Abstract Suicide remains a major cause of preventable death worldwide. A recent guidance document from NHS England (Staying Safe from Suicide, 2025) highlights the limitations of traditional suicide risk prediction methods and advocates for a relational, person-centred approach. While not mental health specialists, chiropractors and osteopaths often work closely with individuals facing musculoskeletal chronic pain, disability, financial stress, and social isolation, all of which are risk factors for psychological distress. This commentary explores how the NHS guidance offers key lessons for chiropractic and osteopathic practice. Valuable contributions to suicide prevention efforts can be made by fostering strong therapeutic relationships, adopting a biopsychosocial view of health, and encouraging help-seeking behaviours where needed. Through small, relational actions, practitioners can support patient wellbeing while working within the boundaries of their professional scope of practice.
Chiropractic, Diseases of the musculoskeletal system
Michael J. Schneider, Carol M. Greco, Amanda M. Acevedo
et al.
ABSTRACT Background Quantitative Sensory Testing (QST), also known as psychophysical testing, includes standardized methods for assessing humans' perceptions of different types of sensory stimuli and their associated pain thresholds. QST results can be used to estimate altered or atypical sensory processing and thus can be useful for determining pain mechanisms such as nociplastic or central nervous system‐mediated pain. The University of Pittsburgh Mechanistic Research Center, entitled, “Low Back Pain: Biological, Biomechanical, Behavioral Phenotypes (LB3P),” is part of the National Institutes of Health's Helping to End Addiction Long‐term Initiative. LB3P conducted a prospective, observational cohort study to identify phenotypes of over 1000 participants with cLBP. QST was conducted on these participants as part of comprehensive data collection. This article reports on the results of the QST procedures performed at the initial in‐person enrollment visit. Methods Four QST procedures were administered to participants of the LB3P study at their enrollment visit: (1) Pressure Pain Thresholds (PPT) over the participant‐reported site of lumbar pain (paraspinals) and a control site (trapezius) using an analog algometer; (2) Temporal Summation (TS) over the lumbar pain and control sites (forearm) using a Neuropen with a 40‐g monofilament; (3) Conditioned Pain Modulation (CPM) using a cold water (5°C) immersion tank; and (4) Cold Water Tolerance time. A subset of LB3P participants was excluded from the CPM and cold‐water immersion procedures due to medical comorbidities such as cardiovascular disease and diabetic neuropathy. Means and standard deviations (SDs) were calculated from three trials of PPT and TS, two trials of CPM, and one trial of cold‐water immersion time. TS was calculated by subtracting the numeric pain scores (0–10 scale) of the first from the 10th pinpricks. CPM was calculated by subtracting the mean trapezius algometer readings during the PPT procedure from those of the trapezius PPT during cold‐water immersion. Results The final cohort of QST participants was 999 adults. The mean/SD of lumbar and trapezius PPTs was 4.6 (2.4) and 4.4 (1.9) kg/cm2, respectively. The mean/SD of lumbar and forearm TS was 1.6 (2.0) and 1.2 (1.8). Lingering pain after the 10th pinprick (after‐sensations) was reported by 19.3% and 15.6% of participants after a series of 10 pinpricks was applied to the lumbar pain site and control site, respectively. The mean/SD CPM was 0.9 (1.2) with a wide range of CPM values from −2.9 to 5.9. The cold‐water tolerance test resulted in a bimodal distribution, with 83% of participants having an average immersion time of 30 s and the remaining 17% reaching the maximum immersion time of 180 s. Conclusions QST data were collected from a large cohort of individuals with cLBP who participated in the LB3P observational study. The QST results provide reference values for persons living with cLBP.
