Journal of Chiropractic Medicine (2015) 14, 99–152

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WFC 2015 Congress Proceedings

WFC'S 13th Biennial Congress Proceedings, Athens, Greece, 10-13, 2015: Abstracts of the Scientific Sessions Key indexing terms: Congresses [Publication Type]; Chiropractic

Abstract The World Federation of Chiropractic (WFC) held its 13th Biennial Congress in Athens, Greece, on May 13 through 16, 2015. The WFC call for abstracts resulted in 237 submissions from 19 countries (Australia, Bahrain, Brazil, Canada, Denmark, Greece, Ireland, Italy, Republic of Korea, Mexico, Netherlands, New Zealand, Norway, South Africa, Spain, Sweden, Switzerland, United Kingdom, and the United States). From these abstracts, a total of 40 platforms and 117 posters were presented at the Congress.

Introduction The World Federation of Chiropractic (WFC) held its 13th Biennial Congress in Athens, Greece, on May 13 through 16, 2015. The WFC call for abstracts resulted in 237 submissions from 19 countries (Australia, Bahrain, Brazil, Canada, Denmark, Greece, Ireland, Italy, Republic of Korea, Mexico, Netherlands, New Zealand, Norway, South Africa, Spain, Sweden, Switzerland, United Kingdom, and the United States). From these, the abstract review committee (Fig 1) selected platform and posters for presentation at the Congress, resulting in 40 platform presentations and 117 poster presentations. The peer review process for selection to the Congress was for selection purposes only and did not provide the opportunity for revision and resubmission. These are abstracts only and do not represent completed research papers. The authors have been encouraged to complete their research publications as full papers and submit to the indexed, peer-reviewed journal of their choice. The publishing of only the abstracts here allows the authors to publish their full papers in a journal without being considered duplicate publication, however it is the authors' responsibility to inform the editor of the journal to which they submit that their abstract has been published in this proceedings document. For ease of searching through this publication, the order has been organized in http://dx.doi.org/10.1016/j.jcm.2015.06.002 1556-3707

platform and poster sections. Each abstract is listed alphabetically by primary author last name. The abstracts published in these proceedings were reproduced from those furnished by the authors. The information included in the abstracts is the responsibility of the authors and not the World Federation of Chiropractic or the Journal of Chiropractic Medicine. All authors were asked permission to have their abstract reproduced in the proceedings published in the Journal of Chiropractic Medicine. Of the authors who agreed and who attended the Congress, their abstracts are published here.

SCIENTIFIC PRESENTATIONS PLATFORM ABSTRACTS Neck pain participants show impaired ability to perform a mental rotation task in a four week longitudinal study as compared to healthy controls Julianne Baarbé, Michael Holmes, Heather Murphy, Heidi Haavik, Bernadette Murphy Objectives: Individuals with subclinical neck pain (SCNP) demonstrate altered cerebellar processing. Mental rotation of an object requires cerebellar processing and has been shown in one previous study to

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WFC 2015 Congress Proceedings • • • • • • • • •

Fig 1.

Chair - Greg Kawchuk, DC, PhD - Canada Pierre Côté, DC, PhD - Canada Christine Goertz, DC, PhD - USA Mitch Haas, MA, DC - USA Heidi Haavik, DC, PhD - New Zealand Scott Haldeman, DC, MD, PhD - USA Jan Hartvigsen, DC, PhD - Denmark Claire Johnson, DC, MSEd - USA Christina Kolberg, DC, PhD - Brazil

Scientific Program Peer Review Team.

improve following neck manipulation, however longitudinal studies in SCNP groups are lacking. The purpose of this longitudinal study was to compare the mental rotation ability between and SCNP and healthy controls at baseline and after four weeks. Methods: Twenty-six volunteers (13 SCNP; 12 controls) were recruited from a university student population. SCNP participants had scores of mild to moderate on the Chronic Pain Grade Scale and controls had minimal or no pain. For the mental rotation task, participants were presented with an object (letter ‘R’) on a computer screen presented randomly in either normal or backwards parity at various orientations (0 o, 45 o, 90 o, 135 o, 180 o, 225 o, 270 o, 315 o). Participants had to indicate the object’s parity by pressing ‘N’ for normal or ‘B’ for backwards. Each orientation for both normal and backward parities was presented 5 times and the average response time for all letter presentations was calculated for each participant, at baseline and four weeks later. Results: Healthy participants had mean response times (± standard deviations) of 994.4 ± 211.9 ms at baseline vs. 834.0 ± 183.3 ms at four weeks. The SCNP group had mean response times of 1220.9 ± 294.5 ms at baseline vs. 1115.8 ± 220.8 ms at four weeks. The overall improvement for both groups was significant (F1, 23 = 8.93; P = 0.006), and response times were significantly different between groups, both at baseline (P b 0.05) and at four weeks (P b 0.05). Discussion: Healthy participants performed better than the SCNP group at both time points. SCNP may impair the ability to perform a complex mental rotation task involving cerebellar connections, possibly due to an altered body schema.

Are there differences in cervical inter-vertebral laxity or translation motion between patients with neck pain and healthy controls? Jonathan Branney, Alan Breen Introduction: This study sought to determine the repeatability of QF in the measurement of cervical inter-vertebral translation and laxity and to determine if these feature more in patients with neck pain than healthy controls. Methods: Twenty-nine patients with subacute or chronic neck pain (21 female) and 30 age and gender-matched healthy controls were imaged during flexion and extension using a standardized QF acquisition protocol. Between-group differences in inter-vertebral translation and laxity (C1/2 to C5/6) were determined using unpaired t-tests. In a subgroup of 10 healthy volunteers, fluoroscopic sequences were analyzed twice six weeks apart by one observer and once by a second observer. Intra- and inter-observer agreement and reliability

were determined using the standard error of measurement (SEM) and intra-class correlation coefficient (ICC). Results: The largest intra-observer SEM for translation at any level was 0.45 mm (0.59 mm for inter-observer). ICCs varied by segmental level and ranged from poor [0.012 (95% CI: -0.749 to 0.760)] to excellent [0.96 (95% CI: 0.829 to 0.991)]. In patients with neck pain translation was significantly reduced compared to healthy controls at C1/2 (mean difference -1.1 mm, 95% CI: -1.90 to -0.36, p = 0.005) and C4/5 in extension (mean difference -0.6 mm, 95% CI: -0.98 to -0.021, p = 0.003). For laxity, the largest SEM at any level was 0.036 and the lowest ICC 0.68 (95% CI: 0.085 to 0.918). The only significant difference in laxity was for C1/ 2 in flexion which was less lax in the patient group (mean difference -0.068, 95% CI: 0.0066 to 0.1300, p = 0.03). Conclusion: QF exhibited good agreement but variable reliability for translation and good overall repeatability for laxity. Neither excessive translation nor laxity was evident in this group of patients with mild-moderate non-traumatic neck pain.

Research utilization and evidence-based practice in chiropractic: A scoping review André Bussières, Fadi Al Zoubi, Kent Stuber, Jill Boruff, Simon French, Aliki Homas Background: Evidence-practice gaps are widespread across health disciplines. Understanding factors supporting the uptake of evidence can inform the design of strategies to narrow these gaps. Although research utilization (RU) and the factors associated with evidence-based practice (EBP) have been reported in several health disciplines, to date this area has not been reviewed comprehensively in chiropractic. The purpose of this review is to report on the current state of knowledge on RU, EBP, and knowledge translation (KT) in chiropractic. Methods: A scoping review using the Arksey and O’Malley framework was used to systematically select and summarize existing literature. Searches were conducted using a combination of keywords and MeSH terms from the earliest date available in each database to March 2014. Both quantitative and thematic analyses of the selected literature were conducted. Results: Most of the 53 included studies were undertaken in Canada, USA, UK and Australia. 70% of studies were surveys addressing issues related to research beliefs and skills among chiropractors. Thematic analysis revealed six major themes (KT, EBP, RU, and a mix of these: EBP/KT, KT/RU and EBP/RU), and three secondary themes: Guideline adherence and evidence gaps; EBP beliefs and attitudes; and Dissemination and implementation. Gaps were noted in the areas of assessment of activity limitation, psychosocial function, and general health indicators; establishing a prognosis; and exercise prescription. While most practitioners believed EBP and research to be important, and a few studies suggested that traditional and online educational strategies can improve patient care, guideline adherence varied widely. Conclusion: Findings suggest a need for the routine use of patient health outcomes, and for promoting self-management strategies. More robust dissemination and implementation research is required to increase guideline adherence and improve patient health outcomes. Educational strategies aimed at practicing chiropractors can lead to more EBP and improve patient care.

WFC 2015 Congress Proceedings Manual therapy for patients with cervico-thoracic angina: two year follow-up Henrik Wulff Christensen, Poul Flemming Høilund-Carlsen, Werner Vach Objectives: We have previously shown that patients with known or suspected angina pectoris and a diagnosis of cervico-thoracic angina (CTA, ie. chest pain which is indistinguishable from angina pectoris, but originates from the cervico-thoracic spine rather from the heart) may benefit from chiropractic manual therapy. The objective of this study was to examine if chiropractic manual therapy reduces chest pain originating from the spine and improves general health after 2 years. Methods: Two-year follow-up data from a non-randomized, open, prospective trial at a tertiary hospital setting in Denmark. Patients referred for coronary angiography because of known or suspected stable angina pectoris were invited in this study. The intervention in the CTA positive group was manual therapy according to chiropractic standards. Results: A total of 275 patients (171 males + 104 females, mean age 56 years) took part at baseline, 50 were diagnosed as CTA positive and 225 as CTA negative. Two-hundred and seven came for 2-year follow-up. Seventy-four percent of the CTA positive patients reported an improvement in chest pain compared to 22% of CTA negative patients (p b 00001), and 74% of CTA positive patients had an improvement in general health compared 20% of CTA negative patients (p b 00001) measured as global perceived effect. Conclusion: The results of this study indicate that manual therapy given to patients with suspected angina pectoris and a chiropractic-based diagnosis of CTA is associated with reduced pain and improvement in general health two years later.

Trajectories of acute low back pain: latent class growth analysis Aron Downie, Mark Hancock, Magdalena Rzewuska, Christine Lin, Christopher Williams, Christopher Maher Objectives: The objective of this study was to investigate the different recovery trajectories after an episode of acute low back pain, and to explore individual characteristics that are associated with each trajectory. Methods: Participants were adults consulting general practice with acute low back pain, recruited for a placebo controlled trial of paracetamol. Pain numerical rating scale data (score range 0-10) was collected at baseline, weeks 1, 2, 4 and 12. Latent Class Growth Analysis (LCGA) was used to identify pain trajectories, based on trichotomized pain scores (0-1 = pain recovery, 2-4 = moderate pain, ≥ 5 = high pain). Multinomial logistic regression analysis was used to explore patient characteristics at baseline that were associated with individual cluster membership. Results: In total, 1,477 participants who provided pain scores at all five collection points were analyzed. Six distinct clusters were identified including: ‘rapid pain recovery’ (n = 518), ‘rapid pain decrease, recovery at 12 weeks’ (n = 403), ‘gradual pain decrease, recovery at 12 weeks’ (n = 180), ‘incomplete recovery’ (n = 180), ‘persistent high pain’ (n = 103) and ‘fluctuating pain’ (n = 93). Higher pain, increased pain duration, and perceived risk of persistence were associated with delayed recovery trajectories when compared to rapid recovery. In addition, a higher number of previous episodes, workers’ compensation, and decreased quality of

101 life were associated with non-recovery trajectories when compared to rapid recovery. Conclusion: Overall, 25% of primary care attendees with acute low back pain show early tendency for pain persistence, recurrence or only partial recovery. Identification of patient characteristics that can influence recovery offers potential targets to improve patient outcomes.

Effect of manually operated chiropractic adjusting instrument with adapter on nociceptive and oxidative parameters in rat submitted to knee-joint immobilization Felipe Duarte, Carolina Kolberg, Ana Riffel, Taína Scheid, Jessica Souza, Andrea Horst, Wania Partata Objectives: This study evaluated the effect of the manually operated chiropractic adjusting instrument with an adapter (AAI-4) on nociceptive and oxidative stress parameters in blood from rats submitted to knee-joint immobilization and treated by 3 weeks, 3 times-week, on the spine during remobilization. Methods: After approval by Ethical Committee (# 21462) adult male Wistar rats were divided into 2 groups: Naive (N - animals which did not undergo immobilization) and Immobilized (I animals which had its right knee-joint immobilized during 4 weeks). Each experimental group was further divided into subgroups that receive AAI-4 treatment in setting force 1 during remobilization (NAAI-4 and IAAI-4). For better comparison it was used two additional groups: one without AAI-4 treatment (I-FR) and another with AAI-4 without retractable portion compressed on the spine (Sham) during remobilization. The mechanical threshold was assessed by electronic von Frey at pre-immobilization and 24 h after joint-cast removal and at end the treatment. After, the animals were sacrificed and blood collected to measure the lipid hydroperoxides and superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GPx) activities. Mechanical threshold were analyzed by repeated measures ANOVA followed by Bonferroni, while oxidative stress parameters by One Way ANOVA. Differences were considered statistically significant when P b 0.05. Results: While AAI-4 significantly increased the mechanical threshold decreased by immobilization, this threshold remained reduced in other groups. The lipid hydroperoxides were significantly higher in plasma of the I-FR group, but no significant change occurred in the other groups. Only CAT activity showed significant reduction in erythrocytes from IAAI-4 group. No significant change occurred in enzymatic activities of the I-FR and Sham groups. Conclusion: Hyperalgesia attributed to the knee-joint immobilization is reduced by AAI-4 treatment and the parallel reduction in CAT activity may be contributing to prevent the increase in lipid hydroperoxides induced by knee-joint immobilization.

A randomized controlled trial of chiropractic and physical therapy for balance impairments and chronic low back pain in community dwelling geriatric patients Dennis Enix, Kasey Sudkamp, Theodore Malmstrom, Joseph Flaherty Objectives: Affecting one third of elderly individuals, falls are a leading cause of injury. When compounded by musculoskeletal

102 pain, falls are a robust predictor of morbidity. This 2 x 2 factorial design evaluated the effectiveness of chiropractic and physical therapy for balance problems and low back pain (LBP) in geriatric patients. Methods: This prospective randomized controlled clinical trial set in a university research clinic, enrolled 168 community dwelling older adults between 60 and 85 years (72.8 +/- 6.8). Participants were randomly assigned to 6 weeks of chiropractic care (n = 83; LBP n = 57; without LBP n = 24) or physical therapy (PT) (n = 85; LBP n = 55; without LBP n = 30). Quality of life, pain, balance, fear of falling, and co-morbidities were recorded at baseline, 6 and 12 weeks post treatment. An intention-to-treat design analysis included a mixed-model analysis of variance (ANOVA) (p b 0.05) and Bonferroni correction (p b 0.017) for outcome measure treatment effects and between group effects. Data met the Kolmogorov-Smirnov goodness of fit test. Results: Participants showed significant improvements in balance, fear of falling and pain after 6 weeks of treatment. Reaction time improved across treatment groups (NeuroCom Limits of Stability test; p b 0.001; 95% CI). Fear of falling decreased by 25% across treatment groups (FES; p b 0.001; 95%). Static and dynamic balance, and gait improved equally with each group (POMA; p b 0.001; 95% CI). Risk of falls decreased equally with each group (timed get-up and go test; p b 0.001; 95% CI). LBP was reported by 67% of study participants. LBP decreased by 54.1% (Chiropractic) and 51.6% (PT) (VAS; p b 0.001; 95%) and the number of days with pain decreased by 29% (Chiropractic) and 23% (PT) (21 point box scale; p b 0.001; 95% CI). Conclusion: Chiropractic care was equal to physical therapy for improving balance problems affecting the elderly. Chiropractic care was marginally superior for reduction of LBP and days pain free.

Direct access to chiropractic services versus physician referral: Analysis of a large data set from the UK Jonathan Field, Dave Newell Objectives: This study looks to describe similarities and differences between the demographics, clinical presentation and outcomes of individuals accessing chiropractic services directly and indirectly across the UK. Further it looks to see if NHS referral compared to direct access is associated with a less favorable outcome when adjusting for baseline variables. Methods: Patient reported outcomes from neck and low back pain patients self-referring or attending via a NHS referral were collected and compared using the Care Response web based system. In addition low back pain patients in both referral routes were categorized as low, medium or high risk using the STarT Back Tool (SBT). Results: Baseline data was collected from 8223 patients attending for chiropractic care over a two year period (41% GP referral). There were significant between group differences in baseline characteristics including duration, having a recurring problem, the proportion with radiated pain, SBT ranking and across all BQ domains. All being more unfavorable in GP referred patients. NHS referred patients received more visits than direct referral patients but had largely concluded care by 30d (6.6 session at 30d and 6.7 at 90d). This was in contrast to those directly accessing the service

WFC 2015 Congress Proceedings (3.6 at 30d and 4.1 at 90d). Both groups demonstrated clinically and statistically significant improvement to 30d in crude BQ change scores and scores adjusted for significant baseline differences in a forward LR logistic model. However, at 90d the NHS group’s improvement whilst still significant, deteriorated (OR for not improving NHS v self-referring 1.6(1.2 to 2.2)). At 90d 63.7% and 79.7% of NHS and self-referring patients respectively reported significant improvement on a global impression of improvement scale. N 99% of patients in both groups reported being satisfied with their experience of chiropractic care. The NHS sample was more likely to have had their expectations of care exceeded (95.0% v 90.6%). Conclusion: Patients referred to chiropractic services by their GP (NHS) were more unwell at presentation and received more treatment sessions at shorter intervals, with their care ended by 30 days. Although both groups showed significant improvement the Self referring patients continuing improve past 30d.

General health and lifestyle characteristics of patients consulting Australian chiropractors Simon French, Melanie Charity, Bruce Walker Objectives: COAST (Chiropractic Observational and Analysis STudy) reported the clinical practices of chiropractors. This study describes the general health and lifestyle characteristics of patients who consulted chiropractors in COAST. Methods: 52 chiropractors in Victoria, Australia, provided information on up to 100 consecutive patients. If patients attended more than once during the 100 encounters, only data from their first encounter were included. Where possible, patient characteristics were compared to the general Australian population. Ethics approval was granted by the University of Melbourne. Results: 52 chiropractors provided data on 4464 encounters, representing 3341 unique chiropractic patients. Self-reported health was described as excellent or very good in 57% of COAST patients; 10% described their health as fair or poor. Seventy percent of male chiropractic patients, and 53% of female patients, were overweight or obese. Fourteen percent of COAST patients were current smokers and 27% did not meet Australian alcohol consumption guidelines. Less than half of the COAST patients participated in vigorous exercise at least twice per week. Approximately 20% of COAST patients ate one serve of vegetables or less each day, and approximately 50% ate one serve of fruit or less each day. Compared to the general Australian population, COAST patients were less likely to smoke, were less likely to be obese and were more likely to describe their health in positive terms. However, COAST patients were less likely to meet alcohol consumption guidelines. Conclusion: Chiropractic patients had more positive health and lifestyle characteristics than the general Australian population. This study cannot determine whether chiropractic treatment enhanced the general health of the patients, because it may be that patients attending chiropractors are healthier than the general population to begin with. Notwithstanding, there is a significant proportion of chiropractic patients who did not meet guideline recommendations about alcohol, smoking, diet and physical activity.

WFC 2015 Congress Proceedings Does the application site of spinal manipulation therapy alter spinal loading? Martha Funabashi, Greg Kawchuk, François Nougarou, Martin Descarreaux, Narasimha Prasad Objectives: To determine if peak loads experienced by a spinal segment are altered significantly when the site of spinal manipulation therapy (SMT) is changed. Methods: In 13 porcine cadavers, a servo-controlled linear actuator provided a standardized, 300 N SMT simulation to 6 different cutaneous locations on the left side of the lumbar spine: L2/L3 and L3/L4 facet joints (FJ), L3 and L4 transverse processes (TVP), and the space between the FJs and TVPs (BTW). Vertebral kinematics were tracked optically using indwelling bone pins, the motion segment removed and mounted in a parallel robot equipped with a 6-axis load cell. The movements of each SMT application at each site were replayed by the robot. Peak forces and moments created at the spine induced by SMT were collected then analyzed with a linear mixed model. This study was approved by the Animal Care and Use Committee of the University of Alberta. Results: Overall, the greatest translation was observed posteroanteriorly (mean: 4.4 mm ± SE:1.55) and the greatest rotation about the superoinferior axis (mean:1.6° ± SE:0.79). The analysis yielded a significant difference (p b 0.05) in peak forces and moments as a function of application site. Specifically for forces, there was no significant difference between conditions when SMT was applied at either TVP, nor at the FJs or between. Alternatively, peak forces were significantly decreased when SMT was applied between TVPs. The moments experienced by the spine during SMT showed increased influence due to application site. The SMT application at different FJ locations generated greater moment change than at different TVP locations. Generally, when compared to each other, peak moments were significantly different between TVP and FJ application sites. Conclusion: When SMT of a constant force is delivered at different application sites, spinal segments are loaded with significantly different magnitudes. The clinical significance of these results will be determined with further studies.

The effect of high and low force cervical manipulation on mechanical neck pain: A randomized controlled trial Lindsay Gorrell, Roger Engel Objectives: While cervical manipulation (CM) improves mechanical neck pain (MNP), the optimal dose required remains unclear. Results from high force manually applied manipulation (MAM) and low force instrument applied manipulation (IAM) are often grouped together despite IAM being considered safer than MAM. If the two are equally effective preference should be given to the safer technique. However, previous studies have suggested a possible dose-response mechanism. This study was designed to determine whether force magnitude is related to the efficacy of CM for MNP. Methods: 65 volunteers with MNP were randomly allocated to three groups: (i) Stretching (Control); (ii) Stretching plus MAM; and (iii) Stretching plus IAM. MAM consisted of a high velocity low amplitude CM while IAM was administered using an Activator® adjusting instrument. Pain visual analogue scale

103 (VAS), pressure pain threshold (PPT), cervical range of motion (cROM), hand grip strength (GS) and blood pressure at the wrist (WBP) were measured at baseline and post-intervention. Follow-up VAS levels were obtained via telephone text message 7 days post-intervention. The trial was conducted at Macquarie University. Results: VAS decreased post-intervention and at 7 day follow-up in the MAM group compared to Control (P = 0.009 and P = 0.007 respectively). Ipsilateral (side of manipulation) cervical rotation increased above the minimal detectable change in the MAM group. PPT, GS and WBP did not change in any group. No moderate or severe adverse events were reported in the trial. Five mild adverse events were reported: control: 4; MAM: 1; IAM: 1. Conclusion: These results show that high and low force techniques affect subjective pain levels and rotation on the side of manipulation differently when compared to stretching. This supports the concept of a dose-response mechanism. The absence of any moderate or severe adverse events suggests that cervical MAM is as safe as IAM.

The most common conditions presenting to the top provider-based complementary and alternative medicine therapies in the US adult population: 2012 National Health Interview Survey Bart Green, Claire Johnson Objectives: The purpose of this study was to determine which complementary and alternative medicine (CAM) therapies are most commonly used in the United States, identify most common conditions presented, and if patients perceived these therapies helped the condition. Methods: We performed a secondary analysis of the 2012 National Health Interview Survey Adult Complementary and Alternative Medicine Public Use File. The first of top 3 most important provider-based therapies were identified. We identified the 5 most common conditions presenting for these therapies and what percentage reported that the therapy helped the condition. Results: Of the 34,525 NHIS respondents, 4496 (13%) reported using CAM. The first of top 3 most important therapies were: chiropractic/osteopathic manipulation (25%), massage (13%), and acupuncture (2.4%). Most common reasons for using these therapies were: back pain (26.0%); neck pain (7.9%); joint pain/ stiffness (7.2%); arthritis (4.1%); and muscle or bone pain (3.6%). Perceptions that the therapy helped for chiropractic/osteopathic manipulation, massage, or acupuncture, respectively, were: arthritis (90%, 85%, 83%), back pain (90%, 85%, 81%), joint pain (90%, 90%, 69%), muscle bone pain (91%, 86%, 73%), and neck pain (92%, 90%, 75%). Conclusion: Chronic musculoskeletal diseases, joint pain, and arthritis are public health priorities. This study showed that musculoskeletal problems are common reasons that adult Americans seek CAM therapies and the most common therapies are chiropractic/osteopathic manipulation, massage, and acupuncture. The majority reported that their top therapy helped their condition. Further studies on the safety, effectiveness, and cost of the top 3 therapies are warranted.

104 Determinants of outcomes in a dose-response trial of spinal manipulation for the care of chronic low back pain Mitchell Haas, Darcy Vavrek, Moni Blazej Neradilek, Nayak Polissar Objectives: Identify determinants of chronic low back pain (cLBP) outcomes from a randomized trial of spinal manipulation. Methods: Participants, 400 with cLBP, were randomized to receive 18 sessions of treatment over 6-weeks. Spinal manipulation was performed by a chiropractor at 0, 6, 12, or 18 visits (dose), with light-massage control at remaining visits. Pain was evaluated for 52-weeks (0-100 scale). Three-quarters of cases-were used to develop predictive models with stepwise regression across all time points using generalized estimating equations. Dose, pain and disability, demographics, general health status, psychosocial, and objective exam findings were investigated as predictors. Confirmatory models used the remaining 25% of cases. One analysis used baseline variables; another used variables collected at the end of care (6 weeks). Results: For the baseline predictor model, statistically significant determinants of future pain included dose, pain, pain unpleasantness, EuroQol general health, and total pain during 6 active lumbar range-of-motion tests. Higher dose of care and better general health predicted less pain, whereas greater baseline pain predicted greater pain over the follow-up period. The determinants explained R-squared = 26.8% of the variance in pain outcomes. The SE of the estimate (prediction error) was 17.4 on the 0-100 scale. Confirmatory analysis did not demonstrate good generalizability of the model with R-squared = 6.6%. However, the prediction error was similar (SE = 19.4). For the 6-week predictor model, statistically significant determinants of future pain included 6-week pain and pain with right lateral bending. Greater pain at the end of care was associated with greater future pain. The model explained 36.6% of the variance in future pain and SE = 16.3. Confirmatory analysis demonstrated adequate generalizability with R-squared = 26.1% and a similar prediction error (SE = 17.5). Conclusion: Current pain, general health, and pain with movement are predictive of population trends in future cLBP intensity. Prediction of individual future pain remains allusive.

Do chronic neck pain patients have an altered response of the cervical lordosis relative to the thoracic inlet morphology? A comparison of a normal and chronic pain population Deed Harrison, Joseph Betz, Jason Jaeger, Jason Haas, Chris Colloca Objectives: The relationship between cervical lordosis and chronic neck pain (CNP) is a controversial topic in chiropractic practice today. The present study investigates the correlation between thoracic inlet morphology (TIM) and cervical lordosis in healthy volunteers compared to CNP subjects. We hypothesized that CNP subjects will have an altered response of their cervical lordosis relative to their TIM. Methods: IRB approval was obtained. 32 controls (8 female), 25-55 years were compared to 32 CNP subjects (23 female) 25-56 years (NRS = 4.59, NDI = 27.68). Subjects received a detailed evaluation. Lateral cervical radiographs were digitized to measurement cervical curvature (posterior bodies C2-C7), posterior body tilt of T1 to vertical (T1-vert), and TIM. Pearson correlations for all variables within and between groups, simple linear regression models to predict

WFC 2015 Congress Proceedings ARA C2-C7, and multiple regression analysis to predict ARA C2-C7 were determined. Statistical significance was set at p ≤ 0.01 (2-sample t-test assuming unequal variances). Results: There were no statistically significant differences between groups for T1-vert (p N 0.05) and TIM (p N 0.05). In contrast, statistically significant differences were found for normal subjects ARA C2-C7 vs. CNP ARA C2-C7 (p b 0.01). CNP subjects had a statistically significant reduced correlation between ARA vs. T1-Vert and ARA vs. TIM compared to the normal controls. A statistically significant multiple regression model to predict ARA C2-C7 from PTSIA and T1-vert was identified for both groups: for the normal subjects (p b 0.000) and for the CNP patients (p b 0.01); these models were statistically different from one another (p b 0.01). Conclusion: Differences in cervical lordosis and sagittal balance were observed for the CNP patients relative to their thoracic inlet morphology; this may reflect either a compensatory or injurious response. It remains to be seen if abnormal lordosis is predictive of CNP and response to rehabilitative treatment.

The Danish version of the Neck Disability Index Henrik Hein Lauridsen, Lotte O'Neill, Alice Kongsted, Jan Hartvigsen Objectives: Neck pain may greatly affect a person’s daily functioning. The Neck Disability Index (NDI) is a functional status measure designed to measure pain-related neck disability. It is a widely used instrument which is translated into numerous languages. This study assesses the clinimetric properties of the Danish version of the Neck Disability Index in chiropractic practice (CP) and an outpatient hospital spine clinic (HSC). Methods: Analyses were based on 326 neck pain patients with or without arm pain seen in five CPs and one HSC. Validity was assessed using a cross-validation factor analytical design and hypothesis testing. Reproducibility was measured using internal consistency, measurement error, the smallest detectable change and intra-class correlation coefficients. Furthermore, responsiveness was investigated by means of criterion and construct responsiveness and Minimal Important Change (MIC) was determined using an anchor-based distribution method. Lastly, floor and ceiling effects were established. Results: The cross-validation factor analyses confirmed a 1-factor structure of the NDI if 2 items were dropped (NDI-8). Analysis of construct validity correctly predicted more than 80% of the formulated hypotheses. Chronbach’s alpha ranged between 0.88-0.89 and intra-class correlation coefficients ranged between 0.90-0.93. The smallest detectable change corresponded to approximately one sixths (CP) and one seventh of the scale (HSC). Criterion responsiveness was problematic in CP patients and construct responsiveness was poor in HSC patients. A change of 10 points represented the MIC in CP patients and was undetermined in HSC patients. A significant floor effect was found primarily in CP patients. Conclusion: The Danish NDI-8 was unidimensional, had construct validity and was a reproducible measurement tool with an acceptable measurement error. The NDI-8 could not detect change accurately in HSC patients and was problematic in CP patients with little neck disability - both require further investigations. A change score representing the MIC is proposed.

WFC 2015 Congress Proceedings Reorganization in secondary somatosensory cortex in chronic low back pain patients Sabina Hotz-Boendermaker, Bart Boendermaker, Michael L. Meier, B. Kim Humphreys Objectives: There is growing interest in using neuroimaging methods to investigate the role of somatosensory processing in low back pain (LBP) and especially in chronic low back pain (CLBP). The present functional magnetic resonance imaging (fMRI) study aimed to investigate the organization of the lumbar spine in S1 and the secondary somatosensory cortex (S2), as well as neuroplastic changes in CLBP patients. Methods: Thirteen healthy subjects and thirteen CLBP patients were investigated in the prone position during functional magnetic resonance imaging (fMRI). An experienced manual therapist applied non-painful, posterior-to-anterior (PA) pressure onto three lumbar spinous processes (L1, L3, and L5). The pressure (30 N) was monitored and controlled by sensors. The experiment consisted of 51 randomized stimuli of 5 seconds duration. FMRI data analysis was performed using SPM8. A region of interest approach for S1 and S2 was applied and the coordinates for the different lumbar levels were extracted and statistically analyzed in SPSS 19. Results: Non-painful PA pressure elicited similar lumbar representations in S1 for CLPB patients and healthy subjects. In S2 in contrast, only the healthy subjects revealed a somatotopy for the individual lumbar vertebrae. Compared to the control group, the CLBP patients demonstrated a reorganization of the lumbar representation in S2. Conclusion: Nociceptive and non-nociceptive information are processed in topographic maps in parallel in S1. In contrast, the integration of multiple bilateral mechanosensory input is computed in S2. Ongoing pain also contributes to this multisensory cortical input and its salience might have induced such reorganizational processes as demonstrated in the present investigation. The smearing of the representation of a body part might have induced abnormal somatosensory functioning and impaired body perception. However, due to the brains plastic abilities, there is evidence that non-painful somatosensory input can reverse cortical changes and restore normal function.

Resorption biomechanics of lumbar disc herniations with spinal manipulation loads is governed by herniation size and load amplitude: a L1-S1 porohyperelastic finite element analysis Mozammil Hussain, Stephanie Nicholson, Saeed Khayatzadeh, Robert Havey, Leonard Voronov, Avinash Patwardhan, Ralph Gay, Kai-Nan An Introduction: Spinal manipulative therapy (SMT) has clinically been shown to affect herniation size; however, underlying resorption mechanisms of lumbar disc herniation (LDH) are not completely understood. Typically, LDHs vary in sizes and its tissue fluid content; therefore, they can readily be influenced by abrupt swelling pressure changes between herniated and that of surrounding disc tissues. The objective of this study is to test the hypothesis that, for LDH resorption, SMT load amplitude is a function of LDH size. Methods: From a normal CT spine scan, we developed a L1-S1 finite element (FE) model. Under physiological moments in three

105 planes without and with compressive follower-preload (400 N), segmental range of motions from FE model was validated with corresponding motions obtained from experimental testing using eight intact L1-S1 cadaver specimens. From validated FE model, 3 additional models were built with LDH of 3 sizes (small, medium, and large). LDHs of protrusion types were simulated at L4-L5 as posterior central, contained, and sub-ligamentous. Spinal tissues were assumed to be porous (fluid flow through deformable solid matrix), with tissue material properties adopted from literature. A non-trust SMT axial distraction (225 N ~ 30% body weight) was applied in a supine posture (400 N) in 3 incremental steps. Loads were applied on superior L1 while inferior S1 was constrained in 3 planes. A transient porohyperelastic consolidation analysis was undertaken using Abaqus FE software. With incremental SMT load amplitudes, LDH resorption (millimeters) was calculated as difference of the herniation depth before and after SMT application. Results: In supine posture, SMT distraction amplitudes (75 N, 150 N, 225 N) influenced LDH resorption [small (0.14, 0.15, 0.16), medium (0.29, 0.32, 0.33), and large (0.45, 0.49, 0.50)]; thereby confirming the study hypothesis. Conclusion: There exist a biomechanical relationship between LDH sizes and SMT load amplitudes that likely explains the biomechanical mechanisms of the LDH resorption.

