Table 1 Aims and conclusions of papers published in the series What is chiropractic?

Beliveau et al. 2017.

The chiropractic profession: a scoping review of utilization rates, reasons for seeking care, patient profiles, and care provided.

Scoping review

To document the current state of knowledge on the: 1) utilization of chiropractic services; 2) reasons for attending chiropractic care; 3) demographic and health profiles of chiropractic patients; and 4) types of chiropractic assessment and treatment provided worldwide.

Across different countries and regions, the average 12- month utilization rate of chiropractic services was 9.1% with little change between 1980 and 2015. Musculoskeletal conditions, such as back and neck pain, were the predominant reason for people attending chiropractic care. Typically, chiropractic patients were female, aged 43.4 years, and employed. Four out of five patients who consulted a chiropractor received spinal manipulation; however, chiropractors also commonly provided other treatments including soft-tissue therapy and formal patient education.

Stochkendahl et al. 2018.

Can chiropractors contribute to work disability prevention through sickness absence management for musculoskeletal disorders?

Comparative qualitative case study

To describe the experiences of chiropractors engaging in sickness absence management (SAM) and to compare and contrast chiropractors’ integration of SAM in their model of care in a context with legislated sickness certification rights (Norway) and in two contexts without sickness certification rights (Sweden and Denmark).

Chiropractors with patient management expertise can fulfil a key role in SAM and by extension work disability prevention when these practices are legislatively supported. In cases where these practices occur informally, however, practitioners face systemic-related issues and professional self-image challenges that tend to hamper them in fulfilling a more integrated role as providers of WDP practices.

Salsbury et al. 2018.

Be good, communicate, and collaborate: a qualitative analysis of stakeholder perspectives on adding a chiropractor to the multidisciplinary rehabilitation team.

Qualitative analysis based on personal and focus group interviews

To explore stakeholder perceptions of the qualities preferred in a chiropractor from the perspectives of patients, families, and interdisciplinary team members affiliated with this rehabilitation setting.

Study participants supported the addition of a chiropractor to the multidisciplinary team who practiced in a safe, evidence-based, patient-centered manner. Interprofessional skills that enhanced teamwork, intrapersonal qualities to support patients’ emotional journeys through the rehabilitation process, and an organizational perspective that amplified the mission of the institution also were desired.

Jenkins et al. 2018.

Current evidence for spinal X-ray use in the chiropractic profession.

Narrative review

To review 1) the current use of spinal X-ray imaging within chiropractic clinical practice; 2) the evidence for potential reasons for obtaining spinal X-rays within chiropractic; 3) the evidence of possible risks or limitations associated with the use of spinal X-rays; and 4) guidelines for the appropriate use of imaging in chiropractic clinical practice.

The use of spinal X-rays in chiropractic has been controversial, with benefits for the use of routine spinal X-rays being proposed by some elements of the profession. However, evidence of these postulated benefits is limited or non-existent. There is strong evidence to demonstrate potential harms associated with spinal X-rays including increased ionizing radiation exposure, overdiagnosis, subsequent low-value investigation and treatment procedures, and increased unnecessary costs. Therefore, in the vast majority of cases who present to chiropractors, the potential benefit from spinal X-rays does not outweigh the potential harms.

Hansen et al. 2018

Work-related acute physical injuries, chronic overuse complaints, and the psychosocial work environment in Danish primary care chiropractic practice - a cross-sectional study.

Cross-sectional study

To describe work-related physical acute injuries and overuse complaints as well as psychosocial stress among chiropractors in primary care chiropractic practice in Denmark during the previous year.

Danish practicing chiropractors commonly reported physical work-related acute injuries or overuse complaints. Overuse complaints are significantly more common in women and occur primarily in the low back, wrist, thumb, and shoulder. Chiropractors with less than five years in practice report more overuse complaints than chiropractors with more than five years in practice. Chiropractors in Denmark generally have a good psychosocial work environment.

