCT02592642 . Registration October 30, 2015.

PurposeEvaluate benefits and harms of structured exercise programs for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline.MethodsWe searched for randomized controlled trials (RCTs) in electronic databases (inception to 17 May 2022). Eligible RCTs targeted structured exercise programs compared to placebo/sham, usual care, or no intervention (including comparison interventions where the attributable effect of exercise could be isolated). We extracted outcomes, appraised risk of bias, conducted meta-analyses where appropriate, and assessed certainty of evidence using GRADE.ResultsWe screened 2503 records (after initial screening through Cochrane RCT Classifier and Cochrane Crowd) and 398 full text RCTs. Thirteen RCTs rated with overall low or unclear risk of bias were synthesized. Assessing individual exercise types (predominantly very low certainty evidence), pain reduction was associated with aerobic exercise and Pilates vs. no intervention, and motor control exercise vs. sham. Improved function was associated with mixed exercise vs. usual care, and Pilates vs. no intervention. Temporary increased minor pain was associated with mixed exercise vs. no intervention, and yoga vs. usual care. Little to no difference was found for other comparisons and outcomes. When pooling exercise types, exercise vs. no intervention probably reduces pain in adults (8 RCTs, SMD = − 0.33, 95% CI − 0.58 to − 0.08) and functional limitations in adults and older adults (8 RCTs, SMD = − 0.31, 95% CI − 0.57 to − 0.05) (moderate certainty evidence).ConclusionsWith moderate certainty, structured exercise programs probably reduce pain and functional limitations in adults and older people with CPLBP.