Alterations of inflammatory cytokine profiles following spinal manipulative treatment (SMT) of low back patients: A single blind pilot clinical trial Stephen Injeyan, Julita Teodorczyk-Injeyan, John Triano, Marion McGregor Objectives: It has been suggested that high velocity low amplitude (HVLA) SMT of the thoracic spine may attenuate the production of pro-inflammatory cytokines. However, direct clinical evidence of SMT-related alterations within the inflammatory cytokine network is lacking. The present study was undertaken to determine whether HVLA-SMT will affect production of inflammatory mediators in patients with chronic or acute low back pain (LBP). Methods: Patients (N = 20) with acute (within 6 weeks of onset) or chronic (N 3 months duration) LBP with a minimum VAS score of 3/ 10 were recruited according to strict inclusion criteria. Blood samples were obtained before and after clinical intervention, which consisted of a single HVLA-SMT to a spinal segment deemed to be the primary spinal lesion on 6 alternate days over a period of two weeks. The levels of inflammatory cytokines, nociceptive chemokines and immunoregulatory mediators were determined in supernatants derived from inducer(s)-activated whole blood cultures, using specific immunoassays. Statistical significance of differences was tested by t test. Results: In chronic LBP patients, application of SMT significantly reduced the production of TNFα , IL-1β and IL-1RA . The production of chemokines CCL2 and CCL4 was diminished by 25-30%. The production of IL-2, IFNγ or IL-10 remained unaltered. In acute LBP patients, TNFα and IL-1 production was marginally (10-15%) lowered and CCL2 significantly reduced following SMT while IL-2 levels increased significantly. The production of IL-10 and IFNγ remained unaltered. Conclusion: In chronic LBP patients SMT reduces production of proinflammatory mediators and may diminish their biologic activity. SMT-related alterations in the inflammatory profile of acute LPB

106 patients are less apparent and may differ from those in chronic pain patients. These results contribute to understanding the role of inflammatory components in the pathophysiology of acute and chronic mechanical back pain and help inform future studies on SMT parameters of treatment.

Utilization and appropriateness of diagnostic imaging for low back pain among Danish chiropractors Tue S. Jensen, Henrik W. Christensen, Anders Munck, Nis Alnor, Simon French, André Bussières Objectives: Little is known regarding practice variations in the use of lumbar spine imaging in chiropractic clinics, and whether such imaging is clinically indicated. The objective of this study was to investigate the referral patterns of patients with low back pain (LBP) for lumbar imaging and to determine the rate of appropriate referrals according to imaging guideline recommendations. Methods: Twenty-nine chiropractors from the Region of Sealand, Denmark, involved in a previous auditing process, were invited to participate in the study. Each chiropractor was asked to record information on 100 consecutive patient encounters over an eight week period, and to also record any additional encounters where patients were referred for imaging. From the 100 consecutive patient encounters, we determined the proportion of patients referred for imaging at each visit. For all recorded encounters where patients were referred for imaging, we determined appropriateness by applying guideline-recommended indicators. Results: Twenty-seven chiropractors from 18 clinics recorded 2742 patient encounters from 1697 individual patients (50% women, mean age 48 years). A total of 342 patients were referred for imaging (90% were radiographs). The rate of referral was highest at the first visit (22%) with smaller ‘peak’ referral rates at the 5th and 8th visits. Based on guideline recommendations, 24% of referrals had one indication, 33% had two and 34% had three or more indications. Nine percent of referrals for imaging were not appropriate. The most common indications for imaging were ‘Significant activity restriction for more than 4 weeks’ (47%) and ‘Age above 50 years’ (45%). Conclusion: Chiropractors in Denmark primarily order radiographs when referring LBP patients for lumbar imaging at the initial patient visit or after the fourth visit. The vast majority of referrals for lumbar imaging of patients with LBP in Danish chiropractic practice are based on guideline-recommended indications.

Compensation claims for chiropractic in Denmark and Norway 2004-2012 Jørgen Jevne, Jan Hartvigsen, Henrik Wulff Christensen Objectives: Adverse events are commonly observed in all parts of health care. and have been reported extensively following manual therapy, including chiropractic. The majority of reported adverse events following chiropractic care are mild, transitory and selflimiting. However, little is known about patient filed compensation claims related to the chiropractic consultation process. The aim of this study was to describe claims reported to the Danish Patient Compensation Association and the Norwegian System of Compensation to Patients related to chiropractic from 2004 to 2012.

WFC 2015 Congress Proceedings Methods: All finalized compensation claims involving chiropractors reported to one of the two associations between 2004 and 2012 were assessed for age, gender, type of complaint, decisions and appeals. Descriptive statistics were used to describe the study population. Results: 338 claims were registered in Denmark and Norway between 2004 and 2012 of which 300 were included in the analysis. 41 (13.7 %) were approved for financial compensation. The most frequent complaints were worsening of symptoms following treatment (n = 91, 30.3%), alleged disk herniations (n = 57, 19 %) and cases with delayed referral (n = 46, 15.3 %). A total financial payment of € 2,305,757 (median payment € 7,730) were distributed among the forty-one cases with complaints relating to a few cases of cervical artery dissection (n = 11, 5.7 %) accounting for 88.7 % of the total amount. Conclusion: Chiropractors in Denmark and Norway received approximately one compensation claim per 100.000 consultations. The approval rate was low across the majority of complaint categories and lower than the approval rates for general practitioners and physiotherapists. Many claims could probably be avoided with adequate information to the patient regarding benign adverse events and reactions.

Instrument-assisted spinal manipulation can ameliorate sciatic nerve injury-induced neuropathic pain HanSuk Jung, JooHyun Ham, SungEun Kim, JinOk Choi, HyeRin Cho, Toshifumi Kuwaoka Objectives: The present study evaluated the effect of instrumentassisted spinal manipulation on neuropathic pain after the sciatic nerve crush injury in rats. Methods: After creating a sciatic nerve injury in Sprague-Dawley rats, rats were randomly assigned into 5 groups (n = 7, respectively): Sham group, Sciatic nerve injury group, Sciatic nerve injury and single impulse thrust treated group, Sciatic nerve injury and five impulse thrusts treated group, and Sciatic nerve injury and ten impulse thrusts treated group. After one day, we applied the impulsive spinal manipulation at the level of L6-S1 using an Impulse Adjusting Instrument® once a day for 7 consecutive days in the respective groups. Thermal hyperalgesia was assessed using a plantar test apparatus, and the expressions of tumor necrosis factor alpha (TNF-α) and cyclooxygenase 2 (COX2) in the sciatic nerve were determined by western blot. Finally, the expression of c-Fos, a neural marker of pain, in the spinal cord (L4-L5) and the ventral lateral periaqueductal grey (vlPAG) was measured using immunohistochemistry. Results: Sciatic nerve crush injury significantly decreased the thermal withdrawal threshold, and increased the expressions of TNF-α and COX2 in injured sciatic nerves (p b 0.05). On the other hand, impulsive spinal manipulation significantly increased the latency time, and suppressed the expressions of TNF-α and COX2 (p b 0.05). Moreover, impulsive spinal manipulation significantly inhibited the expressions of c-Fos in the dorsal horn of spinal cord and vlPAG (p b 0.05). When comparing the treatment groups, the five impulse group showed a trend for benefit over the single thrust or ten thrust group. Conclusion: From these results, it can be inferred that impulsive spinal manipulation may ameliorate the neuropathic pain through

WFC 2015 Congress Proceedings suppressing the expressions of inflammation-related factors after sciatic nerve crushed injury. However, further studies are needed to identify the exact molecular mechanisms of spinal manipulation on the neuropathic pain.

Quality of reporting of randomized controlled trials in chiropractic using the CONSORT checklist Fay Karpouzis, Benjamin Brown, Rod Bonello, Mario Pribicevic, Allan Kalamir Objectives: Reporting quality of RCTs is poor in medicine but unknown in chiropractic. The aim was to assess the reporting quality of RCTs in chiropractic and identify predictors for better reporting quality. It is hypothesized that RCTs with industry funding, positive findings, larger sample sizes, year of publication and type of journal will be associated with better quality of reporting. Methods: Searches for RCTs published in clinical trial registers and PubMed between 2005 and 2014 were conducted. RCTs were included if they involved spinal or extremity manipulation and were conducted within a chiropractic department. Article selection and data extraction were conducted by all reviewers independently, and disagreements were resolved by consensus. Results: Outcomes were: a 39-point overall quality of reporting score (OQRS) based on CONSORT and extension document for Non-pharmacological treatments; and a 4-point score of key methodological items (KMIS), based on allocation concealment, blinding of participants and assessors, and use of intention-to-treat analysis (ITT). Thirty-five RCTs were included. OQRS ranged between 10-33 with median = 25 (IQR = 9). Allocation concealment, blinding of participants and assessors and analysis by ITT were reported in 31 (88.6%), 15 (42.9%), 25 (71.4%) and 21 (60%) of the 35 RCTs, respectively. The items that were most underreported were from the CONSORT Extension for Nonpharmacological Treatments. A multivariable regression analysis revealed that journal of publication (t33 = 3.49, P b 0.001; 95% CI: 2.57, 9.76), sample size (t33 = 2.91, P = 0.006; 95% CI: 1.61, 9.11) and year of publication (t33 = 4.75, P = P b 0.001; 95% CI: 0.77, 1.91) were significantly associated with a better OQRS. Whereas, industry funding and positive findings were not. Conclusion: The overall quality of reporting RCTs in chiropractic ranged from poor to excellent, and has improved between 2005-2014. Reporting of some KMIS remains poor as does the uptake of the CONSORT Extension for Non-pharmacological Treatments. Recommendations are made for future publication quality.

Spinal manipulative therapy or therapeutic exercises do not change plasmatic TNF-α level in patients with chronic neck or low back pain Carolina Kolberg, Andrea Horst, Felipe Coutinho Kullmann Duarte, Ana Paula Konzen Riffel, Taína Scheid, Jéssica Araújo Souza, Angela Kolberg, Wania Aparecida Partata Objectives: Chronic pain is still poorly understood and notoriously difficult to treat. While the beneficial effect of spinal manipulation treatment (SMT) on musculoskeletal chronic pain has been largely demonstrated, the physiological effects are still unclear. It is possible that SMT may down-regulate inflammatory-type responses, as it was

107 observed with tumor necrosis factor α (TNF-α) in whole-blood cultures from normal subjects. In this way the present study aimed to evaluate the effect of SMT or therapeutic exercises on TNF-α level in plasma of patients with chronic neck or low back pain. Methods: Thirty subjects experiencing chronic neck and/or low back pain were allocated into two groups: (1) treated with SMT (n = 18) and (2) treated with a program of therapeutic exercises (n = 12). Treatments were carried out for five weeks twice a week. Self-perception of pain was assessed by visual analog scale (VAS) at baseline, after five weeks and one month after the end of treatment. The TNF-α was quantified by ELISA kit (EZHTNFA_Millipore) before and 24 h after the end of treatment. Results: SMT or therapeutic exercises showed no effect in the TNF-α level (P N 0.05; paired Student’s t-test) despite the 50% improvement in VAS (P b 0.05; Repeated measures ANOVA followed by Bonferroni’s post-hoc test). The self-perception of pain was reduced even for a month after the end of treatment for SMT, but not for therapeutic exercises. Conclusion: Despite no change on plasmatic TNF-α level after five weeks of both SMT and therapeutic exercises, only SMT has a prolonged effect on painful perception in patients with chronic neck or low back pain. It would be interesting to assess different pro- and anti-inflammatory cytokines in the same clinical conditions and in a later time point.

Positive effects of chiropractic manipulation on the bone status of ovariectomized rats Ana López-Herradón, Ricardo Fujikawa, Margaret Gómez-Marín, Joao Paulo Stedile-Lovatel, Francisca Mulero, Juan Antonio Ardura-Rodríguez, Pedro Esbrit, Arantxa Ortega-De Mues Introduction: Our aim was to evaluate the effect of chiropractic manipulation on the bone structure in a rat model of postmenopausal osteoporosis. Methods: Sham-operated (Sh; n = 10) and ovariectomized (OVX; n = 15) Sprague-Dawley rats (6 months-old) were submitted (M) -or not (NM)- to Activator V (at force 1) onto the tibial tubercle of the right hind limb (true chiropractic manipulation; TM) at a 90 o angle applying a medial to lateral vector. Left hind limb was subjected to false chiropractic manipulation (FM) by firing Activator V in the air and gently touching the tibial tubercle. These procedures were repeated 3 times/week for 6 weeks. Before sacrifice, bone mineral density (BMD) and content (BMC) were determined in the long bones and L3-L4 vertebrae. After euthanasia, femora and tibiae were collected for computed tomography (CT) analysis. Results: A significant (p b 0.05 or lower) decrease in BMD and BMC was observed in NM-OVX rats (similar to that in FM-OVX group), compared to Sh rats; these values, respectively, were (%Δ): -14 and -16 (proximal femur); -16 and -20 (distal femur); -21 and -28 (proximal tibia); and -20 and -27 (vertebrae). Significant (p b 0.05 or lower) increases of BMD and BMC occurred in both the distal femur (+ 12.5 and + 5 %, respectively) and proximal tibia (+ 10 and + 11%, respectively) of TM-OVX rats vs NM- and FM-OVX groups. BMD and BMC values of L3-L4 vertebrae (bones subjected to physiological mechanical loading) were similar (p N 0.05) in both M and NM groups of OVX rats, which confirms the specific changes observed associated with Activator adjustment in the long bones of these rats. Using CT, we evaluated several

108 trabecular and cortical structure parameters in the long bones in the different groups of rats. In the proximal and distal femur and in the proximal tibia of NM-OVX or FM-OVX rats, bone volume/ trabecular volume (BV/TV) and trabecular number (Tb.N) decreased 30 to 70 %, while trabecular separation (Tb.S) increased 2-5-fold, compared to NM-Sh rats. TM-OVX group showed a significant (p b 0.05 or lower) improvement of these parameters in the distal femur and proximal tibia vs those in NM-OVX and FM-OVX groups (%Δ): + 25-40 (BV/TV) and + 20-30 (Tb.N), and -20-50% (Tb.S). In cortical bone, no significant changes were observed in the bone volume fraction in any experimental group studied. However, a significant increase in the inner perimeter and marrow area (+ 20-60% and + 50%, respectively) was observed in the distal femur and proximal tibia of both OVX (M or NM) groups vs Sh group. Conclusion: These results in an osteoporosis rat model support the hypothesis that chiropractic manipulation may ameliorate the deteriorated bone structure associated with osteoporosis. Moreover, this study provides novel scientific data which open new possibilities to the current application of chiropractic in pain management towards the treatment of bone diseases.

Cervical facet imaging-guided injections: A comparison of outcomes in patients referred based on imaging findings with patients referred based on palpation for pain Yann LeClec'h, Cynthia Peterson, Florian Brunner, Jürg Hodler, Christian Pfirrmann Objectives: The purpose of this study is to compare outcomes of patients referred for these injections by either an MD basing his decision on imaging findings or a DC using palpation for pain. Methods: This prospective cohort outcomes study included 121 consecutive patients referred for facet injections who completed outcomes questionnaires. 91 patients were referred by MDs and 30 patients from DCs. Baseline numerical rating scale (NRS) pain data was collected. 1 day, 1 week and 1 month after treatment NRS pain levels were recorded. Overall ‘improvement’ at 1 day, 1 week and 1 month was assessed using the Patient Global Impression of Change (PGIC) scale. Only responses ‘much better’ or ‘better’ were considered ‘improved’. This was the primary outcome measure. The proportion of patients reporting ‘worsening’ (slightly worse, worse, or much worse) was also calculated for each data collection time point. The proportion of patients ‘improved’ was calculated for each referral group and compared using the Chi-squared test. NRS change scores for the two groups were compared at 1 day, 1 week and 1 month post injection using the unpaired t-test. The two cohorts were also compared for age using the un-paired Student’s t-test and sex distribution using the Chi-squared test. Results: At one day, ‘improvement’ was reported in 44.8% of DC referred patients and 29.7% of MD referred patients (p = 0.17). At one week 37.9% of DC and 21.3% of MD referred patients reported ‘improvement’ (p=0.03). At one month, ‘improvement’ was reported in 50.0% of DC and 31.0% of MD referred patients (p = 0.1). Additionally, a lower proportion of DC referred patients reported ‘worsening’ of their condition at

WFC 2015 Congress Proceedings all data collection time points but these values were not statistically significantly different. Conclusion: A greater proportion of DC referred patients reported clinically relevant ‘improvement’ at all follow-up time points. This reached statistical significance at 1 week (p = 0.03) with a trend at 1 month (p = 0.1). This is likely due to the fact that the DCs use palpation for pain to determine the level for injection while MDs more often rely on imaging findings. Furthermore, the results suggest that the reported moderate results of facet injections may partially be due to the inaccurate selection of the spinal level to be treated.

Manipulation of dysfunctional spinal joints affects sensorimotor integration in the pre-fontal cortex: A brain source localization study Dina Lelic, Imran Khan Niazi, Kelly Holt, Mads Jochumsen, Kim Dremstrup, Paul Yielder, Bernadette Murphy, Asbjørn Mohr Drewes, Heidi Haavik Objectives: Studies have shown decreases in N30 somatosensory evoked potential (SEP) peak amplitudes following spinal manipulation of dysfunctional segments in subclinical pain (SCP) populations. This study sought to verify these findings and to investigate underlying brain sources that may be responsible for such changes. Methods: Nineteen SCP volunteers attended two sessions in random order (spinal manipulation and control). SEPs from 62-channel EEG electrodes were recorded following median nerve stimulation (1000 stimuli at 2.3Hz) pre and post either intervention. Peak-to-peak amplitude analysis was completed for the N30 SEP component. Dipolar models of underlying brain sources were built by using the brain electrical source analysis. Differences in N30 amplitudes, dipole locations and dipole strengths were assessed by two-way repeated measures ANOVA. Results: Spinal manipulation decreased the N30 amplitude by 16.9 ± 31.3% (P = 0.02), while no differences were seen following the control intervention (P = 0.4). Brain source modeling revealed a 4-source model: primary somatosensory cortex, pre-frontal cortex, cingulate, and bilateral secondary somatosensory cortex. No changes in source location occurred following spinal manipulation, but the pre-frontal source showed reduced activity by 20.2 ± 12.2% (P = 0.03) following spinal manipulation. Conclusion: A single session of spinal manipulation of dysfunctional segments in subclinical pain patients alters somatosensory processing at the cortical level, particularly within the prefrontal cortex. The mechanisms behind pain relief following spinal manipulation in low level pain patients is likely due to improved sensorimotor integration and appropriate motor control, as this is the key function of the prefrontal cortex.

Diagnosis of functional asymmetry of the neck in infants: a pragmatic cross-sectional study Joyce Miller, Charlotte Giuliani Objectives: To investigate the diagnostic properties of “Lateral Head Righting Reaction” (LHRR) in detecting FAN and to compare

WFC 2015 Congress Proceedings the diagnostic properties of LHRR with the conventional diagnostic methods of FAN. Secondly, an inter-examiner observation was conducted to determine the reliability of LHRR. Setting: The study was conducted in a private interdisciplinary clinical setting in Brande, Midtjylland, Denmark, where two clinicians investigated the diagnostic properties of LHRR and conventional tests, against a reference standard for FAN, in a cross sectional study design. Subjects and Methods: 68 eligible infants between the corrected age 3 to 10 months, with a history of DP and/or FAN, were recruited prospectively from the clinical population. The demographic data for the description of the sample and clinical characteristics of the asymmetry were achieved with a parental questionnaire. After the subject was examined by the first examiner, who determined the Reference Standard and LHRR test, the second examiner performed the conventional tests for FAN and LHRR test. All investigations were conducted on the same day and the examiners were completely blinded to one another’s’ findings as well as the parental questionnaire. On the basis of the results the diagnostic properties of the different tests against the reference standard were determined, alongside the interexaminer reliability of LHRR. Results: The following diagnostic properties of LHRR to identify FAN as determined by the reference standard were found: Sensitivity 0.80, Specificity 0.84, Positive Predictive Value 0.89, Negative Predictive Value 0.72, Accuracy 0.82. The inter-examiner reliability of LHRR between two examiners yielded a Cohen’s Kappa value of 0.57; p b 0.001. Conclusion: LHRR showed overall good to very good diagnostic properties and, of all the tests investigated, it had the highest proportion of correctly classified cases from the overall number of cases as reflected in the accuracy of the tests. With a further moderate inter-observer reliability, LHRR can be considered an appropriate clinical tool in the assessment of FAN. However, the pragmatic nature of LHRR test makes interpretation reliant on the experience and clinical background of the examiner. On this basis LHRR should be considered as a component of a composite test for asymmetry in motor performance and not stand alone.

Assessing the predictors of chiropractic service utilization in patients with musculoskeletal pain presenting to an interdisciplinary primary care clinic Silvano Mior, Marion McGregor Objectives: The management of complex health conditions is enhanced by utilizing different interventions in a patient-centered health care setting, such as Family Health Teams (FHT). The purpose of our study was to assess factors associated with the utilization of health care services by patients presenting with musculoskeletal pain (MSK) and the organizational efficiencies in a FHT. Methods: We used Andersen’s behavioral model of health services to frame the contextual and individual characteristics to explain service utilization in a quasi-experimental, cohort design. We used System Dynamics modelling (SDM) to assess the influences of convenience of care, financial burden and physician-chiropractor relations. Descriptive, financial and outcomes data were collected from an urban located FHT. Results: There were 41,248 patient encounters between August 2008 and October 2209. About 4% involved MSK and 47% were

109 referred, most to chiropractors (30%). We collected detailed data on 178 consecutive patients. MSK patients referred for chiropractic care were similar to non-referred except for household income, pain severity and frequency of recurrences. We found similar outcomes to care in both groups except chiropractic patients had greater improvement in low back disability. SDM suggested that convenience of care (i.e. practice location, access, and wait times) is a major lever for change in number of MSK clinic visits seen by physicians and subsequent referrals to chiropractor. Levers associated with change in visits to chiropractors included patient financial burden and the degree of perceived negative attitudes of physicians towards chiropractic care. The importance of negative attitudes of primary care givers in the SDM suggests that interprofessional relationships and trust remain influential in explaining utilization of services. Conclusion: In an interdisciplinary FHT, physicians refer almost 50% of MSC encounters for active care. Referral patterns were consistent with factors from Anderson’s behavioral model of health services such as, accessibility and affordability of care.

Exploration of the chiropractic identity as expert in spinal health care Harrison Ndetan, Cheryl Hawk, Steven Pulvino, Trevor Foshang Objectives: The World Federation of Chiropractic’s Identity of the Profession Task Force recommended in 2005 that Doctors of Chiropractic (DC) should position themselves within the health care system as “the spinal health care experts”. We used the U.S. National Health Interview Survey (NHIS) data to explore whether there is evidence to support the realization of this recommendation. Methods: Both sample adult and complementary/alternative medicine (CAM) files of NHIS-2012 data, the most recent to include a CAM subsample, were analyzed. By applying the complete complex survey design structure (clustering, stratification and weighting), valid weighted frequencies representing the non-institutionalized United States general population were generated for those with spine-related problems using various health care practitioners. Odds ratios (OR) and 95% confidence intervals (CI) were calculated to explore the likelihood that the respondents would see a DC compared to general practitioner (MD/DO), nurse practitioner/physician assistant (NP/PA) and physical/occupational Therapist (PT/OT). Results: About 9.5% of respondents reported their top reason for seeking care as spine-related, of which 77.0% used chiropractic/ osteopathic manipulation. Of these, 97% used chiropractic and 3% used osteopathic manipulation (OR = 11.9, CI = 3.4-41.2). Respondents with spine-related problems were more likely to report that a DC was their personal health care provider, compared to MD/DO (OR = 3.7, CI = 1.7-7.9). In addition, 28.4% reported back/neck pain that interferes with their activities. Among these, 79.7%, 29.4%, 19.6%, and 17.4% saw an MD, NP/PA, PT/OT, and DC, respectively, with OR of 1.0(CI = 0.9-1.1), 1.2(CI = 1.0-1.3), 1.3(CI = 1.1-1.5), and 2.1(CI = 1.8-2.5). These patients were more likely to report seeing a DC exclusively compared to an MD [OR = 1.6(CI = 1.0-2.5)], PT/OT [OR = 1.3(CI = 0.6-2.9)] and NP/PA [OR = 1.5(CI = 0.9-2.6)].

110 Conclusion: The majority (77.0%) of NHIS-2012 respondents who sought care for spine-related problems used spinal manipulation. Of those, 97% used chiropractic and 3% osteopathic manipulation. Overall, respondents with spine-related complaints were more likely to use chiropractic and more likely to see a DC exclusively.

The UK PROMs collection initiative: Final results and reflections on an 18 month study Dave Newell, Jenni Bolton, Emily Diment Objectives: Within the context of such emerging evidence we implemented a web based PROMs collection process in a cohort of UK chiropractic practices to explore the practicality and user experience of this method as well as collecting a number of key outcomes and cost data. Methods: Care response, a web based PROMs collection system was introduced in consenting clinics across the UK. We collected a number of baseline data, including patient and condition characteristics as well as the BQ, EQ5D and STarT Back categorization. These PROMs were also collected at 90 days following the initial treatment. Only those with LBP or neck pain (NP) or both were included in the study. Results: In total, 3779 patient details were entered onto Care Response. Of the 91% eligible, 2757 patients completed the baseline assessment with 1672 completing the follow-up assessment at 90 days. Using the patient global impression of change scale at the 90 day assessment, 77% agreed they felt much or very much improved, with only 4% saying they felt worse. Similarly, 76% of patients experienced a minimal clinically important change of greater than 30% on the BQ. Over 95% of patients were either satisfied or very satisfied with around 90 -96% of patients feeling that enough time, good explanations, involvement in decisions and ample advice on self-management were given. The total mean cost of each patient episode including direct and indirect costs including time off work was £321.13. Using the EQ5D data we calculated Quality-Adjusted Life Years (QALYs). The mean QALYs gained over the 90 day period for chiropractic patients in this study were 0.161 with a mean cost per QALY gained of £2307.41. When only chiropractic treatment costs were included this cost dropped to £1411.66. This figure sits well below the NICE guidelines for the NHS which stipulates an acceptable cost per QALY of less than £30,000. Conclusion: This study has demonstrated that the vast majority of patients undergoing chiropractic care experience substantial clinical improvement at reasonable cost, while recording that the level of care exceeded their expectations. Perhaps even more importantly, the study clearly shows that collecting routine patient data works in the real world of busy practice generating a diversity of information that can be used by patients, clinicians, politicians and health commissioners alike.

Combined effects of spinal manipulation and a brain computer interface based plasticity protocol on corticospinal excitability Imran Khan Niazi, Mads Jochumsen, Kelly Holt, Kim Demstrup, Heidi Haavik Objectives: Previous research has shown that brain computer interface (BCI) based protocols and spinal manipulation can

WFC 2015 Congress Proceedings increase lower limb corticospinal excitability. The objective of this study was to investigate whether combining these two types of interventions would alter such changes in corticospinal excitability. Methods: 13 subjects (8 male, aged 23.3 ± 2.6) participated in this study. Three different interventions were applied in random order over three different days. Ten motor evoked potentials (MEPs) were averaged at stimulus intensities set at 90-130% motor threshold (at 10% increments) from the tibialis anterior muscle pre and post each intervention. The interventions were a BCI based intervention in which motor imagination of ankle dorsiflexion was paired with peripheral electrical stimulation, a spinal manipulation intervention, and a combined BCI and spinal manipulation intervention. To investigate the effects of the different interventions on the maximum MEP amplitudes repeated measures ANOVAs and post hoc paired t-tests were performed. Results: The analysis of the maximum MEP amplitudes revealed a significant interactive effect for factors time*Intervention [F(2,24) = 5.25 p b 0.01]. Paired t-tests revealed that all three interventions resulted in a significant increase in maximum MEP amplitudes (p b 0.05). However the BCI + spinal manipulation intervention session resulted in a significantly greater increase of the maximum MEP amplitudes compared to either the BCI (88.7%; p = 0.02) or manipulation (37.3%; p = 0.03) intervention alone. There was no significant difference between BCI and spinal manipulation alone interventions (p = 0.54). Conclusion: These results confirm that both BCI interventions and spinal manipulation interventions increase lower limb corticospinal excitability. They also suggest that when spinal manipulation is combined with a BCI intervention it increased corticospinal excitability significantly compared to when either intervention are provided alone. Future work should investigate mechanisms for these neurophysiological differences and whether combined interventions may assist in the rehabilitation of patients with brain injuries.

Symptomatic, MRI confirmed cervical disc herniation patients: A comparative effectiveness observational study of two age and gender matched cohorts treated with either spinal manipulative therapy or imaging guided cervical nerve root injections Cynthia Peterson, Christian Pfirrmann, Jürg Hodler, Christof Schmid, Serafin Leemann, Bernard Anklin, B. Kim Humphreys Objectives: The purpose of this study is to compare outcomes of these two treatments in two matched cohorts. Methods: This prospective cohort comparative effectiveness study included 104 patients with MRI confirmed symptomatic cervical disc herniation. Fifty two patients treated with CNRI were age and gender matched with 52 patients treated with high velocity, low amplitude SMT to the level of the MRI confirmed, symptomatic disc herniation. Baseline numerical rating scale (NRS) pain data was collected. Three months after either treatment NRS pain levels were recorded and overall ‘improvement’ assessed using the Patient Global Impression of Change (PGIC) scale. Only responses ‘much better’ or ‘better’ were considered ‘improved’. This outcome data was collected for both treatment cohorts via telephone interview by research assistants from the Orthopaedic University Hospital Balgrist who were unknown to the patient. The proportion of patients ‘improved’ was calculated for each treatment method and compared using the Chi-squared test. This was the primary

WFC 2015 Congress Proceedings outcome. NRS and NRS change scores for the two groups were compared at baseline and 3 months using the unpaired t-test. Acute and subacute/chronic patients in the two groups were compared for ‘improvement’ using the Chi-squared test. Treatment cost comparisons were calculated. Hospital and county ethics approval was obtained and all patients signed informed consent. Results: ‘Improvement’ was reported in 86.5% of SMT patients and 49.0% of CNRI patients (p = 0.0001). Significantly more CNRI patients were in the subacute/chronic category (77%) compared to SMT patients (46%). A significant difference between the proportion of subacute/chronic CNRI patients (37.5%) and SMT patients (78.3%) reporting ‘improvement’ was noted (p = 0.002). Most of the acute patients in both treatment groups improved (p = 0.814). There was no significant difference between the groups for baseline NRS scores. Both cohorts reported statistically significant NRS change scores at 3 months. The SMT group had significantly higher NRS change scores compared to the CNRI group (p = 0.0001). The average cost for treatment with SMT at 3 months was CHF 973.48 and for CNRI it was CHF 931.01. Conclusion: Subacute/chronic patients treated with SMT were significantly more likely to report relevant ‘improvement’. Most of the acute patients in both treatment groups reported clinically relevant improvement. SMT patients had significantly more pain reduction.

Distance education online intervention for evidence based practice literacy Michael Schneider, Mitchell Haas, Roni Evans, Cynthia Long, Cheryl Hawk, Matthew Leach, Greg Cramer, Corrie Vihstadt, Oakland Walters, Lauren Terhorst Objectives: Providers of Complementary and Alternative Medicine (CAM) have not traditionally relied on scientific evidence as a basis for their practices; thus research literacy is a relatively recent emphasis. Chiropractic represents one of the largest CAM professions in the U.S. and serves as a representative subset of CAM professions. Methods: We designed a two-phase research study: 1) a survey of U.S. chiropractors to assess their attitudes, skills, and use of research evidence and 2) an RCT testing the effectiveness of an online educational intervention. This presentation reports the findings of the first phase of the study. Methods: A nationwide survey of U.S. chiropractors was administered online utilizing a validated self-report instrument (E-BASE) in which three subscores were used: attitudes, skills, and use. Descriptive statistics for demographic variables and means/frequency distributions for the sub-scores were generated; sub-scores were dichotomized into “high” and “low” at the mean. Three logistic regression models were created with the sub-scores representing three distinct dependent variables and with the significant demographic, clinical decision, and barrier variables as predictors. Results: A total of 1,314 U.S. chiropractors completed the E-BASE survey; the sample was representative of the U.S. chiropractic profession. Respondents were predominantly white (94.3%), male (75%), 47 ± 11.6 years of age, and practiced more than 10 years (~ 60%). Sub-scores were highest for attitudes (mean = 79) and skills (mean = 68), and lowest for use (mean = 43). More years in practice and having a non-musculoskeletal focus were predictive of

111 lower attitudes sub-scores. Barriers of locating research evidence and applying research in practice were predictive of lower skills and use sub-scores. Frequent reliance on traditional knowledge to make decisions was associated with lower attitudes, skills, and use sub-scores. Conclusion: The results indicate that American chiropractors generally have positive attitudes about EBP, but feel challenged with respect to their skills and use of EBP.

A comparison of spinal manipulation methods and usual medical care for acute low back pain: a randomized clinical trial Michael Schneider, Mitchell Haas, Ronald Glick, Joel Stevans, Doug Landsittel Objectives: This was a randomized-controlled trial with follow-up to six months. The study was designed to explore the comparative effectiveness of: manual versus mechanical assisted spinal manipulation (Activator); and spinal manipulation versus usual medical care. Low back pain (LBP) is one of the most common conditions seen in primary care and physical medicine practice. Manual thrust manipulation (MTM) is a common treatment for LBP. Claims that mechanical-assisted manipulation (MAM) devices are safe and effective alternatives to manual manipulation have yet to be substantiated. In addition, there is still some question about the use of spinal manipulation in acute episodes of LBP, as compared to usual medical care (UMC). Methods: 107 adults with onset of LBP within the past 12 weeks were randomized to 1 of 3 treatment groups: MTM; MAM; or UMC. Outcome measures included the Oswestry LBP disability index and numeric pain rating. Subjects in the manipulation groups were treated twice weekly over 4 weeks and subjects in UMC were seen for 3 visits during this time. Outcome measures were captured at baseline, 4 weeks, 3 months and 6 months. Results: Subjects in the MTM group achieved significantly greater reductions in Oswestry scores at four weeks compared with MAM (-8.1, p = 0.009) and UMC (-6.5, p = 0.032). The MTM subjects also had greater reductions in Numeric Pain Ratings scores at 4 weeks compared with MAM (-1.4, p = 0.002) and UMC (-1.7, p b 0.001). Significant differences in pain scores, in MTM versus MAM and UMC, were also found (with p = 0.05 and p = 0.04) in the repeated measures model. No adverse events were reported in any group. Conclusion: MTM provides greater immediate reductions in selfreported disability and pain scores as compared to UMC or MAM.

Who will have sustainable employment after a back injury? The development of a clinical predication model in a cohort of injured workers Heather M. Shearer, Pierre Côté, Eleanor Boyle, Jill A. Hayden, John W. Frank, Willam G. Johnson Objectives: Clinicians struggle with identifying workers at risk of developing long-term absenteeism because of back pain. Our objectives were: 1) To develop a clinical prediction model to identify individuals who will have sustained patterns of employment following an episode of work-related back pain; and 2) To

112 determine if the addition of clinical and work-related variables improve the predictive accuracy of the models. Methods: We used data from a cohort study of injured workers with back pain from 37 American states to predict employment patterns at one and six months following a workers’ compensation claim. We defined employment patterns as 1) sustained (no absence, initial absence with return), or 2) non-sustained (multiple absences, not yet returned). We developed three levels of models based on a conceptual framework including: 1) basic clinical information; 2) additional clinical variables; then 3) worker and job-related factors. Multivariable logistic regression was used to develop the predictive models. We constructed receiver operator curves and used the c-index to measure predictive accuracy. Results: The proportion of non-sustained employment was 21% and 23% at one and six months, respectively. Non-sustainable employment at one month was predicted by initial back pain intensity, initial leg pain intensity and previous back pain episode (c-index = 0.71). At six months non-sustainable employment was predicted by job class, initial back and leg pain intensity (c-index = 0.70). Additional information about health-related quality of life, claim litigation and who the employer is improved predictive accuracy at one (c-index = 0.77) and six months (c-index = 0.77). Conclusion: We developed clinically-relevant models to predict non-sustainable employment in injured workers who made a workers’ compensation claim for low back pain. Inquiring about back pain intensity, physical and mental health-related quality of life, claim litigation and the employer may be beneficial in developing programs of care. Our models need to be validated in other populations.