Background: Lumbosacral transitional vertebrae (LSTV) are common anatomical variants where the last lumbar vertebra demonstrates unilateral or bilateral enlargement of the transverse processes, with articulation or fusion to the sacrum. This radio-anatomical study sought to investigate the morphological characteristics of LSTV in the South African population and describe unique variations that enhance the traditional Castellvi classification. Methods: A retrospective radiographic review was performed on 3096 consecutive thoracoabdominal pelvic radiographs from two South African hospitals. Targeted osteological appraisal was conducted on selected skeletons containing LSTV sourced from the Raymond Dart Collection of Modern Human Skeletons. The presence of LSTV was classified according to Castellvi, identifying Types II, III, and IV, unilateral and bilateral subtypes. Results: The prevalence of LSTV was 10 %. Morphological distribution was as follows: Type II (67.9 %), Type III (27.6 %), and Type IV (4.5 %). Subtype frequencies were IIA (41.9 %), IIB (26.0 %), IIIB (21.8 %), and IV (5.8 %). Laterality showed a predominance of bilateral cases (47.7 %), followed by left- (26.6 %) and right-sided (21.1 %) variants. Type IV morphology could not be classified by side using traditional methods. Transverse processes at the LSTV level were significantly longer than those in matched controls (p < 0.05). Conclusion: This study proposes two refinements to the Castellvi system: First, Type IV morphology should be assigned left or right at the side of the lumbosacral fusion. Second, a novel transversoiliac articulation was associated with Type II morphology, representing a previously undescribed feature in LSTV morphology. These modifications may enhance diagnostic precision, support recognition of Bertolotti syndrome, and formulate appropriate treatment strategies.
Christine Farag, Laurie C. Caines, Helen Wu
et al.
Purpose: To identify whether exposing medical students to a multimodal curriculum of complementary and alternative medicine (CAM) practices improves their understanding of CAM clinical applications.
Background: A significant portion of the U.S. population uses CAM: 34% of adults and 12% of children. Integrative medicine combines the best of conventional and CAM practices. Despite the increased clinical acceptance of CAM, medical education has been lagging, leaving gaps in learners' knowledge. It is important for medical education to keep pace with these developments by educating students and expanding the view of interprofessional care.
Methods: A total of 101 first-year medical students at the University of Connecticut participated in a multimodal CAM curriculum. This included (1) an hour lecture, (2) an online research assignment for a continuity patient, and (3) 2 of 4 modules: acupuncture, hypnotherapy, Reiki, or pet therapy. Pre- and post-tests were administered 1 week apart to assess familiarity with CAM practices and the perceived safety and efficacy of each modality. The familiarity was rated on a scale of 0 (not familiar) to 10 (very familiar). Paired Student's t-tests assessed changes from pre- to post-tests at significant levels (p?<?0.01).
Results: Overall, the mean percentage of students who were able to identify 1 of the top 8 CAM modalities increased from 38% to 49%. The average familiarity rating of CAM significantly increased from 4.7 pretest to 6.6 post-test (p?<?0.01). The top 8 CAM modalities, as selected by students, included acupuncture, meditation, yoga, massage, Reiki, chiropractic, hypnosis, and pet therapy. Overall, the familiarity ratings increased for both safety and effectiveness with intermodule variability from pre- and post-test (p?<?0.01). Larger increases in effectiveness familiarity were found than of safety familiarity (p?<?0.01).
Conclusions: This multimodal curriculum significantly improved medical students' familiarity with CAM modalities and the perceived safety and effectiveness of the modalities.
Alma Fragoso, Brayan Martínez, María Elena Ceballos-Villegas
et al.
<i>Background and Objectives:</i> Chiropractic spinal manipulation is an alternative medical procedure for treating various spinal dysfunctions. Great interest exists in investigating its neuroplastic effects on the central nervous system. Previous studies have found contradictory results in relation to the neuroplastic changes in the H-reflex amplitude as a response to manual spinal manipulation. The discrepancies could be partly due to differences in the unilateral nature of these recordings and/or the variable force exerted in manual techniques applied by distinct chiropractors. Concerning the latter point, the variability in the performance of manual interventions may bias the determination of the significance of changes in H-reflex responses derived from spinal manipulation. To investigate such responses, a chiropractic device can be used to provide more precise and reproducible results. The current contribution aimed to examine whether spinal manipulation with an Activator IV instrument generates neuroplastic effects on the bilateral H-reflex amplitude in dancers and non-dancers. <i>Materials and Methods:</i> A radiograph verified spinal dysfunction in both groups of participants. Since there were significant differences between groups in the mean Hmax values of the H-reflex amplitude before spinal intervention, an assessment was made of the possible dependence of the effects of spinal manipulation with Activator IV on the basal conditions. <i>Results:</i> Ten sessions of spinal manipulation with Activator IV did not cause statistically significant changes in the bilateral H-reflex amplitude (measured as the Hmax/Mmax ratio) in either group. Furthermore, no significant difference was detected in the effects of spinal manipulation between groups, despite their distinct basal H-reflex amplitude. <i>Conclusions:</i> Regarding the therapeutic benefits of a chiropractic adjustment, herein carried out with Activator IV, the present findings suggest that the mechanism of action is not on the monosynaptic H-reflex pathway. Further research is needed to understand the mechanisms involved.