Innes et al. 2018

Comparing the old to the new: A comparison of similarities and differences of the accreditation standards of the chiropractic council on education-international from 2010 to 2016.

Review of published accreditation standards

1. to compare the Council on Chiropractic Education International 2016 Accreditation Standards with their previous 2010 Accreditation

Standards, including the way they were developed, and; 2. to explore similarities and differences of prescribed recommendations to identify any changes to procedures, concepts, and emphases; 3. to comment on whether these changes are likely to be for the better or the worse.

Some positive changes have taken place, such as having bravely moved towards the musculoskeletal model, but on the negative side, the requirement to produce graduates skilled at dealing with scientific texts has been removed. A more robust development approach including better transparency is needed before implementation of CCE standards and evidence-based concepts should be integrated in the programs. The CCE-International should consider the creation of a recognition of excellence in educational programs and not merely propose minimal standards.

Funk et al. 2018

The prevalence of the term subluxation in chiropractic degree program curricula throughout the world.

Review of websites

To determine the prevalence of the term subluxation in the course titles or descriptions in all chiropractic training programs around the world for which information could be found.

The term subluxation was found in all but two US chiropractic course catalogues. The term was mentioned over eight times more frequently in US than non-US course catalogues. Similarly, subluxation was found greater than nine times more frequently in US course descriptions than in non-US descriptions.

Stochkendahl et al. 2019.

The chiropractic workforce: a global review.

Cross-sectional survey

To describe the chiropractic workforce worldwide in terms of the number of chiropractors, education, access, reimbursement schemes, scope of practice, and legal rights.

The [chiropractic] profession is represented in 90 countries, but the distribution, chiropractic educational institutions, and governing legislations and regulations largely favour high-income countries. There is a large under-representation in low- and middle-income countries in terms of provision of services, education and legislative and regulatory frameworks, and the available data from these countries are limited.

Stochkendahl et al. 2019.

Managing sickness absence of patients with musculoskeletal pain - a cross-sectional survey of Scandinavian chiropractors.

Cross-sectional survey

To 1) determine the prevalence of musculoskeletal practitioners’ key practice behaviors, and perceptions and beliefs about SAM using Scandinavian chiropractors; 2) to determine what characteristics of the practitioners, practice behaviors, perceptions and beliefs, and country were associated with two different practice behaviors.

Whilst not always engaged in sickness absence management (SAM) with regards to musculoskeletal pain, chiropractors favor a ‘return-to-work’ rather than a ‘stay-at-home’ approach. Norwegian chiropractors who have the right to prescribe sick leave consistently report more positive perceptions and beliefs towards SAM and a greater level of involvement with the process compared with the Danish and Swedish chiropractors who do not have these rights. Several practice behaviors and perceptions and beliefs are associated with these outcomes; however, system or organizational barriers are linked to clinician non-engagement.

Mior et al. 2019.

Chiropractic services in the active duty military setting.

Scoping review

To describe 1) access of chiropractic services; 2)

chiropractic scope of practice, e.g. procedures, processes, and actions; 3) service model and location; and 4) type of condition treated, duration, and outcomes of treatment provided to active duty military members.

The majority of the articles emanated from the US and were cross-sectional in nature. Two recent RCTs provide evidence of comparative effectiveness of adding chiropractic care to usual medical care. Despite the reported use of chiropractic services in Australia, Canada, and the US, there is little available published evidence related to the nature, use, and outcomes of chiropractic care in active duty military.

Wirth et al. 2019

An observational study on trajectories and outcomes of chronic low back pain patients referred from a spine surgery division for chiropractic treatment.

Longitudinal cohort study

To describe the trajectories and outcomes of patients with chronic LBP referred from the spine surgery division to the chiropractic teaching clinic.