Spinal manipulation attenuates neuropathic pain through activating endogenous anti-inflammatory cytokine IL-10 Xue-Jun Song, Zhi-Jiang Huang, William B. Song, Xue-Song Song, Arlan W. Fuhr, Anthony L. Rosner, Harrison Ndetan, Ronald Rupert Objectives: Injury and/or inflammation of dorsal root ganglion (DRG) neurons are important in the pathogenesis of low back pain. We have previously demonstrated that spinal manipulation (SM) may reduce DRG neuron hyperexcitability and behaviorally-expressed pain after DRG inflammation. This study was to examine the treatment effects of SM on neuropathic pain after DRG compression as well as to investigate roles of proinflammatory cytokines in chronically compressed DRG (CCD) with or without SM treatment. Methods: CCD was mimicked by implanting unilaterally a stainless steel rod into the intervertebral foramen (IVF) at L4 and L5 in adult, male Sprague-Dawley rats. Neuropathic pain was determined by the increased thermal and mechanical hypersensitivity of the affected hindpaw. Electrophysiological patch-clamp recordings of DRG neurons were used to evaluate the neural excitability. HE Staining was employed to examine the neural inflammation. Levels of proinflammatory cytokines in DRG and the spinal cord were measured by ELISA. Activator III was used to deliver short-duration mechanical spinal manipulative thrusts mimicking SM. Adjustments were applied to the spinous process of L4, L5, or L6 with a series of 10

WFC 2015 Congress Proceedings adjustments in three different settings of a dial mounted on the instrument. Results: Repetitive SM at certain forces and protocols significantly attenuated CCD-induced neuropathic pain. CCD-induced inflammation and the increased excitability of the three categories of DRG neurons, the large- and medium-sized and small neurons, were significantly reduced by repetitive SM. CCD treatment greatly increased levels of expression of pro-inflammatory cytokines TNF-α and IL-1β, but not the anti-inflammatory cytokine IL-10, in DRG and in the spinal cord. Interestingly, SM significantly increased level of IL-10 without altering TNF-α and IL-1β. Conclusion: These findings indicate that SM may attenuate sensory neuron hyperexcitability and behaviorally-expressed pain through activating IL-10, supporting a hypothesis that the endogenous anti-inflammatory cytokines may underlie SM-induced analgesia.

Cost-effectiveness of chiropractic treatment versus self-management in patients with musculoskeletal chest pain: A secondary economic evaluation alongside a randomized controlled trial Mette Jensen Stochkendahl, Jan Sørensen, Werner Vach, Henrik Wulff Christensen, Poul Flemming Høilund-Carlsen, Jan Hartvigsen Objectives: The musculoskeletal system is a generally accepted cause of non-specific chest pain, but cost-effective approaches addressing the musculoskeletal aspect of non-specific chest pain have yet to be established. We have previously reported results from a randomized clinical trial comparing two treatments for acute musculoskeletal chest pain; i.e. four weeks of chiropractic treatment (CT) and self-management (SM). From a societal perspective, this secondary analysis evaluates the 1-year costeffectiveness of the two treatments with respect to health care utilization and medication. Methods: We included 115 consecutive patients with acute chest pain of musculoskeletal origin (CT, n = 59; SM, n = 56). Self-reported clinical outcomes (maximum chest pain and global perceived effect (PGE)), health-related quality of life (HRQoL, EQ5D and SF36), use of non-prescriptive medication and complementary and alternative medicine providers were obtained at 4, 12 and 52 weeks after baseline. Comprehensive national Danish registries provided data regarding frequency and cost of hospital and primary health care contacts, and prescriptive medication. Results: At 52 weeks, the mean difference in maximum chest pain and PGE was 0.12 (95% CI = [-0.98;1.22]) and 0.13 (95% CI = [-0.03;0.29]) respectively, in favor of CT. HRQoL measures showed no statistically significant difference between groups. The average intervention costs per person amounted to € 404 (95% CI = [366.9; 440.6]) for the CT compared to € 45 (95% CI = [44.6; 45.1]) for the SM; the 1-year average costs per person were € 3037 (95% CI = [2326.2; 3747.4]) and € 5278 (95% CI = [3084.6; 7472.3]) respectively, with a mean difference in costs of € 2242 (95% CI = [9.3; 4474.2]) in favor of CT. Conclusion: Results indicate that after one year CT was not more effective than SM. However, the 1-year mean difference in health

WFC 2015 Congress Proceedings care costs was significantly lower with CT. Incremental cost effectiveness ratios, acceptability curves and cost-effectiveness planes will be presented at the time of the conference.

Predicting outcomes in whiplash-associated disorders: prediction models developed and validated in two Canadian provinces Maja Stupar, Pierre Côté, Linda Carroll, Robert Brison, Eleanor Boyle, J David Cassidy Objectives: To develop a clinical prediction rule to predict time to recovery following whiplash-associated disorders. Methods: We applied Cox regression to derive prediction models using a population-based whiplash insurance cohort from Saskatchewan, Canada (n = 4923). We derived multivariable models using predictors that maximize the probability of a self-reported recovery. We developed models including prognostic factors identified by a best-evidence synthesis from confirmatory (model 1) and preliminary evidence (model 2). The models were internally validated using bootstrapping. We externally validated the models in an Ontario cohort (n = 340) of whiplash patients. We used C-statistics to describe the predictive ability of the models. Results: Participants from both cohorts (Saskatchewan; Ontario) were similar at baseline in terms of: mean age (38.3 years; 40.5 years), sex (females: 66.3%; 66.7%), marital status (married: 53.6%; 54.0%), median time since collision (9 days; 6 days) and mean neck pain intensity (Numerical Rating Scale: 6.5/10; 5.7/10). The median time-to-recovery based on a valid self-reported recovery question was 95 days in Saskatchewan and 98 days in Ontario. Our prediction model based on confirmatory evidence (model 1) demonstrated that prior neck injury claims, low expectation of recovery and self-reported post-crash symptoms of anxiety or worry and depression were significant prognostic factors in predicting delayed time-to-recovery (C = 0.626). Adding age, percentage of body in pain, neck pain intensity and headache intensity (prognostic factors from preliminary evidence that remained statistically significant in our model) improved the model slightly (model 2) (C = 0.643). Both models were internally valid (bootstrapped sample model 1 C = 0.626 and model 2 C = 0.643). In the Ontario data, the predictive ability was similar for model 1 (C = 0.608) and model 2 (C = 0.655). Conclusion: We developed clinically useful prediction models for the recovery of whiplash-associated disorders. Future research needs to focus on improving the predictive ability of the models.

Divergent inflammatory profiles in acute and chronic low back pain patients: A single blind pilot clinical trial Julita Teodorczyk-Injeyan, Stephen Injeyan, John Triano, Marion McGregor Objectives: Pro-inflammatory molecules have been localized in spinal soft tissues of low back patients. However the involvement of soluble mediators in the pathophysiology of either chronic or acute low back pain (LBP) remains unclear. The current study was undertaken to determine the inflammatory mediator profiles in acute and chronic LBP patients compared to asymptomatic controls. Methods: Subjects were recruited according to strict inclusion criteria. Blood samples were collected from patients with acute

113 (within 6 weeks of onset) or chronic (N 3 months duration) LB pain and from asymptomatic subjects (N = 20/group). Production of selected mediators was assessed in whole blood cultures following stimulation with lipopolysaccharide and/or phytohaemagglutinin. The levels of pro-inflammatory (TNFα, IL-1β, IL-6), antiinflammatory (IL-10, IL-1RA, TNFRII), immunoregulatory (IL-2, IFNS) mediators and nociceptive chemokines (CCL2, CCL4) were determined by specific immunoassays. Statistical analysis was performed using t test. Results: Compared with asymtomatic controls, the production of TNFα, IL-1β and IL-6 was significantly elevated in chronic pain patients. A significant increase in the level of IL-2 was observed in the acute pain group. All patients showed significantly reduced IFNS production and highly elevated levels of chemokine CCL4. The levels of CCL2 were significantly elevated in subjects with chronic BP. Similarly the production of IL 1RA and sTNFR II was significantly elevated only in chronic BP patients. Conclusive data for correlational analysis of mediator levels vs pain intensity is of yet unavailable. Conclusion: The present report provides evidence that inflammatory profiles in patients with acute vs. chronic back pain are distinctly quantitatively different. These findings will contribute to the understanding of the pathophysiology of mechanical back pain and are useful in guiding studies on the effects and efficacy of spinal manipulation in this clinical model.

Do spinal manipulative therapy responders, non-responders, and asymptomatic individuals share similar spinal stiffness and multifidus muscle characteristics? Arnold YL Wong, Eric C Parent, Gregory N Kawchuk Objectives: Prior studies suggest that responders to spinal manipulative therapy (SMT) for low back pain (LBP) demonstrate significant temporal changes in self-reported function, spinal stiffness and lumbar multifidus. Unfortunately, these studies did not include an asymptomatic control group to better define the clinical impact of these changes. The objective of this study was to compare the baseline and temporal alterations in spinal stiffness and lumbar multifidus contraction thickness among untreated asymptomatic controls, SMT responders and non-responders within one week. Methods: Thirty-two participants with LBP and 57 asymptomatic controls attended three visits over a one-week period. SMT was provided on visits one and two. Before and after each SMT application and within the asymptomatic group, instrumented measures of global/terminal spinal stiffness and ultrasound measures of the L3-4 and L4-5 multifidus thickness ratio [(contracted-rest)/rest x 100%] were obtained. LBP participants were dichotomized as responders/non-responders based on clinically significant improvements of LBP and LBP-related disability over week one. Repeated measures analyses of covariance were used to examine the temporal changes in outcome measures among asymptomatic controls, SMT responders and non-responders. Approval by the local Health Research Ethics Board was obtained. Results: Asymptomatic controls demonstrated significantly higher baseline L4-5 multifidus thickness ratio than LBP participants but there was no significant difference in other baseline physical measures among the subgroups. Asymptomatic controls and nonresponders demonstrated no significant temporal change in spinal

114 stiffness and multifidus thickness ratio over week one. Conversely, responders demonstrated significant decreases in spinal stiffness after each SMT (p b 0.01), and significant improvements in multifidus thickness ratio following the first SMT treatment (p b 0.01). Their improved multifidus thickness ratio was sustained over week one. Conclusion: Our findings suggest that SMT improved clinical outcomes by altering the mechanical and neurophysiological properties of responders as defined by improvements in LBP and LBP-related disability.

SCIENTIFIC PRESENTATIONS POSTER ABSTRACTS The successful use of educreations (an iPad application) in a chiropractic physiology course Kashif Ahmad, Glori Hinck Objectives: Educreations (http://www.educreations.com/) is a free software application that can be used to support chiropractic education. Educreations turns an iPad or a browser into an interactive recordable whiteboard allowing instructors to easily create and share video tutorials that can be used in the flipped model of instruction. We currently use educreations to record short lectures for our physiology courses and post the links to these videos on the Moodle LMS. This allows students to view the lectures when they want, where they want, and how they want. Before implementing widespread curricular changes including the adoption of a flipped classroom, it is important to determine student satisfaction with these new teaching methods. Methods: During the summer of 2013, approximately 150 chiropractic students enrolled in two graduate level medical physiology courses were surveyed using a paper-based questionnaire to determine their satisfaction with the use of educreations videos. The survey was voluntary, anonymous and confidential. Results: One hundred and forty-three students completed the survey. 81% (n = 113) of the students reported finding these lectures to be ‘very helpful’, 13% (n = 18) found them ‘somewhat helpful’, and no students found the lectures ‘not helpful’. Only 4% (n = 6) of students did not view the educreations lectures. Students commented that the educreations presentations were helpful in the following ways: Can review at their own pace, where and when it is convenient, including prior to exams; recordings are short and can be paused to accommodate time for critical thinking or reflection; serve as a backup for missed lectures; can be accessed from device of choice including iPad, computer or phone. Conclusion: Chiropractic student satisfaction with the use of educreations in physiology education is high. Educreations can be used to help support a flipped classroom model and can facilitate anytime, anywhere, any device learning.

Did ancient Egyptian physicians’ management of musculoskeletal injuries include spinal manipulations? Medhat Alattar Objectives: Ancient Egypt is known as a birth place of medicine practices including the management of musculoskeletal and spinal cord injuries. Homer remarked in the Odyssey: “In Egypt, the men

WFC 2015 Congress Proceedings are more skilled in medicine than any of human kind" and “the Egyptians were skilled in medicine more than any other art". Herodotus, Pliny the Elder and Hippocrates all acknowledged the contributions of ancient Egypt to the development of Greek medicine. This paper researched some of the available Ancient Egyptian papyri for diagnoses of musculoskeletal injuries and the methods used in treatment of these conditions including manipulation. Methods: Reviews of the available translations of Edwin Smith Papyrus, the Ebers papyrus, the London Medical Papyrus for recoding of cases of musculoskeletal and/or spinal cord injuries and the treatment methods the ancient Egyptian physicians used. Results: The Ebers Papyrus consist of 877 prescriptions included treatments for headache, back pain, sprains and strains with magical formulas, remedies and incantations. The Edwin Smith papyrus mentioned research methods, how to make a diagnosis and the setting of a treatment. It included 48 cases of injury containing musculoskeletal and spinal cord injuries. Of significance to this paper: Case # 25 (Dislocation of the mandible); case # 30 (Sprain in the cervical vertebrae); case # 31 (Dislocation of the cervical vertebrae); case # 34(Dislocation of the two clavicles); case # 42 (Dislocation in the sterno-costal articulation); and case # 48 (Sprain in a spinal vertebra). Treatments varied from not interfering to setting bones and prescribing formulas made of animal products, vegetable, fruit or minerals. Conclusion: Manipulations of the musculoskeletal system were utilized in ancient Egypt but there are no descriptions of any details of any spinal manipulations used. Future discoveries of ancient Egypt’s practices may uncover these missing details.

The role of chiropractic in supporting of the WHO global program on climate change & health Medhat Alattar Introduction: World Health Assembly Resolution WHA/61.R19 requests WHO to develop capacity to assess the risks from climate change for human health and to implement effective response measures. The chiropractic health sector needs to act assertively to support WHO and its partners to protect health in the present as well as the future. Climate change is already causing shifting patterns of disease, from extreme weather events, and from the degradation of water supplies, sanitation, and impacts on agriculture, according to the most recent WHO data. This paper reviews the readiness of the profession and in preparing doctors of chiropractic as advocates and promoters of healthy living. And proposes a Doctor of Chiropractic Friend of Public Health (DCFHP) initiative. Methods: Review of samples of catalogs of some of USA, Canada, Australia and England chiropractic colleges for information about Public Health courses; content as well as memberships of doctors of chiropractic/students in the APHA. Results: Colleges teach public health concepts as part of a course (usually microbiology) with no specific descriptions of course content. The NBCE Part1 test “Epidemiology and Disease Control” as part of microbiology test. Few chiropractors are active member of the APHA. Discussion: There is a need to expand doctors of chiropractic involvement in public health. “Friends of Public Health” is a global support movement to the new WHO initiative. The profession

WFC 2015 Congress Proceedings worldwide can provide sound scientific information on the connections between weather and climate and major health challenges and support policies to that effect. Following the success of the Chiropractors Against Tobacco program. This proposed initiative can designates DCFPH in different countries. Conclusion: DCFPH can strengthen the relationship between the profession and the WHO through supporting the health benefits gains from fast action to reduce climate change and its consequences.

The PROMIS perspective of children under chiropractic care: a practice-based research network study Joel Alcantara Objectives: This study was designed to evaluate the utility of the PROMIS 25 to measure the quality of life of children ages 8-17 years of age attending chiropractic care in a practice-based research network. When one considers that PROs are acceptable clinical trial endpoints for the Food and Drug Administration, the importance of the pediatric PROMIS instruments become very important in pediatric clinical research and clinical care. Methods: This study received IRB approval from Life University (Marietta, GA). In addition to socio- demographic information, we obtained clinical correlates and quality of life measures using PROMIS-25 for pediatric quality of life. Results: A total of 69 parents (61 females; 8 males) participated in this study. Their average age was 41.22 years and were highly educated with the vast majority (83%) attaining some college education or higher. Half the parents indicated their medical doctor was not aware of their child’s chiropractic care while the other half were aware. The vast majority (N = 45) denied concurrent medical care with chiropractic. A total of 73 children (39 males; 34 females) with an average age of 12.21 years participated. Wellness care figured prominently as a motivation (N = 22) followed by complaints associated with low back pain (N = 10), problems of the lower extremities (N = 5), scoliosis (N = 5) headaches (N = 4), neck pain (N = 4) and other (N = 19). The PROMIS-25 survey T-scores were: anxiety (45.85); pain interference (46.83); fatigue (44.71); depressive symptoms (44.05); peer-relationships (51.95); and physical functioning mobility (52.92). Note that the mean pain intensity for this cohort of children was 2.274. However, after eliminating those responses from individuals without a presenting pain complaint (i.e., wellness care), the mean pain scoring was 3.8. Conclusion: The use of PROMIS-25 was successfully implemented. We encourage further research in this area to examine the impact of chiropractic care to health outcomes.

The PROMIS perspective of parents with children under chiropractic care: a practice-based research network study Joel Alcantara Objectives: Chiropractors and particularly those in the care of children support such efforts in support of evidence-based practice. In an exploratory study, we examined the quality of life children presenting for chiropractic care in a practice-based research network (PBRN).

115 Methods: This study was approved by the Institutional Review Board of Life University (Marietta, GA, USA). In addition to socio-demographic information, we obtained clinical correlates and used the PROMIS pediatrics proxy-report for quality of life. The items were developed so that the phrasing in all items involved reporting on 5-17 year old children. Results: A total of 89 parents/guardians (81 females; 8 males) participated in this study. Their average age was 40.38 years and were highly educated with 83% attaining some college education or higher. Motivation for care included wellness care (N = 25) while the vast majority indicated a combination of wellness care, to relieve symptoms and improve quality of life (N = 45). Fifty seven percent indicated that their MD was not aware of chiropractic care while 37 indicated their MD was aware. One parent indicated their child needed emergency care the previous 3 months while 57 denied the need. Ten children were receiving ongoing/concurrent medical care while 13 indicated no longer under medical care, 33 received no medical care while 33 indicated their child was not presenting with symptoms for chiropractic care. The children reported upon (N = 89; 46 males; 43 females) averaged 11.46 years in age and had PROMIS T Scores of: anxiety (47.5) and depressive symptoms (44.88), fatigue (41.37), pain interference (45.42), peer relationships (47.91) and mobility (49.60). Conclusion: The use of the NIH’s PROMIS pediatric proxy questionnaires in chiropractic research and practice were successfully implemented. We encourage further research in this area to examine the impact of chiropractic care to health outcomes.

Enhanced cerebellar disinhibition when cervical manipulation precedes motor learning in patients with subclinical neck pain Julianne Baarbé, Paul Yielder, Heidi Haavik, Chadwick Debison-Larabie, Michael Holmes, Bernadette Murphy Objectives: Cerebellar disinhibition (CBI) is critical for motor learning and improved when spinal manipulation (SM) was provided prior to motor learning for a subclinical neck pain (SCNP) group. Previous work however, lacked a neck pain control group, healthy controls failed to show inhibition and the CBI50 technique (which individualizes the 50% CBI level) was not employed. We thus set out to: 1) compare CBI50 in healthy and SCNP participants and 2) to compare CBI50 following cervical SM or passive head movement (PHM); before and after motor learning. Methodology: 10 healthy (8 males, 2 females; 21-27 years) and 16 SCNP (12 males, 4 females; 18-26 years) volunteers participated. SCNP participants were pseudo-randomized; 8 receiving manipulation and 8 PHM. Participants performed a motor learning task (typing random eight letter sequences of the letters Z,D,F,P with their right index finger). Motor evoked potentials, resting thresholds and CBI were measured pre and post motor learning. Comparisons were made at CBI50 and at 5% stimulator output above CBI50 (CBI50 + 5%). Results: A significant main effect of pre vs. post was seen at CBI50 and at 5% above CBI50 (F1,16 = 11.894; P = 0.003; η2 = 0.426). A significant interaction of group (manipulation or PHM) on pre vs. post (F1, = 4.886; P = 0.044; η2 = 0.259) was seen as well as a main effect of pre vs. post (F1,14 = 12.638; P = 0.003; η2 = 0.474). Mean

116 inhibition in the SM group rose from 75 ± 32% to 175 ± 105% at CBI50, and 81 ± 52% to 158 ± 124% at CBI50 + 5%. For PHM, changes were seen from 50 ± 18% to 67 ± 20% at CBI50, and 30 ± 17% to 55 ± 22% at CBI50 + 5%. Conclusion: CBI increased when SM preceded motor learning, indicating that SM has an important impact on the cerebellum, possibly by improving integration of sensory input from the neck.

Upper limb function differs between subclinical neck pain and healthy participants during dart throwing task Julianne Baarbé, Bernadette Murphy, Heidi Haavik, Michael Holmes Objectives: Previous work has shown altered elbow proprioception in subclinical neck pain (SCNP) patients, but data on performance during real-world tasks is limited. We sought to compare elbow joint biomechanics during a dart throwing task between SCNP participants and healthy controls. Methodology: Twenty-two volunteers (9 healthy and 13 SCNP) participated (10 females, 12 males; 18 to 27 years). For inclusion, SCNP participants had scores of mild to moderate on the Chronic Pain Grade Scale and healthy controls had minimal or no pain. Participants performed three sets of ten dart throws at both a normal and fast speed. Three dimensional kinematics of the upper extremity were measured using infrared light emitting markers affixed to each participant such that the positions and orientations of each body segment could be measured (3D Investigator, Northern Digital Inc.). Kinematic data were low pass filtered (6 Hz cut-off) and elbow joint angles were calculated as the rotation of the forearm relative to the upper arm. Elbow flexion/extension is reported. Full extension would represent 0Ëš and larger angles represent greater elbow flexion. Results: There were no significant differences between the normal and fast throws, so the data were pooled. The average standard deviation (SD) of elbow flexion (for the 60 throws) was 33.1 (SD 18.9) for healthy participants and 96.3 (SD 66.0) for the SCNP group (P b 0.0001). Average maximum elbow angle (beginning of throw) for healthy participants was 137.5 o (SD 16.1) and 162.8 o (SD 16.2) for SCNP participants (P b 0.0001). Average minimum angle (dart release) was 23.7 o (SD 38.6) for healthy participants and 8.4 o (SD 30.2) for SCNP (P = 0.01). Total elbow excursion for healthy and SCNP participants was 113.8 o (SD 38.0) and 154.4 o (SD 34.9), respectively (P b 0.0001). Conclusion: SCNP participants had greater elbow excursions and much more variable trajectories than healthy controls.

Effect of chiropractic treatment at a large health insurance company in São Paulo city, Brazil: a case series Gilberto Barros, Eduardo Bracher, Dayane Cabral, Julianna Bellangero, Bianca Leme, Marcio Fujikawa, Janete Maeda Objectives: To evaluate the effect of chiropractic treatment on pain intensity, disability and health-related quality of life in a sample of patients from a private insurance company in the city of São Paulo, Brazil. Methods: This longitudinal case series was conducted on thirteen health care units of a large health insurance company. Participants

WFC 2015 Congress Proceedings were patients with chronic musculoskeletal pain, referred by medical doctors to doctors of chiropractic for a four-session chiropractic treatment protocol. Treatment comprised of four 20-minute weekly sessions and was based mainly on manual therapy techniques, including high-velocity, low-amplitude joint manipulation. Assessment included the application of culturally adapted versions of the Chronic Pain Grade (CPG) and EuroQuol health measurement scales. Participants responded the questionnaires personally on the first and fourth sessions and through telephone interviews three and six months after the end of treatment. Results: A total of 38 patients were included in this study. Pain grades, intensity and disability scores were significantly lower at four weeks, three and six months in comparison with intake scores. Average pain intensity of 7.8 on zero to 10 scales at first consultation decreased to 5.3 at six months (p b 0.001). A reduction of disability scores from 6.2 to 3.5 was also observed during this period (p b 0.001). High interference pain (CPG grades III and IV) was present for 55.3% of participants at first consultation and for 26.3% at six months (p b 0.001). An increase of health related quality of life was also observed during this period (p b 0.001). Conclusion: Pain intensity and pain-related disability were significantly reduced, while health related quality of life increased for patients treated with chiropractic at a large health insurance company. This improvement remained stable three and six months after the end of treatment.

Chiropractors’ characteristics associated with physician referrals Marc-André Blanchette, Michèle Rivard, Clermont E. Dionne, J. David Cassidy Objectives: Physicians tend to refer to particular chiropractors, and little is known about the characteristics of those chiropractors. The objective of this study is to identify factors associated with Canadian chiropractors who receive more referrals from medical doctors. Methods: Secondary data analyses were performed on the 2011 survey of the Canadian Chiropractic Resources Databank (CCRD). The CCRD survey included 81 questions about the practice of chiropractors. Of the 6533 mailed questionnaires, 2529 (38.7%) were returned. Of these, 489 respondents did not meet our inclusion criteria, and our final sample included 2040 respondents. Bivariate analyses were conducted between predetermined potential predictors and the annual number of patients referred by physicians. Negative binomial multivariate regression was also performed. Results: On average, chiropractors received 15.6 (standard deviation (SD) = 31.3) patient referrals from physicians per year, and nearly one third did not receive any. The type of clinic (multidisciplinary with MD), the province of practice (Atlantic provinces), the number of treatments provided per week, the number of practicing hours, rehabilitation and sports injuries as the main sector of activity, prescription of exercises, use of heat packs and ultrasound, and the percentage of patients referred to other healthcare providers were associated with a higher number of physician referrals to chiropractors. The percentage of patients with somatovisceral conditions, using a particular chiropractic technique

WFC 2015 Congress Proceedings (Hole In One, Thompson), taking his/her own X-rays, being the client of a chiropractic management service, and considering maintenance/wellness care as a main sector of activity were associated with fewer physician referrals. Conclusion: Canadian chiropractors involved with other health care workers and who focus their practice on musculoskeletal conditions are more integrated into the health care setting. Future qualitative research should try to identify additional factors that influence physician referrals for chiropractic care and better understand their mechanism of action.

Musculoskeletal health in Norwegian school children: A cross-sectional survey Anja Blikstad, Cathrine Herneblad-Due, Mari Slinning Korsnes, Joyce Miller Objectives: Musculoskeletal (MSK) complaints appear common in children, but prevalence rates available are divergent. Minimal information is available on MSK complaints in Norwegian children as well as the care-seeking behavior in children with these complaints. The purpose was to determine the levels of physical activity, prevalence of musculoskeletal complaints and to assess the use of health care practitioners among children with MSK complaints. Methods: A questionnaire was handed out to children between 9-11 years at six primary schools located in Akershus, Østfold and Sør-Trøndelag (Norway). The response rate was 49.7% (N = 317). Results: Fifty per cent of the children in this study reported MSK pain. Headache and “other complaint” (foot/heel) were the most common when assessing period prevalence of six months as well as point prevalence today or this week. Boys had higher levels of activity compared to girls. Mean hours of screen time per day was 4, but there was no statistical significance (p N 0.05) between hours of physical activity or hours of screen time, and presence of MSK pain. Twenty-five per cent of the children reporting MSK complaints were taken to a healthcare practitioner and general practitioners (GPs) were most commonly utilized (57%). One-third (35%, N = 9) of the GP-patients received treatment. Conclusion: Half the group of the Norwegian school aged children studied suffered from MSK complaints within the last six months. The majority suffered from lower limb complaints and headache. Results showed high levels of screen time compared to national recommendations, however no statistical significance was found in the association between level of physical activity/level of screen time and MSK pain. Most of the children suffering from MSK complaints did not visit a healthcare practitioner to receive an examination. GPs were the most preferred practitioner if they did seek help, but the children rarely received any treatment.

Post concussion syndrome, temporomandibular joint disorders, and chiropractic dental co-treatment: A case report Thomas Bloink, Charles Blum Objectives: The awareness of sports-related concussions with post-concussion syndromes is gaining exposure in the chiropractic profession. The following case describes a 21-year-old female

117 patient who had a concussion with subsequent post-concussion syndrome symptoms persisting for five-months. Following the accident she began to feel lightheaded and nauseous when exercising to the point she had to stop all exercise activities. Her symptoms progressed to include frontal and bilateral sphenoid headaches, which aggravated her cognitive activities. Three-months later she felt forced to stay in bed for the rest of the month. Driving caused her headaches, routinely felt off balance when weight bearing, was unable to attend school, and her activities of daily living were compromised. Methods: Five-months following the accident she was seen at this office. The evaluation noted a TMJ disorder (TMD), photophobia, contrast sensitivity, and convergence insufficiency. Treatment focused on balancing pelvic torsion with reduced sacral nutation (sacro occipital technique, or SOT, category one) while supporting stability to her left side sacroiliac joint (SOT category two). Spheno-maxillary and SOT intraoral cranial adjusting were performed along with a referral to dentist that specializes in TMD. She was seen for a total of nine treatments at this clinic with each dental equilibration preceded by chiropractic treatments. Results: Approximately one-month following initiating care the patient was completely pain free with no symptoms of lightheadedness, brain fog, or nausea. She was able to exercise, lift lightweights, and able to run five-miles. The improvement was significant due to her consistent symptoms and lack of function, since her accident. Conclusion: Further research is needed to determine whether a subset of post-concussion or head trauma patients may have TMD, which limits their ability to fully recover. Collaborative efforts between emergency room doctors, chiropractors and dentists (TMD trained) treating patients with post concussion may help lead to improved patient outcomes.

Chiropractic cranial treatment of a patient with idiopathic intermittent hearing loss: A case report Thomas Bloink, Charles Blum Objectives: The first chiropractic adjustment given by D. D. Palmer to Harvey Lillard in 1895 was reported to have cured his deafness. A 2006 Di Duro study concluded that, “manipulation delivered to the neuromusculoskeletal system may create central plastic changes in the auditory system.” A 50-year-old female referred by her dentist for craniomandibular assessment presented with an idiopathic case of intermittent complete hearing loss lasting for over six-years. The hearing loss would often be complete, bilateral or fluctuate between the right and left ears. Prior to presenting for care at this office she was seen by an ENT allopath for two-years with various unremarkable tests performed over that time (e.g., MRI, etc.) and was unresponsive to interventions. Methods: Chiropractic cranial evaluation revealed a left temporal internal rotation restriction with evidence of clenching and maxillary exostosis. Craniofacial analysis revealed a right inferior maxilla with maxillo-zygomatic compression. Sacro-occipital technique (SOT) category two (sacroiliac joint hypermobility) was found on the left side with a category one (sacroiliac joint fixation) on the right side. Results: She was treated 2-times a week for 4-weeks at which time she regained consistent normal hearing in the left ear, her most

118 problematic side. At the 4-week period her left ear went from 0-25% to 75-80%, right ear from 0-25% to 80%, and has been stable for the first time in 2-years. She has been recently referred back to her dentist to change her TMJ appliance from an upper to a lower mandibular appliance to limit incisor contact, improve canine guidance, and equilibrate to the bilateral molar contacts. Conclusion: This case is interesting because of the ongoing unresponsive nature of her condition. The loss of hearing had a profound effect on her ability to function and the temporal nature of her response to the care rendered suggests a relationship.

Is industry money a factor in the publication of chiropractic research? Rod Bonello, Fay Karpouzis, Mario Pribicevic, Allan Kalamir, Benjamin Brown Objectives: It has been well documented that clinical trials in medicine funded by industry, i.e. for-profit organizations, are more likely to be published if they produce positive findings. However, the effect of industry funding on publication rate has not been investigated in chiropractic. This is the first of two studies which explore the following hypotheses: 1) that studies with industry funding are more likely to be published and 2) that studies with favorable findings are more likely to be published. Methods: Ten clinical trial registers, (Australia and New Zealand Clinical Trial Register, US Clinical Trials Register, the European Union Clinical Trials Register, German Clinical Trials Register, South African Clinical Trials Registry, Pan African Clinical Trials Registry, Chinese Clinical Trial Registry, Indian Clinical Trials Registry, Japanese Medical Association Centre for Clinical Trials, and Sri Lanka Clinical Trials Registry), were searched to identify randomized controlled trials conducted in chiropractic, involving joint manipulation for human subjects conducted between January 2005 and June 2014.Article selection and data extraction were conducted by all authors independently, and disagreements were resolved by consensus. Results: 22871 trials were retrieved of which 72 met eligibility criteria. Of these, 35 (48.6%) were published. 39% (13/33) of RCTs published in chiropractic have industry funding, compared with 56% (22/39) of RCTs published in chiropractic with non-industry funding. Overall, it is estimated that 17% more chiropractic RCTs that were not published were found to be industry funded compared to published trials, however this result was not statistically significant (χ2 = 2.07, 1df, P = 0.15). Published RCTs in chiropractic are less likely to have industry funding (OR = 0.69, 95% CI: 0.41, 1.16). Conclusion: The presence of industry funding does not appear to be a factor in the publication rate of chiropractic research.

Intervention in menorrhagia through chiropractic adjustment and spondylotherapy: a case report William Boro Introduction: Low back pain secondary to female reproductive problems are the source of frequent consultations to a chiropractor. This case report describes the clinical course, treatment, and response of a female patient suffering from uncontrolled uterine

WFC 2015 Congress Proceedings bleeding of over two-weeks duration to the application of sacro occipital technique (SOT) chiropractic adjustments and spondylotherapy. A 37-year-old, nulliparous female presented with a history of back and hip pain, headaches and asthma, as well as nonstop menstrual bleeding for the previous two-weeks that also occurred a few months earlier. The patient indicated that her menstrual cycle had never been “normal”. Since the age of 16 her cycles were of 36-45 days duration with bleeding lasting about seven days. She stated that her periods were often accompanied with migraines and significant cramping. Prior to her visit, she had been seen by her gynecologist with unremarkable findings observed on ultrasound and normal hormone levels. However, the patient noted, “it is incredibly uncomfortable to bleed for that long.” Methods: Three-treatments were performed for this patient’s specific menorrhagic condition which included SOT category-two supine block placement, adjustments (with activator instrument) to the lumbar spine (L1-5) and femoral heads bilaterally. Van Rumpt cranial therapies were used and spondylotherapy was administered to C7 (4-minutes), L3 (2-minutes) and L5 (2-minutes) at a percussive rate of 200-beats-per-minute. Results: Following the first office visit the patient reported that the chronic menstrual bleeding had stopped. The patient has returned to this office on 8 other occasions over the past couple years for various reasons (mostly for hip pain), but has had no menstrual or bleeding complaints. Conclusion: Of interest is that the patient had the menstrual condition for years and her response to care and maintained improvement suggests a causal relationship between her presenting condition and the treatment rendered.