Abstract Objective The Thessaly test is a commonly used orthopedic test for meniscus tear evaluation. The study’s objective is to evaluate the degree of medial meniscal extrusion during different loading phases of the Thessaly test. Methods A convenience sample of 60 healthy knees (35 participants) was examined and the data sets were collected from October 8, 2018 through February 8, 2019. Sonographic measurement of the degree of physiologic extrusion of the medial meniscus deep to the medial collateral ligament was taken by two examiners at six different loading phases: supine, standing, 5° knee-flexion with internal (IR)/external (ER) rotation and 20° knee-flexion with IR/ER. The difference in meniscal extrusion by knee position was compared with ANOVA. Interexaminer reproducibility assessment was analyzed using limits of agreement. Results The mean meniscal extrusion for each position was—supine: 2.3 ± 0.5 mm, standing: 2.8 ± 0.8 mm, 5° IR: 2.3 ± 0.9 mm, 5° ER: 2.4 ± 0.7 mm, 20° IR: 1.9 ± 0.8 mm, and 20° ER: 2.3 ± 0.7 mm. Significant increase in extrusion was observed from supine to standing (p < 0.05) and from 20° IR to 20° ER (p = 0.015). Significant decreased measurement was observed from standing to 5° IR (p < 0.05), 5° ER (p < 0.05), 20° IR (p < 0.05) and 20° ER (p < 0.05). There is no significant change between 5° IR and 5° ER (p = 1.0). Agreement parameters revealed that the differences between examiner measurements were minimal; 75% of both examiners’ meniscal extrusion measurements were within 1.0 mm with 97% of measurements falling within 2.0 mm. Conclusion Our study’s novel findings showed various degrees of physiological extrusion of the medial meniscus in asymptomatic knees during the loading phases involved in the Thessaly test. Physiological MME does exist and should not be defaulted to pathologic meniscus as previously described. Agreement parameters suggest that measurement of meniscal extrusion during the Thessaly test is reproducible between different examiners.
Chiropractic, Diseases of the musculoskeletal system
Natalie Clohesy, Anthony Schneiders, Gaery Barbery
et al.
Abstract Background Factors that influence utilisation rates of patient reported outcome measures (PROMs) for low back pain (LBP) within the chiropractic profession of Australia are currently unknown. This study aimed to examine whether factors, including age, sex, experience level, clinical title (principal vs associate), or a clinicians’ perceived value of PROMs, are predictive of the frequency and/or type of PROMs used by chiropractors in the management of LBP. Methods A cross sectional online survey was distributed to members of the Chiropractic Association of Australia (CAA now known as Australian Chiropractors Association-ACA) and Chiropractic Australia (CA). 3,014 CAA members and 930 CA members were invited to participate totaling 3,944, only respondents that were using PROMs were included in the analysis (n = 370). Ordinal logistic regression was used to examine associations between clinician demographics and perceived value of PROMs, and the frequency of pain, health, and functional patient reported outcome measure (PROM) usage by chiropractors. Results Principal chiropractors were more likely (Wald = 4.101, p = 0.04, OR = 1.4 (1.0–2.1)) than associate chiropractors to frequently use pain-related PROMs for the management of patients with LBP. The remaining demographic factors (age, sex, and experience level) were not associated with the frequency of PROM usage; nor were the perceived value clinicians place on PROMs in clinical practice. Conclusion Principal chiropractors were more likely to frequently use pain-related PROMs for the management of patients with LBP when compared to associate chiropractors. Demographic factors, appear to have little influence on PROM usage. While chiropractors place high value on PROMs, these beliefs are not associated with increased frequency of PROM usage for the management of LBP.
Chiropractic, Diseases of the musculoskeletal system
Reidar P. Lystad, Benjamin T. Brown, Michael S. Swain
et al.