Chronic LBP patients with long-lasting pain, reduced general health and high bio-psycho-social impairment, referred from spine surgery to a chiropractic teaching clinic, benefit from being co-managed by surgeons and chiropractors. Present pain intensity and Bournemouth Questionnaire score for bio-psycho-social impairment diminished by about 25% within the first 12 months after the start of chiropractic treatment.

Axen et al. 2019

Chiropractic maintenance care – what’s new?

Systematic review

1. To define the concept of Maintenance Care and the indications for its use; 2. To describe chiropractors’ belief in Maintenance Care and patients’ acceptance of it; 3. To establish the prevalence with which chiropractors use Maintenance Care and possible characteristics of the chiropractors associated with its use; 4. To determine its efficacy and cost-effectiveness for various types of conditions.

Back pain is a chronic disease for most, with episodes at short or long intervals. A preventive approach [to back pain] such as Maintenance Care makes sense. It is still not known if it ‘works’ because of the treatment given or because of the clinical encounter, or how these two components interact.

Gislason et al. 2019.

The shape of chiropractic in Europe: a cross sectional survey of chiropractor’s beliefs and practice.

Cross-sectional survey

To repeat a Canadian study within Europe aiming at categorizing beliefs or potential association with unorthodox practice.

Around one fifth of European chiropractors completing this survey identified themselves with an a priori defined unorthodox description of chiropractic care, i.e. “treating vertebral subluxations as an encumbrance to the expression of health”. The data also showed a number of key predictive practice behaviors statistically associated.

with this unorthodox group, including higher use of x-rays, higher patient visits, absence of differential diagnostic approaches and less favorable views regarding

the benefits of vaccination.

Adams et al. 2018.

Leadership and capacity building in international chiropractic research: introducing the chiropractic academy for research leadership (CARL).

Commentary

To describe the aims, core principles, methodology and evolution of the Chiropractic Academy of Research Leadership (CARL).

The long-term aim of CARL is to develop essential leadership skills and experiences to take on senior CARL mentorship appointments and help secure the successful mentorship of a subsequent early-career researcher cohort of Fellows.

Côté et al. 2019.

The development of a global chiropractic rehabilitation competency framework by the World Federation of Chiropractic.

Commentary

To present a chiropractic rehabilitation competency framework developed by the World Federation of Chiropractic Disability and Rehabilitation Committee.

Presents a chiropractic rehabilitation framework consisting of three domains: basic concepts of rehabilitation and disability; legal, regulatory and ethical components; and, rehabilitation management of disability and other health conditions.

Coulter et al. 2019.

The research crisis in American institutions of complementary and integrative health: one proposed solution for chiropractic profession.

Commentary

To discuss the overall crisis in research in complementary and alternative medicine and propose solutions with a special focus on chiropractic.

If the institutions pool their limited talent and resources, they might be able to compete, but history has shown that the American chiropractic institutions have not yet been able to do that. However, perhaps through a mediator it might be achievable. We are not suggesting this proposal will solve all the problems and we recognize that outside of the US the situation is different. But within the US it seems to us that without some type of response the situation will get worse not better. The RAND Health program has signed onto this proposal and we are currently approaching foundations to fund it.

Leboeuf-Yde et al. 2019.

Chiropractic, one big unhappy family: better together or apart?

Commentary

To examine the chiropractic profession from the perspective of an unhappy marriage by defining key elements in happy and unhappy marriages and by identifying factors that may determine why couples stay together or spilt up.

Chiropractors and chiropractic leaders, regardless of values and persuasion, need to pause and consider, if they are able to live and develop as they would like to in this century-old unhappy marriage.

Strahinjevich and Simpson 2018.

The schism in chiropractic through the eyes of a 1st year chiropractic student.

Commentary

To review the historical origins of the schism in chiropractic and examine the influence the schism has had on the profession and to discuss a possible strategy whereby this schism can be healed.

The schism as it is known has been identified as a division between those who adhere to the dogma of Palmerian ideology and those who embrace scientific advancement. Also considered were some of the reasons, largely external to the profession for the perpetuation of the divide.