Symptoms associated with chiropractic treatment: adverse effects and improvement of primary complaint Eduardo Bracher, Gilberto Barros, Dayane Cabral, Julianna Bellangero, Bianca Leme, Tamires Canin, William Marchetto Objectives: (1) To study the frequency, intensity, duration and time of onset and remission of painful adverse effects due to chiropractic manipulative therapy. (2) To verify the relationship between occurrence of adverse symptoms and improvement of the main complaint. Methods: This study was conducted with patients with musculoskeletal pain from a large health insurance company. Treatment comprised of four 20-minute weekly chiropractic sessions and included high-velocity low-amplitude spinal manipulation. At each session, participants were asked if they felt pain associated with the treatment and, if affirmative, the location, time of onset and remission and intensity of the pain at its most intense moment on a 0 to 10 scale. They were also requested to grade the intensity of the pain or discomfort of their main complaint. Results: A total of 114 participants were included in the study. The frequency of persons who reported pain after chiropractic treatment decreased gradually from 22 (19.3%) on the first visit to 14 (12.3%) on the second and 7 (6.1%) on the third visit (p b 0.001). The majority reported onset of pain on the same day (n = 14, 63.6%) and remission on the same day or the day after treatment (n = 15, 68.2%). Average intensity of pain induced by chiropractic manipulation was 6.14 (SD = 2.7). With respect to the pain that motivated them to seek chiropractic care, average intensity

WFC 2015 Congress Proceedings decreased gradually from 6.8 to 3.2 at the first and fourth sessions (p b 0.001). Disability score also decreased during this period (p b 0.05). Conclusion: Pain after spinal manipulative therapy was of moderate intensity, occurred in less than one-fourth of the persons submitted to chiropractic care and tended to decrease as treatment progressed. Improvement of the main complaint was also noted, and was not affected by adverse effects.

Perceptions and efficacy of chiropractic education to assess and manage psychological disorders: A student survey Carly Bridport, Adrian Hunnisett, Christina Cunliffe Objectives: Comorbid physical conditions and psychological distress has been researched extensively. This study was designed to investigate how chiropractic students perceive their responsibility when qualified to assess, identify and manage patients presenting for chiropractic care with psychological indicators and to establish if they feel their chiropractic education has given them sufficient skills and knowledge to achieve this. Methods: Following ethical approval, a cross sectional descriptive study of chiropractic students was undertaken. Data was collected by an electronic survey questionnaire and analyzed using demographic variables to identify if these might affect the way students responded. The survey instrument collected data on respondent demographics, followed by information related to their perceptions of psychological disorders. This encompassed attitudes and beliefs and knowledge and skills related to psychological diagnosis and treatments. Results: Results show a large majority of participating students have a clear understanding of the relationship between psychosocial factors and physical symptoms, however results suggest students have not gained sufficient knowledge through their education in assessment methods, referral procedures and methods of managing patients that present for chiropractic care with psychological disorders. Conclusion: This study highlights the need for further research into the prevalence of comorbid physical conditions and psychological distress amongst patients presenting for chiropractic care and indicates that a review of the provision of chiropractic education regarding the assessment and management of patients with indicated psychosocial factors is necessary.

Reliability of experimental pain reports in children aged 11-12 years using the numerical rating scale Johanne Brinch Larsen, Lovisa Andersson, Lise Hestbaek, Soeren O'Neill Objectives: The aim of this study was to investigate correlations and reliability of experimental pain tests in healthy children 11-12 years of age. Methods: Using quantitative sensory testing, pain perception was investigated twice, two weeks apart by the same raters, in 39 healthy children: pain testing consisted of pressure pain threshold (lower leg), pressure pain intensity (lower leg and thumb) and cold pressor-test (hand). Results: Spearman’s correlation coefficients from 0.40 to 0.83 were found for test/re-test correlations, but with wide limits of agreement. No clear stimulus-response relationship was found between

119 increasing mechanical pressure and reported pain intensity. There were significant correlations between the various types of pain inducing modalities using NRS as outcome. Conclusion: The used QST is an applicable and reliable method of investigating pain response in children in this age group. Reports of pain intensity using the NRS should be interpreted with caution both in clinical and research settings, as this seems to be influenced by other factors than the actual pain stimulus.

Quality of care in Danish chiropractic clinics: patients’ perception and satisfaction Janni Lee Bang Brodersen Objectives: In the near future, Danish chiropractors are going to be included in the Danish Quality Model of accreditation (DDKM) which splits the quality concept into quality of healthcare, organizational -and patient-perceived quality. The study purpose was to contribute to quality insurance of chiropractic practice by looking at the patients perception based on patient experiences in chiropractic practice, and their assessment of the services they have received. Methods: A quantitative questionnaires with 40 questions was sent to 643 chiropractic patients after the end of their treatment. The response rate was 73.6 % (n = 473). The questionnaire contained mainly closed questions where respondents were asked to complete a 4-point or 5-point-scale. Analyzes was made primarily with descriptive statistics. Results: The results of the study showed great satisfaction rates with treatment in chiropractic practice. A total of 99 % claimed to be satisfied “highly" or “somewhat highly”. 95% said the information was “really good " or “good". 99 % of patients said that the visit lived up to their expectations “very much" or “somewhat much" and the overall impression of the visit was considered to be “really good" or “good" in 98 % of the responses. Patients appear to prioritize the opportunity to receive text-reminders from the clinic on their cellphone as well as an informative website. On the other hand they did not prioritize the possibility to receive newsletters from the clinic or the opportunity to exercise at the clinic. It was the structural conditions like parking and clinic interior that held the greatest opportunities for quality improvement. Conclusion: Danish chiropractic patients are generally very satisfied with their experiences in chiropractic practice. Studies of patient experiences are considered a good source of quality data in developing the quality of chiropractic practice with the focus of incorporating the patients’ perspective.

Chiropractic management of positional head deformity: a retrospective case series Maria Browning Objectives: The objective of this study was to explore whether chiropractic management can reduce positional head deformity (PHD) in infants. PHD is a common presentation to chiropractors in Europe by parents concerned about the cosmetic appearance of their infant and possible long-term consequences. Prevalence of PHD has increased following the introduction of the “Back to Sleep”

120 campaign in 1994, which recommended placing infants supine to sleep in an effort to reduce the incidence of sudden infant death syndrome. Whilst previously considered a purely cosmetic issue, recent research has suggested that infants with PHD may have psychomotor and cognitive issues requiring intervention during their early school years. Methods: Case notes were reviewed of 41 healthy infants (28 male, 13 female, aged 2 to 44 weeks of age (mean 12.5 weeks)) who presented to a chiropractic teaching clinic in the UK with PHD and reduced cervical range of motion. Pre and post treatment skull measurements, recorded bilaterally from the external occipital protuberance (EOP) to the anterior ear, were compared following a course of chiropractic therapy, counter positioning techniques and daily prone awake time. Results: Full cervical range of motion was restored in all 41 infants within 4 weeks of treatment. 2 to 11 weeks (mean 5.4 weeks) after the first treatment, the mean difference between the right and left side EOP to anterior ear measurement reduced from mean 1.9 cm (range 0.5-4.0 cm) to mean 0.8 cm (range 0-3.0 cm). Conclusion: A combination of chiropractic therapy, counter positioning techniques and daily prone awake time appears to reduce PHD in infants. However, the improvement may also be due to natural resolution. A further study could compare infants receiving counter positioning techniques and daily prone awake time alone, compared to infants who receive these plus chiropractic therapy, to assess whether chiropractic adds anything to the management of PHD.

A study to investigate the use of a pressure sensitive pad and ballistic gel material to measure psychomotor skills associated with spinal manipulation and utility in an educational context David Byfield, Tanya Read, Phillip Castor, Asbjorn Amundsen, Alexander Skare, Michiel ten Klooster, Alberto Bronzoni, Lars Leiknes Introduction: Measuring the forces and thrust speed parameters associated with manipulation is an educational challenge. Despite work in the area, assessment, feedback and progression through psychomotor skill training concentrates mainly on visual observation related to posture, hand position, balance and preload. Even though methods to objectively quantify various physical parameters exist, further investigation is warranted. The aim of this study was to continue to investigate the utility of a flexible pressure pad system to measure various physical parameters employed during manipulation and consider inclusion in an educational setting. Methods: Practicing chiropractors and final year chiropractic students were recruited for the study. All participants were asked to perform a series of 3 simulated cross-bilateral manipulations and one unilateral manipulation on a pressure sensitive pad which was placed over two 1.5 cm thick blocks of ballistics gel. A number of biomechanical parameters that occur during the pre-thrust and thrust phase were measured in both experimental groups including, preload force, end preload back off, peak force and contact surface area. Age, sex, height, weight and years of practice were also recorded. Results: Forty-five practicing chiropractors and 45 final year chiropractic student participated in the study. We will report on the results of both experimental groups in terms of speed of thrust, mean peak force, force produced at initial/end preload phase,

WFC 2015 Congress Proceedings contact surface area and pre-thrust back off time. We will also report on any significant difference in these physical parameters between the two groups and compare these findings with previous data to establish consistency and reproducibility of the system. Conclusion: This study demonstrates that this system is capable of objectively measuring and displaying specific manipulative skill outputs. The study also shows that the system can be adapted in an educational environment to provide quantitative feedback regarding acquisition and ongoing competency progression.

A short history of chiropractic in the Eastern Mediterranean and Middle East Alana Callender, Efstathios Papadopoulos Objectives: The objective is to create a comprehensive documentation of the battles of modern day, as well as historic chiropractic pioneers as they interpret and defend, and promulgate chiropractic. Methods: Indexed and non-indexed sources including the World Federation of Chiropractic’s files have been combed for documentation, however meager, of chiropractic activity in the Eastern Mediterranean and Middle East. The area of interest was circumscribed by the countries in the World Federation’s EMME Region. Pioneers have been interviewed in person and by correspondence. Results: Chiropractic is not a new phenomenon in this EMME Region. A chiropractor was reported to be practicing in Persia (Iran) in 1922 and there are sporadic reports after that. A critical mass is not present, however, until closer to chiropractic’s centennial. The countries that make up the Eastern Mediterranean and Middle East Region of the World Federation, from Afghanistan to the United Arab Emirates, represent diverse cultures. On 17-18 April 2010 founding members representing 12 of the 18 countries voted unanimously to form a regional organization. Half of the countries in the region have no chiropractic legislation, although that fluctuates. Many of the doctors are practicing in the same type of unpredictable environment that the earliest pioneers faced: offices shut down, equipment confiscated. For some, these are minor inconveniences. Conclusion: Doctors from these countries coming together around a chiropractic table is an inspiring tale of diplomacy and selflessness for the greater good of the profession. Many of them are expatriates, bringing their own national hubris to the table. And although they are not immune to the rancor that arises from differences in practice philosophies and not without egos, amazing things are being done to promote chiropractic through their dedicated, devoted leadership.

Is there a relationship between spinal adjustment and muscular strength in athletes? Amy Champion, Adrian Hunnisett, Christina Cunliffe Objectives: Previous studies have investigated the relationship between spinal adjustment and muscular strength, hypothesizing correcting vertebral misalignments promotes health by enhancing neurological integrity. If vertebral misalignments are removed, interferences within the nervous system are reduced, allowing muscles to function at their optimum, improving muscular strength and enhancing athletic performance. The aim is to investigate whether

WFC 2015 Congress Proceedings spinal manipulation can directly increase the muscular strength of the quadriceps group. Methods: Following ethical approval, a single-blind, randomized control study was performed on nineteen healthy active individuals. The subjects were randomly assigned to two groups: Spinal adjustment (group A) and Control (group B). The subjects were required to complete a five minute warm up prior to undertaking three separate muscle strength tests. Both groups completed Test 1 comprising a sub maximal isometric contraction to pre-condition the quadriceps muscles. Test 2 included a one minute recovery pre-test, followed by two full maximal isometric contractions. The intervention group received a Toggle Torque Recoil (TTR) adjustment to L3/L4 motion segment. The control group received a sham adjustment. Both groups completed Test 3 without any differences which included a 20 second rest and two further maximal isometric contractions of the quadriceps group. Results: The Intervention Group saw a short-term increase in muscular strength produced by the quadriceps group, compared to the control group who demonstrated only a minimal increase (p = 0.08, borderline). Conclusion: Although the results of strength change for the Intervention Group were not statistically significant, there was a comparable difference between the strength change variance of the two groups indicating a possible trend of improvement following treatment. This would suggest athletes may benefit from receiving spinal manipulation to improve muscular strength, particularly if engaging in sports which activate the fast twitch muscle groups.

"When it works”: academic family medicine staff experiences with advanced access scheduling Yee-Ling Chang, Peranson Judith, Deborah Kopansky-Giles Objectives: The St. Michael’s Department of Family and Community Medicine, an interprofessional (IP) academic family medicine center embarked on a quality improvement (QI) intervention involving the implementation of advanced access scheduling (AAS) for the purpose of improving patient access to care. This scheduling initiative has been implemented in medicine, nursing, nurse practitioner and chiropractic. This qualitative component follows from initial work which examined TNA (third next available appointment, time to access care)over the past 3 years. Interviews focused on elucidating key factors explaining the variability in successful implementation of AAS across the department. The objective was to explore clinic staff experiences with AAS. Design: Focus groups were conducted to discuss enabling factors, challenges, impact on patient care teaching, and recommendations for further change. Intervention: Health professionals and clerical staff from 5 geographically different clinics participated in a total of 6 focus groups. Key questions which included identifying enabling factors, challenges, impact on patient care and teaching, and recommendations for change were posed to each group. Data were coded and tabulated using NVivo Version10 Software. Results: Data were grouped into categories of: facilitators, barriers, patient care, impact on academic teaching and staff/patient satisfaction. Many of the facilitating factors were also seen as

121 barriers. Provider commitment and understanding of advanced access concepts were noted to be variable, and essential for successful implementation. Both staff and patient experiences with well-functioning appointment schedules were positive with increased teaching opportunities. As one participant noted, “when it works, it works well.” All groups recommended patient education, optimizing IP team function and department-wide policies. Communication, team cohesion and respect were seen as key facilitators. Conclusion: Successful implementation of improvement changes requires careful coordination of education, engagement, communication and leadership. Staff and patient satisfaction along with better continuity of patient care and teaching opportunities were some of outcomes when these factors were aligned.

Effect of chiropractic treatment, ultrasound, and kinesio taping treatment on active rotational range-of-motion of sternocleidomastoid muscle JinOk Choi, SungBum Choi, HyeRin Cho, HanSuk Jung, SungEun Kim Objectives: The problem of neck pain is widespread in the working population and is a cause of lost work and disability. The purpose of this study was to investigate the effects of chiropractic, ultrasound, taping method on active rotation ROM of SCM muscle. Methods: Thirty subjects were divided into three groups, group A for chiropractic treatment, group B for ultrasound treatment, and group C for taping treatment. Each group consisted of 10 subjects. Each group was treated two times per week, for 4 weeks. The data were analyzed with SPSS WIN 10.0 using t-test one-way ANOVA. Results: The results of this study were as follows : The hypothesis 1, depending on treatment method, active cervical rotation ROM will have difference, was proved(p b 0.001). The hypothesis 2, depending on age or sex, active cervical rotation ROM will have no difference, was proved(p b 0.001). Each treatment group had the same treatment effect regardless of age. Chiropractic and Ultrasound treatment group had the same treatment effect regardless of sex, while taping treatment group had a better treatment effect in male group than in female group(p b 0.001). The result of this study presents that active cervical ROM has differences depending on chiropractic, ultrasound, or taping method on SCM muscle. Conclusion: SCM can be treated more effectively considering patient age, sex, or treatment environment.

A systematic review to determine the evidence to support the use of flexion distraction chiropractic technique Dillon Cuppusamy, Charmaine Maria Korporaal, Laura Maie O'Connor Background: Evidence based medicine and evidence based practice are core practices for practitioners. By providing summarized, concise, graded levels of evidence surrounding flexion distraction chiropractic technique (FDCT), the practice of evidence based medicine and evidence based practice can be maintained.

122 Objectives: Literature regarding FDCT was screened, whilst evaluating the methodological rigor articles. A systematic review of the studies involved, assessment of the rigor and strength of evidence to support the use of FDCT and the specific conditions for which FDCT is used. Data sources: A systematic review study design incorporated key indexing terms (chiropractic, flexion distraction, protocol and technique). PubMed and Summons databases/search engines were utilized, up to IRB approval (September 2013). Articles had to be in English, available in electronic format, possess one of the key index terms and be of randomized controlled study design or nonrandomized study design. Of the 93 citations found, 18 articles were included into this study for review; with four being non-randomized controlled studies [Newcastle-Ottawa scale,] and 14 being randomized controlled studies [PEDro scale]. All articles were subject to blinded independent review. Study appraisal: Two articles reported on neck pain, two on physiology mechanisms, ten on low back pain, and two on pelvic pain. The review reported limited evidence for the use of FDCT, limited evidence for affecting physiological mechanisms, moderate evidence for single and multimodal intervention for low back pain, and limited evidence for pelvic pain. Conclusion: Limited and moderate levels of evidence exists, with conflicting results. This systematic review revealed that single and multimodal intervention treatment using FDCT in low back pain provides the strongest levels of evidence for its use. The gold standard for research is randomized controlled trials, and further studies using its design would contribute positively towards providing an evidence based approach to practice.

The prevalence and impact of spine pain in Ontario Canada long term care seniors Connie D'Astolfo, Peter Tsasis Objectives: The literature suggests spine pain may be more prevalent in the long term care (LTC) population than diabetes, depression and hypertension and contributes to unnecessary Emergency Department (ED) transfers and hospitalizations. This study is unique in that it focuses on answering questions concerning the prevalence, comorbidities and burden of spine pain, including the rate and cost of preventable ED transfers and hospital visits and will determine the extent of the gap in knowledge regarding the impact of spine pain in this population. Methods: The study involves a quantitative analysis of administrative data from approximately 90,000 LTC seniors across the province of Ontario. Data will be collected retrospectively through CIHI from the Resident Assessment Instrument-Minimal Data Set, NACRS and DAD over a four year period. Data will be evaluated through a multivariate analysis for period prevalence, co-morbidities, rate of ED transfers and length of hospital admission days associated with spine pain. Costs will be calculated from administrative records of the number of ED transfers and hospital days (NACRS and DAD) attributable to spine pain and evaluated through a cost effectiveness study. A qualitative analysis of the study will involve surveying and interviewing administrators across the Greater Toronto Region to determine any gaps in understanding the impact of spine pain.

WFC 2015 Congress Proceedings Results: The study is currently in progress and preliminary results will be presented at the conference. Prevalence and costing data are expected to be consistent with international data suggesting a period prevalence of 60-85% with significant costs associated with ED visits. Conclusion: Accurate prevalence data and the cost of spine pain associated with ED transfer and hospitalization in the Ontario LTC senior population is currently unknown. Insights from this study will have practical implications of how best to manage spine care and provide evidence-based improvements in program development and policy deliberation.

Relationship between clinical methods and dynamic methods in the assessment of the leg length of lower limbs for the efficiency of chiropractor diagnosis Grasiela Roberta de Farias, Eliane Fátima Manfio, Cristina Beroth Objectives: The present study aimed to evaluate the relationship between clinical and dynamic methods in the assessment of leg length for the efficiency of the chiropractor diagnosis. Methods: The study included 22 women, with a mean age of 31.8(9.6) years. To collect data it was used the procedures: Anamnesis; clinical evaluation through Derifield test, the findings from Derifield were compared with: static palpation of the posterior inferior Iliac spine (PIIS), correction Impulse. Based on the results of Derifield test, the lower limbs of the subjects were classified into Short Member(SM) and Long Member(LM) and thus were held to analyze: plantar pressure distribution in standing position and during the gait, performed through a pressure platform EcoWalk composed by resistive sensors (acquisition rate 50Hz). Results: Derifield test may be accompanied by palpation of PIIS and Correction Impulse, as they collaborate for a more accurate diagnosis. There were no significant differences (p b 0.05) in the evaluation of plantar pressure for standing position variables, medium pressure, contact area, distribution of body weight between the members, distribution of body weight in the anterior and posterior region, and for gait assessment, the variables: contact time, average pressure and contact area. Conclusion: It was not possible to prove that the short and long member have distinct characteristics in the dynamics behavior of the plantar pressure in the standing position and during the gait. There are two factors that may have influenced these results, due to the slight difference in leg length, identified by the clinical methods, the subjects adopted compensatory postures masking the difference, not being possible to verify significant differences in the plantar pressure between the short and long member, also the resolution and accuracy of the equipment used in the evaluation of plantar pressure, which was not appropriate or sensitive enough to detect such compensatory changes.

The prevalence and impact of neuropathic pain in older women with arthritis Katie de Luca, Parkinson Lynne, Julie Byles, Henry Pollard, Fiona Blyth Introduction: Pain is cardinal symptom in arthritis, and with studies reporting descriptors of neuropathic pain (NP) in people

WFC 2015 Congress Proceedings with osteoarthritis, the developments of an understanding for a neuropathic mechanism of pain in arthritis is emerging. As yet, the prevalence and impact of having arthritis and NP has not been investigated, nor determinants investigated. Objectives: To examine the prevalence, impact and determinants of neuropathic pain in older women with arthritis. Methods: 700 women were sent a postal survey asking about their health, pain and arthritis. The painDETECT was used to screen for women with a possible NP mechanism. Demographic characteristics and health and pain measures were included in analyses examining the impact and determinants of neuropathic pain in older women with arthritis. Variables have been entered in regression modeling to determine the most parsimonious model to predict NP in older women with arthritis. Results: 82.7% women returned surveys; 108 women had arthritis without NP and 39 women had arthritis with NP. In six of the eight subscales of the SF36, women who had arthritis with NP had significantly lower scores than women who had arthritis without NP. Women with arthritis and NP had significantly higher median scores for measures of health, pain, pain catastrophizing, fatigue and depression than women with arthritis and without NP. The strongest variables associated with neuropathic pain were depression, pain catastrophizing and scores from the McGill Pain Questionnaire Short Form. Conclusion: The findings from this population-based study indicate that women with arthritis and NP have significantly greater disability, pain catastrophizing, fatigue and are more depressed, and have a significantly lower quality of life. They are also more likely to report a range of psychosocial-related problems, particularly with regard to depression, pain catastrophizing and the sensory and affective qualities of pain.

The profile of pain in older women Katie de Luca, Lynne Parkinson, Julie Byles, Henry Pollard, Fiona Blyth Objectives: To describe and compare profiles of pain experienced by a community sample of older women aged in their 60s and identify factors associated with different profiles of pain, and the role of arthritis as a potential effect modifier of these associations. Methods: 700 women were sent a postal survey asking about their health, arthritis and experience of pain. Latent class analysis was used to identify profiles of pain based on nine variables of the pain experience, including location, onset, duration, intensity, qualities, mechanism, catastrophizing, fatigue and bodily pain. Results: 82.7% women returned surveys with 352 (60.8%) of women self-reported being diagnosed or treated for arthritis. Three distinct profiles of pain were identified for older women were defined by latent class analysis. Exploration of the three profiles of pain is currently being conducted, with the association between arthritis and variables, and predicting membership of profiles our outcomes. Conclusion: The data from this population-based study are still being analyzed. Three profiles of pain in older women have been defined by latent class analysis, and data may suggest that variables of pain may tend to cluster in women, and arthritis may be associated with these clusters. Health promotion and treatment options might effectively be targeted to identifiable groups of women with distinct profiles of pain.

123 Attitudes of Dutch and Belgium chiropractors towards the use of diagnostic imaging in private practice: a survey Annemarie de Zoete, Raymond WJG Ostelo, Maurits T. van Tulder Objectives: Chiropractors use diagnostic imaging as part of their diagnostic process, for the evaluation, prognosis and guidance of their treatment of patients with low back pain. Guidelines recommend to avoid early diagnostic imaging, except in patients with suspected serious disease but adherence to guidelines by primary health care providers remains sub maximal. To describe and compare use of diagnostic imaging in chiropractic practices in the Netherlands and Belgium. To identify reasons for the use of diagnostic imaging in chiropractic practice. To determine if chiropractors adhere to diagnostic imaging guidelines. Methods: A web-based survey was used to assess the use of diagnostic imaging in chiropractic private practice in The Netherlands and Belgium. The survey requested information on personal and practice characteristics, use of diagnostic imaging, use of clinical guidelines in managing of low back pain and included 6 vignettes based on 3 acute and 3 chronic low back pain patients. Data were analyzed using SPSS. Results: The analyses of the data will be finished in December 2014. A summary of the preliminary results: the response rate was 60%; reasons for the use of diagnostic imaging by chiropractors are diagnosis and exclusion of contraindications; reason not to use imaging is that chiropractors find that is has limited value; chiropractors with diagnostic imaging facilities in their practice take more x-rays than chiropractors without these facilities and chiropractors without these facilities refer more for MRI than chiropractors with x-ray facilities; most chiropractors see diagnostic imaging as part of their practice. Most chiropractors would like to direct access (either referral or own x-ray facilities) to diagnostic imaging. They read diagnostic imaging themselves.

Use of IPD meta-analysis to inform effective management of spinal manipulative therapy for patients with chronic low back pain Annemarie de Zoete, Sidney M. Rubinstein, Maurits T. van Tulder, Raymond WGJ Ostelo, Michiel R. de Boer, Jill A. Hayden Background: Low back pain (LBP) is a leading cause of pain and disability and as a result has a major socioeconomic impact. The majority of the cost associated with LBP is generated by a small percentage of patients whose condition proceeds to chronicity. For chronic LBP spinal manipulative therapy (SMT) is one of several interventions which evidence suggests is moderately effective. In 2011, a Cochrane review was conducted which investigated the effectiveness of SMT for chronic low back pain. However, one of the problems with traditional meta-analyses is the use of aggregate (mean) data while the use of individual patient data (IPD) allows for a better interpretation of the effects in select subgroups. Objectives: To determine if subgroups of patients or characteristics of spinal manipulative therapy (SMT) (e.g. manipulation, mobilization) can be identified. The greater aim of this project is to more fully inform clinical practice regarding the application of SMT for treatment of chronic LBP. Methods: The original individual participant data will be requested from the authors who published a randomized controlled trial

124 (RCTs) which evaluated the effect of SMT for chronic LBP. The type of comparisons to be included may range from no intervention to other (effective) interventions. In total, 19 of the 26 RCTs which were included in the Cochrane Review on SMT for chronic LBP and were published after 2000 (± 4000 individual patients) are expected to be included. In addition, the inclusion will be complemented by recent studies identified through an update of the search. Self-report pain, functional status and recovery will be the main outcome measures. Results: At the moment, there are no results to present as this project just recently started. At the time of the congress in May 2015, it is expected that we will have some results to present.

Validity of orthopaedic tests to diagnose thoracic outlet syndromes: A diagnostic accuracy study Ingrid Dessureault-Dober, Gilles Bronchti, André Bussières Objectives: Thoracic outlet syndrome (TOS) remains a controversial diagnosis. Clinical features may include neurological and/or vascular symptoms in the neck, shoulder, upper extremity or hand. Orthopaedic tests aim to reproduce patients TOS symptomatology and/or to observe a reduction of the radial pulse while executing specific maneuvers of the neck and arms. However, current literature underlines a lack of accepted criteria for the diagnosis of TOS. Importantly, the accuracy of clinical orthopaedic tests is poorly documented. This study aimed to determine the validity of orthopedic tests commonly used to diagnose a thoracic outlet syndrome. Methods: In phase 1, 15 healthy volunteers (mean age: 26.6) were recruited amongst two chiropractic clinics. Presence/absence of TOS signs and symptoms was documented. Diagnostic ultrasonography was used to document peak systolic blood flow velocity (PSV) of the radial artery. The PSV was recorded during rest and in 15 different positions corresponding to six orthopaedic tests maneuvers for TOS. Results: Repeated-measures ANOVAs were conducted to determine the effect of orthopaedic tests on PSV (cm/s). Post-hoc tests using Bonferroni adjustments revealed a significant effect in all 15 healthy volunteers for: Adson [37.07 cm/s; 95% CI, 29.82-44.32], (F = 47.646, df = 3, p b .000) Halstead [36.95 cm/s; 95% CI, 30.34-43.55], (F = 40.721, df = 3, p b .000); Allen [40.386 cm/s; 95% CI, 26.19-54.58], (F = 13.052, df = 1, p b .003); costoclavicular [43.39 cm/s; 95% CI, 34.84-51.93], (F = 17.394, df = 2, p b .001). Conclusion: Four out of six orthopedic tests yielded a significant PSV decrease in healthy individuals. Results raise concerns over the validity of some commonly used orthopedic tests for the diagnosis of TOS compared to our reference standard. In phase 2, results from 10 symptomatic TOS subjects will be compared with a total of 30 healthy volunteers.

Conservative care with or without manipulative therapy in the management of back and neck complaints in Danish children aged 9-14. Study protocol for a randomized controlled equivalence trial Kristina Dissing, Lise Hestbæk, Jan Hartvigsen, Niels Wedderkopp Objectives: Complaints in the musculoskeletal system often start early in life, and back and neck pain in children are predictors for

WFC 2015 Congress Proceedings similar problems in adulthood. Despite lack of evidence of effectiveness, manipulative therapy is one of the most commonly used treatment modalities for back and neck complaints in children. The primary objective of this study is to evaluate the effectiveness of manipulative therapy when added to other types of manual treatment, exercises and advice as needed, in children with back and neck pain. Methods: The project is nested in the CHAMPS study, which includes around 1200 children aged 9-14, who all were invited to participate in this trial should they experience back and/or neck pain during the two years inclusion period. Parents receive text messages (SMS) on a weekly basis inquiring about the child´s musculoskeletal pain. If pain is reported, the child will be evaluated for inclusion into the trial and randomized into one of two intervention groups: 1) pragmatic advice, soft tissue treatment and exercise-based treatment, or 2) the above plus manipulative therapy. The primary outcome measures are number of recurrences of back and neck pain during the follow-up period and total duration of complaint time. Secondary outcome measures are global perceived effect after two weeks, duration of the presenting complaint, and change in pain intensity after 2 weeks. Baseline descriptive values include quality of life, expectations to treatment, expectations to future course, age, gender, social class and intervention group. Results: Results will indicate whether the addition of manipulative therapy will increase the effect of present gold standard for conservative care for back- and neck pain in children. Conclusion: To our knowledge this is the first large scale randomized controlled trial investigating the effectiveness of commonly used treatments for back and neck pain in children.

Chiropractor’s attitudes towards the role that chiropractic has to play in the treatment of non-musculoskeletal conditions: A cross-sectional survey of the profession Bianca Downey, Adrian Hunnisett, Christina Cunliffe Objectives: It has been reported that 74% of chiropractors claimed to have told their patients that chiropractic adjustments might have non-musculoskeletal (non-MS) effects on their bodies. Although chiropractors are primarily occupied with the treatment of painful backs, historically they have dealt with many kinds of ailments, the three most common non-MS complaints reported by patients to their chiropractors were problems with digestion, circulation and allergy. The aim of this study was to gauge the attitudes of practicing chiropractors to chiropractic care of non-MS conditions, namely asthma, irritable bowel syndrome (IBS) and migraines. Methods: Following ethical approval, a cross-sectional study was undertaken and a questionnaire sent, via email, to all chiropractors registered with the professional associations. Results: A total of 82 responses were received. The majority of respondents (83%) currently use best evidence base to inform their practice. Varying numbers of respondents believe chiropractic is an effective treatment for non-MS conditions (88% for migraines, 44% for IBS and 30% for asthma). The majority (62%) would refer patients with asthma, migraines and IBS back to their general medical practitioner for treatment of that condition. Conclusion: The study showed some positive results for the chiropractic treatment of non-MS conditions, with chiropractors

WFC 2015 Congress Proceedings believing that chiropractic an effective treatment method for migraines and IBS but not for asthma. More evidence-based research needs to be conducted in to the effectiveness of chiropractic in non-MS conditions generally before more firm conclusions can be drawn.

The effect of paraspinal myoelectric activity on the range of lumbar inter-vertebral motion Alister du Rose, Alan Breen Objectives: Muscle activity influences the weight bearing motion of lumbar vertebral segments, however to date there have been limitations in the methods used to investigate this in living subjects. This study used surface electromyography (sEMG) and quantitative fluoroscopy (QF) to explore the effect of paraspinal myoelectric patterns on lumbar inter-vertebral flexion motion. Methods: Lumbar flexion fluoroscopy sequences and sEMG signals from lumbar paraspinal muscles were recorded contemporaneously from 18 male participants with an age range of 22-36 years, and no history of back pain in the previous 12 months. The continuous sEMG data were divided into epochs in order to analyze muscle activity changes at different stages of the flexion cycle. Analysis for associations between the maximum inter-vertebral range (IV-ROM) reached at the 4 levels between L2-S1, and changes in sEMG amplitude at the levels of T9, L2 and L5 were conducted (Pearson correlation). Linear regression analysis determined the effects of sEMG activity on the variance of maximum IV-ROM at all levels. Results: The only significant relationships between sEMG amplitude change and IV-ROM were at L5/S1. The absolute changes in sEMG during early flexion were positively correlated with L5/S1 IV-ROM when sEMG was measured over L2 (r = .50, p = .036, r 2 = .25), and negatively correlated when measured over T9 (r = .48, p = .045, r 2 = .23). In late flexion, the correlation was positive between L5 sEMG change and L5/S1 IV-ROM (r = .48, p = .038, r 2 = .23). Conclusion: There was a small but significant effect of sEMG amplitude change on maximum IV-ROM at L5/S1. Changes in sEMG amplitude explained around a quarter of the variance in L5/ S1 flexion IV-ROM. Other factors, such as BMI, lordosis and inter-vertebral laxity are also likely influences.