Abstract Background Better understanding of the dynamics and temporal changes in manual therapy service utilisation may assist with healthcare planning and resource allocation. The objectives of this study were to quantify, describe, and compare service utilisation trends in the manual therapy professions within the Australian private healthcare setting between 2008 and 2017. Methods Data regarding the number of services, total cost, and benefits paid were extracted for each manual therapy profession (i.e. chiropractic, osteopathy, and physiotherapy) for the period 2008–2017 from the Australian Prudential Regulation Authority. The number of registered providers for each profession were obtained from the Australian Health Practitioner Regulation Agency. Descriptive statistics were produced for two time periods (i.e. 2008–2012 and 2013–2017) for each manual therapy profession. Annual percentage change during each time period was estimated by fitting Poisson regression models. Test for the equality of regression coefficients was used to compare the trends in the two time periods within each profession, and to compare the trends across professions within a time period. Results A cumulative total of 198.6 million manual therapy services with a total cost of $12.8 billion was provided within the Australian private healthcare setting between 2008 and 2017. Although service utilisation and total cost increased throughout the ten-year period, the annual growth was significantly lower during 2013–2017 than 2008–2012. Whereas osteopathy and physiotherapy experienced significant annual growth in the number of services and total cost during 2013–2017, negative growth in the number of services was observed for chiropractic during the same period. The annual number of services per provider declined significantly for chiropractic and physiotherapy between 2013 and 2017. Conclusion Service provision under private health insurance general treatment cover constitute a major source of revenue for manual therapy professions in Australia. Although manual therapy service utilisation increased throughout the ten-year period from 2008 to 2017, the annual growth declined. There were diverging trends across the three professions, including significantly greater decline in annual growth for chiropractic than for osteopathy and physiotherapy.
Chiropractic, Diseases of the musculoskeletal system
Mads Jochumsen, Imran Khan Niazi, Muhammad Zia ur Rehman
et al.
Brain- and muscle-triggered exoskeletons have been proposed as a means for motor training after a stroke. With the possibility of performing different movement types with an exoskeleton, it is possible to introduce task variability in training. It is difficult to decode different movement types simultaneously from brain activity, but it may be possible from residual muscle activity that many patients have or quickly regain. This study investigates whether nine different motion classes of the hand and forearm could be decoded from forearm EMG in 15 stroke patients. This study also evaluates the test-retest reliability of a classical, but simple, classifier (linear discriminant analysis) and advanced, but more computationally intensive, classifiers (autoencoders and convolutional neural networks). Moreover, the association between the level of motor impairment and classification accuracy was tested. Three channels of surface EMG were recorded during the following motion classes: Hand Close, Hand Open, Wrist Extension, Wrist Flexion, Supination, Pronation, Lateral Grasp, Pinch Grasp, and Rest. Six repetitions of each motion class were performed on two different days. Hudgins time-domain features were extracted and classified using linear discriminant analysis and autoencoders, and raw EMG was classified with convolutional neural networks. On average, 79 ± 12% and 80 ± 12% (autoencoders) of the movements were correctly classified for days 1 and 2, respectively, with an intraclass correlation coefficient of 0.88. No association was found between the level of motor impairment and classification accuracy (Spearman correlation: 0.24). It was shown that nine motion classes could be decoded from residual EMG, with autoencoders being the best classification approach, and that the results were reliable across days; this may have implications for the development of EMG-controlled exoskeletons for training in the patient’s home.
Steen Harsted, Anders Holsgaard-Larsen, Lise Hestbæk
et al.