Do psychological and behavioral characteristics of patients with low back pain differ between populations? A descriptive analysis of chiropractic patients and a comparison between four different cohorts Andreas Eklund, Gunnar Bergström, Lennart Bodin, Iben Axén Objectives: The aim of the study was to investigate patients with low back pain LBP with regards to psychosocial and behavioral characteristics. The objectives were to describe a chiropractic primary care population and compare this sample to three other populations with neck pain (NP) and LBP using the West Haven-Yale Multidimensional Pain Inventory (MPI). Methods: This is a cross-sectional study comparing four different patient populations. Population A consisted of 480 subjects with LBP recruited from chiropractic primary care clinics. Population B had 128 subjects from a gainfully employed population at risk of

125 developing chronic NP and/or LBP. Population C was 273 subjects from secondary care rehabilitation clinics with NP and/or LBP. Population D was 235 subjects from a secondary care clinic with chronic NP and/or LBP. MPI was used to collect psychometric data on patients in the four patient populations. The resulting subgroups (adaptive copers, dysfunctional and interpersonally distressed) were derived from a non-hierarchical cluster procedure performed on the 8 MPI-S scales. Results: The chiropractic primary care population scored higher on the MPI scales for pain severity, interference, life control and affective distress compared to the gainfully employed population but lower than the two secondary care populations with chronic NP and/or LBP. MPI scales for support, punishing responses, solicitous responses and distracting responses, the chiropractic primary care population scores the lowest. The proportion of adaptive copers is highest in the gainfully employed population and lowest in the two secondary care populations. The opposite pattern can be seen within the dysfunctional subgroup. The interpersonally distressed group seems to have rather similar proportions across the four patient populations. Conclusion: The study populations appear to be distinctly different, each with particular characteristics. The chiropractic primary care population fits in between the gainfully employed population and the two secondary care populations in terms of psychological and behavioral characteristics.

Elastin fiber content in the dura mater of the cervical spine Dennis Enix, Eric Facemyer, Robert Kelly, Frank Scali Objectives: This in-vitro quantitative analysis of dura elastin fibers examines the concentration and direction of elastin fibers which determine dural tensile properties and influences its ability to resist mechanical stresses. Methods: Six samples each of dura mater from the dorsal surface of the sub occipital, first and second cervical regions were dissected from 8 formalin embalmed cadavers at Logan University, Department of Anatomy for histological analysis. A total of 144 samples were sectioned into 3 mm thick slices, processed in paraffin wax and sectioned in 5 um slices at the Saint Louis University, Department of Pathology. Sections were stained with Verhoeff’s elastic stain, rinsed and counter-stained with Van Gieson’s solution and dehydrated in 90% EtOH and xylene and placed on glass slides. Digital high resolution tif images were taken with a 100x oil immersion microscope using CellSens Standard contrast based autofocus imaging software. The elastin threshold was individually adjusted with Image-J software to identify elastin fibers in each slide. The quantity and percentage of longitudinal to perpendicular elastin fibers was examined by level. Results: There is a significant difference in total amounts of elastin fibers in sub-occipital dura (945.12 ± 482.42 μm) compared to C1 fibers (2512.16 ± 1353.29 μm) (P b 0.001), and C2 fibers (1723.43 ± 834.67 μm) (P b 0.001), and between C1 and C2 samples (P = 0.003). There is a significant difference in the size of elastin fibers in the sub-occipital dura (0.83 ± 0.26 μm) compared to C1 fibers (1.76 ± 0.93 μm) (P b 0.001), and C2 fibers (1.47 ± 0.52 μm) (P b 0.001), but not between C1 and C2 samples (P = 0.165).

126 Conclusion: The size and concentration of cervical dural elastin fibers varies from sub-occipital to C2 regions and has distinct patterns in the orientation of parallel and perpendicular fibers.

Does increasing the dose rate of chiropractic spinal manipulation reduce recovery time from acute low back pain? Austin Everill, James Odell, Adrian Hunnisett, Christina Cunliffe Objectives: To date there is a paucity of research into spinal chiropractic treatment dose rate and its effect on patient recovery from acute low back pain (LBP), which this pilot study aims to help address. The study aimed to test the effect of dose rate of spinal manipulation on patient recovery from acute low back pain. Further analysis looked at patient satisfaction as a possible contributing factor to recovery. Methods: Following ethical approval, a prospective uncontrolled cohort pilot study with 14 patients was divided into either a low dose rate group or a high dose rate group for treatment. Outcome measures included the pain and disability related short form Bournemouth Questionnaire (BQ), and dose rate patient satisfaction and expectation questions. Results: Both groups showed an improvement in recovery rate when comparing post BQ scores and Pre BQ scores with the high dose rate group having the greatest recovery rate overall. There was a positive correlation between dose rate and patient satisfaction and all participants stated they would prefer to have a higher dose rate if rate of recovery was improved. Conclusion: This study’s findings support previous research which demonstrated a linear relationship between dose rate and recovery from LBP. The current study’s findings also suggest a close link between patient satisfaction and increased dose rate, and concludes that patient satisfaction may be a key factor in patient choice and recovery.

An investigation into the efficacy of fear-avoidance beliefs as a predictor of treatment outcomes in McTimoney chiropractic patients Carole Filby, Gabrielle Swait, Adrian Hunnisett, Christina Cunliffe Objectives: Fear Avoidance Beliefs (FABs) have been studied extensively in relation to low back pain patients; but less is known about their relevance to patients presenting with other types of musculoskeletal pain and to chiropractic patients. This study sought to establish whether a link existed between FABs and treatment outcomes in patients undergoing chiropractic treatment. Methods: Following ethical approval, an interventional prospective cohort study of 46 new patients presenting for chiropractic was undertaken. Patients answered questions capturing their FAB levels, pain and disability prior to their first treatment, and then again after 4 treatments using validate questionnaire instruments, the Roland Morris Disability Questionnaire and the Fear Avoidance Belief Questionnaire. Data were analyzed to establish any relationship between FAB levels and treatment outcomes. Results: Patients showed a significant (p b 0.0001) average improvement of 4.94 points on the Roland-Morris Disability

WFC 2015 Congress Proceedings Questionnaire following chiropractic care. Patients with high levels of FABs made an average of 3.885 points improvement following treatment; while patients with low FABs improved by an average of 6.00 points (p b 0.05). Conclusion: This study supports findings from other literature that suggests that FABs are a useful tool in identifying musculoskeletal pain patients with poorer prognoses; and is one of the first to identify this link within chiropractic patients specifically. FABs may be an accurate predictor of treatment outcomes in chiropractic patients. In addition to strengthening the evidence base for the efficacy of chiropractic, this study endorses the need for practitioners to be aware of FABs and strategies for combatting them.

Longitudinal assessment of pressure pain sensitivity following an acute muscular injury and manual therapy Charles Gay, Mark Bishop Objectives: Injuries are believed to increase pain-sensitivity locally and may spread to remote areas. Normalization of pain-sensitivity may underlie pain relief following manual therapy. Our objective was to assess individual changes in pressure-pain sensitivity based on response to a muscular injury and manual therapy (MT). Methods: 69 subjects completed an exercise-muscle-injury protocol and were split into 3 groups. The first group (N = 13) reported no acute low back pain (aLBP), the second group (N = 29) reported aLBP and less pain following MT, and the third group (N = 27) reported aLBP and no change in pain following MT. Pain sensitivity measures were taken 7 times, over three anatomical locations and consisted of: pressure-pain thresholds (PPT), pain intensity at threshold (PI) and ratio of pain to pressure (PR). Three time points occurred prior to the exercise-injury and four time points occurred after. Two of the post-exercise time points occurred 30 minutes before and after MT. Results: A significant group by time interaction was found for PPT and PI measured locally. Graphical visualization of the times series showed a gradual habituation over the first three time points prior to the exercise-injury. Following the injury, pain-sensitivity increased in all groups. Following MT, the change in pain sensitivity differed across groups, where individuals who did not report pain appeared to normalize, subjects who reported less pain showed no change, and subjects who did not report pain relief showed an increase. At the final time point, pain sensitivity normalized in all groups. We did not find significant effects in the remote locations. Conclusion: Following our exercise-injury protocol, we observed local increases in pressure pain sensitivity, even in the absence of reported pain. We did not find these changes in remote locations. MT did not normalized pain sensitivity in subjects who reported pain relief.

Manikin-based simulation: learning and learning retention Dominic Giuliano, Marion McGregor Purpose: Providing large groups of students equal opportunities for role-playing-based learning is an economical and scheduling challenge. It is assumed playing the role of “doctor" in such situations will maximize learning. However, in large classes, not everyone may receive this opportunity. The purpose of this investigation was to determine the impact of “role" in manikin-based simulation.

WFC 2015 Congress Proceedings Methods: The proposed study used a comparative design. Students in a manikin-based simulation lab, underwent a cardiac event scenario twice during one lab experience and then again six months later. As a result, a total of 69 videos were captured (23 early in lab, 23 late and 23 six months later). All students (n = 185) were 4th year interns enrolled at Canadian Memorial Chiropractic College. Interns entered the lab in groups of 5-9 students. One student per group was haphazardly assigned to play the critical role of “doctor". At the six-month follow-up 12 interns who played the role of doctor in the initial session were assigned that role again (old doctor). Eleven interns, who played non-critical roles initially, were newly assigned the role of doctor (new doctor). All videos were scored independently and in a blinded fashion, by three judges. Judges used a pre-tested checklist of 16 items for a total possible score of 18. Results: Analysis of variance indicated a statistically significant difference in video scores based on time in the lab (F = 72.22, p = 0.00). Checklist assessment scores were more than double for both the late-in-the-lab videos (16.04) and the six-month follow-up videos (15.27), compared to the early-in-lab videos (6.55). Follow-up scores comparing old doctors to new doctors showed no statistical differences (15.36 verses 15.18 respectively, t = 0.26, p = 0.80). Conclusion: This study demonstrated that for this cardiac scenario, learning retention was maintained regardless of role played.

Manikin-based simulation: online orientation and student anxiety Dominic Giuliano, Loretta Howard, Rebecca Taylor, Marion McGregor, Rachel Statz, Christina Bagnell, Madolyn Linka Introduction: This study examined the role of technology in orienting students to a manikin-based simulation lab. Student anxiety levels are typically high when entering a simulation environment and lab time is relatively short and expensive. Thus it is critical that students do not enter the environment excessively anxious, and that all time spent with the simulation experience be available for learning. It was purposed that the addition of an online orientation prior to the actual lab would save time for more learning content during the session. Concerns were raised that student anxiety could increase with a priori knowledge of the technology and processes used during simulation. Methods: Initial anxiety scores were gathered from 477 fourth year chiropractic interns from the classes of 2010, 2011 and 2012 using a Visual Analogy scale (VAS). The interns from 2010 and 2011 experienced a thirty-minute in-person orientation to the laboratory as part of their two hour simulation experience, and therefore provided scores prior to their orientation. In contrast, interns from the 2012 class was required to complete an online orientation module prior to attending the lab, and therefore provided their anxiety scores after their orientation. Results: Results indicated that mean anxiety scores were not statistically different (F = 0.13, p = 0.88) between the three academic years (2010 = 39.60, 2011 = 40.84 and 2012 = 39.78) regardless of when and how the orientation was provided. Conclusion: The implications of manikin-based simulation training are known to involve both physiological and psychological components. Results of this study demonstrate no statistically

127 significant effect on students’ self-perceived anxiety scores associated with the implementation of an online orientation module in preparation for a simulation based exercise. However, using this technology to orient interns to the lab provided an additional 25-30 minutes of training during the simulation experience.

Forces and durations measured during delivery of a manual cervical distraction procedure Maruti Ram Gudavalli, Robert Vining, Stacie Salsbury, Cynthia Long, Avinash Patwardhan, Christine Goertz Objectives: Neck pain is the second most common condition treated by doctors of chiropractic (DCs). This study quantified DC-applied traction forces, posterior-to-anterior (PA) forces, and force durations during a clinical trial of manual cervical distraction (MCD). Methods: This study received institutional review board approval. 48 consented participants with chronic neck pain were randomly allocated to MCD delivered within 1 of 3 prescribed traction force ranges (low force, b 20 Newtons (N); medium force, 21-50 N; high force, 51-100 N). Participants received 5 treatments over 2 weeks. MCD included manual traction applied at 2 contact locations (C5; occiput) with patients lying prone on a specially designed table. DCs applied forces cyclically in 3 sets of 5 cycles. Force and duration measurements were obtained with force plates connected to a computer. Peak traction forces, peak PA forces and total force duration were descriptively analyzed. Results: Means and standard deviations (SD) of peak traction forces by group were: low 15.7 N (5.7 N); medium 34.3 N (17.9 N); and high 67.1 N (22.6 N). Peak PA forces by group were: low 29.8 N (14.7 N); medium 44.9 N (22.7 N); and high 65.7 N (33.4 N). DC1 peak PA forces by set were: Set-1 37.5 N (17.9); Set-2 35.1 (18.9 N); and Set-3 34.5 N (18.9 N). DC2 peak PA forces by set were: Set-1 57.0 N (30.1); Set-2 59.8 N (32.1); Set-3 62.6 N (34.1). Total force durations in seconds by group were: low 54.9 (9.7); medium 66.2 (14.4); and high 68.2 (16.8). Total force duration in seconds for DC1 was 53.7(8.0) and for DC2 69.8 (15.5). Conclusion: This study demonstrated the feasibility of measuring peak traction forces, PA forces and force durations during MCD. DCs consistently applied both forces during MCD delivery, although variability in PA forces and treatment durations was noted between clinicians. Higher traction forces resulted in higher PA forces. Future trials of MCD should measure both traction and PA force delivery.

The effects of a single session of chiropractic care on lower limb muscle strength Heidi Haavik, Imran Khan Niazi, Jens Duehr, Mat Kingett, Kelly Holt Objectives: Previous studies have shown changes in various surface electromyographic (sEMG) measures pre vs post spinal manipulation. The objective of this study was to investigate changes in lower limb muscle maximum strength following a single session of spinal manipulation and compare this with sEMG findings. Methods: Three single group, basic science, cross-over experiments (n = 8-11) with two assessment sessions were conducted. Interventions were either spinal manipulation or control.

128 Outcomes were maximum isometric force and muscle fatigue measured during isometric maximum voluntary contractions (MVCs) of ankle plantar and dorsiflexors. Force and fatigue was measured using both sEMG and an isometric strain gauge (absolute force). Study one involved sEMG assessment of soleus, study two involved absolute force assessment of ankle plantarflexors, and study three involved absolute force assessment of ankle dorsiflexors. The highest plantar flexor EMG activity and highest strain gauge recording during MVCs were used to measure strength changes. Time-dependent shifts in mean power frequency (MPF) of sEMG and decrease in absolute force values were used to measure fatigue. Results: After the spinal manipulation intervention MVC of the soleus muscle, as determined by sEMG, increased significantly by 59.5% (p = 0.03), and absolute MVC force significantly increased by 16.1% (p b 0.001) during plantarflexion and by 10.5% (p b 0.001) during dorsiflexion. Fatigue occurred after the control interventions as indicated by a decrease in the mean power frequency for the soleus EMG (9%, p = 0.04) and a significant decrease in absolute MVC force during plantarflexion (11.4%, p = 0.03) and dorsiflexion (6.2%, p = 0.02). The within group mean change scores were all significantly different between interventions (p b 0.001). Conclusion: These studies suggest that spinal manipulation not only increased muscle strength but also prevented fatigue in ankle dorsi and plantarflexor muscles. This has clinical implications for a variety of patient populations. Further research is now required to corroborate these findings.

Cervical lordosis as an adaptation to the morphology of the thoracic inlet angle Deed Harrison, Joseph Betz, Chris Colloca Objectives: Cervical lordosis has been reported to have a wide distribution; from mildly kyphotic to deep lordosis. The anatomic determinants of cervical lordosis are poorly understood and often neglected. The present study investigates the correlation between thoracic inlet morphology and the cervical lordosis in healthy volunteers. Our hypothesis is that cervical lordosis is dependent on thoracic inlet morphology. Methods: IRB approval and informed consent were obtained. 32 normal volunteers (8 female), 25-50 years, received a detailed evaluation. Lateral cervical radiographs were digitized including vertebra from C1-T1 and the top of the manubrium sternum. Measurements of cervical curvature (posterior bodies C2-C7), sagittal balance (C2-C7 plumbline), posterior body tilt of T1 to vertical (T1-vert), and thoracic inlet morphology (posterior tangent sternal incidence angle (PTSIA)) were obtained. All variables were evaluated for normal distributions; reported as means ± SD. Pearson correlations for all variables vs. each other, simple linear regression models to predict ARA C2-C7, and multiple regression analysis to predict ARA C2-C7 were determined. Statistical significance was set at p ≤ 0.01 (2-tailed t-test). Results: The average cervical lordosis was ARA C2-C7 of -25.5° ± 10.6°, T-vert of 28.2° ± 8.6°, C2-C7 plumb of 12 mm ± 11.7, and a PTISA of 72.8° ± 9.5°. Significant correlations were found between the following variables: PTSIA vs. T1-vert (r = 0.673, p b 0.001), PTSIA vs. ARA C2-C7 (r = -0.531, p = 0.002), PTSIA vs. T1-vert (r = 0.673, p b 0.001), T1-vert vs. ARA C2-C7 (r = -0.822, p b 0.000).

WFC 2015 Congress Proceedings A significant multiple regression model to predict ARA C2-C7 from PTSIA and T1-vert was identified: ARA = 0.763 + 0.45(PTSIA) 1.048(T1-vert), (r = 0.882, R2 = 0.676, p b 0.000). Conclusion: The analyses suggest that posterior body of T1-vertical and thoracic inlet morphology are good predictors of the magnitude of cervical lordosis in healthy individuals.

A systematic review of the effectiveness of the Gonstead technique Michael Robin Harrison, Charmaine Maria Korporaal, Graeme Harpham Background: Practitioners are required to practice evidence-based medicine, as the demand is driven by patients and third party payers. With large volumes of information available, difficulties arise for the practitioner to apply this. A systematic review allows literature to be organized, rated and rendered useful to a practitioner. Objectives: The effectiveness of the Gonstead chiropractic technique (GCT) was evaluated to present current evidence available for various conditions for which GCT is utilized in clinical practice. Methods: A literature search was conducted with the following key terms: Gonstead and manual, Gonstead and technique, and Gonstead and manipulative/manipulation. Databases searched were: CINAHL Plus, Google Scholar, MEDLINE, Metalib, Pubmed, Science Direct, Springerlink and Summons. Articles were screened for inclusion, reviewed by six independent reviewers. Data Collection and Analysis: Appropriate scales were used to rate the methodological rigor of each article. This was analyzed and the articles were subsequently ranked. Discussion then contextualized these outcomes in the context of the clinical results obtained in each study. Results: Citations (447) were identified, twenty-six articles remained after screening. A secondary hand-search added two additional articles. The results indicated limited to no evidence for neck pain/ headache/face pain where limited evidence was available for gynecological issues, scoliosis, neurological disorders, fractures, BP and physiological presentations. Consensus was evident for gynecological issues, neurological disorders, fractures (with the exception of the undiagnosed fracture) and physiological presentations whereas the neck pain/headache/face pain and scoliosis were conflicting. Conclusion: This limited evidence indicates the need for further studies (particularly RCTs) to be done with stringent methodological rigor, so as to investigate the appropriateness or inappropriateness of the use of the GCT.

Social media and chiropractic colleges: Opportunities and imperatives Glori Hinck, Monika Brady Objectives: Are chiropractic colleges fully leveraging the opportunities offered by social media? Social media can serve an important role as a marketing and brand awareness tool and allows colleges to create and digitally share new user-generated or existing content through multi-way communication. In this process colleges can directly engage with prospective and current students, a majority of whom are digital natives, and communicate with them in a familiar voice. The goal of this quantitative research study is to evaluate the types of social media used among chiropractic colleges, and their level of activity on these social media sites.

WFC 2015 Congress Proceedings Methods: The English language websites of each chiropractic college worldwide (n = 31) were accessed and evaluated to determine their use of social media. Data were analyzed using descriptive statistics. Results: Out of 31 English language websites evaluated, 29 had at least one social media site. Of these, 100% had a Facebook profile. The average number of social media sites presented per institution was 3.4 with Twitter (77%), YouTube (68%), and LinkedIn (39%) following Facebook. Facebook “likes” ranged from 0 to 194,920 with an average of 3761. Facebook posts over a 30-day period ranged from 0 to 50 with an average of 18. Only 9 colleges published a social media policy on their website. Conclusion: The research indicates that virtually all chiropractic institutions evaluated include some form of social media on their websites. However, deeper examination finds that actual social media utilization is often quite low indicating that institutions are not taking full advantage of the opportunities offered by social media to build and maintain relationships. In addition, a majority of schools do not make their social media policies publicly available on their website, which may contribute to inappropriate social media use.

Chiropractic clinical research: an analysis of ClinicalTrials.gov Nicole Homb, Robert Vining, Dana Lawrence, Christine Goertz Objectives: The objective of this study was to provide a descriptive analysis of clinical trials of chiropractic registered at ClinicalTrials.gov and to compare findings with the chiropractic clinical research agenda. Methods: Chiropractic related interventional trials registered on ClinicalTrials.gov from registry inception to January 25, 2014 were identified and evaluated according to trial design characteristics. The term “chiropractic” was searched using the advanced search form of the web-based registry. Two temporal subsets were derived for further characterization relative to clinical research agenda recommendations. Results: A total of 149 chiropractic related interventional clinical trials were registered with ClinicalTrials.gov since the registry’s inception in 2000 to January 25, 2014. There were no obvious differences in data element characteristics for all trials in the data set relative to each of the 2 temporal subsets of data. Back pain, neck pain and headache accounted for 43.0% of all registered trials included in the sample. The most common study purpose was treatment-oriented, accounting for 85.2% (n = 127) of all registered interventional trials within the chiropractic discipline. Conclusion: Our analysis shows that many of the recommendations contained within the chiropractic clinical research agenda exhibit significant progress. With the lack of clinical trials of diagnosis and measurement being the exception, chiropractic related interventional trials generally mirrored the recommendations outlined within the previous white papers on the topic. This demonstrates that the recommendations were relevant to the chiropractic profession during the corresponding time periods.

Maternal report of feeding: a cross-sectional survey of parents presenting infants to the AECC Ann Kristin S Homdrum, Joyce Miller Objectives: The objectives of this survey were to investigate maternal choices to initiate or preserve exclusive breastfeeding and

129 to map out the main problems with feeding in infants and use the results as a guide in order to be able to provide support for long-term breastfeeding for the health of the child. The purpose of this survey was to determine the incidence of and the risk factors for suboptimal infant feeding behavior. Methods: A cross-sectional survey of parents who presented their infants to a chiropractic teaching clinic. 1753 surveys were collected. Each form was coded with a number and data entered into an Excel spread sheet. Two main software packages were used to analyze data; Microsoft Excel 2000 spreadsheet/SPSS-17 and GraphPad Instat Statistical analysis software. SPSS-17 was used for data storage and these data were sequentially exported and analyzed using Instat. Results: Most mothers (88%) initiated breastfeeding. The mean age when mothers stopped breastfeeding (BF) was 3 weeks (SD = 5.5). Amongst women who stopped BF (n = 502), 197(39%) had routine vaginal births and 305 (61%) had assisted births. There was no significant correlation between type of birth and feeding. There was a significant correlation (0.048) between when the mothers stopped breastfeeding and the lack of satisfaction with the breastfeeding experience. Of those mothers who stopped breastfeeding, mothers who planned to breastfeed whilst being pregnant, breastfed for twice as long compared to the women who did not plan to breastfeed (p = .005). Conclusion: Breastfeeding initiation rate was high in this population, with early discontinuation. Further study is required to determine which factors might work toward helping new mothers continue.

Should healthcare in rural Botswana focus on integration and group activities to ease the burdens associated with muscle, bone and joint disorders? The World Spine Care MuBoJo project Maria Hondras, Helle Johannessen, Jan Hartvigsen, Corrie Myburgh, Scott Haldeman Objectives: Healthcare inequities and limited resources exist in Botswana for people with Muscle, Bone and Joint (MuBoJo) disorders. In response, World Spine Care established two clinics and initiated research in Botswana. This study examined the burden of living with and caring for MuBoJo conditions among Villagers residing in this rural setting. Methods: Ethnographic fieldwork over eight months included participant observation and 70 interviews with 48 participants (35 villagers, 13 healthcare providers). Villager interviews were typically conducted in Setswana with an interpreter. Audio-recordings were transcribed verbatim and contextually translated into English. Theoretical perspectives guiding analysis included Kleinman’s “explanatory model” and Bury’s notion of “biographical disruption”. Constant comparative methods facilitated pattern finding to reveal insights for the study aim. Results: Villagers expressed gratitude for dialogue about MuBoJo conditions to improve daily lives. Interviews revealed social suffering related to drought, poverty and outmigration or other shifts within family structures. The temporal sequence of lives disrupted by MuBoJo troubles was less important than loss of independence and social identity to fulfil traditional duties. Activities limited by pain and disability included: caring for family members who suffer debilitating conditions; walking; sweeping; hand-washing clothes; fetching water; farming; harvesting grasses; and, (re-)constructing homesteads with mud and thatch. Villagers conveyed interest for group activities to improve MuBoJo health. Word of mouth fueled villager concerns

130 about treatment adverse effects, but most were interested in what, “the westerners offer at the caravan”. Providers encouraged integration of MuBoJo care with health and lay personnel, but thus far provide parallel care without engaging the community. Conclusion: Uncovering burden is an important first step to address musculoskeletal care needs. In rural Botswana, MuBoJo conditions disrupt everyday lives contributing to loss of independence and social identity. Community-engaged partnerships are needed to develop healthcare programs to manage the burden of muscle, bone and joint disorders.

Walking sticks for muscle, bone and joint health in rural Botswana: Villager perspectives from the World Spine Care MuBoJo project Maria Hondras, Stacie Salsbury, Nina Nissen, Helle Johannessen Objectives: People of rural Botswana rely on walking as their principal mode of transport over long distances and rugged geographical terrain. For those who suffer from Muscle, Bone and Joint (MuBoJo) disorders, navigating spaces and places contributes to everyday burdens that are not well represented in the literature. In this qualitative study we observed the use of walking sticks amongst villagers in rural Botswana and examined how they might support MuBoJo health. Methods: Ethnographic fieldwork over eight months included participant observation, document review, and 70 interviews with 48 participants (35 villagers and 13 healthcare providers). Analysis included constant comparative methods followed by a structured approach to identify and assemble walking stick text for interpretation. Results: Observations and discussions revealed that many walking sticks were handcrafted from natural or household objects. From a therapeutic perspective, homemade and commercial aids were improperly fitted and poorly maintained. Villagers reported walking stick use to: uphold posture and balance; relieve MuBoJo pain; honor fashionable tradition; and assist visually impaired persons to negotiate rough terrain. Non-use was related to fear of dependency on sticks and inability to go without aids once used. Villagers frequently self-prescribed mobility aids, were self-taught in their use, and habitually used sticks on the ipsilateral side of lower extremity involvement. When prescribed by healthcare providers, villagers claimed little or no instruction for use; no educational notes were identified in villager health cards. Conclusion: Many walking sticks are homemade and most are used without professional instruction. To promote MuBoJo health amongst villagers in Botswana, it is essential that healthcare providers are educated to assess and train villagers for mobility aid fit, use, and maintenance. Frequent follow-up observations also are important. Engaging trusted opinion leaders might be valuable to initiate and sustain community-based interventions for walking sticks to support muscle, bone and joint health.

Somatotopy of the lumbar spine in the secondary somatosensory cortex Sabina Hotz-Boendermaker, Bart Boendermaker, B. Kim Humphreys, Michael L Meier Objectives: Mechanosensory stimulation of the lumbar spine induced bilaterally somatosensory maps in the primary somatosen-

WFC 2015 Congress Proceedings sory cortex (S1) in healthy subjects, however not in a somatotopical order. There is evidence of a body representation in the secondary somatosensory cortex (S2). The present study aimed to investigate a somatotopical arrangement of individual lumbar vertebrae in S2. Methods: Thirteen participants were investigated in the prone position during functional magnetic resonance imaging (fMRI). An experienced manual therapist applied non-painful, posterior-to-anterior (PA) pressure onto three lumbar spinous processes (L1, L3, and L5). The pressure (30 N) was monitored and controlled by sensors. data analysis was performed using SPM8. A region of interest approach for S2 was applied and the coordinates for the different lumbar levels were extracted and statistically analyzed in SPSS19. Results: PA pressure induced significant activation patterns for lumbar vertebrae in S2 in a somatotopical order. Based on statistical analysis of the x (medial-lateral), y (anterior-posterior), and z (superior-inferior) coordinates, L1 was located significantly different in the x and y directions compared to L3 and in the x, y, and z directions to L5. In contrast, the coordinates for L3 and L5 were not significantly different. Conclusion: While sensory modalities are processed individually in S1, S2 integrates bilateral multiple somatic input and enhances attention towards sensory stimulation. The demonstrated somatotopy in S2 might represent the mechanosensory information induced by PA pressure that reflect the biomechanical function of lumbar vertebrae. Anatomically, L1 is located at the thoraco-lumbal junction and involved in rotation movements in contrast, L3 and L5 represent force loading flexion/extension movements. The S2 somatotopy might be the first demonstration of individual mechanosensory processing areas for the different lumbar levels. It supports clinical experiences that in lumbar segmental examination with the use of PA pressure, a person can differentiate between individual lumbar vertebrae.

Differences in practice characteristics between male and female chiropractors in Switzerland B. Kim Humphreys, Cynthia Peterson Background: Currently 30% of Swiss chiropractors are women. However, approximately 70% of students in the chiropractic medicine program at the University of Zurich are female. Within medicine in western countries the proportion of females is increasing. Governments worry that this “feminization” will lead to a physician shortage as women work fewer hours and see fewer patients as they try to balance work-home requirements. The same may become true for the chiropractic profession as the number of women chiropractors increases. Therefore, the purpose of this study is to compare male and female chiropractors for differences in practice characteristics in Switzerland. Methods: This cross-sectional study uses data from the “Swiss Job Analysis” study. The survey instrument was adapted from the US and UK chiropractic job analysis questionnaires and administered to all 260 Swiss chiropractors using Survey Monkey. Gender of the chiropractor was collected in addition to questions regarding practice characteristics and treatment techniques. All data were categorical. The Chi-squared test was used to assess for differences between the genders for each practice characteristic and each treatment option. P b 0.05 was considered statistically significant.

WFC 2015 Congress Proceedings Results: Males work significantly more hours (p = 0.0001), see more patients per (p = 0.0001), and see more new patients (p = 0.001) per week. Females spend significantly more time per patient during follow-up visits (p = 0.007) but not for new patients. No gender differences for chronicity of patients treated, age groups treated, male vs. female patients treated, or for any of the treatment options used, including high velocity, low amplitude spinal manipulation were found. Conclusion: As women chiropractors work fewer hours and see fewer patients per week, this will likely lead to a shortage of chiropractors in the future if efforts are not made to increase the number of male students into the profession.

In patients with low back pain can the use of a clinical prediction rule be used to help identify those more likely to respond to manipulation? A literature review Mark Jessop Objectives: Low back pain is a common and costly condition. Research into the effectiveness of manipulation for low back pain has produced conflicting results; however this research often assumes nonspecific low back pain to be a homogeneous condition. It has been hypothesized sub-groups may exist within non-specific low back pain sufferers with some patients more likely to benefit from receiving manipulation than others. The aims of this study were to search and review the literature to investigate if the use of a clinical prediction rule can be used to identify those likely to respond to manipulation. Methods: In April 2014 a search of the literature was conducted using predefined search criteria by means of a PICO format to identify key words and concepts. Searches were carried out on Pubmed, CINAHL, Cochrane and SCOPUS. CASP tools for randomized controlled trials were used to critically appraise the selected studies that were chosen based on inclusion and exclusion criteria. Results: Nine studies were identified following evaluation of inclusion and exclusion criteria and three randomized controlled trials were appraised. Two high quality studies had conflicting results with one finding the use of a Clinical prediction rule effective and the other finding no difference between groups. A lower quality study partly supported the use of a clinical prediction rule. Conclusion: A paucity of research exists within this area. There is conflicting evidence as to the benefit of a clinical prediction rule in identifying favorable responders to manipulation. It has been shown to be effective but cannot currently be generalized to different populations. In addition the clinical prediction rule appears only to apply to high velocity low amplitude techniques but is not currently applicable to non-thrust techniques. More research is needed to clarify its effectiveness and generalizability.

Incidence, course and prognosis of mid-back pain after traffic collisions: a population-based cohort study Melker S. Johansson, Eleanor Boyle, Jan Hartvigsen, Mette Jensen Stochkendahl, Linda Carroll, J. David Cassidy Objectives: The umbrella-term “whiplash-associated disorders” covers a wide range of symptoms reported after traffic collisions. In comparison with other traffic injuries and their related conditions

131 (e.g., neck pain, low-back pain and depression) mid-back pain (MBP) is one of the least studied. The incidence and prognosis of traffic-related MBP is unknown. The aims of this study were to describe the incidence, course of recovery and prognosis of MBP after traffic collisions. Methods: A population-based inception cohort consisting of all traffic injuries occurring in Saskatchewan, Canada, was formed during a two-year period, and participants were followed over one year. Annual overall and age-sex-specific incidence rates of MBP were calculated. Survival analysis methods were used to describe the course of recovery and to explore associations between participant characteristics and time-to-self-reported recovery using the Kaplan-Meier technique and Cox proportional hazards models, respectively. Results: The study cohort consisted of 3,711 MBP cases. During the study period, the annual average incidence rate was 236 per 100,000 population. The highest incidence rates were found in women and in young persons. The median time-to-first reported recovery was 101 days (95% CI: 99-104). About 23% were still not recovered one year post-crash. Participant’s expectation for recovery, general health, extent of severely affecting comorbidities, and having experienced a previous traffic injury were some of the factors associated with recovery. Conclusion: Traffic-related MBP is common and can result in a long recovery process for some individuals. A range of biopsychosocial factors influence the prognosis.

Impact of a single interprofessional education intervention on nutritional competency Gena E. Kadar, H. Garrett Thompson, Elizabeth O'Toole, David Kilgore Objectives: The World Health Organization predicts that by 2020, two-thirds of diseases worldwide will be the result of poor nutrition and other lifestyle choices. Nutritional therapies have been shown to mitigate the onset or chronicity of many health conditions including back pain. It is therefore imperative that healthcare providers are competent in clinical nutrition and coordinate patient care to support effective prevention and management of these conditions. However, interprofessional education (IPE) opportunities and training in the application of clinical nutrition remain limited within many complementary and alternative medicine (CAM) and conventional medical education curricula. The objective of this study was to measure the impact of a single nutrition-focused IPE intervention on nutrition competency among chiropractic (DC), masters of acupuncture and oriental medicine (MAOM), and medical (MD) students, and a medical resident. Specifically, we addressed if participants: 1) improved confidence in their ability to deliver evidenced-based nutrition advice; 2) were more inclined to incorporate evidenced-based nutrition advice; and 3) incorporated more healthy food choices in their own diet. Methods: DC (n = 11), MAOM (n = 2), MD (n = 15) students and a medical resident (n = 1) voluntarily participated in a “culinary medicine workshop.” A twenty-one question survey measured the impact of the intervention and was distributed prior to, following, and six-weeks after the workshop.