Abstract Background Investigations into the possible associations between early in life motor function and later in life musculoskeletal health, will require easily obtainable, valid, and reliable measures of gross motor function and kinematics. Marker-based motion capture systems provide reasonably valid and reliable measures, but recordings are restricted to expensive lab environments. Markerless motion capture systems can provide measures of gross motor function and kinematics outside of lab environments and with minimal interference to the subjects being investigated. It is, however, unknown if these measures are sufficiently valid and reliable in young children to warrant further use. This study aims to document the concurrent validity of a markerless motion capture system: “The Captury.” Method Measures of gross motor function and lower extremity kinematics from 14 preschool children (age between three and 6 years) performing a series of squats and standing broad jumps were recorded by a marker-based (Vicon) and a markerless (The Captury) motion capture system simultaneously, in December 2015. Measurement differences between the two systems were examined for the following variables: jump length, jump height, hip flexion, knee flexion, ankle dorsi flexion, knee varus, knee to hip separation distance ratio (KHR), ankle to hip separation distance ratio (AHR), frontal plane projection angle, frontal plane knee angle (FPKA), and frontal plane knee deviation (FPKD). Measurement differences between the systems were expressed in terms of root mean square errors, mean differences, limits of agreement (LOA), and intraclass correlations of absolute agreement (ICC (2,1) A) and consistency of agreement. Results Measurement differences between the two systems varied depending on the variables. Agreement and reliability ranged from acceptable for e.g. jump height [LOA: − 3.8 cm to 2.2 cm; ICC (2,1) A: 0.91] to unacceptable for knee varus [LOA: − 33° to 19°; ICC (2,1) A: 0.29]. Conclusions The measurements by the markerless motion capture system “The Captury” cannot be considered interchangeable with the Vicon measures, but our results suggest that this system can produce estimates of jump length, jump height, KHR, AHR, knee flexion, FPKA, and FPKD, with acceptable levels of agreement and reliability. These variables are promising for use in future research but require further investigation of their clinimetric properties.
Chiropractic, Diseases of the musculoskeletal system
Abstract Background Musculoskeletal injuries are one of the most prevalent battle and non-battle related injuries in the active duty military. In some countries, chiropractic services are accessed to manage such injuries within and outside military healthcare systems; however, there is no recent description of such access nor outcomes. This scoping review aimed to synthesize published literature exploring the nature, models, and outcomes of chiropractic services provided to active duty military globally. Method We employed scoping review methodology. Systematic searches of relevant databases, including military collections and hand searches were conducted from inception to October 22, 2018. We included peer-reviewed English literature with qualitative and quantitative designs, describing chiropractic practice and services delivered to active duty military worldwide. Paired reviewers independently reviewed all citations and articles using a two-phase screening process. Data from relevant articles were extracted into evidence tables and sorted by study type. Results were descriptively analyzed. Results We screened 497 articles and 20 met inclusion criteria. Chiropractic services were commonly provided on-base only in the US. Services were accessed by physician referral and commonly after initiation or non-response to other care. Use of scope of practice was determined by the system/facility, varying from intervention specific to comprehensive services. Back pain with and without radiculopathy accounted for most complaints. Treatment outcomes were reported primarily by case reports. However, two recent randomized trials reported improved pain, disability, and satisfaction when adding chiropractic care to usual medical care compared to usual medical care alone in management of low back pain. Specific reaction time measures in special operation forces military did not improve after chiropractic care compared to wait-list control. Conclusions Our scoping review found the majority of published articles described chiropractic services in the active duty military in the US setting. Recent RCTs suggest a benefit of including chiropractic care to usual medical care in managing back pain in active duty military. Yet despite reported benefits in Australia, Canada, and the US, there is a need for further qualitative, descriptive, and clinical trial data worldwide to inform the role of chiropractic services in active duty military.
Chiropractic, Diseases of the musculoskeletal system
M. John Petrozzi, Andrew Leaver, Paulo H. Ferreira
et al.
Abstract Background Low back pain (LBP) is prevalent, costly and disabling. A biopsychosocial treatment approach involving physical and cognitive behavioural therapy (CBT) is recommended for those with chronic LBP. It is not known if online psychological coaching tools might have a role in the secondary prevention of LBP related disability. To assess the effectiveness of an internet-delivered psychological program (MoodGYM) in addition to standard physical treatment in patients with chronic non-specific LBP at medium risk of ongoing disability. Methods A multisite randomized controlled trial was conducted with 108 participants (aged mean 50.4 ± 13.6 years) with chronic LBP attending one of six private physiotherapy or chiropractic clinics. Disability (Roland Morris Disability Questionnaire) and self-efficacy (Patient Self-Efficacy Questionnaire), were assessed at baseline, post-treatment (8-weeks) with follow-up at six- and twelve-months. Participants were randomized into either the intervention group, MoodGYM plus physical treatments, or the control group which received physical treatments alone. Results No statistically significant between group differences were observed for either disability at post-treatment (Effect size (standardised mean difference) 95% CI) RMD − 0.06 (− 0.45,0.31), 6-months RMD 0.01 (− 0.38,0.39) and 12-months − 0.20 (− 0.62,0.17) or self-efficacy at post-treatment PSEQ 0.06 (− 0.31,0.45), 6-months 0.02 (− 0.36,0.41) and 12-months 0.21 (− 0.16,0.63). Conclusion There was no additional benefit of an internet-delivered CBT program (MoodGYM) to physical treatments in those with chronic non-specific LBP at medium risk of ongoing disability measured at post-treatment, or at 6 and 12 months. Trial registration This trial was prospectively registered with Australian New Zealand Clinical Trials Registry Number (ACTRN) 12615000269538.