132 Results: Significantly improved confidence in ability to deliver evidenced-based nutrition advice and short-term improvement in self-care practices were observed. No significant differences in survey responses were found between DC and MD students. Conclusion: This study demonstrates that a single IPE intervention has lasting benefits on self-assessed ability to deliver nutritional support to patients. A single intervention may also enhance dietary self-care practices, but was not maintained at six-weeks. The study also reveals an alignment of attitudes among DC and MD students regarding interprofessionalism, the importance of nutritional counseling, and self-assessed nutritional competency.

A preliminary investigation into the effects of cervical spinal manipulation on cardiac autonomic control by measuring heart rate variability Antonia Kam, Adrian Hunnisett, Christina Cunliffe Objectives: The aim of this study is to determine whether upper cervical adjustment of C1 elicits a response from the cardiac autonomic control system in terms of producing a predominant parasympathetic or sympathetic response post-treatment in contrast to the response of the individuals undergoing sham and control groups. Methods: Following ethical approval, a single-blinded randomized controlled trial was undertaken. A total of 45 asymptomatic subjects were randomly assigned to three groups: intervention (upper cervical manipulation of C1) (n = 15), sham protocol (n = 15) and control (n = 15). The heart rate variability (HRV) data were recorded and analyzed over the 5-minute pre-treatment and post-treatment intervals. The HRV data were recorded using a PowerLab 26 T Teaching System dual BioAmp. The power spectral analysis was performed with LabChart HRV Module V8. Results: In asymptomatic adults, cervical spinal manipulation was associated with changes in HRV that were not seen with the sham procedure. In the intervention group, there were significant increases in the normalized low frequency (LF) component and the low frequency to high frequency ratio (LF/HF) and a significant decrease in the normalized high frequency (HF) component. There were also significant increases aspects of HRV (p b 0.05) in the intervention group. In subjects undergoing sham adjustment, there was no statistically significant change in the HRV measurements. Conclusion: An upper cervical spinal adjustment to C1 appears to influence autonomic cardiac control in ways that are not duplicated by a sham procedure or control. The HRV results for the intervention group show a significant increase in overall sympathetic output.

Injuries in elite Taekwondo Poomsea athletes Mohsen Kazemi, Gina Hua, Anas Ingar, Ali Jaffery, Gillian Huang Objectives: Poomsae is the only non-contact and no opponent form of Taekwondo. With age classification for competition, Poomsae athletes can compete at world level almost at any age. As such there has been astronomical increase in competitors

WFC 2015 Congress Proceedings worldwide and hence the need for clear understanding of risks involved. The purpose of this study is to determine type and rate of injuries (location, severity, age of the athlete, mechanism, and occurrence during training vs competition) in elite Canadian Poomsae athletes. Methods: This longitudinal retrospective study consisted of 34 male and female elite Poomsae athletes competed in three consecutive World Poomsae Championships. Injuries were recorded by the team doctor on an injury form. Means are used to describe number of athletes, number of reported injuries, injury rates, body location, injury type and mechanism, and descriptive statistics are used to describe the sample population in terms of anthropomorphic factors (population number, number of males and females, age range and mean age, and experience level expressed as a belt level). Results: Strain, sprain and joint dysfunctions are the most common type of injuries in Poomsae. Lower limb and back were the most common area of injury in females and males respectively. Males with a 3rd degree black belt or lower are most likely to have an acute injury. Females who incurred chronic overuse injuries were less experienced compared to their male counterparts and were more likely to suffer from chronic overuse injuries. Athletes 40 year old and under were more prone to acute injuries compared to athletes over 40. Conclusion: Taekwondo Poomsae Athletes have far less complicated injuries compared with sparring or any other martial arts. Poomsae athletes suffer more from chronic overuse injuries compared to the sparring athletes. Joint dysfunction was the second most common type of injury among poomsae athletes.

Rasch analysis of the 23-item version of the Roland Morris Disability Questionnaire Peter Kent, Margreth Grotle, Kate M. Dunn, Hanne B. Albert, Henrik H. Lauridsen Objectives: To determine the psychometric properties of the 23-item version of the Roland Morris Disability Questionnaire (RMDQ-23) and quantify their stability across two cultures/ languages and two types of care-settings. Methods: Rasch analysis of data from 1,000 patients with low back pain from primary care (United Kingdom and Denmark) and secondary care (Denmark). Results: The RMDQ-23 is unidimensional if local item dependency issues are accommodated but contains several poorly fitting or overdiscriminating items, some poor targeting of items, and the scoring of 4 to 5 items is differentially affected by common clinical characteristics (such as age, gender, pain intensity, pain duration and care setting), depending on the country. Conclusion: As similar results have been found for the RMDQ-24, we believe it is timely to reconsider whether: (i) the RMDQ should be reconstructed using an Item-Response Theory-based approach that includes consideration of new items and response options, or (ii) the use of alternative questionnaires should be recommended, such as the Oswestry Disability Index, that have shown evidence of fitting the Rasch Model, or (iii) a completely new condition-specific questionnaire should be developed, perhaps utilizing a computerized adaptive testing platform.

WFC 2015 Congress Proceedings Major Classification systems for jobs and occupations: inclusion of chiropractic and chiropractors Baiju Khanchandani, Donatello Testerini, John Williams Background: Health work force planning is new to many EU countries. Changes in primary health care and skills, knowledge and competences of the health workforce are being debated. National Health systems compete with other economic sectors and countries to attract workers. EU Classification systems help identify skills shortages and facilitate worker mobility. Purpose: The skills, knowledge and competences and training of chiropractors and sub-groups are referenced and an overview of occupation classification systems and the inclusion of chiropractors provided. Methods: The skills, knowledge and competences of chiropractors, and major global, European and national classification systems were examined. Information was gleaned from participation in the drafting of classification systems. The structure of the chiropractic profession was compared to other health care professions. Results: Some classification systems have evolved and changed the position of chiropractors. Other classification systems do not reflect the actual role of chiropractors in health systems nor the skills, knowledge and competences, and level of training of chiropractors. Conclusion: The number, type and sphere of practice of primary care providers is expanding. HSs preach prevention but allocate less than 3-7% of budgets to it. Neuromusculoskeletal disorders are a leading cause of disability, suffering and cost to society. Chiropractic primary health care practitioners have appropriate skill sets for these challenges. Recognition of chiropractors at all levels will encourage chiropractic utilization. Classification systems are a level of recognition in addition to inclusion in University education systems, legislation, regulation, and quality standards such as CEN. The profession needs to participate as a stakeholder in the review of classification systems; and codify the skills, knowledge and competences of the chiropractor at various career levels and fields of endeavor such as the clinical chiropractor, chiropractic educator, the chiropractic researcher, and the chiropractor specialized in specific fields such as radiology, sports, pediatrics, and neurology.

Emerging, evidence-informed models for decreasing costs and improving clinical outcomes in spine-related disorders: a narrative literature review Melissa Kimura, Robb Russell Objectives: Spine-related disorders (SRDs) are the largest cause of disability in the world with enormous global economic impact. Large increases in expenditures for spine care in the past decade have not resulted in improved clinical outcomes. Research on SRD costs and outcomes is challenging due to variability in care. Our objective was to perform a qualitative literature review on evidence-based approaches for managing SRDs in order to create a standardized spine care pathway for use in our academic health center. Methods: We performed a qualitative literature review on relevant literature published from 1985-2014 utilizing the electronic databases MEDLINE, Academic Search Premier, AltHealth Watch, AMED, SPORTDiscus, and checking reference lists. We analyzed relevant articles to identify common themes utilized to improve SRD patient outcomes while decreasing costs.

133 Results: Our review of literature suggests that models of care for SRDs that consider biopsychosocial approaches, and utilize diagnostic and/or symptom-based stratification offer the greatest potential for maximizing value via increased efficacy, improved clinical outcomes, and reduced cost. Additionally, the literature suggests SRD care teams should consist of specialists who serve the most common needs of SRD patients with a designated primary spine practitioner responsible for initial triage and conservative management. Conclusion: Evidence-informed themes for optimal management of SRDs uncovered in our literature review have been incorporated into a standardized spine care pathway that is has been introduced into our academic health center. Further research to measure costs and outcomes associated with this model is currently being conducted.

An academic health center’s quest to implement an emerging, evidence-informed model for decreasing costs and improving clinical outcomes in spine-related disorders Melissa Kimura, Robb Russell Objectives: Spine-related disorders (SRDs) are the largest cause of disability in the world with enormous global economic impact. Large expenditure increases in the past decade have not resulted in improved clinical outcomes. The biomedical model plus licensure and specialty-based silos have contributed to the dysfunction. Our objective was to implement an integrative, evidence-based approach for SRDs designed to improve clinical outcomes and decrease costs and conduct practice-based research to measure the results. Methods: We performed a qualitative literature review on evidence-based approaches for managing SRDs and identified themes with strongest evidence for improving outcomes and decreasing costs. We also visited hospitals and clinics employing emerging models and interviewed health care providers. We incorporated the evidence-based themes into a standardized spine care pathway. Results: Two doctors of chiropractic (self-selected) received spine care pathway training and adopted the model in our academic health center. From January 2013 through August 2014, they saw 286 unique patients and completed 1905 encounters. Clinical outcome and cost data relative to chiropractic visits have been collected. To facilitate tracking costs and outcomes for complete episodes of care, we sought to establish a closed system environment; however many payers in Southern California were reticent to explore this model. Conclusion: Emerging integrative models of care that consider biopsychosocial approaches plus diagnostic and/or symptombased stratification offer potential for improved value (efficacy, clinical outcomes, and reduced cost). Multiple spine care centers in the United States have adopted such models; however we have found that in Southern California, we were able to implement the care delivery model with relative ease, but the quest for partners willing to collaborate to study total-episode costs and outcomes is challenging. Despite the challenges, we entered into a collaborative proposal seeking funds jointly with a large regional payer and 300-bed hospital to conduct a demonstration project.

134 Practice profiles, satisfaction, and perceptions towards chiropractic education in Canada among recent chiropractic graduates: A cross-sectional survey Lauren Kitchen, Allison Kivisto, Anna Dowgialo, Jessica Wong Objectives: To assess the practice profiles, satisfaction, and perceptions towards chiropractic education from a Canadian educational institution among recent chiropractic graduates. Methods: We utilized a 25-item cross-sectional electronic survey that assessed practice demographics, satisfaction, and perceptions towards chiropractic education. We developed the survey using recommended survey development methodology, pre-tested, and field tested the survey. The target population was all chiropractors who graduated between 2007 and 2011 from a four-year full-time undergraduate program at a Canadian educational institution. We introduced the survey via telephone, administered the survey electronically using SurveyMonkey, and provided follow-up telephone calls to non-responders. Analysis included descriptive statistics, Spearman’s rank correlation coefficient and Kruskal-Wallis rank sum test to assess for correlation between satisfaction with education and other variables. We used the constant comparative method to assess for emergent themes in the written comments. Results: The survey was completed by 191 chiropractors (36.5% response rate). Most respondents: 1) practice full-time in urban or suburban settings in Ontario, Canada; 2) were satisfied or highly satisfied with their chiropractic education and career choice as a chiropractor; and 3) felt least prepared in business and jurisprudence, wanting improvements in the course content and format of delivery. There was no significant correlation between satisfaction with chiropractic education and average annual net income, weekly patient load, satisfaction with career choice, or self-reported level of preparedness for clinical practice. High levels of satisfaction with education significantly correlated with predominant chiropractic treatment views around musculoskeletal, neuromusculoskeletal, and/or biomechanical conditions, whereas low levels significantly correlated with other predominant treatment views. Conclusion: Recent chiropractic graduates in Canada are satisfied with their chiropractic education and chiropractic as their career choice. Business and jurisprudence courses may need to be modified in the chiropractic curriculum. Future research should explore satisfaction with chiropractic education in relation to predominant treatment views of chiropractors.

Are chiropractic patients afraid of moving? You can easily find out if your patients are Alice Kongsted, Kai Leland, Sture Hammern Objectives: Fear of movement (kinesiophobia) is associated with a poor prognosis in low back pain, but it is not known if this is relevant to chiropractic patients. Even if so, practitioners may consider questionnaires such as the 17-item Tampa Scale of Kinesiophobia too extensive for routine clinical use. Therefore, our objectives were to test if chiropractic patients would complete the Tampa Scale, if they considered the items relevant, and if using only a few questions from the scale would be sufficient.

WFC 2015 Congress Proceedings Methods: Twelve chiropractic clinics included adult patients with spinal pain. Patients completed the 17-item Tampa scale which had been extended with the response options ‘don’t know’ and ‘Not relevant to me’. The usefulness of the Tampa scale was evaluated by describing the prevalence of missing values and to what extent the items were considered irrelevant. The single items that best represented the entire scale were identified by correlating each item to the total score. The ability to identify kinesiophobia of the items with the highest correlation was then evaluated in terms of area under the curve (AUC). Results: A total of 109 patients were included, 93% responded to at least ten items, and 32% showed signs of kinesiophobia. Three items were considered irrelevant by N 10% of patients. A combination of items 1 and 7 was identified as the best short-form and detected kinesiophobia identified by the total scale with a high accuracy (AUC = 0.82). Conclusion: The Tampa Scale was considered relevant in Danish chiropractic patients, where kinesiophobia was present in one out of three patients. Screening for fear of movement could be conducted by asking if patients agreed with just two statements: “I’m afraid that I might injure myself if I exercise” and “Pain always means I have injured my body.”

Chiropractic patients consider treatment necessary: and that is not a bad thing Alice Kongsted, David Lüttge Jensen, Nicolas Crone Søndergaard, Lise Hestbæk Objectives: Patients’ beliefs about their condition and their expectations in relation to the prognosis seem to be of importance for outcome of a low back pain (LBP) episode. Having strong beliefs that treatment is needed may indicate negative illness beliefs, or contrarily, positive expectations that something can be done. This study aimed at investigating chiropractic patients’ agreement with the statement “Treatment is crucial to improvement of my pain”, describing characteristics associated with such treatment beliefs, and exploring whether treatment beliefs were associated with 3-months outcome. Methods: Patients seeking chiropractic care for LBP completed a baseline questionnaire at their first visit and a mailed questionnaire after 3 months. At baseline they were asked the treatment beliefs question (0 = totally agree treatment is crucial; 10 = totally disagree) as well as questions related to LBP symptoms, social factors, psychological factors, and demographics. The outcome measures were LBP intensity (numeric rating scale 0-10) and activity limitation (Roland Morris Disability Questionnaire (RMDQ) 0-100%) change scores. Results: A total of 920 patients were included from 17 chiropractic clinics and 79% completed follow-up. The most prevalent response was ‘totally agree’ (37%), and a response towards agreement (scores 0-4) was chosen by 65%. Stronger beliefs in treatment being crucial was weakly associated with higher age and more activity limitation, but not associated with any of nine other investigated baseline factors. Agreeing was very weakly associated with larger improvement in LBP intensity (β = -0.06, p = .05) and in RMDQ (β = -1.2, p b .01). Conclusion: Around 2 out of 3 LBP patients visiting chiropractors largely believed that treatment was crucial to their improvement. Patient characteristics did not explain differences in treatment

WFC 2015 Congress Proceedings beliefs and treatment beliefs were only slightly associated with outcome; indicating that believing in treatment was at least not harmful. The tested treatment beliefs question is not considered helpful for clinical use.

Reflections on the life of the father of modern chiropractic in Greece Stavros D. Ktenas, Alana Callender Objectives: The primary objective of this study was to explore Dr Kleanthis A. Ligeros contributions to the Hellenic Chiropractic profession. Methods: From March to August 2014, a research literature review was undertaken, which encompassed multiple searches conducted at museums, tertiary institutions, professional bodies/ associations and Government Agencies both in the U.S. and Greece. Results: Kleanthis A. Ligeros was a pioneer of modern chiropractic in Greece. He was both a trained chiropractor and medical doctor, in addition to being a bilingual academic and historian. His endless efforts and research for the promotion of chiropractic both in the U.S. and Greece is noteworthy. Despite being born in Greece, he was an integrated bi-cultural patriotic Greek-American and a U.S. war veteran, who loved and was heavily influenced by ancient Greek scholars. His major contribution towards the Hellenic chiropractic profession however, can be encapsulated in his attempts to establish the first chiropractic school, achieve a legal status quo for the profession and stop the persecution of chiropractors in Greece. Conclusion: Therefore, he was the iconic cornerstone of the Hellenic chiropractic profession.

Lactation consultants’ perceptions of musculoskeletal disorders of breastfeeding: a cross-sectional survey Valerie Lavigne, Joyce Miller Objectives: There is some evidence that manual therapies may improve musculoskeletal problems linked to breastfeeding. This study investigated North American International Board Certified Lactation Consultants (IBCLCs) demographic profile, perception of musculoskeletal disorders of breastfeeding in infants and referral patterns. Methods: IBCLCs were invited to participate to an online survey. The questionnaire had 17 questions. Results: A total of 13,017 emails resulted in 2,457 answers (response rate of 18.9%). Most IBCLCs were 50-59 year-olds (40%). Most had a university degree (40%) or a college degree (34%), a nursing background before becoming IBCLCs (64.8%) and practiced in a hospital setting (57%). Most IBCLCs reported referral of infants for musculoskeletal treatment (73.9%). The first professional referral was made to the infant’s pediatrician (47%) followed by craniosacral therapist (16%) and chiropractor (14%). The second professional referral was almost equal between pediatricians (23%) and chiropractors (21%). Professional expertise was the chief reason for referral (43%). Most babies were 0-3 weeks old (64%) when recommended for further care. The most common

135 latch issues referred were tongue-tie (27%), painful latch (24%), neck problems (18%) and non-latching (9%). Congenital torticollis (25%) and neck tension (14%) were the top two musculoskeletal problems recognized by IBCLCs. Approximately half of the respondents (51%) were comfortable recognizing musculoskeletal issues in babies. Most referrals from IBCLCs were done on the same day as the visit (49%). The majority of respondents (91%) noticed an improvement in breastfeeding following the use of manual treatment. Conclusion: IBCLCs refer widely to musculoskeletal specialists quickly after the first visit. However, they are not always very comfortable at recognizing infants that require referrals. More collaboration between the musculoskeletal professions and IBCLCs may help to foster the type of wide interprofessional support needed to ensure better breastfeeding rates.

Os odontoideum in a 27 year old chiropractic patient. A case report Melissa Loschiavo Objectives: The objective of this study was to educate chiropractors on the radiographic appearance, clinical importance and management of os odontoideum in a chiropractic patient. Methods: A 27 year old female patient presents with a history of occasional headaches and neck pain and stiffness for over ten years. No significant trauma was reported. A standard cervical radiographic series with flexion and extension views were taken prior to chiropractic care. Results: Upon radiographic examination it was determined that there was failure of union of the odontoid process to the base of the body of axis. These adjacent surfaces were confirmed to be smooth and well defined. The anterior tubercle appeared hypertrophic with a molding defect. Anterior displacement of atlas was noted upon cervical flexion indicating intersegmental instability. Prior to chiropractic adjustments of the cervical spine a neurological referral with advanced imaging was requested to rule out associated soft tissue derangement and/or neurological compromise. Conclusion: The etiology of os odontoideum may be either congenital lack of complete fusion of the synchondrosis of C2 versus an occult fracture of the odontoid process with the body of C2. The clinician must diagnose this radiographic presentation and refrain from chiropractic adjustments until an adequate neurological assessment is made. Vascular and/or neurological symptoms, such as vascular insufficiency or cord compression may present secondary to the instability of the upper cervical segments suggesting surgical correction. The review of the literature revealed the importance of ruling out spinal instability radiographically prior to cervical manipulation in a patient with os odontoideum.

What factors predispose rowers in developing a rowing related injury? Lijs Marquenie, Andrew L. Vitiello Objectives: The aim of this study was to gather information useful to healthcare professionals, coaches and athletes highlighting the possible risk factors for injuries related to rowing.

136 Methods: A 12-month retrospective electronic survey open to active rowing athletes from around the world. Respondents (n = 444) were recruited either by personal email or through different websites and social media. Binary logistic regression was performed to identify relationships between explanatory and dependent variables, i.e. the reporting of an injury. A univariate logistic regression analysis was performed for each of the explanatory variables of interest. Statistically significant (p b 0.05) explanatory variables were then considered for a final multivariate logistic regression analysis model. Results: The final population investigated included 19 amateur, 145 semi-professional and 213 professional rowers. Univariate analysis investigating the odds ratio of reporting an injury associated with either sweep or sculling rowing was non-significant (p = 0.68). Multivariate regression analysis demonstrated that sweep rowers training for more than six hours per week (OR = 2.18; 95% CI 1.10-4.35; p = 0.027), weight training for either 1-2 hours per week (OR = 2.00; 95% CI 1.12-3.53; p = 0.018) or for greater than two hours per week (OR = 2.35; 95% CI 1.24-4.43; p = 0.008), were all related to increased injury rates. Another regression model created for low back injuries showed that doing weight training for more than two hours per week (OR = 3.08; 95% CI 1.40-6.76; p = 0.005) and rowing training in the morning (OR = 2.00; 95% CI 1.16-3.43; p = 0.012) were associated with a significantly higher reporting of injuries in the preceding 12 months. Conclusion: The findings of this study conclude that there was no significant difference in the injury rates between sweep and sculling rowing. Rowers training for more than six hours per week, while performing weight training, were related with an increased injury rate. Weight training for more than two hours per week together with rowing training in the morning increased the injury rates of low back injuries.

Cases series: scoliosis correction in AIS; chiropractic vs. Scolibrace Jeb McAviney Introduction: A review of 2 cases of adolescent idiopathic scoliosis (AIS) that progressed while receiving chiropractic care but improved and remain stable following bracing with a new type of scoliosis brace called a ScoliBrace. Many chiropractors believe that AIS can be improved with chiropractic adjustments, however little evidence exists supporting this assertion. A cohort time series trial by Lantz showed no discernible effect of adjustments on AIS. Adjustments however are not the only tool available to chiropractors and scoliosis bracing may play a role in stopping curve progression. These 2 cases were treated with a unique type of scoliosis brace a Scolibrace. Results: Case 1) Started chiropractic care with a 46° curve, Risser 0. Under chiropractic the curve progressed to 72°. The curve was braced and at one month follow-up reduced to 42° in-brace (Risser 2). 3 months later the curve was 55° out-of- brace. Bracing continued for 2 years full time. At the end of treatment (Risser 5), and at the 6 and 18 month follow ups the curve measured 56°. Case 2) Started chiropractic care with a primary 32° curve, Risser 0. Under regular chiropractic the curve progressed to 46°. The curve was braced and at one month follow-up reduced to 28° in-brace

WFC 2015 Congress Proceedings (Risser 1). 3 months later the curve was 38° out-of- brace. Bracing continued for 2 year full time. At the end of treatment (Risser 5), and at the 6 and 12 month follow ups the curve measured 42°. Discussion: Both cases worsened while under chiropractic care but demonstrate correction of the curve following bracing that has been maintained after finishing brace treatment. These cases highlight the importance of earlier referral for specialized bracing rather than continued chiropractic treatment to achieve the best outcome for patients with AIS.

Neurobiological risk factors for chronic low back pain in healthy individuals Michael Lukas Meier, Phillipp Stämpfli, Andrea Vrana, Kim Humphreys, Erich Seifritz, Sabina Hotz-Boendermaker Objectives: From a preventative perspective, neurobiological evidence for back pain-related fear and brain imaging signatures before any injury of the back will be crucial if we are to identify the relevant vulnerable networks for chronic low back pain. Therefore, we investigated possible neuronal aberrant functioning in healthy individuals at risk for showing elevated back pain-related fear. Methods: 28 subjects (mean age = 29.73, SD = 10.4) completed a modified German 17-item version of the Tampa Scale for Kinesiophobia (TSK-G). The TSK-G measures pain-related fear in the general population by specifically focusing on movement-related fear of pain. Subjects were divided into groups with high and low TSK-G scores using a median split (median = 35). Functional connectivity between the amygdala and other brain regions was measured by using functional magnetic resonance imaging (fMRI). We primarily focused on the amygdala and the prefrontal cortex because these brain areas represent key regions in the evaluation and modulation of fear intensity and are strongly related to treatment response in chronic pain conditions. Results: The mean TSK-G score was 35.34 (SD = 7.31). Group-level statistics yielded a strong functional coupling between the amygdala and the ventromedial prefrontal cortex (vmPFC). Stronger amygdala-vmPFC coupling was negatively associated with high movement-related fear of pain (r = -0.43, p = 0.025). Conclusion: Adverse psychological factors such as movement-related fear of pain in healthy individuals may increase the risk of developing long-term back pain problems. Current investigation adds new evidence by demonstrating related vulnerable brain mechanisms. Individuals with high movement-related fear seem to have a predispositional neurobiological mechanism that might be important for the development of chronic low back pain. These study results call for a greater education in terms of erroneous beliefs regarding back pain in the daily chiropractic routine and training.

Sling exercises compared to a community fall prevention program: improvement of dynamic balance in elderly adults Laura Mendoza, Catherine Lagacé, Jean-Alexandre Boucher, Martin Normand Introduction: According to statistics, 20% to 30% of elderly people fall each year and it remains the principal cause of injury-related

WFC 2015 Congress Proceedings hospitalizations. Falls impose a heavy financial cost to the health care system. Research shows that 90% of the hip injuries are related to a fall and 20% of the victims will eventually die that following year due to that same fall. There are several physical changes in elderly as sarcopenia and decrease of proprioception. These changes are among the causes of loss of balance. Most falls occur when the senior is challenged in his dynamic balance capacity and is not able to recover from the perturbation. Proprioception, motor control and recruitment of core muscles should be improved in these populations. Many fall prevention programs exist and are currently being used among the elderly but they focus mainly in static balance. Objectives: The aim of this study is to compare the effectiveness, in terms of improvement of static and dynamic balance, of two different training programs. “Stand up” is one of the main multifactorial fall prevention programs in Quebec. The second program is based on motor control exercises with slings (Redcord). Methods: Twenty-eight subjects participated in this study. Twelve subjects followed the Stand-up program. Sixteen active subjects followed the sling exercises protocol. Assessment tools include three static and one dynamic balance tests. Results: The analysis results show that the groups were significantly different at the beginning for static tests only (Redcord being best). At the end of the process the Stand-up group showed a significant improvement for static tests only. However, only the Redcord group showed a statistically significant improvement in Y-Balance Test. Conclusion: Sling exercises were more effective to improve dynamic balance. It seemed to enhance proprioception, motor control and core muscles recruitment.

Interdisciplinary clinical care for pediatric patients: short and long-term reports of effect of combined midwifery and chiropractic feeding clinic in the UK: A service evaluation Joyce Miller, Monica Beharie, Alison Taylor, Sue Way Objectives: Early cessation of breastfeeding is a major public health concern. Very little research has focused on an inter-disciplinary model of chiropractors and midwives to seek improved outcomes and better longevity in breastfeeding. Methods: A cross-sectional survey was designed to elicit if women had a positive experience attending the clinic and the prevalence of exclusively breastfed infants 12 weeks or more after attending. Women were surveyed after attending the clinic for the first time asking about their perception of the clinic and whether they understood what the professional team had offered. After 12 weeks, women were sent a postal questionnaire to inquire the current feeding method of the baby. Bournemouth University Ethics Committee determined that these surveys were considered evaluations of a service and therefore no further ethical review was required. Results: 85 mothers took part in the initial survey and 72 (85%) of those returned the second survey. The age of the infants at the initial consultation ranged from a few days old to 12 weeks of age and most attended the clinic in the first month of life. In response to five statements relating to the service offered mothers positively agreed or strongly agreed at a rate of 93-98%. The rate of exclusive breastfeeding (EBF) on the first visit to the clinic was 26%. The rate of EBF at or beyond 12 weeks was 74% indicating positive

137 breastfeeding outcomes following attendance at the clinic. The relative risk was 3.6 (CI 2.3 to 5.6) that babies attending the clinic were breastfed at 6 months of age. Conclusion: Breastfeeding after attending the clinic compared favorably with UK statistics that b 1% of infants in the UK are exclusively breastfed at 6 months of age. Further study of interdisciplinary interventions are indicated in the world-wide effort to improve health through optimal feeding practices.

Where’s the middle? The challenge of defining the continuum of adverse events in spinal manipulation therapy Silvano Mior, Heather Boon, Linda Rozmovits Objectives: Spinal manipulation therapy (SMT) is commonly used in managing neck and back pain by chiropractors, physiotherapists, naturopaths and physicians (providers). While serious AEs are rare, post-treatment stiffness or soreness are common. Little is known about how these providers define such events. Our study explored how health care providers perceive adverse events related to SMT within the context of a culture of patient safety. Methods: We conducted semi-structured telephone interviews with 18 professional leaders from regulatory colleges, educational institutions and professional associations (key informants) and 39 frontline chiropractors, physiotherapists, physicians and naturopaths. Constant comparative analysis was used to code for both anticipated and emergent themes. Recruitment ceased upon reaching saturation. Results: Participants acknowledged a spectrum of potential risks associated with SMT. Many emphasized the limited and conflicting evidence which made it difficult to be definitive. Some felt that the risks were often overstated or that risk was often presented in a de-contextualized way. Participants generally believed that SMT was safest when practiced by members of their own profession. Participants readily identified increases in discomfort associated with SMT (e.g., stiffness, soreness or mild bruising), but these were generally not thought of as adverse events. All identified the potential for extremely rare, serious adverse events (e.g., strokes). However, they found it difficult to identify unintended effects of SMT that fell between the two extremes, raising the question of what, if anything, is in the middle of the continuum. Conclusion: While safety was a priority among SMT providers, AEs were considered difficult to define. At present, establishing a system of incident reporting would be difficult since providers generally perceive AEs as being either minor and expected or rare and catastrophic. Most struggled to identify avoidable unintended effects in the middle of the continuum.

Influence of the Gonstead Technique’s cervical chair manipulative procedure in the Neck Disability Index in patients with chronic neck pain Iã Ferreira Miranda, Daniel Facchini, Eliane Fátima Manfio Objectives: To evaluate the influence of the Gonstead Technique’s cervical chair manipulative procedure (GTCC) in the Neck Disability Index (NDI) of patients with chronic neck pain compared to a manipulative sham group.

138 Methods: A randomized, controlled clinical trial. 15 patients with chronic neck pain, was randomly assigned into one of 2 groups. Experimental Group (EG), with 8 patients (2 male and 6 female), mean age of 30.6 (13.7) years, mean weight of 68.3 (10.3) kg and mean height of 1.64 (0.06) m. Sham Group (SG), with 7 patients (1 male and 6 female), mean age of 38.9 (17.0) years, mean weight of 78.0 (18.1) kg and mean height of 1.64 (0.08) m. All the patients signed a voluntary informed consent document, approved by the university’s research ethics committee. The NDI was used to evaluate the neck. It is a questionnaire with 10 objective questions about pain intensity, daily activities, weight lifting and sleep quality. The EG intervention was the GTCC, performed 4 times, along a mean of 39.2 days. The SG was subjected to a similar cervical manipulative sensory experience (touch at restriction side, head positioning, movement and sound of drop headpiece), also performed 4 times, along a mean of 30.6 days. Paired and unpaired Student’s t-test was used to assess intra and inter group differences, respectively. Results: Statistically significant differences (p = 0.000) were found for NDI between the pre and post-treatment evaluations of both the EG (26.3(5.0)% pre; 10.9(7.1)% post) and the SG (30.1(3.7)% pre; 18.4(5.3)% post). There were no significant differences for NDI in the pre-treatment between groups (p = 0.122), however statistically significant differences were found in the post-treatment between the EG and the SG(p = 0.039). Conclusion: This results shows that after the treatment period, both groups showed improvement for NDI, however the GTCC in the EG resulted in an improved outcome in the treatment of patients with chronic neck pain.

The efficacy of cervical lordosis rehabilitation for nerve root function, pain, and segmental motion in cervical spondylotic radiculopathy: a randomized control trial Ibrahim Moustafa, Aliaa Mohamed Diab, Deed Harrison Purpose: To test the hypothesis that improvement of cervical lordosis in cervical spondylotic radiculopathy (CSR), using 3-point bending extension traction, will improve clinical features in a population suffering from CSR. Methods: Thirty chronic lower CSR patients with cervical lordosis b 25° were included. IRB approval and informed consent were obtained. Patients were assigned randomly into two equal groups, study (SG) and control (CG). Both groups received stretching exercises and infrared; the SG received cervical extension traction. Treatments were applied 3 x per week for 10 weeks, care was terminated and subjects were re-evaluated at both 3-months and 2-years. Amplitude of dermatomal somatosensory evoked potentials (DSSEPS), lordosis C2-C7, and visual analogue scale (VAS) were measured at 4 intervals. Results: The SG had an increase in cervical lordosis post treatment (p b 0.0001), this was maintained at 3-months and 2 years. No statistical improvement in lordosis was found for the CG. A significant reduction in VAS for SG after 10 weeks of treatment with non significant change at 3-month and 2-years was found. CG had less significant improvement in post treatment VAS; the 3-month and 2-year measures revealed significant worsening in VAS. An inverse linear correlation between increased lordosis and VAS was found (r = -.49; p = 0.0059) for both groups initially and maintained in SG at follow ups (r = -.6; p = 0.0138). At 10-weeks, we found significant

WFC 2015 Congress Proceedings improvements in DSSEPS for both groups (p b 0.0001). At 3-month follow up, only the SG showed improvement compared to baseline (p b 0.006); whereas the CG values returned to baseline measurement (p b 0.153). We identified a linear correlation between initial DSSEPs and lordosis for both groups (r = .65; p b 0.0001), maintained only in the SG at final follow-up (r = .55; p = 0.033). Conclusion: Improved lordosis in the SG correlated with significant improvements in nerve root function and VAS rating in patients with CSR.

Does improvement towards a normal cervical sagittal configuration aid in the management of lumbosacral radiculopathy: A randomized controlled trial Ibrahim Moustafa, Aliaa Mohamed Diab, Deed Harrison Objectives: To investigate the effects of cervical lordosis rehabilitation on 3D spinal posture, back and leg pain, disability, and S1 nerve root function in patients with chronic discogenic lumbosacral radiculopathy(CDLR). Methods: 80 (35 female) patients, 40-55 years of age, experiencing CDLR with hypolordotic cervical spine and forward head posture were randomized to either a study (SG) or control group (CG). IRB approval and informed consent was obtained by our university. Both groups received TENS therapy and hot packs; the SG received the denneroll cervical traction orthotic. Interventions were applied 3 x per week for 10 weeks; or 30 sessions. Both groups were followed for 6 months after treatment terminated. Outcomes included radiographic lordosis C2-C7 and anterior head transition; rasterstereography postural measurements; leg and back pain scores; Oswestry Disability Index (ODI; and H reflex latency and amplitude. Each variable was measure at three intervals. Results: A significant difference between the SG and the CG adjusted to baseline values at 10 weeks post treatment with respect to the following postural measures was identified: lumbar curve (P = .002), thoracic kyphosis (P = .001), trunk inclination (P = .01) and imbalance (p = .001), pelvic inclination (p = .005), surface rotation (p = 0.01). The radiographic measured cervical lordosis (p = .001), AHT (p = .002), and H reflex amplitude (p = .007) and latency (p = .001) were likewise statistically different between the groups at 10 weeks favoring the SG. At 10-weeks, there was no significant difference for back pain (p = .2), leg pain (p = .1) and ODI (p = .6) improvements between the SG and CG. However, at 6-months, there were statistically significant differences between the SG and CG for all variables at 10-weeks (p b .05); indicating the SG improvements were maintained while the CG values regressed back to baseline. Conclusion: Restoring cervical lordosis was found to have a positive impact on 3D posture, leg and back pain scores, ODI, and H reflex in CDLR patients.

Does rehabilitation of cervical lordosis influence sagittal cervical spine flexion extension kinematics in cervical spondylotic radiculopathy subjects? Ibrahim Moustafa, Aliaa Mohamed Diab, Deed Harrison Objectives: To test the hypothesis that improvement of cervical lordosis in cervical spondylotic radiculopathy (CSR) will improve cervical spine flexion/extension end range of motion kinematics in a

WFC 2015 Congress Proceedings population suffering from CSR. This trial was part of a clinical intervention assessing pain, disability and functional improvement of CSR patients; whereas herein we report only the end range sagittal plane kinematic findings. Methods: Thirty chronic lower CSR patients with cervical lordosis b 25° were included. IRB approval and informed consent were obtained. Patients were assigned randomly into two equal groups, study (SG) and control (CG). Both groups received stretching exercises and infrared; the SG received 3-point bending cervical extension traction. Treatments were applied 3 x per week for 10 weeks, care was terminated. Subjects were evaluated at 3 intervals: baseline, 30 visits, and 3-month follow-up. Radiographic neutral lateral cervical lordosis (ARA C2-C7) and cervical segmental (C2-C7 segments) rotational and translational flexion-extension kinematics analysis were measured for all patients at the three intervals. The outcome were analyzed using repeated measures one-way ANOVA. Tukey’s post-hoc multiple comparisons was implemented when necessary. Pearson correlation between ARA and segmental translational and rotational displacements was determined. Results: Both groups demonstrated statistically significant increases in segmental motion at the 10-week follow up; but only the SG group showed a statistically significant increase in cervical lordosis (p b 0.0001). At 3-month follow up, only the SG improvements in segmental rotation and translation kinematics were maintained. Conclusion: Improved lordosis in the SG was associated with significant improvement in translational and rotational motions of the lower cervical spine. This finding provides objective evidence that cervical flexion/extension is partially dependent on the posture and sagittal cervical curve orientation. These findings are in agreement with several other reports in the literature; whereas ours is the first post treatment analysis identifying this relationship.

Danish chiropractic practice: a glimpse into current health care encounters using a consumer’s lens Corrie Myburgh, Eleanor Boyle, Henrik Wulff Christensen Objectives: To develop a contemporary, patient-oriented perspective of chiropractic private practice, as reflected by the setting, practice models and clinical interactions observable in Denmark. Methods: A qualitative point-of-view investigation was conducted making use of participant observation, face-to-face interviews and video analysis. Data were analyzed for content and thematic emergence. Results: A purposive sampling framework yielded 11 clinic sites, representative of prevalent practice models. Data collected over a 6-month period included interviews with 60 patients, 22 health care professionals and 12 administrative staff. These were supplemented with video recordings of 33 clinical interactions. Health care encounters potentially start before patients enter clinics as individuals search websites to identify a suitable environment. In this regard modern, “cozy” clinics are often favored. Danish chiropractors rarely function in a mono-professional setting, thus patients typically encounter one or more non-chiropractor during their treatment. Administrative staff is integral to the functioning of multi-disciplinary clinics, but also appear to function as “informal” sources of information to patients; in particular what they might expect during their consultation and what their clinical consultant “is like”. Clinics tend to have a strong musculoskeletal focus; however, preventative health care thinking

139 and practices form an undertone clearly observable in both staff and patients. Patients value competence and professionalism in their clinical encounter with their chiropractor. Conclusion: Danish chiropractic practice is strongly influenced by modern consumer behavior and team-oriented practice trends. Furthermore, the administrative hub plays an important role in operationalizing this multi-practitioner approach, thus shaping the patient’s experience. And whilst patients appear receptive of this type of clinical encounter, the anchoring role of a competent chiropractor (lead clinician) is key.

Is chiropractic mainstream or complementary? Investigating the question using National Health Interview Survey data Harrison Ndetan, Cheryl Hawk, Eric Russell Objectives: Mainstream health care has been operationally defined as being regulated by State/Federal licensing/certification, covered by health insurance, considered a standard treatment for a common condition, and delivered within facilities either by or in conjunction with mainstream practitioners. The aim of this study was to attempt to answer the question “Is chiropractic care mainstream?” by evaluating these measurable criteria. Methods: Both sample adult and complementary/alternative medicine (CAM) files of NHIS-2012 data, the most recent to include a CAM subsample, were analyzed. By applying the complete survey design structure, weighted frequencies were generated for use of chiropractic care. Odds ratios (OR) and 95% confidence intervals (CI) were calculated comparing chiropractic to acknowledged mainstream practitioners. Results: About 10.2% of respondents used chiropractic manipulation within the past 12 months (9.8 times on average), with 7.6% reporting their Doctor of Chiropractic (DC) as their personal healthcare provider, 12.6% for routine care and 3.6% as usual place of care. About 61% of DC users noted their cost for manipulation was covered by insurance. Among those who used spinal manipulation, 96.7% used chiropractic and 3.3% used osteopathic. About 9.5% of respondents reported that their top reason for seeking care was spine-related (back/neck), and were more likely to use chiropractic compared to osteopathic manipulation [OR of 11.9(CI = 3.4-41.2)]. These respondents were also more likely to report a DC as personal health care provider compared to a medical or osteopathic doctor (MD/DO) [OR = 3.7(CI = 1.7-7.9)]. Those with debilitating back/neck problems were more likely to see a DC [OR = 2.1(CI = 1.8-2.5)] and even exclusively so compared to an MD/DO [OR = 1.6(CI = 1.0-2.5)]. Conclusion: Results of this analysis suggest that chiropractic meets at least some of the criteria for being mainstream. As use and acceptance of CAM changes over time, it is important to continue to examine chiropractic’s position with respect to the health care mainstream.

The role of chiropractic care in the treatment of dizziness and balance disorder Harrison Ndetan, Cheryl Hawk, Vishaldeep Ka Sekhon, Miguel Chiusano Objectives: to assess the role of chiropractic care in the treatment of dizziness and balance disorders.

140 Methods: Analysis was performed on data from the 2008 National Health Interview Survey (NHIS), the most recent to include questions on treatment of dizziness and balance. The study was approved by the lead institution’s institutional review board. National population estimates (NPE) were generated using the NHIS survey strata, clusters and weight and included weighted percent. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using binary logistic regression models of the likelihood of a respondent with dizziness or balance problems perceiving being helped by that practitioner. Results: Eleven percent of respondents reported having had a balance or dizziness problem; 35% of this group were ≥ 65 years. Of the 50.4% who reported seeking care, 84.7% saw general medical physicians (MD). The OR for perceiving that they had been helped by MDs was 0.95 (CI, 0.65-1.37). Only 4.2% reported receiving care from Doctors of Chiropractic (DC); the OR of perceiving being helped was the highest of all practitioners, 1.73 (CI, 0.92-3.24). For respondents ≥ 65 years, the OR for perceiving being helped by DCs [OR(95%CI) = 4.36(1.17, 16.311)] was statistically significantly greater than those b 65 years [OR(95%CI) = 1.13(0.56, 2.31)]. For respondents whose cause of balance or dizziness was head/neck trauma, the OR for perceiving being helped by DCs was 9.5 (CI, 7.92-11.40), compared to OR 0.53 (CI, 0.25-1.13) for MDs. For those reporting neurological or muscular conditions as the cause, the OR for being helped by DCs was 13.78(5.59,33.99). Conclusion: NHIS data indicate that, although seeking chiropractic care for balance or dizziness is not highly prevalent, for those who do, more report that it has helped their condition, compared to all other health professions in the analysis.

Access, usage and payment options for chiropractic services by active duty military or military veterans in the United States Harrison Ndetan, Will Evans, David Walters, Julie Swartz Objectives: Musculoskeletal conditions are a common cause of disability in the military and chiropractic care has been known to be effective in treating these conditions. The purpose of this study was to assess the use of chiropractic services among active duty military and veterans in the United States and evaluate access to care and payment options. Methods: Analysis was performed using the 2012 National Health Interview Survey data from the adult core sample, PERSON, and alternative/complementary medicine files. Using SAS 9.3, the complete complex survey design structure (clustering, stratification and weighting) was applied to generated valid frequencies that represent United States non-institutionalized population of military/ veterans. Odds ratios (OR) and 95% confidence intervals (CI) for the likelihood of active duty military/veterans using chiropractic services were computed from binary logistic regression models. Results: Over 7124 (9.5%) of the survey respondents were active duty military/veterans resulting in a national population estimate (NPE) of 22123064. Among these 9.2% reported having seen a chiropractor in the past 12 months; 5.9% as personal healthcare provider and 0.7% on routine basis. They were slightly less likely than non-military personnel to seek this care [OR(95%CI) = 0.89(0.74,1.07)]. About 48% of those who received spinal

WFC 2015 Congress Proceedings manipulation noted that their cost was covered by insurance while paying, on average, $250 out of pocket. About 8.2% reported a delay in care and 3.9% needed but unable to get care due to cost. Conditions they sought care for were mostly back, neck, and neuromusculoskeletal conditions. Conclusion: There seem to be no significant difference in the use of chiropractic services among the military/veterans compared to the general public. More research should be done to determine the role chiropractic could play in military readiness and care. Using patient reported outcome measures (PROMs) to inform clinical decisions during chiropractic undergraduate clinical training: Barriers and opportunities Dave Newell, Dave Byfield, Niel Osborne, Jonathan Field Objectives: To explore the implementation and impact of using a routine web based PROMs in chiropractic training clinics in UK institutions. Methods: A web based PROMs collection system was introduced at the Anglo European College of Chiropractic and Welsh Institution of Chiropractic teaching clinics in 2013. Students in their final year clinic training engaged in collecting PROMs from patients, which included the Bournemouth Questionnaire, the STarT Back Tool and a Patient Global Impression of Change as a primary outcome. These were collected at key follow up points and were included as an expectation to be both used with the patient and provided as part of the on-going assessment of cases in the teaching clinic. Results: We will report quantitatively on the results achieved as measured by the various outcome measures within the teaching clinics and qualitatively on the barriers and opportunities encountered in the implementation of such a process during clinical training including the impact on patient-student interaction, clinical decision making and the learning process of the student themselves. Conclusion: Patient reported outcomes collected routinely during care are becoming a central expectation within primary care environments. With this in mind we have implemented a PROMS collection during final year clinical training of chiropractors with a view to normalizing such processes to support continued collection and implementation in clinical decision making post-graduation. Two institutions in the UK have chosen a web based system to automatically collect outcomes during and beyond chiropractic care as delivered by chiropractic interns and the success and impact of these efforts on chiropractic clinical training will be reported. Is this what your patients look like? Statistical identification of “patient-profiles” based on first visit characteristics Anne Molgaard Nielsen, Peter Kent, Werner Vach, Lise Hestbaek, Alice Kongsted Objectives: Chiropractors provide care for many low back pain (LBP) patients and often report very positive effects from chiropractic treatment. However, randomized controlled trials show only small effects and one possible explanation is that the benefit of treatment varies across different subgroups. There are a number of methodological approaches to identifying subgroups of patients with similar profiles. The aim of this project was to use a novel method to subgroup LBP patients into distinct clinically recognizable patient-profiles based on diverse patient characteristics.

WFC 2015 Congress Proceedings Methods: LBP patients from 17 chiropractic clinics in Denmark responded to a comprehensive baseline questionnaire (LBP history, pain intensity, activity limitation, psychological factors, general health and social factors) and underwent a standardized physical examination including range of motion, tests for pain centralization, sacroiliac joint tests and neurological examination. A computerized clustering technique combining all the data will be used to identify subgroups of patients with specific profiles. The planned analysis includes health domains (psychological, pain, physical impairment, activity, participation and contextual factors) and thereby takes into account the whole bio-psycho-social aspect of LBP. Resultant baseline subgroups will be described along with the feature of each subgroup that distinguishes it from the others, and a judgment will be made of how clinically recognizable each subgroup is. Results: This study included 928 patients aged 18-65 years. A total of 71 variables were collected and classified into 6 health domains. The statistical analysis will be performed late 2014 and the resulting patient-profiles described afterwards. Conclusion: As this subgroup analysis is more comprehensive than traditional subgrouping methods and more likely to accommodate any complex interplay between patient characteristics, it may show previously unrecognized subgroups. The resulting subgroups will be presented at the conference and will subsequently be tested for their association with patient outcomes.

Efficacy of chiropractic techniques to improve cervical lordosis: a systematic review of all evidence and clinical commentary Paul Oakley, Deed Harrison Objectives: To review the efficacy of chiropractic techniques for improving cervical lordosis. Methods: Literature reviews were performed in various databases using appropriate keywords for all levels of evidence (I-IV). Results: A total of 37 studies were located, reviewed by two raters and categorized by technique: Chiropractic BioPhysics (CBP) (11), Generalized SMT (6), Pierce (5), Gonstead (3), Pettibon (3), Activator methods (2), Diversified (2), Grostic (2), Atlas-Orthogonal (AO) (1), Network Spinal Analysis (1), and Sacro-Occipital Technique (1). Discussion: There were two Level I, (AO, CBP), three Level II (two CBP, SMT), three Level III (CBP, Grostic, Pierce), and 29 Level IV studies. In the Level I studies, AO treatment for Autism and CBP treatment for cervical radiculopathy, both techniques demonstrated improvements in cervical lordosis and objective patient improvement, however the former failed to quantify lordosis increase. Likewise 9/37 reports had no post-measurement; improvement was verified by commentary and/or post-x-ray pictures. Of the 28 studies including measurements, most (20/28) used multiple modalities that might be expected to increase lordosis such as cervical pillows, extension traction methods, and/or corrective exercises. The most common x-ray measurement methods included posterior tangents C2-7, AcuArc ruler and cervical curve depth (CCD), where only the former has established reliability and validity. Since even slight head extension (b 14°) has an effect on global lordosis (C2-7 = 7°), it is an important measure to include, though rarely was. Similarly, very few studies reported segmental angles of lordosis. Considering only the positive Level I-III studies with measurements, mild improvement by Grostic technique (8°) is

141 within the ‘increased lordosis by slight head extension’ range, while both Grostic and Pierce (6°) technique studies had initial and pre-existing lordotic necks. In contrast, the greatest magnitude of consistently reported improvements in cervical lordosis, including initial kyphosis, came from those studies incorporating extension-traction methods using CBP Technique (13-18°).

A comparison of subjective qualitative assessment of cervical spine alignment vs. objective quantitative mensuration: How do medical radiologists fare? Paul Oakley, Leesa Sanchez, Grace Kim, Deed Harrison Introduction: Radiology reports are a standard and required companion to imaging studies. Alignment is one of the anchors for commentary on the radiology report. The purpose of this study is to compare medical radiologists’ subjective qualitative commentary on cervical spine lateral alignment to the images’ actual quantitative and objective mensuration. Methods: In a clinic that refers out for imaging, spanning the years 2010-2012, 108 consecutive patients receiving lateral cervical films were reviewed for medical radiologists commentary on radiology reports regarding the spine alignment. Image digitization and analysis quantified magnitude of forward head excursion (mm), global lordosis angle (C2-7), noting any kyphotic functional spinal units (FSU). To compare quantitative measurements to subjective commentary, we devised definitive clear-cut endpoint classifications corresponding to different lordosis measurements based on previous work. Commentary results were organized into 3 groups: 1) “Normal” alignment; 2) “No comment” on alignment; 3) “Abnormal” alignment. Results: Of the 100 images included for evaluation (8 thrown out), 55 were commented as normal, 20 had no comment, and 25 mentioned an abnormal alignment. Within the normal group, only 16% were actually within contemporary limits of normal; 0% of the abnormal group were. 73% of the entire sample had forward head posture greater than 15 mm, and 80% had at least one functional spinal unit in a kyphotic orientation; no report mentioned either of these features. Only 30% of the no comment group had a lordosis within a normal range. Approximately 50% of the time radiologists include explanations for the loss of lordosis including: muscle spasm, patient positioning and/or degenerative changes. Conclusion: Medical radiologists make generalized, non-specific statements regarding the cervical lordosis and very often are not accurate in their qualitative statements; as well, often omit this information. This downplays the importance of the cervical spine alignment as being involved in a patient’s complaint.

Health professional perspectives regarding the use of patientreported outcome measures in an integrated primary care health center: A pilot project. Kirsten Olesen, Peggy Howard, Shirley Xing, Fok-Han Leung, Deborah Kopansky-Giles Objectives: To assess health professional perspectives surrounding the implementation of a standardized package of patient-reported outcome measures (PROMs) in an inner city, integrative primary

142 health care center and to identify specific PROMs recommended for package inclusion. Methods: This qualitative study involved semi-structured key informant interviews with healthcare practitioners working in the primary care health center. All interviews were transcribed verbatim and coded to ensure anonymity. The constant comparison method was used to identify common themes emerging from the data. REB approval was granted to proceed with the project. Results: Eleven practitioners participated. Responses were divided into major themes: Attitudes around the use of PROMs, PROMs currently in use by the study participant, advantages and disadvantages of implementing a package of PROMs, barriers and facilitators to PROM use in the department, desirable attributes of PROMs to use, and specific PROMs identified for package inclusion. The key informants concurred that the use of PROMs would be useful; however, there were concerns surrounding how the package would be implemented, the relevance to their profession, and how it would be used within and between professions. Participants provided recommendations toward PROMs that should be considered for inclusion as well as suggestions for the department to consider around implementation, specifically a carefully planned and collaborative approach to development to ensure department-wide buy-in. Conclusion: Participants generally agreed that implementing a standardized approach to the use of PROMs in our primary care setting was desirable. Advantages and disadvantages were identified as well as barriers and solutions to overcome these. Participants felt could be resolved by a careful planning and implementation strategy. The findings from this project will be helpful in the development of a full study inclusive of all health providers and department administrators and staff.

Thrust magnitudes, rates and 3-dimensional directions delivered in simulated lumbar spine HVLA adjustments Edward Owens, Ronald Hosek, Linda Mullin, Lydia Dever, Sullivan Stephanie, Russell Brent Objectives: Our chiropractic college is developing equipment and methods for introducing force feedback into early technique courses to enhance students’ abilities to deliver safe and effective manual thrusts. This investigation measured faculty performance of simulated adjustments on a mannequin. Results will be used to develop teaching standards for the classroom. Methods: Adjustment force measures often focus on magnitude and rate, but thrust direction is important in many chiropractic techniques. We measured 3-dimensional transmitted loads using a force plate mounted in the table. Thrusts were delivered through a compliant, jointed mannequin by faculty members along predefined ‘listings’ as taught in lumbo-pelvic technique courses. Results: 11 faculty members participated, delivering 9 thrusts at 3 loads (light, moderate and heavy) along 9 different prone and side-posture listings: 81 thrusts per participant. We analyzed 3 of the prone listing thrusts for resultant magnitude and speed, and component directions. Single-hand Gonstead-style thrusts showed variability in magnitude across participants and loads: light thrusts averaged 365 N (95% CI (327-402)), moderate thrusts 454 N (421-487) and heavy thrusts 682 N (623-740). All faculty could easily distinguish the loads within their performances, but there was some cross-over of load levels between participants. Thrust rates averaged

WFC 2015 Congress Proceedings 3.55 N/ms 95%CI (3.29-3.82). The dominant vector of prone thrusts was in the z-direction (vertically downward), but there were clear side-to-side and inferior-to-superior vector components. Adjustments for PRS and PLS listings were verified to have opposite medial-tolateral components, and all thrusts had significant inferior-to-superior components as expected in Gonstead technique. Conclusion: Faculty members are able to control the thrust magnitude and rate as well as direction in simulated adjustment tasks. There is significant variability in peak loads between participants, which needs to be considered in student learning standards. The findings will be used to help translate understanding of adjustment force characteristics to the technique teaching lab.

Tactile perception influences spinal manipulation dosage Steven Passmore, Brian MacNeil, Geoff Gelley Objectives: Manually delivered spinal manipulation (SM) is a therapeutic intervention requiring tactile contact between the clinician and patient. Typically manual palpation for assessment or anatomical land marking precedes SM. While chiropractors commonly utilize SM, little is known on how or if feedback from tactile assessment modulates clinician delivered output. The purpose of the present study was to determine whether chiropractors use tactile feedback in SM dose delivery modulation. Methods: In a cross-sectional within-participants design experienced clinicians (N 5 years) delivered SM thrusts on low fidelity models. Clinicians (N = 5) were not provided with any hypothetical history or patient characteristics. They were asked to treat the models as they would a patient in clinical practice. Thrust delivery was based solely on tactile characteristics chiropractors perceived from the models. In a randomized order clinicians performed 12 trials of high-velocity low-amplitude thrusts, using a covered-thumb push technique, on each of 4 low fidelity models pressurized to 10, 15, 20 and 25 psi respectively for a total of 48 trials. Custom software (E-prime) synchronized triggering of a force transducer, triaxial accelerometer, and 3D motion analysis system. Each system recorded for five seconds at 300Hz. Dependent variables included preload force, and thrust force. Duration, and peak of both resultant acceleration, and resultant displacement were also recorded. Analysis of each dependent measure utilized one-way repeated measures ANOVA models. Significant findings were post-hoc tested using Tukey’s HSD. Results: Preload force increased as model pressure increased F(3,16) = 6.941, p = 0.006. Peak acceleration of the thrust hand decreased as model pressure increased F(3,16) = 4.138, p = 0.031. Displacement decreased as model pressure increased F(3,16) = 6.316, p = 0.008. Conclusion: Chiropractors modulate the dose of their output based on tactile information they perceive from their SM thrust target. The present experiment provides a foundation for the study of how other perceptual factors may also contribute to SM thrust dose modulation.

Presenting complaints to chiropractors: Has there been any change in the last 10 years? Daniel Piper, Adrian Hunnisett, Christina Cunliffe Objectives: Each year 150,000 new patients consult a chiropractor. A study carried out in 2002 recognized that the typical new patient

WFC 2015 Congress Proceedings to a McTimoney practitioner was female, between the age of 41-60 years old and mostly presented with low back pain (LBP). This study is a comparison of the data in 2012, 10 years on, to determine whether there has been any change in primary presenting conditions over the last 10 years. Methods: Following ethical approval, a retrospective records survey was undertaken from the records of all new patients attending a chiropractic college student clinic during 2012. The data collection process mirrored that of the 2002 study in order to allow a direct comparison. Results: In 2012 there were a total number of 556 new patients with 43% male and 57% female. The primary presenting complaint was LBP (57%) with the next most common condition low back coupled with lower extremity pain (11%). This compared with 45% and 10% respectively in 2002. Analysis of other presenting complaints showed similar patterns of presentation over both sample years. Conclusion: This study clearly shows that low back pain is still the most common primary presenting complaint causing patients to consult a chiropractor. Comparing the results directly with the 2002 study body segmentation, there would appear to be an increase of 12% of new patients presenting with low back pain. The study data indicates a perception that chiropractic is still viewed predominantly for low back pain alone. It is in the interest of the profession that chiropractors attempt to change this stereotype via education of the population at large of the benefits to total body health that chiropractic can provide.

The lived experience of an injured chiropractor: A qualitative investigation of chiropractors’ perception of injury Nikous Poullis, Jacqui Rix Objectives: To gain an understanding of chiropractors’ professional life, mechanisms of injury and impact on their practice and examine any preventative measures taken by chiropractors to cope with and prevent injury or illness. Methods: Eight practicing chiropractors with more than 9 years of practice experience participated in ‘in depth’ interviews. Convenience sampling, followed by snowball sampling, was used. To increase triangulation, six of the interviews were conducted in Cyprus and two in the UK. These followed a structured interview guide and were digitally recorded and transcribed for supplementary analysis. A review of the current literature was also performed with search criteria including PubMed, CINAHL, MEDLINE, Discovery database and ICL using MESH and key words. Results: Chiropractors use chiropractic care for their injuries and emerged as a strong theme as did referral of injured chiropractors patients to colleagues. Exploring mechanisms of injury, comments from participants indicated an experience that injuries occurred in activities away from the practice rather than in clinical practice. However, somewhat contrary to this, most of the chiropractors believe that practicing chiropractic predisposes the practitioner to occupational injuries. Conclusion: Themes emerging from interviews concerning chiropractors’ perception of work place injury are somewhat contradictory. However, the perceived gravity of the effect of injury is high in that they are potentially incapacitating and impact both their own and patient’s lives. Other themes that emerge additional to perception of injury include, genuine care for the patient, high hygiene standards, prevention and adaptation to injury as well as the

143 healthy triad of move well, eat well, feel well. Reflecting on themes, the study proposes that chiropractic education should include information concerning occupational injuries and increased observation of experienced chiropractors at practice and the practices they use to avoid potential injury.

End-feel assessment of hip joint dysfunction and pain at full range of motion in patients with hip osteoarthritis: a reliability study Erik Poulsen, Henrik W Christensen, Søren Overgaard, Jan Hartvigsen Objectives: Examiner assessed end-feel at full passive range of motion is considered important when evaluating indications for manual therapy where an inelastic barrier and pain is interpreted as joint dysfunction. However, no studies have examined the reliability of end range hip examination in patients with hip osteoarthritis (OA). Therefore, the aim of this study was to examine the inter-examiner reliability of end-feel assessment and reliability of patient reported pain at end range assessment in patients with OA of the hip. Methods: Patients with unilateral clinical and radiological hip OA were examined independently and in random order by four clinicians (2 orthopaedic surgeons and 2 chiropractors). Both hips (one with and one without OA) were examined at passive end range for end-feel during flexion, internal and external rotation and patients were then asked if the joint assessment was pain producing. Measurements were dichotomized by clinicians into dysfunction or no dysfunction and by patients into pain or no pain. Reliability is reported using Cohen’s Kappa. Results: A total of 61 patients (122 hips) were examined by the four clinicians and inter-examiner reliability of end-feel assessment between the chiropractors was: flexion, 0.46; internal rotation, 0.63; external rotation, 0.32 and between orthopaedic surgeons: flexion, 0.36; internal rotation, 0.20; external rotation, 0.23. Reliability of patient experienced pain at end range examined by chiropractors was: flexion, 0.61; internal rotation, 0.58; external rotation, 0.41 and by orthopaedic surgeons: flexion, 0.44; internal rotation, 0.46; external rotation, 0.41. Conclusion: In patients with hip osteoarthritis, inter-examiner assessment of hip joint end-range examination in flexion, internal and external rotation between chiropractors is rated fair to moderate and fair between orthopaedic surgeons. Reliability of patient reported pain experienced at end range assessment is rated moderate when assessed both by chiropractors and orthopaedic surgeons.

The clinical reliability of physical tests in the diagnosis of shoulder conditions: a systematic review Mario Pribicevic, Rhea Cambourn, Benjamin Handcock, Ami-Bree Said, Amy Steed, James Dimitroff, Peter Tuchin Objectives: Shoulder pain is a common presentation to chiropractors, with an estimated prevalence of 13-15%. The aim of this review was to assess the reliability and efficacy of examination tests used in the diagnosis of shoulder conditions. This should enhance practitioner understanding of how to interpret examination findings and determine which tests are best in clinical practice (and development a diagnostic flow diagram). Methods: A systematic literature search was conducted on Scopus, Sciverse, Science direct and Medline (up to 2014) using key words

144 of shoulder, diagnosis and orthopaedic tests. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to critique the quality. Results: After exclusions were applied, 25 articles were accepted for the review with a cumulative total of 3030 shoulders tested with orthopaedic special tests (OSTs). For the diagnosis of bicipital tendinopathy tenderness over the bicipital groove revealed an average sensitivity of 43% and specificity of 57%. Speeds test mean sensitivity/specificity values of 30% & 60%, with Yergason’s test demonstrating sensitivity of 24% and specificity 88%. Anterior instability sensitivity and specificity scores for the apprehension test (98.3%, 71.6%), relocation (96.7%, 78%), release test (91.7%, 83.5%), and anterior draw test (58.3%, 92.7%), respectively. Highest sensitivity tests for a SLAP lesion were biceps load test II (79%) and the dynamic labral shear test (92%). Tests with a high mean specificity were the anterior slide test (83%), biceps load test II (74%), compression rotation test (76%), crank test (75%) and the pain provocation (90%). To rule out subacromial impingement Hawkins Kennedy test demonstrated a sensitivity of 80.7% and Neers 78.9%. Conclusion: The review demonstrated that the clinical reliability of single OSTs for the diagnosis of shoulder conditions is limited. However, diagnosis is aided through the use of multiple tests (clusters) in conjunction with clinical history and imaging (if indicated).

Overhauling chiropractic curriculum to meet the educational demands of 21st century Dewan Raja, Bahar Sultana Objectives: The aim of this paper is to identify the areas of farther improvement in the chiropractic curriculum. Methods: We studied the curriculums and catalogues of seventeen chiropractic colleges, twenty colleges of physical therapy, and ten college of occupational therapy, and three medical schools of the United States. Results: From our observation, we found that public health, genetics, pathophysiology, and pharmacology are either absent or present insignificantly in a chiropractic curriculum. Excessive emphasis is placed on the gross anatomy with unrefined redundancy. Students reveal ambiguous information about childhood vaccination and negative rhetoric ideas about medicine and surgery. There is little or no curricular modification to address the new health policy and future health market scenario. The number of academic departments, faculty with specific graduate degrees and degree-based teaching assignment are virtually absent. Many of the chiropractic faculty teach more than one subjects and are overwhelmed with teaching loads. The number of research faculty and quality research is negligible. There is no research laboratory in most of the chiropractic colleges. Chiropractic curriculum differs significantly among the chiropractic colleges even among the different campuses of the same chiropractic college. There is no exchange of faculty or students among the chiropractic colleges. Conclusion: Strategic planning is essential to overhaul the chiropractic college curriculum to address the changing demand of the profession. A balanced, updated, and homogeneous curriculum will be a growth of chiropractic profession.

WFC 2015 Congress Proceedings Defining work ability: a scoping review of the literature Mana Rezai, Pierre Côté, J. David Cassidy, Linda Carroll, Vicki L. Kristman, Selahadin Ibrahim Objectives: The ability to actively participate in the labor market is an important goal for those recovering from an injury. Work ability is also an important construct for workplace employers, policy makers and rehabilitation professionals. The objectives of this study are: 1) to provide a framework for the conceptualization of work ability; 2) to describe the existing scope and breadth of knowledge currently available regarding the definition and measurement of work ability; and 3) to elucidate the key factors contributing to the construct of work ability. Methods: A scoping review of the scientific literature was conducted using the recommended five stages: identifying the research question, identifying the relevant studies, selecting the studies, charting the data, and summarizing and reporting the results. A search was conducted in MEDLINE-Ovid from 1996 to January 2014 and reference lists of all relevant articles were screened. Eligible studies were reviewed and results thematically analyzed and qualitatively synthesized. Results: A preliminary search yielded a total of 666 citations. Citation titles and abstracts were screened and 105 full papers met the eligibility criteria and were retrieved and reviewed. In total, 37 papers contributed information regarding the important components of work ability. Preliminary results of this review suggest that work ability is a complex construct. Existing literature supported the presence of multiple factors that make an important contribution to work ability. These factors are related to several domains of functioning and include: 1) physical functioning; 2) psychological functioning; 3) cognitive functioning; 4) social and behavioral functioning and workplace factors; and 5) factors outside the workplace. Conclusion: There is agreement in the literature that ability to function at work can be affected by multiple factors; however, a clear, agreed upon definition of the components of work ability is absent.

Self-funding chiropractic research: A survey of UK based chiropractor attitudes Eoin Roe, Gabrielle Swait, Adrian Hunnisett, Christina Cunliffe Objectives: The purpose of this study is to evaluate the attitudes of UK-based chiropractors from the various chiropractic professional associations towards funding further research in the profession. The survey also aims to clarify their perceived priorities for further research and the administration of any funds. Methods: Following ethical approval, a cross-sectional survey was undertaken using an electronic survey package (SurveyMonkey.com). The survey questionnaire was designed to collect quantitative data in three main areas: (1) the type of research that should be carried out, and by whom, (2) funding and contributions, and (3) demographic information regarding the respondents’ chiropractic career. Results: The results showed a 14.5% response rate from a possible total of 1100 chiropractors (n = 159). The majority of chiropractors who responded (67%) would be willing to pay a regular monthly subscription to fund further research and 62% would be willing to contribute £10 or more per month. Just under half of respondents (43%) believe that funds should be controlled by an independent

WFC 2015 Congress Proceedings research foundation and 40% believe funds should be actually be collected by an independent research foundation. The majority of respondents felt that research into the physiological basis of chiropractic adjustment should be a priority along with improving patient outcomes (79% and 78% respectively). Half of respondents (52%) disagreed with the statement that chiropractic research should be used to promote further integration with the UK National Health Service, suggesting that it should remain a private medical service. Conclusion: This study demonstrates that UK chiropractors are willing to donate funds for further research, via subscription, at a level of £10 per month. An infrastructure will need to be developed to manage potential funds. Additionally further research will be required to assess chiropractors’ priorities and beliefs regarding further research.

Reliability and validity of therapy localization as determined from multiple examiners and instrumentation Anthony Rosner, Gerry Leisman, James Gilchriest, Eugene Charles Objectives: Therapy localization proposes a change in muscle function when a patient's hand is placed over an area of suspected dysfunction. In manual muscle testing by an applied kinesiologist, is there agreement between examiners (reliability) and is there instrumental and/or symptomatic confirmation (validity) of their muscle classifications produced by therapy localization? Methods: Three Diplomates in applied kinesiolgy performed manual muscle tests (MMTs) of the middle deltoid of 30 volunteers with or without neck pain to assess the degree of examiner concurrence of MMT findings and confirmation by instrumentation and/or association with symptoms. An additional 5 patients with neck pain were tested by the same protocol by 2 Diplomates to assess (1) forces applied with a clnech transducer, (2) the degree of arm movement with an electrogoniometer, and (3) the vibration of the middle delotid by vibromyography. Results: Statistical tests revealed no significant differences among examiners in their muscle classifications or in the forces applied during muscle testing. Clear distinctions between weak and strong muscle classifications both in the absence or presence of therapy localization were indicated by both electrogoniometry and vibromyography but not by electromyography. The presence of neck pain was associated with a significantly greater presence of therapy localization. Conclusion: In manual muscle tests of the middle delotid performed by applied kinesiologists, both the reliability and validity were supported by concurrence among examiners and correlations with the results shown with force transducers, electrogoniometry, and vibromyography. Further data involving a second muscle (hamstrings) as well as larger numbers of subjects whose muscle test results will be correlated with the aforementioned instrumentation will be forthcoming.