Chiropractic, Diseases of the musculoskeletal system
Kristina Boe Dissing, Werner Vach, Jan Hartvigsen
et al.
Abstract Background In children, spinal pain is transitory for most, but up to 20% experience recurrent and bothersome complaints. It is generally acknowledged that interventions may be more effective for subgroups of those affected with low back pain. In this secondary analysis of data from a randomized clinical trial, we tested whether five indicators of a potential increased need for treatment might act as effect modifiers for manipulative therapy in the treatment of spinal pain in children. We hypothesized that the most severely affected children would benefit more from manipulative therapy. Method This study was a secondary analysis of data from a randomised controlled trial comparing advice, exercises and soft tissue treatment with and without the addition of manipulative therapy in 238 Danish school children aged 9–15 years complaining of spinal pain. A text message system (SMS) and clinical examinations were used for data collection (February 2012 to April 2014). Five pre-specified potential effect modifiers were explored: Number of weeks with spinal pain 6 months prior to inclusion, number of weeks with co-occurring musculoskeletal pain 6 months prior to inclusion, expectations of the clinical course, pain intensity, and quality of life. Outcomes were number of recurrences of spinal pain, number of weeks with pain, length of episodes, global perceived effect, and change in pain intensity. To explore potential effect modification, various types of regression models were used depending on the type of outcome, including interaction tests. Results We found that children with long duration of spinal pain or co-occurring musculoskeletal pain prior to inclusion as well as low quality of life at baseline tended to benefit from manipulative therapy over non-manipulative therapy, whereas the opposite was seen for children reporting high intensity of pain. However, most results were statistically insignificant. Conclusions This secondary analysis indicates that children more effected by certain baseline characteristics, but not pain intensity, have a greater chance to benefit from treatment that include manipulative therapy. However, these analyses were both secondary and underpowered, and therefore merely exploratory. The results underline the need for a careful choice of inclusion criteria in future investigations of manipulative therapy in children. Trial registration NCT01504698; results
Chiropractic, Diseases of the musculoskeletal system
Muhammad Samran Navid, Imran Khan Niazi, Dina Lelic
et al.
Objective: The aim of this study was to investigate the effects of different preprocessing parameters on the amplitude of median nerve somatosensory evoked potentials (SEPs). Methods: Different combinations of two classes of filters (Finite Impulse Response (FIR) and Infinite Impulse Response (IIR)), three cutoff frequency bands (0.5−1000 Hz, 3−1000 Hz, and 30−1000 Hz), and independent component analysis (ICA) were used to preprocess SEPs recorded from 17 healthy volunteers who participated in two sessions of 1000 stimulations of the right median nerve. N30 amplitude was calculated from frontally placed electrode (F3). Results: The epochs classified as artifacts from SEPs filtered with FIR compared to those filtered with IIR were 1% more using automatic and 140% more using semi-automatic methods (both <i>p</i> < 0.001). There were no differences in N30 amplitudes between FIR and IIR filtered SEPs. The N30 amplitude was significantly lower for SEPs filtered with 30−1000 Hz compared to the bandpass frequencies 0.5−1000 Hz and 3−1000 Hz. The N30 amplitude was significantly reduced when SEPs were cleaned with ICA compared to the SEPs from which non-brain components were not removed using ICA. Conclusion: This study suggests that the preprocessing of SEPs should be done carefully and the neuroscience community should come to a consensus regarding SEP preprocessing guidelines, as the preprocessing parameters can affect the outcomes that may influence the interpretations of results, replicability, and comparison of different studies.