Application of the STarT Back Screening Tool in an academic chiropractic clinic in the USA Robb Russell, Melissa Kimura, Annie Babikian Objectives: Low back pain (LBP) is the leading cause of disability worldwide, resulting in enormous global economic impact. A 95%

145 increase in expenditures in the USA for management of ambulatory LBP over a decade (1999-2008) does not correlate with improved clinical outcomes. Expert opinions vary as to whether sub-categories of LBP can be identified. Our objective was to describe the clinical categories of patients based on the STarT Back Screening Tool (SBST), a psychosocial assessment questionnaire that stratifies patients into prognostic tiers of low, medium or high risk for poor clinical outcomes. Methods: Of 286 unique patients seen during an 18 month period, 190 were assessed for LBP. Of those, 163 completed the SBST. Clinical categories were tabulated and quantitatively compared with that of published SBST studies for chiropractic clinics in the EU and Norway as well as medical and physical therapy studies in the UK and USA. Results: Our results, the first reported for SBST at an academic chiropractic clinic in the USA, found 44% in the low risk category, 26% in the medium risk category and 29% in the high risk category. These findings are compared to the literature for patients undergoing SBST at chiropractic clinics in the EU and Norway as well as the original reference study. Conclusion: SBST sub-grouped chiropractic patients in the USA in risk categories relatively similar to previously reported in the literature. Conclusions drawn from comparison of populations from different regions as well as those seeking primary medical care and/or physical therapy should be done with caution as variation was noted between the studies, however, insight into patterns of SBST classification distribution may be useful for resource allocation and planning purposes. Further research to measure costs and outcomes associated with SBST is currently being conducted.

Changes in quality of life in older adult patients receiving Activator Methods Chiropractic Technique: A case series David Russell, Elise McMinn, Harriet Cowie, Caroline de Groot, Matthew Sherson Objectives: Therapeutic nihilism is an issue in the care of individuals with a variety of disorders associated with aging. Healthcare providers and older patients themselves may believe that the patient cannot recover as fully as a younger patient. This can lead to treatment either being withheld or not sought because of these limiting beliefs. The aim of chiropractic care is to enhance human potential and health through optimizing nervous system function. If chiropractic care can be shown to have a positive impact on quality of life in older adults, irrespective of their presenting complaints, it may promote a reduction in therapeutic nihilism associated with aging. The objective of this case series is to report on symptomatic and quality of life changes in seven older adult chiropractic patients who were receiving care utilizing Activator Methods Chiropractic Technique. Methods: Chiropractors from two practices in Auckland, New Zealand were asked to provide case notes for consenting, current, older adult patients for whom at least two quality of life assessments had been performed. Seven sets of case notes were received and summarized in this case series. Results: The seven patients, aged 69-80 years, primarily presented for care due to a variety of musculoskeletal conditions. Over the course of weeks to months each patient reported significant improvements in their presenting complaints as well as a number

146 of seemingly unrelated non-musculoskeletal improvements. The average improvement in the physical component of quality of life measured using a Rand-36 questionnaire was 6.4 points and the improvement in mental component was 8.6 points. Conclusion: This case series reports positive changes in musculoskeletal and non-musculoskeletal symptoms, and clinically significant improvements in quality of life in older adults receiving chiropractic care. Further research is required to investigate the potential role for chiropractors in caring for older adult patients.

Determination of radiographic and postural changes in patients treated with chiropractic manipulation Juan José Saldaña-Mena, Jaime Zavaleta Hernandez, Elizabeth Herrera-López, Joel Lomeli- Gonzales, Maria Elena Ceballos, Enrique Montiel-Flores, Ivan Saenz Objectives: The purpose of this study was to analyze the biomechanical and postural changes in students from the State University of the Valley of Ecatepec, Mexico treated with chiropractic manipulation. Methods: 13 students of career chiropractic between 19 and 30 years old were used. Postural and radiographic measurements were obtained before and after chiropractic manipulation. The chiropractic treatment plan consisted of 2 times per week for 4 weeks. At the beginning and end of the chiropractic care were determined changes, were obtained again postural and radiographic measurements to determine changes. Results: Our results showed that after chiropractic manipulation statistically significant changes in biomechanical parameters evaluated were observed in deficiency pelvic, lumbar gravity line, weight distribution and lumbar posture. Conclusion: Chiropractic manipulation changes the biomechanics of the spine, so we propose that this treatment positively impacts the biomechanical dysfunctions.

Patient perceptions of manual cervical distraction: a qualitative study to refine the design of a full-scale trial Stacie Salisbury, Maruti Ram Gudavalli, Robert Vining, Christine Goertz Objectives: Researchers are encouraged to partner with patients to develop healthcare interventions and outcomes. We describe how participant perceptions of manual cervical distraction (MCD) from a pilot trial refined the design of a full-scale randomized controlled trial (RCT). Methods: The collegiate institutional review board approved this study. Participants provided written consent. We conducted a mixed methods, pilot RCT to compare 3 traction force ranges of MCD in 48 adults with chronic neck pain. A structured questionnaire and audio-recorded interviews elicited participants’ perceptions of the trial, the believability and effectiveness of MCD, the credibility of the minimal intervention, adverse events, and expected outcomes. Data were analyzed by treatment group using thematic content analysis. Results: Participants enrolled in the trial in hope of experiencing pain relief and due to the novel nature of the treatment. Participants described MCD as a gentle stretch or massage, contrasting it with the more ‘abrupt’ or ‘aggressive’ characteristics of other neck

WFC 2015 Congress Proceedings manipulations. Participants who received higher traction forces considered MCD a more ‘believable’ treatment, citing relaxation and decreased neck tightness as reasons. Those receiving mediumand low force MCD rated its effectiveness lower than those in the high force group due to limited symptom improvement. Participants receiving low force (92%) identified their traction force group more often than those in medium (31%) or high (15%) force groups. Only 12 participants recalled experiencing an adverse event, compared with 29 participants who reported one during the trial. Expected outcomes mentioned by participants included pain relief, decreased stiffness, better range of motion, and improved function in work and leisure activity. Conclusion: This qualitative study demonstrated the importance of the patient perspective for investigators developing chiropractic clinical trials. We will structure study protocols and modify our minimal intervention control based on pilot participants’ feedback in a full-scale efficacy trial of MCD.

Evaluation of a back school program on content learning, activity modification and perceived benefits Eduardo Sawaya Botelho Bracher, Marines Calori, Marina Aline de Brito Sena, Thaís Bonfim Clemente Objectives: To verify content learning, modification of activities of daily living and perceived benefits for participants of a back school program (BSP). Methods: This study evaluated the results of a BSP developed by doctors of chiropractic at a large health care company in São Paulo, Brazil. The program used elements of somatic education and consisted of two 90-minute interactive encounters during which participants learned about anatomy, pathology and ergonomics and practiced exercises and strategies to perform daily activities for self-management and prevention of musculoskeletal pain. Data collection consisted of an initial questionnaire to evaluate the participants’ lifestyle and symptoms. A second questionnaire at the end of the program investigated perceived benefit. The participants’ spontaneous and stimulated recall of contents learned, and the changes they made on activities of daily living were verified through a telephone interview 30 days after the program. Results: Sixty-eight subjects with chronic low-back (50%), neck (27%), thoracic (13%) and extremities pain (10%) were studied. At the end of the program, over 80% of the participants reported that they had a better understanding about their pain and on how to modify activities in order to minimize it. After one month, participants were able to spontaneously recall on average four (27%) out of 14 key concepts of the BSP. That percentage increased to 59% when the contents were read to them. Three quarters of the participants reported that they had changed aspects of their lifestyle in agreement with what they learned at the BSP. Conclusion: The BSP program evaluated in this paper was successful in stimulating participants to feel more secure of their knowledge about their condition and on how to manage their symptoms. One month after its conclusion, most participants had implemented changes on their lifestyle and were able to recall contents learned during the program.

WFC 2015 Congress Proceedings The effects of a pre-adjustment communication on satisfaction ratings of a chiropractic adjustment David Starmer, Kim Ross, Patricia Adele Boudreau, Antonio DiCarlo, Emily Marshall, Jennifer Bradshaw Objectives: The current study is designed to examine if eliciting a positive or negative treatment expectation will affect the perception and satisfaction outcomes of an individual receiving a chiropractic adjustment. Methods: Data for this investigative pilot study was collected from seventy-three first year Canadian Memorial Chiropractic College (CMCC) students (mean age of 23.81 ± 3.17, male 57% of total participants, and female 43% of total participants). Participants were randomized into three distinct groups; ‘confident clinician’ recording, which is the positive experimental group, ‘unsure intern’ recording, which is the negative experimental group, and the control experimental group, who only receive instructions to lie prone on the treatment table. Then, subjects were blindfolded and received a thoracic adjustment by an experienced clinician on a force-plate table. Following the trial, participants completed a post-trial satisfaction rating. Results: The average peak force for Carver thoracic adjustment was 599.99 N (± 76.87) and was consistent for all the trials with no significance revealed between groups [one-way ANOVA (p = 0.16)]. However, a one-way ANOVA of the post-trial questionnaires revealed a significant difference (p = 0.047) between the ‘unsure intern’ and control group. However, no significance was revealed between all other experimental groups’ post-trial questionnaires. Conclusion: The results of this study indicate that there is an influence of pre-adjustment communication on post-adjustment ratings by the post-trial questionnaires. Future research could focus on the validation of the post-trial questionnaire as well as exploring the effect of negative and positive verbal communication in various clinical settings.

Training leaders in chiropractic: A survey of Canadian Memorial Chiropractic College (CMCC) residency graduates Paula J. Stern, Chadwick Chung, John Jay Triano Objectives: CMCC has three residency programs: Clinical Sciences, Diagnostic Imaging and Sport Sciences. The aim of the programs is to develop researchers, scholars, and specialists. Little is known about professional outcomes of chiropractic residency graduates. Therefore, we aimed to describe and understand the outcomes of the residency programs. Methods: We conducted a program evaluation. We surveyed all graduates (n = 119) from the CMCC residency programs between 1977-2013. Eligible chiropractors were contacted by e-mail. We developed a questionnaire to measure self-rated satisfaction, self-perceived benefits, source of employment and income. Participants were also asked to submit their curriculum vitae. Results: 105 graduates were contacted. (We were unable to retrieve the contact information of twelve chiropractors and two were deceased.) Of those, 55% responded to the survey (58/105) and 39% submitted their curriculum vitae (41/105). 96.5% of respondents were satisfied with their residency training and 92%

147 reported that the training facilitated the advancement of their career. The most common sources of employment were: clinical practice (94.8%), faculty/administration in chiropractic colleges (82.8%), guest lecture (62%), independent medical examination (50%), specialist consultation (43.1%), expert witness (36.2%), sports team chiropractor (33%) and faculty/administration in a university (19%). 53.5% of clinicians reported to practice in interprofessional environments. One third of respondents were involved in research and 43% of graduates earned more than $150,000/year. Finally, 41.6% of those who submitted their curriculum vitae had a master’s or doctoral degree, 36% served as reviewers for professional and academic publications and 15% engaged with professional associations. Conclusion: The CMCC residency programs educate chiropractors who engage in a variety of leadership roles within the chiropractic profession. Most graduates remain involved in clinical practice and expand their activities to professional and academic leadership that ranges from interprofessional practice to research and political engagement.

Shifting the focus to patient-centered improvement: A Canadian chiropractic case study Saira Aaima Sukhera, Jennifer Percival, Silvano Mior Objectives: The increased implementation of technologies in chiropractic practice presents a need to ensure the patient, and not technology, remains the primary focus of care. This case study presents the application and analysis of a chiropractic-based careflow with a patient-centric method of process mapping. We aim to demonstrate the significance of this specialized mapping technique in a health care setting to improve patient outcomes and operational efficiencies following adoption of an electronic health record (EHR) system. We further present a comparison of clinical and functional consistency between two distinct clinic sites within a single organization, complemented with applications in organizational wide administrative support functions. Methods: Data was collected using semi-structured interviews, focus groups and patient observations. The data was used to construct and validate the resulting process models. With the adoption of lean principles to guide analysis and specific metrics of Patient Journey Modeling Architecture (PaJMA), we present a representation of the patient journey to bottlenecks and identify areas of improvement. Results: The resulting process maps provide a basis for balancing the needs of patient care and organizational efficiency. We were able to identify variances of care across clinical sites. The process models supported change management including training of clinical and administrative staff to standardize optimal efficiency while creating ideal patient outcomes including reduced non-value added time within the patient journey. We distinguished the utilization of health information technology to support patient management and reinforce clinical guidelines to ensure patient safety. Conclusion: Through the development and use of the patient journey models, we have increased organizational awareness of the patient experience supported through improved integration of technological systems such as the EHR.

148 Review of the literature and comparison of two practice-based research network recruitment techniques: onsite event recruitment and affiliation recruitment Stephanie Sullivan, Edward Owens, Ronald Hosek, Lucia Paolucci Objectives: Practice-based research has been around since clinicians began observing and reporting the care of patients. In the 1970s, the medical profession began to establish formal networks dedicated to improvement of patient care through study of clinical practice. Chiropractic’s foray into practice-based research networks (PBRNs) has had intermittent success. For all PBRNs, recruitment is a great hurdle to success. The purpose of this study was to review the chiropractic PBRN literature to identify successful recruitment strategies and describe the feasibility of on-site event recruitment compared to institutional-affiliation recruitment. Methods: A review of literature was conducted with follow-up examination of article references. A table was set up at a chiropractic event. Individuals expressing interest in the PBRN completed a sign-up sheet and received 4 follow-up emails regarding registration and a survey request. Similar emails were sent to chiropractors affiliated with the PBRN host institution. Results: The review of literature produced 4 articles specifically addressing chiropractic PBRN recruitment strategies and success rates. Recommended strategies included recruitment through organizational assembly, direct calls, letters, institutional publications, and educational programs. Fifty-three chiropractors indicated interest at the event, five completed the registration process, and eight completed the survey. Affiliation recruitment through institutional publications (14,000), email lists (5,750), and social media yielded fifteen registrations and six survey completions. For registrations, the rate of return was 9.4% for event recruitment and 0.076% for affiliation recruitment. Conclusion: There is a paucity of information in the literature related to recruitment success strategies, and event recruitment in this study required high-level engagement with little return. It is suggested that future event recruitment include on-site registration with improved education regarding the nature of the PBRN. Affiliation recruitment demonstrated modest returns with little effort. The limited literature and success reported in this study highlights the need for increased reporting of best-practice recruiting strategies.

Pain and physical activity in adolescents: Analyses of a population-based international survey Michael Swain, Nicholas Henschke, Steven Kamper, Inese Gobina, Veronika Ottová-Jordan, Christopher Maher Objectives: Somatic pain and physical inactivity in adolescents both pose a major burden to global health. We analyzed three waves of the Health Behaviour in School-aged Children study (HBSC) to determine the prevalence of somatic pain in adolescents and its relationship with meeting recommended physical activity levels. Methods: Two pooled analyses of the HBSC datasets (1997/98, 2001/02, 2005/06) from 28 countries were performed. Survey questions included the HBSC symptoms checklist and a physical activity measure. Pooled prevalence rates of individual and

WFC 2015 Congress Proceedings combined pains were calculated for 1997-2006 data. Multivariate logistic regression models were constructed to investigate the relationship between pain and physical activity, adjusted for regional variation and the HBSC study year. Results: The prevalence of headache was 54.1%, stomach-ache 49.8%, backache 37%, and at least one of the three pains 74.4%. Somatic pain is more prevalent in girls and during late adolescence. In general, the presence of pain was associated with reduced physical activity. Headache alone was associated with reduced physical activity in girls and boys of all ages, and in 11 and 13 year old girls stomach-ache and backache, individually and in combination, were associated with decreased odds of being physically active with odds ratios ranging from 0.72 to 0.89. Conclusion: Pain is very common in adolescents and generally associated with reduced physical activity. The association between pain and physical activity in adolescents varies according to age, gender and the type of pain experienced.

A preliminary investigation into the neurophysiological response to spinal adjustment as measured by changes in electrodermal activity John-Paul Taylor, Adrian Hunnisett, Christina Cunliffe Objectives: This study is a basic science investigation into the neurophysiologic response of a specified chiropractic spinal adjustment, building on scientifically acknowledged spinal adjustment/manipulation research and utilizing EDA as an accepted objective measure of neurophysiologic effect. Findings from the study were also helpful in gaining a better understand of existing neurophysiological theories of spinal adjustment widely held within the chiropractic profession. Methods: Following ethical approval, a randomized, double-blinded, 3-arm (Treatment; Placebo; Control) study was undertaken. A total of 45 subjects were recruited and 15 assigned randomly to each group. Treatment consisted of spinal adjustment to the Atlas vertebra (C1) by a chiropractic clinician. Placebo simulated the intervention without applying force. In the Control group, each subject underwent the same pre- and post-intervention protocols as Treatment and Placebo, but without any physical contact from the clinician. Outcome measures of Skin Conductance (SC) in the ipsilateral upper limb were recorded to reflect Sympathetic Nervous System response. Changes in SC pre and post intervention were analyzed. Results: The chiropractic adjustment to C1 produced a sympathoexcitatory response compared with control group (p b 0.05). No evidence statistically significance was found between either treatment and placebo or control versus placebo. Conclusion: The results from this research study suggest that a single chiropractic adjustment performed on C1 of asymptomatic humans elicited a sympathoexcitatory effect, as measured by an increase in SC of the upper limb (ipsilateral side to Atlas anteriority). The only statistically significant result in peripheral Sympathetic activity was found between the Control versus Treatment (p b 0.05) groups, with no evidence of a difference between Treatment versus Placebo, or Control versus Placebo.

WFC 2015 Congress Proceedings Adverse events after spinal manipulative therapy of the neck Peter Tuchin Objectives: Adverse events (AE) after spinal manipulative therapy (SMT) are an important but under researched area, especially with neck SMT. Retrospective studies have been conducted however, they are limited because of the relatively rare incidence of serious AE. In addition, relevant clinical information about the AE is often not included in the analysis. Therefore, it is important to review the literature, especially clinical factors, regarding cervical spine SMT (CSSMT) and AE. Methods: A systematic search of the Medline, Embase and Pubmed databases (from 1970-2014) was conducted for studies using the keywords SMT, AE and case report. Each paper was reviewed to assess key factors of the AE, the relationship or characteristics of treatment, and the significance to AE. In addition, any confounding factors, practitioner negligence, and rarity of the condition other items was assessed. Results: The search identified 129 papers with 218 cases (after removal of duplicates or abstract review) which were critiqued. The most common AE following CSSMT was VAD, disc herniation, intracranial hypotension, or cases involving misdiagnosis or negligence. A detailed critique revealed that 45% cases probably had non-chiropractic CSSMT, by either another practitioner type or an un-trained practitioner. In addition, most cases (85%) had minimal or no discussion of the onset of the presenting symptoms prior to SMT and whether this may have indicated any contra-indications to SMT. Also, most did not include information on recent trauma, changes in pain patterns or thorough medical history. Conclusion: This review revealed that case reports on AE and SMT have plausible alternatives which may alter conclusions on the risk of CSSMT and practitioner negligence (eg one case of osteomyelitis after SMT). Chiropractors should be vigilant in recording SMT contra-indication factors. However, it is also possible that the published cases of CSSMT may have missed important confounding factors.

A systematic review of adverse events in children after chiropractic treatment Peter Tuchin, Natascha Nixon, James Rudko, Leon Gray, Julian Ascone Objectives: Complications or adverse events (AE) following spinal manipulative therapy (SMT) are common but mostly involve relatively benign outcomes. However, there is controversy on the benefits of SMT versus potential AE, especially assessing the clinical contributing risk factors. Chiropractic SMT for children is especially controversial regarding whether the risks outweigh the benefits. An update of the 2007 Vohra paper, and critical review of clinical details of the AE after chiropractic for children, is required. Methods: A systematic search of the Medline, Embase and Pubmed databases from 2007 for case reports on chiropractic and children. Factors reviewed were clinical features, treatment performed, treatment provider, any time lapse between treatment and the nature/location of the AE.

149 Results: Since the 2007 review paper on chiropractic and children, a number of new papers have been published. Twelve papers which identified 22 cases meet inclusion criteria. Ten cases involved serious AE (hospitalization, permanent disability or death), two involved moderate AE (seeking medical care but not hospitalization) and 10 involved mild AE (self-limiting, not requiring medical care). Most case reports reviewed provided insufficient clinical information and consequently left plausible alternative causes of the AE undisclosed. AE after pediatric SMT included complications after atlas fracture, spinal astrocytoma, and osteogenesis imperfecta. Conclusion: Retrospective studies show that AE after chiropractic in children is a rare event, but these studies do not detail the clinical aspects on each case. However, weaknesses in case reports published (ie lack of clinical detail) also create uncertainty in the reported outcomes. A well written case report should provide appropriate information to inform clinicians of risks inherent in their treatment. Most case reports reviewed did not achieve this and therefore any key risk factors for pediatric SMT remain uncertain. A causal relationship between the AE and pediatric SMT remain unsubstantiated.

Examples of vertebral artery dissection in pediatric patients: the significance for chiropractic practice Peter Tuchin Objectives: Pediatric arterial ischemic stroke (AIS) can occur as the result of the trivial head or neck trauma, which can occur after a sports activity. It is estimated to occur between 2-3 per 100,000, which makes it more common than adult vertebral artery dissection (VAD). However, many chiropractors may be unaware of the significance of AIS in children, especially related to sport. A review case reports of pediatric VAD and examination of the relevance for chiropractic spinal manipulation therapy (SMT) is imperative. Methods: A systematic search was conducted in Medline, Embase and CINAHL databases (from inception to 2014) using the keywords pediatric and VAD (or all synonyms). Each abstract was reviewed for the nature of the VAD reported, clinical details (including any trauma), pain characteristics, any treatment given. Results: From 2297 VAD papers identified, 29 related to a pediatric population. However, a review of the abstracts revealed only 12 case reports with relevance to SMT. A critical review of these cases identified blunt trauma (such as a sports injury) as the significant clinical issue, with the most common presenting symptom being new onset headache or neck pain, often accompanied with dizziness or other neurological symptoms. Cases of pediatric VAD have occurred after numerous sports (rugby, judo, softball) as well as activities such as climbing or associated falls from height. Stroke may occur days to weeks after a trauma-related VAD. Conclusion: Trauma or sports injury (which may seem innocuous) could be a significant risk factor for pediatric VAD. Thorough clinical information is needed for chiropractors to distinguish between benign conditions (such as migraine, which can have similar symptoms) and more serious clinical situations such as VAD. In some cases where chiropractic SMT may appear indicated, further investigation of preceding events may result in a different treatment strategy being adopted.

150 The aging cervical spine facet joints - changes visualized through a microscope Lars Uhrenholt, Annie Vesterby Charles, Markil Gregersen, Jan Hartvigsen, Ellen Hauge Objectives: The objective of this study was to examine cervical spine facet joints age-related changes using systematic histological morphological and histomorphometric methods. Methods: The lower four cervical spine segments (C4-C7 included) were retrieved from 72 subjects during autopsy including 29 females (median age 53 years [22-77]) and 43 males (median age 38 years [20-78 years]). The specimens were embedded in hard plastic, sectioned into 3-mm thick slices from where 10 μm thick histological sections were made available for microscopy. Several morphological and histomorphometric variables were examined using a linear regression model. Results: The regression model predicted significant correlations between increasing age and most morphological and morphometric variables, in particular cartilage splitting, fissures (mild, moderate and severe), osteophytes, maximum cartilage length, thickness of the calcified cartilage and subchondral bone (p b 0.001). With regard to gender, females showed shorter maximum cartilage length, and were affected less severely by age-related changes compared to males. No significant gender differences were observed at the osteochondral junction. However, this particular region, involving the calcified cartilage and the subchondral bone, showed highly significant age-related changes. Synovial folds were identified at the anterior and posterior joint margin in all facet joints. Conclusion: Based on this first of its kind detailed description of the cervical spine facet joints anatomy a clearer understanding of ageand gender related changes has been achieved. Degenerative changes can be observed in both males and females from a young age involving in particular the cartilage and the subchondral bone, and the changes increase with increasing age. This study identifies distinct degenerative changes similar to, but in some aspects different from, those observed in larger weight bearing joints. Hence, age-related degeneration in the cervical spine facet joints requires unique consideration and uncritical extrapolation of knowledge from other anatomical regions should not be performed.

Development of an effective and low-cost system to monitor PROMs using mobile technology and the internet: An exploratory trial of the Patient Health Information (PHI) software application Ahmet Ulusan, Andrew L. Vitiello, David Newell Objectives: To develop and explore the utility of new software system to collect PROMs in real time within a clinical setting using smartphone technology and the internet. Methods: This study took place in four external physiotherapy clinics in North Cyprus and was based on the use of an Android smartphone system. Participants were randomized into two groups (“App” or “No App”) via a predetermined randomization chart. Twelve out of 14 patients were recruited into the “App” group and took part in the study. They were asked to complete five discrete feedback sessions using their smartphone over a 30-day period. Results: Eleven patients successfully completed the study trial with an overall 92% participant response rate. The majority of

WFC 2015 Congress Proceedings participants (63.6%) believed the PHI application was very easy to use while 63.6% also stated PHI would help them cope better with their current pain. The majority (54.5%) also thought PHI had a positive impact with respect to their reliance on their health care provider while also improving their confidence in going about their daily activities (54.5%). In addition, 45.5% of participants stated that they could control their low back pain better following the use of PHI system while 54.5% of the subjects stated that they could manage their low back pain better after using PHI. The majority of participants (54.5%) stated that PHI “most definitely” allowed them to be more actively involved in their treatment. Conclusion: The use of a smartphone based data collection tool has shown promise in helping patients and practitioners better communicate and manage low back pain conditions with participants’ thoughts on using this system being generally positive. Future development of this mobile based data collection is imperative in order to capitalize this innovation, potentially positioning the chiropractic profession as MSK leaders in the emerging digital health revolution.

Racial disparities in use of chiropractic services under Medicare in Los Angeles County, California James Whedon, Melissa Kimura, Reed Phillips Objectives: Racial and ethnic disparities in utilization of chiropractic services have been described at the U.S. state level. The purpose of this study was to describe the utilization of chiropractic services under the U.S. Medicare system in Los Angeles County, California, and to evaluate for local disparities. Methods: We used a cross-sectional design to analyze Medicare data for the year 2008. We restricted the analysis to beneficiaries aged 65-99 years and residing in Los Angeles County. We merged beneficiary demographic data, including race/ethnicity, with a 100% sample of Medicare Part B claims. We used postal code of beneficiary residence as the unit of geographic analysis, aggregated the data by postal code and evaluated for availability and use of chiropractic services by beneficiary racial/ethnic category (white, black, Hispanic, Asian, Native American, or other/unknown). We quantified geographic variations in availability and utilization of services by coefficient of variation, and mapped utilization by selected racial/ethnic categories. Results: 377 chiropractic physicians provided care to 7,502 of 248,116 beneficiaries. Chiropractic physicians per 1,000 beneficiaries varied by postal code from 0 to 15 (mean 2, SD 2). The Medicare beneficiary population was 60% white, 14% Asian, 10% black, 10% Hispanic and 6% other/unknown. 12% of Asian beneficiaries, but only 1% each of blacks and Hispanics used chiropractic services. Chiropractic users per 1,000 beneficiaries ranged from 6 to 113 (mean 32, SD). We observed the greatest variation in the number of chiropractic users among Hispanics, blacks, and Asians; use among whites varied the least. Under Medicare rules, Native American beneficiaries were too few to report by postal code. Conclusion: We found evidence of racial disparities in use of chiropractic services at the local level in Los Angeles County. Older blacks and Hispanics in Los Angeles County may be underserved with regard to chiropractic care.

WFC 2015 Congress Proceedings Continuing professional development: A survey of the opinions of chiropractors in the UK Christopher Wood, Adrian Hunnisett, Christina Cunliffe Objectives: Continuing professional development (CPD) allows chiropractors to maintain and develop skills throughout their career. Currently, there are few studies about chiropractors’ opinions about CPD, or the types of activities they participate in. Understanding what motivates chiropractors, and what may stand in their way when it comes to participation in CPD, is essential in order to adequately facilitate their needs, and ultimately improve the quality of care for those that they serve. The aim of this study was to gain an overview of chiropractors' CPD activities, and to record their opinions, in order to aid the future planning of effective CPD resources. Methods: Following ethical approval, an online survey questionnaire was designed, and distributed to chiropractors registered in the UK via the main professional associations. Results: A total of 208 valid responses were collected. Two thirds of respondents undertook musculoskeletal CPD activities during the last 3 years. Improving technique skills, improving clinical and diagnostic skills and keeping up-to-date with new developments were considered to be the important motivations for undertaking CPD activities. Cost and accessibility were considered the greatest barriers preventing participation in CPD. Evidence-based practices, philosophy, and research were considered important and integral to chiropractic education, but CPD participation in these subjects was low. Conclusion: The results have shown that chiropractors in the UK most commonly participate in musculoskeletal CPD activities. The majority are motivated by improving and maintaining their technique skills and gaining confidence in practice. It also showed that most chiropractors agree that evidence-based practices and research are important and integral to chiropractic education, but few actually participate in these subjects for CPD. Overall, the study indicates that there remains a significant difference between the undergraduate curricula in the UK and the CPD activities undertaken by qualified chiropractors.

Pain, disability and health-seeking behaviors of primiparous women with persistent pelvic girdle pain 9 months postpartum in Ireland Francesca Wuytack, Deirdre Daly, Elizabeth Curtis, Cecily Begley Objectives: Pelvic girdle pain (PGP) is common during pregnancy and may persist postpartum. In Ireland, the prevalence of persistent PGP had not been assessed. This is important to inform postnatal care. The aim was to examine the prevalence of persistent PGP in primiparous women in Ireland 9 months postpartum, and to explore their health-seeking behaviors. Methods: Ethical approval was granted. Primiparous women attending a large maternity hospital completed a self-administered questionnaire during pregnancy and 9 months postpartum. Pain location was determined using a pain diagram. The Pelvic Girdle Questionnaire (PQG) was used, which gives a score from 0-100 with 0 indicating no pain and disability, and 100 maximum pain and disability. Questions concerning medication use and discussion of

151 their PGP with any healthcare professionals were also included. Data were analyzed using descriptive statistics and the Mann-Whitney U test. Results: Five hundred eighty-three women completed the 9 months postpartum questionnaire of which 44.5% (315/578) reported PGP. The majority (82%; 259/315) had also reported PGP during pregnancy and 67% (211/315) had had some PGP before pregnancy. The mean PQG score at 9 months postpartum was 12.1 (SD 10.5); 34.9% said PGP interfered with handling their baby to some extent, 13.4% had taken pain medication for it, and 18% had discussed their complaint with a healthcare professional, most commonly the GP and physiotherapist. There was a significant difference in PGQ scores (U = 734, p b 0.0001) between women who had not discussed their complaint with a healthcare professional (M = 10.5, SD = 8.7) and those who had (M = 18.5, SD = 13). Conclusion: Persistent PGP is common 9 months postpartum, although few women reported severe pain and disability on the PGQ, which may be why only a minority had sought help. In Ireland, where postnatal care ends 6 weeks postpartum, it raises the question if long-term issues may consequently remain largely unaddressed.

Who, at work, is more likely to have low back pain? Haiou Yang, Scott Haldeman, Dean Baker Objectives: Low back pain (LBP) is one of the most important work-related health problem which results in a substantial burden on the healthcare system as well as lost productivity at the societal and individual levels. The goal of this study was to identify work-related factors associated with LBP in the US adult working population. Methods: Data used for this study came from the 2009 to 2012 US National Health Interview Survey (NHIS) core and supplementary surveys. The NHIS is a series of cross-sectional health survey of the population of the US, covering a variety of health topics, including LBP. To account for the complex sampling design, the Taylor linearized variance estimation method was used with logistic regression analysis. The analysis was restricted to working age population (18-64) and those who worked for pay. Results: The findings of the 2010 data indicated that, controlling for demographic characteristics, socioeconomic status and other variables, those who were exposed to hostile work (OR 1.51; 95%CI 1.30, 1.75), work-family imbalance (OR 1.44; 95%CI 1.29, 1.60) or job insecurity (OR 1.29; 95%CI 1.17, 1.43) were all more likely to have LBP. The 2009 to 2012 data indicated that Maintenance and Repair (OR 1.50; 95%CI 1.30, 1.75), Healthcare Support (OR 1.50; 95%CI 1.28, 1.76), Construction and Extraction (OR 1.47; 95%CI 1.28, 1.69) occupations had increased risk for LBP when compared with workers in the education-related occupations. Conclusion: Understanding work-related risk factors for LBP is important if the social and economic impact of this condition is to be addressed. The nature of these risk factors is unlikely that they are secondary but the directionality of these associations should be confirmed by longitudinal studies. These factors should be considered in future decisions by employers, clinicians, including chiropractors, and policy makers attempting to address this major cause of disability.

152 Behavior-related factors associated with low back pain in the US adult population Haiou Yang, Scott Haldeman, Dean Baker Objectives: Low back pain (LBP) is a health problem is the dominant symptoms for which people seek chiropractic care and has profound impact on individuals, business and society. The goal of this study was to explore behavior-related factors associated with LBP in the US adult population, including leisure-time physical activity, sleep deprivation, alcohol use, tobacco use, and obesity, that may provide guidance in the management of patients with LBP. Methods: The data used for this study came from the 2009 to 2012 National Health Interview Survey (NHIS) which is a series of cross-sectional health survey of the population of the US, covering a variety of health topics including LBP which was assessed through self-reporting of LBP in the past 3 months. To account for the complex

WFC 2015 Congress Proceedings sampling design, the Taylor linearized variance estimation method was used. The analysis included 122, 345 adults, aged 18 to 85. Results: Controlling for demographic and other risk factors, compared with those who were inactive, those who engaged in regular aerobic physical at leisure-time (OR 0.82, CI 0.79, 0.85) were less likely to have LBP. Current regular smokers (OR 1.50, CI 1.38, 1.63) were more likely to have LBP. Former regular drinkers (OR 1.30, CI 1.22, 1.39) had an increased risk for LBP. Compared with those who had 7-8 hours of sleep per night, those who slept 3-4 hours per 24 hours (OR 2.81, CI 2.55, 3.11) were more likely to have LBP. Those who were obese also had an increased risk for LBP (OR 1.43, CI 1.37, 1.49). Conclusion: Although it is still unclear whether these behaviorrelated factors are risk, comorbid or prognostic factors for LBP, this study has important policy and clinical implications as these factors are potentially modifiable. This study supports the need for future longitudinal research in this area.